Safety culture concerns within [Operator's] Part 145 Approved Maintenance Organisation

Thank you for the opportunity to respond to the reported safety concerns made by the reporter under the REPCON voluntary reporting scheme. My team and I see this report as an opportunity to review our safety management system both holistically, and in the context of the specific allegations made by the reporter.

The reporter has referenced incidents, scenarios, and issues we as an organisation are aware of and are actively managing. The consistent theme of the allegations relates to the challenges we as an organisation, along with many other smaller general aviation operators, face due to the acute shortage of [aircraft] licenced engineers (LAMEs) in Australia. The loss of two experienced engineers who had recently completed [aircraft] type ratings at the end of last year has had a significant impact to our operations. We have recently hired two LAMES, with two bookings for [aircraft] type rating training in [Country] in the near future. The shortage of [aircraft] type rated LAMEs is exacerbated by the fact that there is no [aircraft] type rating course offered in Australia.

We as an organisation are acutely aware of the ongoing challenges faced as we mature into the CASR Part 145/42 regulatory regime. It should be noted that [Operator] applied under Part 145/42 instead of CAR 30 after advice from CASA that it would be the preferable outcome for ultimate alignment to the new CASA Flight Operations Regulations. This has led to significant challenges in relation to the regulatory key personnel required for an operator that only operates two [aircraft], with a required management structure the same as that of an airline. [Operator] continues to actively recruit and engage suitably qualified and experienced staff to fill these positions, but it is a very lean hiring market, and we are constantly challenged in this space.

Please find the reporter's allegations reproduced below, accompanied by the [Operator] response.

Inadequate staffing levels and inexperienced staff

The reporter states there is a lack of licence coverage within the organisation, with no permanent licenced aircraft maintenance engineers (LAMEs) on site.

[Operator] has licence coverage provided by two LAMEs rated on the [type] aircraft. This number is not optimal in consideration of the availability requirements of the aircraft, and we have two more LAMEs attending [aircraft] type training in [Country] in the near future. Two new LAMEs have also just been employed.

To further support the [aircraft] operation [Operator] routinely contracts the services of [aircraft] type-rated LAMEs during periods of increased planned maintenance activity, and in response to any AOG issues facing the operation. This effectively raises the establishment to six LAMEs which in consideration of the very low number of LAMEs with an [aircraft] type rating in Australia is appropriate as we progress through to further type ratings for full-time LAMEs.

When licence coverage is available, priority is given to the [type] aircraft, leaving little coverage for the remaining VH-registered aircraft.

The [Operator] Part 145 organisation supports aircraft exclusively engaged in emergency response aviation activities. Depending on the requirements of any given day, priority may pass between aircraft types. As documented above, the organisation has identified this, and two further LAMEs will be completing [aircraft] type ratings this year. This is managed daily between the CAM, RM and the engineering staff to ensure work is prioritised to support the emergency service response mission in the most effective and efficient manner possible.

The reporter further states that engineering supervisors/managers are often absent or working overseas, without replacement, for extended periods of time leaving less experienced staff without supervision. This is exacerbated by high staff turnover and little to no training provided to incoming engineering staff. LAMEs are working for extended periods of time in good faith in order to get the job done due to shortage of appropriately licenced engineers.

Due to the chronic shortage of engineering personnel in Australia, and in particular, those domiciled in the [Location] area, [Operator], along with smaller general aviation maintenance organisations continually faces the challenge to attract and retain LAMEs due to the complexity CASR part 145 and CASR Part 66 licencing requirements have brought to industry. However, as documented above, this is being managed as effectively as possible with the employment of two further LAMEs and the upcoming [aircraft] type rating training. At times the RM is absent from the hangar, and during these periods they are available to operational staff and have scheduled regular meetings to meet their obligations in relation to oversight and management of the day-to-day operation.

Lack of staff with understanding/knowledge of CASR 42 and Part 145 regulatory requirements

The reporter states that engineering is not following Continuing Airworthiness Maintenance Organisation (CAMO) instructions. This is evident by certification entries on aircraft technical logs and [program] records not in line with the Part 42 certification process. Many [program] cards reference [overseas regulator] regulations, and there is confusion among LAMEs over maintenance responsibilities for [Country]-registered aircraft.

This issue was identified and reported via the Quality/Safety Management System [number]. This was also self-reported as a non-compliance to CASA. Findings are being addressed and further staff training and a maintenance memo are in place to reduce the likelihood of re-occurrence.

The reporter states there are numerous instances of unauthorised maintenance procedures being conducted. The reporter provided one example that involved the removal of an air conditioning compressor/condenser assembly on one of the [aircraft], where it was removed from the aircraft to have work conducted by a non-approved manufacturer with no records being made. A potential weight and balance issue existed, as there was no record of the item being removed on the weight and balance equipment added/subtracted data sheet. An attempt was then made to install a new unapproved unit on the aircraft. While this incident did not result in a safety concern in this instance, the process of bypassing procedures presents a safety risk.

This issue was identified and reported via the Quality/Safety Management System. An investigation of the matter was completed which found that there was no intent to fit an unapproved part to the aircraft without following the process of an Engineering Order as required by the regulations. The part which had undergone unapproved maintenance was quarantined as appropriate and was not fitted to the aircraft.

The reporter also claims that maintenance tasks are routinely being certified without being done or not completed properly. This is evident by the aircraft being in maintenance for less time than the task(s) requires.

This allegation made by the reporter is of a serious nature, and [Operator] respectfully requests any evidence or information of a substantive nature the ATSB may have to enable appropriate review to be undertaken.

Safety culture

The reporter states pilots are reluctant to report defects as they do not want to be seen to be grounding the aircraft particularly during fire season. There is also a lack of confidence that reporting defects will lead to repair.

This allegation made by the reporter is of a serious nature, and [Operator] respectfully requests any evidence or information of a substantive nature the ATSB may have to enable appropriate further review to be undertaken.

Further to this, during the period [date] to [date] the following is evident:

• [Aircraft type & registration] flew [number] hours with [number] unscheduled defects raised and rectified.
• [Aircraft type & registration] flew [number] hours with [number] unscheduled defects raised and rectified.

This rate of defect is representative of aircraft of that generation, and we are more than capable of rectifying these as they arise.

The reporter states the current system of not addressing defects in a timely manner for [age] aircraft flying in turbulent conditions at low level for which they are not designed is a safety concern.

As with the response above, the allegation made by the reporter is of concern, and it is incumbent upon them to provide the ATSB with evidence if they have it to enable [Operator] to investigate as appropriate. The [type] aircraft is operated in the normal category and in accordance with the requirements and limitations contained within the approved Aeroplane Flight Manual.

The reporter is further concerned that the current staffing and supervisory levels are inadequate to complete upcoming heavy maintenance checks on two aircraft. Overall, the reporter believes that there is a lack of forward planning and a reactive culture when it comes to aircraft maintenance.

Planning for this maintenance activity has been underway since [date]. The maintenance is now underway utilising both full-time and contracted LAMEs. The organisation has hired two more LAMEs, and as referenced above, [aircraft] type rating courses are booked for two full-time LAMEs.

[Operator] is victim to the significant difficulties faced by general aviation operators in relation to Part 145 and Part 66. From the tenor of the allegations made by the reporter, one could reasonably deduce that they have little or no experience in general aviation – this is the reality [Operator] and other like organisations face daily in dealing with the overly complex CASA Regulations.

Tool Control

The reporter states there have been four instances of tools being found on aircraft by pilots post-maintenance.

Tool control has been identified as an area for improvement after several incidents. The process of Toolbox inventory control is of high operational focus, and personal toolboxes not included in this oversight system have been removed from the hangar. This aspect of operations will be a continual focus of the leadership team, and the individual LAMEs.