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Australian Transport Safety Bureau Annual Report 2020-21

Report on performance

This section reviews the ATSB’s results against the performance criteria set out in the Portfolio Budget Statements 2020–21 and the ATSB Corporate Plan 2020–21. The ATSB’s effectiveness in achieving planned outcomes during 2020–21 is also reviewed here.

Annual performance statement

I, as the accountable authority of the Australian Transport Safety Bureau, present the annual performance statement of the Australian Transport Safety Bureau for the year ended 30 June 2021, as required under paragraph 39(1)(a) of the Public Governance, Performance and Accountability Act 2013 (PGPA Act). In my opinion, this annual performance statement is based on properly maintained records, accurately reflects the performance of the entity, and complies with subsection 39(2) of the PGPA Act.

Angus Mitchell
Chief Executive Officer

1 October 2021

Results against performance criteria

Table 1: Results against performance criteria

Purpose
As set out in the Portfolio Budget Statements 2020–21, the ATSB’s purpose is defined by its mission statement: Improve transport safety for the greatest public benefit through our independent investigations and influencing safety action.
In reference to the public benefit: The ATSB focuses on the public interest where the safety of passengers and workers on an aircraft, train or ship is concerned. The ATSB focuses on the public interest when it comes to the significant costs that can result from an accident, particularly where there is significant damage to public infrastructure or an impact on the national economy.
Performance Criterion	Target for 2020–21	Result	Page
Number of safety issues that are addressed through safety action.	65% of safety issues addressed in the last financial year	56% of safety issues identified in 2020–21 adequately addressed through safety action	29
	85% of safety issues addressed in the previous financial year	72% of safety issues identified in 2019–20 adequately addressed through safety action	29
Number of systemic, defined, and safety study investigations completed by ATSB that identify safety issues.	65% of investigations identify a safety issue	59% of systemic, defined, and safety study investigations completed in 2020–21 identified safety issues	30
Percentage of all investigations that identify at least one safety issue not already identified by others.	Establish a baseline	Not established	31
On an average annual basis, the ATSB will be conducting around twice the number of investigations as it has available investigators.	Projecting 90 active investigations	An average of 89 active investigations	32
Median time to complete investigations.	Short: 9 months	11.4 months	33
	Defined: 18 months	20.7 months	33
	Systemic: 24 months	36.9 months	33
Number of changes to the ATSB’s published investigation findings over the previous financial year.	Zero	Zero	34

Performance at a glance

New performance criteria for the ATSB were introduced in 2020–21. The new criteria aim to:

better articulate the agency’s evolving services and contributions to transport safety
reflect the best practice recommendations from the Australian National Audit Office’s (ANAO) PGPA Act, Implementation and Corporate Planning audits – ANAO report 33 2017–18 and ANAO report 36 2017–18.

The revised criteria balance effectiveness, efficiency and outputs by demonstrating the safety action taken in response to ATSB investigations, ensuring that ATSB resources are being used efficiently and that our investigations deliver the greatest public benefit. Performance results against the new performance criteria will improve as the agency works to further refine and embed these into business processes.

In a challenging year for the transport industry, the ATSB continued to focus on improving transport safety through ongoing investigations into large-scale accidents that occurred in early 2020. These investigations included:

Collision with terrain of the C-130 firefighting aircraft near Cooma, New South Wales, in January 2020.
Train derailment near Wallan, Victoria, in February 2020.
Mid-air collision of two aircraft near Mangalore, Victoria, in February 2020.
Controlled flight into terrain of a Cessna 402 aircraft at Lockhart River, New South Wales, in March 2020.

This number of investigations challenged the ATSB’s capacity to complete investigations in timeframes shorter than those outlined in its key performance indicators. There was also a significant effort made to complete older investigations during the financial year. Publication of a number of these in the financial year affected timeliness targets. These investigations included:

Collision with water involving a de Havilland Canada DHC-2 Beaver aircraft, VH‑NOO, 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, at Bowen Hills, Queensland, on 10 January 2018.
Loss of control and collision with water involving Eurocopter EC120B, VH-WII, Hardy Reef, Whitsundays, Queensland, on 21 March 2018.
Loss of cyclic control and in-flight break-up involving Robinson R22 helicopter, VH-HGU, 7 km north-north-west of Cloncurry Airport, Queensland, on 2 August 2017.
Collision with terrain involving AS350, VH-SZS, 60 km east of Woomera, South Australia, on 20 March 2019.
Fire on board Iron Chieftain, Port Kembla, New South Wales, on 18 June 2018.

The replacement of the ATSB’s obsolete investigation management system was a key focus in 2020–21. This significant and essential project required the redirection of several investigator resources to ensure the design and build of the new purpose-built system, which uses cloud technologies and software, meets the ATSB’s investigation information management needs for many years. In the short-term, fewer investigators were available to progress investigations, however, in the longer term, investigators will be able to access data and upload evidence to the new system anywhere on any device, while the removal of labour-intensive processes promises to improve our productivity.

Key results

Table 2 summarises the ATSB’s performance against key indicators published in the Portfolio Budget Statements 2020–21.

Table 2: ATSB performance against key performance indicators

Outcome
Improve transport safety for the greatest public benefit through independent investigations and influencing safety action.
Performance Criterion
Number of safety issues that are addressed through safety action.
Target		Result	Achieved
65% of safety issues addressed in the last financial year		56% of safety issues identified in 2020–21 adequately addressed through safety action	✘
85% of safety issues addressed in the previous financial year		72% of safety issues identified in 2019–20 adequately addressed through safety action	✘
Detail
Year	Number identified ¹	Number addressed
2020–21	59	33
2019–20	46	33
2018–19	54	43
Analysis
To be effective against the ATSB’s purpose, safety action needs to be taken once safety issues are identified by ATSB investigations. This performance criterion measures the effectiveness of the ATSB to influence entities to address identified safety issues and therefore improve transport safety. Safety issues: can reasonably be regarded as having the potential to adversely affect the safety of future operations are characteristic of an organisation or a system, rather than a characteristic of a specific individual, or characteristic of an operational environment at a specific point in time. Some safety issues will take time to be actioned by stakeholders. We expect that some safety issues not actioned in the year they are identified will be addressed the ensuing year. There also needs to be some tolerance for a minority of safety issues identified not being actioned. The ATSB does not have powers to force operators, manufacturers and regulators to take action – the ATSB relies on its ability to influence. The ATSB is currently putting in place systems which will allow for easier identification of safety actions that have not been addressed. As this is the first year of measuring this performance criterion, it has been retrospectively applied to previous financial years for comparative purposes. Further details of the safety issues identified and actioned in 2020–21 are included in Section 5 – Formal safety issues and actions.
Data source: The ATSB’s investigation management system.
Methodology: Analysis of safety issues identified through investigations and safety studies that have been addressed through safety action.
Reference: 2020–21 Portfolio Budget Statements, page 244; 2020–21 Corporate Plan, page 12.

¹ Includes safety issues identified by rail investigations conducted on behalf of the ATSB by OTSI NSW and CITS Victoria. The figures do not include safety issues which have been closed (no longer relevant).

Outcome
Identify safety issues additional to those identified by industry and government safety agencies for the greatest public benefit through ATSB occurrence investigations and safety studies.
Performance Criterion
Number of systemic, defined, and safety study investigations completed by ATSB that identify safety issues.
Target		Result		Achieved
65% of investigations identify a safety issue		59%		✘
Detail
Investigation type	Year	Number completed ²	Number with safety issues
Defined investigations
All modes	2020–21	32	16
	2019–20	34	10
	2018–19	19	6
	2017–18	18	2
Systemic investigations
All modes	2020–21	7	7
	2019–20	13	6
	2018–19	14	12
	2017–18	14	4
Analysis
To be effective against the ATSB’s purpose, the ATSB needs to demonstrate value through the identification of safety issues. This performance criterion measures the effectiveness of the ATSB in identifying safety issues so that others can act and therefore improve transport safety. Defined investigations may include safety issues, and systemic investigations will likely identify several safety issues. Safety studies may be either defined or systemic investigations, and may be referred to as safety issues or research investigations conducted under the TSI Act by ATSB. Improvements to investigation management processes in 2020–21 resulted in a 25% increase in the number of investigations which identify a safety issue compared with the level achieved in 2019–20. There has been a 40% increase in the number of investigations which identify a safety issue compared with the level achieved in 2017–18. As this is the first year of measuring this performance criterion, it has been retrospectively applied to previous financial years for comparative purposes. Examples of investigations with identified safety issues (AO-2017-118, AO-2018-026, RO-2018-002, RO-2019-002, 346-MO-2018-011) are summarised in Section 4 – Significant safety investigations. Further details of the safety issues identified and actioned in 2020–21 are included in Section 5 – Formal safety issues and actions.
Data source: The ATSB’s investigation management system.
Methodology: Analysis of investigations containing a safety issue.
Reference: 2020–21 Portfolio Budget Statements, page 244; 2020–21 Corporate Plan, page 13.

² Includes occurrence, safety issues and research investigations conducted under the TSI Act by ATSB. The figures do not include rail investigations conducted on behalf of the ATSB by OTSI NSW and CITS Victoria or assistance to investigations conducted by an external party. Note, in 2016–17 and earlier, ATSB annual reports include assistance to investigations conducted by an external party. The figures will, therefore, appear higher in previous annual reports. Note, previous ATSB annual reports reported ‘complex investigations’ to refer to the combination of ‘defined’ and ‘systemic’ investigations.

Outcome
Identify safety issues additional to those identified by industry and government safety agencies for the greatest public benefit through ATSB occurrence investigations and safety studies.
Performance Criterion
Percentage of all investigations that identify at least one safety issue not already identified by others.
Target	Result	Achieved
Establish a baseline	Baseline not established and will be completed in 2021–22	–
Analysis
To be effective against the ATSB’s purpose, the ATSB needs to demonstrate value and relevance through the identification of safety issues not already identified by others. As an independent agency, the ATSB can investigate where others cannot. This performance criterion measures the effectiveness of the ATSB in identifying systemic safety issues across transport systems so that others can act and therefore improve transport safety. With investigator capacity reduced in 2020–21 due to the redirection of resources to build the new investigation management system and staff on long-term leave, the establishment of a baseline for this performance criterion was postponed to 2021–22 which will be aided by the new investigation management system.
Data source: The ATSB’s investigation management system.
Methodology: Analysis of investigations containing a safety issue and confirmation of which safety issues were identified first by the ATSB.
Reference: 2020–21 Portfolio Budget Statements, page 244; 2020–21 Corporate Plan, page 13.

Outcome
Efficiently use resources to conduct investigations through selective investigation processes and project management discipline.
Performance Criterion
On an average annual basis, the ATSB will be conducting around twice the number of investigations as it has available investigators.
Target	Result	Achieved
Projecting 90 active investigations	An average of 89 active investigations	✔
Detail

Analysis
To be efficient against the ATSB’s purpose, the ATSB needs to ensure that limited resources are prioritised to investigations with the broadest safety effect on transport systems. This performance criterion measures the efficiency of the ATSB in balancing investigation demand (the number of investigations commenced each year) and capacity (resources available to complete investigations). The target is consistent with resourcing and investigation output expectations for similar investigation agencies internationally. The ATSB’s workload over the previous three reporting periods, with investigation numbers well in excess of 100 active investigations, demonstrates demand has been greater than capacity, resulting in a large volume of older investigations. The impact of COVID-19 on the transport industry has enabled a focus on completing older investigations to achieve an average of 2 active investigations per investigator conducted in 2020–21. During 2020–21, the ATSB intended to set a baseline target for the cost of investigations to be calculated considering recorded labour inputs. With investigator capacity reduced in 2020–21 due to the redirection of resources to build the new investigation management system and staff on long-term leave, the establishment of a baseline for this performance criterion was postponed to 2021–22.
Data source: The ATSB’s investigation management system and workforce planning records.
Methodology: Quarterly reviews of investigations compared to the number of available investigators. Investigators may be unavailable due to extended leave, training or diversion to enabling projects.
Reference: 2020–21 Portfolio Budget Statements, page 244; 2020–21 Corporate Plan, page 13.

Outcome
ATSB safety-related information is shared in a timely manner for the benefit of those needing awareness of relevant hazards, risks and trends or taking safety action, through publishing information in accordance with committed timeframes.
Performance Criterion
Median time to complete investigations
Target		Result		Achieved
Short investigations	9 months	11.4 months		✘
Defined investigations	18 months	20.7 months		✘
Systemic investigations	24 months	36.9 months		✘
Detail
Investigation type	Year	Number completed ³	Median time to complete investigations (in months)
Short investigations
All modes	2020–21	23	11.4
	2019–20	22	12.9
	2018–19	34	10.3
	2017–18	43	5.3
Defined investigations
All modes	2020–21	32	20.7
	2019–20	34	22.1
	2018–19	19	18.1
	2017–18	18	15.9
Systemic investigations
All modes	2020–21	7	36.9
	2019–20	13	33.1
	2018–19	14	27.0
	2017–18	14	31.9
Analysis
This performance criterion focuses on the timeliness of the ATSB’s investigation products. Timely sharing of safety information is important for our stakeholders with responsibility for managing risk. The result indicates the concerted efforts made during 2020–21 to clear the backlog of older investigations, and this is reflected in the median times taken to complete investigations being above the targets. As this is the first year of measuring this performance criterion, it has been retrospectively applied to previous financial years for comparative purposes, noting that there have been adjustments to the definitions of short, defined and systemic investigations over financial years.
Data source: The ATSB’s investigation management system.
Methodology: Calculation of median time (from decision to investigate to publication).
Reference: 2020–21 Portfolio Budget Statements, page 244; 2020–21 Corporate Plan, page 14.

³ Includes occurrence, safety issues and research investigations conducted under the TSI Act by ATSB. The figures do not include rail investigations conducted on behalf of the ATSB by OTSI NSW and CITS Victoria or assistance to investigations conducted by an external party. Note, in 2016–17 and earlier, ATSB annual reports include assistance to investigations conducted by an external party. The figures will, therefore, appear higher in previous annual reports.

Outcome
Investigations of transport occurrences, safety studies are defendable, to ensure industry and government confidence in the ATSB’s work, through the use of evidence-based and systemic investigation processes.
Performance Criterion
Number of changes to the ATSB’s published investigation findings over the previous financial year
Target		Result		Achieved
Zero		Zero		✔
Detail
Investigation type	Year	Number completed ⁴	Number of changes to published findings
Short investigations
All modes	2020–21	23	0
	2019–20	22	0
	2018–19	34	0
	2017–18	43	0
Defined investigations
All modes	2020–21	32	0
	2019–20	34	0
	2018–19	19	0
	2017–18	18	0
Systemic investigations
All modes	2020–21	7	0
	2019–20	13	0
	2018–19	14	0
	2017–18	14	0
Analysis
The ATSB is committed to ensuring that all published investigations are factually accurate, defendable and evidence-based, with the accuracy of the public record for all investigation findings continuing to be maintained. 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.
Data source: The ATSB’s investigation management system.
Methodology: Review of investigations published during the previous financial year.
Reference: 2020–21 Portfolio Budget Statements, page 244; 2020–21 Corporate Plan, page 14.

⁴ Includes occurrence, safety issues and research investigations conducted under the TSI Act by ATSB. The figures do not include rail investigations conducted on behalf of the ATSB by OTSI NSW and CITS Victoria or assistance to investigations conducted by an external party. Note, in 2016–17 and earlier, ATSB annual reports include assistance to investigations conducted by an external party. The figures will, therefore, appear higher in previous annual reports. Note, previous ATSB annual reports reported ‘complex investigations’ to refer to the combination of ‘defined’ and ‘systemic’ investigations.

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