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Fostering safety awareness, knowledge and action

This section describes the ATSB’s performance relating to the ATSB’s role in building capability, education and promotion, as published on page 8 of the ATSB Corporate Plan 2020–21.

Industry engagement and events

The ATSB works to build awareness of its functions and enhance its reputation through its communication and stakeholder engagement activities. This is vital to ensure the industry is receptive to safety messaging and that the ATSB meets its aim of fostering public awareness of transport safety. The ATSB continues its strong record of engagement with industry through:

  • participation in consultative forums with industry and other safety agencies
  • representation at conferences and events
  • bilateral engagement with operators, associations and other stakeholders
  • active involvement in safety education forums.

The ATSB regularly participates in national and international conferences and industry events where doing so presents an opportunity to share safety messages and engage with relevant stakeholders. In 2020–21, our participation was again impacted by the COVID-19 pandemic, which saw a number of planned industry engagements cancelled or postponed.

CASA FlySafe

Following on from the success of the joint FlySafe 2019 safety forum delivered in 2018–19, the ATSB is a regular participant in CASA’s newly launched FlySafe forums, which began nationally during the reporting period.

In joining with CASA, Airservices Australia, Bureau of Meteorology, and Department of Defence, the ATSB presented to a wide range of aviation industry participants under the FlySafe banner, with a key focus on influencing the fitment of active carbon monoxide detectors in piston-engine aircraft. FlySafe was held in Adelaide and Darwin during 2020–21, with further forums scheduled in Brisbane, Melbourne, Perth and Sydney during 2021–22.

International Convention of Aviation Regulation and Safety

The ATSB partnered with the Defence Aviation Safety Authority (DASA) and CASA in organising and hosting the inaugural International Convention of Aviation Regulation and Safety (ICARAS) event, which focused on safety management systems and regulation. More than 270 civilian and defence aviation industry delegates, including a number of overseas participants from 10 countries, attended the two-day ‘virtual’ convention in November 2020.

The ATSB’s Chief Commissioner, a Director Transport Safety, and the Head of Engagement and Influence gave pre-recorded video presentations focusing on safety management systems and how the ATSB communicates with influence to improve transport safety after an investigation.

Joining DASA and CASA to discuss a range of themes around safety management at ICARAS in 2020 was an important step to improve safety for all airspace users.

Other industry engagement

Due to the continued pandemic, the ATSB harnessed video conferencing and other digital technology to continue its engagement with industry at conferences and forums, where practicable.

In 2020–21, the ATSB participated in 27 external industry engagement events, including:

  • Australian Airports Association’s Emergency Management Forum
  • Australian Airports Association’s Airport Safety Week activities
  • Australian Association for Unmanned Systems' RPAS in Australian Skies Conference
  • Australian Helicopter Industry Association’s Rotortech Conference and Exposition
  • CASA’s FlySafe forums
  • Centenary of Civil Aviation conference
  • Centenary of the Royal Australian Air Force activities
  • International Transportation Safety Association Annual Conference
  • International Confidential Aviation Safety Systems forum
  • Regional Aviation Association of Australia’s Regional Roadshow Rail Industry Safety and Standards Board’s Rail Safety Conference
  • Rail Industry Safety and Standards Board’s Sharing Investigations forums
  • Rail Industry Safety and Standards Board’s Rail Safety Managers Group forums.

The ATSB also hosted a number of industry visitors to its office in Canberra throughout the year, providing an opportunity for representatives from the aviation, marine and rail sectors to meet key staff and tour the technical facilities and media studio.


In 2020–21, the ATSB continued to promote its SafetyWatch initiative. SafetyWatch highlights the broad safety concerns that come from the ATSB’s investigation findings and occurrence data reported by industry.

The ATSB encourages the transport industry to give heightened attention to the following priority areas (where more can be done to improve safety):

  • too low on approach
  • fatigue
  • in-flight decision-making
  • safe work on track
  • data input errors
  • non-controlled airspace
  • safety risk of RPAS
  • marine pilotage.

Throughout the year, the ATSB undertook a range of communication activities (website news stories, social media and general media) to raise awareness of these issues within the transport industry.

To remain contemporary, the ATSB will regularly review its SafetyWatch priority areas and the effectiveness of the initiative during 2021–22.

Social media

The ATSB continued to make effective use of its social media platforms to engage with the transport industry, the media and the travelling public during 2020–21. The ATSB continued to focus on measuring the overall number of engagements with its published content.

For the reporting period, the ATSB posted 125 times to Facebook, 159 times to Twitter, 85 times to Instagram and 109 times to LinkedIn.

The ATSB Facebook page had the highest number of engagements (the total number of likes, comments, reposts, clicks, reactions, forwards), with our followers recording 20,773 post engagements during the period. The Facebook post with the highest engagement was a news story supporting the publication of the pilot incapacitation involving Cessna 208B, VH-DQP, near Brisbane Airport, Queensland, on 2 July 2020 (AO-2020-032).

The ATSB Instagram page recorded 6,775 engagements, followed by our LinkedIn page with 4,852 engagements, and our Twitter account with 2,507 engagements.

In 2020–21, overall engagement with the ATSB’s suite of social media channels increased by 22%, compared with 2019–20 engagement figures.

Since launching in 2015, the ATSB Facebook page has attracted more than 21,000 followers. This channel has been particularly effective in referring followers to view content published on the ATSB website.

The ATSB’s Twitter account continues to be a key channel for highlighting the release of reports and investigation updates, particularly to the media. Through this social media platform, the ATSB provides a short safety message along with a link to more information on its website.

By the end of June 2021, the ATSB’s Twitter followers had increased to over 9,000, including journalists, transport industry specialists and members of the general public. Engagement with this channel decreased by 19% in 2020–21 (compared with 2019–20 engagement figures).

The ATSB uses the LinkedIn professional networking social media platform, with more than 14,000 followers – a 40% increase in followers across the year. Engagement with this channel increased 33% in 2020–21 (compared with 2019–20 engagement figures).

In May 2019, the ATSB launched its Instagram account, which has since attracted more than 2,000 followers. Engagement with this channel increased 29% in 2020–21 (compared with 2019–20 engagement figures).

In 2019–20, the ATSB increased its engagement with audiences through videos, which were distributed to traditional media outlets and published across all of its social media channels.

The ATSB’s YouTube channel saw a 23% increase in subscribers across the year – the second highest percentage increase in seven years – and now has over 1,350 subscribers. During the reporting period, the ATSB published four videos to support the release of SANs and final reports, including:

  • In July 2020, the ATSB published a video to promote two SANs arising from the then ongoing investigation into the 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 (AO-2017-118). The video achieved significant positive feedback from viewers about our delivery of safety messaging through the use of video. The video has been watched more than 14,000 times across all of our social media channels.
  • In July 2020, the ATSB published a video to promote the safety messaging of the final investigation report into the loss of control and collision with terrain of a Eurocopter AS350BA helicopter at Hobart Airport on 7 November 2017 (AO-2017-109). This video included an animated flight path of the accident sequence, a professional voiceover, and still images from the accident report while highlighting the report’s key safety messaging. The video has been viewed more than 6,000 times across all of our social media channels.
  • In August 2020, the ATSB published a video to promote the release of the final report into the fatal collision with terrain involving experimental ASH-25E glider, VH-GOA, 13 km west-north-west of Bathurst, New South Wales, on 21 January 2018 (AO-2018-009). The video included a detailed animated flight path of the accident flight. The video was distributed through the ATSB’s social media channels and has been viewed more than 800 times across all of our social media channels.
  • In January 2021, the ATSB published a video to promote the safety messaging associated with the final report into the 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 (AO-2017-118). The detailed video, which includes a high-fidelity animation of the aircraft’s flight path, along with drone footage provided by the NSW Police Force, and a professional voiceover, has been viewed more than 6,700 times across all of our social media channels.

Traditional media

The ATSB undertakes proactive and responsive media activities in conjunction with media outlets to inform the transport industry and travelling public of its investigations and safety messaging. During the year, the ATSB worked closely with local, state, national and international media to promote community and industry awareness of its transport safety messages.

The ATSB’s proactive media management activities include media conferences, interviews, media statements, pitches to journalists, opinion pieces and the distribution of pre-recorded content.

Throughout the year, the ATSB utilised its in-house media studio facility to produce and distribute 32 pieces of pre-recorded audio, video and video overlay content for distribution to national radio and TV outlets.

The ATSB also managed responses to 361 media enquiries during 2020–21.

During 2020–21, a total of 1,997 stories about the ATSB and its investigation activities were published or aired by mainstream and transport industry media outlets. Of these, 1,261 stories (approximately 63%) carried safety messaging relating to a final investigation report, with 95 stories (approximately 5%) carrying safety messaging published by transport industry media outlets.

Communication and education

As Australia’s national transport safety investigator, the ATSB is committed to communicating the safety lessons from its investigation findings, research activities and occurrence reports. This information has valuable safety messages which can help improve transport safety and, ultimately, save lives.

In 2020–21, the ATSB continued to highlight emerging safety issues and trends, using a range of communication channels and activities, for the benefit of industry and the travelling public.

During the year, the ATSB focused on promoting the use of active warning carbon monoxide detectors, following the release of its final report into the 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 (AO-2017-118). The ‘Know CO – Use an active warning carbon monoxide detector’ safety promotion activity encouraged pilots as operators of piston-engine aircraft to carry and use a detector, while alerting them to the dangers of exposure to the insidious gas.

In October 2020, the ATSB and Airservices Australia reminded all pilots and operators to be aware that stop bar lights at runway intersections are now in operation at five capital city airports around Australia, and not to cross a lit stop bar at any time, as part of the Australian Airports Association’s Airport Safety Week campaign.

Following the publishing of the final report into a runway incursion and subsequent rejected take-off event at Perth Airport on 28 April 2018 (AO-2018-032), the ‘Don’t cross it, STOP IT’ safety promotion activity highlighted the need for all pilots, no matter their experience or what aircraft they fly, to always observe for, and comply with, the stop bar directions.

The ATSB also found several opportunities to continue promoting its ‘Don’t Push It, DON’T GO – Know Your Limits Before Flight’ safety messaging, which was originally launched in December 2019.

The ATSB was also involved in supporting the TrackSAFE Foundation’s Rail Safety Week in August 2020 to promote safety for road users and rail passengers when interacting with the rail network.


The atsb.gov.au website continues to be the ATSB’s principal communication channel. In 2020–21, the ATSB website supported 2,040,406 page views and 803,339 user sessions.

The ATSB continually evolves its website to meet audience needs and allow for new and emerging technologies, and is a central element of the ATSB’s response to the Australian Government’s ‘digital first’ agenda.

During 2020–2021, the ATSB established a project to transfer its website onto the GovCMS content management system website platform. The ATSB’s new GovCMS-based website is anticipated to go live before the end of November 2021.

Online aviation database

The ATSB National Aviation Occurrence Database contains de-identified information on aviation accidents and incidents in a searchable format. The database has been designed to fulfil searches for information involving the most common requests received by the ATSB, including date range, aircraft and operation type, injury level, occurrence category and type, location, and airspace type and class. Users are able to search aviation occurrence statistics from the ATSB website at www.atsb.gov.au/avdata.

In 2020–21, the National Aviation Occurrence Database had 5,844 page views.

Partnership with the RMIT University

The partnership the ATSB has formed with RMIT University provides industry bodies in Australia and throughout the Asia Pacific region with access to high-quality training in transport accident investigation as well as providing a framework to facilitate important transport safety-related research through a credible university-based methodology.

Given the unpredictable COVID-19 conditions being experienced around the world, the ATSB and RMIT moved the Graduate Certificate in Transport Safety Investigation to an online environment. In October 2020, our second cohort of students began their studies for the Graduate Certificate in Transport Safety Investigation. The cohort totalled 22, consisting of six ATSB investigators, two investigators from the Office of Transport Safety Investigation NSW and 14 students from a broad range of industry organisations.

The ATSB and RMIT are investing more time and resources in co-designing a Graduate Diploma in Transport Safety Investigation ready for delivery in 2022.

Regional cooperation

The ATSB has a significant program of regional engagement, underpinned by the ATSB’s reputation as a world-leading transport safety investigation agency. This content addresses the deliverable to produce a report on the transport safety contribution of this engagement.

In support of the Australian Government’s transport safety agenda in the Asia Pacific region, the ATSB takes a leading role in the ICAO Asia Pacific Accident Investigation Group and the Marine Accident Investigators Forum in Asia. Australia was re-elected as the Vice-Chair of the ICAO Asia Pacific Accident Investigation Group at its eighth meeting in October 2020.

The ATSB places a specific emphasis on engagement with Indonesia, through the ongoing involvement in the Australian Government Indonesia Transport Safety Assistance Package (ITSAP), and Papua New Guinea (PNG), consistent with the Memorandum of Understanding on Cooperation in the Transport Sector. COVID-19 affected the ATSB’s international programs over 2020–21, with remote delivery used to deliver the capacity building programs.


Under the ITSAP program, funded by the Department of Foreign Affairs and Trade, the ATSB continues to help develop capability within the National Transportation Safety Committee (NTSC), the Indonesian agency responsible for the investigation of aviation, rail, marine and land transport accidents and incidents.

The three main strands of the ATSB–NTSC program of activities include:

  • provision of NTSC investigator training and professional development
  • guiding and mentoring of NTSC investigators by ATSB investigators
  • development of the NTSC transport recorder capability.

Significant ATSB–NTSC achievements under the ITSAP program in the reporting period included:

  • a number of professional development and training opportunities for NTSC investigators across specialist working groups
  • well-developed NTSC capability for the download and analysis of aircraft flight data recorder (FDR) and cockpit voice recorder (CVR) ‘black boxes’.

Papua New Guinea

Under the PNG Memorandum of Understanding on Cooperation in the Transport Sector, the ATSB has an ongoing program of cooperation and capability-building with the PNG Accident Investigation Commission (AIC), PNG’s aviation safety investigation agency.

Key elements of the ATSB–AIC program include:

  • mentoring and coaching of AIC investigators
  • training and professional development for AIC investigators
  • technical support for AIC investigations.