Lack of aircraft systems knowledge and complacency displayed by licenced aircraft maintenance engineers

We would like to thank the report author and the ATSB for bringing the information of this report to our attention. A full review of the information contained has taken place by the respective divisions within [Operator] and the Maintenance Organisation.

There are multiple take-aways from this report and we have split the key themes of the report below with a view to address each of them comprehensively.

Immediate actions taken by [Operator] include:

• [Operator] has taken the de-identified information from this report and raised this as a confidential safety report to address the key elements appropriately.
• An initial technical assessment was carried out by the Airline & Maintenance Organisation of the specific incident detailed in the report which indicates there are no immediate safety concerns.
• [Operator] has launched an independent peer review by subject matter experts of the event.

[Operator] will also take the key themes of the report and focus on the following:

• Clarity of reporting streams to all users to manage rightful expectations of closed loop feedback when requested.
• Distinguishing the different Quality & Safety teams selections (drop down menu) for Part 42 and Part 145/7 organisations.
• Review quantity and quality of prior feedback in both [reporting program] and the [engineering process].
• Review Original Equipment Manufacturer (OEM) Instructions for Continued Airworthiness (ICA) regarding the clarity of instructions provided to address such conditions consistently.

We have now broken down the individual concerns raised by the report author and have provided comments in relation to each.

Lack of acknowledgement and feedback from management for submitted safety reports.

The [Operator] Safety Management System documents clearly the process for managing safety reports when they are submitted into the safety reporting system. Each report is risk rated daily and using a risk-based approach, corrective and or preventative actions are taken. The data from safety reporting is also used to identify trends which are raised within the safety governance framework, also documented in the SMS manual which ensures responsible and accountable managers are across issues and concerns within the airline.

If the report author requests feedback within [reporting program] (by ticking a box for feedback), feedback will be provided once appropriate actions have been taken by the airline to address the risk and the report cannot be closed until feedback has been provided.

Lack of acknowledgement and feedback from management for QA [engineering process].

[Engineering process] is an electronic workflow multi-dynamic form used to capture requests varying in nature relevant to the functions of the Continuing Airworthiness Management Organisation (CAMO). They are raised both by approved maintenance organisations (AMOs) and other CAMO/Business departments requesting engineering support or action.

When an [engineering process] is allocated for review and actioning, a notification email is sent to the allocated area and to the [engineering process] originator. When an [engineering process] is marked as closed an email is sent to appropriate engineering teams and to the originator notifying them that the [engineering process] has been closed. The originator will then be able to open the [engineering process] and review the [reply].

There are policies requiring the oversight of the [engineering process] system. Depending on the [engineering process] type, the owners review department and statistical reports pertaining to their areas of responsibility at least monthly.

An overall lack of aircraft systems knowledge and complacency displayed by licenced aircraft maintenance engineers.

All Part 145 engaged Engineers must hold a CASA AMEL (or as allowed under Regulation other NAA equivalencies outside Australian Territories) and have completed an ICAO Type II aircraft specific type course and practical training. Obtaining and retaining a Part 145 Quality Authorisation thereafter follows a rigorous process including technical assessment and quality interview. All QA authorisations are renewed on a two-yearly basis and have mandatory prerequisites before such reissue occurs.

First time licence and quality authorisation holders are excluded from supervising maintenance and from issuing a certificate for release to service (CRS) for a period determined by their supervisors and peers [time frame].

Degrees of experience are as diverse as the workforce and relies on the use of maintenance data to perform actions.

Multiple engineering safety reports related to aircraft maintenance defect troubleshooting and resolutions that have been submitted to the Quality Assurance department were not taken seriously and/or dismissed.

Technical assessment of conditions and defects are made by qualified [engineers] in the Fleet Engineering department.

Defects with history are tracked by the [section] team as well as Maintenance Watch.

CAMO assesses the referred actions taken from [engineering process] or safety reports for appropriateness or, in the case of a quality issue concerning the maintenance provider, refers it on to the Part 145 AMO Quality Department for a formal response.

There is more of a focus on compliance with respect to the engineering documentation being completed correctly rather than if the actual maintenance carried out was correct for the reported defect and/or task.

The reporter’s submission that incorrect or incomplete documentation is a focus of the Quality departments is correct, but not at the expense of incorrectly completed maintenance. Both are a focus and as stated above incorrect maintenance is both referred to the operator’s CAMO as well as the AMO’s Quality and Safety department for investigation as per their SMS.

Maintenance errors and maintenance escapes, including the actions taken to address either individual occurrences or trends are reported to the [safety and risk] meetings monthly. These meetings are documented as part of the airlines safety governance framework in the SMS.

CAMO safety investigations are conducted under the overarching Safety Management System and are recorded in [reporting program]. Maintenance logs and work orders are sampled during audits for the correct conduct of maintenance. Several audits this year have identified examples of incorrect Instruction for Continuing Airworthiness (ICA) references and errors recording maintenance carried out. Findings and actions resulted from these audits and were entered into the [reporting program] safety database.

AMO safety investigations into maintenance escapes and maintenance errors are conducted in accordance with the AMO’s SMS [document] under the auspices of the Part 145 Safety Manager.

The crew of [aircraft] received a 'RH Bleed Trip Off' alert while starting the no. 2 engine on [date].

The engineering attending team closed the defect stating that 'no maintenance action was necessary in accordance with Fault Isolation Manual (FIM) task 36- 10 task 801 Rev 81'.

In accordance with the FIM, the minimum action for this defect should have been to carry out the initial evaluation and fault isolation procedure preliminary checks.

The aircraft departed and was subsequently grounded after arrival in [Location] with the same defect. In the FIM task referred, there is a note which allows the 'no maintenance action necessary' for a bleed trip off light if it resets successfully when the BLEED switch is selected immediately after a NO BLEED takeoff.

This was not the case for this defect as it happened during engine start. Upon inspection, the engineering team found an engine wiring harness damaged and a worn butterfly shaft in the high stage valve.

The reporter believes the defect required positive maintenance action to investigate and rectify the fault prior to departure.

[Operator] Line Maintenance Engineers (LAME) are required to follow the Fault Isolation Manual (FIM) (and thereafter other ICA) as a primary tool for addressing fault conditions or defects. This can be seen in Appendix 1. (Supplied to the ATSB). The FIM does not set a ‘minimum action’ threshold, therefore it is the judgement of the licensed and authorised engineer to assess the condition and take appropriate action per the ICA. Based on the information below, the LAME has acted in accordance with the data.

Report in Maintenance Log was:

“R/H “Bleed trip off” annunciated when starting no. 2 Engine. QRH actioned light extinguished.”

Resolving Action was:

“Info Noted, No Maintenance Action is necessary IAW FIM [task]. Nil history noted. Nil faults evident”

TRIP OFF light can be reset, no maintenance action is necessary.

The Engineer has addressed the defect appropriately and dispatched as allowed by the ICA to the satisfaction of the CAMO (QM). Subsequent troubleshooting identified the source of the fault, but no improper action or omission was deduced from the engineer’s actions. A subsequent occurrence was addressed in the same way as the first until the third event (defect now has history) resolved the issue as described.