The report, which also pinpoints deficiencies in the way cabin crew handled passengers, said there was no evidence of any surveillance of cabin-crew safety training in 10years, and only minimal surveillance of the performance of cabin crew during line operations. CASA surveillance would focus on operators' management systems rather than the product. Neither does walking round the hangar tell you the weaknesses in a maintenance organisation. He said that CASA was encouraging the adoption of a safety culture through its systems auditing. Good systems produce good results.
Weak systems increase the likelihood of bad results.
In practice, we are finding that we are learning far more, as are the management teams who hold the responsibility. We encourage an adoption of a safety culture which ensures the defence mechanisms are in place to minimise failures. We audit the systems which create that culture. Ian Hamilton rejects this finding and questions the separation of powers between ATSB and CASA because both report to Transport Minister John Anderson. Hamilton is opposed to Toller continuing and argues persuasively for cockpit surveillance, and even the walking around hangars, where he says a trained eye will always find evidence of system failures and corner-cutting if an inspector opens enough cupboard doors.