Safety culture

The reporter stated that [Operator] holds a contract with TAFE [State] to undertake flight training for students wanting to obtain a Commercial Pilot's Licence under TAFE's Diploma of Aviation course. The reporter further stated that [Operator] operates a culture of bullying, intimidation, and suppression resulting in systemic unsafe practices. The reporter asserts that:

• Students are routinely yelled and sworn at, in open forums and in the cockpit, creating a situation where inexperienced pilots are in a state of heightened stress and anxiety when performing aerial manoeuvres they are unfamiliar with and during critical flight phases. Instructors are easily frustrated and aggressive when students make errors resulting in a complete lack of crew resource management on dual training flights. Students are afraid to speak up or question an instruction in the cockpit. The reporter advised that instructors have taken over the controls, without following correct handover/takeover protocols leading to confusion over when the instructor has the controls and/or exactly which controls the student is supposed to be operating. This practice has, on at least one occasion, resulted in a serious incident. The reporter further states that students have been threatened with non-employment within the industry if they question actions or instruction at [Operator] or report any concerns regarding the organisation externally.
• Mandatory reportable incidents are not reported by the operator. Students are told to learn the reporting requirements in order to pass their CASA theory exam, but that they will never need to use them again. The reporter advised being aware of at least two reportable matters, as defined in the Transport Safety Investigation Act 2003 that were not reported to the ATSB.
• Robinson R22s are routinely operated over the maximum seat and/or gross weights on dual training flights and flight tests. The reporter states that there have been several ATSB investigations that attribute overloading as contributing factors in R22 accidents. The reporter believes that this practice alone compromises the safety of the crew, without the added factors of inexperienced pilots being yelled at during critical phases of flight.

It is common practice for instructors to alter aircraft configurations such as fuel shut-off valves, prior to students entering the cockpit, to highlight the importance of pre-flight checks. However, there are no risk controls in place to ensure that these alterations are returned to their correct position prior to departure. Students, instructors, and aircraft are often changed to a different combination at the last moment. The absence of a checklist, or any other form of control, increases the risk of an incorrect setting remaining upon take-off, which could have catastrophic consequences.

ATSB Comment:  As part of the REPCON verification process, the ATSB has completed an analysis of all incidents reported to the ATSB by [Operator] in the past 10 years.