We initiated the development of our new strategic plan to better position the agency to make the most effective use of our resources, and to ensure we continue to improve transport safety for the greatest public benefit through our independent investigations and influencing safety actions as Australia’s national transport safety investigator.
The plan outlines the ATSB’s goals and strategies that will enable and enhance the effectiveness of our operations and functions under the Transport Safety Investigations Act.
We have published the plan in a ‘placemat’ format for ease of reading and educating all our stakeholders, including the travelling public, on who the ATSB is, what it is we do, how we do it, and for who we do it.
This guideline has been prepared by the Australian Transport Safety Bureau (ATSB) to:
Outline the role and responsibilities of the ATSB.
Detail required actions by an aerodrome operator in the event of an aviation accident.
Outline possible actions by the ATSB to investigate an aviation accident.
Your Aerodrome Emergency Plan should include reporting an aircraft accident to the ATSB as part of the standard response to the accident.
Who is the ATSB?
The ATSB is an independent Commonwealth Government statutory agency governed by a Commission. It investigates transport safety occurrences in accordance with the Australian Transport Safety Investigation Act 2003 (TSI Act). The ATSB is responsible for investigating accidents and incidents involving civilian aircraft. The ATSB is entirely separate from the Civil Aviation Safety Authority and Airservices Australia.
The ATSB investigates to find out what happened and to disseminate safety messages aimed at preventing or minimising repeat occurrences. It does not seek to apportion blame or legal liability.
The ATSB has powers under the TSI Act to secure the site of an accident and to preserve evidence associated with it. The international standards and recommended practices for aircraft accident and serious-incident investigations are covered under Annex 13 to the Chicago Convention of 1944, to which Australia is a signatory.
Actions in the event of an aircraft accident
If an aircraft accident occurs, an aerodrome operator must,
Respond to the accident in accordance with the aerodrome emergency plan
Report the accident to the ATSB
In conjunction with emergency services, preserve the scene for accident investigation.
Definition
An accident for the purposes of this guide is an occurrence involving an aircraft where,
A person dies or suffers serious injury
The aircraft is destroyed or is seriously damaged, or
Any property is destroyed or seriously damaged.
Reporting
Under the TSI Act and Regulations, a ‘Responsible Person’ must report an aircraft accident immediately to the ATSB. The TSI Regulations define Responsible Person to include the owner, operator or crew of the aircraft, as well as other aviation personnel including the operator of an aerodrome.
If calling from outside Australia, please use +61 2 6230 4470.
What information should I report?
You should immediately report as many of the following details as possible:
Your name and contact details
Aircraft registration and manufacturer/model if known
Date and time of the accident
Location of the accident
Nature of the accident (eg phase of flight and description of occurrence)
Extent of any injuries to the occupant(s) or others
Extent of damage to the aircraft
Number of crew and passengers
Any response by police or emergency personnel
Action taken to secure the accident site.
ATSB accident investigation
How will the ATSB respond?
The ATSB has investigators on call 24 hours a day to respond to aviation incidents and accidents. If investigators attend the scene of an accident, it may take some time for them to travel to the location. In the meantime, aerodrome operators and first responders have a role to make sure that the accident site is secured to ensure safety and to preserve evidence.
Preservation of evidence
Under Section 43 of the TSI Act, the ATSB may issue a Protection Order for the accident site to ensure the preservation of evidence.
The purpose of the Protection Order is to secure the accident site to prevent unauthorised persons from entering the area and to minimise disruption to, or loss of, evidence.
The Protection Order prohibits anyone from entering or interfering with the accident site unless authorised by the ATSB or where necessary to:
Ensure the safety of persons, animals or property
Remove deceased persons or animals from the accident site (although this should only be done under police supervision)
Move the transport vehicle, or the wreckage of the transport vehicle, to a safe place (if there is a risk that significant evidence could be lost by leaving it in situ), and/or Protect the environment from significant damage or pollution.
A Protection Order may be issued verbally in the first instance – for example, over the phone – with written confirmation to follow. The Protection Order may initially be made over an area much larger than the immediate accident site, such as over the approach to the aerodrome.
The Protection Order may be provided directly to the aerodrome or the emergency services. It is imperative that the aerodrome and emergency services work together to ensure the Protection Order is followed.
The ATSB may grant permission under a Protection Order for certain specified actions to be taken that otherwise would be prohibited by the Order. The Protection Order will be revoked when it is no longer required for the purpose of the ATSB investigation.
The secure area may vary depending on the spread of the wreckage and the terrain, but it should normally extend to at least 50 m from the edge of the wreckage. If the aircraft has disintegrated in-flight, the wreckage may be scattered over a wide area and there may be a requirement for more than one secured site.
The role of first responders
First responders need to deal with the immediate aftermath of an accident, including rescuing and attending to survivors or removing the deceased and dealing with fire and hazardous materials. The ATSB will be available by phone to first responders on the ground to provide advice and make arrangements for the security of the site until ATSB investigators arrive.
When the ATSB investigators arrive at the accident site they will coordinate with the site commander to arrange an appropriate time to take control of the site.
Recovery and resumption of normal operations
Depending on the exact location and severity of the accident, aerodrome operations may be curtailed or have to cease completely during the on-site phase of the investigation. The time taken for the on-site phase of an investigation will vary depending on the circumstances.
For an accident involving a light aircraft, it may typically be several days. However, the on-site investigation phase may be considerably longer for an accident involving a larger aircraft.
The ATSB will make every effort to minimise the effect of the investigation on aerodrome operations, to the extent that it can without compromising the investigation process. Under Section 12AC of the TSI Act, the ATSB must have regard to the desirability of minimising any disruption.
Recovery and salvage of the wreckage
After the on-site investigation is completed or if the ATSB decides not to conduct an on-site investigation, the ATSB Investigator in Charge (IIC) will advise other parties when the ATSB no longer requires control over the aircraft wreckage. The ATSB may require all or part of the wreckage for off-site examination.
The ATSB will offer the wreckage to the coroner and the Civil Aviation Safety Authority (CASA) prior to releasing it back to the aircraft owner/operator. Arrangements for salvage and site clean-up are then a matter for the aircraft owner/operator and the aerodrome operator.
Will the ATSB always investigate?
The ATSB does not investigate all aviation accidents. The ATSB selectively investigates serious occurrences including fatal accidents that it believes will yield the most useful safety benefits for the travelling public.
In some cases the ATSB will conduct an office-based investigation that do not require physical attendance by ATSB investigators. In that case, the ATSB will provide advice to first responders and other relevant organisations including the aerodrome operator as to the ATSB’s requirements. This cooperation could include asking the aerodrome operator to capture detailed photographs of the accident site or to quarantine any recorded information, such as Avcharge transmission recordings.
Media
Depending on the exact location and severity of the accident, a spokesperson from the ATSB may deploy to the accident site to manage the media interest, and to provide journalists with a briefing.
Should a media spokesperson not be available, aerodrome operators are encouraged to direct all media enquires about the investigation to the ATSB.
Aerodrome media officers are encourage to contact the ATSB’s media team at any time to discuss and confirm media activity and messaging following an accident. In addition, the ATSB should be considered when an aerodrome conducts its emergency plan training.
Witnesses
Should witnesses to the accident contact the aerodrome directly, operators should direct them to contact the ATSB.
In the event that an aerodrome operator is faced with an aircraft accident, a good understanding of the role of the ATSB and the investigation process will ensure that the investigation is not impeded and that disruption to aerodrome operations is minimised.
Accidents and serious incidents which affect the safety of aircraft must, in the first instance, be reported to ATSB by calling 1800 011 034.
The Australian Transport Safety Bureau (ATSB) is Australia’s national transport safety investigator. When things go wrong in transport safety, we find out what happened so it doesn’t happen again. We don’t investigate to lay blame but to improve safety.
Making safe transport safer
The ATSB’s accident investigation role is a fundamental part of Australia’s transport safety framework.
Equally important is the information we hold on safety related events. We use that information to identify safety issues and trends.
These issues and trends—and what we find from our investigations—are used to educate industry and promote positive safety action.
The goal is always improved safety.
When things go wrong in transport safety, the ATSB finds out what happened so it doesn’t happen again.
The ATSB does not investigate to lay blame but to improve safety.
Where the ATSB fits
The ATSB works with operators and regulators to ensure safe transport for the travelling public and industry participants.
In the overall system of transport safety, operators manage their safety risk and regulators ensure that safety risk is managed well. The ATSB steps in when things go wrong to see if changes need to be made to the overall system of safety.
Aviation
The ATSB is responsible for the independent investigation of accidents and incidents involving civil aircraft in Australia. Our primary focus for investigations is on fare-paying passenger operations. However, all accidents and incidents related to flight safety in Australia or involving Australian registered aircraft overseas must be reported to the ATSB. While the ATSB does not investigate all of these, we still need to be notified so that the data can be recorded for future safety research and analysis.
Please call the toll-free number 1800 011 034 for advice on reporting requirements or visit www.atsb.gov.au
Australia is a member of the Council of the International Civil Aviation Organization, which is made up of 190 countries. The ATSB has frequently assisted with international investigations, including through the analysis of flight and cockpit voice recorder (‘black box’) data.
Marine
Marine transport accounts for the vast majority of imports and exports of cargo in and out of Australia, and also plays a significant role through coastal trade. Cruise shipping is also a growth industry.
The ATSB conducts marine investigations into accidents and serious incidents involving Australian registered ships anywhere in the world, foreign flag ships within Australian waters, or where evidence relating to an accident involving ships is found in Australia. Accidents and serious incidents must be reported as soon as practicable to the ATSB. Often such a report will be made through the Australian Maritime Safety Authority. If you wish to report a marine accident or incident, you may contact the Australian Search and Rescue (AusSAR) on 1800 641 792 or the ATSB on 1800 011 034.
Australia is also a council member of the International Maritime Organization, and actively participates in its forums on accident investigations in the interests of making global improvements to shipping safety.
Rail
Rail is a vital part of the nation’s transport infrastructure, moving volumes of people every day in Australia’s major cities and providing an important alternative to road transport for the country’s increasing freight distribution.
The ATSB conducts rail investigations into accidents and serious incidents involving passenger and freight rail operators. The ATSB has partnered with New South Wales and Victorian investigation agencies to deliver rail investigations in those States.
For most operations, accidents and serious incidents (Category A occurrences) must be reported as soon as practicable to the ATSB. Please call the toll-free number 1800 011 034 to notify the ATSB of such accidents or incidents. Other reporting requirements are fulfilled by contacting the Office of the National Rail Safety Regulator.
The ATSB helps make significant improvements in rail safety through its investigations. We widely disseminate our findings through the public release of our reports, making our safety findings accessible to all.
We understand that any accident that results in a serious injury or loss of life can have profound effects. A fatality begins a complex process of grieving for those close to the individual(s) involved. Families and friends naturally want to know why the accident happened, and how to prevent someone else having to experience such loss.
This page and accompanying brochure attempt to answer some of your questions about a transport safety investigation conducted by the Australian Transport Safety Bureau (ATSB) where there has been a fatality.
The ATSB is governed by a Commission and is entirely separate from transport regulators, policy makers and service providers.
The ATSB investigates accidents and incidents to find out what happened to prevent it from happening again. We don’t investigate to lay blame but to improve safety.
Accident investigations
The ATSB does not investigate all accidents. It focuses its limited resources on fatal and other accidents that are required to be investigated under international agreements, and also those it believes will yield the most useful safety knowledge - particularly for fare-paying passenger operations.
ATSB staff may seek to interview anyone directly or indirectly associated with a transport safety occurrence. As part of its investigation, the ATSB may need to ask some questions in order to understand crew members’ activities in the days before the accident. In this situation, you may be asked for information on your loved one’s recent rest periods, sleeping patterns, medication, general state of health, work history and other important aspects. Discussing these matters in such circumstances can be particularly difficult, so we encourage you to consider having another family member or friend available for support during the interview. ATSB staff members are trained to assist you through the interview process.
To gather relevant information, the ATSB may:
interview any witnesses and other relevant persons
obtain additional information relevant to the investigation from a number of different sources
conduct tests and research, as appropriate
analyse data recorders, such as transport vehicle voice and data recorders/loggers (the ‘black boxes’) and air traffic control tapes and other media.
During the report writing stage, a draft report is prepared for comment by persons and organisations directly involved in the accident. A person in possession of a draft report is not permitted to copy or disclose the contents of a draft report except for the purpose of providing comments to the ATSB on the draft, or to take safety action in response to the report’s findings. The ATSB carefully considers any comments by persons who have received a report prior to finalising its investigation.
As next of kin, you are generally not provided with a draft report for the purpose of commenting to assist with finalising the investigation, unless you have specialist technical knowledge, or are directly involved in the circumstances and issues that contributed to the accident. You will, however, receive a ‘for information’ copy of that draft.
Normally, you can expect a preliminary report within 30 days of a significant accident, and regular interim reports or web updates (usually every 6 months) until the final investigation report is completed. By their nature, those reports include factual information only, but will not include any analysis of the facts to date. You can also expect that there may be a number of short web updates during the course of an ATSB investigation. While the ATSB understands that this can be frustrating for relatives, it could be harmful to make conclusions before establishing all of the facts.
A copy of the final report will normally be available to you and your immediate family a number of days before its public release.
Other investigations
It may be that you feel the investigation and report have not met your expectations. The following organisations, however, may undertake a separate investigation. The intent and/or processes of these investigations will differ to the ATSB’s:
Coronial Inquest or Inquiry: Your state or territory Coroner may hold an inquest or inquiry into a fatal transport accident, and the coronial and ATSB investigations are complementary. All queries relating to an inquest or inquiry, or to any police investigation carried out for the Coroner, should be directed to your Coroner’s Office. Coronial services can also offer face-to-face assistance and advice, and most Coronial jurisdictions provide grief counselling and other support by trained professionals. A list of those and other relevant support services is enclosed.
Regulatory investigation: The relevant transport regulatory authority, such as the Civil Aviation Safety Authority (CASA), Australian Maritime Safety Authority (AMSA), the Office of the National Rail Safety Regulator (ONRSR), Workcover or the police may conduct investigations to determine whether there was a breach of any legislation.
Investigation reports
ATSB transport safety investigation reports do not include the names of individuals. In many situations, however, an individual’s position (for example, the ‘pilot in command’, ship’s master, locomotive driver) may need to be stated so that the reports make sense and lessons can be learned by others. The ATSB provides copies of final investigation reports to the public and the reports are made available on our website.
Your contact with the ATSB
While the ATSB is very conscious of your loss and privacy at this very delicate time, we seek to keep you informed as the investigation proceeds. Early in the process, the investigator in charge will seek your input to plan regular communications. That communication can be with yourself or, if you would prefer, through an intermediary nominated by you. Please check that the ATSB has accurate, up-to-date contact details of your or your preferred point of contact. In addition, you can contact the investigator in charge using the information at the back of this brochure.
An integral part of the communications planning is for the investigator in charge to advise you of the pending release of any transport safety report. As well, you can expect to be offered a brief by the investigator in charge at that time, the aim of which is to explain the investigation and findings, and to attempt to answer any questions you may have. If you agree to a briefing, you should be aware that it can become very emotional, and you might consider having a friend available for support.
The investigator in charge will advise an appropriate contact number. However, if you do not have or have lost that number, you can call 1800 020 616 during business hours and ask for an investigation update. If you would rather use email, please address your correspondence to atsbinfo@atsb.gov.au.
State Coronial Counselling Services
The Coronial counselling service in your state can provide support and information to families affected by the death of a loved one that is under investigation by a coroner.
