REPORT OF THE INDEPENDENT REVIEW PANEL

Allegations of Fraudulent Air Transport Pilot Licence Examination Practices
August 2000

A: INTRODUCTION

The South African Civil Aviation Authority of South Africa is a statutory body established in terms of the provisions of the South African Civil Aviation Authority Act, No 4 of 1998. It began to function as from 1 October 1998 and took over the statutory and regulatory, functions and duties which were previously performed by the Department of Civil Aviation which fell under the control of the Department of Transport.
The primary function of the CAA is to regulate and control the aviation industry in South Africa. It does so by implementing a variety of regulations, some of which were promulgated by the former Department of Civil Aviation. These regulations are commonly known as Air Navigation Regulations ("ANRs"). It also does so by promulgating its own regulations, which are commonly known as the Civil Aviation Regulations ("the CARs") and Civil Aviation Technical Standards ("the CATs"). The CAA also publishes a variety of circulars commonly known as "Aeronautical Information Circular" ("the AICs"), which generally set out its policy directives and practices it follows in the course of its regulation and control of the aviation industry.
CAA regulates primary entry into the aviation industry by requiring persons who wish to become pilots to successfully undertake pilot's examinations. It directly presents a variety of examinations, namely examinations for commercial pilot's licences ("CPLs"), airline transport pilot's licences ("ATPs") and practical flight tests for private pilot licence ("PPLs"). The theoretical examinations for a PPL is undertaken by flying training schools accredited by the CAA.
During March 2000 a holder of a CPL licence and former employee of the DCA made allegations of fraudulent and irregular practices by certain pilots and staff members of the CAA regarding the ATP examinations undertaken by those pilots. Those allegations were partially corroborated by a staff member of the CAA, who was employed in its Examination and Licensing Department. Certain internal review and "investigation" of those allegations undertaken by some employees of the CAA led to the conclusion that the allegations were substantiated.
The Independent Review Panel ("the Panel") was constituted by the Board of directors of the CAA to investigate and report on these allegations of fraudulent and irregular examination practices. The initial terms of reference require the Panel to -

review the internal investigation undertaken by Mr KC Marobela into those allegations of fraud and irregularities in order to verify the correctness or otherwise of his findings;

consider new evidence relating to those allegations;

make recommendations to the Commissioner of the CAA regarding the allegations of fraud and irregularities.

On 24 May 2000 the Board of the CAA resolved to extend the Panel's terms of reference which require the Panel to investigate and report on the accident/incident involving the chief executive officer of the CAA, Trevor Abrahams, at the Rand Airport on 18 July 1999. The extended terms of reference require the Panel to investigate -

the facts / circumstances relating to the accident/incident, having regard to the standard CAA policies and practices;

the procedures observed or not observed in the accident/incident investigation;

the status of the licence held by Abrahams at the time of the accident/incident;

the events ancillary to the accident/incident both within the CAA and outside;

any matter which is relevant to the accident/incident, and to make recommendations to the Board of the CAA regarding the accident/incident.

Furthermore, the Panel is required to review the procedures of the CAA for issuing licences and to assess threat of fraud in the light of the discovery of fraudulent pilot licence documents, of the pilot who died in a plane crash in Mozambique on 2 April 2000, and to make the necessary recommendations in order to curb the recurrence of such fraudulent licence documents and to detect any fraudulent licences which may be in circulation or use.
The Panel has now completed its investigations relating to the matters referred to in its initial and extended terms of reference, described in paragraphs 5(a) to (c), 6(c) and 7 above. The Panel now reports to the Board of the CAA on the nature and extent of its investigation, its findings and recommendations.
The matters described in paragraphs 6(a), (b), (d) and (e) above will be investigated by the Panel in a reconstituted form.

B: THE STRUCTURE OF THE REPORT

The report is divided into various chapters: The first chapter outlines the process of investigation undertaken by the Panel; the second describes the documentary material and oral evidence considered by the Panel and its findings on the issues investigated by it. This chapter also describes the recommendations of the Panel, having regard to its findings. The third chapter describes strategy for the implementation of the recommendations made by the Panel.

CHAPTER 1

C: THE PROCESS OF INVESTIGATION

On 22 and 23 June 2000 the Panel conducted an on-site inspection of the examination and licensing department at the premises of the CAA. The purpose of the inspection was twofold:

First, to gain an appreciation of the examination systems operated by the CAA in respect of the ATP examinations. In this regard the Panel inspected -

the procedures followed by the CAA in conducting those examinations;

the security features of the examination systems and its implementation;

the duties of the CAA employees involved in the implementation of the examination systems.

Secondly, to gain an appreciation of the procedures followed by the CAA in processing and issuing pilot licences upon completion of the relevant examinations.

The on-site inspection revealed the following matters regarding the examination systems:

The CAA conducts a bifurcated ATP examination systems. At its premises a computerised "on-line" examination system is conducted. This is essentially a multiple choice examination presented through a computer programme capable of making a random selection of the question papers. The ATP examination comprises seven subjects. Each subject has ten different series of papers ranging from series 1 to 10. All things being equal, a candidate would not be able to know in advance the type of series he or she will be required to "write" when he undertakes his or her examination, simply because of the random selection series of papers by the computer.

Although the computer programme has security measures capable of ensuring the integrity of the examination system, those security measures may be overridden manually by an operator of the computer. This process has been identified as "forcing" the computer system. We deal more fully below with the nature of the security elements of the computer programme, and how they could be overridden so as to affect the integrity of the examination system.

The Panel was also informed of the procedures followed by the CAA in the conduct of the examination. In this regard it was informed that -

a candidate for ATP examinations is required to complete an examination entry form before he or she writes that examination;

on the examination entry form a candidate is required to indicate the date or dates preferred by him or her to sit for the subjects he or she wishes to write;

a candidate is required to undertake a minimum of four subjects at his or her initial sitting. He or she will be allowed to carry credits if he or she passes at least three of the subjects he or she has entered for;

a candidate would not be allowed to repeat any subject or subjects which he or she has failed, until the expiry of a period of thirty days from the date on which he or she had written the examination he or she had failed.

However, the period of thirty days is not rigid. It may be relaxed where -

a candidate had only failed one subject, in which event he or she would be allowed to repeat within a period of a week; or

he or she has failed two subjects, in which event he would be allowed to rewrite within a period of two weeks; or

he or she had failed three subjects in which event he or she would be allowed to re-write within a period of three weeks; or

a request for exemption from the period of thirty days has been made by a candidate and that exemption had been granted by the section head of the Examination Section or his or her superior.

After completion of the entry form by a candidate, an employee of the CAA would receive the form and immediately approve the dates requested by a candidate. Once the dates have been approved and a candidate has paid an examination fee, he or she would there and then be informed that he or she has been scheduled to write the examinations on the date or dates set out in the entry form, as approved by the employee of the CAA.

On the day of the examination a candidate would not be allowed to enter the examination room with any scrap paper or material other than the rough paper given to him by an invigilator.

In the examination room the candidate would conduct the examination through a computer monitor and a mouse. After completing the examination a candidate would be told there and then of his or her results. Furthermore, he or she is entitled to obtain a computer print-out of the results statistics which set out the questions he or she did not attempt or answered incorrectly.

Outside the premises of the CAA, ATP examinations are conducted on behalf of the CAA at the "out-stations" in Durban, Cape Town, Port Elizabeth and Windhoek. At these out-stations candidates are given written questionnaires and are required to answer them in writing. After completion of the examinations the answered questionnaires are returned to the premises of the CAA where they are marked. It is only after the questionnaires have been marked that a candidate would know the outcome of the examination. The marked questionnaires would be stored for a limited period of time and thereafter they would be shredded.

Regarding the licensing department, the Panel observed the following during the on-site inspection:

After successful completion of the requirements for ATP licences a pilot would make written application for the issuing of an ATP licence;

The application would be processed by the staff of the CAA, which would work through a system of a check-list;

After the application has been processed the CAA will issue a licence to a pilot in the form of a blue booklet. The blue booklet sets out the nature of the licence issued and the privileges accompanying that licence;

The CAA does not keep a duplicate or copy of the blue booklet. It merely keeps a computer record of the details of a licence issued to a pilot.

Although the CAA staff, whose duty it is to issue licences, are required to work through a system of "check-list" in processing licences, there are no set manuals of procedures guiding their functions.

After the on-site inspection the Panel obtained documents relating to -

the pilots who have been implicated by the allegations relating to the ATP examination fraud or irregularity;

the organizational structure of the CAA, more particularly the examination and licence department;

the operating instructions, AICs and check-lists relating to the implementation of the examination system and the issuing of the ATP licences;

the affidavit made by Maloma, written statements made by CAA employees, Brandon Harris and Nancy Mashamaite. The Panel also received the CAA internal reports of investigations made by its employees, relating to Maloma's allegations.

Four lever-arch files were prepared for the Panel in this regard.

After the review of the documents the Panel conducted public hearings on the matters investigated by it. During the hearings the Panel received oral and documentary evidence from -

employees of the CAA;

four pilots who have been implicated by the allegations of the ATP examination fraud and irregularities;

senior executives of South African Airways;

a senior executive of SA Airlink;

a pilot who has been designated as a CAA examiner;

a freelance journalist writing for SA Flyer magazine

an aviation consultant and his attorney. A list of the witnesses heard by the Panel is Appendix "A".

Before the hearings commenced, the Panel issued advanced notification of the hearings to the public, interested parties and pilots implicated by the allegations. In this regard, the Panel issued -

a public notice, which was published in the various newspapers of the date, time, place and purpose of the hearing. Members of the public were invited to assist the Panel by furnishing relevant information;

direct notices to the various persons who made or supported the allegations of fraud or irregularities relating to the ATP examination. Notices were given to Louis Maloma, Brandon Harris, Wollie de Kock, Murad Ismail and Jan van Wyk.

Written notices to the pilots implicated by the allegations. These were ID Nombo; N Kotu-Rammopo; SR Moje; SC Sali; TN McClain and JC de Omar Tayob. Another pilot, JD Heyns, who was also implicated, passed away in December 1999, before Maloma made allegations of fraud or irregularities.

The evidence given at the hearings was received under oath and was subject to cross-examination. That evidence was also received during open hearings. Save for two instances relating to portion of the evidence of Ismail and Abrahams, the Panel had no occasion to hold a confidential hearing.
The Panel also made written inquiries to Rennie van Zyl and the Federal Aviation Authority in the USA, regarding the licence status of Abrahams.

D: PROBLEMS ENCOUNTERED

During the course of its investigation the Panel encountered the following problems:

Members of the South African Police Services arrested key witnesses at a time when the Panel was conducting its public hearings. Some of these witnesses recanted on their earlier undertaking to testify before the Panel, because they had, upon their arrest, either become State witnesses or had become accused against whom criminal charges had been brought.

The following witnesses refused to testify before the Panel:

Louis Maloma. After his arrest, two members of the Panel visited Maloma in prison. He undertook, during the visit, that he would testify once he is released on bail. Through the efforts of the Panel's representatives, his bail was reduced from R15 000 to R5 000, and he was released on bail on 21 July 2000. Despite his release from jail Maloma refused to testify before the Panel.

Brandon Harris also refused to testify, despite a written notice to appear before the Panel. He did so on the ground that he had become a State's witness against the implicated pilots.

Nancy Mashamaite: Despite being represented by an attorney, and having cross-examined one of the witnesses who testified, failed to appear before the Panel to give her evidence.

Murad Ismail: He testified before the Panel, and was warned, at the conclusion of his evidence, that he would be recalled so as to be cross-examined by those against whom he made certain allegations. When he was recalled for the purpose of cross-examination he refused to attend on the ground that he had now become a State witness.

Manie Esterhuizen, who is the father of an aircraft mechanic who died in the air crash which occurred in Mozambique on 2 April 2000. He also gave an undertaking to appear before the Panel in order to give his testimony. However, he subsequently refused to appear on the ground that he had been threatened with death should he give testimony.

Cynthia Mhlongo, who is employed by the Department of Transport. Despite her earlier undertaking to appear before the Panel, she failed to appear on the date scheduled for her evidence.

A further problem experienced by the Panel is that some of the documents which became relevant during the course of the hearings and which had been in the possession of the CAA, were confiscated by the police. These documents were mainly from the files of the pilots who had been implicated. The Panel was unable to obtain these documents after confiscation.
A disconcerting feature of police confiscation is that the on-line examination system was also confiscated by the police. The integrity of the examination system has been affected, or will be potentially affected by this confiscation.
Despite these problems the Panel was able to obtain sufficient information from its investigation in order to discharge its mandate.

CHAPTER 2

D: ALLEGATIONS OF FRAUD RELATING TO ATP EXAMINATION

The primary author of the allegations of fraud or irregularities relating to the ATP examination is Maloma. The uncontested evidence which emerged during the hearing shows that on 4 March 2000 Maloma made telephonic contact with Ismail, Van Wyk and Captain Brett Gebers of South African Airways. He informed them that certain of the implicated pilots obtained, through illicit means, ATP examination question papers in advance of undertaking those examinations. Maloma mentioned specific names of the affected pilots.
On 6 March 2000 Captain Gebers addressed, on behalf of South African Airways, a letter to the CEO of the CAA, in which he recorded the allegations made by Maloma. He also specified the names of the pilots employed by South African Airways who were implicated in the alleged fraud or irregularities. These were McClain, Sali and Nombo. He requested the CAA to undertake an urgent investigation of these allegations and advise South African Airways of the outcome.
On the morning of 6 March 2000, Van Wyk reported Maloma's allegations to the Project Manager, Louise Viljoen and the General Manager: Air Safety Infrastructure, Ken Van Niekerk. Thereafter, Van Wyk extracted a computer print-out of the ATP examination results of the affected pilots. His analysis of those results led him to conclude that the allegations made by Maloma were correct.
The letter of Captain Gebers was received by Ms Vicky Buxton, the General Manager: Operations, who is responsible for, amongst other things, the Licensing and Examination Department. She attended a meeting with Captain Gebers on 8 March 2000, where she was briefed more fully about the latter's conversation with Maloma.
On her return to the office, Buxton set about investigating Maloma's allegations. She discussed these allegations with Viljoen, who, by then, had already been told about these allegations by Van Wyk two days earlier. At that time Van Wyk and Ismail were out of office, performing calibration duties.
On 10 March 2000 Buxton called Van Wyk and Ismail to a meeting in her office. At this meeting Van Wyk and Ismail disclosed, for the first time, to Buxton the telephonic conversation which they had had with Maloma on 4 March 2000. It is regrettable that Van Wyk and Ismail did not disclose Maloma's allegations to Buxton immediately, despite the fact that these allegations were not only serious but also affected her portfolio. During their testimony Van Wyk and Ismail admitted that they did not disclose the allegations to Buxton until she called them to her office on 10 March 2000. Their explanation for this serious omission is they did not trust Buxton, by virtue of her supposed close association with the CEO. They explained further that they wanted to obtain an "independent" investigation of these allegations. Van Wyk's and Ismail's attitude reflects a serious cultural problem within the CAA. The Panel deals with this aspect more fully below.
At the meeting of 10 March 2000 Buxton requested both Ismail and Van Wyk to contact Maloma so that she could hold an interview with him. Their attempts to get hold of Maloma were not successful. According to Ismail, Brandon Harris called him to a meeting on 21 March 2000 at Eastgate Shopping Centre. There, Harris disclosed to Ismail that he illicitly gave certain ATP examination papers to Maloma so that he could write and pass those examinations. He also told Ismail that he did not ask for or receive money from Maloma for those papers.
Ismail also said that Brandon indicated that he obtained unauthorised access to the computer system, through using a password of his colleague, Jenny Lightfoot. He then extracted ATP question papers from the computer and gave them to Maloma.
On 23 March 2000 Maloma made telephonic contact with Ismail. They arranged to meet on 24 March 2000 so that Maloma could confirm his allegations by making a sworn statement. Indeed, on 24 March 2000 Ismail and Van Wyk met Maloma at the Protea Hotel in Midrand. Once again Van Wyk and Ismail did not inform their superiors, at least Buxton, about the fact that they had arranged to meet with Maloma in order to obtain a sworn statement from him. They proceeded on their own, without the knowledge or authority of their superiors, to hold an interview with Maloma and to secure a statement from him.
At the meeting Maloma's allegations were reduced to writing. Van Wyk had with him the various examination statistics of the implicated pilots. He tested Maloma's allegations against those examination statistical records in order to reassure himself that Maloma's allegations were correct. Thereafter, Ismail and Van Wyk caused Maloma's statement to be typed at the hotel. They took Maloma to the Midrand Police Station, where he signed the statement and attested to it as a sworn affidavit. Three original copies were made and each of them took a copy for himself. A copy of the affidavit is Appendix "B" of this report. The contents of this affidavit will be dealt with later in this report.
On 29 March 2000 Harris made a written statement in which he stated that he was approached by Maloma to help Nombo by giving him ATP examination papers so as to enable him to pass the ATP examination. He agreed to help Nombo. He went on to state that he gave Nombo Series No 7 of the examination papers and in return he was given R7 000 therefor.
Furthermore, in his written statement Harris also indicated that after he had helped Nombo, Maloma also approached him for the same kind of help. He then gave Maloma Series No 7 of the ATP examinations. He was unable to recall whether or not he gave Maloma series No 3 and 5, or answers to series 3, as is claimed by Maloma in his sworn statement. Harris' written statement is Appendix "C" of the report.
On 30 March 2000, Nancy Mashamaite also made a written statement in which she denied ever having participated in the alleged examination irregularities. Her written statement is Appendix "D" of this report.
On 27 March 2000 the CEO convened a meeting to discuss Maloma's allegations. Both Van Wyk and Ismail attended the meeting and were requested to provide a written account of their knowledge of the allegations, and their investigations of those allegations. In his written report, dated 17 April 2000, Van Wyk confirmed that his analysis of the results of the implicated pilots confirmed the correctness of Maloma's allegations. He also noted that he requested De Kock to undertake an "independent research" into Maloma's allegations, because of the impression gained by him that the CEO wanted to do his own investigation entirely by himself.
De Kock undertook his independent research at the request of Van Wyk. He compiled a report, with the help of Van Wyk, and thereafter addressed it to the CEO, on 17 April 2000. It also emerged during the evidence that Van Wyk assisted De Kock in the compilation of his report.
In his evidence De Kock admitted that his report was no more than "second opinion" of the conclusions already reached by Van Wyk. Like Van Wyk, he tested the correctness or otherwise of the allegations contained in Maloma's affidavit by reference to the examination statistical records of the implicated pilots.
De Kock also admitted that his report goes much wider and further than the allegations made by Maloma. He admitted that -

although his report specifically records that 29 ATP examination papers were compromised, Maloma's affidavit does not mention the specific quantity of the compromised examination papers. His conclusion that 29 examination papers were illicitly obtained was no more than an assumption not based on fact;

his conclusion that the compromised papers included Series 3 was not consistent with Maloma's affidavit. That affidavit simply recorded that what was compromised in relation to Series 3 was not the questionnaires but only answers to those questionnaires;

furthermore, his conclusion that Series 4 was also compromised was not specifically mentioned by Maloma in his affidavit. That was no more than an assumption or an inference made by De Kock, simply because Nombo wrote Series 4;

his conclusion that Series 2 was also compromised was not specifically mentioned by Maloma. It was, once again, an inference made by De Kock from the fact that McClain wrote Series 2;

his conclusion that apart from the eight ATP candidates, there were two AMEs who also illicitly obtained their examination papers, was also not mentioned by Maloma. He said that he obtained information regarding the AMEs from Van Wyk. De Kock's report is Appendix "E".

The CEO appointed the legal manager of the CAA to undertake an investigation into Maloma's allegations. A meeting was held with Maloma on 4 April 2000 at the Protea Hotel in Midrand. Certain inconsistencies were noted between Maloma's sworn statement and what he disclosed during the meeting. The legal manager compiled his report, in which he recorded his findings and recommendations. A copy of this report is Appendix "F" hereto.
Despite the fact that neither Maloma nor Harris testified, and that their evidence was not tested by way of cross-examination, the Panel was able to test the allegations made by them in their written statement by reference to the totality of documentary and oral evidence received by it. The Panel has come to the conclusion that the material allegations made by Maloma cannot be substantiated. To that extent, the Panel disagrees with the conclusions reached by Van Wyk and De Kock that those allegations are correct. For the reasons set out below the Panel is unable to accept Maloma's allegations.

ALLEGATIONS AGAINST NOMBO

Maloma stated that the implicated pilots obtained unauthorised access to the compromised ATP examination papers after he resigned from the Department of Transport in 1998. He is contradicted by Harris, who states that he was approached by Maloma and Nombo during 1996 when Maloma was still employed by the Department of Transport. Nombo sat for his ATP examination from 1 to 11 September 1997. On the records made available to the Panel, Maloma resigned from the Department on 29 May 1997. He resigned therefrom before Nombo wrote his ATP examination.
The Panel cannot accept Maloma's allegations relating to the date when the implicated pilots allegedly obtained examination papers.
The Panel is also unable to accept Harris' allegation that Maloma and Nombo approached him during the course of 1996 in order to illicitly obtain examination papers. As pointed out above, Nombo undertook his ATP examinations during the first two weeks of September 1997. These dates are corroborated by a variety of uncontested documentary evidence, including the examination entry forms completed by Nombo and approved by the CAA, and the computer statistical record of Nombo's examination results. Moreover, Harris' allegations are inconsistent with Maloma's allegations. The Panel therefore concludes that Maloma and Harris contradict each other as to when Nombo allegedly approached Harris. Their respective versions are unreliable as to be rejected as unsubstantiated.
Maloma stated that Harris handed examination papers to Nombo at a meeting at which he was present. Although he indicated that he "identified" the set of papers supposedly given by Harris to Nombo, he did not specifically mention the series of papers in question. However, Harris in his written statement identified those papers as Series 7. The analysis of Nombo's examination statistical records show that -

he did not write Series 7 in his ATP examination;

he wrote Series 4, which was neither mentioned nor identified by Maloma or Harris;

he wrote all seven subjects from 1 to 4 September 1997 and passed six of them with exceptionally high marks. He failed Subject 5, which he repeated on 11 September 1997 and passed it with exceptionally good results. Thus, in his first attempt, Nombo did not write any of the alleged compromised papers mentioned by Maloma in his affidavit;

Nombo repeated Subject 5 within a period of a week after his first attempt. This is consistent with the procedures adopted by the CAA because he had carried sufficient credits so as to enable him to repeat within a period of one week.

When he repeated Subject No 5, he wrote a different series. As we have noted above, what was allegedly compromised in relation to Series 3 was answers to questionnaires rather than the questionnaires themselves. The fact that Nombo wrote a different series is consistent with a random selection of the question papers or questionnaires. There can hardly be a suggestion of "forcing" the computer system so as to enable him to repeat the same series.

In light of the uncontested documentary evidence, the Panel is unable to accept Harris' allegations that he gave Nombo question papers. Those allegations are not only contradicted by documentary evidence, but are inconsistent with the reality of the situation.
Van Wyk and De Kock sought to give credence to Maloma's and Harris' allegations of Nombo's involvement in examination irregularities by relying on the sole fact that Nombo passed the ATP examination with "exceptionally high" results. Van Wyk's conclusion is hopelessly superficial and certainly unfair against the affected pilot. There was no attempt to investigate Nombo's background to determine his historical performance before he wrote his ATP examinations.
In any event, the evidence of Nombo indicates that he had historically performed well since he started his career in aviation. His results obtained during his studies in Finland's Aviation College where he wrote his Finnish ATP examinations are also exceptionally high and are consistent with those he obtained when he undertook his ATP examinations with the CAA. Furthermore, Nombo was required to write the theoretical examination relating to special navigation procedures when he validated his foreign licence. He passed that examination with 75%.
Nombo's uncontested evidence indicated that at the time when he wrote his ATP examination, he had accumulated approximately 12 000 hours of flying time without any incident or blemishes on his record. He flew as a pilot-in-command for various regional airlines. He also joined South African Express Airlines and with time was promoted to the status of a captain. Thereafter, he resigned from South African Express Airlines and joined SAA, where he successfully completed his conversion and flight test and has since been an in-flight relief pilot on Boeing 747-400 aircraft on long range routes.
The Panel is satisfied that Nombo's ATP results are consistent with his historical performance, and that those results do not suggest anything irregular or fraudulent on his part.

ALLEGATIONS AGAINST SALI

In his affidavit Maloma alleges that after he had surreptitiously passed his ATP examinations, Harris asked him to pass on the alleged compromised ATP examination papers to Sali. Sali then collected the papers from Maloma's house, thereafter telephonically requesting Mashamaite to load Series 7 for him during his ATP examinations.
According to Maloma Sali wrote Series 7, which he failed, because he did not have sufficient time to study for those papers. Sali then failed his subsequent attempts. He then finally returned to Maloma to obtain examination papers for Series 3 and 7. Maloma goes on to state that Sali informed him that Mashamaite would load, once again, Series 3 and 7 for him.
Maloma's allegations are vague as to the time or period when Sali and Mashamaite would have collaborated in the alleged examination irregularities. In his written statement Harris denies that he requested Maloma to hand over the alleged compromised ATP examination papers to Sali. Harris states that Maloma sent Sali to him so that he could help him in the same way he supposedly helped Nombo, but he refused to do so. Once again, the versions of Maloma and Harris are contradictory in material respects.
The computer transcript of Sali's examination history shows that he has written and repeated ATP examinations on no less than ten occasions. He attempted these examinations for a period of approximately one year, starting from 20 April 1998 to 26 March 1999. Until his last attempt, Sali's performance has not been impressive. He had not carried over any credits for the ATP subjects he had written, for a period of approximately eleven months. On his final attempt, commencing from 23 to 26 March 1999, he passed his examination with exceptionally good results. His explanation for this exceptional performance was that when he wrote the ATP examinations previously he did not have sufficient time to study because of his flying commitments. On his final attempt he rescheduled his flying commitments so that he could have - and did in fact have - six days to study before the examinations. He also explained that by 23 March 1999 he had accumulated sufficient data of ATP examination questions from his previous attempts.
Although in his previous attempts there were odd occasions on which Sali obtained isolated exceptionally high results, his last performance stood in stark contrast to the previous results he obtained. However, the reasons given by him for the exceptional performance are not unreasonable. The reasons are consistent with the record of his ATP examinations:

First, Sali had written every series of the ATP examination by the time he undertook his last attempt. Thus, he had already written from Series 1 to Series 10 of the ATP subjects. Paradoxically, on his first attempt Sali wrote four subjects of Series 3, all of which he failed. Yet, on his last attempt he wrote seven subjects of Series 3, which he passed exceptionally well. It was therefore not his first attempt to write Series 3.

Secondly, Sali wrote his penultimate ATP paper on 17 March 1999. He commenced his last attempt on 23 March 1999. The interim period is six days, and would be consistent with his explanation that he had six days to study for the examinations on his final attempt.

A worrying feature of Sali's examination history is that he wrote his last attempt barely six days after he had previously failed the ATP examinations. This was contrary to the thirty-day rule set out in the AIC for ATP examinations. When he wrote his last attempt he did not carry any credits and could therefore not have appropriately sat for the examinations within a period of six days.
Sali was unable to explain why he sat for the ATP examinations within a period of six days, from his last attempt. During the first four attempts, Sali was permitted to repeat his ATP examinations without waiting for a period of thirty days as required by the AIC. In fact, when he repeated his examination his waiting period was no more than eleven days on the second occasion and ten days on the third and fourth occasions. He indicated that the thirty-day rule was not brought to his attention and that he was not prevented from writing when he repeated within the above periods. The Panel has come to the conclusion that although Sali's above examinations were undertaken contrary to the thirty-day period, inconsistent with the AIC waiting period, that fact cannot be entirely blamed on him, but largely on the staff of the CAA which did not apply this rule in his case.
According to Maloma, Brandon gave him answers to questions of Series 3 of all seven ATP subjects. On Maloma's version Sali did not have the question papers but answers to Series 3. If Maloma's version is correct, Sali would have entered the ATP examination room with the answers to Series 3. Various witnesses heard by the Panel indicated that it is an almost impossible feat to memorise all the answers of the seven subjects of the ATP examinations. It is a multiple choice examination comprising approximately twenty-five questions per subject. Sali would therefore have had to memorise all the answers to approximately 25 questions of each subject. Alternatively, he would have had to write these answers on a piece of paper, which he would have had to carry into the examination room surreptitiously. The Panel is unable to establish or confirm either of those possibilities as probable. There is no evidence that Sali went into the examination room with a piece of paper on which he had scribbled the answers. It is also highly improbable that he would have memorised all the answers of the seven subjects of the ATP papers prior to writing those papers.
The Panel therefore, on the evidence available, comes to the conclusion that Maloma's allegations against Sali cannot be substantiated.

ALLEGATIONS AGAINST KOTU-RAMMOPO

Maloma also accused Kotu-Rammopo of having had prior access to Papers 3 and 7 before his examinations. He states that Rammopo arranged with Mashamaite to have Papers 3 and 7 loaded into the computer for him when he undertook the examination.
On Maloma's version, Kotu-Rammopo would have had access to and studied for Papers 3 and 7 before he wrote the examination. Yet, Kotu-Rammopo wrote Series 4 on his first attempt. He passed two subjects with exceptionally good results, and failed three others. On his second attempt he wrote Series 10. Again, he passed two subjects, failed four and was absent for one subject. On his last attempt he wrote five subjects of Series 3 and two subjects of Series 5.
Kotu-Rammopo's statistical record does not accord with Maloma's evidence that he had access to, and did in fact, write Series 7. He wrote Series 5, and not 7.
Furthermore, the criticisms which the Panel has levelled against Maloma in respect of Series 3 (relating to Sali) apply with equal force in respect of Kotu-Rammopo: there were no questionnaires or question papers of Series 3 which were compromised; Only answers to Series 3 were allegedly compromised; Kotu-Rammopo would have had to commit to memory the answers to Series 3, in all five subjects he wrote, which we have stated was an almost impossible feat; or he would have had to sneak into the examination room with a paper on which he scribbled those answers. There was no evidence that he did so.
The Panel has come to the conclusion that Maloma's allegations against Kotu-Rammopo cannot be substantiated.

ALLEGATIONS AGAINST McCLAIN

McClain has been accused of having received compromised ATP examination papers from Sali and thereafter proceeding to write those papers with the assistance of Mashamaite. According to Maloma, McClain paid an amount of R8 000 to Sali for receiving the alleged compromised papers.
McClain's statistical records indicate that he wrote five subjects of Series 7 from 4 to 7 May 1999. He passed two, failed two and was absent for one subject. His performance is not consistent with a candidate who would have had prior access to the alleged compromised papers?
On the subsequent occasion, McClain wrote seven subjects of Series 3. He passed six and failed one subject. His performance was exceptionally good. He failed subject 3 with 66%. A week later he repeated that subject, but wrote Series 2 and achieved 80%.
It is correct that Sali wrote Series 3 approximately three months before McClain wrote the same series of the ATP examinations. But according to Maloma the arrangement, if one was ever made, between McClain and Mashamaite was that the latter would load Series 7 for McClain. Maloma did, on his version, confirm with Mashamaite that she had loaded Series 7 for McClain. On Maloma's version, McClain would therefore have had to prepare himself for Series 7 and would have written that series, as arranged with Mashamaite.
As pointed out above, McClain's statistical records do not accord with Maloma's version. The compromised examination of which he has been accused of relates to Series 7 and not Series 3. Again, question papers or questionnaires of Series 3 were not compromised. What was compromised was the answers to those question papers or questionnaires.
Furthermore, McClain has been accused of having had prior access to the subject which he repeated. Maloma states that McClain obtained the assistance of de Omar Tayob in order to gain prior access of that series. The plan was, according to Maloma, that Tayob would enter the examination room, through some form of a pretext of writing the Radio Aids, copy the entire paper and furnish it to McClain, who then studied for that paper and proceeded to repeat it. Mashamaite was allegedly paid for her efforts in loading Radio Aids [Subject 3] for McClain when he repeated it.
On 30 May 2000 de Omar Tayob was interviewed by Johan De Waal and Sam Van Zyl of SAA, and was questioned about Maloma's allegations that he gave Radio Aids [Subject 3] paper to McClain. A transcribed copy of the interview indicates that de Omar Tayob denied ever attending a meeting with Maloma and McClain, where he agreed to help McClain, as alleged by Maloma. In fact, the tenor of the whole interview indicates that de Omar Tayob was not aware of the types of papers written by the implicated pilots, including McClain. All he said about the examination irregularities was that Maloma told him that he sold various papers to the implicated pilots.
At the end of the transcribed interview with de Omar Tayob, mention is made of the fact that de Omar Tayob requested that the tape-recorder be switched off. Thereafter, he admitted to knowing and participating in the examination irregularities. He supposedly admitted that he did copy a paper for McClain and he was given money in return for what he has done. It seems that de Omar Tayob was prepared to admit that he assisted McClain in obtaining examination papers but was not prepared to do so on record.
It is clear that de Omar Tayob has made two different versions to both De Waal and Van Zyl during the course of the interview. He was not prepared to admit, on record, that he knew about and participated in the examination irregularities. Yet, he was prepared to admit, off the record, that he knew and participated in the examination irregularities. The Panel is not prepared to rely on the information made available to De Waal and Van Wyk by de Omar Tayob because of the conflicting nature of that information. Moreover, de Omar Tayob appears to have had an ill-motive when he held an interview with De Waal and Van Zyl. He always put, as a precondition, a demand that he should be employed by SAA before he disclosed his knowledge about and/or participation in the examination irregularities.
A comparison of McClain and de Omar Tayob's examination records indicate that McClain wrote Subject 3 (Series 3) on 3 June 1999 and failed it with 56%. He repeated Subject 3 (Series 2) on 26 July 1999 and passed it with 80%. de Omar Tayob wrote Subject 3 (Series 2) for the first time on 14 July 1999. He failed it with 25%. de Omar Tayob would therefore have written the latter subject before McClain repeated it on 26 July 1999.
The mere fact that McClain repeated Subject 3 (Series 2) when de Omar Tayob had already written and failed the same subject does not lead to the conclusion that McClain must have obtained the paper in question from de Omar Tayob before writing it. To arrive at such conclusion, one would have to accept that de Omar Tayob copied the paper with the assistance of Mashamaite, as alleged by Maloma.
We have already referred to the interview which de Omar Tayob had with SAA officials in which he denied any involvement. Moreover, McClain's repetition of Subject 3 was consistent with a possibility of the random selection of the series by the computer programme. His initial marks on the particular subject were not entirely hopeless. His marks on repeating the subject are consistent with earlier marks he obtained on the other six subjects which he passed. Those marks are also consistent with his previous performance on 5 May 1999, when he wrote the same subject, but Series 3, which he passed with 70%.
There are other discrepancies of Maloma's allegations relating to McClain's alleged participation in the examination irregularities. For examples, McClain is alleged to have had three outstanding subjects (including Radio Aids) when he repeated his ATP examination. The Panel has already pointed out that at no point in the course of his examination history did McClain have three outstanding subjects. At best for Maloma, McClain had one outstanding subject, namely Subject 3, which he repeated on 26 July 1999.
Having regard to the inconsistencies in Maloma's affidavit and the inconsistencies between the allegations in that affidavit and McClain's examination statistical records, the Panel finds no support or substantiation for Maloma's allegations.

ALLEGATIONS AGAINST MOJE

Maloma also accused Moje and Heyns of making unlawful arrangements with Mashamaite to load papers for them before they wrote those papers. It has been pointed out above that Moje did not testify, despite having been given a written invitation to do so. Heyns passed away before the Panel conducted its investigations. Maloma's allegations against them are therefore assessed without the benefit of their evidence, but tested on the documentary evidence which the Panel received.
Regarding Moje, Maloma alleges that Moje assisted Sali by working out the answers to Paper 7 when the latter was about to write his ATP examinations. We have already pointed out above that the examination which Sali is accused of having passed relates to Series 3 and not Series 7. Maloma states that Moje phoned Mashamaite in his presence, requesting her to load a particular paper for him and promised to remunerate her for her efforts. Maloma has not specified the particular paper which Moje requested that it be loaded for him.
The analysis of Moje's examination statistical record indicates that he wrote four subjects, Series 2, on 16 October 1997. A year later he entered for four subjects, all of which were Series 3. He wrote 2 and failed them and was absent for the remaining two. He then wrote seven ATP subjects, six of which were Series 7 and one was Series 4. He passed all the subjects of Series 7 with good results. He dismally failed Series 4 with 21%. He repeated that subject on 3 May 1999 and wrote Series 1 thereof. He passed it with 70%. If ever there was collaboration between Moje and Sali, it would have been easier for them to write the same series of the papers, having regard to the fact that they wrote one week apart.
The fact that Moje did not perform well in his previous attempts, but performed better on his last attempt, cannot lead to a justifiable inference that he had prior access to the examination papers before he wrote on the last attempt. It is also significant to note that when he repeated Subject 7, which he previously failed dismally, he wrote Series 1 and passed with 70%. It has not been suggested by Maloma or any other person who supports his allegations, that Series 1 was one who compromised papers. Thus, Moje's good performance on repeating Subject 7 cannot be attributed to the supposed fact that he had prior access to the paper in question.
Moje's performance on his last attempt of his ATP examinations does not exclude the possibility that he would have prepared himself better on his last attempt than he did on previous attempts. There is also a possibility that he would have gained sufficient knowledge of the ATP examinations, when he previously wrote and failed. The panel cannot ignore those possibilities simply because Maloma has accused Moje having participated in the examination irregularities. Moreover, these possibilities are consistent with the fact that Maloma failed to mention, in his affidavit, the particular papers which Moje's supposedly requested Mashamaite to load for him. The Panel cannot assume that the series in question was 7 simply from the fact that Moje wrote that series and passed it well. The Panel therefore is unable to accept Maloma's allegations as being probable.

ALLEGATIONS AGAINST HEYNS

Heyns also wrote his ATP examinations from 19 to 22 April 1999. He wrote Series 7 and passed it exceptionally well. Maloma's allegations against Heyns are that he received papers from Moje and paid R7 000 therefor. Once again, Maloma does not specify the type of papers which Moje allegedly sold to Heyns.
Heyns wrote Series 7 a month after Moje wrote that series. The mere fact that both of them wrote the same series does not lead to the conclusion that they had prior access to that paper before they wrote it, or that one of them sold the paper to the other. The Panel has come to the conclusion that Maloma's allegations against Heyns are not substantiated.

ALLEGATIONS AGAINST DE OMAR TAYOB

Maloma also accused de Omar Tayob of making unlawful arrangements with Mashamaite to load papers for him. He does not mention what the nature of those arrangements were, and the type of series which de Omar Tayob requested it be loaded for him. De Omar Tayob's examination records indicate that he entered for four ATP subjects on 14 to 15 July 1999. He wrote one subject and failed dismally. He did not write the remaining three subjects.
From 17 to 20 August 1999 he wrote seven ATP subjects, all of which were Series 3. On 27 August 1999 he repeated the subject he previously failed. He wrote Series 7 and once again failed that subject. It is inconceivable that de Omar Tayob would have failed that subject of Series 7, if he had had prior access to that series. In the absence of sufficient specificity as to the nature of the arrangements which Tayob is alleged to have made with Mashamaite, and the type of subjects which Mashamaite supposedly would have loaded for de Omar Tayob, the Panel cannot make a finding that Maloma's allegations are correct. The fact that de Omar Tayob failed to testify cannot elevate Maloma's generalised accusations so as to make them acceptable. They remain vague and unsubstantiated.

CONCLUSION ON THE ALLEGATIONS BY MALOMA AND HARRIS

The Panel concludes that Maloma's allegations against the implicated pilots cannot be substantiated. They are substantially at variance with the statement made by Harris, who allegedly participated in "helping" some of the affected pilots. Both Maloma's and Harris' versions are at variance with documentary evidence, more particularly the statistical records of the pilots' examination results.
The Panel has pointed out above that Van Wyk and De Kock came to the conclusion that the affected pilots have participated in the examination irregularities, simply by virtue of the exceptionally good results obtained by them and the series of subjects written by them. Such a conclusion is superficial in the extreme, and too simplistic a view to take. It is not consistent with the history of some of the pilots who gave reasons for their exceptional performance. Those reasons are acceptable and justifiable.
The fact that Maloma failed and refused to testify, despite his previous undertaking to do so casts serious doubt on allegations made by him in his statement. Equally, Harris' refusal to testify also casts serious doubt on his allegations.
The Panel therefore concludes that Maloma's and Harris' allegations which have not yet been tested by way of oral testimony and cross-examination, but which have been tested through documentary evidence and oral evidence placed before the Panel, are not substantiated.
The Panel has noted certain coincidences in the series of papers written by the implicated pilots. Series 3 and 7 featured predominantly in the ATP examinations written by the implicated pilots.
Furthermore, some of the implicated pilots wrote their ATP examinations more or less during the same period. Some also wrote shortly after they had previously failed their ATP examinations. Some of the pilots were under pressure to obtain their ATP licences in order to maintain or enhance their seniority within the airlines of their employment. There was therefore some degree of urgency in writing and passing their ATP examinations.
Whilst these factors raised some suspicion in the mind of the Panel, they were not corroborated by credible and accepted evidence so as to alleviate such suspicion to a positive finding of fact against the affected pilots that they participated in the alleged examination irregularities.

THE REPORT OF KC MAROBELA

In light of the findings made by the Panel regarding Maloma's allegations, the Panel comments as follows to the findings made by Marobela at page 15 of his report.
In paragraph 1 of his findings Marobela has come to the conclusion that there is "prima facie" evidence of leakage of Series 7 of the ATP examination papers. He appears to have come to this conclusion based on a written statement made by Harris.
Whilst the Panel accepts that Harris admitted in his written statement to illicitly providing Series 7 to Molama and Nombo, the Panel has already indicated that that admission is inconsistent with the evidence of Nombo in relation to the series of papers he wrote in his ATP examination. Moreover, Harris has indicated that he did not give further papers to any of the implicated pilots who were allegedly sent to him by Maloma.
The Panel has therefore come to the conclusion that Harris' statement does not constitute "prima facie evidence" of a leakage of Series 7 of ATP examination question paper because Harris' statement is questionable. Even if Harris' admission can be construed as evidence, it certainly does not amount to prima facie evidence of a leakage of Series 7 in relation to Nambo. It may be prima facie evidence in relation to Maloma.
In paragraph 2 of his findings Marobela has come to the conclusion that there is "prima facie" evidence that the implicated pilots may have had access to some of the leaked question papers. The Panel does not agree with this conclusion. The evidentiary material considered by the Panel does not support such a conclusion.
In paragraph 3 of the findings, Marobela has come to the conclusion that there is no "prima facie" evidence of the implicated pilots having passed their ATP examinations through the leaked question papers. The Panel agrees with this conclusion.
In paragraph 4 of the findings, Marobela has come to the conclusion that there is "conclusive" evidence that ATP candidates were allowed to repeat question papers before completing the ten series without the aid of an employee. The precise meaning of this finding is not clear to the Panel. However, the finding seems to suggest that there was a "forcing" of the system so as to permit candidates to repeat a series of papers which they had previously failed. Apart from Maloma, the Panel did not find evidence of forcing the system in relation to the implicated pilots. The Panel therefore does not agree with the conclusion reached by Marobela.
In paragraph 5 of the findings, Marobela has come to the conclusion that there is "prima facie" evidence that Harris participated in the alleged ATP examination fraudulent practices whilst he was still employed by the DCA. Once more, the Panel has noted that Harris' written statement contains an admission that he did in fact make available Series 7 to Nombo and Maloma. Once more, the Panel has noted the unacceptability of Harris' statement regarding Nombo and its probability regarding Maloma.
Finally, it should be noted that in the recorded telephonic conversation which Maloma had with the SAA executives on 17 May 2000, Maloma indicated that he was instructed by Ismail to destroy examination papers which he obtained from Harris. It is regrettable that an employee of the CAA, who was highly involved in the investigation of the allegation made by Maloma and who came to the conclusions those allegations have some merit, would instruct their author to destroy important evidentiary material.

E: RECOMMENDATIONS ON MALOMA'S ALLEGATIONS

In light of the findings made by the Panel relating to Maloma's and Harris' allegations, the Panel makes the following recommendations:

No disciplinary or regulatory steps which would lead to the withdrawal or revocation of ATP licences or examination credits should be instituted against the affected or implicated pilots.

The CAA should immediately institute disciplinary or regulatory proceedings against Maloma so as to determine his suitability or otherwise to continue to hold CPL licence and the privileges enjoyed by him in terms of that licence.

Disciplinary proceedings should be instituted against Ismail for -

engaging in unauthorised investigations of Maloma's allegations, without the knowledge and authority of his superiors;

instructing Maloma to destroy material evidence which would otherwise substantiate his allegations.

Disciplinary steps should be taken against Harris for having, on his version, unlawfully and improperly given examination papers to Maloma.

There is no basis to recommend that disciplinary steps be taken against Mashamaite. The Panel has been informed that Mashamaite has been put on suspension. In the light of the Panel's findings, there is no basis to continue with Mashamaite's suspension. The Panel therefore recommends that the suspension be uplifted.

F: ORGANIZATIONAL ISSUES

In this section the Panel addresses the terms of reference set out in paragraph 7 of this report. In order to appreciate the Panel's findings and recommendations, it was appropriate to investigate organizational issues which affect the CAA's operations, more particularly the implementation of the examination system and the procession and issuing of licences.
Although strictly speaking the organizational issues did not fall within the Panel's terms of reference, the Panel investigated these issues so as to assess the ability of the CAA to issue licences in a way which would prevent fraud, or curb its occurrence. In regard to the organizational issues, the Panel had regard to the CAA's statement of vision, mission and values, including its strategic objectives. The mission statement describes the CAA's vision, mission and values as:-

" The CAA wishes to position itself among the leading aviation authorities worldwide both in a regulatory and supportive role to the region's aviation industry.

In line with this more outward-looking participating approach, the CAA's vision statement is:

Promoting global excellence in aviation safety through partnership.

In order to achieve this vision, the CAA's mission is to:

Work towards excellence in aviation safety through:

Partnerships with the aviation industry and/or stakeholders.

Developing and maintaining high levels of customer service.

Ensuring an aviation industry that is safe, high quality, compliant with international standards and which contributes to the economic and social growth and sustainability of Southern African region.

Developing the potential of all employees.

Within its values the CAA wishes to foster a strong organizational culture and shared values so that all its actions and that of its employees will:

Promote quality and safety.

Demonstrate integrity, honesty, non-discrimination, ethics and consistency.

Be transparent and consultative.

Focus on our customer needs and provide a high level of customer orientation.

Develop staff and create a satisfying and happy workplace.

Develop a spirit of teamwork within the CAA and with its clients.

Promote equity and opportunities for previously disadvantaged groups."

107 Desirable as they may be, the vision, mission and value statement of the CAA ought not to overlook its statutory object, set out in s 3 of the South African Civil Aviation Authority Act, No 40 of 1998. That object requires the CAA to -

" control and regulate civil aviation industry in the Republic and to oversee the functioning and development of the civil aviation industry, and, in particular, to control, regulate and promote civil aviation and security."
The Panel's investigation relating to the terms of reference set out in paragraph 7 above proceeds on the assumption that whatever mission, vision or values the CAA designs for itself, they must predominantly reflect its statutory objects. It is against the context of that overall statutory object that the Panel investigated the organizational issues in order to determine the weaknesses and/or strengths in the CAA as presently structured to fulfil this statutory objective.
The CAA, like any statutory or corporate organization, must pursue an organizational strategy which consists of the actions and business approaches which its management employs to achieve its targeted organizational performance set out in its objectives.
Furthermore, consistent with its agreed strategic policy there must be the requirement to have an effective implementation strategy with supportive policies which will ensure best practices for the continuous improvement of systems and procedures. In addition, it is important for an organization such as the CAA to have its own unique organizational culture, its own business philosophy and principles, and its own ways of approaching problems and decisions. The organization's culture is an important contributor to a successful strategy implementation.
In any organization there is a potential for unhealthy cultural characteristics which may undermine an organization's business performance. An internally politicised environment is an example of an unhealthy organizational trait which may allow managers to operate within their domain autonomously and resist the need for change. Another unhealthy cultural trait may occur when an organization is suddenly confronted with fast-changing business conditions, which results in hostility to change and to resist new ways of doing things.
In the course of its investigations, more particularly during the evidence given by the employees of the CAA, the Panel noted the following organizational and implementation problems:

Certain employees perform their functions autonomously without being accountable to their organization or line-function superiors;

There is a lack of adequate management procedures and systems which guide the organization and employees;

There is a lack of, disregard for, existing systems, procedures and internal control;

There are unclear lines of responsibility;

There is a lack of adequate security relating to the systems and procedures, more particularly to the computerised systems and procedures;

There is resistance to change, emerging mainly from employees of the former Department of Civil Aviation which have since been taken over by the CAA;

Management relationships are strained, resulting in perceptions of fear, intimidation and lack of trust;

There is a visible cultural divide between certain management officials and employees;

There is limited training of employees to perform their duties;

There is also limited team spirit to reflect a shared vision and culture;

There is an incomplete or inadequate system of record-keeping;

There is no defined and guiding discretionary application of the regulations.

All of these problems, operating either individually or collectively, provide a seed-bed of opportunity for wholesale irregularities relating to the implementation of the examination systems or the issuing of the licences, which were investigated by the Panel. The Panel has reason to believe that these problems also affect other departments of the CAA, and instances of such effects were found by the Panel in the Flight Operations Department.
In relation to each of the above identified problems, the Panel received evidence and, having assessed that evidence, it came to the following conclusions on each of the above identified problems.
Much evidence was given regarding the development of the on-line examination system. Essentially, it was developed by and around a single individual, Van Wyk. The entire examination process, including information technology, software development, curriculum development, system procedures and security were done by him, supposedly in his capacity as the curriculum developer.
By virtue of his experience and central involvement in the on-line examination system, he acquired an undesirable degree of autonomy: for example, he decides when, who and what level of access to the examination system should be given. In this regard he has authorises different levels of access to the computer systems to various employees in the examination section, including a password to his superior. This has been done without reference to the information technology manager of the CAA. In authorising levels of access Van Wyk did not issue a standard rule prohibiting the holders of the passwords from making them available to their colleagues. In fact, the evidence suggested that unauthorised access into the examination questionnaires which are alleged to have been compromised was gained by an employee of the CAA using a password of his colleague.
Furthermore, access to the computer system through a password is not recorded by the computer programme itself. There is therefore no record of whatever transaction which takes place on the computer by whomever (or history) may have accessed it through a password.
In light of the above findings, the Panel makes the following recommendations relating to the security system of the on-line examination system:

The authority to allocate a particular level of access and a password to whichever employee of the CAA authorised to operate the on-line examination system must be that of the Information Technology Manager of the CAA. It is unthinkable, in the Panel's view, that a curriculum developer would have such authority.

The entire security system of the on-line examination system ought to be reviewed by an IT company, preferably with experience in examination applications. In the review of the security system the IT company, if engaged, should also consider the following internal controls of the security system:

The long-on/log-off procedure needs to be revised so that access to or exit from the computer is recorded;

Passwords should not be interchangeable, and should be accompanied by personal identification numbers;

Although, strictly speaking, not necessary, we recommend that access into the computer room should be strictly controlled.

We have pointed out above the nature of the ATP examination papers. The Panel has been informed that the content of the examination papers has remained unchanged for a considerable period of time. This relates to a major number of the question papers. The Panel has also been told that Van Wyk, as a curriculum developer, exercised the prerogative of changing the questions, by way of adding or subtracting, or even updating them. The Panel has no evidence of guidelines, if any, which he follows when he changes the examination questions.

The Panel has also been informed that the on-line examination is, by its nature, a closed-book examination where the questionnaires are not known in advance by a candidate. It has been told that the CAA has considered the American method of examination, which allows prior access to all questions captured in a wide database, and other systems operated in countries such as Australian and British aviation systems.

It is not for the Panel to recommend a particular examination system. However, the Panel's concern is that whatever examination system is pursued by the CAA, that system must be on par with internationally accepted standards. There is a need to review the questions and questionnaires at regular intervals in order to ensure that they meet the required aviation standards. Secondly, regular reviews of the questions or questionnaires would also avoid the possibility of leaked papers being of any long term value to those who may have obtained them illicitly.

A further recommendation of the Panel is that the syllabus content should be reviewed at regular intervals, and that the content and the question should have the benefit of input from all interested stakeholders and not be left primarily to one person, ie Van Wyk. The Panel recommends that there should be established a formal curriculum or syllabus Panel comprising all stakeholders.

The Panel has received evidence on the following aspects of the examination system and makes recommendations in regard to these aspects:

EXAMINATION SECTION
Selection of examination papers

It was alleged that operators were allowed, at their own discretion, to schedule examination papers within the series from 1 to 10. It was further alleged that some operators scheduled papers at the specific request of students. It is recommended, in future, that examination papers should not be at the discretion of the operator but on a random selection basis determined by the computer software programme. The operator should be unaware, prior to the commencement of the examination, which papers are scheduled to be written.

"Forcing the System"

The Panel was informed that a procedure known as "forcing the system" was available on the computer to allow a student to rewrite a paper he had previously written and failed, when the system was designed to allow the student only to re-write a paper after he had written and completed all ten series of papers.

It was alleged that this procedure has been subject to abuse, and that candidates have been allowed to re-write the same series of subjects, prior to having written all ten series of papers.

Maloma's student information records show us that on one occasion he was allowed to re-write a subject which he had previously failed before he completed all ten series of that subject.

It is recommended that the operator does not have the authority or discretion to force the system unless authorised in writing by the IT manager on each specific occasion, and this authority should be recorded on the pilot's personal file.

As a long-term recommendation, the Panel recommends that the system of series of papers be dispensed with and that a substantial database of questions for each subject be developed, and that in future examinations the questions in a paper are drawn from this large database through a random selection of questions.

Another element of a properly-functioning system of an on-line examination is a vigorous invigilation system. The evidence shows that the process of invigilation begins with the entry of a candidate into the examination room and ought to continue for as long as the candidate is in the examination room.

The Panel has heard evidence that the invigilation system was not satisfactory. The invigilators monitor the candidates through a glass screen, and yet the candidates' desks are in a cubicle form, often preventing an invigilator from seeing precisely what a candidate is doing. Furthermore, the evidence showed that the invigilators could not say with certainty that the candidates who entered the examination room did not carry with them unauthorised material or paper. Likewise, they could not say that the candidates who had undertaken the examination would emerge therefrom with questions written on an unauthorised piece of paper.

Invigilation

Although AIC No 31.1.3 of 15 November 1999 spells out what a candidate may or may not do, it does not provide clear guidance to the invigilator as to what the invigilation procedure ought to be. We recommend that -

an invigilator must satisfy himself that a candidate does not enter the examination room with any unauthorised material or equipment. It should be the responsibility of an invigilator to implement this recommendation;

an invigilator should always be present in the examination room whilst the examination is being undertaken. This has an added advantage that his or her mere presence would assist in solving a candidate's problem there and then. The Panel believes that this rule would promote the integrity of the examination system.

Thirty-Day Rule

The Panel has already referred to the thirty-day rule in paragraphs 12.2 to 12.3 above. The Panel has also referred to the exemptions relating to that rule. However, the request for the exemption and the granting thereof were not recorded in any of the pilots' files to which the Panel had access, more particularly those pilots who had written their examinations contrary to the thirty-day rule.
The Panel recommends that whenever a request for an exemption from the thirty-day rule is made, such a request must be made by a candidate in writing, and the granting of such an exemption must also be made in writing. Both the request and the grant must be recorded in the pilot's personal file.
The Panel has noted some of the rules relating to the frequency with which the examination may be undertaken or repeated, and the process of carrying credits. These rules may constitute undue restrictions and frustrate access to the ATP examinations by the pilots who wish to obtain those qualifications. The Panel recommends a review of these rules by a qualified institution such as a university. This review would assist in determining whether or not these rules of limitation serve any relevant purpose, or enforce the attainment of the objective of the examination. The Panel recommends that the CAA should identify an academic institution which has expertise in aviation to review some of the examination rules set out in the AICs.

Out-station examination

The major portions of the Panel's recommendations made in relation to the on-line examination system apply also in relation to the off-line examination system.
However, there were certain security features of the off-line examination system which require specific mention. These are:-

The printing of question papers, dispensing of the papers to out-stations, third-party invigilation, subsequent re-packaging and return of the questions and answered papers (including rough work papers) to the CAA was not adequately accompanied by sufficient security.

In addition, the storage of the question and answer papers, after their return to the CAA offices, and prior to their shredding, lacked sufficient internal control, to avoid a possibility of abuse of irregularity. The Panel was informed that on occasions the question and answer papers were left in the storeroom for a number of months before they were shredded. Moreover, the storeroom was not sufficiently secured, and therefore opened the possibility of access to those question and answer papers.

As a long-term objective, the Panel recommends that the CAA should dispense with a bifurcated examination system, divided into an on- and off-line systems. Recent technological developments make the presentation of an on-line system throughout the country viable, affordable, and also promoting the integrity of the examination system. A single and uniform on-line examination system, would promote the security and integrity of the examination system. Should the CAA decide to present on-line examination systems at out-stations, the examination centres should be the tertiary institutions which have effective invigilation capabilities.

LICENSING SECTION

The Panel has referred to its on-site inspection of the Licensing Section. Apart from its observations recorded in paragraph 13 above, evidence was heard from the individuals who are employed in the Licensing Section. The Panel addresses the following critical issues of the Licensing Department.

The process of checklists;

Record-keeping;

The system of a checker.

Checklists

The Panel was informed that the Licensing Section processes and issues licences by utilising checklists. It is essentially a document which sets out all the requirements which must be met and which must be checked by the issuing staff before the licence is issued.
The use of a checklist is commendable. However, the CAA employees in the Licensing Section do not adhere to the proper implementation and use of the checklist. In this regard the Panel noted the following:

The checklists included in the pilots' files which the Panel reviewed were not identified as checklists relating to those pilots;

The checklists were not signed by the issuing officers so as to identify the role they played in issuing the licences;

There are instances where licences were issued without properly complying with the requirements of the checklists. For example, the instrument rating issued to Abrahams was issued without complying with the checklist.

The Panel recommends that the checklist must be adhered to at all times. It also recommends that the checklist should be improved to reflect the following:

The name of the officer processing the licence in question;

Confirmation, by way of a signature, that each and every requirement of the checklist has been complied with in relation to the processing of the licence;

Dates on which the requirements of the checklist were checked and complied with; and,

finally, an indication in the pilot's file of the name of the person who has completed the checklist in relation to the licence issued.

Computer records of the licences issued

The Panel has noted above that the CAA does not keep a duplicate copy of a blue booklet issued to the pilot setting out the type and privileges of the licence issued. In addition to this omission, the Panel discovered that the computer print-out of some of the pilots' licences was not in accordance with documentation in their personal files. It is recommended that the CAA keep hard copies of the blue booklet issued to a pilot, and such amendments as are affected from time to time.
Moreover, the computer programme permits those who have access to it to add or delete entries in the computer printout of a pilot's licence. Thus it raises security features such as those discussed under the on-line examination system. The Panel therefore recommends that the security features it recommended in relation to the on-line examination system must apply with equal force in relation to the computer records.
The Panel also received evidence indicating that there was no adequate system of record-keeping or filing which indicated, at any given time, where the pilots' files were. Of concern is that a pilot's file could be removed from the registry without any indication of who removed it. The Panel received evidence that Ismail removed Abraham's pilot file, made copies thereof and stored that file in his home without any indication that he did so. But for his admission, the CAA would not have known about this unfortunate event. It is regrettable that employees of the CAA would have unlimited access to the records of their colleagues, which may include confidential matters, and make copies thereof without being detected.
A further aspect of record-keeping which is of concern is that there were discrepancies between the statistical records of the pilots' examinations, on the one hand, and the letters written by the CAA to those pilots, informing them of the results of their examinations. In the instances where these discrepancies arose, there was no material prejudice to the pilots. However, there are conceivable cases where these discrepancies may result in dire consequences for examination candidates.

Checker

The checker plays a vital role in the process of issuing a licence, and this role cannot be under-estimated. The checker's task should extend to the contents of the licence details recorded in the computer system. By introducing this form of extended checking system, inadvertent alterations and other irregularities would be avoided when a licence is printed at any time.
In addition to the above, the Panel recommends that the type of paper on which the licence and its privileges are printed ought to be specially designed with important security features so as to avoid any alterations, unauthorised duplication or forgery.

G: EXISTING ORGANIZATION STRUCTURE

The existing organization structure of the examination and licensing sections needs to be reviewed and clarified in order to ensure a full understanding of each person's role and responsibility. The Panel heard evidence of not only a lack of clarity in the sections, but the overall matrix organization structure is not fully understood by all employees. Furthermore, the dual-reporting role envisaged by the matrix organization structure either needs to be reviewed or a training process embarked upon to clarify the reporting role and responsibilities within the management structure.
Within the examination section the roles and responsibilities require a redefinition, and in particular the role played by Van Wyk. Although Van Wyk is not the head of section, he appears to have autonomous, if not bordering on autocratic, control for the entire examination process.
In order to achieve clarity on a healthy organization structure and clarity of the roles and responsibility of employees within that structure it is recommended that the CAA consider the appointment of external management consultants to address these issues.

MANUAL OF PROCEDURES

The Panel heard testimony to the effect that there are no effective manuals of procedures in the departments although in many cases there are isolated and unco-ordinated lists of instructions, many of which appear to have been carried over from the former Department of Civil Aviation. In the absence of manuals and procedures, employees depend on "word-of-mouth" training with the consequence that not all employees interpret and process matters and procedures in the same manner. There is also strong evidence that even when systems or procedures are in place they are not always carried out correctly, but often at the instance and discretion of the employee concerned. This comment applies to all three Sections, ie Licensing, Examinations and the Flight Operations Department.
It is recommended that a manual of procedures be developed and introduced with appropriate internal control systems to ensure that deviations from normal procedures are immediately identified. The Panel is aware that progress has been made on the development of a manual of procedures, but at this stage it is incomplete and has not been approved and authorised. It is also recommended that this incomplete draft manual be referred to the external management consultant recommended above for advice.

JOB DESCRIPTIONS AND QUALIFICATIONS OF STAFF

Consistent with the organization structure, it is important that each employee's role and responsibility within that structure is clearly defined. The present position leaves room for doubt and uncertainty, particularly within the Examination Section. In addition to job descriptions, an annual performance appraisal should be introduced to measure an employee's performance against agreed objectives.
The appointment of employees to management positions within the Examination and Licensing Sections and Flight Operations Department does not necessarily reflect the experience and knowledge of all employees within those departments. It is recommended that, in addition to redefining roles and responsibilities, the appointment of appropriate employees to management positions be reviewed.
In the course of hearing evidence on the Examination and Licensing Sections, including the Flight Operations Department, it was evident that management training in these departments has not been a priority and needs senior management's consideration. Heads of sections/departments gave the impression that senior levels of management would also benefit from management training to complement their technical knowledge.

HUMAN RESOURCES / BUDGET CONSTRAINTS

It was alleged that there are human resource shortages in the Examination Section of the Flight Operations Department and budgetary constraints were suggested as the main reason for manpower shortages. Furthermore, it is understood that manpower shortages is the reason that some tasks are not undertaken as effectively as they should be. This understanding coincides with concerns expressed by the aviation industry, but budgetary constraints are a serious limiting factor in the overall activities of the CAA. This aspect should be addressed in line with paragraph 5 of the South African Civil Aviation Authority Act. Furthermore, s 14 of this Act provides for various enabling tools of funding the activities of the CAA.

MANAGEMENT / EMPLOYEE CULTURE

A disturbing allegation placed before the Panel is that there is a culture divide between senior management and other employees, which results in low team spirit and co-operation. Employees allegedly feel threatened and intimidated and fear the actions of top management. Conversely, some of those making the allegations appear to have formerly been with the Department of Civil Aviation and have shown a reluctance to change and adapt to new management styles and techniques. An "Us" and "Them" culture has been reported to the Panel, as have allegations of distrust of top management. Where the fault lies is not clear, but it is essential that a strong strategy, supportive and team-building culture be developed in order to motivate employees to achieve the CAA's strategic objectives.
It is paradoxical that the CAA is still trapped in this cultural divide, when it has already adopted a mission statement containing values which are intended to address this problem. The Panel recommends that the management of the CAA should adopt an effective implementation strategy to address this cultural problem. Once again, the assistance of an external management consultants will be valuable.

H: ABRAHAMS' LICENCE

We have previously recorded that this issue was part of the Panel's extended terms of reference. The board of the CAA requires the investigation of this issue as a result of an accident/incident which occurred on 18 July 1999 at Rand Airport involving Abrahams. As a result of this accident/incident the licence status of Abrahams was put to issue. The Panel's investigation on this issue was limited to the licence status of Abrahams and not the accident/incident which, as we have mentioned before, will become the subject-matter of a further investigation by the Panel in its reconstituted form.
The evidence placed before the Panel indicates that Abrahams obtained a commercial pilot's licence ("CPL") in the United States of America, issued by the Federal Aviation Authority ("FAA") on 14 August 1983. Some of the privileges conferred upon Abrahams in terms of that licence included qualifications of "airplane single and multi-engine land instrument-airplane".
Abrahams also obtained a South African private pilot's licence ("PPL"). He did so after -

he undertook and completed all the practical flight tests relating to a PPL licence;

obtaining an exemption from complying with and completing the theoretical examinations relating to the air law and procedures;

obtaining a validation by the South African Telecommunication Regulatory Authority of his general radio-telephony operator's certificate issued in the USA.

The South African PPL issued to Abrahams reflected the following privileges which he enjoyed before the controversy relating to his licence emerged:

He obtained a night rating;

He was qualified to fly twin-engined aircraft, including BE55 and PA30;

A restricted radio telephony certificate.

After he obtained his PPL, Abrahams added an instrument rating to his PPL. He did so after he completed his instrument rating practical flight test on a BE20 Super King Air aircraft. The flight tests were done by the CAA's designated examiner, AE Smit, on 24 February 1999. It is common cause that Abrahams did not write the theoretical examination relating to the instrument rating before he undertook the practical flight tests.
Claudia Lackay, who issued the instrument rating added onto Abrahams' PPL, said in her evidence that a day after she issued the instrument rating to Abrahams she discovered that a mistake was made. She indicated that the instrument rating was issued without any record of Abrahams having completed the theoretical examination relating to the instrument rating.
Lackay approached Van Zyl, who was the technical adviser to the CEO, in order to correct this mistake. Her efforts to obtain Van Zyl's assistance were fruitless. She then approached her general manager, Buxton, to correct the mistake. In the meantime Abrahams got involved in the Rand Airport accident/incident on 18 July 1999. It was after this accident/incident that Buxton instructed Lackay to remove the instrument rating from Abrahams' PPL licence.
The Panel's investigations relating to Abrahams' CPL licence issued by the FAA revealed that that licence had a material error in it. The licence indicated that Abrahams had a twin-engine rating, and yet the FAA has confirmed that he was only entitled to fly a single-engine aircraft in terms of that licence. The FAA has also confirmed that Abrahams was not entitled, in terms of his CPL licence, to fly a twin-engine aircraft. The FAA further confirmed that it discovered this error only recently, on or about 11 July 2000. They further confirmed that since then the error was brought to the attention of Abrahams and they have re-issued a "corrected certificate" on 20 July 2000, correcting the error.
The Panel is unable to make a finding on the question whether or not Abrahams knew about the error in his CPL licence when it was issued. The Panel therefore recommends that the CAA should investigate this matter, including an investigation relating to the implication, if any, of that error to the PPL issued to him in South Africa.
In regard to the South African PPL, the Panel makes the following findings in relation to Abrahams' licence:

Abrahams undertook the practical flight test with the designated examiner, Smit, before he completed the theoretical examination, as required by clause 3.12 of the Air Navigation Regulations ("the ANRs").

Lackay issued the instrument rating to Abrahams without properly following the procedures for the issue of such rating. She was aware that the checklist relating to instrument rating required her to ensure that the theoretical examination was passed by Abrahams before she issued that licence. She did not follow the checklist properly and did not therefore satisfy herself that Abrahams completed the theoretical examination.

The licence also reflected that the radio certificate issued to Abrahams was restricted, yet the validated radio certificate issued by SATRA was not restricted, but general. It is clear that the licence does not properly reflect the nature and extent of the radio telephony certificate issued to Abrahams by SATRA. It also did not correctly reflect the renewed validation number of the radio-telephony certificate.

Furthermore, a holder of a restricted telephony radio certificate would not be entitled to and cannot qualify to obtain an instrument rating. Thus, the licence reflects a contradictory entry when it records that Abrahams had a restricted radio telephone certificate and at the same time records that he had an instrument rating.

The Panel is satisfied that Abrahams was aware that he had to comply with the requirement relating to a theoretical examination, before he obtained his instrument rating. He was advised in writing on 15 December 1998 by Van Zyl of three options available to him:

The first option was to validate his FAA CPL and instrumental rating.

The second was to obtain a South African CPL with instrumental rating.

The third option was to obtain a South African PPL with instrument rating. This option required a successful completion of theoretical examination in respect of instrument rating.

The Panel is satisfied that Abrahams ought to have known that when he chose to follow the option of obtaining a South African PPL with instrument rating he would have been required to pass the theoretical examination relating to instrument rating. He did not write that examination. The instrument rating added to his PPL licence was therefore irregular and invalid. The staff of the CAA acted correctly in removing or deleting instrument rating from Abrahams' PPL licence. Once this irregularity was brought to Abrahams' attention he agreed that the instrument rating be removed or deleted from his licence.
In the light of the above findings the Panel recommends that Abrahams be at least reprimanded by the Board. The Panel recognises that the Board may wish its discretion to institute a disciplinary hearing against him.

I: LICENCE ISSUED TO PILOT INVOLVED IN FATAL ACCIDENT IN MOZAMBIQUE

In terms of the extended terms of reference dated 23 May 2000, the Panel is required to review CAA procedures for issuing licences to assess the threat of fraud in the light of the discovery of fraudulent pilot licence documents of a pilot who died in a plane-crash in Moçambique on 2 April 2000. The Panel was also requested to make recommendations to the authority with regard to curbing recurrence and detecting any fraudulent licences that may be in circulation or use.
The pilot who died in the Moçambique accident was CN Delacovia, who undertook the following flights:

Delacovia undertook a commercial flight between Klerksdorp, Nelspruit, Maputo and Inhambahe on 24 March 2000. The aircraft carried six passengers and the aircraft registration was ZS-NGV. The aircraft was leased by Flightline Charter Services CC from the owner of the aircraft, Wainwright CC. The charter operator for the flight was Flightline and the charter party appears to be Moab Khotsong Mine.

The aircraft had a landing gear defect which resulted in it being repaired in Inhambane. The pilot and the mechanic took off on the return flight to fly the aircraft back from Inhambane to South Africa via Maputo. It was reported that the aircraft impacted with high tension wires after take-off. The occupants of the aircraft were killed on impact. The question that has to be addressed is whether or not the pilot had a valid licence with appropriate ratings for the series of flights.

In its initial aircraft accident report, the CAA came to the conclusion that the pilot was validly licensed and rated for the flight. The Panel has come to the conclusion that the entire flight was a commercially planned flight with commercial passengers on board the aircraft between South Africa and Moçambique. In order to undertake this flight Delacovia would have required a commercial pilot's licence.
The return flight was conducted as a ferry flight and had only a mechanic on board, and therefore could have been flown by a pilot with a private pilot's licence and did not have the requirement for a commercial pilot's licence.
According to Delacovia's pilot's file at the Civil Aviation Authority Delacovia held a valid PPL, including night rating. Delacovia's conversion onto the Chieftain PA31-350, although not reflected in the CAA pilot's licence file, is recorded in his logbook and is regarded as satisfactory by the Panel.
After the aircraft accident on 2 April 2000, two pilot's licences were found in Delacovia's pilot's bag. The Moçambique authorities took possession of these documents, and submitted faxed copies to the CAA. In addition, the pilot's logbook was obtained from his family, and in the back of the logbook was a copy of the pilot's licence printout that is usually handed to a pilot after he renewed his licence. On this copy the information reflected Delacovia as a holder of CPL and instrument rating issued by the CAA. The information in this licence print-out is not consistent with Delacovia's pilot's records held by the CAA. The Panel concludes that Delacovia did not hold a valid CPL with instrument rating.
The tragedy of the accident involving the loss of life of Delacovia and Mr Esterhuizen re-inforces -

the recommendation that the CAA keep a hard copy of the blue booklet which is issued to a pilot;

the recommendation that pilot licences should be issued on security paper which will not render the licence easily changed or forged by the pilot or third parties.

The Panel also accepts that it is the responsibility of the airline or charter operator, when retaining the services of a pilot either on a permanent basis or on an ad hoc basis to ensure that he is properly licensed to undertake the particular responsibility. To give effect to this responsibility the Panel recommends that the CAA should be prescriptive in terms of the regulations that when a pilot is employed a formal check be undertaken by the operator to ensure that what is recorded on the pilot's licence is in accordance with what is recorded at the CAA in terms of their own pilot's records.

J: OTHER MATTERS

The Panel has investigated further issues which were not, strictly speaking, within its terms of reference. These matters emerged in the course of its investigations and oral evidence. The Panel feels obliged to report on these issues in order to assist the CAA in avoiding fraudulent practices in the conduct of the examinations or the issuing of licences. The following matters were investigated and the Panel reports thereon.

FLIGHT OPERATIONS DEPARTMENT

The evidence shows that this department is in charge of accrediting flying training schools and performs audits of charter and scheduled airline operators. It emerged that this department is under-staffed and does not have a sufficient number of inspectors to undertake regular in-depth audits as is required.
The Panel believes that the proper functioning of this department would not only prevent, but would also detect, possible fraud and irregularities. It therefore recommends that the requirements of this department ought to be addressed as urgently as possible.
The Panel has come to the conclusion that the shortage of inspectors impacts on the ability of the Operations Department to conduct effective safety oversight and other functions performed by it. The Panel recommends that the CAA liaise with and obtain assistance from other stakeholders in the industry in order to enable it to properly and effectively discharge its duties.

D E PANEL

The Panel received conflicting evidence as to whether or not a DE panel which is functioning at the CAA is an officially recognized structure of the CAA. There was evidence to indicate that the DE panel was not officially recognised by the CAA. It is important that this matter be addressed so that any doubts in this regard are resolved.
Furthermore, there was evidence that the DEs do not follow standard procedural requirements before they undertake practical flight tests. Evidence showed that some DEs do not satisfy themselves that a candidate has completed a theoretical examination before he or she undertakes the practical flight test. Evidence also indicates that it is not a specific requirement of the regulations that a DE should satisfy himself or herself in that regard.
In order to avoid any different practices, the Panel recommends that a DE should be required to follow a system of checklists to ensure that the necessary prerequisites are met by a candidate before undertaking a practical flight test. The Panel also recommends that such a checklist be developed by the CAA in conjunction with all the designated DEs so that a standard checklist is adopted. It may also be necessary for the CAA to promulgate an AIC to give effect to this requirement.
Should the CAA accept the need for a D E panel, then its composition should be reviewed to reflect industry-wide participation by relevant stakeholders.

VALIDATION

In terms of the regulations, more particularly s 2.17 of the Air Navigation Regulations, validation of foreign licences is authorised. However, this section does not prescribe how validation has to be implemented.
The CAA, and previously the DCA, implemented the process of validation through AIC No 30.7 of 15 July 1991. That AIC sets out the policy and requirements for validation of different types of licences, including PPLs, CPLs, ATPs and instrument ratings.
The Panel received evidence that certain validations were done with a discretion of a commissioner, without strict adherence to the policy set out in the AIC. Having reviewed the provisions of clause 2.17 of the ANRs and the relevant AIC, the Panel believes that there can be no basis to undertake the process of validation without complying with the requirement of the relevant AIC. The Panel therefore recommends that whatever validation the CAA would undertake must comply with the provisions of the relevant AIC.
The Panel was also informed that a new policy relating to validation is being considered by the CAA. Until the new policy has been given legal validity, the Panel recommends that the policy and requirements in the relevant AIC must be complied with.
The Panel also recommends that the formulation of a new policy relating to validation ought to be undertaken with the participation of stakeholders in the aviation industry. It is an issue which does not simply impact on the regulatory functions of the CAA, but also affects the interests of the stakeholders in the aviation industry.

AICs AND ANRs

Regarding the AICs the Panel discovered that they are not fully descriptive of the practices and procedures adopted by the CAA in its regulatory functions. For example, the Panel discovered, in the course of evidence, the AIC relating to ATP examinations do not fully describe the nature and extent of the period within which an ATP candidate was permitted to re-write or repeat his or her examination. This practice is important and ought to have been included in the relevant AIC.
The Panel recommends that the AICs, at least those which are crucial to the regulatory functions of the CAA, should be reviewed regularly in order to ensure that they accurately and fully reflect the regulatory practices of the CAA.
Regarding the Civil Aviation Regulations ("CARs") and in particular Part 61 relating to pilot licensing, it is noted that this section has not yet come into operation; it has been reported to the Panel that this is causing confusion amongst both the CAA personnel and also the pilots from within the industry. It is recommended that Part 61 should be introduced without undue delay.

PRIVATE PILOT LICENCES EXAMINATIONS

Evidence was heard from a number of witnesses expressing concern that the CAA does not exercise any effective control over the theoretical examination of PPLs. Concern was expressed that there are over 100 flying training schools with various degrees of standards and competence. The inference is that a high standard of theoretical knowledge could be compromised due to lack of effective examination control and that this could have an impact on air safety.
The CAA Licensing Section issues PPL licences on the basis of recommendations of the flying training schools, who undertake and administer the theoretical examination in addition to the practical flight test. It is the theoretical examination that is the cause of concern and, by inference, that which is likely to be the subject of abuse or irregularity.
The CAA inspects flying training schools once per annum (however, not in all cases). This appears to be a cursory examination which in the main varies between two and five hours per school. A concern which was raised in evidence is that the CAA should introduce a system which exercises more control over the PPL syllabus and examination standards. Where the CAA exercises little or not control and relies on third parties for PPL examinations, then there is doubt regarding the standards of achievement and the quality of the licence becomes questionable.
The Panel recommends that the CAA Board review this significant policy issue to enable it to exercise more control over the theoretical PPL licence examination.

AUDIT OF PILOT LICENCES

The Panel was requested by South African Airways to recommend that all the pilots' licences issued by the CAA and the erstwhile DCA should be reviewed and audited so that doubt should not exist as to the status of such licences. This request is sensible and ought to be given effect. There is no doubt that the CAA's records regarding or relating to pilots' licence details are not always consistent with the licence document issued to pilots. The Panel has canvassed the licence documents relating to Delacovia and Abrahams which reflected inconsistencies between the records of the CAA and those given or held by them.
There is a need for the CAA to undertake this audit as a matter of urgency, and to ensure that the information is regular, proper and consistent.

CHAPTER 3

K: CONCLUSION

The Panel has made various findings of fact accompanied by certain recommendations. Whilst the Panel recognizes that the implementation of most, if not all, of the recommendations made by it will require time, effort and financial resources, the Panel believes that some of the recommendations ought to be implemented in the short term without delay. Some of these recommendations require a policy decision or decisions by the Board, preferably taken after consultation with various stakeholders in the industry. Others, particularly those recommendations of an operational nature, do not require policy decision by the Board and would be capable of immediate implementation. The Panel therefore believes that the variety of recommendations made in this report can be classified into three categories, namely immediate, short-term and long-term recommendations.

The Panel is of the view that the immediate and short-term recommendations should be put into effect, without delay. These recommendations include:

Promoting security and integrity of the on-line examination system. In this regard the Board should consider implementing those recommendations relating to access into the on-line system via pass word and personal identification number; programming the computer system to exclude overriding ("forcing") by a computer operator; invigilation during on-line examination;

Promoting and improving the security of the computer room and the store room where the off-line examination material is stored;

Issuing directives to the Section Head of the Examination Department relating to the grant or refusal of the exemption from the 30 day rule;

Issuing directives on compliance by the Licensing Section on complying with the checklist;

Taking measures to improve the system of record keeping and filing;

In the short-term the Board should consider implementing the following recommendations:

Engaging an external management consultant to assist in addressing the organisational issues and organisation structure discussed in the report;

Engaging external management consultant to assist the CAA in formulating manuals of procedures and internal rules;

Undertaking an audit of the records kept by the CAA to bring them in line with all the pilots' licenses. The Panel records that the industry is willing to assist the CAA in this process of auditing the licenses.

Finally the Panel wishes to record that the observations, findings and recommendations made by it ought not to be construed as criticism of the CAA or its employees. The Panel recognises that the CAA is newly established organisation which has been established to undertake an important and difficult regulatory task and that it has done its best in a short space of time and within the available means. The Panel's observations, findings and recommendations are intended to assist the CAA in its continuing task of being an excellent regulator in the aviation industry in South Africa.

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I V MALEKA

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Captain D LEATHERS

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JOHN MORRISON

REPORT OF THE INDEPENDENT REVIEW PANEL

Allegations of Fraudulent Air Transport Pilot Licence Examination Practices August 2000

CHAPTER 1

CHAPTER 2

CHAPTER 3

Allegations of Fraudulent Air Transport Pilot Licence Examination Practices
August 2000