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How the ATSB reports

Section 63A of the TSI Act requires that:

The annual report prepared by the Chief Executive Officer and provided to the Minister under section 46 of the Public Governance, Performance and Accountability Act 2013 (PGPA Act) for a period must include the following:

  • prescribed particulars of transport safety matters investigated by the ATSB during the period
  • a description of investigations conducted by the ATSB during the period that the Chief Commissioner considers raises significant issues in transport safety.

The ATSB observes and complies with Resource Management Guide No 135—Annual report for non-corporate Commonwealth entities issued by the Department of Finance.

This annual report details the ATSB’s performance against the program objectives, deliverables and key performance indicators published in the Infrastructure, Regional Development and Communications Portfolio Budget Statements 2020–21. The ATSB annual report also includes audited financial statements in accordance with the PGPA Act.

Priorities for investigation

The ATSB focuses on transport safety as the highest priority. In 2020–21, the ATSB gave priority to transport safety investigations that have the potential to deliver the best safety outcomes for the travelling public. A new Statement of Expectations from the Minister for Infrastructure, Transport and Regional Development, provided to the ATSB in June 2021, sets the direction for the ATSB to give priority to transport safety investigations that have the highest risk or potential to deliver the greatest public benefit through systemic improvements to transport safety. The evolution in the ATSB’s mission from focusing on the travelling public to driving safety that is for the greatest public benefit is necessary to reflect the contribution the ATSB makes to preventing loss of life, as well as avoiding significant local, state and national economic costs that can be associated with an accident. The ATSB is not resourced to investigate every single accident or incident that is reported but allocates priorities within the transport modes to ensure that investigation effort achieves the best outcomes for safety improvement. The ATSB recognises that there is often more to be learned from serious incidents and patterns of incidents, and gives focus to these investigations, as well as specific accident investigations.

Three ways to action

The TSI Act requires specified people and organisations to report to the ATSB on a range of safety occurrences (called ‘reportable matters’). Reportable matters are defined in the TSI Regulations. In principle, the ATSB can investigate any of these reportable matters. In practice, they are actioned in one of three ways to contribute to the ATSB’s functions:

  1. A report of an occurrence that suggests a safety issue may exist will be investigated immediately (occurrence investigation). Investigations may lead to the identification/confirmation of the safety issue and evaluation of its significance. It will then set out the case for safety action to be taken in response.
  2. A report of an occurrence that does not warrant full investigation may benefit from an office-based short investigation for safety education and promotion, and enable a richer dataset for future safety analysis, to identify safety issues or trends (such as inclusion in a safety study).
  3. Basic details of an occurrence, based primarily on the details provided in the initial occurrence notification, will be recorded in the ATSB’s occurrence database to be used in future safety analysis to identify safety issues and trends (including safety studies), and in aviation, will be available in the online searchable occurrence database. These may be published individually as occurrence briefs.

Aviation broad hierarchy

The ATSB allocates its investigation resources to be consistent with the following broad hierarchy of aviation operation types:

  1. passenger transport – large aircraft
  2. passenger transport – small aircraft:
    a) regular public transport and charter of small aircraft
    b) humanitarian aerial work (for example, the Royal Flying Doctor Service, search and rescue flights)
  3. commercial with passengers (fare-paying and recreation – for example, joy flights)
  4. aerial work with participating passengers (for example, news reporters, geological surveys)
  5. flying training
  6. other aerial work:
    a) non-passenger carrying work (for example, agriculture, cargo)
    b) private transport or personal business
  7. higher-risk personal recreation/sports aviation/experimental aircraft operations.

The ATSB endeavours to investigate all fatal accidents involving VH-registered powered aircraft subject to the potential transport safety learnings and resource availability.

Marine broad hierarchy

The ATSB allocates its investigative resources to be consistent with the following broad hierarchy of marine operation types:

  1. passenger operations
  2. freight and other commercial operations
  3. non-commercial operations.

Rail broad hierarchy

The ATSB allocates its investigative resources to be consistent with the following hierarchy of rail operation types:

  1. mainline operations that impact on passenger services
  2. freight and other commercial operations
  3. non-commercial operations.

Level of response

The level of investigative response is determined by resource availability and factors such as those detailed below. These factors (expressed in no particular order) may vary in the degree to which they influence the ATSB’s decisions to investigate and respond. Factors include:

  • the anticipated safety value of an investigation, including the likelihood of furthering the understanding of the scope and impact of any safety system failures
  • the likelihood of safety action arising from the investigation, particularly of national or global significance
  • the existence and extent of fatalities/serious injuries and/or structural damage to transport vehicles or other infrastructure
  • the unique value an ATSB investigation will provide over any other investigation by industry, regulators or police
  • the obligations or recommendations under international conventions and codes
  • the nature and extent of public interest – in particular, the potential impact on public confidence in the safety of the transport system
  • the existence of supporting evidence, or requirements, to conduct a special investigation based on trends
  • the relevance to identified and targeted safety programs
  • the extent of resources available, and projected to be available, in the event of conflicting priorities
  • the risks associated with not investigating – including consideration of whether, in the absence of an ATSB investigation, a credible safety investigation by another party is likely
  • the timeliness of notification
  • the training benefit for ATSB investigators.