Submission 54 - Name Withheld.
Via GA Inquiry submissions page, there is a new submission that IMO should be essential reading for all the Committee members, the new DAS and indeed the mandarins from the Department. Inside of 4 pages, this submission cuts to the chase and highlights very clearly all that is wrong inside of the Flight Operations division of the regulator - Well done that girl...
:
We are making this submission to the enquiry because we have personal experience with
regards to the failings of the Civil Aviation Safety Authority. We are the family of one of the
pilots killed in the tragic accident at Renmark in 2017 which occurred during a training flight
which should never have taken place. We would like to point out that we are not making this
submission simply from the perspective of bereaved lay-people with no knowledge of the
workings of the aviation industry. We have combined backgrounds which include, among
other things, a CPL(H), a law degree and an engineering degree. The following submission
will focus specifically on the operation and effectiveness of CASA, with particular reference
to CASA’s aviation safety frameworks, in the context of the accident investigation report
issued by the ATSB (AO-2017-057 - 30 April 2020).
1. CASA approval of incorrect procedures
Following their very lengthy investigation, ATSB finally produced a draft report in late
December 2019. This was presented to Directly Involved Parties (DIP’s) for comment and
clarification prior to the final report which was expected 30 days later.
The draft report made reference to the fact that the operator’s procedure for simulating
engine failure after take-off was different to the procedure outlined in the Pilot's Operating
Handbook and the Civil Aviation Advisory Publication (5.23-1(2).
The draft report further states:
ATSB has sought information from CASA regarding the circumstances under which the
incorrect procedure was approved for use by the operator. Analysis of CASA’s response will
be outlined in the final investigation report.
The final accident report published on the 30 April 2020 states the following:
The ATSB sought information from CASA regarding the circumstances under which the
incorrect procedure was approved for use by the operator. Despite this request, no
information was provided by CASA. Consequently, the ATSB was unable to determine
whether the approval of incorrect information was an isolated human error or symptomatic of
a systemic deficiency with the approval process.
Despite there being four months instead of the expected 30 days in between the draft and
final reports, it would appear that CASA did not respond to the request for information from
the ATSB. It would also appear that ATSB did not bother to exercise their rights under
section 32 of the Transport Safety Investigation Act 2003 to compel them to do so.
In recent correspondence in respect of the above the DAS/CEO CASA stated:
CASA provided all information we understood to be required or that was formally requested
by ATSB and we have since confirmed that ATSB is of the same view. We acknowledge that
there was an absence of clarity here and that it should have been resolved prior to the
finalisation of the report.
This statement merely confirms that CASA and ATSB have had communications with each
other, however this information was not in the final report and has never been made
available publicly or to DIP’s. Despite this, ATSB claimed that the information was sought in
a manner that was transparent to all Directly Involved Parties. There is no transparency with
regards to the fact that we still do not know whether this was an isolated human error or
symptomatic of a systemic deficiency with the CASA approval process.
2. Issues surrounding auditing
It would be hoped that such a fundamental, yet very serious error made by CASA in
approving the incorrect operations manual would be detected and rectified during a routine
CASA formal audit. The following extract from the ATSB report explains why this did not
occur:
In the 5 years leading up to the accident, the Civil Aviation Safety Authority had not
conducted a systemic or detailed audit during that period, and its focus on a largely informal
and often undocumented approach to oversight increased the risk that organisational or
systemic issues associated with the operator would not be effectively identified and
addressed.
In their investigation report ATSB published a flight operations surveillance table which
showed the recommended frequency for audits at Rossair as one per year. Unbelievably, the
last recorded audit was undertaken in 2012, and even this audit was performed on Air South
prior to their merger with Rossair.
ATSB go on further to state:
Rossair personnel reported that the lack of formal oversight placed them in a position where
they did not always have the required support for safety related initiatives and, as a result,
addressing commercial matters became a higher priority (emphasis added). The risks of
informal surveillance have been shown in previous accident investigations.
The 2009 Pelair Westwind ditching highlighted CASA’s process for obtaining information with
regard to the nature and extent of an operator’s procedures as limited and informal, yet
incredibly the same mistakes were still being made in 2017 and are likely to be continuing to
be made today.
Despite CASA personnel advising that the recommended frequency of surveillance was not
achievable with their current resources, the DAS/CEO CASA has attempted to justify CASA’s
failure to adhere to their own surveillance schedule in the following statement:
CASA’s approach to the safety oversight of air service providers is risk-based, having regard
to a range of relevant factors. This does not always translate into a fixed schedule or
mandatory frequency of audit and surveillance uniformly applicable to all operators, or even
all operators within the same sector.
This statement was made despite the knowledge by CASA, albeit informally, that a formal
audit was urgently required in order to address serious concerns raised with regards to high
levels of work-related stress and financial pressures placed upon staff. Had such an audit
occurred, it would have identified the serious cultural flaws and apparent lack of resources
affecting the company.
3. Lack of simple risk assessment
On the accident flight was a pilot undergoing a check flight for induction into the company.
The Chief Pilot was performing this check, however he was also undergoing a check by the
CASA flying operations inspector (FOI) to assess his competence for this role. With both the
flying pilots undergoing supervision, the FOI was the most experienced Cessna 441 pilot on
board and a valuable available resource. Despite this, the only avenue of communication
between the FOI and the pilots was a tap on the shoulder, yet still the flight was authorised
to proceed.
In 2015 CASA produced an advisory publication (CAAP 5.23-1(2)) in which they state that
the use of simulators has reduced the perils of simulating engine failures after take-off,
however where simulators are not available, instructors should not simulate engine failures
below 400ft AGL to provide a reasonable safety margin.
In June 2017 CASA issued a Temporary Management Instruction, part of which mandated
that simulated engine failures not be attempted below 1000ft AGL, however this has now
expired and there is no evidence to suggest that this will become part of the regulations. Is it
unreasonable to assume that older aircraft are less likely to have simulators available and
are more likely to sustain maintenance issues due to their age? Is it also unreasonable to
assume that extra altitude during highly risky training manoeuvres allows more time for
issues to be rectified?
According to DAS/CEO CASA there have been subsequent improvements to internal
procedures and guidance for staff conducting in-flight aircraft activities as a means of further
supporting future activities, however this is of little consequence to the three pilots who lost
their lives due to lack of a simple risk assessment.
4. CASA regulations re on-board recording devices
Under current regulations there is no requirement for any on-board recording devices in
aircraft of this weight, however in 2008 ATSB made a recommendation (R2006004)
regarding the fitment of lightweight recorders:
The Australian Transport Safety Bureau (ATSB) recommends that the Civil Aviation Safety
Authority (CASA) review the requirements for the carriage of on-board devices in Australian
registered aircraft as a consequence of technical developments.
It is now 13 years since that recommendation, and technology is even further advanced yet
still the Safety Authority is procrastinating over the use of this basic simplistic device. If
CASA had made a conscious safety decision, in respect of ATSB’s recommendation, in all
probability we would know the cause of this accident rather than being guided by some
outlandish hypothesis proposed by an investigation report which took three years to produce
at huge expense to the tax-paying public.
The point has been made in many other submissions to this inquiry that the production of
reams of new regulations has taken almost thirty years and enormous amounts of money
and man hours. Surely it would make more sense for a safety regulator to move away from
such onerous, prescriptive rules and focus their attention on monitoring to ensure aviation
companies are financially stable and running safe and competent operations. Accidents are
generally extremely detrimental to the viability of most aviation operations and therefore it
would be presumed that safety would be paramount to ensuring business continuity.
Regular, thorough and competent safety audits would identify and rectify those operators
who are not running their business in such an ethical manner. The travelling public surely
has a right to expect that this is how their tax-payer funded money is being spent?
In 2018 and 2019, during presentations to a number of aviation bodies, the DAS/CEO of the
CASA made references to the apparent dark days in safety standards prior to the formation
of CASA in 1995. He went on to emphasise just how good CASA currently is in exercising its
responsibility in respect of aviation safety.
In one of his speeches from 25 May 2018 he states "Aviation Safety and the safety of the
travelling public is CASA’s number one priority. We are the Safety Regulator and our
principle mandate is aviation safety. Our operations are based on the Civil Aviation Act 1988.
One of the most formative amendments of the Act was in 1995 when we became the Civil
Aviation Safety Authority, and a conscious decision was made that our focus would be first
and foremost of Safety".
It would appear the principle mandate of CASA failed abysmally on 30 May 2017.
Hmm...wouldn't this submission be a worthy contribution to the ANAO Audit??
MTF...P2
Via GA Inquiry submissions page, there is a new submission that IMO should be essential reading for all the Committee members, the new DAS and indeed the mandarins from the Department. Inside of 4 pages, this submission cuts to the chase and highlights very clearly all that is wrong inside of the Flight Operations division of the regulator - Well done that girl...
:We are making this submission to the enquiry because we have personal experience with
regards to the failings of the Civil Aviation Safety Authority. We are the family of one of the
pilots killed in the tragic accident at Renmark in 2017 which occurred during a training flight
which should never have taken place. We would like to point out that we are not making this
submission simply from the perspective of bereaved lay-people with no knowledge of the
workings of the aviation industry. We have combined backgrounds which include, among
other things, a CPL(H), a law degree and an engineering degree. The following submission
will focus specifically on the operation and effectiveness of CASA, with particular reference
to CASA’s aviation safety frameworks, in the context of the accident investigation report
issued by the ATSB (AO-2017-057 - 30 April 2020).
1. CASA approval of incorrect procedures
Following their very lengthy investigation, ATSB finally produced a draft report in late
December 2019. This was presented to Directly Involved Parties (DIP’s) for comment and
clarification prior to the final report which was expected 30 days later.
The draft report made reference to the fact that the operator’s procedure for simulating
engine failure after take-off was different to the procedure outlined in the Pilot's Operating
Handbook and the Civil Aviation Advisory Publication (5.23-1(2).
The draft report further states:
ATSB has sought information from CASA regarding the circumstances under which the
incorrect procedure was approved for use by the operator. Analysis of CASA’s response will
be outlined in the final investigation report.
The final accident report published on the 30 April 2020 states the following:
The ATSB sought information from CASA regarding the circumstances under which the
incorrect procedure was approved for use by the operator. Despite this request, no
information was provided by CASA. Consequently, the ATSB was unable to determine
whether the approval of incorrect information was an isolated human error or symptomatic of
a systemic deficiency with the approval process.
Despite there being four months instead of the expected 30 days in between the draft and
final reports, it would appear that CASA did not respond to the request for information from
the ATSB. It would also appear that ATSB did not bother to exercise their rights under
section 32 of the Transport Safety Investigation Act 2003 to compel them to do so.
In recent correspondence in respect of the above the DAS/CEO CASA stated:
CASA provided all information we understood to be required or that was formally requested
by ATSB and we have since confirmed that ATSB is of the same view. We acknowledge that
there was an absence of clarity here and that it should have been resolved prior to the
finalisation of the report.
This statement merely confirms that CASA and ATSB have had communications with each
other, however this information was not in the final report and has never been made
available publicly or to DIP’s. Despite this, ATSB claimed that the information was sought in
a manner that was transparent to all Directly Involved Parties. There is no transparency with
regards to the fact that we still do not know whether this was an isolated human error or
symptomatic of a systemic deficiency with the CASA approval process.
2. Issues surrounding auditing
It would be hoped that such a fundamental, yet very serious error made by CASA in
approving the incorrect operations manual would be detected and rectified during a routine
CASA formal audit. The following extract from the ATSB report explains why this did not
occur:
In the 5 years leading up to the accident, the Civil Aviation Safety Authority had not
conducted a systemic or detailed audit during that period, and its focus on a largely informal
and often undocumented approach to oversight increased the risk that organisational or
systemic issues associated with the operator would not be effectively identified and
addressed.
In their investigation report ATSB published a flight operations surveillance table which
showed the recommended frequency for audits at Rossair as one per year. Unbelievably, the
last recorded audit was undertaken in 2012, and even this audit was performed on Air South
prior to their merger with Rossair.
ATSB go on further to state:
Rossair personnel reported that the lack of formal oversight placed them in a position where
they did not always have the required support for safety related initiatives and, as a result,
addressing commercial matters became a higher priority (emphasis added). The risks of
informal surveillance have been shown in previous accident investigations.
The 2009 Pelair Westwind ditching highlighted CASA’s process for obtaining information with
regard to the nature and extent of an operator’s procedures as limited and informal, yet
incredibly the same mistakes were still being made in 2017 and are likely to be continuing to
be made today.
Despite CASA personnel advising that the recommended frequency of surveillance was not
achievable with their current resources, the DAS/CEO CASA has attempted to justify CASA’s
failure to adhere to their own surveillance schedule in the following statement:
CASA’s approach to the safety oversight of air service providers is risk-based, having regard
to a range of relevant factors. This does not always translate into a fixed schedule or
mandatory frequency of audit and surveillance uniformly applicable to all operators, or even
all operators within the same sector.
This statement was made despite the knowledge by CASA, albeit informally, that a formal
audit was urgently required in order to address serious concerns raised with regards to high
levels of work-related stress and financial pressures placed upon staff. Had such an audit
occurred, it would have identified the serious cultural flaws and apparent lack of resources
affecting the company.
3. Lack of simple risk assessment
On the accident flight was a pilot undergoing a check flight for induction into the company.
The Chief Pilot was performing this check, however he was also undergoing a check by the
CASA flying operations inspector (FOI) to assess his competence for this role. With both the
flying pilots undergoing supervision, the FOI was the most experienced Cessna 441 pilot on
board and a valuable available resource. Despite this, the only avenue of communication
between the FOI and the pilots was a tap on the shoulder, yet still the flight was authorised
to proceed.
In 2015 CASA produced an advisory publication (CAAP 5.23-1(2)) in which they state that
the use of simulators has reduced the perils of simulating engine failures after take-off,
however where simulators are not available, instructors should not simulate engine failures
below 400ft AGL to provide a reasonable safety margin.
In June 2017 CASA issued a Temporary Management Instruction, part of which mandated
that simulated engine failures not be attempted below 1000ft AGL, however this has now
expired and there is no evidence to suggest that this will become part of the regulations. Is it
unreasonable to assume that older aircraft are less likely to have simulators available and
are more likely to sustain maintenance issues due to their age? Is it also unreasonable to
assume that extra altitude during highly risky training manoeuvres allows more time for
issues to be rectified?
According to DAS/CEO CASA there have been subsequent improvements to internal
procedures and guidance for staff conducting in-flight aircraft activities as a means of further
supporting future activities, however this is of little consequence to the three pilots who lost
their lives due to lack of a simple risk assessment.
4. CASA regulations re on-board recording devices
Under current regulations there is no requirement for any on-board recording devices in
aircraft of this weight, however in 2008 ATSB made a recommendation (R2006004)
regarding the fitment of lightweight recorders:
The Australian Transport Safety Bureau (ATSB) recommends that the Civil Aviation Safety
Authority (CASA) review the requirements for the carriage of on-board devices in Australian
registered aircraft as a consequence of technical developments.
It is now 13 years since that recommendation, and technology is even further advanced yet
still the Safety Authority is procrastinating over the use of this basic simplistic device. If
CASA had made a conscious safety decision, in respect of ATSB’s recommendation, in all
probability we would know the cause of this accident rather than being guided by some
outlandish hypothesis proposed by an investigation report which took three years to produce
at huge expense to the tax-paying public.
The point has been made in many other submissions to this inquiry that the production of
reams of new regulations has taken almost thirty years and enormous amounts of money
and man hours. Surely it would make more sense for a safety regulator to move away from
such onerous, prescriptive rules and focus their attention on monitoring to ensure aviation
companies are financially stable and running safe and competent operations. Accidents are
generally extremely detrimental to the viability of most aviation operations and therefore it
would be presumed that safety would be paramount to ensuring business continuity.
Regular, thorough and competent safety audits would identify and rectify those operators
who are not running their business in such an ethical manner. The travelling public surely
has a right to expect that this is how their tax-payer funded money is being spent?
In 2018 and 2019, during presentations to a number of aviation bodies, the DAS/CEO of the
CASA made references to the apparent dark days in safety standards prior to the formation
of CASA in 1995. He went on to emphasise just how good CASA currently is in exercising its
responsibility in respect of aviation safety.
In one of his speeches from 25 May 2018 he states "Aviation Safety and the safety of the
travelling public is CASA’s number one priority. We are the Safety Regulator and our
principle mandate is aviation safety. Our operations are based on the Civil Aviation Act 1988.
One of the most formative amendments of the Act was in 1995 when we became the Civil
Aviation Safety Authority, and a conscious decision was made that our focus would be first
and foremost of Safety".
It would appear the principle mandate of CASA failed abysmally on 30 May 2017.
Hmm...wouldn't this submission be a worthy contribution to the ANAO Audit??
MTF...P2