The ATSB Annual Report 2021-22 outlines performance against the outcome and program structure in the Department of Infrastructure, Transport, Regional Development, Communications and the Arts' Portfolio Budget Statements 2021–22

I am pleased to be able to introduce this annual report on the ATSB activities for 2021–22, a year that continued to present challenges not just for the agency but for the transport sectors we serve due to the ongoing COVID-19 pandemic as well as challenging economic circumstances.

I commenced my term as Chief Commissioner and Chief Executive Officer on 2 September 2021, amidst lockdowns that saw our Canberra, Sydney and Melbourne staff all working from home. It is testament to our staff resilience and flexibility, and the robustness of the ATSB IT systems, that we were able to continue operations with minimal disruptions despite lockdowns, working-from-home requirements, and travel restrictions across the country.

On joining the ATSB I was also well aware that the ATSB is highly respected internationally for its best-practice transport safety investigation, a reputation I will uphold and build upon.

During 2021–22, the ATSB completed and published 60 complex and industry-significant investigation reports into transport accidents and incidents that provided the relevant transport modes with wide-ranging safety learnings. Among the higher profile investigations concluded during the year were:

  • The runaway and derailment of a loaded iron ore train south of Port Hedland, Western Australia, on 5 November 2018. The ATSB investigation established that the train operator’s risk assessments had limited focus on the potential causes of, and critical controls for preventing, a runaway event.
  • The evacuation of an A330 passenger aircraft at Sydney Airport, New South Wales, on 15 December 2019 – our investigation highlighted the importance of clear passenger information and commands, and resulted in the airline amending its safety material, cabin crew training, and other procedures as a result of the incident.
  • The near collision of passenger trains at Park Road Station, Brisbane, on 25 March 2019, following a signal passed at danger (SPAD). Our investigation found that change management relating to the moving or installation of signal aspect indicators, to facilitate the rollout of new rollingstock, did not provide sufficient detail to ensure consistent and conspicuous placement on platforms.
  • The collision of a fishing vessel with a bulk carrier in darkness near the entrance to Port Adelaide Harbour, South Australia, on 29 February 2020, where we flagged our ongoing concern about collisions between trading ships and small vessels on the Australian coast.
  • The mid-air collision of 2 twin-engine training aircraft near Mangalore Airport, Victoria, on 19 February 2020, fatally injuring four pilots. The accident was the first mid-air collision in Australia between 2 civilian aircraft operating under instrument flight rules procedures that have been in place for many decades, and our investigation highlighted the potential for ‘ADS-B IN’ technology to improve pilots’ situational awareness in non-controlled airspace.

In addition to ATSB-led investigations, independent investigation agencies in New South Wales and Victoria conduct rail investigations in their jurisdictions on behalf of ATSB under the Commonwealth Transport Safety Investigation Act 2003 (TSI Act). In 2021–22, the ATSB published and promoted 5 rail safety investigations conducted by the New South Wales Office of Transport Safety Investigations (OTSI) and one rail safety investigation conducted by Victoria’s Chief Investigator, Transport Safety (CITS).

The investigations published in 2021–22 identified no fewer than 56 safety issues – factors that if unaddressed have the potential to adversely affect the safety of future operations. Safety issues are characteristic of an organisation or a system, rather than an individual or an operational environment at a specific point in time.

Further, I am pleased to confirm that no changes to published investigation findings were required in 2021–22, evidence of the ATSB central commitment that all published investigations are factually accurate, defendable and evidence-based.

In 2021–22, the ATSB also:

  • initiated 51 new aviation occurrence investigations, 6 new marine occurrence investigations, and 5 rail occurrence investigations published 15 occurrence briefs, which are short reports that allow us to share safety learnings from a transport safety occurrence that did not meet the threshold of requiring investigation under the TSI Act
  • received and processed 115 notifications under the REPCON confidential reporting scheme, of which 49 were assessed and classified as meeting the REPCON criteria – during the year, 37 REPCON reports were completed, of which 22 (59%) resulted in safety action being taken by stakeholders
  • commissioned our new ATSB Investigation Management System (AIMS), a cloud-based IT system used to manage all aspects of our investigations, including logging occurrence notifications, electronic evidence storage and record management for physical evidence, assigning tasks, and recording effort to manage report approvals and distributions
  • commissioned purpose-built state-of-the-art technical facilities in our Canberra office that will enhance our ability to conduct detailed technical examination of evidence from accident sites.


The upcoming 2022–23 period promises to be a year of consolidation as we plan for a more sustainable future for the ATSB. I am aware of the calls stemming from a number of inquiries and associated reports, seeking to extend the ATSB services through an expanded remit. The ATSB will provide input into those inquiries as required.

However, any decisions to change the ATSB remit are a matter for government. It is my immediate priority to address the ATSB existing budgetary challenges – specifically the shortfalls in rail investigation resources resulting from unsustainable funding arrangements outside our core appropriations.

To better position the agency to face the challenges ahead, and to ensure we are making the most effective use of our resources, in 2021–22 I initiated the development of a new strategic plan for the ATSB. This plan, which I intend to publish in early 2023, will set out the ATSB priorities and the actions we will take to ensure we are best positioned to fulfil our responsibilities to government and deliver best practice transport safety investigations for the greatest public benefit.

It will focus on enhancing our best-practice approach to investigations, engaging with stakeholders and influencing improvements in transport safety, fostering our organisational resilience, and affirming our role as the national transport safety investigator.

I look forward to supporting our staff in delivering that plan

Angus Mitchell
Chief Commissioner and CEO

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Annual Report 2021-22