Safety Issue
CASA did not require operators to conduct structured and/or
comprehensive risk assessments, or conduct such assessments itself,
when evaluating applications for the initial issue or subsequent
variation of an Air Operator's Certificate.
Safety Recommendation
The Australian Transport Safety Bureau recommends that the Civil
Aviation Safety Authority undertake further work to address this
safety issue.
Risk assessment concepts continue to be developed in CASA. Risk
assessment training has been provided to staff with the emphasis
now changing to incorporate safety management principles. The
AS/NZS4360: 2004 standard on risk assessment is referenced in the
Surveillance Procedures Manual.
Additionally, work has commenced on a new CASA Surveillance IT
system to be incorporated into Aviation Industry Regulatory System.
This system will include a risk module. Such a system should
significantly improve CASA's governance, risk identification and
reporting capability leading to more effective surveillance of the
industry.
The ATSB acknowledges CASA's on-going development of risk
assessment concepts. However, the safety issue also relates to the
lack of a regulatory requirement for operators to conduct and
provide a risk assessment of initial issue or subsequent renewal of
an AOC, as well as CASA's ability to evaluate such risk
assessments.
CASA acknowledges this recommendation but does not support its
categorisation as a contributing safety factor at paragraph
3.2.4.
There is no legislative requirement that operators conduct, or
that CASA require such operators to conduct or itself to conduct,
structured and/or comprehensive risk assessments, when operator's
make an application for the initial issue or subsequent variation
of an Air Operator's Certificate.
However, as acknowledged by the ATSB, CASA has encouraged
operators to adopt Safety Management System (SMS) over the past 10
years and many have done so.
CASA is drafting an amendment m Civil Aviation Order (CAO) 82.0
to mandate SMS to ensure that all passenger carrying operators
establish and use a system for managing safety. It is anticipated
that this amendment will be made before the end of 2007. A SMS, by
its nature, will include a structured risk assessment methodology
for evaluating change, including change of the scope of
operations.
The ATBS Report acknowledges that CASA intends to mandate Crew
Resource Management training for passenger carrying operators. The
proposed amendment to CAO 82.0 will also require Air Operator
Certificate holders to provide this type of training for their
crews.
CASA has also employed six Field Safety Advisors who provide
safety advice to members of the aviation community. This is
particularly important to industry members living in regional areas
who do not have the opportunity m receive safety information from
other sources. The programs of safety education being
provided, including SMyS advice and education are a continuation of
those provided by CASA for more than a decade.
CASA is producing a booklet for operators about Change
Management which will be published for distribution in July
2007.
CASA is developing a Safety Management "toolkit" for smaller
operators. This will be introduced by September 2007 in the form of
the successful, "Briefing in a Box" concept.
This Toolkit will identify means by which an operator can better
understand and evaluate issues such as equipment, routes, key
personnel, classification of operations and organisational
structures in a changing environment.
In addition, CASA is developing a product that addresses non
technical skills for flight crew such as situational awareness,
fatigue, threat and error management and workload issues.
The requirement for operators to have a structured risk
assessment methodology will be included in the proposed Civil
Aviation Safety Regulation (CASR) Part 119 (Air Operator
Certification - Air Transport). This Part is planned to be made in
2008. CASA will publish an acceptable means of compliance and an
Advisory Circular (AC)on the subject. This will provide guidance
material for industry to assist in complying with particular
legislative requirements.
The ATSB defines a safety issue as a safety factor that
(a) can reasonably be regarded as having the potential to adversely
affect the safety of future operations, and (b) is a characteristic
of an organisation or a system, rather than a characteristic of a
specific individual, or characteristic of an operational
environment at a specific point in time. As such, the
classification of the safety issue as a contributing safety
factor is irrelevant in terms of safety action.
While the ATSB acknowledges the lack of any specific regulatory
requirements relating to risk assessment, it would appear that
Section 28(1) and (2) of the Civil Aviation Act 1988
implies a process of risk assessment. Regardless, the ATSB notes
the actions being taken by CASA to address the safety issue and has
amended the status of this recommendation to 'Monitor'.
CASA has now expanded the Aviation Safety Advisors program in
2008 to a total of eleven advisors who provide safety advice to
members of the aviation community. This is particularly important
to industry members living in regional areas who do not have the
opportunity to receive safety information from other sources. The
programs of safety education being provided, including Safety
Management advice and education are a continuation of those
provided by CASA for more than a decade.
CASA has developed a Safety Management Toolkit for operators.
The final production is underway and distribution started in
March/April 2008 with the initial components being the Message to
CEOs, a Best Practice SMS booklet and DVD, the previously existing
SMS DVD and the Change Management Booklet. Other safety management
issues will be included in due course. The CEO Booklet aims at
providing CEOs with a strategic direction with respect to Safety
Management. The Best Practice material provides current industry
safety management norms as told by the industry. The distribution
of the Change Management booklet has been held pending the
completion of the Safety Management Toolkit of which it now forms a
part. This booklet identifies means by which an operator can better
understand and evaluate issues such as equipment, routes, key
personnel, classification of operations and organisational
structures in a changing environment.
CASA has engaged a consultant and is currently developing a
"Briefing in a Box" product that addresses non technical skills for
flight crew such as situational awareness, fatigue, threat and
error management and workload issues. This product will provide
operators with the tools to conduct their own training and
education for staff and crew.
The Industry Oversight Project provides all CASA oversight with
a clear risk based framework, which assesses safety risk within
Permission Holders, the risks associated with managing safety
oversight of a wide variety of permissions and the risks associated
with oversight strategy, which includes hazards identified across
the industry, as well as responding to government guidance. The
Framework provides the various levels of surveillance activity and
management within the organisation with clear guidance on
assessment of risk and the treatments/controls available for their
use. Entry Control in particular is provided with clear guidance on
assessment of safety risk. This is tied closely to the development
of the Part 119 Regulation which requires Permission Applicants to
provide an Exposition for assessment. The Exposition is a
demonstration of the operator's understanding of the risks
associated with their own activity as well as their strategies for
controlling these risks.
The ATSB acknowledges CASAs commitment to providing educational
material to industry to assist operators manage changes to
operations from a safety management system perspective, as well as
CASAs commitment to use a risk-based approach for the over-sight of
industry. The ATSB also recognises the Civil Aviation Orders 82.3
and 82.5, as amended 3 February 2009, which require regular public
transport operators to have a safety management system in place
that, 'as a minimum, include ....... (b) a safety risk management
plan, including documented details of the following: (i) hazard
identification processes; (ii) risk assessment and mitigation
processes'.
