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ATSB reports not identifying CASA’s surveillance as a contributing safety factor when it is identified in the analysis as deficient

The following demonstrates the real underlying issue in ATSB investigations, when CASA has failed to properly surveil the operator, leading to an operational issue. Further, ATSB is not issuing the “safety factor” on the regulator. Surely, this leaves both CASA and ATSB in breach of CAAct 9A(1)

Mode Aviation
Reference No. AR201400079
Date reported 18 September 2014
Concern title ATSB reports not identifying CASA’s surveillance as a contributing safety factor when it is identified in the analysis as deficient
Concern summary The concern relates to a number of ATSB investigation reports that, although they identify both that CASA have detected issues within an operator before an accident and have not taken any action, this has not been included as a contributing safety factor in the ATSB investigation findings.
Industry / Operation affected Aviation: Other
Concern subject type Aviation: Other

Reporter’s concern

The reporter expressed a safety concern regarding the number of Australian Transport Safety Bureau investigations which have indicated in their report that the Civil Aviation Safety Authority (CASA) have detected issues during their audits but have not taken the appropriate action to fix the issues. However, these reports have then not indicated that this was a contributing safety factor in the accident.

The investigations include but are not limited to AO-2011-102 [– Maree Squirel accident], AO-2011-033 [– Thursday Island Aero Commander]  and AO-2009-072 [– PelAir – Norfolk Island].

Operator’s response (Operator 1)

In order to respond to this REPCON, it is of benefit to understand the different outcomes likely when comparing a regulatory surveillance activity with the conduct of a safety investigation:

  • Regulatory oversight.Routine regulatory surveillance cannot examine all aspects of an operator on a frequent basis, and it cannot identify all the issues with an operator (or similar organisation) or their operation. More specifically, unless other intelligence or specific concerns have been identified previously to indicate otherwise, such activities generally examine a relatively broad range of aspects of an operation or operator at limited depth.

The frequency and depth of this ‘routine’ surveillance could be expected to be based on factors such as the type or classification of operation and size of the operator or operation.

In general, less surveillance might be expected for smaller operators, for non-passenger-carrying activities and for operators using smaller aircraft.

  • Safety investigations. Safety investigations conducted after an accident or serious incident are often able to identify problems or safety issues that may not be easily detected during a regulator’s routine surveillance activities. More specifically, a safety investigation conducted after an accident/serious incident usually has a more targeted scope as a result of the evidence already gained from other sources, and generally has more time to identify potential safety issues than in the case of a routine audit. Finally, whereas surveillance activities traditionally focus on regulatory compliance, safety issues identified as a result of safety investigations are not restricted to compliance with regulatory requirements.
  • Safety investigation and ‘contribution’.Given their limited resources and many potential occurrences to investigate, safety investigation agencies carefully scope their work to maximise the efficiency of their investigations and the potential for safety enhancement.

Before the ATSB includes a detailed examination of the effectiveness of a regulator’s surveillance activities as part of an investigation’s scope, it would generally need to establish that:

  • There are significant problems (in terms of number and/or level of risk) with the relevant operator’s risk controls and/or safety management processes, which are related to the investigated occurrence.
  • Given factors such as the severity of these safety issues, the length of time they existed, the size of the operator and the nature of its operations, it is reasonable to expect that a regulator’s oversight activities probably should or could have identified these safety issues.

Ultimately, to conclude that any potential problems with regulatory oversight processes were a contributing factor to an accident/serious incident would require the investigation to have, in the first instance, concluded that problems with the operator’s occurrence-specific risk controls and/or safety management processes contributed to the accident/serious incident. In addition, a problem with the design, implementation or other aspect of the regulator’s surveillance processes would need to have been shown (‘existence’) and the conclusion reached that the surveillance problem(s) could have realistically prevented or significantly reduced the likelihood or magnitude of one or more of the operator’s safety issues (‘influence’).

Given this understanding, the following discussion explains why no safety issues associated with regulatory surveillance were identified as contributing factors in the ATSB investigations highlighted by the REPCON reporter:

  • AO-2011-033. This investigation involved a small operator conducting primarily freight charter operations in light, twin-engine aircraft. In terms of the scope of the investigation, the ATSB did not consider a detailed review of the regulator’s oversight activities was warranted. The ATSB report noted that CASA found several problems with the operator after the accident, but these problems were not directly related to the circumstances of the accident and safety issue relating to the operator identified by the investigation.
  • AO-2011-102. This occurrence involved a small operator conducting primarily aerial work and some charter operations with film crew as passengers and, as part of the scope of the investigation, the ATSB obtained CASA regulatory surveillance documentation. The ATSB did not consider that the nature of the safety issue it identified with the operator would reasonably have been identified by CASA during its routine surveillance activities. However, the ATSB did conclude in its report that there were problems with relevant regulatory requirements and a safety recommendation was issued to CASA in that regard. The ATSB continues to monitor CASA’s action in response to this safety issue.
  • AO-2009-072. This investigation involved an aerial work operation and, as part of the scope of the investigation, regulatory surveillance documentation was obtained from CASA and examined.In respect of the safety issue that was identified with the operator, the ATSB considered that it was not an issue that would or should necessarily have been identified as a result of routine surveillance activities.

    However, problems were found with the general nature of the available regulatory guidance on fuel planning and on seeking and applying en route weather updates, which increased the risk of inconsistent in-flight fuel management and decisions to divert.

    As indicated in the investigation report, safety action was taken by the operator and CASA in response to these safety issues in an effort to prevent a recurrence of the accident.

Regulator’s response (Regulator 1)

CASA has reviewed the REPCON and concurs with the response provided by the ATSB.


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