The ATSB Annual Report 2023–24 outlines performance against the outcome and program structure in the Department of Infrastructure, Transport, Regional Development, Communications and the Arts' Portfolio Budget Statements 2023–24.
Chief Commissioner’s Review
I am privileged to present the ATSB annual report for 2023–24, a year in which the agency took significant steps to drive greater efficiencies in our operating model, while delivering an increase in our measured effectiveness in improving transport safety for all Australians.
Central to our ability to undertake this important work has been the ATSB’s relatively small staff base. Since becoming Chief Commissioner and CEO in September 2021, ensuring our staff are supported, enabled and valued for their work in improving transport safety has been a key priority. Continuing to enhance our efficiency and effectiveness relies on attracting, developing and retaining experienced staff that are empowered to perform at their best.
Pleasingly, that focus on our staff has been reflected in our results for the 2024 Australian Public Service (APS) annual employee census. The survey showed that overwhelmingly our staff believe strongly in the purpose and objectives of the agency, are proud to work here and are prepared to go the extra mile to meet the demands. I want to acknowledge the considerable work that has been undertaken over the past 12 months to focus on staff wellbeing, organisational culture and leadership.
During 2023–24, the ATSB completed and published 61 industry-significant investigation reports into transport accidents and incidents. Among the higher profile investigations concluded during the year were:
- The collision with terrain of an EC130 helicopter at Mount Disappointment, north of Melbourne on 31 March 2022. The helicopter was operating a charter flight and inadvertently entered instrument meteorological conditions when the helicopter was not equipped and the pilot was not qualified to fly in those conditions. Tragically, all 5 on board lost their lives.
- A fire in the engine room of the MPV Everest, a multi-purpose vessel chartered by the Australian Antarctic Division (AAD), while 1,560 miles from mainland Australia in the South Ocean, on 5 April 2021. On board were 37 crew and 72 AAD staff.
- A fatal level crossing accident at Wynnum West, in Brisbane’s East, on 26 February 2021. A motorist was fatally injured when their car was struck by a passenger train upon entering the crossing after very likely following run line markings on the road, past the end of the lowered boom barrier, which was not long enough to meet the Australian Standard.
In all, the investigations we published in 2023–24 identified no fewer than 70 systemic safety issues – factors that if unaddressed have the potential to adversely affect the safety of future operations.
Some 81% of the systemic safety issues we identified have already been addressed through an effective mitigating safety action. The risk of a repeat occurrence has been reduced in these instances. And where identified systemic safety issues were not being effectively mitigated, the ATSB had cause to make 3 formal safety recommendations to the owners of those safety issues. We will continue to monitor the responses of the risk owners with the objective of influencing them to take further effective safety action.
Broader safety concerns were also raised through the release of 5 Safety Advisory Notices (SANs) to industry. Our shorter form investigations that we release do not scope systemic safety issues. However, they all identified factors that increased overall risk to everyday operations. The safety messaging from these SANs forms a crucial part of our role in improving safety to a broad transport industry.
In addition to occurrence investigations, we also published a longitudinal safety study that considered the risks associated with level crossing collisions, particularly those involving heavy road vehicles. This study was released ahead of a national rail level crossing safety roundtable in March 2024. Several findings from the study have now been shared with the Australian and international rail industries that will allow a better understanding of the risks involved in level crossings and potential effective mitigations to reduce the likelihood of future fatalities in both rail and heavy vehicle drivers.
During the year, we launched a new interactive National Aviation Wildlife Strike Dashboard on our website. This new interactive tool allows pilots, aerodrome and aircraft operators, and members of the public to review figures on wildlife strikes with aircraft across Australia. Knowing the risks and when they are likely to present allows for a more effective planning process.
Finally, we took part in a significant number of coronial inquests across the country, where ATSB reports were crucial in establishing the facts and circumstances surrounding a fatal incident. All inquests concluded with similar findings to the ATSB, with the Coroner reports being another important vehicle in increasing the reach of our safety messaging.
To ensure that we can continue to do more of this valuable work and meet the safety investigation needs in aviation, rail and marine into the future, the ATSB launched a renewed Strategic Plan in 2023. This plan has been our roadmap in response to the Minister’s Statement of Expectations for the 2023 to 2025 period, and details our goals to:
- influence positive transport safety outcomes through independently identifying and sharing safety concerns and fostering safety awareness, knowledge and action
- position the ATSB to be Australia’s national transport safety investigator, maximising safety outcomes across transport sectors through growth and innovation
- be an enduring and adaptable organisation that delivers on its mission across changing environments by investing in its people, systems and partnerships.
Some of the actions taken to date in pursuit of these goals include:
- prioritising the release of factual information through the investigation process through the publication of preliminary and interim reports, and regular updates to investigation pages on the ATSB website
- developing new ATSB stakeholder engagement strategies
- actively engaging in the Australian Transport Safety and Investigations Bodies Financial Sustainability Review, focusing on the efficiency of our processes for some of our investigations
- developing partnerships with educational institutions to provide a centre of excellence for transport safety investigations
- strengthening regular collaboration with other countries to improve accident investigation capability and compliance with international protocols.
In closing the review of our year, I would like to acknowledge the service of Catherine Scott, whose term as an ATSB Commissioner concluded on 7 September 2023. During her 3 years on the ATSB Commission, Ms Scott contributed her considerable industry expertise and knowledge to help shape ATSB rail investigation reports, and helped guide the ATSB during a time of significant uncertainty due to the COVID-19 pandemic.
On 9 October 2023, we welcomed Ms Julie Bullas to the ATSB Commission. Ms Bullas has brought extensive rail industry experience and pedigree to the ATSB, having served for 10 years as Executive Director, Policy, Reform and Stakeholder Engagement at the Office of the National Rail Safety Regulator (ONRSR).
Ms Bullas, along with Commissioners Gary Prosser (marine) and Peter Wilson (aviation) are a strong team with significant expertise working with me to oversee ATSB investigations.
Outlook
Through the continued implementation of our Strategic Plan and our continual focus on efficiency and effectiveness, we are working to ensure the ATSB is best positioned to meet the challenges and opportunities of the future.
One of those opportunities is our participation in and support of the Department of Foreign Affairs and Trade’s Transport Safety in the Pacific Program, where we are working to bolster the aviation accident investigation capabilities across the region. Already we are supporting Tonga and Vanuatu with aircraft accident investigations in those countries.
Meanwhile, we continue to work with the Commonwealth and state governments and industry stakeholders to ensure expectations around the ATSB remit, role and resourcing are well defined.
In particular, we remain focused on addressing the ATSB’s role as the national safety investigator for rail accidents and incidents, and we stand ready to address outcomes relevant to the ATSB from the Australian Transport Safety and Investigation Bodies Financial Sustainability Review.
I look forward to continuing to work with the government to ensure we are responsive to its expectations, and that we are best positioned to effect safety improvements well into the future.
Angus Mitchell
Chief Commissioner and CEO