The ATSB Annual Review 2001 documents ATSB's achievements and safety activities from 1 July 2000 to 30 June 2001 and outlines its business planning for 2001-2002.
Producing the annual review is in line with a recommendation of the McGrath report into the former Bureau of Air Safety Investigation released in August 1999 to improve the transparency and accountability of the Bureau.
Creation of the ATSB on 1 July 1999 brought together the safety investigation, statistical analysis, research and safety program management of the Commonwealth's transport safety role in one multi-modal agency within the Department of Transport and Regional Services. ATSB intends to prepare an annual review to provide all stakeholders with an overview of its activities and safety in each transport mode. This first review covers a range of topics including:
The 2005-06 financial year continued to have a substantial building element for the ATSB as rail investigation further matured and aviation investigators were trained and prepared for 2006-07 implementation of a new aviation safety database with associated project and risk management.
The Bureau is continuing its commitment to training its investigators through the Diploma of Transport Safety Investigation. In 2005-06, ten staff completed the Transport Safety Investigation (TSI) Diploma and a further 25 were progressing through the coursework and mentoring.
In addition to releasing 93 final aviation investigation reports, ten aviation safety research reports and eight grant reports, substantial work occurred on the fifteen-fatality Lockhart River accident investigation, including the issuing of a number of safety recommendations.
In marine, 13 investigation reports were released including a major report into the loss of the Department of Immigration and Multicultural Affairs vessel Malu Sara in Torres Strait which resulted in five fatalities. The ATSB also continued an education campaign within the fishing industry on commercial fishing vessel safety.
The ATSB's rail safety investigation team released 11 final reports under the TSI Act. In October 2005 the Queensland Minister of Transport released the final report of the joint Queensland Transport/ATSB investigation into the Tilt Train accident which occurred north of Bundaberg in November 2004, and in February 2006 the Victorian Minister for Transport released the final ATSB report on the Benalla level crossing fatal accident.
The ATSB continued to support Ministers with road safety advice and coordinated input with other jurisdictions. In 2005-06 we released 22 road safety research and statistical publications including an Indigenous Road Safety Update. Preparations were also made for a national indigenous road safety forum later in 2006.
There were two areas of particular disappointment in 2005-06. First, there was little progress on a road safety education trial for novice drivers in partnership with NSW and Victorian governments and industry bodies primarily because of finance, risk and governance issues with Victoria.
Second, rail regulators advised the ATSB that even the very basic safety data that had been provided for several years was not accurate or comparable and broader data promised under an April 2005 memorandum of understanding would be significantly delayed. Obtaining quality rail safety data from jurisdictions has been a goal of the ATSB since 1999. The ATSB provided $80,000 late in 2005-06 to rail regulators to support an audit to seek to resolve data issues and provide a basis to make real progress for the future.
On 1 March 2006 I became the Chairman of the International Transportation Safety Association (ITSA), which includes a dozen of the major independent transport safety investigation bodies from around the world. The annual ITSA meeting was held in Canberra later that month and was a very helpful forum for exchanging information and enabling learning from sharing the good (and less good) experiences of colleagues.
A number of valued staff members retired during the year or prior to publication of this Review. I wish to express my particular appreciation for the long term contribution to marine and rail safety by Captain Kit Filor PSM who has been the ATSB's Deputy Director of Surface Transport Investigation since July 1999 and previously the Inspector of Marine Accidents from January 1991. Kit has made an enormous contribution in Australia and internationally.
I am grateful to the Minister for Transport and Regional Services, the Hon. Warren Truss MP, the Minister for Local Government, Territories and Roads, the Hon. Jim Lloyd, MP, and to the Secretary of the Department of Transport and Regional Services, Mr Mike Taylor for their support throughout the year.
Producing the annual review is in line with a recommendation of the McGrath report into the former Bureau of Air Safety Investigation released in August 1999 to improve the transparency and accountability of the Bureau.
Creation of the ATSB on 1 July 1999 brought together the safety investigation, statistical analysis, research and safety program management of the Commonwealth's transport safety role in one multi-modal agency within the Department of Transport and Regional Services. ATSB intends to prepare an annual review to provide all stakeholders with an overview of its activities and safety in each transport mode. This first review covers a range of topics including:
The ATSB has come a long way since its creation on 1 July 1999. Legislation, training and IT systems have all been upgraded. The ATSB has an increasingly national and international reputation for independent safety material. This is reflected in the almost 800,000 new visitors to the ATSB website which also had more than 30 million 'hits' in 200607, and in multiple articles in such publications as the prestigious US-based Flight Safety Foundations AeroSafety World.
During 2006 - 07, the ATSB finalised its complex investigation into Australian civil aviation's worst accident since 1968, the 15-fatality aircraft accident near Lockhart River, Queensland on 7 May 2005. The 500-page final report released on 4 April 2007 identifies important safety issues to enhance future aviation safety relating to the crew, the operator, regulatory oversight and instrument approach chart design. Three ATSB factual reports, a research report and ten safety recommendations were released during the course of the almost two-year investigation. A further ten safety recommendations were issued with the final report, which also utilised an enhanced ATSB investigation and analysis methodology. Among other coronial inquests, the ATSB assisted with the inquest into the Lockhart River accident by the Queensland State Coroner which included a month of hearings on Thursday Island and in Brisbane. The Coroner reported on 17 August 2007.
During the year the Bureau released 80 final aviation investigation reports, 19 aviation safety recommendations, 10 aviation safety research reports and five research grant reports. The ATSB also cooperated with the Indonesian National Transportation Safety Committee (NTSC) in the investigation of the Garuda Airlines Boeing 737-400 accident at Yogyakarta Airport on 7 March 2007 in which 21 died, including five Australians, and 12 were seriously injured. ATSB assistance included an on-site team comprising a Deputy Director and two senior investigators, flight recorder analysis in Canberra, and the drafting of preliminary and final reports.
In April 2007 the Bureau introduced a new Safety Investigation Information Management System (SIIMS) aviation database which will be extended to rail and marine in 2007-08. SIIMS was developed using the $6.1 million committed by the Australian Government in the May 2004 Budget, and was within time and budget.
In marine, the ATSB released 14 investigation reports, issued 38 safety recommendations and continued an education campaign on commercial fishing vessel safety. International success included ATSB coordination and facilitation of recent amendments to the Code for Investigation of Marine Casualties and Incidents as a member of the IMO Flag State Implementation Subcommittee. The ATSB also assisted with the inquest into the loss of the Immigration vessel Malu Sara with five fatalities in the Torres Strait.
The ATSBs rail safety investigation team released nine final reports and 39 safety recommendations under the Transport Safety Investigation Act 2003 (TSI) which included a number of level crossing accidents. In June 2007, the ATSB published jurisdiction regulators rail safety occurrence data in eight key categories covering the period January 2001 to December 2006. Further improvements in rail safety data are being sought through a process coordinated by the National Transport Commission.
The ATSB is continuing its commitment to training its investigators through accredited Diploma of Transport Safety Investigation. In 200607, 12 staff completed the TSI Diploma with 13 progressing through the required coursework and mentoring.
In March 2007 I completed my term as Chairman of the International Transportation Safety Association (ITSA), which includes major independent transport safety investigation bodies from around the world. ITSA has been revitalised and has grown to include the UK, Japan and Norway. France and South Korea are potential new members.
The ATSB continued to support Ministers with road safety advice and coordinated with other jurisdictions to develop the National Road Safety Action Plan for 2007 and 2008, which was approved by Ministers of the Australian Transport Council. While the challenges in road safety are immense, progress is being made in jurisdictions and through other stakeholders. It has been my privilege to chair the National Road Safety Strategy Panel since 1999 and work with such dedicated officers as ATSB General Manager Joe Motha and Team Leader John Goldsworthy and senior staff including Chris Brooks.
In 2006-07 the ATSB released 25 road safety research and statistical publications including a report on transport injuries amongst Indigenous people. The Bureau also helped organise an Indigenous road safety forum in October 2006. Work continued in preparation for the major novice driver research trial in New South Wales and Victoria which the Australian Government is supporting. Partners are scheduled to finalise the curriculum and conduct pilot testing before the end of 2007.
All of the achievements made in 2006-07 and on an ongoing basis are the result of the dedication of ATSB professional officers. For this untiring service, I salute them all. Most have made major personal sacrifices to make a difference for future transport safety. I particularly recognise my direct report colleagues: Peter Foley, Kerryn Macaulay, Joe Motha, Alan Stray and Julian Walsh. The investigator-in-charge of the Lockhart River investigation, Greg Madden and his team also deserve special praise.
Financial year 2007-08 was in many respects a watershed year. In road safety, the November election of the Rudd Government led to the move of road safety from the ATSB to the Department proper from the end of March 2008 to better align with the new Government's priorities. While I was proud to chair the National Road Safety Strategy Panel from 1999 to 2008, the establishment of a higher level Commonwealth/State body holds the promise of making further gains in reducing the nation's unacceptably high road toll. However, I was personally sad to lose the road safety branch led by Joe Motha and John Goldsworthy and their dedication and professionalism from the ATSB and am grateful for all they did while in the Bureau.
In surface safety investigation, we exceeded our output targets and are well positioned to improve future timeliness of reports. I was particularly pleased with the final Pasha Bulker marine investigation report and the rail investigation report at Ban Ban Springs and associated work on the safety of very large trucks at level crossings. I thank Peter Foley in particular for his leadership in surface safety.
Internationally, we were instrumental in gaining International Maritime Organization approval of a new marine investigation code and the role of Patrick Hornby deserves special commendation. Our contribution to the Government 'ITSAP' assistance program to Indonesia included substantial input led by Alan Stray in the finalisation of the Indonesian National Transportation Safety Committee investigation reports on fatal 737 accidents involving Garuda and Adam Air. Alan and Kerryn Macaulay also ensured that the ATSB's part of the 2008 ICAO state audit was very positive. A wide range of other ATSB outputs, including aviation research, technical analysis, occurrence notifications, and IT, benefited from Kerryn's leadership.
The greatest organisational pressure during 2007-08 was faced by the aviation investigation branch led by Julian Walsh. It is very difficult to select up to 80 investigations from the more than 8,000 accidents and incidents reported annually and inevitably parties associated with occurrences on the margins may not agree with the selection. There are also competing priorities between investigating fatal general aviation accidents to a level sought by state and territory coroners (and the further resources needed in any ensuing inquests), and doing more investigation of fare-paying passenger regular public transport incidents where there may be more future safety value. There is often a further trade-off between numbers of new investigations and timeliness. I am extremely grateful for Julian's leadership in managing, with his team leaders, in this environment. The 'Miller Review' was a further pressure that required substantial ATSB input. The new Government's announcement, through portfolio Minister the Hon Anthony Albanese, of an aviation Green and White Paper process was seen as a significant opportunity and warmly welcomed by the ATSB.
I also wish to publicly thank the ATSB training manager, Colin McNamara, for volunteering to coordinate the ATSB's central office move from 15 Mort Street to 62 Northbourne Avenue. His planning during 2007-08 led to a smooth move in September 2008.
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.
