The ATSB Annual Report 2024–25 outlines performance against the outcome and program structure in the Department of Infrastructure, Transport, Regional Development, Communications, Sport and the Arts' Portfolio Budget Statements 2024–25(Opens in a new tab/window).
Chief Commissioner's Review
On behalf of the Australian Transport Safety Bureau (ATSB), I am pleased to present the ATSB Annual Report 2024–25. This was a significant year as we celebrated the 25th anniversary of our establishment on 1 July 1999. As we have for each of those 25 years, in 2024–25 we continued delivering on our purpose of improving transport safety for all Australians.
During the year, we focused on the direction contained in the Minister’s Statement of Expectations 2023 to 2025, and the priorities as detailed in the ATSB Strategic Plan. Through our strategic plan we aim to:
» influence positive transport safety outcomes through independently identifying and sharing safety concerns and fostering safety awareness, knowledge and action
» further position the ATSB as Australia’s national transport safety investigator, maximising safety outcomes across transport sectors through growth and innovation
» be an enduring and adaptable organisation that delivers on its mission across changing environments by investing in its people, systems and partnerships.
Some of the actions taken during the year demonstrating our progress in line with these goals included:
» increasing engagement and awareness through investment in stakeholder relationships and the promotion of safety messages through videos and animations
» prioritising the release of timely information from our investigations through prioritising the publication of preliminary and interim reports
» continuing to strengthen our partnership with RMIT University to provide a centre‑of‑excellence for transport safety investigation with the roll-out of the Graduate Diploma in Transport Safety Investigation postgraduate qualification
» strengthening our relationships with our counterparts internationally to improve accident investigation capability and compliance with international protocols and obligations.
In 2024–25, the ATSB published 142 safety-related products, including 67 final investigation reports, 10 preliminary and interim reports, 46 occurrence briefs, 14 safety promotion videos, and 5 safety advisory notices covering the aviation, marine and rail modes of transport.
Significant investigations completed during the year included:
» Gold Coast – Aviation tourism. In April 2025, we released the final report into the midair collision between 2 Eurocopter EC130 helicopters conducting scenic flights on the Gold Coast in early January 2023 (AO-2023-001). The investigation made 28 findings, identified 12 safety issues, and resulted in the release of 2 safety advisory notices. The investigation stressed a number of key safety messages including the potential for unintended consequences when managing changes in aviation operations, and the correct fitment and wearing of seatbelts in helicopter tourism operations.
» Cloncurry – Aviation fire spotting. In June 2025, the final report was released into the pilot incapacitation, loss of control and collision with terrain of a Gulfstream fire surveillance aircraft, south-east of Cloncurry, Queensland, on 4 November 2023 (AO‑2023‑053). The report, supported by a safety promotion video, underscored the dangers of operational practices which circumvent critical safety defences, and the insidious and deadly potential of altitude hypoxia.
» Sydney – Marine SOLAS. Our investigation of a near grounding of the bulk carrier Portland Bay off Royal National Park, south of Sydney in July 2022 (MO-2022-006), resulted in the ATSB issuing formal recommendations to one federal and 2 state government agencies and a salvage operator. The investigation, released in May 2025, identified 9 safety issues, and found a key factor in the prolonged exposure of the ship and its crew to stranding was the extensive delay in tasking the state’s nominated ocean-going emergency towage vessel.
» Brisbane – Rail passenger. In June 2025, we released a final report (RO-2023-004) into a signal passed at danger (SPAD) involving a Brisbane suburban passenger train that passed a stop signal after its driver was briefly impaired. The investigation highlighted the potential limitations of automatic warning system (AWS) alerts to prevent SPAD events. The investigation resulted in one safety recommendation being issued to the operator.
Our investigations over the year uncovered a total of 90 safety issues – factors that if unaddressed have the potential to adversely affect the safety of future operations. Of those safety issues identified, 57% were addressed through appropriate safety action, and a further 10% were partially addressed. Where identified safety issues were not effectively mitigated, the ATSB had cause to make 19 formal safety recommendations to the owners of those safety issues. We will continue to monitor the responses of the risk owners, with the objective of influencing them to take further effective safety action.
Central to our ability to achieve significant outcomes from our investigations are our dedicated staff. During the year we continued working to ensure everyone at the ATSB is supported and valued for their important roles in improving transport safety through implementing several development and wellbeing initiatives. These initiatives have also led to significant improvements in our Australian Public Service (APS) employee census results across all areas of employee engagement, communication and wellbeing.
Our staff are also supported by my fellow Commission members Mr Gary Prosser, Mr Peter Wilson and Ms Julie Bullas. I thank them for their expertise and advice in shaping ATSB investigation reports, which is central to delivering on our role as Australia’s national transport safety investigator.
As we transition into the 2025–26 period, we will continue to focus on the implementation of our strategic plan with a particular focus on improving the efficiency and effectiveness of our operations. We will continue to build our relationships with key stakeholders, including regulators, state governments, industry, and international counterparts. Similarly, we will focus on maintaining our positive APS employee census results by investing further in leadership development, data and innovation to ensure our staff have the appropriate tools and resources to do their jobs.
I look forward to continuing to work with government and all our stakeholders to ensure we are best positioned to effect safety improvements well into the future.
The ATSB Annual Report 2023–24 outlines performance against the outcome and program structure in the Department of Infrastructure, Transport, Regional Development, Communications and the Arts' Portfolio Budget Statements 2023–24(Opens in a new tab/window).
Chief Commissioner’s Review
I am privileged to present the ATSB annual report for 2023–24, a year in which the agency took significant steps to drive greater efficiencies in our operating model, while delivering an increase in our measured effectiveness in improving transport safety for all Australians.
Central to our ability to undertake this important work has been the ATSB’s relatively small staff base. Since becoming Chief Commissioner and CEO in September 2021, ensuring our staff are supported, enabled and valued for their work in improving transport safety has been a key priority. Continuing to enhance our efficiency and effectiveness relies on attracting, developing and retaining experienced staff that are empowered to perform at their best.
Pleasingly, that focus on our staff has been reflected in our results for the 2024 Australian Public Service (APS) annual employee census. The survey showed that overwhelmingly our staff believe strongly in the purpose and objectives of the agency, are proud to work here and are prepared to go the extra mile to meet the demands. I want to acknowledge the considerable work that has been undertaken over the past 12 months to focus on staff wellbeing, organisational culture and leadership.
During 2023–24, the ATSB completed and published 61 industry-significant investigation reports into transport accidents and incidents. Among the higher profile investigations concluded during the year were:
The collision with terrain of an EC130 helicopter at Mount Disappointment, north of Melbourne on 31 March 2022. The helicopter was operating a charter flight and inadvertently entered instrument meteorological conditions when the helicopter was not equipped and the pilot was not qualified to fly in those conditions. Tragically, all 5 on board lost their lives.
A fire in the engine room of the MPV Everest, a multi-purpose vessel chartered by the Australian Antarctic Division (AAD), while 1,560 miles from mainland Australia in the South Ocean, on 5 April 2021. On board were 37 crew and 72 AAD staff.
A fatal level crossing accident at Wynnum West, in Brisbane’s East, on 26 February 2021. A motorist was fatally injured when their car was struck by a passenger train upon entering the crossing after very likely following run line markings on the road, past the end of the lowered boom barrier, which was not long enough to meet the Australian Standard.
In all, the investigations we published in 2023–24 identified no fewer than 70 systemic safety issues – factors that if unaddressed have the potential to adversely affect the safety of future operations.
Some 81% of the systemic safety issues we identified have already been addressed through an effective mitigating safety action. The risk of a repeat occurrence has been reduced in these instances. And where identified systemic safety issues were not being effectively mitigated, the ATSB had cause to make 3 formal safety recommendations to the owners of those safety issues. We will continue to monitor the responses of the risk owners with the objective of influencing them to take further effective safety action.
Broader safety concerns were also raised through the release of 5 Safety Advisory Notices (SANs) to industry. Our shorter form investigations that we release do not scope systemic safety issues. However, they all identified factors that increased overall risk to everyday operations. The safety messaging from these SANs forms a crucial part of our role in improving safety to a broad transport industry.
In addition to occurrence investigations, we also published a longitudinal safety study that considered the risks associated with level crossing collisions, particularly those involving heavy road vehicles. This study was released ahead of a national rail level crossing safety roundtable in March 2024. Several findings from the study have now been shared with the Australian and international rail industries that will allow a better understanding of the risks involved in level crossings and potential effective mitigations to reduce the likelihood of future fatalities in both rail and heavy vehicle drivers.
During the year, we launched a new interactive National Aviation Wildlife Strike Dashboard on our website. This new interactive tool allows pilots, aerodrome and aircraft operators, and members of the public to review figures on wildlife strikes with aircraft across Australia. Knowing the risks and when they are likely to present allows for a more effective planning process.
Finally, we took part in a significant number of coronial inquests across the country, where ATSB reports were crucial in establishing the facts and circumstances surrounding a fatal incident. All inquests concluded with similar findings to the ATSB, with the Coroner reports being another important vehicle in increasing the reach of our safety messaging.
To ensure that we can continue to do more of this valuable work and meet the safety investigation needs in aviation, rail and marine into the future, the ATSB launched a renewed Strategic Plan in 2023. This plan has been our roadmap in response to the Minister’s Statement of Expectations for the 2023 to 2025 period, and details our goals to:
influence positive transport safety outcomes through independently identifying and sharing safety concerns and fostering safety awareness, knowledge and action
position the ATSB to be Australia’s national transport safety investigator, maximising safety outcomes across transport sectors through growth and innovation
be an enduring and adaptable organisation that delivers on its mission across changing environments by investing in its people, systems and partnerships.
Some of the actions taken to date in pursuit of these goals include:
prioritising the release of factual information through the investigation process through the publication of preliminary and interim reports, and regular updates to investigation pages on the ATSB website
developing new ATSB stakeholder engagement strategies
actively engaging in the Australian Transport Safety and Investigations Bodies Financial Sustainability Review, focusing on the efficiency of our processes for some of our investigations
developing partnerships with educational institutions to provide a centre of excellence for transport safety investigations
strengthening regular collaboration with other countries to improve accident investigation capability and compliance with international protocols.
In closing the review of our year, I would like to acknowledge the service of Catherine Scott, whose term as an ATSB Commissioner concluded on 7 September 2023. During her 3 years on the ATSB Commission, Ms Scott contributed her considerable industry expertise and knowledge to help shape ATSB rail investigation reports, and helped guide the ATSB during a time of significant uncertainty due to the COVID-19 pandemic.
On 9 October 2023, we welcomed Ms Julie Bullas to the ATSB Commission. Ms Bullas has brought extensive rail industry experience and pedigree to the ATSB, having served for 10 years as Executive Director, Policy, Reform and Stakeholder Engagement at the Office of the National Rail Safety Regulator (ONRSR).
Ms Bullas, along with Commissioners Gary Prosser (marine) and Peter Wilson (aviation) are a strong team with significant expertise working with me to oversee ATSB investigations.
Outlook
Through the continued implementation of our Strategic Plan and our continual focus on efficiency and effectiveness, we are working to ensure the ATSB is best positioned to meet the challenges and opportunities of the future.
One of those opportunities is our participation in and support of the Department of Foreign Affairs and Trade’s Transport Safety in the Pacific Program, where we are working to bolster the aviation accident investigation capabilities across the region. Already we are supporting Tonga and Vanuatu with aircraft accident investigations in those countries.
Meanwhile, we continue to work with the Commonwealth and state governments and industry stakeholders to ensure expectations around the ATSB remit, role and resourcing are well defined.
In particular, we remain focused on addressing the ATSB’s role as the national safety investigator for rail accidents and incidents, and we stand ready to address outcomes relevant to the ATSB from the Australian Transport Safety and Investigation Bodies Financial Sustainability Review.
I look forward to continuing to work with the government to ensure we are responsive to its expectations, and that we are best positioned to effect safety improvements well into the future.
The ATSB Annual Report 2022-23 outlines performance against the outcome and program structure in the Department of Infrastructure, Transport, Regional Development, Communications and the Arts' Portfolio Budget Statements 2022–23(Opens in a new tab/window).
Chief Commissioner's Review
I am proud to present the ATSB’s annual report for 2022–23, a year in which we continued to work towards our mission of improving transport safety for the greatest public benefit through our independent investigations and influencing safety action. This was supported through the development of our Strategic Plan.
We initiated the development of our new Strategic Plan to better position the agency to make the most effective use of our resources. The plan provides a roadmap for the ATSB in response to the Minister’s Statement of Expectations for the period 2023 to 2025. A copy of the strategic plan in placemat format is available on the ATSB website at www.atsb.gov.au. It includes our goals, which are to:
» influence positive transport safety outcomes through independently identifying and sharing safety concerns and fostering safety awareness, knowledge, and action
» position the ATSB to be Australia’s national transport safety investigator, maximising safety outcomes across transport sectors through growth and innovation
» be an enduring and adaptable organisation that delivers on its outcome across changing environments by investing in its people, systems, and partnerships.
There are supporting strategies for these goals as well as a number of actions which are being progressed through the ATSB’s annual plan. The ATSB will continue to review and update progress against the plan.
During 2022–23, the ATSB completed and published 59 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 collision with terrain of a Lockheed C-130 large air tanker during the 2019/20 Australian bushfire season. This investigation highlighted multiple key safety lessons relating to the tasking and operation of large air tankers – an operation becoming more prevalent in Australian firefighting.
» The collision of the bulk carrier Goliath with 2 tugs at Devonport, Tasmania, with our investigation highlighting the importance of bridge resource management.
» An empty ore train’s collision with stationary wagons at a bauxite loading station north of Weipa, Queensland. This investigation made findings around survivability aspects in how the locomotive was manufactured.
We also completed a significant safety study into the aerodrome design standards and the Bulla Road Precinct development at Essendon Fields Airport.
Those 59 investigations published in 2022–23 identified no fewer than 58 safety issues – factors that if unaddressed have the potential to adversely affect the safety of future operations.
Pleasingly, 68% of safety issues identified in 2022–23 were adequately addressed through safety action.
Against safety issues not addressed, the ATSB made 18 formal safety recommendations to the owners of those safety issues.
And once again I am pleased to confirm that no changes to published investigation findings were required in 2022–23, evidence of the ATSB central commitment that all published investigations are factually accurate, defendable and evidence-based.
In addition to occurrence investigations, we published 15 occurrence briefs, which are short reports that allow us to share safety learnings from a transport safety occurrence.
The ATSB also received and processed 120 notifications under the REPCON confidential reporting scheme in 2022–23, of which 49 were assessed and classified as meeting the REPCON criteria. During the year, 33 REPCON reports were completed, of which 7 resulted in safety action being taken by stakeholders.
During 2022–23 we initiated 64 new aviation occurrence investigations, 4 new marine occurrence investigations, and 7 rail occurrence investigations.
Those new investigations include high profile accidents such as the mid-air collision between 2 Airbus EC130 helicopters over the Broadwater at the Gold Coast on 2 January 2023, the collision with terrain of a Boeing 737 large air tanker on 6 February 2023, and the propulsion failure of the bulk carrier Portland Bay off Port Kembla, NSW on 4 July 2022.
Also, during the course of 2022–23, updated and streamlined Transport Safety Investigation Regulations took effect. The TSI Regulations set out the ATSB’s safety occurrence reporting scheme and prescribe what occurrences must be reported to the ATSB, the timeframes those reports must be made in, the ‘responsible persons’ who are required to make a report, and the particulars to be included in a report.
Finally, we launched our revised SafetyWatch initiative. SafetyWatch highlights the broad safety concerns that come from ATSB investigation findings and occurrence data reported by industry. As such, we encourage the transport industry to give heightened attention to the following priority areas where more can be done to improve safety:
» improving the management of fatigue
» reducing the collision risk around non-towered airports
» reducing passenger injuries in commercial ballooning operations
» improving risk management associated with change
» encouraging the use of available technology to enhance safety
» reducing the severity of injuries in accidents involving small aircraft.
In closing the year in review, I would like to acknowledge former ATSB Commissioner Chris Manning. Commissioner Manning completed his term in June 2023. Since being appointed as the first aviation commissioner in 2015, those who have interacted with Commissioner Manning would know he brought his significant industry expertise and credibility to the agency to influence the ATSB’s standing. He had the strongly held belief that the ATSB not only conduct investigations to the world’s best-practice standards, but equally that we shine a light on areas that require improvement and work to ensure our reports ultimately have an impact on the industry we seek to influence.
In July 2023, Mr Peter Wilson was appointed as the new aviation commissioner. Commissioner Wilson has an impressive aviation resume, commencing his professional piloting career with Qantas in 1985. Over the following 20 years, Commissioner Wilson held a number of key senior management appointments, including Senior Check Captain Boeing 767, General Manager of Boeing 767 Operations and General Manager of Airbus A330 Operations. He also held the senior executive appointments as Qantas Chief Pilot and Chief Operating Officer. Together with the other Commissioners, we are looking forward to working with Commissioner Wilson as he brings his experience to bear in supporting the agency to fulfil its transport safety mission.
Outlook
Between the implementation of our Strategic Plan and our continual focus on efficiency and effectiveness, I believe the ATSB is being well positioned to meet the challenges of the future as we contribute to improving safety in a transport industry facing the challenges of advances in technology, new service delivery models, evolving regulatory standards and varying financial conditions.
We look forward to providing input into the Government’s Review of Operations and Financial Sustainability of Australia’s Transport Safety and Investigatory Bodies announced in the 2023–24 Budget, and will be ready to implement actions arising from the Government’s Aviation White Paper and reviews that may affect the extent of the ATSB’s modal jurisdiction.
I am confident that the ATSB is well positioned to meet the future expectations of the Government, industry and the travelling public.
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(Opens in a new tab/window)
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.
Outlook
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
I am pleased to deliver this annual report for the Australian Transport Safety Bureau (ATSB), my first as Chief Commissioner and Chief Executive Officer.
While continuing to navigate the challenges of the COVID-19 pandemic, 2020–21 saw the ATSB commence, progress and complete a series of complex transport safety investigations; continue to deploy to transport accident sites; develop and implement a new core enterprise investigation information management system; and implement key elements of our strategic property plan.
For this sustained performance in a complex operational environment, I would like to acknowledge the leadership and service of my predecessor, Mr Greg Hood, who retired on 30 June on the completion of his five-year term as Chief Commissioner and Chief Executive Officer.
Mr Hood drove an innovation and transformation agenda at the ATSB, which saw the introduction of world-leading practices like a multi-modal teams approach to investigations, new recruitment practices, a tertiary partnership for transport safety investigator training with RMIT University, and new technologies to support investigations such as remotely piloted aircraft and 3D modelling.
The ATSB has a well-deserved reputation of excellence – and for that I acknowledge Mr Hood’s transformational stewardship. It is without doubt that the ATSB has grown in both stature and importance under his watch.
I would also like to acknowledge and thank our Chief Operating Officer, Mr Colin McNamara, who acted as Chief Commissioner and Chief Executive Officer from Mr Hood’s retirement until my appointment took effect on 2 September 2021. Mr McNamara shouldered a substantial load in acting as Chief Commissioner during an incredibly dynamic and demanding operating environment.
May I also acknowledge the contributions of Ms Carolyn Walsh, who finished her more than 10-year term as an ATSB Commissioner in September 2020. The ATSB benefited greatly from her expertise in transport safety, occupational health and safety, risk management, and regulatory frameworks and governance.
In turn during 2020–21, we welcomed Ms Catherine Scott, who has extensive experience in rail safety and road transport, finance and risk management, and board directorships, with her appointment to the ATSB Commission in September 2020.
I look forward to working with Ms Scott and her fellow Commissioners, Chris Manning and Gary Prosser, to continue to ensure all ATSB staff are resourced and empowered to bring their expertise to the forefront. This then will allow me to deliver on my other responsibility to build on the ATSB’s long-term success by continuing to increase the relevance and value that our work brings to all those whom we are entrusted to deliver safety outcomes.
Achievements
The ATSB continues to work towards achieving our new performance measures established in our 2020–21 Corporate Plan. Through revised performance criteria, we are focused on improving our timeliness, demonstrating safety action taken in response to our investigations, ensuring our findings are defendable, and using our resources efficiently and effectively to achieve the greatest safety outcomes across our multiple modes of transport.
With fewer safety occurrence notifications reported to the ATSB during the year, we were not required to commence as many new investigations when compared to previous years. This allowed the ATSB to focus on, and close, several complex older investigations from early 2020. ATSB investigator resources were also allocated to support the design and build of the new purpose-built investigation management software system. The ATSB’s new Investigation Management System (AIMS) comes online in 2021–22 and is set to deliver significant productivity improvements through the removal of time-intensive manual processes. Additionally, the system’s cloud-based functionality will allow investigators to access data and upload evidence in-the-field on any device.
During 2020–21, the ATSB completed 62 occurrence investigations. Among the higher profile investigations published during the year were:
The collision with water of a de Havilland Canada DHC-2 Beaver aircraft at Jerusalem Bay, Hawkesbury River, New South Wales, on 31 December 2017.
Signal ME45 passed at danger involving suburban passenger train TP43 and near collision with another suburban passenger train, Bowen Hills, Queensland, on 10 January 2018.
The loss of control and collision with water of a Eurocopter EC120B helicopter at Hardy Reef, Whitsundays, Queensland, on 21 March 2018.
The fire on board the self-unloading bulk carrier Iron Chieftain at Port Kembla, New South Wales, on 18 June 2018.
The collision with terrain involving an AS350 helicopter during powerline stringing operations 60 km east of Woomera, South Australia, on 20 March 2019.
ATSB investigations place considerable focus on identifying safety issues that can be addressed by the parties that are ultimately responsible and best positioned for managing risk. This includes both operators and regulators. In 2020–21, 59% of our completed systemic, defined and safety study investigations identified new safety issues.
In all, 60 safety issues were identified in the reporting period, of which the ATSB determined 33 had been adequately addressed by 30 June 2021.
The ATSB is steadfast in its commitment that all published investigations are factually accurate, defendable and evidence-based. Accuracy of investigation findings remain integral to ensuring industry and government confidence in ATSB safety information in order to take action to improve transport safety. Consequently, I am pleased to confirm no changes to published investigations findings were required in 2020–21.
In the delivery of rail safety investigation services in New South Wales and Victoria, the ATSB has a collaboration agreement with independent investigation agencies in those states who conduct investigations under the Commonwealth’s Transport Safety Investigation Act 2003 (TSI Act). In 2020–21, the ATSB published and promoted eight rail safety investigations conducted by the New South Wales Office of Transport Safety Investigations (OTSI) and four rail safety investigations conducted by Victoria’s Chief Investigator, Transport Safety (CITS).
In 2020–21, the ATSB also:
Initiated 49 aviation occurrence investigations, three marine occurrence investigations and five rail occurrence investigations.
Published 39 occurrence briefs (38 aviation occurrences and one marine occurrence). Occurrence briefs are short reports that allow us to share safety learnings from a transport safety occurrence notification where the occurrence has not met the threshold of being subject to a transport safety investigation.
Processed 10,634 aviation transport safety occurrence notifications, 716 marine notifications and 882 rail notifications. From those, the ATSB safety reporting team identified 4,073 aviation and 294 marine accidents, serious incidents and incidents for the year. (In rail, the Office of the National Rail Safety Regulator (ONRSR) is responsible for processing all notifications from industry into occurrences in the Australian national rail occurrence database shared with the ATSB.)
Received and processed 198 notifications under the REPCON confidential reporting scheme, of which 75 were assessed and classified as meeting the REPCON criteria. During the year, 47 REPCON reports were completed, of which 18 (38%) resulted in safety action being taken by stakeholders.
Despite the limitations of the pandemic, participated in 27 key industry engagement events, including the International Confidential Aviation Safety Systems, the Rail Industry Safety and Standards Board’s Rail Safety Conference, and the Australian Association for Unmanned Systems' RPAS in Australian Skies Conference. Former Chief Commissioner, Greg Hood also hosted the International Transportation Safety Association’s Annual Conference.
Managed 361 media inquiries, used our in-house media studio to produce and distribute 32 packages of pre-recorded audio, video and video overlay content for distribution to national radio and TV outlets, and logged the publication and airing of 1,997 stories about the ATSB and its investigation activities by mainstream and transport industry media outlets. Of those, 1,261 stories (approximately 63%) carried safety messaging relating to our investigations.
Promoted a number of safety education campaigns, including highlighting the dangers of CO gas exposure in piston-engined aircraft, reminding pilots of the need to be aware of stop bars at major airports across Australia, and supported the TrackSAFE Foundation’s Rail Safety Week in August 2020 to promote safety for road users and rail passengers when interacting with the rail network.
Published a video to promote the safety messaging from the investigation into Beaver aircraft the collision with water accident on the Hawkesbury River, which included a high-fidelity animation of the aircraft’s flight path. This video has been viewed more than 6,700 times across all of our social media channels.
Continued to support our regional partners build transport safety investigation capacity, in particular via the ongoing involvement in the Australian Government Indonesia Transport Safety Assistance Package (ITSAP), and assisting Papua New Guinea consistent with the Memorandum of Understanding on Cooperation in the Transport Sector.
Supported external agencies by assisting Recreational Aviation Australia and the Civil Aviation Authority of the Philippines – Aircraft Accident Investigation and Inquiry Board to recover and analyse data from damaged recording devices.
Progressed the rationalisation of our accommodation footprint with the leasing of new premises for the Canberra central office and the Melbourne regional office. This ensures we have highly capable technical facilities to support our operational requirements and a more dispersed workforce that will enhance our ability to deploy to transport accident sites throughout Australia.
Established a project to transfer our website onto the GovCMS content management system website platform.
Supported the delivery of the third Graduate Certificate in Transport Safety Investigation course in partnership with RMIT University. The course was delivered online to a cohort of 22 consisting of six ATSB investigators, two investigators from the Office of Transport Safety Investigation NSW, and 14 students from a broad range of industry organisations.
Outlook
In a challenging year for the transport industry, the ATSB continued to focus on improving transport safety through our independent transport safety investigations.
The COVID-19 pandemic has been a time of great uncertainty for the transport industry in general, none more so than aviation. Cognisant of these challenges, I am committed to ensuring that the ATSB continues to effectively apply our safety knowledge and expertise in identifying safety risks in industry, and in monitoring the return to safe and reliable air transport operations as the pandemic eases.
And as an operational agency, the ATSB will continue to deploy accident investigation teams where and when necessary during the pandemic, whenever it is safe to do so.
The challenges experienced by workplaces and workforces across the country over the past year are both generic as well as very individual and personal. One of my key responsibilities and my initial focus as Chief Commissioner and Chief Executive Officer will be to ensure we continue to have a well-supported workforce that delivers world-class transport safety investigations that contribute to a safe and efficient Australian transport industry.
In a time of great uncertainty due to the COVID-19 global pandemic, I am proud to report that in 2019–20 the Australian Transport Safety Bureau (ATSB) has been able to continue our focus on improving transport safety through the independent investigation of accidents and incidents, with minimal impact on our productivity and performance.
With many ATSB investigators and operational support staff having come from aviation, rail and marine transport backgrounds, and continuing to maintain those strong industry links, we have great empathy for operators and their respective workforces who are facing an indeterminate future and challenging road to recovery.
Other than the secondment of some staff to Services Australia, we have not been directly involved in the pandemic relief and recovery efforts. However, in support of the transport industry we have continued to apply our safety knowledge and expertise in carefully monitoring the return to operations of safe and reliable transport.
As an operational agency undertaking an essential service, despite the COVID-19 travel restrictions, the ATSB has and will continue to deploy transport safety investigation teams where and when required across the nation during the course of the pandemic. Further, the ATSB’s ICT infrastructure has successfully supported working from home arrangements for our staff. I have worked hard to ensure our staff know that they are supported and feel connected during periods of home-based work and a period of unprecedented uncertainty.
The ATSB has seen a lessening in the number of transport safety occurrences reported to it in the second half of 2019–20, reflective of decreased activity in the aviation industry in particular, due to the COVID-19 pandemic. In addition, we have worked hard as an organisation to reduce the number of active investigations undertaken over time, as we more effectively manage our resources to ensure improved timeliness of report completion.
Nonetheless, during the summer months of 2019–20 we launched a number of complex investigations into significant transport safety accidents, including:
the collision between two freight trains at Jumperkine, Western Australia
the collision with terrain of a C-130 Hercules large air tanker near Cooma, New South Wales
the derailment of an XPT passenger train at Wallan, Victoria
the mid-air collision between two twin-engined training aircraft near Mangalore, Victoria.
Then in early March we launched our investigation into the collision with terrain of a Cessna 404 twin-engine aircraft, with the loss of life of all five on board, near Lockhart River, in far north Queensland.
That long summer of 2019–20 saw the worst bushfire season in Australia’s living memory, which meant a period of high operational tempo for aerial firefighting across Australia. In response to the subsequent Royal Commission into Natural Disaster Arrangements’ request for information, the ATSB produced a safety analysis of aerial firefighting occurrences in Australia, covering the period July 2000 to March 2020. This research report found that estimates of aerial firefighting activity for the 2019–20 bushfire season were around four times higher than other recent bushfire seasons, with more reported occurrences involving aerial firefighting aircraft in Australia in the financial year covering the last bushfire season (between July 2019 and March 2020) than any financial year since July 2000.
The ATSB will continue to examine aviation firefighting safety occurrences with a systemic safety study to commence in 2020–21.
As the COVID-19 pandemic saw a reduction in transport industry activity and transport safety occurrences, in the later months of the year our focus has been on finalising investigations and publishing their final reports. I am pleased to report for 2019–20, we completed and published 47 complex investigations, compared to 34 completed and published complex investigations in 2018–19.
A number of those completed and published complex investigations have led to meaningful improvements in transport safety, and better understandings of transport safety risks. Examples of safety issues raised by ATSB investigations published during 2019–20 concerned upper torso restraints in light aircraft, container ship cargo planning processes, and procedures and guidance for two-driver train operations.
These published investigations, and our new investigations commenced in 2019–20, are consistent with our Minister’s Statement of Expectations, for the period 15 July 2019 to 30 June 2021, which directs us to focus on transport safety as the highest priority, and to give priority to transport safety investigations that have the potential to deliver the greatest public benefit through improvements to transport safety.
These principles guide us in determining which accidents and incidents to investigate, and how best to direct our time and resources, to ensure the best safety outcome for the greatest public benefit. We focus on the public interest where the safety of passengers and workers is concerned, and also on the significant costs to the national economy that can result from an accident.
People and capabilities
It is the skills, professionalism and experience of our people, combined with our highly developed technical expertise and analysis capabilities that enable us to undertake those investigations that have the potential to deliver the greatest public benefit. Right across the agency our staff have broad skillsets, expertise and experience relevant to our role as the nation’s transport safety investigator. And nowhere is that expertise more evident than the ATSB’s governing Commission.
I am very pleased to note that in October 2019, Mr Gary Prosser was appointed to the ATSB Commission. Mr Prosser has 40 years’ experience in the maritime industry, coming from a seagoing career and serving on a wide variety of Australian ships in both the international and domestic trades. More recently, Mr Prosser was the Deputy Chief Executive Officer of the Australian Maritime Safety Authority (AMSA), and he has also served as the Secretary General to the International Organization for Marine Aids to Navigation (IALA).
I am equally pleased to note that Mr Chris Manning was in June 2020 reappointed to the ATSB Commission for a further three years. A former Chief Pilot with Qantas Airways, Mr Manning’s work on the Commission has been exemplary, and we are fortunate to have him with us, working to make transport safer in Australia.
Our Commissioner, Ms Carolyn Walsh also had her tenure extended until September 2020 making her the longest-serving ATSB commissioner.
I would also like to acknowledge and thank Mr Noel Hart for his service to the ATSB Commission and his commitment and passion for improving transport safety since he was first appointed as a Commissioner of the ATSB in July 2009. Mr Hart provided invaluable maritime industry knowledge and experience to countless ATSB investigations.
Also central to the quality of investigations is our ongoing investment in technologies, training and professional development to ensure our investigators have the best available tools and skillsets.
The professional development pathway for our investigators begins with our program of tertiary qualifications the ATSB initiated in partnership with RMIT University in 2019. The inaugural delivery of the Graduate Certificate in Transport Safety Investigation saw 25 participants from both the ATSB and industry gain this coveted tertiary qualification.
The RMIT University partnership will expand to include the development of Graduate Diploma and Masters Programs over time, and is an integral component of our strategy to create a centre of excellence for transport safety investigation in the Asia Pacific region. The ATSB will continue to advance its own safety investigation capabilities through the delivery of these courses, in addition to ensuring that the opportunity exists for industry to do the same.
And we continue to make investments in systems and technologies to ensure our investigators have the best available to effectively undertake their work. Examples include our laser scanning and remotely piloted aircraft systems (RPAS) combined with high accuracy differential GPS data to produce a range of outputs from videos to three-dimensional models of accident sites and vehicles.
Influencing safety action, education and collaboration
Through stakeholder engagement, communication, education and collaboration, the ATSB aims to improve transport safety via influencing safety action. Through our investigations we can identify safety issues but have no powers to make others take safety action. Instead, the ATSB actively engages with stakeholders who are already safety advocates and who may be able to work with us on influencing others to improve safety.
In 2019–20, the ATSB took advantage of a number of key forums and events hosted by industry partners to share priority safety messages and educate key stakeholders as to our role and responsibilities.
In October 2019, we were proud to co-host, alongside the Rail Industry Safety and Standards Board (RISSB) and the Office of the National Rail Safety Regulator (ONRSR), rail safety experts from across the globe at the 29th International Railway Safety Council in Perth.
Also in October, we held our inaugural maritime safety forum, SeaSafe 2019. Following on from the success of our FlySafe 2019 and RailSafe 2019 safety forums delivered in 2018–19, SeaSafe 2019 aligned with the two-day Pacific 2019 International Maritime Exposition in Sydney in order to maximise participation from key stakeholders.
In May 2020, we had planned to host the annual forum of the International Transportation Safety Association (ITSA), for which I am currently the Chair. ITSA is the international network of heads of agencies of independent transport safety investigation authorities from 17 nations, covering aviation, marine, rail and road transport, as well as pipelines and underground infrastructure. This year’s forum, which was to have been held in Sydney, was deferred due to the COVID-19 pandemic.
The mission of ITSA is to improve transport safety in each member country by learning from the experiences of others. It is my hope that that mission can be furthered with our next forum some time in 2021, whether that is held in person in Sydney, or virtually.
And while COVID-19 travel restrictions have placed many conferences and forums on hold, the ATSB has enthusiastically embraced virtual conferences and events to share our safety messages.
Sharing of resources and knowledge is central to our collaboration with our colleagues at the Defence Flight Safety Bureau (DFSB). In January, we were able to exercise the provisions of our Memorandum of Understanding (MoU) with DFSB when they seconded a representative with expertise in the C-130 aircraft to join our investigation team working on the C-130 large air tanker accident.
The ATSB also has in place memoranda of understanding with a number of industry associations that are in a position to reach out to their members with messaging that is tailored to their working environment.
Another example of cooperation was in November, when the ATSB’s communications team hosted media and communications representatives from the AMSA, the Civil Aviation Safety Authority (CASA), Airservices Australia, and the then Department of Infrastructure, Transport, Cities and Regional Development for the first in a series of regular meetings to share details of communications, media and safety promotion activities across the broader group.
This forum will allow the portfolio agencies to work together on promoting and sharing safety issues and education campaigns, such as the ATSB’s ‘Don’t Push it, Don’t Go’ campaign, launched in September 2019 to raise awareness of the dangers of visual flight rules (VFR) for pilots flying into instrument meteorological conditions (IMC).
Outlook
In 2020–21, we will be aligning a new set of performance measures with our Vision 2030 statement. These have been designed to demonstrate our effectiveness against our mission to:
Improve transport safety for the greatest public benefit through our independent investigations and influencing safety action.
Through the revised performance criteria, we are focused on being able to demonstrate the safety action taken in response to our investigations, ensuring that our findings are defendable and timely, and that our resources are being used efficiently.
I intend to publicly release our Vision 2030 statement during 2020–21 at an appropriate time, mindful of and sensitive to the changes occurring within the transport industry.
Another key focus for our agency in 2020–21 will be the replacement of our investigation information management system. This is a significant and essential project utilising cloud technologies and software that will service the ATSB’s investigation information management needs for many years. Investigators will be able to access data and upload evidence to the new system anywhere on any device, while the removal of labour-intensive processes promises to improve our productivity.
From bushfires to a global pandemic, 2019–20 has been a year of unprecedented challenge. I am proud of the ATSB’s staff who have, time and time again, proven themselves resilient and adaptable during this period of uncertainty. Like all Australians, ATSB staff across the nation have had to adapt to changing circumstances during this pandemic. At a professional level they have remained committed to their work, whether this be from the office, home or deploying to transport accident sites across state borders.
Australia’s aviation, rail and marine industries are safer for their efforts.
In 2018–19, the ATSB continued to make a significant contribution to transport safety in Australia, thanks to the release of several substantial and high-profile investigation reports which contained valuable safety learnings for the aviation, rail and marine transport modes. During the year, we also entered into a strategic partnership with the Royal Melbourne Institute of Technology (RMIT) University, continued with our program of work to further improve our operational efficiency and effectiveness, and implemented an initiative to increase the number of Memoranda of Understandings (MOU) with transport industry associations.
There was much attention on the agency in September 2018 with the publication of the final report from our investigation into a King Air aircraft’s collision with a building in a retail precinct at Melbourne’s Essendon Airport in 2017 (AO-2017-024).
The investigation found the aircraft’s rudder trim was set incorrectly for take-off, resulting in a loss of directional control. The investigation drew upon the ATSB’s world-leading human factors capabilities, which resulted in safety messaging around the use of checklists as an essential tool for overcoming limitations with pilot memory and ensuring action items are completed in sequence without omission. This messaging highlights the ATSB’s approach to safety investigation, which is to ensure that all the lessons can be learnt to help stop accidents in the future.
On an international level, the ATSB’s contribution to safety was exemplified by the release of our final report from the investigation into a serious incident involving an ATR 72 turboprop airliner, which experienced an inadvertent pitch disconnect following an in-flight upset. This resulted in serious structural damage to the aircraft’s horizontal tailplane (AO-2014-032). The investigation into this complex event identified a number of safety factors, including some in relation to the continuing airworthiness of the aircraft, and aircraft certification standards.
As a consequence, the ATSB issued Safety Recommendations to the European Union Aviation Safety Agency to review the current design standards in consideration of the effect that dual pilot control inputs may have on the safe operation of an aircraft.
The ATSB is tasked with using its resources to improve transport safety for the greatest public benefit. We do this through systemic safety investigations that can lead to wide-reaching safety actions, thanks to our highly developed technical expertise and investigation analysis capabilities. I am proud of our capabilities and our program of continual improvement to best deliver transport safety outcomes.
Those capabilities were demonstrated when, during the year, the ATSB sponsored one of the premier psychology, human factors and crew resource management symposiums in the Asia–Pacific region. The ATSB also facilitated additional human factors training courses, adding to the more than 40 courses we have conducted since 2000 to educate those in a position to influence safety.
Partnership with Royal Melbourne Institute of Technology (RMIT) University
The ATSB is focused on ensuring its own people have the highest investigative capabilities and in educating others to achieve the same. If the public trusts that investigators, regulators and operators are identifying and managing safety risks, then there is confidence in safety of the transport system. A significant achievement that I recognise as realising this objective is the partnership entered into this year between the ATSB and RMIT University.
This partnership is part of a vision to create a centre of excellence in the field of accident investigation and transport safety in the Asia–Pacific region. Industries in Australia, throughout the Asia–Pacific and around the world are now able to obtain ATSB-sponsored qualifications in transport safety investigation. The partnership expects to extend to offering a Master’s-level qualification, as well as facilitating transport safety related research.
The first intake of students occurred on 1 July 2019 to study for a Graduate Certificate in Transport Safety Investigation. In 2020, a Diploma in Transport Safety Investigation will be offered before evolving into a Master’s program. Students will gain access to the best insights into the fundamentals of accident investigation, from attending an accident scene and gathering evidence, through to identifying human and other factors that contributed to an accident, investigation analysis and technical report writing.
Enhancing our efficiency
The ATSB is undertaking a program of work to enhance its operational efficiency and effectiveness. The ATSB’s interest is in making the greatest possible contribution to transport safety across the aviation, rail and marine modes of transport with its available resourcing. In particular, we are striving to make sure that our investigation reports are delivered in a timely manner.
During 2018–19, we benchmarked our performance against similar accident investigation agencies overseas. I am pleased to report that our performance is comparable with a number of internationally respected agencies. The median length of time we take to complete an investigation is slightly higher by comparison, but the ATSB is completing more per investigator than some of its comparators. We recently introduced amended key performance indicators to reflect the time it takes to complete complex investigations that look at in-depth systemic factors.
The Australian National Audit Office (ANAO) also audited our operational efficiency during the year. The ANAO found the ATSB has established key elements of an overall framework to promote efficient investigation processes. The ANAO also found that our efficiency had been declining with its use of resources, but acknowledged a number of actions that had already been taken by the ATSB to make improvements, including formalising aspects of its program-managed approach to investigations.
Our continued efficiency improvements will be supported by the large cohort of 17 new transport safety investigators who commenced with us in 2018. After completing their training and gaining further investigation experience, these recruits will take on higher levels of responsibility within the ATSB’s teams-based approach to investigation.
Building our networks
The ATSB recognises the value of being able to call upon the highest levels of expertise to best identify safety issues, and to that end, in 2018–19 we embarked upon an initiative to enter into Memoranda of Understandings (MOU) with transport industry associations. MOUs have now been signed with the Australian Federation of Air Pilots, the Australian and International Air Pilots Association, the Australian Licenced Aircraft Engineers Association, the Australian Association for Unmanned Systems, the Australian Certified Unmanned Aerial Vehicle Operators, Civil Air, and the Human Intervention Motivation Study Australia Advisory Group.
The ATSB will seek to further its reach by signing additional MOUs with industry associations and activating those relationships in 2019–20.
We are also deepening our partnership with the Defence Flight Safety Bureau (DFSB), which performs an equivalent role to us for Defence aviation. Both organisations are committed to investigating accidents and incidents, and analysing occurrence data under the ‘no-blame’ philosophy, with the sole aim of preventing recurrences. Under our MOU, the organisations can conduct joint investigations and participate in each other’s investigations. The relationship and knowledge sharing was strengthened during the year through a secondment of a DFSB investigator, who brought further human factors expertise to the ATSB.
Communicating with influence
The ATSB actively works to influence safety well beyond the publication of investigation reports. This year we held our inaugural FlySafe and RailSafe safety forums, while our SeaSafe marine safety forum will be held in 2019–20. These forums target safety messaging to receptive audiences from across the modes with the expectation that those audiences will share the safety messages with their industry-based colleagues. We have participated in a number of other industry-led safety conferences with this intent.
We have been active online using our website as an engaging information portal, as well as using our social media channels to publish information that is relevant to our stakeholders. In June, we published a video targeting emergency personnel on the potential dangers of inactivated rocket-deployed parachute systems on aircraft. The video has been viewed more than 2,600 times on YouTube, and more than 15,000 times on Facebook. We are a modern investigation agency that knows how to harness the available and emerging communication mediums to influence safety action.
We are focused on delivering the right content to traditional media, too. We have our own dedicated media studio for producing video and audio content for television and radio broadcasts. Conscious of the need to remember those who can inspire us to innovate, our studio is named after Macarthur Job OAM. ‘Mac’ was a pioneer of aviation safety messaging in Australia, editing the principal safety promotion publication of the Department of Civil Aviation’s Air Safety Investigation Branch – the Aviation Safety Digest. Known as the ‘crash comic’, we have further preserved this history by making the 150 editions of the digest (spanning 1953 to 1991) available online through the ATSB’s website.
Aviation
During the year, we completed 32 complex aviation safety investigations and 28 short investigations.
In addition to the aviation accidents previously highlighted, other significant aviation investigation reports released in 2018–19 include a runway excursion at Darwin Airport involving a Boeing 737 aircraft in December 2016 (AO-2016-166); a collision with terrain involving a Diamond DA40 aircraft near Southport, Queensland in September 2017 (AO-2017-096); and an in-flight upset involving a Boeing 747-400 aircraft near Hong Kong Airport in April 2017 (AO-2017-044).
The Darwin runway excursion resulted from factors that included a small increase in crosswind that led to a significant deviation of the aircraft from the runway centreline at a critical time during the final approach. The investigation highlighted the challenges of landing in darkness and poor weather conditions when landing on wide runways that lack centreline lighting. The operator and Darwin Airport have taken action to provide flight crews with information about the specific risks of approaches at the airport, while a safety recommendation made to the International Civil Aviation Organization has been referred to that body’s Aerodrome Design and Operations Panel for further study.
The collision with terrain of a Diamond DA40 aircraft near Southport resulted in fatal injuries to the instructor and student pilot on board. The aircraft entered a developed spin during manoeuvres consistent with advanced stall recovery training, which likely included intentional incipient spins. The spin continued until the aircraft collided with terrain. Although the investigation could not fully establish the reasons for the accident, the investigation identified varying interpretations of an ‘incipient spin’. The ATSB advised that operators and pilots should clarify with manufacturers the extent to which the early stages of a spin are permissible and ensure aircraft are always operated in accordance with limitations.
The in-flight upset of a Boeing 747 aircraft near Hong Kong resulted from factors that included the aircraft’s aerodynamic stall warning stick shaker activating a number of times and the aircraft experiencing multiple oscillations of pitch angle and vertical acceleration. The safety messaging from this investigation covered the need for comprehensive theory and practical training to ensure flight crews have a complete understanding of aircraft systems and they maintain effective handling skills. The training should provide flight crews with the knowledge to correctly configure the aircraft’s automatic flight systems and manual handling skills to respond adequately to in-flight upsets.
Rail
The ATSB completed seven complex rail safety investigations and two short investigations in 2018–19. Included in these releases is the ATSB’s investigation into the derailment of a coal train near Oakey in Queensland in July 2017 (RO-2017-007). It was found to be highly likely the underframe of a heavy road vehicle collided with rail infrastructure at a level crossing. Rail lines were displaced, causing the derailment and destroying about 300 metres of rail infrastructure. The accident highlights how vitally important it is for a driver in a road incident at a level crossing to report any damage and for rail infrastructure managers to ensure crossings are subject to regular and effective inspection.
We released our report from an investigation into another derailment involving an ore train near Walla in Western Australia in December 2015 (RO-2015-023). The derailment occurred due to a broken rail. A fracture of the rail was probably initiated by the rapid growth of a detectable, yet unidentified, fatigue-related defect. It is important that track maintenance and infrastructure fault detection is of a high standard to avoid similar occurrences.
A further derailment investigation involved a freight train near Dry Creek, South Australia in July 2017 (RO-2017-008). There had been a break in the section of track that was precipitated by a defect in the rail introduced in the manufacturing process 90 years ago. The rail break was not visually obvious, and when the freight train passed over it, the last three wagons derailed. The safety message in this accident was around the inspection of rail infrastructure. If an inspection cannot test or can only partly test rails, maintenance personnel must report the shortfall to highlight operational risk and the requirement for a timely supplementary examination.
Marine
The ATSB completed five complex marine safety investigations and four short investigations. The published reports included an investigation into a fall from height and serious injuries to crew members on board the Shanghai Spirit near Port Alma, Queensland in January 2017 (MO-2017-001). A mobile scaffold tower was used to conduct routine painting and touch-up work in the cargo holds. Two crew members conducted the work from the upper tiers and remained unsecured when the scaffolding was moved. The tower became unbalanced and toppled forward onto the deck. The safety message highlighted the importance of adhering to procedures that assure safety, as well as the value of effective supervision.
We released our report from the grounding of the Australian Border Force cutter Roebuck Bay on Henry Reef in the Great Barrier Reef in September 2017 (MO-2017-009). The vessel’s route plan had been amended during the passage planning process, resulting in the route being inadvertently plotted across Henry Reef. The cutter’s electronic chart display and information system (ECDIS) identified the reef as a danger to the planned route. However, the vessel’s officers did not identify the danger, either visually or using the ECDIS. The investigation highlighted that the safe and effective use of ECDIS as the primary means of navigation depends on the mariner being thoroughly familiar with the operation, functionality, capabilities and limitations of the specific equipment in use on board their vessel.
The report for the investigation into contact with a wharf by the vessel Madang Coast in Townsville, Queensland in November 2015 (MO-2015-007) was also released. As the Madang Coast moved alongside the wharf, the forward spring line slipped and could not be used during the manoeuvre, as the distance from the stern to the wharf was too far for the aft mooring party to throw any heaving lines ashore. The stern’s movement away from the wharf continued, making contact with another ship, while the bow made contact with the wharf. In this case, the risk management processes were not sufficiently mature nor resilient enough to effectively identify and mitigate risks in pilotage services. The investigation highlights the value of a safety management system that includes effective risk management processes.
Outlook
Appointed as the Chair of the International Transportation Safety Association (ITSA) in 2019, I will host an ITSA forum in Sydney in 2020. ITSA is a network of the heads of independent safety investigation authorities from around the world. The forum is valuable for sharing safety information and pursuing best practices in investigations. The ATSB will be seeking to continue to benchmark its performance against its peers to ensure that we are delivering optimal outcomes for transport safety in Australia.
Before ITSA, I will be releasing the ATSB’s ‘Vision 2025’ statement. The ATSB’s vision is to ‘stop accidents’, with a mission to ‘drive safety action in a rapidly changing transport environment.’ Vision 2025 is aspirational, sharpening the agency’s focus when conducting investigations, while the mission recognises the transformational nature of the transport operating environment in which investigations are being conducted, and our intention is to influence safety outcomes in that environment.
The vision statement will reflect elements of the Minister’s new Statement of Expectations, issued on 15 July 2019. This includes the need to give priority to transport safety investigations that will deliver the greatest public benefit through improvements to transport safety. Focusing on the public benefit means that the ATSB will have regard for factors that include the potential to save lives, as well as preventing serious adverse economic impacts that result from accidents. There are costs that come with providing safe transport systems, but the cost of an accident can be much higher.
I will also ensure the ATSB pays close attention to the government inquiries related to transport reforms. Two in particular have the potential to result in jurisdictional changes for the ATSB if there are any recommendations resulting in policy change. The Productivity Commission’s inquiry into National Transport Regulatory Reform is looking at the impacts of the rail, marine and road heavy vehicle changes that came out of intergovernmental agreements from 2011 to move the industries towards single national jurisdictions. The Australian Government Review of National Road Safety Governance is examining how to bring down the number of road deaths and serious injuries. Consistent with the Minister’s Statement of Expectations, the ATSB is providing input into these reviews.
I am positive about the agency and the role we will play in improving transport safety going forward. The ATSB has been through significant organisational change over the last few years, all directed towards enhancing our productivity and establishing a shared vision. The ATSB’s staff are dedicated, hard-working experts in their field. Their contribution to safety is highly valued and, with their support, I intend to ensure they are empowered and enabled to make this contribution well into the future.
In my second year as Chief Commissioner, the team and I have continued to position the ATSB as a multi-modal, teams-based, world-class transport safety investigation agency. At the start of 2017–18, the Australian Government allocated the ATSB additional funding to address the resourcing challenges encountered in previous years. We have used this funding to put the ATSB on a path of transformation.
We recruited 17 new investigators who are already making an active contribution to transport safety. We are investing significantly in the development of our investigators to position them to be able to disseminate safety findings to industry and the public as quickly as possible. As a team, we have also prioritised the completion of a number of complex investigations, delivering safety outcomes while also freeing up key resources for new investigation priorities. The investment made over the last year will see continued improvement towards the ATSB being able to meet its deliverable targets.
Over the year, we were pleased to bring on board Executive Director Transport Safety, Nat Nagy. Mr Nagy, along with myself and Chief Operating Officer Colin McNamara, constitute the ATSB’s Executive. The Executive are working well with the ATSB’s Commission to build the ATSB up as a world-class investigator for the future. We are fortunate to have the Minister for Infrastructure and Transport reappoint Commissioners Carolyn Walsh, Noel Hart and Chris Manning. The expertise provided by these Commissioners across the aviation, rail and marine transport modes is essential for ensuring we are meeting the interests of our stakeholders with our investigations.
Multi-disciplinary workforce
The ATSB’s greatest resource continues to be its people. We are creating an environment where our employees are empowered. With the multi-disciplinary teams-based approach to our work implemented in 2017–18, we have removed the structural barriers between investigators, researchers and data analysts. The majority of our people are multi-skilling across all these disciplines.
We also have investigators with a background in one particular mode stretching themselves to become involved in investigations from other modes. We are bringing to bear our collective core investigative skills, shared values, passion and drive to improve transport safety.
Building our networks
In 2017–18, we committed to building our networks to deliver our safety messages further. The ATSB was represented at a large number of industry events during the financial year and a number of presentations were provided to stakeholders from the aviation, rail and maritime industries. In May, I presented at Rotortech 2018 on the Sunshine Coast. This provided a platform to launch ‘Don’t Push It, Land It’—a new safety initiative for the helicopter industry, in conjunction with the Australian Helicopter Industry Association and the Civil Aviation Safety Authority. We were also represented by our Executive Director Transport Safety at the RISSB Rail Safety Conference in Sydney. This year I had the honour of being asked by the Royal Aeronautical Society to present the Lawrence Hargrave Memorial Lecture in Melbourne.
In May, I attended the International Transportation Safety Association meeting in Baku, Azerbaijan. This provided a valuable opportunity to exchange information and knowledge with my international counterparts. I was also appointed to the Defence Aviation Safety Council.
We have worked to enhance the mediums through which we communicate. To counter misinformation and provide transparency, we have become more proactive in engaging early with media when there is a transport safety occurrence. We have also been making information more accessible through the use of social media and visual mediums, such as infographics and the production of videos.
Our devotion to making sure that key safety messages are heard is essential for influencing industry and the travelling public towards safe outcomes on the back of our investigative work.
Aviation
During the year, we completed 25 complex aviation safety investigations and 34 short investigations.
The ATSB released the findings from its second investigation into the ditching of an Israel Aircraft Industries Westwind aircraft (VH-NGA) off Norfolk Island in 2009 (AO‑2009‑072). The release of this report demonstrates the diligence of the ATSB in ensuring that it drives safety forward. Thirty-six safety factors were included in the report, with the key message for flight crew, operators and regulators being that unforecast weather can occur at any aerodrome. There is a need for robust and conservative in‑flight fuel management procedures for passenger-transport flights to remote islands and isolated aerodromes.
Another published report relating to weather was the investigation into a collision with terrain involving an Airbus Helicopters EC 135 T1 (VH-GKK) at Cooranbong, New South Wales in 2015 (AO-2015-131). The safety message from this investigation is that avoiding deteriorating weather conditions requires thorough pre-flight planning. Pressing on into instrument meteorological conditions without a current instrument rating carries a significant risk of encountering reduced visual cues leading to disorientation.
Two reports were published covering pilot interaction with automated technology: a collision with terrain involving a Cessna 172 (VH-ZEW) near Millbrook in Victoria in 2015 (AO-2015-105) and a near collision involving Beech Aircraft Corp B200 (VH-OWN and VH-LQR) at Mount Hotham in Victoria in 2015 (AO-2015-108). Pilots need to have a thorough understanding of all systems on board their aircraft and have the skill to provide redundancy when those systems fail, or their performance is reduced.
In addition to completing some significant investigations, a number were also commenced over the year. The collision with water involving a de Havilland Canada DHC-2 Beaver aircraft (VH-NOO) on the Hawkesbury River in New South Wales on New Year’s Eve drew substantial media attention (AO-2017-118). The ATSB response demonstrated our ‘on-call’ readiness at all times. The preliminary factual report was released on 31 January 2018.
Rail
The ATSB completed 13 complex rail safety investigations and three short investigations. Included in these releases is the publication Safe work on track across Australia: Analysis of incident data, 2009–2014 (RI-2014-011). The review of data showed that incidents while maintenance work was being carried out were predominately a result of errors during the implementation or dissolution stage of providing track protection. Protections were either removed incorrectly or prematurely, or key communication exchanges failed to establish the location of the worksite with respect to approaching rail traffic. Improving the levels of safe working on track continues to be an ATSB SafetyWatch priority.
The derailment of train 3MP5 at Rawlinna, Western Australia in 2016 (RO-2016-005) was significant for demonstrating the risks of approaching safety-critical zones at higher speeds. The publication of a report into a signalling control system irregularity at Ballarat, Victoria in 2016 (RO-2016-011) showcased how critical it is for system designers to ensure that the functionality and performance requirements needed to meet all operational scenarios are incorporated within the system. The ATSB found that the train controller had placed a block on the three sets of points, but these ‘blocks’ were ineffective due to design errors within the train control system.
With Queensland coming on board within the national rail safety system, the ATSB commenced eight investigations into rail occurrences in the state over the 2017–18 year. In recognition of the complementary role the regulator and investigator play in the national rail safety system, the Office of the National Rail Safety Regulator and the ATSB signed a new Memorandum of Understanding (MOU) to set out the roles and relationships of the respective organisations. Under the terms of the MOU, in the coming year the ATSB will look forward to receiving a greater range of occurrences information to assist with data analysis and research.
Marine
The ATSB completed four complex marine safety investigations and three short investigations. The published investigations included a loss of propulsion event on the passenger cruise ship Norwegian Star in Bass Strait in February 2017 (MO-2017-003). This investigation highlighted that the operation of newly designed equipment without redundancy increases operational risks. Equipment manufacturers and ship operators must apply extra diligence when designing, installing and operating modified equipment, especially safety-critical equipment.
The ATSB continues to have collisions between trading ships and small vessels reported. A common contributing factor that was present in the investigation into a collision between the container ship Glasgow Express and the fishing vessel Mako in Bass Strait, Victoria in 2017 (MO-2017-007) is the failure to use all available means to accurately appraise a situation and obviate the risk of collision. The ATSB reinforces the importance of a proper lookout by all available means, including radar, to masters, owners, operators and skippers of all vessels.
With the Australian Maritime Safety Authority (AMSA) taking full responsibility for domestic commercial vessels from 1 July 2018, the ATSB invested in seeking to understand the role it can play in the new national maritime safety system. While there is no agreement for an ATSB-funded role, the ATSB committed to a policy to make itself available for major accidents where resources are made available. The ATSB will continue to work with the appropriate Commonwealth and state agencies to clarify its role.
Malaysia Airlines Flight 370—international contribution
On 3 October 2017, the ATSB published its final report into its work coordinating the search for missing Malaysia Airlines Flight 370 (MH370) (AE-2015-054). The search for MH370 has been a complex international program; the largest and most complex search for a missing aircraft in history. The effort of the dedicated ATSB and associated personnel involved in the search is a testament to their ingenuity, adaptability and resilience.
With the finalisation of the ATSB’s work, responsibility for MH370 matters was handed over to the Joint Agency Coordination Centre (JACC) in the Department of Infrastructure, Regional Development and Cities.
Outlook
The ATSB will continue to perform its primary function of ‘improving transport safety’ in an operating environment of continuing growth and change in the aviation, rail and marine transport industries. During the year, I will release a ‘Vision 2025’ statement for the ATSB. The statement will explain the ATSB’s vision to ‘drive safety action in a rapidly changing transport environment’.
Over the next few years, the transport sector is expected to see significant changes in technology, including increased automation (or remotely piloted operation), manufacturing efficiencies and enhanced use of big data to predict future hazards. Workforce challenges are also expected, with shortages of key personnel in some sectors and increased movement of operational staff between employers. From the ATSB’s perspective, we also expect to see opportunities to broaden our jurisdiction across transport modes.
The ATSB must be able to maintain its status as a world leader, implementing best practice in transport safety investigation in this changing environment. It is essential that we are positioned to be able to expose the critical safety issues that others cannot and influence the necessary safety action to provide confidence in our transport systems.
The immediate focus in 2018–19 will be to make progress in addressing some of our key performance indicators around the timeliness for completion of reports. I am confident that we can make good progress, particularly following our recent investigator recruitment exercise. The year will be a positive one, with our team committed to making our aviation, rail and marine modes of transport safer.
Appointed Chief Commissioner on 1 July 2016, I was honoured to be provided the opportunity to lead a world-class transport safety investigation agency. As the accountable authority, I was acutely aware that the ATSB’s primary function is to improve transport safety with priority given to delivering the best safety outcomes for the travelling public. Having worked in other agencies within the transport portfolio for an extended period of time, I was also cognisant of the agency’s operational environment and the associated challenges. It was within this context that I determined the ATSB needed to be repositioned to face these challenges with courage and determination.
Evolving our capabilities and capacity
The ATSB has undertaken a significant transformation program designed to enable better resource allocation and utilisation across the agency. A number of change imperatives underpinned this program which provided the impetus to refine our business practices and expand our deliverables.
In demonstrating increased effectiveness, we have become more selective in how we allocate resources towards investigating those accidents and serious incidents that have the greatest potential for safety learnings and enhancement. Concurrently, we have expanded our capacity to improve transport safety outside of these traditional investigations, through safety issue investigations, greater interaction with operators and regulators, with data and other intelligence in our possession, and through amplified communications, safety education and promotion.
Key success factors
The ATSB’s greatest resource continues to be “its people” and while there have been changes within our organisational structure—most notably the introduction of multi-disciplined/modal investigator teams—we are well on the way to creating an environment where our employees are empowered. Our people are provided greater opportunities to bring to bear their collective core investigative skills, shared values, passion and drive to improve transport safety. This equally applies to our dedicated and professional operational support staff.
Through the Government’s recent 2017–18 Budget measure “improving transport safety”, the ATSB has been able to re-establish a sound financial position over the next four years. This increase in funding will enable the ATSB to replenish its workforce and re-profile its capital investment strategies to meet its projected needs in essential technical equipment, data warehousing requirements and core enterprise systems.
Core business
The ATSB has committed considerable resources and time to re-engineering its operational model over 2016–17. We did so whilst taking appropriate measures to ensure this did not impact our ability to conduct core business activities, as demonstrated through the range of significant and comprehensive investigations that were either commenced or completed during the financial year.
In relation to other broader functions, the ATSB has completed its transition to becoming the national rail safety investigator, as established through the Council of Australian Governments’ Intergovernmental Agreement on Rail Safety Regulation and Investigation Reform. This milestone coincides with the Queensland Parliament’s agreement to join the national rail safety scheme from 30 June 2017.
Internationally, we have continued an active program of regional engagement with other transport safety agencies within the Asia–Pacific region—most notably with our Indonesian and Papua New Guinean counterparts.
Aviation
During the year, we completed 39 complex aviation safety investigations and 108 short factual investigations.
This year a second interim report was released into the in-flight pitch disconnect of a Virgin Australia Regional Airlines ATR 72 aircraft that occurred about 50 km west-southwest of Sydney Airport, NSW. That report identified a safety issue concerning activation of the aircraft’s pitch uncoupling mechanism with world-wide implications. The ATSB has issued safety recommendations to the aircraft manufacturer, the Civil Aviation Safety Authority (Opens in a new tab/window)(CASA) and the European Aviation Safety Agency(Opens in a new tab/window) to take action to ensure that the aircraft can safely withstand the loads resulting from a pitch disconnect.
A report was also released for an investigation involving the collision with terrain of a parachuting aircraft at Caboolture Airfield, Queensland that fatally injured the five occupants. The ATSB identified that the aircraft aerodynamically stalled at a height from which it was too low to recover control prior to collision with terrain. As a result of that investigation, the ATSB recommended that CASA introduce risk controls to provide increased assurance of aircraft serviceability, pilot competence and adequate regulatory oversight. The ATSB also recommended that CASA work in collaboration with the Australian Parachute Federation to increase the usage of dual point passenger restraints in parachuting aircraft.
Another significant aviation investigation included a traffic management occurrence involving a Jetstar Airbus A320 and a Beech Aircraft Corporation BE-76 Duchess at Ballina/Byron Gateway Airport, NSW. That investigation identified a safety issue relating to the available traffic advisory facilities. The introduction of a certified air/ground radio service to provide weather services and traffic information at the airport in March 2017 is expected to address that safety issue.
The ATSB also released the first research report on Remotely Piloted Aircraft Systems (RPAS). This report showed that there has been a steep rise in the number of RPAS certificate holders in 2016, coinciding with a similar rise in safety occurrences. About half of the 180 occurrences from the past five years related to near encounters with manned aircraft. Of these, 60 per cent were in 2016. Fortunately, there have been no collisions in Australia between RPAS and manned aircraft. The potential consequences of a collision remain uncertain given the limited research available. However, RPAS are an emerging risk that require close monitoring as the number of these aircraft continues to grow.
Rail
During the year, the ATSB completed 16 rail safety investigations. These involved collisions, derailments and failures of safe work practices. Of significance were a level crossing collision between a freight train and a road-train truck near Narromine, NSW, (RO-2015-016) and the derailment of a freight train carrying dangerous goods near Julia Creek, Queensland (RO-2015-028).
The ATSB also continues its focus on occurrences where breaches of safe work practices may place maintenance crews and operators at risk. An investigation has commenced into a fatal collision between a track worker and passenger train near Petrie, Queensland which occurred on 29 May 2017 (RO-2017-003). In addition, our safety issues investigation into safe work on track is nearing completion and will go through a period of public consultation in preparation for final release before the end of 2017.
Marine
The ATSB completed five marine safety investigations in 2016–17. One significant investigation involved a crew member fatality on board the offshore support vessel Skandi Pacific, off the West Australia coast (MO-2015-005). The crew member was crushed while attempting to secure containers during worsening weather conditions.
The investigation complements an ATSB SafetyWatch priority focusing on marine work practices and resulted in a Safety Advisory Notice being issued to highlight the risks posed by open stern vessels in the industry.
The report into the breakaway of the Spirit of Tasmania II from its mooring at Station Pier in Melbourne, Victoria (MO-2016-001) highlighted that all ships, especially those with high windage, are prone to breaking away from moorings during short-term events such as thunderstorms and squalls. The risks this presents to ships with large numbers of people on board means that weather monitoring, mooring systems and procedures need to be regularly checked and verified for changing weather conditions.
Malaysia Airlines Flight 370—international contribution
In January 2017, a Joint Communiqué issued by the Tripartite Governments (Malaysia, Australia, and the People’s Republic of China) formally announced the suspension of the underwater search for missing Malaysia Airlines Flight 370 (MH370) following completion of the 120,000 km2 search area. Should credible new information emerge that can be used to identify the specific location of the aircraft, consideration will be given to determining next steps.
Whilst search operations have been suspended, search area analysis and activities have continued, and an end of search report was released in the third quarter of 2017.
The search for MH370 has been a complex international program, the largest and most complex search for a missing aircraft in history. The effort of the dedicated ATSB and associated personnel involved in the search is a testament to their ingenuity, adaptability and resilience. Consistent with Government policy and direction, the ATSB will continue to provide a supporting role to Malaysia as the country responsible for the investigation into the disappearance of MH370.
Outlook for 2017–18
The ATSB will continue to perform its primary function of “improving transport safety” in an operating environment of continuing growth and change in the aviation, rail and marine transport industries.
In recognising these environmental challenges, the ATSB will adopt and implement a range of strategies designed to further increase its overall efficiency and effectiveness.
Selective investigations
The ATSB will refine its methodologies in selecting the accidents and incidents it investigates, recognising its finite resources, differences in jurisdiction across the modes, and its particular focus on the safety of the travelling public.
Data driven
To position the ATSB to become more proactive in its identification of safety issues, we will continue to build our capability to source data nationally on aviation, rail and marine transport safety occurrences and events, and use that data to identify and communicate safety risks and emerging trends.
We will also deliver a program of safety research and analysis that draws on the results of investigations and the interrogation of safety occurrence datasets.
Stakeholder engagement
To encourage greater safety action, the ATSB will enhance stakeholder relationships, with a particular focus on ensuring a strong culture of reporting safety matters, and through transparent arrangements for the appropriate sharing and use of safety information.
Focused communications
To ensure the targeted delivery of its safety messages, the ATSB will undertake safety communication and education with an emphasis on identifying priority areas where safety risk can be reduced.
We will also increase public awareness of the ATSB’s safety activities by developing a broader range of communication and education products and pursuing their delivery to transport industries and the travelling public through media that interact with a variety of stakeholders.
Workforce capabilities
To enhance its workforce capability the ATSB will complete the implementation of its organisational change program, embedding a multi-discipline teams-based approach to investigations, with the objective of enhancing the agency’s efficiency and effectiveness.
We will expand our resource base through attracting, retaining and developing professional staff as well as developing networks with skilled professionals who the ATSB can work with to fulfil its transport safety functions.
Expanding jurisdictions
While the ATSB has a broad jurisdiction in aviation, there is further work to be done as part of the national rail and marine safety reforms. The ATSB will examine how to best address some of the issues surrounding the independent investigation of serious incidents and accidents in the domestic commercial vessel (DCV) sector consistent with any direction as agreed by governments.
These strategies, the associated deliverables and performance indicators (specifically our commitment to improving the timeliness of our outputs), are detailed and presented in the ATSB’s Corporate Plan 2017–18, published on 31 August 2017.
The 2017–18 year will be a positive and exciting period for the ATSB, and I remain confident that the continued professionalism and capability of our people will ensure the ATSB remains a world-leading transport safety investigation agency.
This was the ATSB’s seventh year as a fully independent body within the Infrastructure and Regional Development portfolio. 2015–16 also marked the final year of Martin Dolan’s tenure as the ATSB’s Chief Commissioner. While Martin’s real and significant contributions to improving transport safety have been widely acknowledged, it was his passion, energy and commitment to maintaining the ATSB’s reputation as a world-leading safety investigation body that will be remembered as his most enduring qualities.
Ongoing challenges
As foreshadowed through the ATSB’s 2015–16 Corporate Plan, the ATSB entered this reporting period faced with an operating environment of continuing growth in, and progressive changes to, the composition of the aviation, rail and marine transport sectors. In contrast, the ATSB has continued to experience successive reductions to its base appropriations with further reductions projected over its forward estimates. To manage these fiscal circumstances, the ATSB has reduced its core staffing profile, including specialist investigators, by approximately 25 per cent from when it was established as an independent statutory authority in July 2009.
Notwithstanding these challenges, the ATSB was able to complete a range of significant and comprehensive investigation reports during 2015–16, in addition to supporting the secondment of a number of specialist staff to the continuing search for the missing Malaysia Airlines Flight MH370 and the reopened investigation into the Norfolk Island ditching accident.
Limitations
When reflecting on the agency’s overall performance against its key deliverables and performance indicators, the ATSB has continued to meet its targets in terms of the quality and quantity of investigation reports completed and published per year. However, it is evident the ATSB has not been able to complete these reports within the published prescribed timeframes.
In relation to other key functions and broader portfolio responsibilities, the ATSB continues to maintain a capacity to record, analyse and research safety data and produce timely reports on safety trends and other research publications. Given its resource constraints, the ATSB has limited capacity to foster safety awareness, knowledge and action through safety education and has relied heavily on social media(Opens in a new tab/window) to disseminate key messages.
The ATSB has continued its transition to becoming the national rail safety investigator, as established through the Council of Australian Governments Intergovernmental Agreement on Rail Safety Regulation and Investigation Reform. In addition to the Defined Interstate Rail Network, the ATSB now has primary responsibility for investigating rail safety accidents and incidents on regional networks and metropolitan passenger networks in all states and territories other than Queensland.
Similarly, the ATSB has continued an active program of regional engagement with other transport safety agencies within the Asia Pacific region. Consistent with the approved projects and associated program funding agreements, the ATSB has undertaken a range of capacity building activities including investigator training and mentoring, policy and guidance development, and establishing compliance with international standards.
Since May 2014, at the request of the Malaysian Government, the ATSB has been leading the search operations for missing Malaysia Airlines Flight MH370, in the Southern Indian Ocean. The search for the Boeing 777 aircraft remains a major priority for the ATSB.
During the year, the operational search faced a number of significant challenges, including lost and subsequently recovered underwater electronic search equipment, medical evacuation of unwell crew and prolonged severe weather.
In December 2015, the search identified the wreck of a ship, likely to be a steel or iron vessel, dating from the turn of the 19th century. Importantly, the discovery of the shipwreck shows how the methods and technology used in the search will effectively detect and identify the missing Boeing 777 aircraft.
ATSB technical specialists also examined a number of items of aircraft debris, which were discovered on the shorelines of western Indian Ocean states. Several pieces were recovered and examined, one by the French authorities and the remainder by the ATSB. Other parts are being retrieved by the Malaysian Investigation Team for further assessment.
We continue to work with our Minister and our Malaysian and Chinese counterparts to ensure that they are kept appraised of the search progress and to enable joint decisions to be made when required.
Aviation
During the year we completed 44 aviation safety investigations and 90 short factual investigations. One significant aviation investigation involved the landing below the minima of two Boeing 737 aircraft at Mildura Airport, Victoria due to fog conditions (AO-2013-100). Both aircraft were on scheduled flights when, on nearing Adelaide Airport, fog precluded their landing.
ATSB has recommended that Airservices Australia work in collaboration with the Bureau of Meteorology to instigate a system change to reinstate the alerting function of special weather reports currently not available through an Automatic Broadcast Service.
In parallel with this occurrence investigation, the ATSB commenced a research investigation to examine the reliability of aviation weather forecasts. This research will analyse Bureau of Meteorology weather data for major Australian airports.
Other significant aviation investigations have led to improvements in the inspection method for detecting cracks in the wing attachment fittings in M18 Dromader aircraft and the removal of at-risk lateral tie rods from DH82 and DH82A Tiger Moth aircraft, with worldwide implications for this aircraft type. The ATSB also concluded its involvement as an accredited representative to the investigation by the Dutch Safety Board of the crash of Malaysia Airlines Flight MH17 in Hrabove, Ukraine on 17 July 2014.
Marine
The ATSB completed seven marine safety investigations in 2015–16. Significantly, two of the occurrences we investigated—an engine room fire on board bulk carrier Marigold and a man overboard fatality from Cape Splendor, both at Port Hedland, Western Australia—highlight the importance of investigating incidents and accidents to improve safe marine work practices.
ATSB urges the maritime industry to give heightened attention to marine work practices. As these incidents have shown, it is essential that employees implement good risk management and safety practices to prevent injury and loss of life.
Rail
During the year, the ATSB completed 19 rail safety investigations. The most significant of these involved rail collisions, derailments and a passenger fatality at Heyington Railway Station in Victoria.
As part of this investigation, we have collected and analysed over 12,000 records, categorised under the Safework Rule Procedure Breach guidelines, between June 2009 and June 2014.
Of these, approximately 15 per cent were assessed by the ATSB as being work on track-related occurrences. Preliminary analysis indicates that the majority of these occurrences can be traced to protection types being insufficient or incorrect, protection location being incorrectly positioned, protections being incorrectly removed and worksite location being incorrectly identified.
This new focus in Western Australia will result in more investigations conducted across a greater range of safety matters. It also means that the ATSB is the mandatory notification point for all Category-A occurrences within Western Australia.
We are continuing our negotiations with Queensland to complete the process of establishing a unified national system of rail safety investigation.
As the newly appointed Chief Commissioner on 1 July 2016, I am proud to lead a world-class and lean transport safety investigator. But I am keen to reshape how we commit our limited resources to improve safety for the travelling public.
We will continue investigating the majority of accidents and serious incidents involving the travelling public. This is where there is the greatest risk of loss of life and the greatest likelihood of finding significant safety issues that lead to important safety actions.
We will, however, seek to improve our efficiency by becoming more data-driven. The ATSB has one of the richest national information datasets of all safety-related occurrences in aviation as well as accidents and significant safety occurrences in the rail and marine sectors.
We use this data to identify safety trends in the aviation, rail and marine sectors but I would like to interrogate the data more actively. In so doing, we will be able to more selectively allocate our limited resources to investigating those accidents and incidents that that have the greatest potential for improving safety. If there is no obvious public safety benefit to investigating an accident, the ATSB is less likely to conduct a complex, resource-intensive investigation.
The ATSB endeavours to investigate all fatal accidents involving VH-registered powered aircraft subject to the potential transport safety learnings and resource availability. But we will need to carefully consider the resources we allocate to investigations into general aviation fatal accidents and constrain the scope of investigations into non-fatal accidents in this sector.
Safety education is key to addressing accidents and incidents that recur in general aviation. There are diminished safety benefits from investigating occurrences where there are obvious contributing factors, such as unauthorised low-level flying or flying visually into poor weather. Instead, educating pilots on the dangers of high-risk activity is where we will refocus our efforts, with an emphasis on using social media.
There are many challenges facing us in the future. Technology is already having an influence on our work. The use of remotely piloted aircraft is increasing significantly—pizza delivery by drone is reportedly imminent.
How ATSB investigates and monitors the safety of an increasing number of low-cost carriers operating within Australia will require careful consideration.
The ATSB will accumulate and interrogate its data rigorously to determine if there are indeed any systemic safety issues that affect the safety of the travelling public and others in the industry.
In the meantime, we will work with the marine, rail and aviation industries to highlight the safety concerns already identified from our occurrence data and investigation findings.
While the ATSB faces significant challenges, I am confident that the professionalism and capability of our people will ensure the ATSB remains a world-leading transport safety investigator.
