Aviation safety investigations & reports

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

Investigation number:
Status: Discontinued

Discontinuation notice

Discontinuation notice published 27 March 2020

Section 21 (2) of the Transport Safety Investigation Act 2003 (TSI Act) empowers the ATSB to discontinue an investigation into a transport safety matter at any time. Section 21 (3) of the TSI Act requires the ATSB to publish a statement setting out the reasons for discontinuing an investigation.

Overview of the investigation

As part of the occurrence investigation into the In-flight upset, inadvertent pitch disconnect, and continued operation with serious damage involving ATR 72, 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 on 19 October 2017 a separate Safety Issues investigation was commenced to examine the implementation of an organisation's SMS during a time of rapid expansion, along with ongoing interactions with the regulator.

As part of its investigation, the ATSB:

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

ATSB comment

Based on a review of the available evidence, the ATSB considered it was unlikely that further investigation would identify any systemic safety issues. Additionally, in the context that the investigation examined a time period associated with the early implementation of an SMS, it was also assessed that there was minimal safety learning that was relevant to current safety management practices. Consequently, the ATSB has discontinued this investigation.

The evidence collected during this investigation remains available to be used in future investigations or safety studies. The ATSB will also monitor for any similar occurrences that may indicate a need to undertake a further safety investigation. The ATSB will also continue to examine safety management systems, and their oversight, in other systemic investigations.

General details
Date: 19 October 2017   Investigation status: Discontinued  
  Investigation level: Systemic - click for an explanation of investigation levels  
Location   (show map): 47km WSW, Sydney    
State: New South Wales    
Release date: 27 March 2020   Occurrence category: Other  
Report status: Discontinued   Highest injury level: None  
Anticipated completion: 1st Quarter 2019    
Last update 03 April 2020