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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 phase: Evidence collection 
Location   (show map):47km WSW, Sydney  Investigation type: Safety Issue Investigation 
State: New South Wales  
 Occurrence class: Technical 
Report status: Pending Occurrence category: Other 
Anticipated completion: 1st Quarter 2019 Highest injury level: None 
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Last update 07 August 2018