Aviation safety investigations & reports

Case study: implementation and oversight of an airline's safety management system during rapid expansion

Investigation number:
Status: Active
Investigation in progress


As part of the occurrence investigation into the in-flight pitch disconnect and maintenance irregularity involving an ATR72, VH-FVR (AO-2014-032) investigators explored the operator's safety management system (SMS), and also explored the role of the regulator in oversighting the operator's systems. The ATSB collected a significant amount of evidence and conducted an in-depth analysis of these organisational influences. It was determined that the topic appeared to overshadow key safety messages regarding the occurrence itself and therefore a separate Safety Issues investigation was commenced to outline the implementation of an organisation's SMS during a time of rapid expansion, along with ongoing interactions with the regulator.

The investigation will examine the chronology of the operator's SMS implementation and some of the key issues encountered. This will include:

  • interviews with current and former staff members of the operator, regulator and other associated bodies
  • examining reports, documents, manuals and correspondence relating to the operator and the methods of oversight used
  • reviewing other investigations and references where similar themes have been explored.


General details
Date: 19 October 2017   Investigation status: Active  
  Investigation level: Complex - click for an explanation of investigation levels  
Location   (show map): 47km WSW, Sydney   Investigation phase: Evidence collection  
State: New South Wales    
  Occurrence category: Other  
Report status: Pending   Highest injury level: None  
Anticipated completion: 1st Quarter 2020    
Last update 20 September 2019