I am pleased to present the Australian Transport Safety Bureau (ATSB) Corporate Plan for the period 2024-25 to 2027-28.
This Corporate Plan has been prepared consistent with paragraph 35(1)(b) of the Public Governance, Performance and Accountability Act 2013 and the relevant provisions of the Transport Safety Investigation Act 2003 (the TSI Act), which establishes the ATSB. The Corporate Plan is also consistent with the Statement of Expectations 2023-25 (SOE) for the ATSB, as notified under Section 12AE of the TSI Act, by the Minister for Infrastructure, Transport, Regional Development and Local Government.
The SOE sets out clear expectations relating to the ATSB’s governance, strategic direction, key initiatives, and stakeholder engagement, such that the ATSB’s resources be used in an efficient, effective, and ethical way, following best practice principles and guidelines.
To that end, a key focus for the agency has been the implementation of our strategic plan, which we launched in 2023. Developed with extensive involvement of staff, the plan clearly identifies the ATSB’s key objectives, strategies, and actions for the short to medium term, with a particular focus on:
- enhancing our products and stakeholder engagement for improving transport safety
- fostering organisational resilience
- affirming our role as the national transport safety investigator.
We are continuing to work towards achieving the goals while being adaptable to our changing and growing operating environment, and the expectations of government. For example, we will be adjusting operations to participate in the Department of Foreign Affairs and Trade’s Transport Safety in the Pacific program. We are already supporting Tonga and Vanuatu with investigations in those countries. We will also be prepared to address outcomes of the Aviation White Paper relevant to the ATSB. Further, we are focussed on addressing the ATSB’s role as the national safety investigator for rail accidents and incidentsnoting the funding parameters that have resulted from the intergovernmental framework for rail safety.
It remains a priority across the aviation, marine and rail transport modes for the ATSB to work with governments and industry to ensure expectations are well defined, with the ultimate goal of making the greatest possible positive contribution to transport safety. A key tenant to this goal continues to be the publishing of high-quality transport safety investigation reports that lead to definable safety improvements across the broad spectrum of transport industry stakeholders.
For example, our investigation into a fire in the engine room of a multipurpose vessel chartered by the Australian Antarctic Division that was transiting the Southern Ocean in April 2021 identified eight safety issues. The investigation had findings covering technical faults, inappropriate watchkeeping practices, characteristics of the ship’s integrated automation system, crew fatigue, and the design of the ship which itself contributed to fuel oil overflowing into the engine room, and the subsequent fire. Although the 37 crew and 72 passengers faced an extremely precarious emergency situation more than 1,500 miles from the nearest refuge, there were miraculously no reported physical injuries.
Meanwhile, our investigation into an EC130 helicopter accident on Mount Disappointment, north of Melbourne in March 2022, highlighted the importance of having multiple layers of controls to effectively manage the risk of inadvertent entry into instrument meteorological conditions (IIMC).
The pilot, operating under visual flight rules (VFR), rapidly sought to change course to avoid entering cloud. However, without visual cues in reduced visibility the helicopter developed a high rate of bank and descent during the attempted U-turn, resulting in the collision with terrain. Tragically all five occupants of the helicopter were fatally injured. The ATSB investigation found that the pilot had no instrument flying experience, nor was the commercially chartered helicopter equipped with any form of artificial stabilisation, neither of which are required for visual flight rules flying.
The subject of risk controls was also a key message from an ATSB longitudinal safety study investigation into accidents at rail level crossings involving heavy vehicles. The study found that in a large majority of accidents at passively-controlled crossings (without flashing lights or boom gates), the heavy vehicle driver did not either detect the train or recognise an imminent risk was present until it became too late to avoid a collision.
So long as passively-controlled level crossing safety systems rely on road vehicle drivers always detecting the presence of trains, it is certain that this will fail from time to time and continue, without further effective risk mitigations, to result in future accidents. The study noted that additional engineering controls to alert road users to the need to stop would almost certainly provide an enhanced level of safety at level crossings.
Those investigation case studies demonstrate our expertise in uncovering safety issues and driving safety change, work that builds on decades of experience performing this function in the transport safety system. On 1 July 2024, the ATSB celebrated the 25th anniversary of our establishment. In the 25 years since, the ATSB has commenced more than 1,950 investigations, uncovering over 1,230 safety issues and issuing 221 safety recommendations and 104 safety advisory notices.
While the number of lives that have been saved because of the work conducted by the ATSB is difficult to measure, the deaths that continue in our transport networks are measured both in both financial impacts and more pointedly in the lifelong impact and trauma to family, friends and colleagues.
Angus Mitchell
Chief Commissioner and Chief Executive Officer