Part 6: Surveillance follow-up

• Findings and corrective actions
• Internal auditors’ concerns
• Clearance of Finding Notices

6.1
In this Part, we assess whether the CAA’s follow-up practices ensure that unsafe operator behaviour and practices identified during surveillance are addressed in a timely manner.

Findings and corrective actions

6.2
We reviewed a sample of audit reports to establish whether inspectors had raised all instances of non-compliance or non-conformance in a Finding Notice, as required by the Surveillance Policy. In many cases, this had not been done.

6.3
One audit report contained the following observations, that appeared to note instances of non-compliance or non-conformance and for which a Finding Notice had not been issued–

Maintenance planning is rudimentary relying on the technical log and other information generated by the maintenance organisation. As all of the required inspections are not being tracked it is conceivable that some items in relation to the major replacement and routine inspection of components could be missed.

No occurrences have been reported in the last year. In the course of the audit some defect incidents were found that should have been reported (tail rotor gearbox problems).

6.4
We note that this same issue had been raised as a finding in a routine audit report by a different inspector for another operator.

6.5
We found 2 instances of non-compliance and non-conformance where Finding Notices had not been raised because the operator was in the process of doing something about the problems–

• The other equipment attached to the helicopter was spray gear identified as that produced under the Marine helicopter modification. There is no indication that this equipment has undergone any inspection, and the maintenance requirements should be included in the maintenance programme. With the introduction of the new helicopter the maintenance requirements for fitted role equipment will be required to be included in the maintenance programme.
• The Exposition has not been amended since re-certification and some editorial corrections to delete reference to the Planning Manual and VFG and include the new references (Aeronautical Information Publications Volume 1 and Volume 4 respectively) are due. The Company has an Exposition amendment under way to reflect the proposed changes.

6.6
Even if the operator is in the process of taking corrective action, we consider that a Finding Notice should still be raised to ensure that the operator follows through and fixes the problem.

6.7
We also noted that the copy of the Finding Notice that should have been given to the operator at the conclusion of the audit was still on the CAA file, which raises 2 issues. The first is that the procedure of giving the Finding Notice to the operator at the end of the audit had not been followed. The second is that, as the operator was not given a copy of the notice, it is unlikely that corrective action would have been taken.

6.8
In a separate case, the audit report noted an instance where an occurrence report had not been submitted to the CAA as required by the CARs. However, the operator’s non-compliance was not raised as a Finding Notice –

A main rotor lead-lag had been replaced on 21 June 2002 due to cracking. There was no evidence that a defect report had been submitted. Mr [name of operator] was requested to ensure that a defect report is submitted as soon as possible.

6.9
In another case, the spot check audit report noted –

Discussions with the Maintenance Controller…left the Airworthiness Inspector with a feeling that [organisation’s name] … approved procedures were not being followed and also a poor attitude to CARs requirements with Tech Logs being raised for periods greater that the approved maintenance programme. Mr… was also observed to fit an altimeter without carrying out a leak test.

No findings were raised as a result of this spot check.

6.10
In another case, the audit report noted that –

the standard of maintenance control and planning was hampered by Logbook sections not being fully completed and a fragmented approach to scheduling and tracking of required maintenance.

6.11
Again, no Finding Notices were raised as a result of this review. However, the letter to the operator’s Chief Executive did advise that a spot check would be carried out in the future, concentrating on the areas identified.

6.12
In another case, the audit report on a spot check of critical areas prone to cracks located cracks in the engine mounting brackets. According to the report, the cracks were highlighted to the maintenance engineer for rectification. No findings were raised as a result of this spot check.

6.13
In another case, a spot check report noted –

No physical checks of aircraft were carried out although we were shown the various aircraft under restoration. There is not really any question of the quality of the workmanship but the recording of what is being done leaves something to be desired.

Again, no findings were raised as a result of this review.

6.14
In the case of another operator, the audit report noted that –

Pilot competency and currency due dates were monitored on a computer database but it was noticed that there was some mixing of due and actual dates.

The company will need to review its internal audit program checklist for Quality Assurance to ensure that Rule requirements do not appear to be compromised.

The audit showed deficiencies in the fatigue monitoring system (because it had not been completed), which will need to be addressed, especially if operations increase.

Despite these comments, no findings were raised.

6.15
In a later audit of the same operator, the inspector commented –

During boarding at Wellington, the first wave of passengers wandered off across the apron toward the wrong aircraft…. They were intercepted by loading staff who redirected them. The cause of that incident was a lack of ground staff at the gate. There was only one staff member handling the boarding and he was inside checking tickets so was unable to marshal the passengers at the same time. Another staff member should be on the apron to guide and supervise passengers.

6.16
This represented a significant safety issue for the passengers involved. However, no finding was raised.

Internal auditors’ concerns

6.17
The CAA’s internal auditors were also concerned about findings not being raised when they should have been, and about inconsistencies in practice between inspectors (as well as between the Airline and General Aviation Groups). For example, a finding might be raised in one case, but not in others that warranted the same treatment.

6.18
After conducting internal audits of both the Airline and General Aviation Groups, an internal auditor reported in August 2002 that he had–

…observed variations in auditing practice between Flight Operations Inspectors and Airworthiness Inspectors within the AL [Airline] Group. Also observed were variations in the auditing practice between the AL Group and the GA [General Aviation] Group.

6.19
Later in the same report, the internal auditor noted–

The lack [sic] use of the findings process to effect corrective and preventative action is a concern that needs to [be] addressed across the CAA. Recent internal audits of both the GA Group and AL Group have identified this issue and finding notices against CAA have been issued accordingly to address it.

6.20
After the publication of the internal audit report, the Airline and General Aviation Groups held workshops in an attempt to improve the consistency of audit practice.

Clearance of Finding Notices

6.21
Along with our concern about findings not being raised, we are also concerned about the length of time taken to close the findings that are issued, and the way in which some of them are closed. This concern is based on data on all Finding Notices issued to both Airline and General Aviation operators over a 12-month period.

6.22
Operators are supposed to provide supporting evidence for their claim that they have carried out the corrective action required to close a finding. We found that some inspectors attached supporting evidence for closing a finding, while others appeared to close findings simply on an operator’s assurance that appropriate action had been taken.

6.23
In one case, 10 Finding Notices were issued. However, at the time of our audit, both copies (the CAA copy as well as the copy that should have been given to the operator) were still on the file. In short, there was no evidence that the operator had taken corrective action, and the inspector had taken no follow-up action to find out why these matters were still outstanding.

6.24
In another instance, vague wording made it difficult to identify exactly when the finding had been closed. For example, a finding required the Operations manager to remind all pilots to take more care in completing documentation. This kind of action should be an ongoing responsibility, rather than one to be completed within a finite period. At the time of our fieldwork, action on this finding was more than a year overdue.

6.25
We also found a large number of findings where corrective action was significantly overdue. For example, a routine audit in January 2004 noted that findings raised at the time of the compliance inspection had not been cleared. Effectively, this meant that the operator had been non-compliant with the CARs for over 12 months.

6.26
We are concerned at the time that it takes to close critical findings in the General Aviation Group. The CAA describes a critical finding as An occurrence or deficiency that caused, or on its own had the potential to cause, loss of life or limb. We therefore expected that CAA inspectors would ensure that appropriate action was taken by the operator immediately or within the following month.

6.27
We analysed the time taken to close critical findings during the 12 months from July 2002 to June 2003 (the General Aviation Group closed 32 critical findings during this period). We consider that an unacceptably long time was taken to close the majority of these findings. For example, 11 findings took over 200 days to be closed, and only 5 were closed in less than 25 days. The time taken is shown in Figure 3.

Figure 3
Time taken by the General Aviation Group to close critical findings

6.28
In addition, there was one critical finding dating back to March 2003 that had not been closed at the time of our audit.

6.29
However, we were pleased to note that, for the one critical non-compliance identified by the Airline Group for this period, the finding was closed in a day.

6.30
We are equally concerned about the number of “major” findings for which corrective action was overdue. At the time of our audit, 22 major findings were outstanding in the General Aviation Group (20 non-compliances and 2 non-conformances). Seven findings dated back to late-2001, 2 were made in December 2002, and the remaining 12 were made prior to June 2003 (more than 9 months before our audit). Six major findings were outstanding in the Airline Group (3 non-compliances, 2 non-conformances and 1 observation).

6.31
We found that 2 of the 6 findings outstanding in the Airline Group (one a major noncompliance and the other a major observation) had been assigned to a person who had since left the CAA. This resulted from the CAA having no process for reassigning outstanding findings when staff leave.