[Peetwo]

The lessons of 1st PelAir final report; obfuscated and forgotten a decade on?? -   

Reference: A decade of obfuscating an open safety loop??

And in particular this 'supposedly' adequately addressed/closed ATSB Safety Issue: https://www.atsb.gov.au/publications/inv...190-si-14/  

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

Safety issue description
The Civil Aviation Safety Authority’s procedures and guidance for scoping an audit included several important aspects, but it did not formally include the nature of the operator’s activities, the inherent threats or hazards associated with those activities, and the risk controls that were important for managing those threats or hazards.

Proactive Action

Action number: AO-2014-190-NSA-040
Action organisation: Civil Aviation Safety Authority
Date: 23 November 2017
Action status: Closed

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 which is documented in the CASA Surveillance Manual (CSM). The CSM identifies possible systems and system elements for holders of each authorisation type, and necessitates that those elements relevant to a particular authorisation holder are identified when preparing for a surveillance event—including noting areas of potential system vulnerability.

In the preparation process, inspectors are required to review a range of information—including the authorisation holder's policy and procedures manuals—and identify specific areas and risks to be assessed or reviewed. The information, data and history known about the authorisation holder assists in determining the scope and depth of each surveillance event.

CASA has developed safety risk profiles for a number of sectors of the aviation industry, and is continuing to develop safety risk profiles for the remaining sectors. These sector safety risk profiles enable a shared understanding between CASA and industry of hazards that sector participants must address in order to manage their risks and enhance safety outcomes for the sector. CASA is working to enhance the use of sector safety risk data to inform the scoping of surveillance activities.

CASA is currently developing and implementing a National Surveillance Selection Process (NSSP), which will be an enhanced systematic approach to the prioritisation of CASA's surveillance activities. This will include improved authorisation holder risk and performance profile capabilities, including integration of relevant sector information. The NSSP is expected to be fully deployed by June 2018.

Then this reference to the now discontinued investigation into the VARA SMS and CASA oversight of that SMS:

The ATSB notes the surveillance planning and scoping form provided by CASA to its inspectors is still the same as the form used from 2004–2009, and this form does not refer to the nature of the operator’s activities, the inherent threats or hazards associated with those activities, and the risk controls that were important for managing those threats or hazards.

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).

 
So after reading any of the above waffle does any reasonably intelligent, rational person honestly believe that the safety issues highlighted by the PelAir (cover-up) ditching investigation (x2) and the damning VARA (cover-up) accident investigation (In-flight upset, inadvertent pitch disconnect, and continued operation with serious damage involving ATR 72 aircraft, VH-FVR, 47 km WSW of Sydney Airport, NSW on 20 February 2014) have actually been adequately addressed - anyone?? -        

Which brings me to the following (related) CASA Additional Estimates AQON (remembering that PelAir is a subsidiary company of Rex Airlines):

Senator Malarndirri McCarthy asked:

Senator McCARTHY: The Australian Licensed Aircraft Engineers Association has raised the issue of another Rex engineer who has been treated in a way that is contrary to the principles of just culture. I'm talking about an engineer who was subject to disciplinary action after the aircraft he was taxiing clipped a bin. The engineering investigation found that the line markings on the tarmac for taxiing were in the wrong place and had been incorrectly marked, and no fault was attributed to the engineer. The Rex general manager, however, ordered an investigation be conducted by human resources and determined that the engineer was professionally negligent. Has this been reported to CASA and are you aware of this?
Ms Spence: I'm not aware of it. I will have to take on notice whether it was reported to CASA.
Senator McCARTHY: I do understand that the association has reported it.
Ms Spence: I'm just not aware of it, I'm sorry.

Answer:

On 27 May 2019, the Australian Licensed Aircraft Engineers Association (ALAEA) informed the Civil Aviation Safety Authority (CASA) Chief Executive Officer/Director of Aviation Safety, Mr Shane Carmody, by email of concerns relating to Regional Express (Rex) Approved Maintenance Organisation (AMO). These complaints related to the Safety Management System (SMS), the discouraging of reporting maintenance errors or defects, and Just Culture.

Included in this letter were incidents relating to a single engineer, including the taxi incident.

CASA contacted Rex about the allegations and conducted two surveillance events in July and October 2019 at the Rex’s Wagga Wagga maintenance facility, and Rex’s Sydney Head Office, with a focus on safety culture and the reporting of defects and maintenance errors by engineers.

The intent of both audits was to establish whether the alleged safety-related risks identified in the ALAEA letter had any foundation, ascertain what follow up of the events had been carried out, the operational effectiveness of the Just Culture within the Rex AMO, and for CASA to be satisfied with the level of operational aviation safety in the Rex operation.

As reflected in its Regulatory Philosophy, CASA defines ‘Just Culture’ as follows.

CASA embraces, and encourages the development throughout the aviation community of, a 'just culture' as an organisational culture in which people are not punished for actions, omissions or decisions taken by them that are commensurate with their experience, qualifications and training, but where gross negligence, recklessness, wilful violations and destructive acts are not tolerated.

Interviews were held with four engineers. Some were selected at random from a shift roster during the Wagga Wagga visit on 4 July and some volunteered for an interview following the Sydney visit of 28 August. From the interviews conducted the engineer cohort were seen to have an understanding of Just Culture in the organisational and individual context.

As a result of the two surveillance activities, the audit team were satisfied that the Rex SMS was operating and effective in the areas examined. The Accountable Executive and the senior management team were aware of the safety risks faced by the organisation. SMS principles, including Just Culture, were found to be implemented throughout the organisation.

The evidence produced or discovered during the 2019 audits did not result in any Safety Findings or Safety Observations.

  
Hmm...I wonder if CASA (as per the ATSB/CASA MOU) shared the findings of their 2019 investigations/audits with the ATSB?  - 

Maybe they did and maybe that is why the ATSB decided to discontinue the VARA SMS investigation:

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.

v

Regulatory surveillance – scoping of audits

The Civil Aviation Safety Authority’s procedures and guidance for scoping an audit included several important aspects, but it did not formally include the nature of the operator’s activities, the inherent threats or hazards associated with those activities, and the risk controls that were important for managing those threats or hazards.

Safety issue details
Issue number: AO-2014-190-SI-14
Who it affects: All operators
Status: Adequately addressed

Reference - safety issues: https://www.atsb.gov.au/publications/inv...-2009-072/

Much MTF...P2