The ATSB is Australia’s national transport safety investigation agency. Its primary function is to improve aviation, rail and marine safety. It does this by receiving information about accidents and other safety occurrences, analysing data, and investigating occurrences and safety issues in order to identify and communicate factors that affect, or might affect, transport safety.
The ATSB is part of the Department of Infrastructure, Transport, Regional Development and Communications portfolio. Within the portfolio are other important transport agencies, whose roles are focused on delivering an efficient, sustainable, competitive, safe and secure transport system for all transport users, through regulation, financial assistance and safety investigations. These include:
- Civil Aviation Safety Authority (CASA)
- Airservices Australia
- Australian Maritime Safety Authority (AMSA)
- Office of the National Rail Safety Regulator (ONRSR)
- National Transport Commission.
The ATSB is an independent statutory agency of the Australian Government. It is governed by a Commission and is entirely separate from transport regulators, policy makers and service providers. At the same time, it is required to cooperate with others who have a role in maintaining and improving transport safety. The ATSB’s purpose is to improve the safety of aviation, rail and marine transport through:
- the independent investigation of transport accidents and other safety occurrences
- safety data recording, analysis and research
- fostering safety awareness, knowledge and action.
The ATSB performs its functions in accordance with the provisions of the Transport Safety Investigation Act 2003 (TSI Act) and, where applicable, relevant international agreements. The TSI Act makes it clear that the ATSB cannot apportion blame, assist in determining liability or, as a general rule, assist in court proceedings. Its sole focus remains the prevention of future accidents and the improvement of safety.
The TSI Act also sets out the independence of the ATSB, in the interests of avoiding conflicts of interest and external interference in its role in transport safety investigation, research and analysis, and fostering public awareness of transport safety.
The ATSB maintains a national information dataset of all safety-related occurrences in aviation and accidents, and significant safety occurrences in the rail and marine sectors. The information it holds is essential to its capacity to analyse broad safety trends and to inform its investigation and safety education work.
The ATSB participates in overseas investigations involving Australian-registered aircraft and ships, and cooperates more broadly with its overseas counterparts.
The ATSB has a specific mandate to report publicly on its analysis and investigations, and to conduct public education programs to improve transport safety.
The ATSB’s role
While independent, the ATSB is accountable to Parliament through the Minister for Infrastructure, Transport and Regional Development. Consistent with the Minister’s Statement of Expectations, the ATSB gives primacy to transport safety investigations that have the potential to deliver the greatest public benefit. The ATSB does this through:
- receiving and assessing reports of transport safety matters, including notifications of safety occurrences and confidential reporting
- independently conducting ‘no-blame’ investigations of accidents and other safety occurrences
- conducting research into transport statistics and technical issues
- identifying factors that contribute to accidents and other safety occurrences that affect, or have the potential to affect, transport safety
- encouraging safety action in response to safety factors by acknowledging action taken by operators, and by issuing safety recommendations and advisory notices
- raising awareness of safety issues by reporting publicly on investigations and conducting educational programs
- assisting Australia to meet its international regulatory and safety obligations, and conducting an active program of regional engagement with other transport safety agencies.
The ATSB’s objectives
In fulfilling its role of improving transport safety and cooperating with others, the ATSB:
- focuses its resources in the areas that are most likely to result in safety improvements
- harnesses the expertise and information necessary to perform its safety role
- conducts impartial, systemic and timely investigations
- identifies safety issues clearly and objectively without attributing blame or liability
- ensures the significance of safety issues are clearly understood by all concerned
- promotes effective safety action.
Cooperation with the transport industry
The ATSB works cooperatively with the aviation, rail and marine industries, as well as with transport regulators and governments at state, national and international levels, to improve safety standards for all Australians.
The ATSB relies on its ability to build trust and cooperation with the transport industry and the community for its success in improving safety. The TSI Act requires the ATSB to cooperate with government agencies, private organisations and individuals who have transport safety functions and responsibilities, or who may be affected by the ATSB’s transport safety activities. The ATSB also cooperates with equivalent national bodies in other countries and international organisations with responsibilities for worldwide transport safety standards.
The ATSB actively targets communications to ensure that transport industry stakeholders understand the importance of no-blame investigations. In order to cultivate a strong reporting culture within the transport industry, the ATSB promotes an appropriate level of confidentiality and protection for sensitive safety information provided during the course of an investigation.
Mandatory occurrence reporting
The TSI Act requires any responsible person who has knowledge of any accident or serious incident (or any immediately reportable matter) to report it as soon as it is reasonably practicable. Immediately reportable matters also require a written notification within 72 hours, as do safety incidents (or routine reportable matters).
While the terms of this requirement may seem broad, the Transport Safety Investigation Regulations 2003 (TSI Regulations) provide a list of persons who, by the nature of their qualifications, experience or professional association, would be likely to have knowledge of an immediate or routine reportable matter for their mode of transport.
In addition, responsible persons are not required to report a transport safety matter if they believe, on reasonable grounds, that another responsible person has already reported, or is in the process of reporting, that matter.
The ATSB maintains a 24-hour service to receive notifications, including a toll-free telephone number (for immediately reportable matters in all modes). In aviation, a secure online form for written notifications is available on the ATSB website. In rail, as of 1 July 2019, all immediately notifiable matters are reported to the ONRSR, who then report to the ATSB (prior to this date the telephone notifications came to the ATSB first). The written notifications are provided to the ATSB via reporting to the ONRSR. In marine, both immediately reportable and routine reportable matters are reported to the ATSB via AMSA.
Every year the ATSB’s notifications team receives more than 16,000 notifications of safety occurrences. These are spread over aviation, marine and rail. Inevitably, there are duplicate notifications and many of the notifications submitted are about matters not required to be reported under the TSI Act. Nevertheless, each one is reviewed and recorded.
In 2019–20, the ATSB’s notifications team received 17,017 aviation notifications, 663 rail notifications and 234 marine notifications in the form of telephone calls, emails and website contact. From those, the team has identified 6,113 aviation and 234 marine accidents, serious incidents and incidents for the year. In rail, all 663 notifications were processed as a reportable matter.
While not all reported occurrences are investigated, the details of each occurrence are retained within the ATSB’s occurrence database. These records are a valuable resource, providing a detailed portrait of transport safety in Australia. The ATSB regularly analyses the database to identify emerging trends and issues. The searchable public version of the aviation occurrence database is available on the ATSB website at www.atsb.gov.au and contains data from July 2003 onwards. The online database is used by industry, academics, the media and regulators to search and research past events.
The ATSB investigates accidents and incidents involving civil aircraft in Australia and Australian-registered aircraft overseas. It does so in a manner consistent with the Convention on International Civil Aviation (Chicago Convention 1944) Aircraft Accident and Incident Investigation (Annex 13). The ATSB also assists with the investigations of overseas agencies involving Australian-registered aircraft and may assist with foreign aircraft if an overseas investigation authority seeks assistance and the ATSB has suitable resources available. The ATSB may also have observer status in important overseas investigations. This provides valuable opportunities to learn from overseas organisations and to benchmark knowledge and procedures against counterpart organisations.
The ATSB analyses data on all notified accidents and incidents. It conducts research into specific matters of concern that emerge from data analysis, and specific incidents or matters that may be referred by other organisations. The ATSB cooperates with organisations that are best placed to improve safety, such as CASA, Airservices Australia and the DFSB, as well as aircraft manufacturers and operators. The ATSB also works collaboratively with the Department of Infrastructure, Transport, Regional Development and Communications and other safety agencies to assist the Australian Government in implementing transport safety initiatives.
The ATSB investigates incidents and accidents involving Australian-registered ships anywhere in the world, and foreign ships in Australian waters or en route to Australian ports.
The ATSB works cooperatively with international regulatory authorities, AMSA and other transport safety investigation agencies, as well as ship owners and operators.
Marine investigations are conducted in a manner consistent with the International Maritime Organization’s Casualty Investigation Code.
The ATSB publishes and distributes a range of marine transport safety reports and safety educational material to the international maritime community, the International Maritime Organization, educational institutions, and maritime administrators in Australia and overseas.
From 1 July 2018, AMSA’s regulator role extended to include service delivery for all domestic commercial vessels (DCVs) as part of the Council of Australian Governments’ 2011 national maritime reforms. The national reforms do not include funding for the ATSB to conduct DCV investigations, so the ATSB’s marine jurisdiction continues to be limited to interstate and overseas shipping.
As of 1 July 2017, the ATSB became the single national rail safety investigator for all states and territories in Australia.
This role includes collecting occurrence information, analysing data, and investigating rail transport safety matters on the metropolitan, regional and freight networks.
The ATSB works cooperatively with organisations such as the ONRSR and rail operators – all of whom share a responsibility to improve safety. The ATSB also has collaboration agreements with New South Wales (NSW Office of Transport Safety Investigations – OTSI) and Victoria (Victorian Office of Chief Investigators – CITS) state safety investigation organisations.
Specialist investigation capabilities
Material failure analysis
The ATSB maintains in-house capabilities for examining any physical evidence relating to transport safety investigations. The group of engineering specialists comprise experts across multi-disciplinary engineering fields to conduct forensic analysis of components and structures from aviation, rail and marine occurrences at the ATSB’s engineering facility in Canberra. The experts collaborate with other ATSB investigators, external stakeholders and subject matter experts from similar agencies around the world to provide detailed insight into the often complex set of technical factors that contribute to transport safety occurrences.
Data and recorder recovery
The ATSB maintains a centre of excellence for aviation, marine and rail ‘black box’ data recovery and analysis. Flight data recorders, cockpit voice recorders, quick access recorders, ground proximity warning systems, voyage data loggers and train data loggers can all be downloaded and analysed at the ATSB.
The data from other electronics installed in aircraft, such as GPS, mobile phones and digital cameras, can also be recovered using in-house chip recovery expertise.
The ATSB has investigators with qualifications and specialist expertise in the capabilities and limitations of human performance in relation to the design, manufacture, operation and maintenance of products and systems. Human factors are a core component of every ATSB safety investigation and this area includes the examination of elements such as decision-making, focus of attention, the role of workload and fatigue management.
Licensed aircraft maintenance engineers
The ATSB employs a number of investigators with a background as licensed aircraft maintenance engineers to undertake technical work necessary for investigations into aviation accidents and incidents. These investigators combine their extensive industry knowledge of the installation, maintenance and repair of aircraft, aircraft systems, structure and surfaces to determine whether any part of the aircraft system contributed to an occurrence.
Other transport specialists
ATSB investigators come from a variety of backgrounds and have a range of specialist skills, which are combined to ensure investigations are considered from multiple angles. In addition to those mentioned above, specialists on staff at the ATSB include:
- aeronautical, mechanical and civil engineers
- ship captains and officers
- ship engineers
- train drivers
- rail signal and system experts
- data scientists.
The strength of the ATSB’s investigation analysis, and its findings, rests on the ability to collect as much data as possible about and from an accident. In addition to the expertise of its investigators, the ATSB incorporates technology to collect and process information about accident sites. This technology includes 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.
Since 2010, the ATSB has used FARO Focus 3D laser site scanning equipment. This equipment has allowed accident sites and vehicles to be captured from ground level in high detail, enabling analysis of the accident site and for the development of accurate stakeholder engagement materials such as 3D models and re-creations of accident sequences.
Since 2017, the ATSB’s RPAS program has complemented laser scanning, allowing the agency to capture larger areas and angles that would not otherwise have been possible without a helicopter. Under a remotely piloted aircraft operator's certificate (ReOC), issued by CASA, the ATSB operates a fleet of six DJI Phantom 4 series aircraft. These aircraft, located in ATSB’s offices across Australia, assist in conducting initial site safety assessments, capture of photogrammetric site mapping data and other on-site evidence collection. Eighteen personnel have been trained to operate these aircraft and gather data.
To support both these technologies the ATSB makes use of a highly accurate differential GPS data unit, allowing personnel to record the location and dimensions of wreckage, ground scars and key points on the accident site more precisely. This data can also more accurately position images and models captured on an accident site.
The ATSB is able to post-process data using a variety of software applications, including Pix4DMapper, FARO Scene, Trimble GPS Pathfinder office and Google Earth Pro, facilitating access to highly accurate and useable information.
As new technologies, software and equipment become available the ATSB seeks to embrace their use to provide our investigators with the best available tools.
Range of investigation and other products
The ATSB produces a final report for all its investigations. Reports communicate important safety issues, safety actions and information, and provide transparency into the ATSB investigation process.
The main products produced are occurrence investigations, occurrence briefs, safety studies and statistical reports. The ATSB also produces an up-to-date online searchable aviation occurrence database and weekly summaries of marine occurrences and concerns raised via the REPCON (confidential reporting) system.
Occurrence investigations typically examine a single accident or incident in detail. The sequence of events and factual background information are documented, and findings are presented along with a safety analysis to explain those findings. These investigations may identify safety issues – ongoing systemic risks to safety – and the safety actions taken by organisations to address these safety issues. The ATSB may also issue formal safety recommendations.
Safety studies typically investigate multiple occurrences of a similar nature, or a potential or emerging safety issue. Conducted as an investigation under the TSI Act, they aim to uncover safety issues through the analysis of occurrence and other data.
The ATSB produces official Australian aviation occurrence statistics each year, and aviation wildlife strike statistics every two years. The ATSB also conducts trend monitoring of all aviation occurrences – the results of which are used to help decide which occurrences the ATSB investigates and which safety studies are conducted. Statistical reports are not conducted under the TSI Act.
Introduced in 2018, occurrence briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation.
The ATSB’s response to reported safety matters is classified by the level of resources and/or time they require, as well as their complexity. The following safety investigation levels were used by the ATSB for occurrence investigations and safety studies in 2019–20. Each level presented below (in order) builds on the previous level.
Short investigations are limited-scope and generally office-based investigations conducted under the TSI Act. Investigation activities generally include sourcing photos and documentation of any transport vehicle damage and/or the accident site, interviews with involved parties, the collection of documents, such as procedures, and internal investigations by manufacturers and operators. Occurrences investigated are normally simple and common accidents and incidents. A short summary report of up to eight pages will be produced, which includes a description of the sequence of events, limited contextual factual information, a short analysis and findings. Findings include safety factors (events and conditions that increase risk) which are limited to those relating to the occurrence. Any proactive safety actions taken by industry will also be reported. Short investigations usually require only one ATSB staff member.
Defined investigations may involve in-the-field activity or may be conducted as an office-based investigation. They require numerous ATSB resources and result in an agreed-scope product with a limited set of findings and a defined-size report. Evidence collected for defined investigations can also include recorded information, multiple interviews, analysis of similar occurrences, and a review of procedures and other risk controls related to the occurrence or set of occurrences. Occurrences investigated are generally less complex accidents and incidents. Investigation reports are typically 10–20 pages, with an expanded analysis to support the broader set of findings that may also include safety factors not relating directly to or contributing to the occurrence(s). Defined investigations may also identify safety issues (safety factors with an ongoing risk) relating to ineffective or missing risk controls. Identified safety issues are documented in the investigation report, along with proactive safety action taken by industry and ATSB safety recommendations.
Systemic investigations generally involve in-the-field activity, and a range of ATSB and possibly external resources. They are less confined in scope and will involve a significant effort collecting evidence across many areas. The breadth of the investigation will often cover multiple organisations. Occurrences and sets of occurrences investigated normally involve very complex systems and processes. In addition to investigating failed and missing risk controls, systemic investigations also investigate the organisational processes, systems, cultures and other factors that relate to those risk controls, including from the operator, regulator, and certifying and standards authorities. Systemic investigations result in substantial reports, often with several safety issues identified.
For the purpose of reporting against key deliverables and key performance indicators, ‘complex investigations’ refer to the combination of ‘defined’ and ‘systemic’ investigations.
Major investigations are reserved for very significant accidents and are likely to involve significant ATSB and external resources and additional one-off government funding. They result in a comprehensive report.
Confidential reporting (REPCON)
The ATSB operates the voluntary and confidential reporting scheme (REPCON) for the aviation, rail and marine industries. Any person within these industries, or member of the travelling public, may submit a REPCON report of a reportable safety concern. The scheme is designed to capture safety concerns – including unsafe practices, procedures and risk controls within an organisation or affected part of the industry.
Each reported safety concern is de-identified by the ATSB by removing all personal details concerning the reporter and any individual named in the report. This de-identified text is passed back to the reporter, who must authorise the content before the REPCON can be proceeded further. The de-identified text is then forwarded to the relevant organisation that is best placed to address the safety concern. The organisation’s response will then be forwarded to the relevant regulator for further action, as deemed necessary.
The aim of the REPCON scheme is to ensure safety action is taken to address the reported safety concerns. This can include variations to standards, orders, practices and procedures, or an education campaign. The ATSB may use the de-identified version of the reported safety concern to issue an information brief or alert bulletin to whichever person or organisation is best placed to take safety action in response to the safety concern. The ATSB publishes the outcome of each REPCON on its website.
The ATSB is committed to close engagement with its international counterpart agencies and relevant multilateral organisations. In line with Australian Government policy, the ATSB places a specific emphasis on engagement with countries in the Asia Pacific region, particularly with Indonesia and Papua New Guinea.
The ATSB is actively involved in the work of the International Civil Aviation Organization (ICAO), specifically the ICAO Asia Pacific (APAC) Accident Investigation Group (AIG) and the International Maritime Organization (IMO). The ATSB is an active member of ITSA, with Chief Commissioner, Greg Hood as the current Chair. Australia was due to host the annual ITSA meeting in May 2020, however this was postponed due to COVID-19.
The ATSB continues to make its expertise and resources widely available in support of transport safety. Representatives from Timor-Leste, Taiwan, Philippines, Singapore, Malta, Indonesia and New Zealand visited the ATSB for discussions related to transport safety over this reporting period. In addition, participants from Papua New Guinea, Hong Kong, South Korea, the Maldives, Malaysia, Timor-Leste and Singapore attended specialist investigator training courses at the ATSB.
Every year the ATSB cooperates with international state aviation investigation agencies, in accordance with clause 5.18 of Annex 13 to the Convention on International Civil Aviation, by appointing accredited representatives to their investigations that involve an Australian registered aircraft, an Australian operator, or an Australian manufacturer.