The concern related to management directing crew not to write defects into the maintenance release to ensure aircraft are continuously available.
The reporter expressed a safety concern relating to the writing up of defects in the aircraft’s maintenance release (MR) by pilots employed by [operator].
The reporter has advised that the operator’s management have an attitude that the aircraft must be available at all times.
To ensure this occurs the pilots are instructed by management, not to write defects on the aircraft’s maintenance release as this may ground the aircraft if parts are not received within the allowed minimum equipment list (MEL) period. This has resulted in aircraft being flown with known technical faults and crews having to informally advise the crew on the next flight about the issue.
This has also resulted in aircraft (where a known engine fault had not been reported) being turned around during a flight when, during engine monitoring, the manufacturer has discovered a serious technical issue and grounded the aircraft immediately.
The reporter has advised that the aircraft are flown regularly with faults such as cockpit voice recorders (CVR)s not working and fuel tanks misreading. These issues could be checked by comparing dates on the maintenance release to the engineering email address and engineering logs.
Reporter’s comment: [Operator] has all the makings of another accident along the same lines as the Pel-Air ditching.
The operator provided a comprehensive response to this safety concern. A summary of the conclusions and safety actions is provided below:
Issue 1: Management have an attitude that aircraft must be available at all times
In 2015, a safety report titled ‘Pressure to maintain operational capability’ was logged resulting in a year-long project, overseen by the safety committee, that reviewed, assessed, and actioned improvements into addressing issues identified.
This project did identify flight crew pressures (perceived or otherwise) in an attempt to adhere to set reportable KPIs. It should be noted that these KPIs were in the domestic operational base and not the base in question and that no such contractual reportable KPIs are associated with this base operation. Although some crews do operate in both facilities.
Over the year, active improvements were made at all levels of the operation to relieve the identified pressures, until the Safety Committee was satisfied the actions were effective and closed out the safety event report in August 2016.
Issue 2: Management instruct crews not to write up defects on the aircraft MR as it may affect the MEL
Our flight ops manual clearly defines all defects, whether they are minor or major or a non-airworthiness defect, must be entered into the MR so that the engineering section are given the opportunity to investigate and address.
We do acknowledge the issues surrounding the reporting of defects has always been an area where, depending on previous employment history and type of operation, some interpretation may occur, but this is not just at [operator], but an industry wide issue. To remind/refresh crews of our view, several emails were forwarded to the pilot groups, instructing them to use the MR as well as to utilise [email address] to doubly ensure awareness of any defects.
Action taken before receipt of the REPCON report:
- Refresher emails distributed, supporting previous email notifications about [operator’s] point of view that all defects, whether they are minor or major or a non-airworthiness defect, must be entered into the MR.
Issue 3: Aircraft have been flown with known technical faults (and regularly flown with faults such as CVR’s not working and fuel tanks misreading)
We acknowledge that aircraft, on occasion, do fly with technical faults – but reviewing the records identified no aircraft flew unsafe; in that they were either grounded or adequately MEL’d, and repaired accordingly.
A specific review of CVRs not working revealed only 2 events (one in each [aircraft]) and on both occasions, they were MEL’d, with repairs undertaken within the 21 day operational restriction of the MEL.
A specific review of fuel tank gauges’ issues identified 13 events for the aircraft of the Jet Ops - all in one aircraft. Each event was reviewed and found genuine issues of which had been immediately repaired and/or adequately MEL’d with repairs undertaken within stated operational restriction.
Issue 4: Crews informally advise the following shift about known technical faults
This type of informal advice can only be given during face to face handover of shifts. Due to the nature of the work, and frequency of flights out of this base, such types of handover rarely occur. Because of this nature, the process of informing subsequent crews of issues is primarily electronic. The daily work routine outlined in the local operating procedures includes the first daily work routine (on-base) checklist items is to check the MR and emails – where such technical faults would be identified.
Issue 5: Mission turnaround when the manufacturer has discovered a serious technical issue and grounded the aircraft
This specific event was identified and subsequently did result in actioned improvements in the flight data monitoring program. At the actual time of this event we were unable to electronically interpret full authority digital engine control (FADEC) data about exceedance in temperature. A decision to continue aircraft operation was made purely on the visual cues from the cockpit (that the exceedance was well within acceptable limits). Routinely FADEC data is sent to the USA, for review of the observed exceedances, who returned a determination that there was an issue in that the duration was actually longer than visually represented in the cabin. At the time of receiving this information, the aircraft had departed for another flight – it was immediately grounded (i.e. turned around mid-mission and returned to base, as this was the closest point to ground the aircraft).
Action taken before receipt of the REPCON report:
- Ops Notice – critical to safety distributed to staff about the differences in visual and electronic cues for exceedances.
- Operator ability to immediately review FADEC data – to reviews all logged exceedances before aircraft returned to service
Future actions:
Specific staff survey
While the ‘pressure to maintain organisational capability’ project was deemed closed out by the Safety Committee in August 2016, it is recommended that the company undertake an evaluation of the outcomes of the actions implemented in the course of that project. Although the project did not identify aircraft availability, an anonymous survey could include this specific aspect, but would also benefit management into the other pressures that were identified in the ‘project’. It would be beneficial to differentiate between operational bases and airframes to see if there is disparity in any pressure identified (and if there is a genuine specific base issue over aircraft availability). The survey could also be utilised to judge the extent of the developing just culture across the organisation.
Refresher on Part [#] and defect reporting
While there have been intermittent reminders distributed about use of the MR and defect reporting, it is recommended to issue another operation’s notice critical to safety, or similar communique, to refresh staff of the requirements of Part [#] of the Flight Ops Manual. This could be followed up by an annual reminder/refresher.
CASA has reviewed the REPCON and notes that the operator has reviewed its operation and subsequently provided a comprehensive response which appears to adequately address the concerns by the reporter.