ao-2014-032_figure-7.jpg ATSB

ATSB Developing Case Study on Airline SMS

Virgin Australia incident findings prompt broader examination.

Australian investigators are developing a case study to examine how a safety management system (SMS) supports an airline during expansion as it works to accomodate growth and satisfy regulatory requirements. 

The Australian Transport Safety Bureau (ATSB) says the study stems from lessoned learned during its probe of a February 2014 incident involving an in-flight pitch disconnect on a Virgin Australia ATR 72 during an approach. The incident, which is still being investigated, caused substantial, visible damage to the elevator and tail assembly that was not discovered for five days. 

ATSB and ATR subsequently discovered similar in-flight pitch-disconnect incidents. While none of these caused the type of damage found on the Virgin Australis aircraft, the findings convinced ATR to make several flight operations and maintenance procedures.

"As part of the occurrence investigation into the in-flight pitch disconnect and maintenance irregularity…investigators explored the operator's safety management system (SMS), and also explored the role of the regulator in oversighting the operator's systems," ATSB says. "It was determined that the topic appeared to overshadow key safety messages regarding the occurrence itself and therefore a separate safety issues investigation was commenced to outline the implementation of an organization's SMS during a time of rapid expansion, along with ongoing interactions with the regulator."

ATSB says its study will examine "the chronology" of Virgin Australia's SMS implementation "and some of the key issues encountered." The study is expected to be released in about a year.

Investigators have released two interim reports on the Virgin Australia incident, with the most recent coming out in May. Neither discusses SMS.

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