Aviation safety issues and actions

Air display approval and oversight

Issue number: AO 2017-013-SI-01
Who it affects: Air displays: Organisers and participants in air displays
Issue owner: Civil Aviation Safety Authority
Transport function: Aviation: Other
Background: Investigation Report AO-2017-013
Issue release date: 19 November 2019
Current issue status: Open – Safety action pending

Safety issue description

The Civil Aviation Safety Authority (CASA) did not have an effective framework to approve and oversight air displays, predominantly due to the following factors:

  • While the Air Display Manual provided guidance to organisers conducting an air display, it did not inherently provide the processes and tools needed for CASA to approve and oversee one and no other documented guidance existed.
  • Unlike the accreditation models adopted by some other countries, CASA did not have a systematic approach for assessing the suitability of those responsible for organising, coordinating and participating in air displays.
  • CASA did not have a structured process to ensure that risks were both identified and adequately treated.

The combination of these factors significantly increased the likelihood that safety risks associated with the conduct of the air display were not adequately managed.

Proactive action

Action number: AO 2017-013-NSA-01
Action organisation: Civil Aviation Safety Authority
Date: 19 November 2019
Action status: Released

At the time of the occurrence, the Civil Aviation Safety Authority (CASA) had a revised air display guidance manual in draft. This was subsequently published in September 2017 as the Air Display Administration and Procedure Manual. Version 3.0 of this manual was published in April 2018. Pro-active safety actions arising from the new publication included:

  • the requirement to conduct a risk assessment as part of the air display planning
  • the requirement for the display organiser and display coordinator to document their relevant qualifications and associated display experience, to allow CASA to assess their suitability for the role
  • further clarification of roles and responsibilities, and display organisational expectations
  • enhanced forms for display pilots and additional crew, to assist the display coordinator in their assessment of the pilot and display, and to ensure all persons on board are identified and authorised.

ATSB comment:

The ATSB acknowledges the improvements to the Civil Aviation Safety Authority’s Air Display Administration and Procedure Manual, and associated forms. While these changes improve existing guidance and partially address the safety issue, The ATSB considers that further improvements can be made to provide additional assurance of the suitability of key personnel, and to provide enhanced guidance and tools around the approval and oversight of air displays. Accordingly, the ATSB issues the following recommendation.

Safety recommendation

Action number: AO-2017-013-SR-029
Action organisation: Civil Aviation Safety Authority (CASA)
Date: 19 November 2019
Action status: Released

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority undertake further work to enhance their tools and guidance for air display approval and oversight, and procedures to ensure the suitability of those responsible for organising, coordinating and participating in air displays.

Additional correspondence

Response date: 25 February 2020
Response from: Civil Aviation Safety Authority (CASA)
Action status: Monitor
Response text:

Response to Safety Recommendation

Overview:

CASA acknowledges the recommendation and agrees that formal procedures to ensure the suitability of those responsible for organising, coordinating and participating in air displays is an essential component of the guidance material to be included in the CASA air display manual.

CASA has had a documented Air Display approval process manual since 1998. The manual has undergone various iterations over the years with a comprehensive rework in 2017 to enhance guidance material for display organisers.

After the Swan River accident, a Regulatory and Safety Review (RSR) was conducted by CASA. Information from that report was used in the ASTB report on the accident. The RSR also contained recommendations that were provided to the DAS for consideration. In December 2017, a signed minute from the DAS was produced in respect to those recommendations.

The 2017 document provided updated detail on key roles and responsibilities. Further, the amendment introduced a requirement to conduct a risk assessment as part of the application process. The amendment also aligned references to Parts 61/141/142.

In April 2018, version (3.0) of the manual updated the participant form, which was expanded to assist pilots with their display preparation. The form included a requirement to identify and provide justification for any additional persons on board a display aircraft. The form also included a section to provide additional assurance around completion of the display coordinator’s responsibilities. Version 3.0 was approved by the Executive Manager, Regulatory Services and Surveillance Division (EM, RSSD). The sponsor of the manual is the Branch Manager, General Recreation & Sports Aviation (GRSA). The manual is due for review in April 2020.

Current state:

From early 2018 and continuing today, the following are updates/amendments/additions that have been undertaken since the issue of the minute by the DAS.

  • Updated CASA Air Display Administration and Procedures Manual & ongoing review and amendments.
  • Standardisation of Display approvals / instruments.
  • Individual display approvals issued to pilots based on review of experience and proposed flying displays.
  • Mandatory specialist internal training for Air Display Assessors & requirement for ongoing refresher training.
  • Mandatory training includes a practical component, that being assessment and surveillance of an air display.
  • Mentoring of newly trained display assessors is conducted in an ongoing manner to ensure consistency in approach.
  • Only CASA Staff with Air Display Assessment training can undertake the assessment of an air display application.
  • Development of Air Display checklist and guidance material to ensure an appropriate level of assessment has been undertaken on all air display applications.
  • Peer review of all display approvals conducted by General Recreational and Sport Aviation (GRSA) prior to issue.
  • EAP (CASA workflow/IT) process about to go live for receiving and tracking of Air Display Applications.
  • Specific experience requirements documented within Air Display Manual for Air Display Organisers and Display Coordinators for all air displays.
  • Ongoing review and improvements to air display assessments and requirements based on review and consultation with other NAA’s (specifically FAA and UK CAA).
  • Proposed further mandatory training of display organisers and coordinators (Flying Display Directors) in line with FAA and UK CAA requirements.

Future state:

Currently, the Executive Manager, RSS is the Manual Owner for the Air Display Manual. However, the Manual and assessment process has been sponsored by content from the Branch Manager, GRSA. Recent discussions have centred around moving the Air Display Process wholly within RSS, with GRSA Sport SMEs available for complex technical advice only – not routine peer review.
This will centralise the business and manual amendment processes and streamline the assessment of air display applications.

Summary:

CASA is continually reviewing the Air Display assessment process including information contained within the Air Display Administration and Procedure Manual. Following the move to centralise oversight of Air Displays within RSSD, a more holistic review and amendment process can be achieved to further improve the guidance material for both CASA and industry participants.

Response date: 03 July 2020
Response from: Civil Aviation Safety Authority (CASA)
Action status: Monitor
Response text:

Current State:

Following the initial changes made in 2018 and as part of the continual improvement process, a comprehensive review of the Display Administration and Procedure Manual (ADAPM) and associated processes, forms and guidance was completed in June 2020, to ensure:

  1. The ADAPM continues to be fit for purpose and integrates seamlessly with transition to the new Flight Operations Regulations. An update of the ADAPM was completed in June 2020 and is currently progressing through the final legal review process for publishing.
  2. Capability exists with the number of trained FOI’s who are approved to assess applications and commence training of additional initial and recurrent training courses for inspectors. A review of the current inspector training course is in progress, to align with the new application forms, updated ADAPM and assessor worksheet. Additional training is planned to commence for inspectors in August 2020 and will also include refresher training for those inspectors currently approved to undertake assessment.
  3. Application forms, development of assessor worksheet and additional guidance material to permit an expedited nationally consistent application process. New application forms have been approved and will be published alongside the updated ADAPM. The new forms better align with CASA forms philosophy, are clear and simple and better align with requirements of the ADAPM. The updated forms place greater responsibility on the Display Organiser to ensure accurate information is submitted and will result in a higher standard of application to strengthen the assessment process. A new Post Display Report form has combined older forms to simplify administrative workload for the Display Organiser, whilst providing greater assurance for CASA. A new Assessor Worksheet has also been developed, which will bring consistency and standardisation to the assessment process. This form will be implemented with introduction of the new forms and ADAPM at the soonest opportunity.
  4. Improved communication and consultation with industry in relation to CASA’s oversight and regulatory management of Air Display’s and the transition to Part 91. A new industry facing webpage will be added to the CASA website that will provide specific information regarding Air Displays and the requirements and forms needed to assist application. Industry consultation is scheduled to commence in September 2020 and will seek to inform stakeholders about the changes to the Air Display process being proposed with transition into Part 91 and alignment with international best practice.

A key focus of the review was to strengthen existing processes for current legislation, whilst enabling a seamless transition to Part 91 and the proposal to align with international best practice. As the review has been recently completed and the document approval process is nearing finalisation, once formal approval has been granted, CASA will forward all updated documentation, including the ADAPM, Assessor Worksheet, Forms 696 (Air Display Application), Form 697 (Air Display Pilot Details) and new Post Display Report to the ATSB. In the interim, examples of the standard Air Display Approval and Pilot Approvals are attached for reference.

It is envisaged that once published, the new forms, industry facing website and ADAPM will provide additional guidance to industry, and clearly state all considerations required to conduct an air display in a safe and compliant manner. It is anticipated the new forms and updated ADAPM will improve the quality of applications received from Display Organisers and will provide relevant information to CASA in a timelier manner. Air display assessments will be conducted by inspectors that have undertaken the required training with emphasis being placed on the use of the updated ADAPM, assessor worksheet and standard approvals. Additional inspector training is scheduled to commence for both initial and recurrent training in August 2020.

Internal Training Documentation for Assessors is currently being reviewed and updated to align with the ADAPM, application forms and assessor worksheet. All updated documentation will be provided to the ATSB for review as soon as the document approval process is complete.

Approval for Display Organisers will be implemented as part of the transition to Part 91 and will be addressed in accordance with the proposed timeline (below).

  • Transfer of Responsibility to EM RSS (completed April 2020)
  • Review of ADAPM (completed June 2020)
  • Review of Industry Application Forms and Supporting Documentation (Completed June 2020) 
  • Development of Assessor Worksheet (Completed June 2020)
  • Implementation of Change Management Plan to align Part 91 as Aviation Event (Commenced May 2020)
  • Review of ADAPM Inspector training (Underway – to be completed June 2020)
  • Initial and Recurrent Inspector training (August 2020)                                 
  • Industry Consultation and Communication of Change for transition to Part 91 (September 2020)
  • Update of ADAPM to align with Part 91 (June 2021)
  • Commencement of Inspector Training for Part 91 implementation (July 2021)
  • Commencement of Industry training for Display Organiser and Flying Display Director Approvals (August 2021)
  • Implementation of Part 91 and Aviation Events (December 2021)
  • Post Implementation review (August 2022)

Future State and Proposed Timelines:

A key element of the continual improvement process adopted by CASA has been to conduct a first principles review of the legislation governing air displays and a gap analysis between Domestic and International Regulations and world’s best practice. The review has concluded that it would be highly beneficial for CASA to adopt elements of Part 91 rules pertaining to Aviation Events found in the New Zealand and UKCAA rulesets. Planning for the integration into the existing CASA Part 91 ruleset is well underway and would permit a seamless and highly beneficial transition for both CASA and Industry.

Benefit to CASA and Industry:

  • Simpler, less complex ruleset that clearly defines what an Aviation Event is and when approval is required
  • Removes a significant administrative and assessment burden for activities that do not require approval
  • Provides industry with time and cost savings for unneeded approvals
  • Places greater responsibility for compliance on industry while ensuring appropriate oversight by having robust procedures and allowing more time and capacity for CASA to conduct surveillance for safety outcomes.
  • Adopts industry best practice of providing training and approvals to Display Organisers and enhances Display Pilot approvals

Along with the work that has already been completed and by adoption of the proposed timelines for the transition to Part 91 and future state, CASA will be able to strengthen existing processes and better align with world’s best practice.

ATSB comment date: 20 July 2020
ATSB comment:

The ATSB welcomes the safety action taken by CASA to date and acknowledges the procedural improvements in the planning, approval and conduct of air displays. The ATSB will continue to monitor CASA’s planned safety improvements, in anticipation that successful implementation will address the safety issue and align with international best practice.

Last update 10 August 2020