Perhaps we could just openly dismiss the recent Senate committee report and Forsyth review; that would at least be honest. The ship of state has set course, once again the destination is known and we will at least avoid the huge impost of the pointless, empty 'inquiry' pantomime. Just bury the dead, scrape the airframe remains off the runway and get back to being the proud, aviation superstar we claim to be; strutting our proud heritage on the world stage. Bugger the incredible number of ignored recommendations, edicts, policies and bollocks uttered by neutered politicians, coroners and independent report writers. "Sleepy Hollow rules: OK, you got it. Good, now STFU, give us your money and do as you're told"..(instant compliance).. "There now, there's a good little industry".
85 recommendations from Senate/Govt inquiry/review in last five years...
Pilot training and airline safety; and Consideration of the Transport Safety Investigation Amendment (Incident Reports) Bill 2010
Recommendation 1 - The committee is of the view that an ATPL should also be required for first officers in high capacity regular public transport (RPT) jet aircraft such as Boeing 737, A320 and other aircraft of similar or greater capacity, and that consideration be given to implementing this as a standard.
Recommendation 2 - The committee recommends that for non-jet operations which employ low-experience first officers, operators be required to provide enhanced supervision and mentoring schemes to offset such lack of experience.
Recommendation 3 - The committee recommends that Air Operators Certificate (AOC) holders be required to develop and implement 'green on green' policy positions relating to the use of low experience pilots in RPT operations, to maximise, wherever possible, the collective experience level of flight crew.
Recommendation 4 - The committee recommends that Civil Aviation Safety Regulation (CASR) Part 61 ensure that all prospective regular public transport (RPT) pilots be required to complete substantial course-based training in multi-crew operations and resource management (non-technical skills) and human factors training prior to, or in reasonable proximity to, initial endorsement training; the committee recommends that the Civil Aviation Safety Authority (CASA) expedite, and assign the highest priority to, the implementation of CASR Part 61.
Recommendation 5 - The committee recommends that the Civil Aviation Safety Authority (CASA) ensure that Part 61 of the Civil Aviation Safety Regulations currently being reviewed place sufficient weight on multi-engine aeroplane experience as opposed to the current recognition of glider and ultra-light experience.
Recommendation 6 - The committee recommends that the Civil Aviation Safety Authority (CASA) be required to undertake a risk assessment of current simulator training to assess whether the extent, aims and scope of such training is being utilised to achieve optimum safety outcomes rather than minimum compliance objectives.
Recommendation 7 - The committee recommends that the Civil Aviation Authority (CASA) expedite, and assign the highest priority to, the implementation of Civil Aviation Safety Regulations (CASR) Part 141 'Flight Training Operators' and Part 142 'Training and Checking Operators'.
Recommendation 8 - The committee recommends that the Government require the Productivity Commission or another suitable body to undertake a review of the current and future supply of pilots in Australia, with particular reference to the general aviation and cadet training pathways, and HECS HELP and VET FEE-HELP arrangements.
Recommendation 9 - The committee recommends that the Civil Aviation Safety Authority (CASA), the Australian Transport Safety Bureau (ATSB) and Australian aviation operators review the final findings of France's Bureau of Investigation and Analysis into Air France 447, including consideration of how it may apply in the Australian context. Subject to those findings, the committee may seek the approval of the Senate to conduct a further hearing in relation to the matter.
Recommendation 10 - The committee recommends that the Minister for Infrastructure and Transport provide a report to Parliament every six months outlining the progress of the Civil Aviation Safety Authority's (CASA) regulatory reforms and specifying reform priorities, consultative processes and implementation targets for the following 12-month period.
Recommendation 11 - The committee recommends that the Government undertake a review of the funding to the Civil Aviation Safety Authority (CASA) to ensure that there is sufficient specific funding to support an expedited regulatory reform process.
Recommendation 12 - The committee recommends that, as an ongoing measure, the Government provide the Civil Aviation Safety Authority (CASA) with specific funding to enable it to offer salaries that are competitive with industry; in addition, or as an alternative, the Government should consider implementing formal mechanisms for the sharing of expertise between industry and CASA.
Recommendation 13 - The committee recommends that the Transport Safety Investigation Amendment (Incident Reports) Bill 2010 not be passed.
Recommendation 14 - The committee recommends that the current prescriptive approach needs to be supplemented with a general obligation to report whenever the 'responsible person' believes that there is an urgent safety risk that must be addressed.
Recommendation 15 - The committee recommends that the Australian Transport and Safety Bureau (ATSB) review its approach to the investigation and publication of human factors with a view to achieving a more robust and useful learning tool for the industry.
Recommendation 16 - The committee recommends that the Australian Transport and Safety Bureau (ATSB) review existing processes for the categorisation of aviation events to ensure that miscategorisation is minimised and opportunities for system improvement are not lost.
Recommendation 17 - The committee recommends that the Civil Aviation Safety Authority (CASA), in concern with Australian Transport and Safety Bureau (ATSB), consider developing and publishing guidance on model reporting to minimise understatement of the actual or potential significance of aviation events.
Recommendation 18 - The committee recommends that Civil Aviation Safety Authority (CASA) require operators to observe the highest standards of incident reporting from their personnel and provide appropriate training as part of the safety promotion function of their SMS.
Recommendation 19 -The committee recommends that, in order to enhance 'just culture' and open reporting of incidents, aviation operators should ensure that their relevant managers are adequately trained in procedural fairness.
Recommendation 20 - The committee recommends that, following the release of the International Civil Aviation Organization (ICAO) fatigue guidelines, the Civil Aviation Safety Authority (CASA) should expedite necessary changes and/or additions to the regulations governing flght and cabin crew fatigue risk management as a priority
Recommendation 21 - The committee recommends that, in the event that the International Civil Aviation Organization (ICAO) fatigue guidelines do not extend to cabin crew duty limits and fatigue risk management more broadly, the Government should amend the Civil Aviation Act 1998 to include cabin crew fatigue risk management under the Civil Aviation Safety Authority's (CASA) regulatory oversight.
Recommendation 22 - The committee recommends that the Civil Aviation Safety Authority (CASA) specify the type of training and amount of training required for cabin crew, including mandatory English language standards.
Aviation accident investigations
Recommendation 1 - The committee recommends that the ATSB retrieve VH-NGA flight data recorders without further delay.
Recommendation 2 - The committee recommends that the minister, in issuing a new Statement of Expectations to the ATSB, valid from 1 July 2013, make it clear that safety in aviation operations involving passengers (fare paying or those with no control over the flight they are on, e.g. air ambulance) is to be accorded equal priority irrespective of flight classification.
Recommendation 3 - The committee recommends that the ATSB move away from its current approach of forecasting the probability of future events and focus on the analysis of factors which allowed the accident under investigation to occur. This would enable the industry to identify, assess and implement lessons relevant to their own operations.
Recommendation 4 - The committee recommends that the ATSB be required to document investigative avenues that were explored and then discarded, providing detailed explanations as to why.
Recommendation 5 - The committee recommends that the training offered by the ATSB across all investigator skills sets be benchmarked against other agencies by an independent body by, for example, inviting the NTSB or commissioning an industry body to conduct such a benchmarking exercise.
Recommendation 6 - The committee recommends that, as far as available resources allow, ATSB investigators be given access to training provided by the agency's international counterparts. Where this does not occur, resultant gaps in training/competence must be advised to the minister and the Parliament.
Recommendation 7 - The committee recommends that the Transport Safety Investigation Act 2003 be amended to require that the Chief Commissioner of the ATSB be able to demonstrate extensive aviation safety expertise and experience as a prerequisite for the selection process.
Recommendation 8 - The committee recommends that an expert aviation safety panel be established to ensure quality control of ATSB investigation and reporting processes along the lines set out by the committee.
Recommendation 9 - The committee recommends that the government develop a process by which the ATSB can request access to supplementary funding via the minister.
Recommendation 10 - The committee recommends that the investigation be re-opened by the ATSB with a focus on organisational, oversight and broader systemic issues.
Recommendation 11 - The committee recommends that CASA processes in relation to matters highlighted by this investigation be reviewed. This could involve an evaluation benchmarked against a credible peer (such as FAA or CAA) of regulation and audits with respect to: non-RPT passenger carrying operations; approach to audits; and training and standardisation of FOI across regional offices.
Recommendation 12 - The committee recommends that CASA, in consultation with an Emergency Medical Services industry representative group (eg. Royal Flying Doctor Service, air ambulance operators, rotary wing rescue providers) consider the merit, form and standards of a new category of operations for Emergency Medical Services. The minister should require CASA to approve the industry plan unless there is a clear safety case not to. Scope for industry to assist as part of an audit team should also be investigated where standardisation is an issue. This should be completed within 12 months and the outcome reported publicly.
Recommendation 13 - The committee recommends that a short inquiry be conducted by the Senate Standing Committee on Rural and Regional Affairs and Transport into the current status of aviation regulatory reform to assess the direction, progress and resources expended to date to ensure greater visibility of the processes.
Recommendation 14 - The committee recommends that the ATSB-CASA Memorandum of Understanding be re-drafted to remove any ambiguity in relation to information that should be shared between the agencies in relation to aviation accident investigations, to require CASA to:
- advise the ATSB of the initiation of any action, audit or review as a result of an accident which the ATSB is investigating.
- provide the ATSB with the relevant review report as soon as it is available.
Recommendation 15 - The committee recommends that all meetings between the ATSB and CASA, whether formal or informal, where particulars of a given investigation are being discussed be appropriately minuted.
Recommendation 16 - The committee recommends that, where relevant, the ATSB include thorough human factors analysis and discussion in future investigation reports. Where human factors are not considered relevant, the ATSB should include a statement explaining why.
Recommendation 17 - The committee recommends that the ATSB prepare and release publicly a list of all its identified safety issues and the actions which are being taken or have been taken to address them. The ATSB should indicate its progress in monitoring the actions every 6 months and report every 12 months to Parliament.
Recommendation 18 - The committee recommends that where a safety action has not been completed before a report being issued that a recommendation should be made. If it has been completed the report should include details of the action, who was involved and how it was resolved.
Recommendation 19 - The committee recommends that the ATSB review its process to track the implementation of recommendations or safety actions to ensure it is an effective closed loop system. This should be made public, and provided to the Senate Regional and Rural Affairs and Transport Committee prior to each Budget Estimates.
Recommendation 20 - The committee recommends that where the consideration and implementation of an ATSB recommendation may be protracted, the requirement for regular updates (for example 6 monthly) should be included in the TSI Act.
Recommendation 21 - The committee recommends that the government consider setting a time limit for agencies to implement or reject recommendations, beyond which ministerial oversight is required where the agencies concerned must report to the minister why the recommendation has not been implemented or that, with ministerial approval, it has been formally rejected.
Recommendation 22 - The committee recommends that Airservices Australia discuss the safety case for providing a hazard alert service with Fijian and New Zealand ATC (and any other relevant jurisdictions) and encourage them to adopt this practice.
Recommendation 23 - The committee recommends that the relevant agencies review whether any equipment or other changes can be made to improve the weather forecasting at Norfolk Island. The review would include whether the Unicom operator should be an approved meteorological observer.
Recommendation 24 - The committee recommends that the relevant agencies investigate appropriate methods to ensure that information about the incidence of, and variable weather conditions at, Norfolk Island is available to assist flight crews and operators managing risk that may result from unforseen weather events.
Recommendation 25 - The committee recommends that the Aeronautical Information Package (AIP) En Route Supplement Australia (ERSA) is updated to reflect the need for caution with regard to Norfolk Island forecasts where the actual conditions can change rapidly and vary from forecasts.
Recommendation 26 - The committee recommends that in relation to mandatory and confidential reporting, the default position should be that no identifying details should be provided or disclosed. However, if there is a clear risk to safety then the ATSB, CASA and industry representatives should develop a process that contains appropriate checks and balances.
1. The Civil Aviation Safety Authority delegates responsibility for the day-to-day operational management of airspace to Airservices Australia, including the designation of air routes, short-term designations of temporary Restricted Areas, and temporary changes to the classification of airspace for operational reasons.
2. The Department of Infrastructure and Regional Development and Department of Defence (and appropriate agencies) establish an agreed policy position on safety oversight of civil operations into joint user and military airports.
3. The Civil Aviation Safety Authority changes its regulatory philosophy and, together with industry, builds an effective collaborative relationship on a foundation of mutual understanding and respect.
4. The Civil Aviation Safety Authority continues to provide appropriate indemnity to all industry personnel with delegations of authority.
5. The Civil Aviation Safety Authority finalises its Capability Framework and overhauls its training program to ensure identified areas of need are addressed, including:
a. communication in a regulatory context
b. decision making and good regulatory practice
c. auditing.
9. The Civil Aviation Safety Authority publishes and demonstrates the philosophy of ‘just culture’ whereby individuals involved in a reportable event are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training. However, actions of gross negligence, wilful violations and destructive acts should not be tolerated.
10. The Civil Aviation Safety Authority reintroduces a ‘use of discretion’ procedure that gives operators or individuals the opportunity to discuss and, if necessary, remedy a perceived breach prior to CASA taking any formal action. This procedure is to be followed in all cases, except where CASA identifies a Serious and Imminent Risk to Air Safety.
11. The Australian Transport Safety Bureau transfers information from Mandatory Occurrence Reports to the Civil Aviation Safety Authority, without redaction or de-identification.
12. The Australian Transport Safety Bureau transfers its safety education function to the Civil Aviation Safety Authority.
13. The Civil Aviation Safety Authority changes its organisational structure to a client-oriented output model.
14. The Civil Aviation Safety Authority establishes small offices at specific industry centres to improve monitoring, service quality, communications and collaborative relationships.
15. The Civil Aviation Safety Authority shares the risk assessment outputs of Sky Sentinel, its computerised risk assessment system, with the applicable authorisation holder.
16. The Civil Aviation Safety Authority provides full disclosure of audit findings at audit exit briefings in accordance with international best practice.
17. The Civil Aviation Safety Authority introduces grading of Non-Compliance Notices on a scale of seriousness.
18. The Civil Aviation Safety Authority assures consistency of audits across all regions, and delivers audit reports within an agreed timeframe.
19. The Civil Aviation Safety Authority implements a system of using third-party commercial audits as a supplementary tool to its surveillance system.
20. The Australian Transport Safety Bureau transfers its safety education function to the Civil Aviation Safety Authority.
21. The Civil Aviation Safety Authority changes its organisational structure to a client-oriented output model.
22. The Civil Aviation Safety Authority establishes small offices at specific industry centres to improve monitoring, service quality, communications and collaborative relationships.
23. The Civil Aviation Safety Authority shares the risk assessment outputs of Sky Sentinel, its computerised risk assessment system, with the applicable authorisation holder.
24. The Civil Aviation Safety Authority provides full disclosure of audit findings at audit exit briefings in accordance with international best practice.
25. The Civil Aviation Safety Authority introduces grading of Non-Compliance Notices on a scale of seriousness.
26. The Civil Aviation Safety Authority assures consistency of audits across all regions, and delivers audit reports within an agreed timeframe.
27. The Civil Aviation Safety Authority implements a system of using third-party commercial audits as a supplementary tool to its surveillance system.
28. The Civil Aviation Safety Authority establishes a safety oversight risk management hierarchy based on a categorisation of operations. Rule making and surveillance priorities should be proportionate to the safety risk.
29. Recreational Aviation Administration Organisations, in coordination with the Civil Aviation Safety Authority, develop mechanisms to ensure all aircraft to be regulated under CASR Part 149 are registered.
30. The Civil Aviation Safety Authority changes the current two-tier regulatory framework (act and regulations) to a three-tier structure (act, regulations and standards), with:
a. regulations drafted in a high-level, succinct style, containing provisions for enabling standards and necessary legislative provisions, including offences
b. the third-tier standards drafted in plain, easy to understand language.
31. The Civil Aviation Safety Authority structures all regulations not yet made with the three-tier approach, and subsequently reviews all other Civil Aviation Safety Regulation Parts (in consultation with industry) to determine if they should be remade using the three-tier structure.
32. The Civil Aviation Safety Authority reassesses the penalties in the Civil Aviation Safety Regulations.
33. The Civil Aviation Safety Authority applies a project management approach to the completion of all Civil Aviation Safety Regulation Parts not yet in force, with drafting to be completed within one year and consultation completed one year later, with:
a. a Steering Committee and a Project Team with both CASA and industry representatives
b. implementation dates established through formal industry consultation.
34. The Civil Aviation Safety Authority’s Director of Aviation Safety meet with industry sector leaders to jointly develop a plan for renewing a collaborative and effective Standards Consultative Committee.
35. The Civil Aviation Safety Authority devolve to Designated Aviation Medical Examiners the ability to renew aviation medical certificates (for Classes 1, 2, and 3) where the applicant meets the required standard at the time of the medical examination.
36. The Australian Government amends regulations so that background checks and the requirement to hold an Aviation Security Identification Card are only required for unescorted access to Security Restricted Areas, not for general airside access. This approach would align with international practice.
37. The Civil Aviation Safety Authority amends the current Terms of Reference of the Industry Complaints Commissioner so that:
a. the ICC reports directly to the CASA Board
b. no CASA staff are excluded from the ICC’s jurisdiction
c. the ICC will receive complaints that relate to both the merits and the process of matters
d. on merits matters, including aviation medical matters, the ICC is empowered to convene an appropriately constituted review panel, chaired by a CASA non-executive director, to review the decision
e. while all ICC findings are non-binding recommendations, the original decision-maker is required to give reasons to the CASA Board if a recommendation is not followed.
TBC...
