Regulatory surveillance – assessing process in practice
Date issue released
Safety Issue Description

Consistent with widely-agreed safety science principles, the Civil Aviation Safety Authority’s approach to surveillance of larger charter operators had placed significant emphasis on systems-based audits. However, its implementation of this approach resulted in minimal emphasis on evaluating the actual conduct of line operations (or ‘process in practice’).

Issue number
Transport Function
Aviation: Air transport
Issue Owner
Civil Aviation Safety Authority
Mode of Transport
Issue Status Justification

The ATSB is satisfied that CASA has undertaken action to address this issue since November 2009.

Proactive action
Action number
Civil Aviation Safety Authority
Action date
Action Status
Action description

In August 2017 (after receiving the draft ATSB report for the reopened investigation), CASA advised the ATSB:

CASA implemented a national approach to surveillance in 2012 with the introduction of the CASA Surveillance Framework including the CASA Surveillance Manual (CSM). The CSM aims to ensure that 'process in practice' is given appropriate emphasis in CASA's surveillance approach. This was emphasised through the surveillance training delivered to all inspectors.

'Process in practice' is one of the four attributes of the Management System Model (MSM) described in the CSM as operating within an authorisation holder's organisation to provide effective control. The CSM requires that the evidence gathered during surveillance events must be framed around all four attributes of the Management System Model to determine the level of control the authorisation holder applies. 'Process in practice' includes assessment of compliance with procedures.

In describing the process to conduct process verification during surveillance events, the CSM states that during verification inspectors should adequately confirm the 'process in practice' including outputs, and requires all levels of an authorisation holder's operation to be considered during sampling.

The CSM also prescribes recommended frequencies for the conduct of various surveillance types. One such type is an 'operational check', which is focused on assessing the actual conduct of line operations, a product check that the system is operating as intended and is compliant with legislative requirements. For the surveillance of Air Operator's Certificates (AOC), recommended frequencies are prescribed for 'operational check' as well as for other surveillance types—for large charter operators, 'systems audit' and 'operational check' are the two surveillance types with associated frequencies. Other surveillance events and types in excess of those recommended in the CSM can also be proposed as considered appropriate, to ensure adequate assessment of line operations.

ATSB Response

The ATSB notes the recommended frequencies for various types of surveillance tasks included in the CSM since 2012 were similar to the recommended frequencies for such tasks prior to the introduction of the CSM.

Nevertheless, the ATSB acknowledges CASA’s surveillance processes have undergone significant evolution since 2009, and that it is continuing to review and develop its surveillance processes. It should also be noted that the ATSB will review CASA’s oversight processes since the introduction of the CSM in 2012 during the course of other investigations, including investigation AI-2017-100 (Case study: implementation and oversight of an airline's safety management system during rapid expansion).