Organisational influences – CASA
An Air Operator’s Certificate (AOC) holder had a clearly defined responsibility
under the Civil Aviation Act 1988 to ensure the safety of its operations. The
regulator, CASA, also had defined responsibilities for oversighting the activities of an AOC holder, through the processes of approving AOC variations and other permissions, as well as conducting surveillance of the activities of the operator.
AOC approval and surveillance processes will always have constraints in their
ability to detect problems. There is restricted time available for these activities.
Regulatory surveillance is also a sampling exercise, and cannot examine every
aspect of an operator’s activities, nor identify all the limitations associated with
these activities. In addition, to a large extent AOC approval and surveillance
processes have to focus on regulatory requirements, which provide legal checks
and a minimum standard of safety, rather than safety management processes that
can exceed these minimum standards.
Despite these constraints, CASA still had significant interaction with Transair,
through the conduct of scheduled audits and a series of approval activities, as well
as other activities such as the assessment of a complaint from a company pilot. As
a result of these interactions (most notably its audits), CASA identified areas for
improvement in Transair’s procedures and practices, primarily in the area of
maintenance control. However, it did not detect fundamental problems associated
with the Transair’s management of RPT flight operations, such as the problems
with pilot training, pilot checking, supervision of line flight operations, standard
operating procedures, operations manual format useability, organisational structure,
risk management processes and demonstrated management commitment to safety
outlined in Sections 2.6 and 2.7.
Given the significance of the problems within Transair, and the amount of
interaction CASA had with the operator, it is reasonable to conclude that some of
these problems should have been detected by CASA. In considering the reasons
why these problems with Transair were not detected, the investigation identified
safety factors in the following areas:
• consistency of oversight activities with CASA policies, procedures and
guidelines;
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• guidance for evaluating management systems;
• risk assessments for changes in operations;
• regulatory requirements for safety management systems;
• guidance for evaluating the useability of operations manuals; and
• processes for assessing an operator’s risk profile.
In addition, limitations were identified with CASA’s processes for validating
instrument approaches.
The relationship between these factors and other factors identified during the
investigation is shown in Figure 46.
2.8.1 Consistency of oversight activities with CASA policies,
procedures and guidelines
There were instances where CASA’s oversight of Transair did not appear to be
consistent with CASA’s own requirements and guidelines.
• The initial approval for Transair to conduct RPT (cargo) operations in
October 1999 did not appear to be subject to a full evaluation process
consistent with CASA’s AOC Manual. More specifically, proving flights
and port inspections were not completed before the approval of operations.
• Transair’s application to add the Inverell – Brisbane route to its AOC was
recommended for approval by the Brisbane airline office on 7 April 2004.
However, on 8 April, the airworthiness inspector who had assessed the
application recommended that the approval not be processed until Transair
demonstrated that it had adequate maintenance control in place. The AOC
was issued on 8 April by a delegate in Canberra, and no information
addressing the airworthiness inspector’s concerns was recorded on file.
The extent to which the delegate in Canberra had been made aware of the
airworthiness concerns could not be determined.
• The first systems-based audit in December 1999 identified several
significant management problems. Transair provided undertakings to
address these problems, yet there was no explicit monitoring of Transair’s
implementation of the agreed improvements. In addition, there was no
recorded evidence that CASA completed the activities it proposed to do,
such as ensuring that Transair submitted weekly progress reports and
conducting a special audit 90 days after the agreement.
• After Transair recommenced RPT operations in September 2001, CASA
generally conducted scheduled audits about every 6 months, in accordance
with CASA’s specified schedule for airline operations. However, the
August 2002 audit primarily focussed on Transair’s helicopter charter
operations. Therefore, there was a period of 15 months between November
2001 and February 2003 when minimal auditing of the operator’s RPT
passenger operations was conducted.
Sarcs that's just a small sample from the actual report of the CASA deficiencies that the ATSB reported on. If you read the whole report there is no doubt that there is no "Pelair" style disregard for the regulator's role in oversighting the operation. In this instance there was more to it than just the sloppy CASA paperwork. The report is 265 A4 pages long and that's before you get to the Appendices. If you are looking for examples of ATSB reports that are superficial and don't provide a lot of detail then Lockhart River is not one of them.
As for the Brasilia the ATSB had already recommended that such MBS be done in a simulator and CASA had already mandated it. I think that's how the system is supposed to work. Its unfortunate that this flight was conducted at all but what further improvement in safety can be made if the ATSB has already recommended that such flights should be done in a simulator?