[Peetwo]

Chalk & Cheese: S is for? - Surveillance.

Via the Su_Spence thread:  Su_Spence breach of statutory duty and negligence timeline - Part II

S is for? - Surveillance This is an easy one  (IE refer to the 'Contents' [pg v - vii of the report]): According to the ATSB AO-2022-009 Final Report there is no relevant section or reference applicable to regulator surveillance activities in regards to rotary wing HEC (crocodile egg collecting) AOC approvals between 2007 and 2023. Nor is there any indication that surveillance had been conducted of the operator Helibrook?? - 

As a clear chalk and cheese comparison, I refer to another ATSB systemic investigation - AO-2018-078. In regards to CASA oversight, the following is the overview summary (page 29):

The Civil Aviation Safety Authority (CASA) had two primary means of oversighting a specific operator’s aviation activities: regulatory services and conducting surveillance of its activities. They also used a scale of prioritisation, based on risk, to determine where to focus resources. This prioritisation was based on several factors, such as the sector of operation, organisational changes and challenges.

To maintain oversight across Australian operators (authorisation holders), CASA had a number of certificate management teams in different locations, made up of CASA officers, including flying operations inspectors, safety systems inspectors, and airworthiness inspectors. Each of these teams oversighted multiple authorisation holders. At the time of the accident, the team responsible for the oversight of Airlines of Tasmania comprised of one certificate team manager, three flying operations inspectors, four airworthiness inspectors and one safety system inspector. The team had oversight of 58 AOC holders, 50 aviation maintenance organisations and four delegates.

This oversight summary is strangely remiss in the AO-2022-009 report, despite (I would have thought) being equally applicable??

Next the regulatory services processes:

Regulatory services processes

Regulatory services included assessing applications for the issue or variation to an operator’s AOC and associated approvals, key personnel approvals, maintenance personnel approvals, and check pilot approvals and renewals. Regulatory services provided by CASA for Airlines of Tasmania in 2014–2018 included:

• a review of changes to the SMS manual (2014, 2017–2018)
  
• approval of the chief pilot (2016)
  
• approval of the safety manager (2016 and 2018).
  

Hmm...amazing the parallels? - 

On the subject of surveillance refer from bottom of page 27.

Extracts:

Risk-based surveillance adopts a structured process and is used by CASA in its oversight of authorisation holders and prioritisation of its surveillance activities based on authorisation holders’ risk profiles. It focuses on an authorisation holder’s effectiveness in managing its systems risks and enables targeted surveillance of high-risk areas of an authorisation holder’s systems. It is also a method by which CASA can evaluate that all activities conducted by an authorisation holder are as safe as reasonably practicable.

 
Except it seems if you're a top-end R44 operator approved to conduct HEC operations for the collection of crocodile eggs. Or you're a owner/pilot of multiple rotary and fixed wing aircraft, deployed throughout the region conducting aerial work and charter operations, that has been involved in several safety incidents and is known to be conducting illegal aero-med retrievals that have been invoiced for??

Next under 'Surveillance Findings':

In accordance with the CSM, once a surveillance event was completed, the surveillance team members ‘review the evidence obtained for each assessed system risk to determine the level of effectiveness of the associated controls’. Depending on the nature of the deficiencies identified in these controls, written notices in the form of a safety observation or safety finding are issued to the authorisation holder to highlight potential and/or actual breaches.

Safety observations advise an authorisation holder of latent conditions resulting in system deficiencies that have the potential to result in a breach if not addressed. They also identify potential areas of improvement in safety performance. Safety observations do not require a response from the authorisation holder.

Safety findings (previously known as a notice of non-compliance or NCN), were issued for the ‘purposes of identifying a breach of a legislative provision or a provision of the authorisation holder’s written procedures’. These findings will generally be issued when CASA is satisfied that the authorisation holder has the willingness and ability to take remedial and corrective actions to address this.

When a safety finding was issued, the authorisation holder was required to respond to CASA within a specified period of time, providing evidence of any remedial action, root cause analysis, and corrective action taken. The response and associated evidence would be reviewed to determine whether the authorisation holder ‘has returned to a compliant state’ and ‘is actively working towards implementing the corrective action to mitigate the potential of recurrence of the identified deficiency’. If CASA rejected the response, the authorisation holder would be provided another opportunity to respond. If the response was accepted by CASA, the safety finding was acquitted and the authorisation holder notified accordingly.

However, if CASA could not be satisfied that the authorisation holder was willing or able to do so, the finding would be issued and the CASA coordinated enforcement process would be initiated.

A repeat safety finding was issued when the same breach was identified during subsequent audits. To issue a repeat finding, the criteria of the breach had to be exactly the same, that is, the same section of the regulations was not being complied with. The CSM provided limited details about assessing and acquitting repeat safety findings aside from referring the operator to coordinated enforcement. The CSM and CASA Enforcement Manual stated that:

When conducting the post-surveillance review and analysis, if the authorisation management team identify repeated breaches of a similar nature from the review of previous surveillance events, the authorisation management team, in conjunction with the Controlling Office Manager, must initiate the Coordinated Enforcement Process (CEP)...The CEP will provide a forum for better informed decision making and for discussing alternative options. [CSM]

This [process] may identify which particular enforcement tool or combination of tools that would be most likely to achieve the optimal safety outcome…However, the most appropriate response may ultimately involve a combination of: enforcement and compliance tools, compliance tools alone, or voluntary action initiated by the industry participant. [Enforcement Manual]

There follows a long winded description of the CASA surveillance procedures and assessment tools:

A summary of the overall scores and comments made during AHPI assessments for Airlines of Tasmania in 2017 (AOC only)[27] are shown in Table 5. In these assessments, high scores were given for the parameters under ‘safety outcomes’, which included regulatory history breaches and enforcement. This related to repeat safety findings and the associated unsatisfactory responses (refer to the section titled Surveillance events for Airlines of Tasmania). There were also several comments in the assessments that noted the SMS was not operating effectively. There were no AHPI assessments conducted in 2018.

In bold compare to the disturbing ATSB performance summary of the Helibrook SMS...

Included in the report was an interesting section titled, 'Previous investigations with surveillance and hazard identification findings':

Previous ATSB investigations have identified findings relating to CASA surveillance events, activities and/or processes. These included two collision with terrain accidents in 2017 involving a Cessna 441 and another involving a Cessna 172M, and the ditching of an Israel Aircraft Industries Westwind 1124A in 2009. Specifically, the findings were:

In the 5 years leading up to the accident, the Civil Aviation Safety Authority had conducted numerous regulatory service tasks for the air transport operator and had regular communication with the operator’s chief pilots and other personnel. However, it 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. [ATSB investigation AO-2017-057]

The Civil Aviation Safety Authority’s procedures and guidance for scoping a surveillance event 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. [ATSB investigation AO-2017-005]

Although the Civil Aviation Safety Authority (CASA) collected or had access to many types of information about a charter and/or aerial work operator, the information was not integrated to form a useful operations or safety profile of that operator. In addition, CASA’s process for obtaining information in the nature and extent of an operator’s operations were limited and informal. These limitations reduced its ability to effectively prioritise surveillance activities. [ATSB investigation AO‑2009-072]

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. [ATSB investigation AO-2009-072]

In addition to the above findings:

Although the operator’s safety management processes were improving, its processes for identifying hazards extensively relied on hazard and incident reporting, and it did not have adequate proactive and predictive processes in place. In addition, although the operator commenced air ambulance operations in 2002, and the extent of these operations had significantly increased since 2007, the operator had not conducted a formal or structured review of its risk controls for these operations. [ATSB investigation AO-2009-072]

Anyone else see the ironies of the examples that the ATSB has picked on?? Wonder why they didn't include the VARA ATR-72 broken tail accident?? Oh that's right they farmed that part of the investigation off to a 'Case study: implementation and oversight of an airline's safety management system during rapid expansion':  Update: ATSB PC accident investigation AO-2014-032

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.
  

This stitched up Hooded Canary investigation waffled along aimlessly for 3 years until it was subsequently discontinued: 

 

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.

    

Hmm...wonder why the 'evidence collected' etc. was not used in the AO-2018-078 or AO-2022-009 investigations and why a 'further safety investigation has not been initiated given the evidence of the 'previous investigations'?

Next I note that the AO-2018-078 investigation findings led to a safety issue being issued to the regulator and was then escalated to a very rare safety recommendation, which was finally assessed as appropriately acquitted by the ATSB in February this year:

Action description

• The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority amend its acquittal process for repeat safety findings to ensure it is effective in ensuring that all previous findings of a similar nature are also appropriately assessed prior to the current and all associated safety findings being acquitted.
  

(Go to the link - HERE - for the SR text and responses etc.)

 
Passing strange coincidence but the CASA final response was received 2 days before the ANAO released their audit report into the 'Civil Aviation Safety Authority Planning and Conduct of Surveillance Activities'.

I note recommendation 2:

Recommendation no. 2
Paragraph 2.63

The Civil Aviation Safety Authority improve its approach to risk by:

• incorporating risk likelihood as part of its approach to surveillance planning or clearly establish the basis for not considering risk likelihood in its prioritisation of authorisation holders for surveillance; and
  
• applying the risk and prioritisation framework consistently across all sectors and industry delegates.
  

Civil Aviation Safety Authority response: Agreed

Anyone else believe that recommendation has been appropriately acquitted?

Oh well perhaps Skerrit's 'Ghost' review will provide the panacea for Miniscule Dicky King to justify topping up the CASA and ATSB troughs of money, in order for Su_Spence and Popinjay to address the many endemic cultural and organisational deficiencies within their flawed agencies?

CATHERINE KING: No, no, and what I would say is I have got at the moment John Skerritt who used to head up the Therapeutic Goods Administration, I appointed him when we were last in government, it’s a regulatory agency around the safety of medicines and products. He has now left the TGA, and he is undertaking a piece of work for me across CASA, ATSB and AMSA, which is the Australian Maritime Safety Agency, to look at a couple of things. First is sustainable funding models, so we need to make sure we’ve got enough resources so that they can do their jobs, and also to look at the regulatory environment in which they operate in.

So he’s having a look at that for me at the moment, and certainly if there’s anything further that we need to do, or if CASA identifies anything further they think we need to do, then I am up for that.

---

CATHERINE KING: But I would say that it, you know, like they do investigate, you know, they do investigate. But again, if there are things that need to be done to improve, not just CASA’s presence, but what they are doing in terms of general aviation more broadly, then, you know, I’m up for that, and part of what John Skerritt will be looking at is to look at whether the systems are working as they should be, not just at CASA but across all of my safety agencies.

In the meantime from the BRB, here is the 'King Aviation Swiss Cheese' model for the Miniscule to refer...




MTF...P2