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Report on performance

Outcome 1-Transport outputs and programmes

Output 1.1.1-Investigation

Highlights

On 4 April 2007, the Australian Transport Safety Bureau (ATSB) released its comprehensive, 500-page final report into a fatal accident involving a Fairchild Metroliner aircraft on a regular public transport service operated by Transair, on approach to Lockhart River, Queensland. The 'controlled flight into terrain' accident, which occurred on 7 May 2005, resulted in the death of both pilots and all 13 passengers, and was Australia's worst civil aviation accident since 1968.

A large team of ATSB investigators devoted nearly two years of painstaking investigation to completing the final report, which identifies important safety issues relating to the crew, the operator, regulatory oversight and instrument approach chart design. Three factual reports, a research report and 10 safety recommendations were released by the ATSB during the course of the investigation. A further 10 recommendations to enhance aviation safety were issued with the final report.

Overview-Output 1.1.1-Investigation

Output 1.1.1 covers the transport safety investigation activities of the Australian Transport Safety Bureau (ATSB). The ATSB undertakes independent 'no blame' investigations of aviation, interstate rail and international and interstate marine accidents and incidents, seeking to uncover causal factors and encourage safety action to prevent future accidents.

Table 3.2 summarises the output's performance in 2006-07.

Summary of performance-Output 1.1.1-Investigation

Table 3.2 Summary of performance-Output 1.1.1

PBS/PAES performance indicators Results
Effectiveness

Stakeholders undertake safety action in response to critical and significant safety issues identified through safety investigations

In 2006-07 aviation safety stakeholders undertook 205 separately identified safety actions linked to 41 ATSB aviation investigations, leading to strong gains in safety culture and practices. The ATSB issued a further 19 aviation safety recommendations which also generated safety actions.

Regarding the high-profile risks associated with rail level-crossing collisions, the ATSB made a number of recommendations to state and territory rail regulatory authorities and level-crossing committees during 2006-07.

Transport safety and public confidence in transport safety is maintained or improved

The ATSB's final report on the Lockhart River investigation has had a positive impact on transport safety and public confidence through the comprehensive identification of issues relating to the crew, the operator, regulatory oversight and approach chart design. Aviation safety stakeholders and industry largely accepted and acted on the report's recommendations and undertook associated safety actions.

The ATSB assisted the Indonesian National Transportation Safety Committee to investigate the accident involving a Garuda Airways Boeing 737 aircraft that occurred at Yogyakarta airport on 7 March 2007, in which five Australians died.

ATSB marine and rail reports and recommendations were well accepted by marine and rail authorities, operators and other safety stakeholders.

Quality

Australia's transport safety investigation regime meets international standards

The principles of relevant international agreements are embodied within the provisions of the Transport Safety Investigation Act 2003 and given force through section 17 so that Australia legally complies with these international agreements.

The ATSB Executive Director was the Chairman of the International Transportation Safety Association (ITSA) from March 2006 to March 2007. ITSA noted in particular the ATSB's Lockhart River report and associated methodology.

Investigations are completed, on average, within one year

The median completion time for ATSB investigation reports in 2006-07 was 353 days, comprising 358 days (379 in 2005-06) for aviation, 320 days (234 in 2005-06) for marine and 369 days (479 in 2005-06) for rail reports. The rail report timeliness was significantly improved as a result of the additional experience acquired by investigators, and more streamlined report procedures.

Major accident investigation response capabilities are reviewed and tested annually

The ATSB's executives were part of two 'desktop' discussion exercises in November 2006 and April 2007. The simulated marine and rail exercises involved a broad range of external participants. The 2006-07 review and testing of the response capabilities of ATSB staff complemented previous testing of ATSB operational readiness.

The new Safety Investigation Information Management System 'SIIMS' is successfully commissioned The ATSB successfully commissioned the Safety Investigation Information Management System (SIIMS) on 16 April 2007, when all new aviation investigations transferred to SIIMS. The system was commissioned on time and within budget.
Quantity
More than 6,000 aviation, marine and rail safety accident and incident reports are assessed and entered into the safety database The ATSB's notification staff assessed 7,995 aviation, marine and rail safety accident and incident reports, and entered these reports into the bureau's safety databases.
Approximately 120 fatal accidents and other serious occurrences are investigated to improve future safety The ATSB released 103 final accident and incident investigation reports in 2006-07, comprising 80 aviation, 14 marine and nine rail reports. Fewer aviation reports were released than planned, because substantial resources were diverted to high-priority investigations (such as Lockhart River) and associated coronial inquests, and to training (such as SIIMS).
Price
$19.7 million The actual price of this output in 2006-07 was $19.3 million.
Overall performance

Detailed report on performance-Output 1.1.1-Investigation

Effectiveness indicators-Output 1.1.1

Stakeholders undertake safety action in response to critical and significant safety issues identified through safety investigations

 

 

Aviation safety actions

In 2006-07 the ATSB issued 80 aviation safety investigation final reports and 19 safety recommendations. Aviation safety stakeholders undertook 205 separate safety actions relating to 41 aviation safety investigation reports.

Responses to recommendations

The ATSB's aviation safety recommendations in 2006-07 included the 10 recommendations issued to the Civil Aviation Safety Authority (CASA), Airservices Australia and Jeppesen with the final report on the Lockhart River investigation. The three bodies have responded to all 10 recommendations and the ATSB is monitoring their progress on addressing the safety issues identified in the recommendations.

The ATSB also made six recommendations to CASA and Airservices Australia on safety issues relating to area navigation (RNAV) global navigation satellite system (GNSS) approaches, in the research report Perceived pilot workload and perceived safety of RNAV (GNSS) approaches.

CASA and Airservices Australia responded to all six recommendations. The ATSB has classified their responses on a recommendation relating to late notice of clearances to crews by air traffic control as 'closed-accepted', and is monitoring progress on addressing the safety issues identified in the other recommendations.

Other actions

Following the final report of the Lockhart River investigation, CASA undertook a range of safety actions to address safety issues relating to:

  • risk assessment, by both the operator and CASA, when evaluating applications for air operator's certificates;
  • guidance for the content and evaluation of operations manuals;
  • regulatory requirements for crew resource management and multi-crew training; and
  • regulatory requirements for safety management systems.

Other examples of aviation safety actions taken in Australia in response to ATSB reports include the following.

  • CASA reviewed Lancair aircraft operations and revised and re-issued its Flight instructors manual-Aeroplane, providing greater emphasis on actions associated with engine failure on take-off, following the ATSB investigation into a fatal Lancair aircraft accident at Bankstown, New South Wales.
  • A New South Wales power company improved helicopter crew clothing and training, risk management and ongoing hazard identification, following the ATSB investigation into a wirestrike accident at St Albans, New South Wales.
  • An airport operator developed an updated runway incursion chart, and a tug operator and air traffic service provider improved radio communication and incursion alerts at the airport, following the ATSB's investigation into a runway incursion at Sydney Airport.
  • Mandatory safety action was also required by the United States Federal Aviation Administration following the ATSB's investigation into an in-flight upset of a Malaysian Airlines Boeing 777 aircraft that was caused by problems with the aircraft's flight control computer software.

Marine safety actions

In 2006-07 the ATSB issued 14 marine safety investigation reports, which included 38 safety recommendations to stakeholders.

The ATSB report on the collision between the bulk carrier Global Peace and the tug Tom Tough at Gladstone, Queensland, and the resulting oil spill, included a number of recommendations dealing with the need for a better approach to risk analysis in the towage industry.

In response to the report, the tug operator, Adsteam Harbour, commissioned the School of Mechanical Engineering at the University of Adelaide to investigate and report on the causes of clutch oil pipe failure and to suggest design and construction changes. The company also decided to replace the port and starboard pipes on Tom Tough and similar vessels, and designed a protective block to be fitted on the vessels to reduce the consequences of any contact with other vessels or structures.

In its report on the grounding of the bulk carrier Crimson Mars as it was departing the port of Bell Bay, Tasmania, the ATSB issued a number of recommendations dealing with pilotage procedures and practices. In response to the report, TasPorts is reviewing its passage planning procedures, including contingency planning, and procedures for the use of mobile phones during pilotage.

The investigation also identified issues regarding bridge design for consideration by the International Association of Classification Societies, which publishes classification rules for vessel construction and service and provides certificates for insurance purposes.

Rail safety actions

In 2006-07 the ATSB issued 39 safety recommendations in nine final and two preliminary rail investigation reports.

Important recommendations of the ATSB report on a major level-crossing collision that occurred at Lismore, Victoria, in May 2006 included:

  • auditing of all level crossings in Victoria;
  • assessment of risks associated with B-double and higher mass vehicles using level crossings; and
  • measures to raise public awareness of the need to drive according to the environmental conditions, particularly at passively protected level crossings.

The investigation also noted that the Victorian Department of Infrastructure had scheduled the level crossing to be upgraded from passive to active protection in March 2007 and that in June 2006 the Australian Transport Council had approved a level-crossing strategy aimed at modifying road user behaviour to improve railway level-crossing safety.

Significant recommendations were also made in the ATSB report on a derailment of the XPT (express passenger train) scheduled service, due to failure of a power car axle, at Harden, New South Wales. The report recommended that the train operator, RailCorp, review XPT axle maintenance procedures, and that all rail vehicle operators consider risks associated with axle failures and review maintenance practices accordingly.

In response to the report, RailCorp and the Independent Transport Safety and Reliability Regulator of New South Wales have undertaken a number of safety actions, including measures aimed at the early detection and prevention of axle fatigue cracks in XPT and other diesel fleet rail vehicles, to limit the risk of axle failures.

The ATSB issued a safety advisory notice, advising the risks associated with axle failures resulting from fatigue cracks initiated by ballast strikes and the need for rail vehicle operators to review their maintenance practices accordingly.

Transport safety and public confidence in transport safety is maintained or improved

 

Aviation safety

The ATSB improved safety and public confidence in aviation through its Australian investigations, its work to assist Indonesian investigations, and the introduction of a confidential reporting system to capture information on safety concerns from members of the public.

Australian investigations

In aviation safety, the ATSB commenced 89 investigations and released 80 final investigation reports in 2006-07, and had 87 investigations ongoing at 30 June 2007. The high-profile reports released included the final reports on the Fairchild Metroliner aircraft accident on approach to Lockhart River, an aircraft evacuation involving a Boeing 717-200 aircraft at Hobart Airport, and the loss of control of a Fairchild Metro III aircraft in flight near Canberra.

As noted above, the accident at Lockhart River was Australia's worst civil aviation accident since 1968. The ATSB's 500-page final report on the investigation of the accident followed a resource-intensive two-year investigation which also generated three factual reports, a research report and 10 interim safety recommendations. The outputs of the investigation have had a positive safety impact within the industry: CASA, Airservices Australia and Jeppesen have taken significant safety actions in response to the report's recommendations. The operator, Transair, has ceased flying.

ATSB aviation safety investigations and recommendations, and the resulting safety actions, bolster public confidence. The bureau's role as an independent, 'no blame' aviation safety investigator is widely recognised and accepted in Australia and overseas.

Assistance to Indonesia

In 2007, through AusAID's Australian Leadership Awards Fellowship programme, the ATSB invited an Indonesian investigator to Australia to complete the bureau's 12-month diploma-level training as an aviation safety investigator. The ATSB acknowledges the support of AusAID and, in particular, the efforts of Allison Sudradjat, who subsequently lost her life in an accident involving a Garuda Airways Boeing 737 aircraft at Yogyakarta Airport on 7 March 2007. Through Australian Government funding, the ATSB will expand its programme of capacity-building assistance to Indonesia in 2007-08, providing new opportunities to enhance aviation and marine safety.

The ATSB provided cooperation and assistance in the investigation of the fatal accident at Yogyakarta Airport. The ATSB's involvement was at the invitation of the Government of Indonesia, and involved a team of three investigators assisting the bureau's Indonesian counterpart, the National Transportation Safety Committee (NTSC). Additional technical support was provided by the ATSB's flight data and cockpit voice recorder experts in Canberra. The ATSB assisted the NTSC to develop a preliminary report and is continuing to support the NTSC to develop the final report. It is also providing assistance for other high-profile aviation investigations in Indonesia.

The fatal Garuda Airlines Boeing 737-400 aircraft accident on 7 March 2007 at Indonesia's Yogyakarta Airport (Photo DOTARS)
The fatal Garuda Airlines Boeing 737-400 aircraft accident on 7 March 2007 at Indonesia's Yogyakarta Airport (Photo DOTARS)

Confidential reporting scheme

In January 2007 the ATSB introduced the REPCON (Report Confidentially) reporting scheme, which aims to improve aviation safety by enabling any person who has an aviation safety concern to report it confidentially to the ATSB. Protection of the reporter's identity is a primary element of the scheme, which can result in the rectification of otherwise unreported safety issues. REPCON is consistent with International Civil Aviation Organization (ICAO) recommendations.

By 30 June 2007, the ATSB had received 62 REPCON reports and issued 25 REPCON notices.

Marine safety

In marine safety, the ATSB initiated 15 investigations and issued 14 investigation reports in 2006-07, and had 11 investigations ongoing at 30 June 2007.

Reports released included the final report on the investigation of the grounding of the bulk carrier Crimson Mars as it was leaving the port of Bell Bay, Tasmania. This report was very well accepted by the pilotage industry, and is being used as a case study by several pilot-training organisations both in Australia and overseas.

Another significant report concerned the grounding of the tanker Desh Rakshak on the approaches to the Port of Melbourne. The collision between the bulk carrier Global Peace and the tug Tom Tough at Gladstone, Queensland, and the resulting oil spill, highlighted the need for greater risk analysis in the towage industry.

ATSB marine investigations and recommendations, and the resulting safety actions, bolster public confidence. The bureau's role as an independent, 'no blame' marine safety investigator is widely recognised and accepted in Australia and overseas.

The ATSB marine investigation workload included provision of support for the investigator in charge preparing for the coronial inquest into the disappearance of the Malu Sara in the Torres Strait.

In addition, staff of the ATSB made presentations at fishing industry safety meetings in various ports in both South Australia and Western Australia. ATSB staff also presented at and/or participated in pilotage training, a Nautical Institute workshop and a workshop on the introduction of E-Nav, a new concept supporting enhanced marine navigation.

Rail safety

In rail safety, the ATSB initiated 13 investigations and issued nine final investigation reports in 2006-07, and had 12 investigations ongoing at 30 June 2007.

Reports released included the final reports on the major level-crossing collision at Lismore, Victoria, and the derailment of the XPT service at Harden, New South Wales. As a result of the report on the accident at Harden, RailCorp and the Independent Transport Safety and Reliability Regulator of New South Wales undertook safety actions, including measures aimed at the early detection and prevention of axle fatigue cracks in XPT and other diesel fleet rail vehicles.

ATSB rail safety investigations and recommendations, and the resulting safety actions, bolster public confidence. The bureau's role as an independent, 'no blame' safety investigator for the defined interstate rail network is now widely recognised and accepted in Australia.

The Victorian Minister for Public Transport requested ATSB expertise to assist with the investigation of a collision that occurred between a passenger train and a B-double truck at a level crossing at Kerang, Victoria, on 5 June 2007. The accident resulted in fatal injuries to 11 passengers, serious or minor injuries to most other passengers, and serious injuries to the truck driver.

Although the accident did not occur within the ATSB's agreed jurisdiction, ATSB investigators assisted the Victorian Office of the Chief Investigator with aspects of the investigation, including human performance, the accident site survey, animation of the accident sequence, and assessment of the compliance of the level crossing with the relevant Australian Standard for signage and sighting.

Quality indicators-Output 1.1.1

Australia's transport safety investigation regime meets international standards

 

Australia's transport safety investigation regime is set out in the Transport Safety Investigation Act 2003 (TSI Act) and accompanying regulations.

The legislation empowers the ATSB, through its Executive Director, to:

  • investigate safety accidents and incidents involving civil aviation, international and interstate shipping and the defined interstate rail network; and
  • conduct 'no blame' investigations, to improve future safety, in which the focus is on learning rather than on criminal or civil liability.

The principles of relevant international agreements are embodied within the provisions of the TSI Act and given force through section 17 so that Australia complies with the international agreements.

The ATSB's Executive Director was the Chairman of the International Transportation Safety Association (ITSA) between March 2006 and March 2007, when responsibility transferred to the Chair of the Transportation Safety Board of Canada.

The ATSB improved the rigour of its investigation processes through the development of, and training in, a comprehensive investigation analysis methodology. This best-practice methodology received significant interest at an international level, through ITSA forums and through the conference of the International Society of Air Safety Investigators held in September 2006.

In 2006-07 the ATSB continued to play a leading role in the review of the International Maritime Organization (IMO) Code for the Investigation of Marine Casualties and Incidents. The code now contains proposed mandatory and recommended practices for investigating marine casualties and is on track to be incorporated as an annex to the IMO's Safety of Life at Sea Convention in 2007-08.

Investigations are completed, on average, within one year

Turnaround times for safety investigations improved considerably in 2006-07. Results were on target for aviation and marine investigations, and close to target for rail investigations.

In 2006-07 the ATSB's median time to complete reports for aviation investigations was reduced to 358 days, from 379 days in 2005-06. However, the number of aviation investigation reports released was also reduced, to 80 from 93 in 2005-06. This was the result of the diversion of resources to conduct the Lockhart River investigation (which involved up to 12 investigators for two years); provide input to coronial inquests; provide investigator and technical support to Indonesia; and provide staff development, including the training of several new investigators and training in preparation for the implementation of SIIMS.

The median report completion time for marine investigations was 320 days, up from 234 days in 2005-06 but still within the target of 365 days. The increase in median processing time was due to the finalisation of some older investigation reports. At 30 June 2007, all but one of the ongoing marine investigations were less than 12 months old.

For rail reports under the TSI Act, the median completion time of 369 days was well below the previous year's result of 479 days and close to the target of 365 days. The timeliness of the ATSB's rail investigation reports is improving as the bureau's rail investigators become more experienced, and as investigation processes are improved.

Table 3.3 shows the trends in transport safety investigation.

Major accident investigation response capabilities are reviewed and tested annually

The 2006-07 review and testing of the response capabilities of ATSB staff complemented previous testing of ATSB operational readiness.

The ATSB contributed to two 'desktop' emergency management exercises on marine safety and rail safety during the year. With representatives of other agencies, ATSB executives participated in a simulated rail emergency, Exercise Throstle, in November 2006, and a simulated marine emergency, Exercise Dargle, in April 2007.

Both exercises enabled participating agencies to better appreciate the respective roles and responsibilities of other agencies and understand the impact of the emergency response scenario on each organisation, which will assist them to coordinate joint emergency responses.

The new Safety Investigation Information Management System 'SIIMS' is successfully commissioned

The ATSB successfully commissioned the Safety Investigation Information Management System (SIIMS) on 16 April 2007, when all work on new aviation investigations was transferred to SIIMS. The project was on time and within budget, and will progressively deliver efficiencies as well as improved processes for managing information, assessing and analysing evidence and reporting on investigations.

The implementation of marine and rail modules and other enhancements is expected to be completed in the second quarter of 2007-08.

Table 3.3 Trends in transport safety investigation

2003-04 2004-05 2005-06 2006-07 2007-08 estimate
Civil aviation
Accident and incident notificationa
Incidents notified 4,417 5,810 7,435 7,720
Accidents notified 152 157 124 112
Total accidents and incidents notified 4,569 5,967 7,559 7,832 -b
Volume of investigations
Investigations started during year 75 109 84 89 80
Investigations completedc 63 98 93 80 80
Investigations continuing at 30 June 76 86 81 87 80
Timeliness of investigations
Median time to completion (days) 347 247 379 358 <365
Number of ongoing investigations more than one year old at 30 June 15 14 18 9 h
Outcome of investigations
Recommendations issued 46 21 22 19 No set target
Safety reports received under the REPCON Aviation Confidential Reporting System n/a n/a n/a 62 No set target
Safety notices issued under the REPCON Aviation Confidential Reporting System n/a n/a n/a 25 No set target
Maritime investigations
Accident and incident notification
Total accidents and incidents notified Not reported 92 79 117 No set target
Volume of investigations
Investigations started during year 8 13 12 15 10
Investigations completed 17 11 13 14 10
Investigations continuing at 30 June 9 12 10 11 10
Timeliness of investigations
Median time to completion (days) 484 372 234 320 <365
Number of ongoing investigations more than one year old at 30 June 6 3 2 1 No set target
Outcome of investigations
Recommendations issued 47 42 40 38 No set target
Safety notices issued under the Marine Confidential Reporting System n/a 13 13 8 No set target
Rail investigationsd
Accident and incident notification
Total accidents and incidents notified Not reported 61 39 46 No set target
Volume of investigations
Investigations started during year 5 7 9 13 10
Investigations completed 3e 3 13f 9 10
Investigations continuing at 30 June 6 11 8 12 10
Timeliness of investigations
Median time to completion (days) -g 519 479 369 <365
Number of ongoing investigations more than one year old at 30 June 1 3 - 2 No set target
Outcome of investigations
Recommendations issued 23 22 83 39 No set target
Total price of output i $12.5m $17.5m $19.0m $19.3m $23.0m

a Fewer notifications were made in 2003-04 due to the initial impact of changed reporting requirements from 1 July 2003 under the Transport Safety Investigation Act 2003 and regulations.
b At least 6,000 aviation, maritime and rail accident and incident reports are expected to be received in 2007-08.
c While the government has provided extra funding for more investigations from 2004-05, the time required to recruit and train investigators delayed the average number of investigations completed and the median completion time for investigations.
d Until 1 July 2003, investigations were a state responsibility and the ATSB was involved only at the request of state governments. Median completion times for these investigations were not reported due to the time required for state governments to consider some reports before their release.
e This includes the Chiltern rail investigation report submitted to the Victorian Government in late 2003-04. This report was released to the public in October 2004.
f This includes the Benalla steam train rail investigation report submitted to the Victorian Government in September 2004 and released to the public in February 2006.
g Until 1 July 2003, investigations were a state responsibility and the ATSB was involved at the request of state governments. Median completion times for these investigations are not reported due to the time required for state governments to consider reports before their release. Completion time estimates for rail investigations under the ATSB's new powers cannot be reported, as none were completed in 2003-04.
h The target is for no Level 2 investigations over 18 months old, no Level 3 investigations over 12 months old and no Level 4 investigations over nine months old.
i This includes the direct cost of investigations as well as indirect costs such as DOTARS-attributed corporate overheads.

Quantity indicators-Output 1.1.1

More than 6,000 aviation, marine and rail safety accident and incident reports are assessed and entered into the safety database

In 2006-07 the ATSB assessed more than 13,465 notifications (up from approximately 12,500 in 2005-06), of which 7,995 met the definition of a transport safety matter and were subsequently entered into modal safety databases. These comprised 7,832 aviation occurrences, 117 marine occurrences and 46 rail occurrences. The 7,995 occurrences comprised 275 accidents and 7,720 incidents.

The overall increase was almost exclusively attributable to an increase in aviation reporting, considered to be the result of an increase in aviation activity and greater familiarity with the reporting requirements contained in the Transport Safety Investigation Regulations 2003.

Jurisdictional differences in marine and rail reporting mean that the number of accidents and incidents reported to the ATSB is a subset of all accidents and incidents, the remainder of which are reported to, and fall within the jurisdiction of, agencies of the relevant states and the Northern Territory.

Approximately 120 fatal accidents and other serious occurrences are investigated to improve future safety

In 2006-07 the ATSB released 103 final investigation reports (down slightly from 119 in 2005-06), comprising:

  • 80 aviation reports (93 in 2005-06);
  • 14 marine reports (13 in 2005-06); and
  • nine final rail reports (13 in 2005-06).

The reduction in the number of aviation reports was the result of the diversion of resources to conduct the Lockhart River investigation (which involved up to 12 investigators for two years); provide input to coronial inquests; provide investigator and technical support to Indonesia; and provide staff development, including the training of several new investigators and training in preparation for the implementation of SIIMS.

Outlook-Output 1.1.1-Investigation

The ATSB plans to commence and conduct approximately 80 aviation, 10 marine and 10 rail investigations in 2007-08, including appropriate safety action to enhance transport safety. The bureau will seek to complete its occurrence and technical analysis investigations in a timely, high-quality manner.

The ATSB expects to assess more than 6,000 occurrence reports and enter them into the SIIMS database, and to assess confidential reports through the REPCON scheme. The implementation of the SIIMS database will continue: rail and marine modules are expected to be rolled out during the second quarter of 2007-08.

Other activities in 2007-08 will include providing assistance and evidence as required to coronial inquests and facilitating the introduction of legislation to amend the TSI Act. The ATSB will also contribute to the Transport Safety Assistance to Indonesia programme and provide other international assistance in transport safety investigations.

Did you know?

The aim of the Confidential Marine Reporting Scheme (CMRS) is to improve safety in Australian waters by enabling the ATSB to receive, assess and act on confidential reports to prevent or reduce the risks of marine accidents. Reports may be made by telephone, email or fax, or by completing a confidential marine reporting form.

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