Engine failure involving a

Boeing Company 737-838,

VH-XZB
En route from Auckland, New Zealand to Sydney, New South Wales, on
18 January 2023

ATSB Transport Safety Report

Aviation Occurrence Investigation (Short)
AO-2023-007
3 August 2023
Released in accordance with section 25 of the Transport Safety Investigation Act 2003

Publishing information
Published by: Australian Transport Safety Bureau
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Office: 12 Moore Street, Canberra, ACT 2601
Telephone: 1800 020 616, from overseas +61 2 6257 2463
Accident and incident notification: 1800 011 034 (24 hours)
Email: [email protected]
Website: www.atsb.gov.au

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Addendum

Page Change Date

Executive summary
What happened
On the afternoon of 18 January 2023, a Boeing 737-838 aircraft, registered VH-XZB and operated
by Qantas, departed Auckland, New Zealand on a scheduled passenger service to Sydney,
Australia. While in the cruise, about 1 hour and 24 minutes after departure, there was an
uncommanded shutdown of the left engine. Due to their location at the time, the flight crew
declared a MAYDAY, to prioritise communications with air traffic control and to ensure they were
cleared for an immediate descent to flight level 240 (24,000 ft). The engine could not be restarted
in-flight, and the flight crew conducted an uneventful single-engine landing at Sydney Airport
about 1 hour later.

What the ATSB found

The engine examination identified separation of the radial driveshaft (located in the inlet gearbox),
which resulted in a mechanical discontinuity between the engine core and accessory gearbox.
Loss of drive to the accessory gearbox resulted in a loss of fuel pump pressure and
uncommanded shutdown of the engine. There was also secondary damage to some components
as the engine shut down. In addition, the failed driveshaft prevented the engine restarting in-flight.
Further, the ATSB found that the cockpit voice recorder was inadvertently overwritten during
maintenance activities conducted after the aircraft arrived at Sydney Airport.

What has been done as a result

As a result of this incident, Qantas has enhanced their procedures to prevent inadvertent
overwrite of cockpit voice recorders and flight data recorders.

Safety message
It has been well established that the importance of training, following standard procedures, and
effective communications are crucial to aviation safety. This incident highlighted the positive
benefits of effective decision-making and management of an unexpected situation. Such actions
are best demonstrated by:
• maintaining a high level of situation awareness, utilising all sources of information, via
procedural checklists and communications, including with cabin crew and air traffic control
• consideration of all options and evaluation to decide the best course of action to ensure
additional operational difficulties are not inadvertently introduced
• a frequent review to ensure appropriate actions are being maintained throughout changing
circumstances.
In addition, operators need to ensure correct procedures are in place to protect information
recorded during the flight that enhances the accuracy and effectiveness of a safety investigation.

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The investigation
Decisions regarding the scope of an investigation are based on many factors, including the level
of safety benefit likely to be obtained from an investigation and the associated resources
required. For this occurrence, a limited-scope investigation was conducted in order to produce a
short investigation report, and allow for greater industry awareness of findings that affect safety
and potential learning opportunities.

The occurrence
On the afternoon of 18 January 2023, a Boeing 737-838 aircraft, registered VH-XZB and operated
by Qantas Airways, was being prepared for a scheduled passenger service from Auckland, New
Zealand to Sydney, Australia. On board were 2 flight crew, 5 cabin crew and 143 passengers. The
captain was designated as the pilot flying and the first officer was the pilot monitoring. 1
The captain reported that the pre-flight briefing package identified good weather conditions for
Auckland, en route, and Sydney. The weather forecast for additional airports was also included, in
case of the requirement for a diversion. The flight was dispatched as an extended diversion time
operations (EDTO) 2 flight authorised to operate up to 180 minutes or 1,200 NM (2,222 km) from
an alternate aerodrome. The required EDTO maintenance had been completed in Auckland. This
inspection included engine and auxiliary power unit (APU) 3 oil quantity checks, and a review of
recent oil consumption records. The aircraft departed Auckland at 1430 local time and reached a
cruise altitude of flight level (FL) 4 360 about 20 minutes later.
The flight crew reported that they carried out an EDTO brief before entering the EDTO segment.
The EDTO briefing included that, in the event of an engine failure, Auckland and Sydney were the
primary airports.
After about 1 hour in the cruise, the flight crew transferred high frequency (HF) radio
communications from Auckland to the en route controller at Brisbane Centre (en route controller). 5
Once the en route controller accepted monitoring of the aircraft, the flight crew requested to climb
to FL 380. About 3 minutes later, and before the climb was authorised, the flight crew reported
hearing a ‘pop’ sound, followed by the autopilot and auto throttle disengaging, with associated
warning lights and horn. They then identified left (#1) engine was not operating. The flight crew
broadcast MAYDAY, 6 citing an engine failure and requested an immediate descent to FL 240. The
en route controller enquired if it was a single or double engine failure, to which the flight crew
confirmed a single-engine failure (Figure 1). About 1 minute later, the en route controller
authorised a descent to FL 240 when ready.

1
Pilot flying (PF) and pilot monitoring (PM): procedurally assigned roles with specifically assigned duties at specific
stages of a flight. The PF does most of the flying, except in defined circumstances; such as planning for descent,
approach and landing. The PM carries out support duties and monitors the PF’s actions and the aircraft’s flight path.
2
Extended diversion time operations (EDTO): Any operation by an aeroplane with 2 or more turbine engines where the
diversion time to an en route alternate aerodrome is greater than the threshold time established by the State of the
Operator. For VH-XZB, the threshold time was 60 minutes, or 400 NM (741 km).
3
The auxiliary power unit (APU) is a self-contained gas turbine engine, located in the tail of the airplane. The APU
supplies bleed air for engine starting or air conditioning. An alternating current (AC) electrical generator on the APU
provides an auxiliary AC power source.
4
Flight level: at altitudes above 10,000 ft in Australia, an aircraft’s height above mean sea level is referred to as a flight
level (FL). FL 360 equates to 36,000 ft.
5
Brisbane Centre’s flight information region includes the Oceanic airspace off the east coast of Australia. Aircraft flying
between Auckland and Sydney travel through Brisbane airspace for a significant portion of their journey.
6
MAYDAY: an internationally recognised radio call announcing a distress condition where an aircraft or its occupants are
being threatened by serious and/or imminent danger and the flight crew require immediate assistance.
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 ATSB – AO-2023-007

Figure 1: Map showing VH-XZB flight path and location of the engine failure

Source: APS Flight Analysis System (FAS) using Cesium, annotated by the ATSB

At the same time, following the completion of cabin service, the cabin safety manager (CSM)
heard a noise and felt the aircraft yawing in a manner they described as ‘not normal’. After
confirming that the cabin crew member next to them had also experienced the event, the CSM
advised that they called the flight deck. The captain answered and advised the CSM that they
could not talk at that moment as an engine had just failed. The CSM then called the cabin crew
team leader at the rear of the cabin to inform them of the situation.
About 5 minutes later, the captain called the CSM to the flight deck and explained the situation, in
that the left engine had shut down uncommanded and they were unsure why. The captain further
advised that the aircraft was operating safely on one engine, and they were working through the
engine failure, and associated checklists. The captain requested that the CSM relay this
information to the cabin crew, monitor the passengers and to advise the flight deck if anything
changed in the cabin.
Soon after, the CSM advised the flight crew that the cabin was getting quite warm 7 and power was
not available to various galley equipment and the rear bathrooms. 8 The APU had been selected to
‘on’ as part of the engine failure checklist, however, cabin airflow had been affected. The flight
crew reported they then selected the temperature controller to minimum and conditions improved.
The flight crew continued working through the non-normal checklists, while on a slow descent.
Following authorised descent to FL 200, and with all checklists completed, the flight crew decided
to attempt the in-flight engine restart checklist. While the first few steps were accomplished, the
engine start attempt had to be aborted when a designated parameter could not be achieved. The
flight crew then consolidated their plan and prepared for a single-engine landing at Sydney.

7
Two air-conditioning systems were powered independently by each engine, therefore operating on a single engine
reduced airflow to the cabin.
8
Primary AC power was supplied by 2 engine-driven generators. During flight, if one power source was lost, certain
systems would be shed (automatically removed) in a sequence (from least critical to flight safety), to reduce electrical
load. Engaging the APU could reduce/reverse shedding, depending on total aircraft electrical load.
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 ATSB – AO-2023-007

Throughout the descent into Sydney, en route and Brisbane Centre air traffic controllers 9
maintained contact with the flight crew, with scheduled check-in times to ascertain location details,
operational status, and updates to any requirements in Sydney.
Just prior to top of descent, the flight crew advised Brisbane Centre they were downgrading from a
MAYDAY to PAN PAN 10 but would still like aviation rescue fire-fighting services to attend and
inspect the left engine before they proceeded to the terminal. Shortly after, air traffic control (ATC)
communications were transferred to Sydney.
At about this time the captain made an announcement to the passengers, stating:
• they were to commence the descent into Sydney in a few minutes time
• acknowledging there were some issues with one engine that was affecting the air-conditioning
and some electrical systems
• once on the ground, emergency services would attend the aircraft to inspect the engine, as a
precaution, before they proceeded to the terminal
• reassuring them that everything was okay, and they would make another announcement once
on the ground.
Following an uneventful landing at Sydney at 1526 local time, emergency services met the aircraft
on the taxiway. Once cleared, the aircraft was taxied to the terminal, where engineering personnel
conducted an additional inspection before the airbridge was positioned. At this point, the captain
made a further announcement advising that they had experienced an engine failure about 1 hour
out of Sydney. The captain thanked the passengers for their patience and understanding. In
addition, the flight crew exited the flight deck and personally addressed each passenger as they
disembarked.

Context
Personnel information
The captain held an Air Transport Pilot (Aeroplane) Licence, a current Class 1 Aviation Medical
Certificate, and had accumulated 12,335 hours of aeronautical experience. Of this, about 1,620
hours were on the Boeing 737 type, and the captain had logged 230 hours in the preceding 90
days.
The first officer also held an Air Transport Pilot (Aeroplane) Licence, a current Class 1 Aviation
Medical Certificate, and had accumulated 10,540 hours of aeronautical experience. Of this, about
794 hours were on the Boeing 737 type, and they had logged 165 hours in the preceding 90 days.
The training records showed the most recent full flight simulator session for the captain was
completed in September 2022 and for the first officer in October 2022. In addition, the captain had
practiced one engine inoperative situations (including during the cruise, missed approach and
landing phases of flight) in November 2020, with the first officer completing this training in
February 2022.
The flight crew reported being well rested and alert at the commencement of duty for the flight and
there was no evidence to indicate that fatigue affected their performance during the flight.

9
Brisbane en route handed over to Brisbane Centre when the aircraft entered VHF radio range, shortly after reaching
FL 240.
10
PAN PAN: an internationally recognised radio call announcing an urgency condition which concerns the safety of an
aircraft or its occupants but where the flight crew does not require immediate assistance.
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Aircraft and engine information

General information
VH-XZB was a Boeing Company 737-838 aircraft, powered by 2 CFM56-7B26E 11 high bypass
turbofan engines. The engine is a dual-rotor, axial-flow turbofan. The N1 refers to the rotational
speed of the low-speed spool, which consists of a fan, a low-pressure compressor and a
low-pressure turbine. N1 is the primary indication of engine thrust. The N2 refers to the rotational
speed of the high-speed spool, which consists of a high-pressure compressor (HPC) and a
high-pressure turbine. The N1 and N2 rotors are mechanically independent. The N2 rotor drives
the engine gearboxes.
When the engine is running, the accessory drive system extracts part of the core engine power,
from the HPC (or N2) and transmits it through a series of shafts and gearboxes, to drive the
engine and aircraft accessories, including the:
• fuel pump and hydromechanical unit
• hydraulic pump
• integrated drive generator.
The starter, also located on the accessory gearbox, used the same gearboxes and shafts to drive
the HPC for engine start, either on the ground or in-flight.

Engine examination
An engine teardown inspection was conducted by the engine manufacturer at their technical
facility in Malaysia and was observed by Qantas and the Air Accident Investigation Bureau
Malaysia (on behalf of the ATSB). The examination identified that the inner radial driveshaft
separated at 2 locations, at the mid-length bearing and near the upper spline (Figure 2).
Subsequently, the mechanical discontinuity between the HPC shaft and accessory gearbox
resulted in loss of fuel pump pressure and uncommanded shutdown of the engine. The mid-length
bearing oil feed nozzle appeared clear (nil blockage). There was secondary damage to some
components as the engine spooled down.
The failed driveshaft also prevented the starter from driving the HPC, which prevented the in-flight
engine restart. 12

11
CFM International is 50-50 joint venture between GE Aviation (United States) and Safran Aircraft Engines (France).
12
The engine in-flight restart checklist required 11% N2 (HPC rotation) to be achieved before fuel was introduced. In this
incident, this parameter was not achieved and the attempted re-start was aborted by the flight crew.
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 ATSB – AO-2023-007

Figure 2: CFM56-7B engine, showing the accessory gearbox location, associated

driveshafts and failure locations (red line)

Source: Operator, annotated by the ATSB

The manufacturer advised that the level of deterioration of the failed driveshaft and mid-length
bearing prevented identification of the separation initiator. Further, the inner driveshaft oil supply
features were destroyed by the bearing failure and therefore its condition at the time of the event
could not be determined. Nevertheless, the engine manufacturer reported that the rupture of the
inner driveshaft was considered the primary failure.
It was noted that the CFM56-7B world engine fleet had reported 7 similar radial driveshaft bearing
events since 2012. However, there was no consistent component time accumulation prior to the
failure. At the time of this incident, the approximate totals for the worldwide fleet were 15,200
engines, with 500 million hours in-service and 258 million cycles in-service.

Engine maintenance requirements

The engine oil system included scavenge screens and magnetic chip detectors that could collect
any debris suspended in the oil. Metal contamination of the oil could be indicative of abnormal
wear or impending failure of a component. Any metal contamination was to be examined to
identify its origin and ascertain the quantity of the material. The engine manufacturer’s procedures
then detailed steps to monitor or replace the affected component. In addition, an increase in oil
consumption would require further inspection as per maintenance procedures.
The left engine was the original engine for the aircraft and had not been subject to any major
repairs or overhaul. On 11 December 2022, a 500-hourly inspection was completed on the left
engine oil system. This included a detailed inspection of the forward sump, aft sump, accessory
and transfer gearboxes magnetic chip detectors and scavenge screens for debris and/or metal
contamination. Further, the EDTO inspection completed in Auckland on 18 January 2023 included
a review of the engine oil consumption over the previous 10 flights, to ensure it was within
prescribed limits. Maintenance records indicated no metal contamination was identified and the oil
consumption was within prescribed limits.

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 ATSB – AO-2023-007

Recorded information
The cockpit voice recorder was downloaded at the ATSB’s technical facilities in Canberra.
However, as the aircraft had been powered for maintenance activity following arrival at Sydney
Airport, without the cockpit voice recorder being isolated, the audio data recorded during the
incident flight was overwritten and not available for this investigation.
Data from the flight data recorder and quick access recorder was provided to the ATSB by the
operator. The data showed that, 1 hour and 24 minutes after take-off from Auckland, the left
engine abruptly shut down uncommanded. Further analysis of the data did not identify any
appreciable changes to engine parameters, such as vibrations or temperature increase, prior to
the failure. The flight crew also reported that there were no adverse indications prior to the sudden
engine shutdown.

Operational procedures
Declaration of MAYDAY and PAN PAN
The operator’s procedures defined a MAYDAY and PAN PAN call consistent with the international
standards as:
• MAYDAY: A condition of being threatened by serious and/or imminent danger and requiring
immediate assistance.
• PAN PAN: A condition concerning the safety of an aircraft or other vehicle, or some person on
board or within sight, but which does not require immediate assistance.
The flight crew considered the following regarding their decision to declare a MAYDAY:
• their location mid-way between Auckland and Sydney, and considerable distance to any other
suitable airport
• desire to establish priority communication with Brisbane Centre via HF, which the flight crew
reported could be busy and unreliable at times 13 (there was no satellite communication on the
aircraft, therefore, HF radio was the only means of communication with ATC at that time) 14
• requirement to ensure the airspace was clear for an immediate descent to an optimal altitude
for single-engine operation and aircraft controllability
• uncertainty of the reason for the uncommanded shutdown and whether the remaining engine
may also be affected.
Further, the flight crew advised that their decision to downgrade to a PAN PAN was based on the
following:
• their reducing distance to their destination, and effective very high frequency communications
with Sydney ATC
• all checklists were completed
• continued stable operation on one engine
• single-engine landing at Sydney had been planned and briefed by the flight crew.

Decision to continue to Sydney

The final step in the engine failure or shutdown checklist stated ‘plan to land at the nearest
available airport’. The operator’s procedures stated that, ‘in a non-normal situation, the pilot-in-
command, having the authority and responsibility for operation and safety of flight, must make the

13
The aircraft was not equipped with SATCOM and the reliability of HF can vary considerably, depending on the time of
the day, frequency used and range over water, among other things.
14
VHF relay via nearby aircraft was also possible, in the event that HF become unavailable and nearby aircraft were
monitoring that frequency.
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 ATSB – AO-2023-007

decision to continue the flight as planned or divert’. The procedures also stated considerations
should include suitability of nearby airports in terms of facilities and weather, in decision-making
where ‘the safest course of action is divert to a more distant airport than the nearest airport’.
At the time of the engine failure, the aircraft was located about (distance from) (Figure 3):
• Auckland 611 NM (1,132 km) and a 180° turn
• Sydney 560 NM (1,037 km) continuing on the current track
• Williamtown/Newcastle 550 NM (1,019 km) with a slight diversion to right of track
• Norfolk Island 484 NM (896 km) and a 115° right turn.
Figure 3: Engine failure location with respect to the 400 NM (741 km) EDTO radius from
nearby alternate airports

Source: Google Earth, annotated by the ATSB

The Qantas Route Manual Supplement section for Norfolk Island noted several difficulties
associated with the airport including:
• ‘actual weather can change rapidly and vary from forecast’ and a diversion to Australia may be
required
• high terrain near the airport and rising terrain at the end of runway 11 could result in the illusion
of being too high on approach
• strong winds in February and March could produce severe turbulence
• no mobile services
• the supplement-authorised runway at Norfolk Island was identified as 1,950 m long.
The flight crew reported that Sydney was on their direct route, the forecast weather conditions
were more favourable, and the airport offered extensive emergency response (if required). In
addition, their planned runway for landing was on a straight-in approach and 3,962 m long. The
flight crew therefore elected to continue to Sydney.
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Flight and cabin crew training

The captain and CSM had flown together previously, however, it was the first time either of them
had flown with the first officer. The flight crew and CSM reported that the operator’s crew resource
management training, which was conducted with flight and cabin crew combined, fostered an
understanding of each area of operation, enabling openness and free-flowing sharing of
information between the flight deck and cabin. In addition, role-specific training and use of
standard procedures allowed them to each focus on their required tasks during an unanticipated
situation.

Safety analysis
While in cruise, about 1 hour and 24 minutes from departure and without command, the left
engine shut down. The flight crew reported they did not detect any change in parameters, which
may have alerted them to an impending engine issue. This was consistent with the recorded data,
which showed there was no warning. In addition, recent maintenance was indicative of a normally
operating engine. The reason for the uncommanded shutdown was later established as being the
result of the separation of the radial driveshaft. The mechanical discontinuity between the engine
core and accessory driveshaft resulted in loss of fuel pump pressure and the subsequent engine
failure. The driveshaft failure also prevented the engine restart.
While Norfolk Island was closer at the time of the engine failure, a diversion required a deviation
from their current track. In addition, Norfolk Island presented changeable weather and operational
conditions. In contrast, Sydney Airport was on their direct route, had favourable weather
conditions forecast, had an extensive emergency response, and a straight-in approach on a very
long runway. The flight crew’s decision to continue to Sydney ensured no additional risk was
added to an already high workload situation.
The ATSB publication Black box flight recorders highlights the benefits of aircraft flight recorders
such as the cockpit voice recorder, by creating a record of the total audio environment in the
cockpit area. This includes crew conversations, radio transmissions, aural alarms, and ambient
cockpit sounds, check list management, and decision making. As highlighted in the ATSB’s
publication, around 80% of aircraft accidents involve human factors, which means that crew
performance may have contributed to some events. As a result, the cockpit voice recorder often
provides accident investigators with invaluable insights into why an accident occurred. In this
case, the recorded audio of this incident was inadvertently overwritten during maintenance
operations. However, flight data was available and was found to be consistent with the flight
crew’s recollections and ATC audio recordings.

Findings

ATSB investigation report findings focus on safety factors (that is, events and conditions that
increase risk). Safety factors include ‘contributing factors’ and ‘other factors that increased risk’
(that is, factors that did not meet the definition of a contributing factor for this occurrence but
were still considered important to include in the report for the purpose of increasing awareness
and enhancing safety). In addition ‘other findings’ may be included to provide important
information about topics other than safety factors.
These findings should not be read as apportioning blame or liability to any particular
organisation or individual.

From the evidence available, the following findings are made with respect to the engine failure
involving Boeing Company 737-838, VH-XZB, en route between Auckland, New Zealand and
Sydney, Australia, on 18 January 2023.
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 ATSB – AO-2023-007

Contributing factors
• During cruise, separation of the radial driveshaft led to a mechanical discontinuity between the
engine core and accessory gearbox. This resulted in loss of the accessory gearbox-driven
main fuel pump pressure and uncommanded shutdown of the left engine. In addition, the failed
driveshaft prevented the engine from being restarted in-flight.

Other findings
• Based on the more favourable forecast weather conditions and operational requirements, the
flight crew decided to continue to Sydney rather than divert to Norfolk Island, which ensured
that no additional risk was added to an already high workload situation.
• The cockpit voice recorder was inadvertently overwritten during maintenance activity following
the incident flight. Although not critical to this investigation, this information could have
provided direct evidence regarding the flight crew's coordination, check list management, and
decision making throughout the flight.

Safety actions
Whether or not the ATSB identifies safety issues in the course of an investigation, relevant
organisations may proactively initiate safety action in order to reduce their safety risk. All of the
directly involved parties are invited to provide submissions to this draft report. As part of that
process, each organisation is asked to communicate what safety actions, if any, they have
carried out to reduce the risk associated with this type of occurrences in the future. The ATSB
has so far been advised of the following proactive safety action in response to this occurrence.

Safety action by Qantas addressing preservation of cockpit voice recorders

following an occurrence
Qantas have advised they are taking the following safety action in response to this incident. When
a request is received to secure the cockpit voice recorder and/or flight data recorder, the following
steps are to be carried out:
• immediately notify the duty technical manager to raise a task in the maintenance software to
have the requested item quarantined (or at a minimum, power to the recorders is to be
removed)
• follow up with a telephone call to the respective port and ensure the ground engineer is
advised of the limited timeframe to secure the data
• continually follow up with the applicable ports until positive confirmation of the requested action
has been confirmed.

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 ATSB – AO-2023-007

General details
Occurrence details
Date and time: 18 January 2023 - 0254 UTC
Occurrence class: Incident
Occurrence categories: Engine failure or malfunction, emergency/precautionary descent
Location: 1,035 km east of Sydney, New South Wales
Latitude: 36.8677°S Longitude: 169.0227° E

Aircraft details
Manufacturer and model: The Boeing Company 737-838
Registration: VH-XZB
Operator: Qantas Airways Limited
Serial number: 39360
Type of operation: Part 121 Australian air transport operations - larger aeroplanes
Activity: Commercial air transport - scheduled - international
Departure: Auckland International Airport, New Zealand
Destination: Sydney Airport, Australia
Actual destination: Sydney Airport, Australia
Persons on board: Crew – 7 Passengers – 145
Injuries: Crew – Nil Passengers – Nil
Aircraft damage: Nil

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 ATSB – AO-2023-007

Sources and submissions

Sources of information
The sources of information during the investigation included the:
• flight crew and cabin manager on VH-XZB
• Qantas Airways Limited
• Airservices Australia
• Airways New Zealand
• engine manufacturer
• the flight data recorder.

Submissions
Under section 26 of the Transport Safety Investigation Act 2003, the ATSB may provide a draft
report, on a confidential basis, to any person whom the ATSB considers appropriate. That section
allows a person receiving a draft report to make submissions to the ATSB about the draft report.
A draft of this report was provided to the following directly involved parties:
• Qantas Airways Limited
• the flight crew and cabin service manager on VH-XZB
• engine manufacturer
• United States National Transportation Safety Board
• New Zealand Transport Accident Investigation Commission.
Submissions were received from:
• Qantas Airways Limited
• the captain
• the engine manufacturer.
The submissions were reviewed and, where considered appropriate, the text of the report was
amended accordingly.

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 ATSB – AO-2023-007

Australian Transport Safety Bureau

About the ATSB
The ATSB is an independent Commonwealth Government statutory agency. It is governed by a
Commission and is entirely separate from transport regulators, policy makers and service
providers.
The ATSB’s purpose is to improve the safety of, and public confidence in, aviation, rail and
marine transport through:
• independent investigation of transport accidents and other safety occurrences
• safety data recording, analysis and research
• fostering safety awareness, knowledge and action.
The ATSB is responsible for investigating accidents and other transport safety matters involving
civil aviation, marine and rail operations in Australia, as well as participating in overseas
investigations involving Australian-registered aircraft and ships. It prioritises investigations that
have the potential to deliver the greatest public benefit through improvements to transport
safety.
The ATSB performs its functions in accordance with the provisions of the Transport Safety
Investigation Act 2003 and Regulations and, where applicable, international agreements.

Purpose of safety investigations

The objective of a safety investigation is to enhance transport safety. This is done through:
• identifying safety issues and facilitating safety action to address those issues
• providing information about occurrences and their associated safety factors to facilitate
learning within the transport industry.
It is not a function of the ATSB to apportion blame or provide a means for determining liability.
At the same time, an investigation report must include factual material of sufficient weight to
support the analysis and findings. At all times the ATSB endeavours to balance the use of
material that could imply adverse comment with the need to properly explain what happened,
and why, in a fair and unbiased manner. The ATSB does not investigate for the purpose of
taking administrative, regulatory or criminal action.

Terminology
An explanation of terminology used in ATSB investigation reports is available on the ATSB
website. This includes terms such as occurrence, contributing factor, other factor that increased
risk, and safety issue.

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