Appendix 2: Recommendations in our 2005 report

Responses to the Coroner's recommendations on the June 2003 Air Adventures crash.
  1. That the CAA continue to establish measures to better assess the effectiveness of its safety interventions.
  2. That the CAA improve its analysis of industry information by:
    • including more analysis of the information in the Aviation Safety Report and the Aviation Safety Summary Report to support further action, and to improve the timeliness of these reports; and
    • improving analysis of accident and incident data (for example, by identifying further opportunities - such as the CAA’s joint study of pilot-caused and controller-caused airspace incidents), from which the CAA will draft recommendations for safety intervention mechanisms.
  3. That the CAA further develop the tools it uses to assess the risk associated with individual operators. For example:
    • For the non-compliance index to be more effective, CAA inspectors need to correctly record all instances of non-compliance, as well as the actual audit hours spent with each operator. Operators need to be further encouraged to advise the CAA of instances of non-compliance.
    • For the quality index score to be more consistent, it should be supported by the information in the routine audit report, and reasons for significant changes should be explained.
    • For client risk assessments to be more useful to the surveillance process, the CAA needs to re-assess their function. These assessments identify changes to a company’s operation, but not necessarily changes to risk. We recommend that this tool be used to highlight any changes in the company’s operations for inspectors, who would then be responsible for assessing the effect of those changes on the risk of an individual operator.
  4. That the CAA use better indicators of the financial status of operators when assessing operator risk, both at certification and during surveillance.
  5. That the CAA ensure that its inspectors follow the policies procedures set down for certification.
  6. That the CAA continue with its review of its surveillance function. In undertaking this review and designing a new approach, the CAA should:
    • ensure that the audit process directs resources at the highest-risk operators;
    • direct appropriate activities and interventions at high-risk Safety Target Groups;
    • give priority to the sampling project (a sampling methodology will allow inspectors to make informed decisions on the work necessary to cover the assessed risk);
    • assess where reliance can be placed on operator’s own quality and risk management systems, so that audits can be targeted at higher-risk areas;
    • ensure that the depth and frequency of surveillance is adjusted to reflect operator and operation risk; and
    • develop guidelines to indicate when instances of non-compliance should be referred to the CAA’s Law Enforcement Unit for further action.
  7. That CAA inspectors issue a Finding Notice for all identified instances of non-compliance and non-conformance.
  8. That CAA establish a system that ensures that operators take quick and effective corrective action when inspectors tell them to do so. This system should include re-assignment of responsibility for that function when an inspector leaves the CAA.
  9. That CAA inspectors ensure that they record all time spent on the surveillance function. Continuing to do otherwise will affect the accuracy of the CAA’s risk analysis tools, and its ability to produce accurate business cases.
  10. 10. That the CAA:
    • ensure sufficient investment in training CAA staff so that they develop and maintain the appropriate skills to carry out their functions;
    • review its staffing levels when the current review of the surveillance function has been completed, to ensure that it has sufficient resources to undertake this function (both the review of the surveillance function and the review of staffing levels need to take account of the potential pressures or “surges” put on inspectors as a result of unanticipated requests for certifications);
    • ensure that the operational groups comply with the CAA’s generic policies and procedures (particularly relating to Quality Assurance);
    • promote consistent standards of quality and practices throughout the operational groups by ensuring that they address internal audit Finding Notices; and
    • ensure that the internal audit section is appropriately staffed to enable the CAA’s operations and inspectors to be audited on a more regular basis.
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