Recommendation

SUBJECT: TRAINING OF MAINTENANCE PERSONNEL





Regional Airlines Safety Study



Between October 1995 and July 1997, the Bureau of Air Safety
Investigation undertook a study of the safety of Australian
regional airlines. The objectives of this study were to:



(a) identify safety deficiencies affecting regional airline
operations in Australia; and

(b) identify means of reducing the impact on safety of these
deficiencies.



For the purpose of the survey, regional airlines were grouped
according to the number of passenger seats fitted to the largest
aircraft operated by that airline in January 1997. The groups are
defined as follows:



(a) Group 1: 1-9 seats;

(b) Group 2: 10-19 seats; and

(c) Group 3: more than 20 seats.



The study involved analysing data obtained from:



(a) responses to a survey of Australian regional airline
employees;

(b) discussions with Australian regional airline employees and
managers; and

(c) air safety occurrence reports involving regional airlines over
a 10-year period (1986-1995) from the BASI database.



This Safety Advisory Notice addresses one of the safety
deficiencies identified as a result of this study.





SAFETY DEFICIENCY



Some aircraft maintenance workers are not sufficiently prepared
for working on their current aircraft as a result of inadequate
training.





BACKGROUND



Survey results



Maintenance staff were asked if the training they received on
their most recent aircraft type adequately prepared them for
working on that aircraft. While most respondents were satisfied
with the training, 28% of maintenance personnel were dissatisfied
with the training they had received. Respondents who worked for
Group 3 airlines tended to be less satisfied with their training
than the respondents who worked for Group 1 or Group 2
airlines.



Inadequate training or lack of knowledge was nominated as a factor
in seven maintenance incidents reported to BASI in the regional
airlines safety study employee survey. A theme which emerged from
the incident reports was the incidence of mistakes being made by
new workers and the need for careful supervision and training by
more experienced workers. Inadequate technical training was also
mentioned in the free response section of the survey and was
nominated as a problem by five respondents.



Written responses included the following:



"I have had no training whatsoever in the last 5 years".

- Licensed aircraft maintenance engineer, respondent 384.



"[I witnessed the] incorrect rigging of a [propeller] primary
blade angle. [This incident was caused by the worker's]
misunderstanding of the particular type of installation and lack of
detailed training by the company on the type of aircraft
operated".

- Licensed aircraft maintenance engineer, respondent 300.



"An incorrect rig pin hole was used to rig a stabilator, causing
the pilot to have very little control on the test flight. [This
incident was caused by] lack of training and supervision by
licensed personnel".

- Maintenance supervisor, respondent 365.



An incident investigated by BASI involving a regional airline,
highlighted the lack of formal training on a particular aircraft
type for maintenance personnel. In BASI occurrence number 9403759,
a scheduled passenger service aircraft was dispatched with a rudder
flight control rod incorrectly fitted to the elevator control
system. The fault was only detected in flight when the flight crew
noticed an abnormal control column position. A duplicate
inspection, carried out by maintenance personnel prior to the
incident flight, had also failed to notice the discrepancy.





Current aviation regulations



The Civil Aviation Regulations (CAR) lay down the requirements for
training of maintenance personnel by operators. The Aviation Safety
Surveillance Program (ASSP) assesses an operator for compliance
with the regulation for the training of maintenance staff.



The operator's responsibility with respect to training of
maintenance personnel is laid down in CAR 214. This states:



"An operator shall ensure that provision is made for the proper
and periodic instruction of all maintenance personnel, particularly
in connection with the introduction into service of new equipment
or equipment with which the maintenance personnel are not familiar,
and the training programme shall be subject to the approval of
CASA".



Additionally, CAR 30 details the conditions under which a
certificate of approval is issued to allow maintenance of aircraft,
aircraft components or aircraft materials. CAR 30 (2C)
states:



"A certificate of approval is subject to:



(d) a condition that the holder of the certificate of approval
must ensure that each person employed by, or working under an
arrangement with, the holder receives adequate training in:



(i) the work performed by the person for the purposes of the
activities covered by the certificate; and



(ii) the use of any equipment used in connection with that
work".



The Airworthiness Surveillance Procedures contain a checklist -
"Training of maintenance personnel" (ASSP362) within the system
audit. Completion of the checklist allows Civil Aviation Safety
Authority staff to assess an operator for compliance with CAR
214.



Procedures and guidelines for aircraft maintenance engineer (AME)
training are contained in the Civil Aviation Orders part 100 and
Airworthiness Advisory Circulars part 9. These orders and circulars
detail the AME training required for all aircraft types operated in
Australia.





Proposed aviation regulations



CASA officers are addressing training of maintenance personnel in
their review of the aviation regulations. A survey of maintenance
personnel conducted by CASA, highlighted similar problems with
training of maintenance personnel. Rules regarding the training of
maintenance personnel are contained in the new Civil Aviation
Safety Regulations (CASR) part 145 - Approved Maintenance
Organisations. This regulation was developed in conjunction with
industry, with the latest draft regulation dated 18 February
1998.



CASR part 145.17 addresses the personnel requirements of the
holder of a maintenance organisation certificate. This regulation
clearly describes the requirement to provide approved training
programs (initial, periodic, recurrent, and specialised) to
employees. The regulation also requires maintenance organisations
to provide sufficient personnel trained in the maintenance function
or technique for which the organisation is rated.



CASR part 145.18 addresses the supervisory and maintenance
inspection personnel requirements. This regulation clearly and
prescriptively details the training required for employees to
conduct maintenance inspections, perform maintenance supervisory
roles and certify work. The regulation also specifies the
qualifications/training needed for supervisory tasks.



Discussions with CASA on this issue indicate that CASR part 66 -
Licensing - Maintenance, and CASR part 147 - Approved Maintenance
Training Organisations, complement the new part 145. These proposed
regulations (due for completion in mid-1998), are meant to provide
better standardisation of AME training.





ANALYSIS



Results from the regional airlines safety study indicate that some
maintenance workers (28%) have not been sufficiently prepared for
working on their current aicraft as a result of inadequate
training. Inadequate maintenance training is cited as responsible
for a number of incidents reported in the survey. While current
CASA regulations state the training responsibilities of operators
and certificate of approval holders and provide guidelines and
procedures for AME training, reports indicate that supervisory and
inspection maintenance functions may not be carried out adequately
at some regional airlines.



The review of the Civil Aviation Safety Regulations part 145,
clarifies the requirements of maintenance organisations with
respect to training of maintenance personnel. It also details the
supervisory and maintenance inspection training requirements. CASA
are striving towards clearer instructions and more standardised AME
training in their review of the maintenance regulations.



If the proposed regulations are implemented by industry, the
Bureau considers that this safety deficiency should be adequately
addressed.