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CASA Annual Report 2003 04 Part 2: Operational Report

Operational report

Output 2: Aviation safety compliance


  • Introduction of a fairer and more transparent enforcement system in which natural justice is enhanced and ‘the punishment fits the crime’.
  • Implementation of a comprehensive Surveillance Procedures Manual to get a well-understood, well-accepted and consistently practised approach to surveillance.
  • Development of an award-winning ‘proof of concept’ quantitative risk model which can be used to assess, compare and predict aviation safety risk using parameters such as operators, sectors or locations.
  • Adopt a whole-of-industry perspective for safety risk assessment and management.
  • Increasing the time inspectors spend in the field from 40 per cent to 50 per cent.
  • Inspectors more involved in helping the industry comply.



Secure compliance with Australian aviation safety legislation through effective education, surveillance and procedurally fair enforcement.

CASA is working towards a partnership in safety with the industry that will offer better safety outcomes than it can otherwise achieve. Over the past few years CASA’s approach has been to more closely integrate its regulatory functions of surveillance and enforcement with its safety-related function of encouraging greater acceptance of safety obligations by the aviation industry.

This approach has been reflected in CASA’s adoption of system safety auditing (which will be complemented by a forthcoming requirement for operators to have a safety management system) and by an increasing effort to help the industry comply.

In 2003–04 CASA gave particular attention to getting a better return on the investment of resources in surveillance and to introducing a new enforcement regime that will more constructively motivate compliance.


Budget: $52.030 million

Actual: $53.999 million

Variation: +3.8 per cent


Initiatives, developments and issues in 2003–04


The compliance function of regulatory authorities is commonly seen as being about policing requirements, with education and training a discrete activity. CASA has taken on board urging from the industry to make giving guidance to operators a part of the day-to-day business of its inspectors.

The expanded role requires a broader skill set and some cultural change. This year CASA began looking at temperament and personal qualities as well as technical expertise in selecting the right people for jobs. The coverage of learning and development programs was also reviewed in this context.

During 2003–04, CASA inspectors took part in a number of projects to provide guidance to individual operators. These projects included case managing the implementation of a number of regulatory reforms and using system audits to follow up with individual small operators on their success in trialling safety management systems.

The systems audit project, which was aimed at low-capacity regular public transport operators, integrated education, guidance and surveillance components. This method meant that operators were aware of CASA’s new approach to their surveillance and more proactive in working with CASA to ensure regulatory compliance.



The contribution surveillance makes to aviation safety depends on how appropriately CASA uses available resources, the quality of surveillance techniques and their application, and how effectively CASA translates surveillance findings into lasting safety improvements.

Special surveillance

Risk assessment is the key to effectively targeting surveillance resources. Following a slow start which drew criticism from the Australian National Audit Office,3 CASA has been steadily improving its safety intelligence capability over the past couple of years by establishing the reliability of data sources, identifying operational pressures, developing and refining the accuracy of risk assessment tools, and skilling inspectors in capturing and consistently reporting safety intelligence.

A major achievement in 2003–04 was an award-winning ‘proof of concept’ quantitative risk model, which can be used to assess, compare and predict aviation safety risk using a number of parameters such as operators, sectors or locations.

CASA was using trend information and risk assessment mainly to assist in timing and focusing scheduled audits, and to trigger ‘special’ audits on individual operators, which target specific areas of perceived weakness or risk and are undertaken as needed. In 2003–04 it was determined that a higher priority should be given to addressing significant risks identified from a whole-of-industry perspective.

Risk assessments were undertaken to inform surveillance planning. As a result, the 2004–05 surveillance plan for the airline sector incorporates whole-of-industry risk auditing in the areas of maintenance control systems for airline operators, and control of documents and data for the maintenance organisations servicing them. Whole-of-industry risk auditing is planned for introduction in the general aviation sector by June 2005.


Presence in the field

The general aviation inspectorate increased the proportion of core business devoted to compliance activities from 40 per cent to 50 per cent, so that time in the field increased from six to seven days per inspector per month. The increase was made possible by efficiencies achieved in regulatory service delivery and the approach to enforcement.

Surveillance techniques

2003–04 was an important year of consolidation for CASA’s system safety auditing regime, with the implementation of a comprehensive Surveillance Procedures Manual. The manual was developed over several years and captures CASA’s growing experience in utilising what is conceptually world’s best practice, but still fundamentally new. The improved procedures also address issues raised in external and internal audits of the compliance function.4

The manual is a critical step forward in getting a well-understood, well-accepted and consistently practised approach to surveillance among CASA’s inspectors, who are dispersed across 13 offices around the country. Lack of consistency has been identified as a problem in audits and by the Aviation Safety Forum, and is an ongoing source of complaint by the industry. In particular, the manual was written around the Management System Model, which will provide a consistent standard against which to measure how well operators design, implement and use safety management systems when this requirement is introduced.

Implementation of the manual began in November 2003 with an intensive seven-day training and on-the-job coaching program for all compliance staff. This nationwide program was conducted by a small number of trainers to ensure a consistent approach and included follow-up visits to sample later surveillance work for adherence to the new procedures. A long-term training strategy for inductees is being developed.

An internal quality review plan was put in place to ensure that staff continue to comply with the manual. Quality reviews of five offices were conducted from May to July and found minimal deviation from procedures. Corrective action is being tracked.

A post-implementation review began in May 2004 to verify the relevance and ease of use of documented procedures by field staff, appropriate use of procedures by field office staff and the appropriateness of training provided. The review will identify any significant issues requiring amendments to the manual and will be used to assess CASA’s progress towards acquitting internal and external audit findings.


Translating findings into results

To get the full benefits of systems auditing, CASA has to effectively follow through on the findings with operators. During 2003–04, it re-examined the way requests for corrective action are issued and acquitted. As a result, the requests for corrective action form now identifies ‘system components’ the operator should focus on to eliminate causal factors in operational deficiencies and to prevent recurrence. A clear policy was established on when requests for corrective action can be acquitted and work began on a database to support systematic tracking to acquittal. CASA is also drafting detailed instructions to help inspectors raise a requests for corrective action in a way that will support enforcement action for the safety breach(es) if that proves necessary.

CASA is also looking more closely at the ‘why’ of non-compliance from an industry-wide perspective so as to target the real problem in the right way. The findings of the industry-wide risk audits will be collated nationally and examined to identify whether more or different action is needed by way of guidance material, education and training, changes to ambiguous or impractical regulations, or stricter enforcement.



New enforcement regime

Legislative amendments, which came into effect on 21 February 2004, gave CASA a wider range of enforcement tools and opened up CASA’s decisions to closer scrutiny. The aim of the amendments is to provide a fairer and more transparent enforcement system in which natural justice is enhanced and ‘the punishment fits the crime’.

The new enforcement regime is consistent with a risk-based approach to safety and offers a much better basis for a constructive partnership between CASA and the industry. The new measures:

  • limit CASA’s power to cancel a certificate or licence for a breach of civil aviation law to where a court has found the holder guilty of the offence
  • provide an automatic stay of CASA decisions to suspend, vary or cancel a licence or certificate in cases that do not involve a serious or imminent risk to air safety
  • maintain CASA’s power to immediately suspend a licence or certificate where CASA has reasonable grounds to believe there is a serious and imminent risk to air safety, but require CASA to apply for a Federal Court order to continue the suspension for more than five days
  • introduce a demerit point system based on the system employed by some states for motor vehicle drivers licences
  • establish a scheme of enforceable voluntary undertakings under which CASA may accept a written undertaking in relation to compliance with legislative safety requirements
  • offer protection against regulatory action for licence or certificate holders who report minor breaches of the regulations to the Aviation Transport Safety Bureau within 10 days of committing the breach.



CASA’s implementation of the new enforcement regime required administrative groundwork, promotion of industry awareness and preparation of CASA staff.

The administrative underpinnings included finalising regulations to enable implementation of the new procedures, establishing a Demerit Points Register and establishing a system for administering enforceable voluntary undertakings. These were all successfully accomplished for the 21 February commencement date.

To inform the industry, CASA placed an explanatory statement of the changes on the CASA web site and distributed an easy-to-read booklet to licence and certificate holders.

Preparation of CASA staff included educating them about the objectives of the new approach, and training them in the new procedures in conjunction with issuing a comprehensive new Enforcement Manual. CASA is very conscious that the value of the new provisions will be undermined by inconsistency in the way they are applied and by any failure to take advantage of the full range of enforcement options now available.

CASA will undertake a review of the new enforcement procedures in 2004–05 to check whether they are working as intended and to identify any changes required to fix problems that may have become evident in light of experience.


Bright Idea by Compliance

CASA’s Aviation Safety Compliance Division staff introduced a simple, effective and constructive way to put forward ideas for improving the way they get their job done.

A ‘bright ideas’ page was set up on the intranet – CASAconnect – to collect suggestions for improving processes, strategies and the work environment. All suggestions are acknowledged, reviewed in an appropriate forum and given a considered response.

The trigger for creating a formal system for collecting ideas was the employee survey, which indicated that staff were keen to put forward suggestions as long as they were given to management and acted upon.

A web-based form has been developed where ideas are put up in detail, with background, perceived benefits and suggestions fleshed out. A monthly report shows the number of suggestions received, and the status and progress of bright ideas that have been taken on.

By the end of 2003–04, Compliance staff had submitted 17 ideas, of which nine had been implemented, six were in progress and two were on hold.


Performance measures

Strategy: Secure compliance through the application of surveillance activities using a systems safety approach, procedurally fair and consistent enforcement action, and continued application and development of risk assessment tools
Measure Staff are fully complying with the procedures laid down in the Surveillance Procedures Manual.
Result Minimal deviation from procedures found to date. Corrective action tracking is in place.
Progress On track. The new Surveillance Procedures Manual was implemented during the year. All inspectors received training and coaching in the new procedures and a long-term training strategy for inductees is being developed. Quality reviews of three offices were conducted from May to June 2004 (and of another two offices in July). A quality review plan has been developed to monitor continued compliance with the procedures.
Measure Consistency of application of informal enforcement actions.
Result Use of informal enforcement was tracked. Procedures for informal enforcement were incorporated in the new Enforcement Manual and in the training provided to staff on the new enforcement regime.
Progress Further monitoring is needed to establish a full picture of consistent usage.
Measure Consistency and accuracy of Safety Trend Indicator completion by the inspectorate.
Result A Safety Trend Indicator V1.1 e-form introduced last year has improved consistency and accuracy of data as the forms are linked to CASA’s database and require full completion before submission is possible.
Progress On track. The clarity of the Safety Trend Indicator V1.1 form was further improved during 2003–04 and additional efficiencies achieved through database linkages reducing the text input required for the form. A Working Group has been established to develop Safety Trend Indicator V2.0. This version will be one of the inputs to risk-based auditing decisions for general aviation.
Measure Evaluation and testing of desktop tools undertaken by users. Develop desktop tools to assist operational level risk management.
Result A prototype desktop risk tool for use by general aviation sector inspectors was developed.
Progress On track. The implementation phase will begin early in 2004–05. An application of the desktop risk tool for airline operations inspectors will begin in 2004–05.
Strategy: Encourage acceptance of operator management responsibility for systems safety in the aviation industry
Measure Full and effective implementation of the audit index process
Result The Audit Indicator is being refined in view of amendments being made to the Surveillance Procedures Manual.
Progress On track. It is expected that the Audit Indicator will be ready to trial in the last half of 2004. This project is associated with the implementation of risk-based auditing for general aviation.
Measure Operators audited according to plan by sector Target Achieved
Result General aviation 100% 96%
Progress CASA completed 539 of the audits scheduled for general aviation for 2003–04. Originally 550 audits were planned for the financial year. Approximately 90 audits were moved or removed for reasons such as the certificate being surrendered or cancelled or the operator not operating (12 were due to CASA resource issues). Approximately 70 audits were added with the addition of new operators and the correction of planning errors. Scheduled audits that were not completed in accordance with the amended plan were replaced by an equivalent form of scrutiny, or based on their low risk, were rescheduled for the first quarter of 2004–05.
Result Domestic airline operations Target Achieved
    100% 88%
Progress CASA completed 114 of the audits scheduled for domestic airlines for 2003–04. Originally, 155 audits were planned for the financial year, but with amendments to the audit plan, 130 audits remained for the year. The operators that were not audited due to shortage of resources are being monitored through ‘desktop’ audits and regulatory services tasks and were selected on the basis of their low risk.
Result International airlines Target Achieved
    100% 83%
Progress CASA completed 92 of the audits scheduled for international airlines for 2003–04. Originally, 115 audits were planned for the financial year. Planned amendments (primarily due to the operator no longer operating in Australia) reduced the plan to 110. Scheduled audits that were not completed in accordance with the amended plan were replaced by an equivalent form of scrutiny, or based on their low risk, were rescheduled for the first quarter of 2004–05.
  Target Achieved
Result Aviation infrastructure and sports aviation audits 100% 93%
Progress CASA completed 224 of the audits scheduled for 2003–04. Originally, 229 audits were planned for these areas, but this was increased to 240 audits following some catch-up from the 2002–03 plan. Scheduled audits that were not completed in accordance with the amended plan were replaced by an equivalent form of scrutiny, or based on their low risk, were rescheduled for the first quarter of 2004–05.
Measure Percentage of ‘desktop’ audits achieved against the Safety Trend Indicator (STI) audit plan Target Achieved
    100% 99%
Result CASA completed 2853 of the audits scheduled for 2003–04. Originally, 2750 STIs were planned, but this increased with the addition of new operators entering the industry and STIs being done at the time of Special Audits.
Strategy: Achieve consistency in regulatory decision making
Measure Inspectorate core competencies identified and training gap analysis of inspectorate complete.
Result Training programs to develop identified core capabilities are run quarterly. Inspectorate needs analysis completed.
Progress On track. The results of the inspectorate needs analysis will inform the development of priority specialist and/or regulatory programs for 2004–05.
Measure Policy requirements identified, refined, developed and implemented.
Result Not completed.
Progress Slippage. A planned extensive re-write of the Air Operator’s Certificate Manual was deferred pending finalisation of new entry control regulations. A project is underway to make immediately required amendments to procedures for issuing airline operator’s certificates.
Measure Information technology (IT)/database options for a repository of information to support standardisation and consistency have been identified, and information requirements and protocols developed.
Result Options identified.
Progress On track. Information requirements and protocols are being developed in consultation with the Aviation Safety Forum and will be completed by the end of 2004. A feasibility study is to be undertaken prior to preparing a business case for consideration by the end of June 2005 against other IT development priorities.
Measure Undertake an internal survey to assess usefulness of initiatives to facilitate consistent regulatory decision making.
Result Not undertaken.
Progress Survey deferred until all IT/database options have been reviewed.


Crocs ‘n floods challenge Northern Territory staff

The environment for the staff of CASA’s Northern Territory and Kimberley office features extremes of weather, floods, fires and cyclones. And with that go power and water failures, road closures and aerodrome closures to make their work interesting and challenging.

Surveillance operations

Surveillance operations are controlled by the vagaries of the ‘wet’ and the ‘dry’ seasons – there is no summer, winter, autumn and spring. The dry season is usually very pleasant with daily temperatures in the range of 16°C to 25°C. Light easterlies and blue skies dominate the weather, but this deteriorates towards the end of the season in September–October with reduced visibility from intense bushfire activity.

Conversely, the wet season doesn’t vary much from 32°C most days and nights with very humid conditions dominated by amazing electrical and thunderstorm activity, continuous heavy rain and cyclones. The skyscapes throughout the year have to be seen to be believed and introduce many phenomenal experiences for aircrews.

Surveillance staff have to contend with either flying to available airstrips that are still serviceable or driving for periods of up to 16 days in four-wheel-drive vehicles that are equipped with camping, survival and satellite telephone equipment. There are no motels at many locations and the inspectors rough it under canvas while sorting out their surveillance reports.

CASA’s Northern Territory operations put real meaning into the importance of occupational health and safety and recruitment of resilient and resourceful staff. On one occasion an unseen wall of water hit two inspectors while they were trying to cross a flood plain in East Arnhem Land, rolling them and the vehicle into swirling waters. On another, an inspector attending the site of a crashed helicopter to assist with an investigation was visited by a Mama crocodile that was rather upset about the invasion of the helicopter in her nest.