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Tēnā koutou,
It’s been a busy couple of months for our teams at the Civil Aviation Authority since I was appointed as Acting Director and Chief Executive in early May.

Since then we have completed the long-running restructure of our regulatory and support service teams, and started to review our costs as an organisation, resulting in a report which was submitted to the Minister of Transport for his consideration at the end of June.

It is really important that we are operating efficiently as an organisation and responsibly using the money we get from industry and passengers through our various fees, levies and charges, as well as the taxpayer money we are currently receiving to cover the shortfall in our funding. When the economic effects of the COVID-19 pandemic started to become clear we moved swiftly to reduce our costs- this included immediately reducing fixed term and contractor positions. We will continue to review costs to make sure that we are spending in the right areas, and that this reflects the expectations Government has of us as well as the needs of industry.

We have also launched a programme to improve our culture, address the findings of the Ministerial Review into our organisational culture, and implement all its recommendations. We are assembling a taskforce made up of our staff and union representatives, who will keep us on the right track to build an enduring, positive workplace culture where our people are safe and enjoy coming to work each day. It is this positive and respectful culture we expect to see reflected in the how we deal with you too.

Our new structure is now in place

On 1 July we moved to our new structure as we completed our ‘Organisational Design Review’ programme. This restructure was first announced in May 2019, and its main change was a move from being sector based to a functional design. In practice this means that we now have separated out our teams so that we have a clear line between the units which conduct certification, and those which are responsible for our ongoing monitoring and assurance work. This will bring more consistency to the certification process and more focus on being a risk-based regulator.    

We are well into the process of making appointments for roles in the new structure and are working to update the contact details for our new regulatory teams. These contact details, along with explanations of what each team in the Aviation Safety group is responsible for, will be uploaded to our website over the next couple of weeks. In the meantime, please continue to use your existing contacts at the Authority if there is anything you need to discuss with us.

Lessons learnt during lockdown

During the Alert Level 4 lockdown and period of Level 3 travel restrictions we learnt a lot as an organisation about how we can be doing things differently. One example which really stands out to me is that we almost immediately shifted to conducting some interviews over Skype when we were no longer able to travel, and this is an initiative I expect our regulatory teams to continue where appropriate. It’s a seemingly small change, but when you add it up over the course of the year it will save an enormous amount of time, money and hassle. Our operational teams can’t do everything by Skype, of course, but when there are better and more efficient ways we can do things, we will certainly consider these.

The Aviation Security Service part of our organisation has also gone through an extraordinary period of change as its role has grown to include supporting New Zealand’s managed isolation and quarantine hotels. This has presented us with challenges as demand for domestic travel and our traditional on-airport security work has ramped up, particularly during the current school holiday period. I’m proud of the way our team has adapted so quickly to such a different role, and their ongoing commitment to keeping New Zealand safe and secure in such uncertain times.

Managing the flow-on risks from COVID-19

We have also had to adapt to the changing risks that COVID-19 presents to New Zealand and its aviation industry. This means we have had to identify the risks associated with the COVID-19 pandemic and economic downturn on our aviation sector, and then worked through prioritising those risks. We’ve done this work in collaboration with industry representative organisations, with a survey that went out across all aviation sectors. The analysis from this provided us with useful insights into which sectors, regions and types of operators are most at risk.

I’m sure you’ve heard us talk before about being a risk-based, intelligence-led organisation. We are committed to this approach which involves the better use of information to identify risks and guide our monitoring activities, and which we will be using to address the risks associated with the change and uncertainty you are facing in this post-COVID environment.

Finally, I want to echo some of comments you’ll see below from our Acting Deputy Chief Executive for Aviation Safety, Dean Winter. Ultimately our team at the Authority wants the same thing that you do – safe and secure skies. As the Minister of Transport said at a recent Select Committee hearing, he wants the Authority to be “a modern, efficient public agency” that treats people well and delivers on its task of ensuring that the skies are safe for New Zealanders. During my time as Acting Director and Chief Executive, I’m committed to ensuring we improve our performance.

Ngā mihi nui,
Shelley Turner, Acting Director of Civil Aviation and Chief Executive

Meet Acting Deputy Chief Executive for Aviation Safety Dean Winter

In each edition of the CAA Briefing over coming months we will be profiling the members of our Authority Leadership Team. Today we introduce Dean Winter, who is currently our Acting Deputy Chief Executive for Aviation Safety.
 
What were you working on before you joined the Authority in February?

My career has involved working with several sectors and organisations to implement or improve their regulatory and monitoring systems. That includes working with Trademe, work on the Emissions Trading Scheme, the Real Estate Agents Authority, Crown Law , and more recently at the Tertiary Education Commission creating oversight of the $3 billion a year invested into the tertiary education system. In my early career I was a Detective and a Police diver, which was hard work, but rewarding, as most Police work was.

What’s your view on how we engage with operators and the aviation sector?

My philosophy is that we need to get out there, talk to people and  listen – to work with the sector, because all of us ultimately want the same thing, a safe aviation sector. We might have different roles to play in that but we strive for the same outcome. The aviation sector is driven by a safety culture, but that doesn’t mean things can’t improve, and we shouldn’t be complacent.

The way we do things is as important as what we do, and that is something we want to improve. As regulators it’s difficult to avoid some level of tension at times between what we do and opinions of participants, but it’s our job to be professional, respectful and fair in everything we do.

What will you do to make sure that’s happening?

We can’t keep doing the same things and expect different outcomes, so I want to look at everything we do and how we do it. I’ll never accept that we can’t constantly strive to improve how we operate and how we are perceived as a regulator. To do that our workforce must be equipped with the skills and tools to do the job.

It also means listening, and questioning ourselves about our engagement, both why and how we do things. The risk based approach is important because it answers the ‘why’ we do things in the monitoring space, it means we will better utilise the information we have to identify and address risk, it is proactive, a better use of our limited resources and will led to safer outcomes.

What’s your view on how Just Culture fits in to our regulatory approach and prosecutions?

Just Culture is important to us - we want to encourage people to come forward with information, but the balance is around the public interest in our role as a regulator. People have expressed concern to me about our approach to prosecutions and how that fits with Just Culture, but it’s important to emphasise that prosecutions are a last resort, and although high profile, they’re actually very rare. In recent years we used prosecution as an outcome for 0.07% of occurrences reported. 

What you will see is us using the results of prosecutions to promote safety messages more than you might have seen in the past. Using learnings of what are often tragic outcomes to reduce the risk of repeat incidents aligns with what should be the primary tool of any good regulator – education. I’m looking forward to getting out and meeting people, gaining an understanding of where we are doing well, and where we might learn to improve. We should never be afraid to say we can do better.

Update on our recent prosecutions

Health and Safety prosecution over fatal hang gliding accident

On 16 June 2018, a student pilot died during a hang gliding training exercise at a beach in north Auckland. Following an investigation into the circumstances surrounding the accident, the CAA brought a prosecution under the Health and Safety at Work Act 2015 (HSWA) against both the company (a Person Conducting a Business or Undertaking, or PCBU) and against the instructor as the director, an officer of the PCBU.

The findings serve as an important safety message for operators to take care in avoiding accidents in similar circumstances, and as a reminder of obligations under health and safety legislation.    

Most hang-gliding activity in New Zealand is recreational, with participants operating under CAA Rules Part 91: General Operating and Flight Rules, Part 106: Hang Gliding – Operating Rules and Part 149: Aviation Recreation Organisations – Certification. It’s not unusual for rated hang-gliding instructors to provide guidance and assistance to their fellow pilots on a voluntary basis. However, in this instance, as the student made payment to the instructor’s organisation for its instructional services, the PCBU and the officer/ instructor were obliged to meet the duty of care and due diligence requirements of HSWA.

On the day of the accident, shortly after being towed airborne, the student experienced a lockout. This is a condition that occurs when a glider being towed drifts sideways from the direction of the towline so far that the pilot’s control inputs can no longer overpower the turning forces caused by the towline. This causes a rapid increase in tow tension and the lockout will quickly worsen unless the tow tension is reduced quickly.

On noticing the student was turned away from the towline direction, the instructor activated the quick (tow rope) release mechanism from the interior of their vehicle. However, the vehicle tow line release system failed to operate. The hang glider went into a steep descent and crashed into the ground. The student pilot died from the injuries sustained.

The charges relate to the PCBU and officer not taking the identified reasonably practicable steps that exposed the student to a risk of death or serious injury:

  • Not having a safe system of work to carry out the hang-gliding ground tow instruction safely.
  • Not ensuring that effective emergency procedures specific to the operations were in place.
  • Not using safe tow equipment that ensured the safety of the student during flight.
  • Not providing adequate training and instruction to student pilots on the phenomenon of lockout, how to recognise and recover from lockout.

Sentencing occurred on 15 June and the Court awarded the victim’s family $115,000 for emotional harm reparation and $191,659 for consequential harm reparations.

Sentencing over fatal helicopter accident

In June 2018 a helicopter crashed during a low flying operation to inspect crops, resulting in one fatality. The company was charged with operating an aircraft in a careless manger. The charges relate to having non-essential passengers onboard during a high-risk activity, which is prohibited in the Civil Aviation Rules to minimise the consequences of a potential accident.

Sentencing for this accident occurred in early June 2020 and a fine of $6000 was imposed. Although the fine in this instance was small, the sentence highlights the importance for operators of adhering to the rules relating to non-essential passengers.

Recent sentencing over operating an aircraft without a current PPL

An individual was charged with twelve counts of operating an aircraft without holding a current PPL. The offending occurred over a seven-month period and was aggravated by the fact that he was previously investigated by the CAA for identical offending in 2016, which he had received a warning over.

In this case, Judge Edwards agreed that the aggravating factors were the deliberateness of the offending (following the pervious warning), the scale and duration of the offending, and the risk presented to the individual’s passengers. In sentencing, the Judge considered the fact that the individual had been flying without a licence for a long period of time and had been previously warned but acknowledged that he had entered an early guilty plea. Ultimately the individual was ordered to pay $7,000.

The message from this case is clear – if you’re not permitted to fly, don’t fly!

International recognition for our safety investigators

In June we took some time to celebrate the Themes and Systems Safety Investigation (TSSI) approach which two members of our Safety Investigation Unit had developed over the last few years. TSSI investigations take a system-wide view to problem-solving possible safety risks across the aviation system. It involves identifying patterns and similarities in occurrence safety data (that is identifying a problem), and an investigation to determine the factors causing the problem.


From left: John Kay, Ben Smith, Matt Harris, Dan Foley, Shelley Turner, and Jim Burtenshaw.

The essence of a TSSI is to precisely define the problem and why it exists.  It then involves systems thinking, providing the right information to the right people, to enable them to do the right things to solve the problem. The TSSI approach is proactive in preventing incidents.

Matt Harris (now our Chief Advisor – Human Factors) and Dan Foley developed and implemented the Themes and Systems Safety investigation methodology over the last five years and have since employed the TSSI methodology to solve complex system problems. The resulting regulatory interventions have been highly successful due to them addressing the main contributing factors deep within the system. In one case the likelihood of a significant accident was greatly reduced, thereby significantly improving aviation safety.

Matt and Dan were so passionate about they approach they had worked on that they wanted to ensure it could be shared with other safety professionals, so they collaborated with the CAA’s Learning and Development Team to develop TSSI online learning modules. This has had significant organisational benefit by making the TSSI systems thinking more accessible for other CAA employees.

Dan and Matt also co-authored a TSSI paper for the International Society of Air Safety Investigators (ISASI). The paper was chosen to be presented at the ISASI 2020 annual conference in The Hague. Dan Foley presented the TSSI methodology and received overwhelmingly positive feedback, with a number of organisations approaching the CAA to adopt its use. Most recently the United States Naval Aviation Safety School has added it to their safety training curriculum.

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