The following is what I sent in to CASA today.
This article was under the header of Flight Safety Advisors – Albert Fleming – FSA Sydney, so I will address my thoughts to him.
Dear Albert,
Nice piece of Swiss Cheese (James Reason would be proud of you).
Based on the story content only and taking it on face value we are clearly looking at several serious breaches of common sense by senior management, not to mention legislation. Lets just deal with the common sense matters here and leave the CAR’s CASR’s CAO etc etc to others to wax lyrical about.
- Why did CASA not insist that this company had a Deputy MC?
- Why did the CEO of company X not insist on a deputy MC?
- Why did the MC not insist he/she had a deputy?
- Lets assume the above three questions are not based on fact and there was a Deputy MC. Why was there not a documented (Perhaps there was, but if there was it clearly wasn’t used) and well understood procedure for the Deputy MC to take over responsibility whenever the normal MC was off-line (For whatever reason)?
- Why was this modern (Another assumption on my part) company not using CASA’s email alert system via its emergency IT system. An off site back-up computer who’s operator was alerted whenever the companies IT system went down. This emergency PC Operator was also trained in essential services support such as AD Alerts.
- Lets again assume that by “computer system was down” what is meant is a bigger problem. ie: Nationwide loss of IT capability for whatever reason. At approx 08:35 Hrs the new receptionist places the FAX in the MC’s IN TRAY, he/she should be trained to not simply place pieces of paper from CASA into “IN TRAYS”, he/she must be trained to verbally advise the owner of that “IN TRAY”. Can’t find the owner? Tell his/her deputy. Can’t find his/her deputy? Tell a technical person of some type (In this case the Maintenance Specialist). Can’t find anyone in the office? Call the Chief Pilot. Can’t contact Chief Pilot or his/her deputy? Call the CEO (By whatever title he/she uses).
- As an aside have you ever seen those “IN TRAYS” that look like the owner never clears them? You know, its about a foot high with documents of all types stacked therein. Now how can anyone be sure that when placing anything (In this case a mission critical FAX) into such a beast it will stay on top for long? What the MC (And his/her deputy) must have are dedicated URGENT IN TRAY’s (That must not be allowed to grow contents wise) or they might even have a dedicated CASA Comms/AD IN TRAY.
- OK so the receptionist simply does as explained – places FAX in MC IN TRAY. The maintenance specialist only becomes aware at 13:00 Hrs. Lets also assume that the compliance time clock started ticking as described at 08:30 Hrs (Time AD received). Further that we are talking about ten hours of normal time not ten flight hours (This only becomes clear later when we are told how the IT guy enters the AD into the computer). Based on these assumptions at 13:00 Hrs the clock hours to run would be at 5.5 hours. Maintenance specialist gets the AD inputted into computer by IT guy, who stuffs it up. Two very important steps appear to be missing here:
i) The maintenance specialist should have observed the data entry process carefully to ensure our IT guy did it correctly.
ii) As soon as the maintenance specialist became aware of the AD he should have telephone all affected outstations to ensure they were aware of the very short compliance time line and he/she should have faxed a copy of the AD to each outstation.
h) Event is logged into the companies SMS dB and the following recommendations are entered and acted upon:
i) CASA are advised of the breach by the MC and the corrective actions being undertaken.
ii) A deputy MC position is established (If not already in place)
iii) All involved are trained/retrained on the required procedures. This includes AD processing and computer data entry.
iv) Emergency plans reviewed to ensure loss of IT capability is adequately covered
v) Quality Systems Manager to carry out several random audits of the process over the coming months to ensure the system operates as required.
vi) The audit findings are also logged in the SMS dB.
Anyone interested in a very good SMS dB should contact me. I am currently (This may change with time) offering a FREE dB tool to clients. There will of course be some costs involved in installation and training of key staff. In the short term I would be more than happy to send you a demo CD.
