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Safety Action


Local safety action

As a result of this investigation, the following safety actions were initiated by the operator:

  1. The operator advised that action would be taken to ensure a uniform standard of crew resource management across the company.
  2. The pilot in command was provided with additional training to address deficiencies in his knowledge of night visual approaches.

BASI safety action

As a result of investigations into a number of previous occurrences involving crew resource management issues, the Bureau issued interim recommendation IR950101 on 17 July 1995 to the Civil Aviation Safety Authority.

The Bureau of Air Safety Investigation recommends that the Civil Aviation Safety Authority (CASA) require operators involved in multi-crew air transport operations to ensure that pilots have received effective training in crew resource management (CRM) principles. To this end, the CASA should publish a timetable for the phased introduction of CRM training to ensure that:

  1. CRM principles are made an integral part of the operator's recurrent check and training program and where practicable, such training should be integrated with simulator LOFT exercises;
  2. the CASA provides operators and/or CRM course providers with an approved course syllabus based on international best practice;
  3. such training integrates cabin crew into appropriate aspects of the program; and
  4. the effectiveness of each course is assessed to the satisfaction of the CASA".

The following response was received from the Civil Aviation Safety Authority on 8 September 1995:

"I refer to your Interim Recommendation No IR950101 concerning the B747-312 accident at Sydney on 19 October 1994.

CASA fully endorses the principles of and accepts the benefits flowing from CRM and similar training as well as strongly encouraging such training for flight crew, cabin crew and other operating crew. However, CASA is not fully convinced that mandating CRM or similar training, particularly for high and low capacity RPT operations, will necessarily prevent or reduce the incidence of such accidents in the future.

Nonetheless, CASA is willing to further investigate CRM training including the position taken by leading overseas regulatory authorities in this regard, particularly in relation to high and low capacity RPT operations. To this end, CASA intends to consider the issue as part of a major project to commence in the latter part of 1995. This project is to review all aspects of RPT operations conducted under CAR 217 in relation to Training and Checking organisations and is the first major review of such operations to be carried out for some time.

CASA undertakes to advise BASI of the outcome of that review in relation to CRM and similar training".



The following response was received from the Civil Aviation Safety Authority on 26 February 1997, and stated in part:

"I refer to BASI Interim Recommendation IR950101 and the Civil Aviation Safety Authority responses of September 1995 and January 1996.

My purpose in writing is to provide you with a formal update on the CASA position on this recommendation. I understand that the CASA General Manager Flying Operations informally conveyed this position to Director BASI earlier this year and sought from him copies of up to date material on crew resource management (CRM) training acquired by BASI at a recent Orient Airlines Association seminar. The CASA position for publication is shown in the quotes below."

"After further review along the lines indicated in our response of 8 September 1995, CASA agrees that regulations should be introduced requiring operators engaged in multi-crew air transport operations to have effective crew resource management training programs.

This is one of the tasks being actioned by the Air Transport Technical Committee of CASA's Regulatory Framework Program. The crew training project team working under that committee, which includes representatives from industry, is also considering introduction of other best practice initiatives such as the Advanced Qualification Program (AQP) introduced by the FAA and the New Zealand CAA. Introduction of any new legislation on these matters is of course subject to requirements for appropriate consultation with industry. The RFP has a timetable to complete and publish a new set of Civil Aviation Safety Regulations (CASRs) and associated advisory material by the end of 1998. However, where possible new CASRs will be introduced progressively before that date."


"I would also like to take this opportunity to invite BASI to provide a human factors qualified observer/adviser to assist the project team developing the CRM/AQP regulations and advisory material."

Response classification: CLOSED - ACCEPTED

CASA has since issued a Notice of Proposed Rulemaking (NPRM9809RP) on regulations relating to passenger and crew-member safety. Whilst all aircraft operators and crew members will be affected to some degree by the NPRM, the principal thrust of the proposed changes is to "upgrade safety with respect to the carriage of fare-paying passengers in aircraft requiring the carriage of cabin crew". This implies that the NPRM is largely directed toward multi-crew operations in passenger-carrying aircraft. Section 121.YY of the NPRM refers to crew-member emergency procedures training. Each operator will be required to conduct initial and ongoing CRM training for each crew-member position required for a particular aircraft type.

On 16 September 1999 the Bureau received the following advice from CASA regarding CRM training and the date of introduction of CASR Part 121A:

"It is not anticipated that new Part 121A will be effective before 1 January 2002. However, CASA is aware of the importance of CRM training for crew members and will be issuing a policy that will require operators to conduct such training. This policy will be issued in advance of the introduction of the new regulations and is expected to be in place by 1 July 2000."

The Bureau is currently monitoring implementation of IR950101.

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