A History of Aviation Accident Investigation in Australia
by Ian Leslie

Accident investigation has always been an essential element in the development and safety regulation of aviation.

In Australia prior to 1927 accidents were investigated by Boards of Inquiry. Separate Boards were assembled for each accident, members being selected from suitably qualified officers of the Commonwealth Public Service: but public dissatisfaction led in 1927 to the creation of the Air Accident Investigation Committee to investigate all civil and RAAF aircraft accidents which the Committee deemed advisable to investigate.

The Committee had the power to make recommendations to the Minister for the prevention of recurrence of accidents. The Minister appointed the members of the first Committee: the President being Mr. H.Payne, an engineer; the Chairman Mr. Marcus Bell, Superintendent of Defence Laboratories; Colonel H.B.Gibbs, Chief Inspector Munitions Inspection Branch; Squadron Eric Harrison RAAF; and Captain Eric. J. Jones, Superintendent, Flying Operations, Civil Aviation Branch. An RAAF officer was appointed secretary to the Committee.

The Regulations required that all accidents be reported to the Controller of Civil Aviation and thence to the Minister and to the Committee. Early in 1931 the Committee was reconstituted to comprise a Chairman with only two other members, the Chairman being the Chief Inspector Munitions Supply Branch, and the other members being drawn, one each, from the RAAF and the Civil Aviation Branch.

During the period 1935-1936 the accidents dealt with by the Committee were: RAAF - 5 major and 66 minor; civil aviation - 15 major and 107 minor. With some accidents the Committee authorised respected members of the aviation community to conduct the investigations. Reports of investigations would then be considered by the Committee. Proceedings were not open to the public and interested parties did not participate in the proceedings other than as witnesses. The findings of the Committee were usually made public by the Minister through the Press.

In 1932 an informal group of engineers in Sydney voiced strong criticism of the investigation into an accident of an experimental aircraft in which the pilot and passenger were killed. Their criticisms were, firstly, that the Committee was comprised of Defence Department officials who, it was alleged, tended to protect the interests of the Defence Department, and interested parties were not able to participate, and secondly, that qualifications of the members of the Committee were not suited to the conduct of investigations of a technical nature.

This criticism and others in the Press probably had an important bearing on the decision to conduct in public the inquiry into the 'Kyeema' accident in 1938.Two additional members were appointed to the Committee: Mr. E.F. Herring KC, and Captain P.G.Taylor. Furthermore, interested parties could have had legal representation. The report from this Inquiry called for review of the organization of the Civil Aviation Branch and there were further calls for a reform of the investigation of accidents.

In response, the Government decided to appoint Air Courts of Inquiry. Essentially this is the concept which, in various modified forms, has prevailed since that time in respect of those major accidents when the Minister has decided that there should be a public inquiry. Prior to 1946 the investigation and study of accidents were not the function of any particular section within the Department and investigations were conducted by the most appropriate officer.

It was not until close to the end of the Second World War that there was a proposal for a re-organization of the Department. This was to establish a number of Directorates and was submitted to Mr. Daniel McVey, the Director-General, who made the following comment: "A Governmental civil aviation authority has important responsibilities regarding the issue of many types of licences. Discussions and decisions regarding those licences may affect considerably the liberty of the subject. For this reason I am rather concerned with the way that such decisions thereby are forced to be in the practice of applying administrative justice. In the same sense I am not at all happy in regard to the proposals I am making in regard to the investigation of accidents. In the present circumstances setting up of a quasi-judicial body similar to that which exists in the United States is not practicable. It is therefore proposed, as an interim step, that such of the duties that are exercised by the CAB in the United States and which are applicable to Australia should be distributed among the Directorates that are proposed. This step may be regarded as a temporary measure only, particularly as far as air accidents are concerned."

The proposal included the formation of a Directorate of Air Navigation and Safety (DANS). The Public Service Board commented "Regarding the objectives of the DANS, if what is intended is the getting of data which will assist in the preparation of rules, regulations etc., no comment is offered but it would not be appropriate for the Directorate responsible for the testing, licensing etc to have the conduct of investigations to determine the causes of accidents..." Consequently the organization proposal was varied to meet these expressed concerns. The investigation of major accidents was then included in the duties of a Chief Inspector of Accidents within the Directorate of Air Transport and External Relations (DATER).

In 1948 this accident investigation unit was removed from DATER and reported direct to the Director-General. Earlier, in 1946, the Superintendent of Accident Studies within DANS was appointed and the work of that Branch was to investigate minor accidents and to develop a system for the gathering of information and the analysis of matters related to the safety of aircraft operations. Accordingly, an Air Safety Investigation Report, CA225, was introduced to be submitted by field operation staff and covered all instances of aircraft defects, failures of airways facilities and other matters which could jeopardise air safety. It was found to be so successful that another Air Safety Investigation Report form, CA225A, was introduced to enable pilots also to bring to attention matters which they felt could jeopardise safety.

The Accident Studies Branch comprised a Superintendent, a radio inspector and an aircraft maintenance inspector. This reporting system was an Australian initiative and was unique in the aviation world but in recent years various types of incident reporting have been adopted in many other countries. Another responsibility was to disseminate safety information and this led the development of the Aviation Safety Digest.

Following the Air Court of Inquiry into the "Lutana" accident in 1948, the Minister raised concerns that the investigation proved unsatisfactory in that the reports of these Courts had indicated a serious lack of appreciation of the technical aspects of civil aviation. In 1949 the Director-General appointed a panel to examine the existing form of inquiries into aircraft accidents and to make recommendations. The panel comprised Mr. A.B.MacFarlane, Director DATER, Mr. J.H.Harper, Chief Inspector of Accident Investigations and Mr. H.W.Poulton, Senior Legal Officer. The panel submitted a number of recommendations, and changes to public inquiries were made.

Future Boards of Inquiry would be comprised of a Chairman and two or more members, each with the power of adjudication. The Chairman was to be a practising lawyer of wide experience, and the assessors or members would be selected as having wide experience with personal knowledge and expertise in air navigation. Interested parties could have legal representation and copies of the Departmental investigation report of the occurrence would be available to the Board and to interested parties.

New Air Navigation Regulations (ANRs) were introduced in 1947 following the coming into force of the Chicago Convention on Air Navigation, part of the development of the International Civil Aviation Organization (ICAO) . The Regulations relating to accident investigations retained the dual system of investigations with the Department investigating all accidents, but if the Minister decided that it would be desirable in the public interest he would then appoint a Court of Inquiry.

In 1952 the functions of incident investigation were combined with accident investigation and in 1954 the Branch was created as a separate Division, consisting a Director and a team of specialist investigators led by a Senior Inspector. It was designated DASI, but always referred throughout the Department as 'Daisy'. In a later variation of Departmental structure it was named the Air Safety Investigation Branch (ASIB).

The re-organization of the Department introduced the establishment of Regional Offices. The investigation of accidents and incidents, other than those taken over by Central Office investigators, were handled by Regional Operations Branch staff, then reviewed by Central Office ASIB. During the 1950s ASIB Branches were established in the NSW, Vic/Tas and Queensland Regions, with SA/NT and WA following in early the 1960s.

These were staffed with investigators, now termed Inspectors of Air Safety, who were responsible to the Regional Director and to the Head of ASIB in Central Office. The Branches notified all occurrences to Central Office and sent reports of investigations for final review. In the event of a serious accident Central Office would either take over or assist in the investigation. The first head of the Air Safety Investigation Branch was Mr. Jim Harper, followed by Allan Lum, David Graham, Frank Yeend, Ian Leslie and then Grif Hughes.

The name of the judicial inquiry was also changed from Court to a Board of Accident Inquiry in 1955. Since that time there have been four Boards, the most recent (as of 2006) being into the accident involving Super King Air VH-AAV in Sydney in 1980.

With the rapid development of aviation in the post-War years and the increasing sophistication of modern aircraft types, the methods of investigation changed, particularly with the introduction of flight data and cockpit voice recorders. Investigation facilities were improved and engineering laboratories were introduced, together with specialist staff. When the Department of Transport was created, the ASIB retained the same reporting responsibility as previously but later it was named Bureau of Air Safety Investigation (BASI) and was relocated in Canberra in 1983 with the head, the Director, reporting direct to the Secretary and with direct access to the Minister.

When the Department of Aviation was abolished in May 1982, the Bureau was transferred to the Department of Transport and Communications, later, on 1 July 1999, becoming a part of the multi-modal Australian Transport Safety Bureau (ATSB), an 'outrider' element of the Department of Transport and Regional Services.


Consult an Index of Public Inquiries into Air Accidents

View an Air Safety Incident Report ('225') from 1954

Back to the main Air Safety & Accident Investigation index

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