The Civil Aviation Safety Authority’s acquittal process for repeat safety findings was not effective in ensuring that all previous findings of a similar nature were also appropriately assessed prior to the current and all associated safety findings being acquitted.
The Civil Aviation Safety Authority (CASA) has taken a number of actions to reduce the potential for repeat safety findings to be closed without ensuring that previous findings have been appropriately assessed. This includes improved guidance in the CASA surveillance manual around preparation for surveillance activities, and definition of roles for personnel involved in these activities. Additionally, all open findings are discussed at a weekly forum, ensuring higher visibility across the organisation.
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.
With regards to the report, the safety recommendation, and as part of recent surveillance activity, the CASA Surveillance Manual (CSM) has been updated.
Section 4.6.4 of the CSM (Surveillance Findings) now states the following.
Note: When conducting the post-surveillance review and analysis, if the surveillance team identifies repeated breaches of a similar nature from the review of previous surveillance events and the surveillance team is no longer satisfied that the authorisation holder is willing or able take remedial and corrective actions to address the breaches, the surveillance team, in conjunction with the Surveillance Manager must consider initiating the Coordinated Enforcement Process (CEP) in accordance with section of the Enforcement Manual. Writing Compliance Findings (Level 1 and 2 surveillance types).
This demonstrates that CASA has amended its acquittal process for repeat findings and has a process in place so that repeated findings should trigger enforcement action where there is a lack of will or ability to acquit those findings.
Further to this, we now have greater visibility of open Safety Findings across the organisation than before.
Email sent to CASA 10 May 2022, with a view to clarifying information in the above response and ask for additional information
The Civil Aviation Safety Authority provided the most recent version of the CASA Surveillance Manual (CSM version 5.0).
Open Safety Findings form part of the discussion at the weekly Surveillance Managers’ meeting. Open findings are tracked by status and issuing office, with the status classifications being;
At the management meeting, the status of open findings is discussed generally, with a more specific and detailed discussion occurring for individual operators who are showing a lack of ability or willingness to close out findings satisfactorily. These operators are then either subject to additional activity from the surveillance team, which may include correspondence from the National Manager, and if all surveillance options are exhausted, then a referral to enforcement is then made following the CEM process.
The additional oversight provided by discussions at the weekly surveillance manager's meeting was only considered to be relevant to open findings, and does not specifically mention how repeat findings are to be managed.
It was noted however, that CSM Version 5.0 contained additional guidance around surveillance event planning, including more specific references to the Surveillance Planning and Scoping Development Form, and an additional list of responsibilities for both the surveillance lead, and new reference to a surveillance technical officer. It is likely that this would increase the visibility of open findings to the surveillance team, and would ensure that the deficiencies identified in the finding are assessed at the surveillance event, and where the breach has not been rectified, future findings written appropriately.
In addition, the CSM version current at the time of the accident (3.2) included a comment that where a response required verification by CASA, consideration should be given to acquitting the Safety Finding and adding a comment to authorisation holders file in Sky Sentinel that verification is to be carried out at the next surveillance event. This comment has been removed from CSM version 5.0, which decreases the likelihood that verification may be missed at subsequent inspections.
