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Recommendation issued to: Civil Aviation Safety Authority

Recommendation details
Output No: R20070003
Date issued: 04 April 2007
Safety action status: Closed - Action Taken
Background: Why this Recommendation was developed

Output text

Safety Issue

CASA did not require operators to conduct structured and/or comprehensive risk assessments, or conduct such assessments itself, when evaluating applications for the initial issue or subsequent variation of an Air Operator's Certificate.

Safety Recommendation

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority undertake further work to address this safety issue.

Initial response
Date issued: 23 March 2007
Response from: Civil Aviation Safety Authority
Action status: Open
Response text:

Risk assessment concepts continue to be developed in CASA. Risk assessment training has been provided to staff with the emphasis now changing to incorporate safety management principles. The AS/NZS4360: 2004 standard on risk assessment is referenced in the Surveillance Procedures Manual.

Additionally, work has commenced on a new CASA Surveillance IT system to be incorporated into Aviation Industry Regulatory System. This system will include a risk module. Such a system should significantly improve CASA's governance, risk identification and reporting capability leading to more effective surveillance of the industry.

ATSB response:

The ATSB acknowledges CASA's on-going development of risk assessment concepts. However, the safety issue also relates to the lack of a regulatory requirement for operators to conduct and provide a risk assessment of initial issue or subsequent renewal of an AOC, as well as CASA's ability to evaluate such risk assessments.

Further correspondence
Date issued: 01 June 2007
Response from: Civil Aviation Safety Authority
Response status: Monitor
Response text:

CASA acknowledges this recommendation but does not support its categorisation as a contributing safety factor at paragraph 3.2.4.

There is no legislative requirement that operators conduct, or that CASA require such operators to conduct or itself to conduct, structured and/or comprehensive risk assessments, when operator's make an application for the initial issue or subsequent variation of an Air Operator's Certificate.

However, as acknowledged by the ATSB, CASA has encouraged operators to adopt Safety Management System (SMS) over the past 10 years and many have done so.

CASA is drafting an amendment m Civil Aviation Order (CAO) 82.0 to mandate SMS to ensure that all passenger carrying operators establish and use a system for managing safety. It is anticipated that this amendment will be made before the end of 2007. A SMS, by its nature, will include a structured risk assessment methodology for evaluating change, including change of the scope of operations.

The ATBS Report acknowledges that CASA intends to mandate Crew Resource Management training for passenger carrying operators. The proposed amendment to CAO 82.0 will also require Air Operator Certificate holders to provide this type of training for their crews.

CASA has also employed six Field Safety Advisors who provide safety advice to members of the aviation community. This is particularly important to industry members living in regional areas who do not have the opportunity m receive safety information from other sources. The programs  of safety education being provided, including SMyS advice and education are a continuation of those provided by CASA for more than a decade.

CASA is producing a booklet for operators about Change Management which will be published for distribution in July 2007.

CASA is developing a Safety Management "toolkit" for smaller operators. This will be introduced by September 2007 in the form of the successful, "Briefing in a Box" concept.

This Toolkit will identify means by which an operator can better understand and evaluate issues such as equipment, routes, key personnel, classification of operations and organisational structures in a changing environment.

In addition, CASA is developing a product that addresses non technical skills for flight crew such as situational awareness, fatigue, threat and error management and workload issues.

The requirement for operators to have a structured risk assessment methodology will be included in the proposed Civil Aviation Safety Regulation (CASR) Part 119 (Air Operator Certification - Air Transport). This Part is planned to be made in 2008. CASA will publish an acceptable means of compliance and an Advisory Circular (AC)on the subject. This will provide guidance material for industry to assist in complying with particular legislative requirements.

ATSB response:

The ATSB defines a safety issue as a safety factor that (a) can reasonably be regarded as having the potential to adversely affect the safety of future operations, and (b) is a characteristic of an organisation or a system, rather than a characteristic of a specific individual, or characteristic of an operational environment at a specific point in time. As such, the classification of the safety issue as a contributing safety factor is irrelevant in terms of safety action.

While the ATSB acknowledges the lack of any specific regulatory requirements relating to risk assessment, it would appear that Section 28(1) and (2) of the Civil Aviation Act 1988 implies a process of risk assessment. Regardless, the ATSB notes the actions being taken by CASA to address the safety issue and has amended the status of this recommendation to 'Monitor'.

Further correspondence
Date issued: 08 October 2008
Response from: Civil Aviation Safety Authority
Response status: Closed - Accepted
Response text:

CASA has now expanded the Aviation Safety Advisors program in 2008 to a total of eleven advisors who provide safety advice to members of the aviation community. This is particularly important to industry members living in regional areas who do not have the opportunity to receive safety information from other sources. The programs of safety education being provided, including Safety Management advice and education are a continuation of those provided by CASA for more than a decade.

CASA has developed a Safety Management Toolkit for operators. The final production is underway and distribution started in March/April 2008 with the initial components being the Message to CEOs, a Best Practice SMS booklet and DVD, the previously existing SMS DVD and the Change Management Booklet. Other safety management issues will be included in due course. The CEO Booklet aims at providing CEOs with a strategic direction with respect to Safety Management. The Best Practice material provides current industry safety management norms as told by the industry. The distribution of the Change Management booklet has been held pending the completion of the Safety Management Toolkit of which it now forms a part. This booklet identifies means by which an operator can better understand and evaluate issues such as equipment, routes, key personnel, classification of operations and organisational structures in a changing environment.

CASA has engaged a consultant and is currently developing a "Briefing in a Box" product that addresses non technical skills for flight crew such as situational awareness, fatigue, threat and error management and workload issues. This product will provide operators with the tools to conduct their own training and education for staff and crew.

The Industry Oversight Project provides all CASA oversight with a clear risk based framework, which assesses safety risk within Permission Holders, the risks associated with managing safety oversight of a wide variety of permissions and the risks associated with oversight strategy, which includes hazards identified across the industry, as well as responding to government guidance. The Framework provides the various levels of surveillance activity and management within the organisation with clear guidance on assessment of risk and the treatments/controls available for their use. Entry Control in particular is provided with clear guidance on assessment of safety risk. This is tied closely to the development of the Part 119 Regulation which requires Permission Applicants to provide an Exposition for assessment. The Exposition is a demonstration of the operator's understanding of the risks associated with their own activity as well as their strategies for controlling these risks.

ATSB response:

The ATSB acknowledges CASAs commitment to providing educational material to industry to assist operators manage changes to operations from a safety management system perspective, as well as CASAs commitment to use a risk-based approach for the over-sight of industry. The ATSB also recognises the Civil Aviation Orders 82.3 and 82.5, as amended 3 February 2009, which require regular public transport operators to have a safety management system in place that, 'as a minimum, include ....... (b) a safety risk management plan, including documented details of the following: (i) hazard identification processes; (ii) risk assessment and mitigation processes'.

 
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Last update 05 April 2012