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Management and accountability

The Commission

The ATSB is governed by a Commission, comprising a Chief Commissioner and three part-time Commissioners.

The Commission provides guidance on the selection of accidents and other safety incidents to be investigated. The Commission is responsible exercising the power to publish reports of accident investigations. It also supports the ATSB in encouraging safety action ahead of final reports, thus reducing the need to issue safety recommendations.

The Commission operates within the corporate governance framework of the ATSB Commission Governance Manual. The manual sets out the Commission’s legislative requirements, parliamentary and ministerial accountability, membership and functions, administrative policies and procedures, and reporting obligations.

The Commission meets face-to-face at least four times a year and manages ATSB business through regular teleconferences and electronic communications in accordance with its obligations under the TSI Act and its agreed policies.

Senior Leadership Team

During 2019–20, the ATSB Senior Leadership Team (SLT) met fortnightly to discuss strategic management issues and priorities. The SLT consisted of the Chief Commissioner, the Executive Director Transport Safety, the Chief Operating Officer, the Directors Transport Safety and the Directors Operational Support.

Audit and Risk Committee

In 2019–20, the Committee advised and provided assurance on a range of matters including the ATSB’s:

  • Internal Audit Annual Program
  • enterprise risk management, fraud control and business continuity frameworks
  • performance reporting
  • financial statement preparations
  • work health and safety management
  • compliance with the PGPA Act and the associated Rule
  • internal audit governance framework – including the Internal Audit Charter and Internal Audit Strategic Plan 2018–20.

The internal audit program for 2019–20 focused on assuring the ATSB’s legislative compliance and performance against its core functions. The program included the following internal audits:

  • targeted control review – monitoring safety recommendations
  • funding model arrangements
  • the ATSB’s performance measures
  • enterprise risk management.

The Audit and Risk Committee is monitoring the implementation of the recommendations coming out of the Australian National Audit Office’s (ANAO) efficiency audit of the ATSB in 2018–19. A copy of the Audit and Risk Committee Charter is available on the ATSB website at www.atsb.gov.au.

Business planning and reporting

Each year, the ATSB develops an Annual Plan to set business objectives for the financial year. The Annual Plan is consistent with the strategic direction provided through the Corporate Plan, published on the ATSB website. The Annual Plan incorporates the operational priorities, activities, deliverables and key performance indicators for the financial year.

The ATSB Annual Plan 2019–20 gave priority to:

  • safety data recording, analysis and data sharing
  • occurrence and safety issue investigations of accidents, serious incidents and other occurrences
  • communication and education
  • maintaining and enhancing capability and readiness
  • strategic projects
  • managing ATSB resources.

Risk management

Consistent with the PGPA Act, the ATSB maintains a risk management framework. The framework includes a Risk Management Policy, Risk Management Strategy, Risk Management Plan and Enterprise Risk Register. The framework is an integral element of the ATSB’s broader governance, planning and management framework. The ATSB has integrated risk assessment and mitigation into business practices, planning and performance reporting – at both corporate and business unit levels.

The ATSB is committed to a comprehensive, coordinated and systematic approach to the management of risk – directed towards supporting managers at all levels to anticipate and plan for risk, and to respond appropriately. For 2019–20, the ATSB focused on risks related to capability, reputation, health and safety, and jurisdictional reach.

During 2019–20, the ATSB undertook a comprehensive review of its risk management framework. The ATSB collaborated with an IT service provider to develop an online risk management system, which will allow risks to be managed and viewed electronically. The system will be rolled out to staff in 2020–21.

Business continuity plan

The ATSB’s business continuity management framework details the policies and procedures for the agency to respond to a business disruption. The framework ensures the ATSB is well-placed to implement recovery processes and return to business‑as‑usual as quickly as possible while preserving the safety of staff and limiting the damage and disruption to business operations.

In 2019–20, the ATSB conducted a business continuity exercise to the management framework. COVID-19 has also tested the framework and lessons learnt are being incorporated into revisions.

Fraud control

In accordance with the PGPA Act, the ATSB maintains a fraud management framework which includes a Fraud Policy and Strategy Statement and a Fraud Control Plan.

The ATSB manages a fraud risk register to identify potential fraud risks and subsequently minimise the incidence of fraud. This process is accompanied by development, implementation and regular assessment of fraud prevention, detection and response strategies.

The ATSB’s staff awareness program incorporates activities for existing and new staff.

The Audit and Risk Committee and the Commission receive regular reports on fraud risks and the implementation of controls and treatments. The Committee and the Commission review the Fraud Control Plan to ensure the ATSB has appropriate processes and systems in place to capture, and effectively investigate, fraud-related information.

Ethical standards

During the reporting period, the ATSB continued to demonstrate its commitment to promoting ethical standards and behaviours relating to workplace and employment.

Initiatives for 2019–20 included:

  • providing information on the APS values, Employment Principles and Code of Conduct in induction packages and during training sessions
  • promoting the APS Values, Employment Principles and Code of Conduct through individual performance development plans
  • providing staff with access to information on ethical standards via the ATSB’s intranet and the Australian Public Service Commission’s (APSC) website
  • providing staff with guidance on Public Interest Disclosure policy and procedures
  • ensuring all staff review their conflict of interest declarations twice a year
  • providing staff with information and guidance on bullying and harassment policy and procedures
  • providing staff with training on the ATSB’s fraud control policy and procedures and acceptance of gifts and benefits policy
  • promoting the APS Values, Employment Principles and Code of Conduct in recruitment and selection activity.

Staff management

The ATSB’s workforce planning capability is maturing and is an integral component of the ATSB’s planning cycle. Ensuring we have a workforce that is flexible, engaged and has the capabilities to meet our emerging business requirements remains our priority.

During 2020, the ATSB dedicated significant time and resources to managing our response to the COVID-19 crisis, ensuring up-to-date information was available to decision makers and employees, and supports were in place for all of our employees regardless of their work location.

Initiatives for 2019–20 included:

  • a review of our human resource systems, processes and internal procedures to ensure consistency with best practice and contemporary management principles
  • the adoption of regular performance and career conversations throughout the performance and development cycle
  • leadership development opportunities, including 360-degree feedback
  • the expansion of coaching methods
  • health and wellbeing sessions and plans
  • providing data and research to support better workplace conditions and arrangements.

Staffing profile

In accordance with workforce planning projections, the ATSB’s staffing profile has remained relatively stable, from 101 at the end of June 2019 to 104 by the end of June 2020. The associated staff turnover rate was approximately 11 per cent. Table 17 displays the ATSB staff numbers, by classification, as at 30 June 2020.

Table 17: The ATSB’s staffing profile at 30 June 2020


Gender x

Female (full






Statutory office holders





Senior Executive Service (SES)




EL 2






EL 1



























This total is comprised of the following employment arrangements:

  • ninety-eight staff (representing all non-SES employees) covered by the enterprise agreement
  • two SES employees covered by section 24(1) determinations, established in accordance with the ATSB’s SES remuneration policy
  • four statutory office holders (representing the Commissioners) determined by the remuneration tribunal.

There are no other employment arrangements in place and there is no provision for performance pay.

Of the 104 SES and non-SES employees, 77 employees were based in Canberra, 13 based in Brisbane, three based in Adelaide, five based in Perth, five based in Melbourne and one based in Sydney.

Non-salary benefits provided to employees under the enterprise agreement include:

  • options for home-based work
  • ability to work part-time
  • flexible working arrangements
  • access to different leave types
  • influenza vaccinations and health checks
  • access to the Employee Assistance Program.

Indigenous employees

At 30 June 2020, the ATSB had no employees who identified as Indigenous.

Salary rates

Table 18 displays the salary rates supporting the above employment arrangements at 30 June 2020.

Table 18: The ATSB’s salary rates at 30 June 2020

Substantive classification



Statutory office holders

As determined by the remuneration tribunal
















* Maximums include transport safety investigator and respective supervisor salaries, representing a $2,083–$10,652 increase on standard APS 6–EL2 rates.

** Senior executive remuneration for the 2019–20 financial year is captured and presented through Table 22: Information about remuneration for key management personnel.

Training and development

The ATSB is committed to building a strong, capable and resilient workforce. It does so by embracing greater opportunities for learning through on-the-job activities (70%), relational learning through peers and networks (20%) and blended training (10%).

During 2019–20, the ATSB procured and implemented a learning management system. ATSB courses have been identified and prioritised for transition from face-to-face delivery to self-paced online delivery through the new learning management system. The ATSB now has a strong platform for the delivery of learning and development opportunities for staff into the future.

Initiatives for 2019–20 included:

  • 22 transport safety investigators completed the Graduate Certificate in Transport Safety Investigation through our partnership with RMIT University
  • the ATSB continued to make enhancements to its training resources and materials, and provided over 17 different face-to-face training courses to employees throughout the year
  • an induction course for new Commissioners was developed and implemented
  • 18 managers and employees undertaking a workplace coaching program
  • a new learning management system was procured and implemented, and this system integrates with the electronic performance management system
  • 11 self-paced online courses available for employees in the learning management system.


The ATSB purchases goods and services in accordance with the Commonwealth Procurement Rules (CPRs). These rules are applied through the Accountable Authority instructions. The ATSB’s procurement policies and processes have been developed to ensure that:

  • it undertakes competitive, non-discriminatory procurements
  • it uses resources efficiently, effectively, economically and ethically
  • it makes all procurement decisions in an accountable and transparent manner.


The ATSB engages consultants when it lacks specialist expertise, or when independent research, review or assessment is required. Consultants are typically engaged to:

  • investigate or diagnose a defined issue or problem
  • carry out defined reviews or evaluations
  • provide independent advice, information or creative solutions to assist in the ATSB’s decision-making.

The ATSB policies on selection and engagement of consultants are in accordance with the CPRs. Before engaging consultants, the ATSB considers the skills and resources required for the task, the skills available internally and the cost effectiveness of engaging an external contractor.

During 2019–20, three new consultancy contracts were entered into involving total actual expenditure of $23,775 (GST Inclusive). There were no ongoing consultancy contracts carried over from the 2018–19 year.

Annual reports contain information about actual expenditure on contracts for consultancies. Information on the value of contracts and consultancies is available from the AusTender website at www.tenders.gov.au

Australian National Audit Office access clauses

There were no contracts during 2019-20 that did not provide for the Auditor-General to have access to the contractors’ premises.

Exempt contracts

No contracts were exempted on public interest grounds from publication on AusTender during 2019-20.

Procurement initiatives to support small business

The ATSB supports small business participation in the Commonwealth Government procurement market. Small and medium enterprises (SME) and small enterprise participation statistics are available on the Department of Finance’s website at www.finance.gov.au

The ATSB seeks to support SMEs, consistent with paragraph 5.4 of the CPRs. It ensures that its communications are expressed in clear and simple language. Its finance system is set up to ensure prompt payments to all contractors and suppliers, and it makes use of credit cards.

Legal services and expenditure

Paragraph 11.1(a) of the Legal Services Directions 2017, issued by the Attorney-General under the Judiciary Act 1903, requires chief executives of departments and agencies to ensure that legal services expenditure is appropriately recorded and monitored. Chief executives must also ensure that their agencies make records of their legal services expenditure for the previous financial year, available by 30 October in the following financial year. The following amounts are exclusive of GST.

The ATSB’s expenditure on legal services for 2019–20 was $121,768 comprising:

  • $19,099 on external legal services
  • $102,669 on internal legal services.

External scrutiny and participation

Coronial Inquests

Findings for one coronial inquest that the ATSB had previously participated in was handed down in 2019–20.

Loss of control involving Cessna Aircraft Company U206G, VH-FRT Caboolture Airfield, Queensland, on 22 March 2014 (AO-2014-053)

The ATSB attended two hearings of an inquest conducted by State Coroner Terry Ryan in 2018. The inquest was into a matter involving a Cessna U206G aircraft, registered VH-FRT, that was being used for tandem parachuting operations at Caboolture Airfield, Queensland. On 22 March 2014, the aircraft took off from Caboolture Airfield with a pilot, two parachuting instructors and two tandem parachutists on board.

Shortly after take-off, witnesses at the airfield observed the aircraft climb to about 200 ft above ground level before it commenced a roll to the left. The left roll steepened and the aircraft then adopted a nose-down attitude until impacting the ground in an almost vertical, left-wing low attitude. All the occupants on board were fatally injured. A post‑impact, fuel-fed fire destroyed the aircraft.

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. The reason for the aerodynamic stall was unable to be determined. Extensive fire damage prevented examination and testing of most of the aircraft components. Consequently, a mechanical defect could not be ruled out as a contributor to the accident.

A number of safety issues were also identified by the ATSB. These included findings associated with occupant restraint, modification of parachuting aircraft and the regulatory classification of parachuting operations.

The current classification of parachuting as a private operation means there are fewer risk controls than for other similar aviation activities that also involve payment for carriage. Prospective tandem parachutists should be aware that accident data indicates that parachuting is less safe than other aviation activities, such as scenic flights.

The ATSB released its findings on 23 June 2017. The full ATSB investigation report (AO‑2014-053) is available on the ATSB’s website at www.atsb.gov.au.

The Coroner handed down his findings on Tuesday 20 March 2020. The Coroner agreed with the ATSB’s finding that shortly after take-off, and for reasons that could not be determined, the aircraft aerodynamically stalled at a height from which the pilot was unable to recover prior to collision with terrain. In making the finding the Coroner acknowledged the limited evidence available to determine that it was a seat slide or some other event.

The Coroner supported the recommendations of the ATSB that CASA introduce appropriate “risk control” measures in respect of parachuting operations that provide “increased assurance of aircraft serviceability, pilot competence and adequate regulatory oversight”.

Senate Rural and Regional Affairs and Transport Legislation Committee

Collision with terrain involving SOCATA TB-10 Tobago, VH-YTM, near Mount Gambier Airport, South Australia, on 28 June 2017 (AO-2017-069)

In August 2019, the ATSB published its final report into a collision with terrain involving an Angel Flight community service flight near Mount Gambier Airport in June 2017. The pilot and both passengers were fatally injured. The occurrence is highlighted in section 4 of this report: Significant Safety Investigations.

Following the release of the investigation, the Senate Rural and Regional Affairs and Transport Legislation Committee commenced an inquiry into the ATSB’s report. The Committee published its report in October 2019 and the Australian Government provided its response in November. The Australian Government noted the Committee had recognised the expert analysis conducted by the ATSB in examining Angel Flight operations. The Australian Government further acknowledged that while the Committee provided comment on whether non-passenger operations should have been included in the ATSB’s main calculations of risk, the government noted the ATSB’s focus on passenger carrying operations is consistent with the government’s Statement of Expectations for the ATSB.

The Committee did not have any recommendations for the ATSB.

Productivity Commission

In 2019, the Productivity Commission commenced an inquiry into the National Transport Regulatory Reforms involving rail, marine and heavy road vehicles. The ATSB participated in the inquiry, making two submissions and appearing in person before the Commission.

The ATSB’s involvement concerns its jurisdiction for investigating rail accidents and incidents, and inconsistencies with the funding arrangements from states and territories. The Commission also received submissions advocating a role for the ATSB in heavy road vehicles and domestic commercial vessels.

The Productivity Commission provided its report to the Australian Government in April 2020. The government has 25 sitting days from receipt of the report to table the report in both houses of parliament.

Joint Committee of Public Accounts and Audit

In November 2019, the ATSB gave evidence to an inquiry by the Joint Committee of Public Accounts and Audit (JCPAA) into Efficiency and Effectiveness audit reports by the ANAO. In 2019, the ANAO finalised a report into the efficiency of the ATSB, finding the ATSB had established key elements of an overall framework to promote efficient investigation processes. The ANAO also found that the ATSB’s 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.

JCPAA concluded in its final report handed down in June 2020:

The Committee recognises that several programs and governance structures have been put in place both during and following the audit process. As such, results in relation to timeframes have yet to be fully realised. The Committee acknowledges the efforts of the ATSB regarding benchmarking and the prioritisation of investigative resourcing.