The ATSB Annual Report 2022-23 outlines performance against the outcome and program structure in the Department of Infrastructure, Transport, Regional Development, Communications and the Arts' Portfolio Budget Statements 2022–23.
Chief Commissioner's Review
I am proud to present the ATSB’s annual report for 2022–23, a year in which we continued to work towards our mission of improving transport safety for the greatest public benefit through our independent investigations and influencing safety action. This was supported through the development of our Strategic Plan.
We initiated the development of our new Strategic Plan to better position the agency to make the most effective use of our resources. The plan provides a roadmap for the ATSB in response to the Minister’s Statement of Expectations for the period 2023 to 2025. A copy of the strategic plan in placemat format is available on the ATSB website at www.atsb.gov.au. It includes our goals, which are to:
There are supporting strategies for these goals as well as a number of actions which are being progressed through the ATSB’s annual plan. The ATSB will continue to review and update progress against the plan.
During 2022–23, the ATSB completed and published 59 industry-significant investigation reports into transport accidents and incidents that provided the relevant transport modes with wide-ranging safety learnings. Among the higher profile investigations concluded during the year were:
We also completed a significant safety study into the aerodrome design standards and the Bulla Road Precinct development at Essendon Fields Airport.
Those 59 investigations published in 2022–23 identified no fewer than 58 safety issues – factors that if unaddressed have the potential to adversely affect the safety of future operations.
Pleasingly, 68% of safety issues identified in 2022–23 were adequately addressed through safety action.
Against safety issues not addressed, the ATSB made 18 formal safety recommendations to the owners of those safety issues.
And once again I am pleased to confirm that no changes to published investigation findings were required in 2022–23, evidence of the ATSB central commitment that all published investigations are factually accurate, defendable and evidence-based.
In addition to occurrence investigations, we published 15 occurrence briefs, which are short reports that allow us to share safety learnings from a transport safety occurrence.
The ATSB also received and processed 120 notifications under the REPCON confidential reporting scheme in 2022–23, of which 49 were assessed and classified as meeting the REPCON criteria. During the year, 33 REPCON reports were completed, of which 7 resulted in safety action being taken by stakeholders.
During 2022–23 we initiated 64 new aviation occurrence investigations, 4 new marine occurrence investigations, and 7 rail occurrence investigations.
Those new investigations include high profile accidents such as the mid-air collision between 2 Airbus EC130 helicopters over the Broadwater at the Gold Coast on 2 January 2023, the collision with terrain of a Boeing 737 large air tanker on 6 February 2023, and the propulsion failure of the bulk carrier Portland Bay off Port Kembla, NSW on 4 July 2022.
Also, during the course of 2022–23, updated and streamlined Transport Safety Investigation Regulations took effect. The TSI Regulations set out the ATSB’s safety occurrence reporting scheme and prescribe what occurrences must be reported to the ATSB, the timeframes those reports must be made in, the ‘responsible persons’ who are required to make a report, and the particulars to be included in a report.
Finally, we launched our revised SafetyWatch initiative. SafetyWatch highlights the broad safety concerns that come from ATSB investigation findings and occurrence data reported by industry. As such, we encourage the transport industry to give heightened attention to the following priority areas where more can be done to improve safety:
In closing the year in review, I would like to acknowledge former ATSB Commissioner Chris Manning. Commissioner Manning completed his term in June 2023. Since being appointed as the first aviation commissioner in 2015, those who have interacted with Commissioner Manning would know he brought his significant industry expertise and credibility to the agency to influence the ATSB’s standing. He had the strongly held belief that the ATSB not only conduct investigations to the world’s best-practice standards, but equally that we shine a light on areas that require improvement and work to ensure our reports ultimately have an impact on the industry we seek to influence.
In July 2023, Mr Peter Wilson was appointed as the new aviation commissioner. Commissioner Wilson has an impressive aviation resume, commencing his professional piloting career with Qantas in 1985. Over the following 20 years, Commissioner Wilson held a number of key senior management appointments, including Senior Check Captain Boeing 767, General Manager of Boeing 767 Operations and General Manager of Airbus A330 Operations. He also held the senior executive appointments as Qantas Chief Pilot and Chief Operating Officer. Together with the other Commissioners, we are looking forward to working with Commissioner Wilson as he brings his experience to bear in supporting the agency to fulfil its transport safety mission.
Outlook
Between the implementation of our Strategic Plan and our continual focus on efficiency and effectiveness, I believe the ATSB is being well positioned to meet the challenges of the future as we contribute to improving safety in a transport industry facing the challenges of advances in technology, new service delivery models, evolving regulatory standards and varying financial conditions.
We look forward to providing input into the Government’s Review of Operations and Financial Sustainability of Australia’s Transport Safety and Investigatory Bodies announced in the 2023–24 Budget, and will be ready to implement actions arising from the Government’s Aviation White Paper and reviews that may affect the extent of the ATSB’s modal jurisdiction.
I am confident that the ATSB is well positioned to meet the future expectations of the Government, industry and the travelling public.
Angus Mitchell
Chief Commissioner and CEO