[Peetwo]

 FRMS/SMS a lip service exercise - Part IV

Before we continue to follow the CASA breadcrumb trail of tick-a-box oversight of FRMS/SMS, the following are quote extracts from the last two entries to the now strangely -  - dormant published ATSB REPCON archive: https://www.atsb.gov.au/repcon_reports/?mode=Aviation

Reporter's concern

The reporter expressed a safety concern related to the lack of organisational accountability shown by [operator] when their crewing department contacts flight crew, on their rostered day off, within three to four hours of sign on, to request that they accept an additional ‘back of clock’ duty.

The reporter advised that on multiple occasions they have been contacted by the crewing department to operate a ‘back of clock’ duty, as the pilot in command of a return flight from Sydney to either [location 1] or [location 2]. This involves a continuous duty of between 10:50 to 11:05, if there are no delays, at a time of low circadian rhythm. To operate these flights, the crewing officer was offering no less than $3,870 plus meal allowances on top of any normal remuneration. No questions were asked by the crewing department related to whether they were fit to accept the duty.

The reporter advised that even though it is a crew member’s responsibility to ensure that they are not fatigued before accepting the flight, [operator] also has a responsibility to ensure that the crew member is not fatigued.

Reporters comment: It appears evident that the crewing officers are making requests on a ‘Don’t ask, don’t tell’ basis as it relates to the rest that has been achieved by the flight crew member in spite of the ‘mutual responsibility’ to fatigue management.

This is concerning when considered in the context of the significant financial incentives, flight crew members have to self-define the meaning of ‘adequate rest’ as it relates to any given duty without any objective guidance provided for comparison.

The nature of fatigue on such a duty poses a significant risk to flight safety and the financial incentives for flight crew to either disregard or inadequately address such safety risks is of a compounding nature.

&..

Reporter's concern

The reporter expressed a general safety concern related to the recent management and oversight of [operator].

The reporter advised that under the previous organisational structures, the safety culture was changing and becoming more mature and safety focused. This seems to be reversing in recent times, with staff noticing a change in the focus of management's attitude, where safety is being prioritised after financial and organisational structural change. This has resulted in employees not having a clear direction when safety concerns are experienced.

The reporter advised that due to this, shortcuts are now being taken, where company and aircraft operating procedures are not being followed. The reporter also advised that the focus has changed to non-aviation matters, to the detriment of safety within the operational area. Staff members are still using the safety reporting system, but limited changes and lengthy review times, with many investigations remaining open is making staff lose faith in the system.

Reporter comment: I feel that a thorough investigation into the operation of the operator and the current management structure adopted is required to assist those people in the organisation who are attempting to adopt the safety culture required for an organisation such as this.

  
Now coming back to the PelAir MKII report the following is an extract from the 'Other factors which increased risk' (pg 354 of the 2nd report):

- Due to limited sleep in the previous 24 hours, the captain was probably experiencing a level of fatigue that has been demonstrated to adversely influence performance.
 - The operator’s application of its fatigue risk management system overemphasised the importance of scores obtained from a bio-mathematical model of fatigue (BMMF), and it did not have the appropriate expertise to understand the limitations and assumptions associated with the model. Overall, the operator did not have sufficient risk controls in addition to the BMMF to manage the duration and timing of duty, rest and standby
periods. [Safety issue]
- Guidance material associated with the FAID bio-mathematical model of fatigue did not provide information about the limitations of the model when applied to roster patterns involving minimal duty time or work in the previous 7 days. [Safety issue]

 
And this was how the (top) 'safety issue' was apparently proactively addressed (since 2014??) by the operator:

Proactive safety action taken by Pel-Air Aviation
Action number: AO-2014-190-NSA-031

After the accident, the operator undertook a series of actions to improve its fatigue management practices. These included:

- revised the callout time for air ambulance tasks from 2 hours to 3 hours
- developed and introduced a face-to-face introductory course on fatigue management and revised the content of the computer-based training course
- developed a fatigue assessment form to be used to assess the likelihood of fatigue prior to the assignment of ad hoc charter flights to flight crew who were on standby (with the form including a small number of questions to obtain basic information about a pilot’s recent sleep and rest)
- introduced a requirement to reduce the maximum period of 24 hour standby to 28 days (after which crew required a minimum of 8 days off duty)
- modified the FRMS to include longer required rest periods following duty periods involving large time-zone changes (more than 3 hours)
- conducted a workshop with a sample of the operator’s managers and flight crew (across all fleets) to identify fatigue hazards and risk controls.

In October 2017, the operator advised the ATSB:

Since the accident, continuous improvement and advancement has been made to the Pel-Air FRMS including the use of and understanding of the BMMF.

The FRMS has also become an integral part of the Pel-Air and Group Safety Management System and is a standing item that is tracked and reviewed by the Safety Management Group (SMG).

In addition to the existing recorded pro-active actions, other examples of development include;
- A formal Risk Assessment completed in relation to duty across different time zones and a set of guide lines were published as a result and the document (Acclimatisation Guidelines for Trans-Meridian Operations) is available to crew via the Flight Crew Notices Webpage.
- All Pel-Air crew, when submitting a report in the Safety Management System online reporting system, must select ‘Yes’ in relation to fatigue report, and submit all the required details, irrespective of whether or not fatigue is considered a contributing factor.
- Further review, research and improvements were made in relation to the Extension of Duty assessment process.
- Completion of an FRMS Crew Survey.
- Pel-Air is also ISO 9001:2015 certified and holds BARS Gold Accreditation both of which are heavily weighted on the Safety Management System which include the FRMS.

Current status of the safety issue

Issue status: Adequately addressed
Justification: The ATSB notes the operator undertook several actions to address its risk
controls regarding fatigue management on its Westwind fleet, and more broadly across its operations. Although not every aspect of the safety issue was specifically addressed, the overall level of action reduced the risk of this safety issue.

If nothing else at least this time round the subject of fatigue and the FRMS was comprehensively reviewed and two 'safety issues' identified but the outstanding questions still remain:

Q/ Why didn't this same level of investigative scrutiny of the operator FRMS/SMS not occur with PelAir MK I?

&.. Reference email Steve W to Karen C in 2015:

Hi Karen


These three files summarise the concerns CASA had about PelAir's fatigue management as far back as 2004. This included an RCA (Request for Corrective Action) issued by CASA in May 2006 (2nd file) So there is long established history of CASA being concerned about fatigue management at PelAir. 


The safety alert (a 2nd RCA) was issued in March 2008 (3rd file). This was quickly rectified, and there was a prompt return to FRMS operations. 


So why did the 2009 audit devote 5 pages to fatigue management. The following quotes come from the 2009 audit. 


•                "Most crew identified a lack of understanding of the FRMS processes, and crews regarded the training as inefficient and ineffective." Page 22.
•                There was an "FRMS knowledge gap displayed by the pilots." Page 22.
•                "PelAir have not managed fatigue risk to a standard considered appropriate..." Page 23.
•                No evidence was found that supported the claim that Pel-Air FRMS had ever managed fatigue risk to a standard considered appropriate, particularly for an operator conducting adhoc, back of the clock medivac operations.
•                It is evident the fatigue reporting culture within Pel-Air is deficient. This cannot be fixed quickly, and will require a number of months to determine whether this reporting culture has improved. An open and honest reporting culture is critical to the success of any FRMS and there is evidence to suggest one or two key personnel may be the root cause of this cultural problem.


So CASA have concerns back at least as far as 2004. There were two RCA’s - 2006 and 2008. Yet CASA still find a litany of fatigue management problems in the 2009 post crash audit.


Very odd


Steve

Q/ Why did CASA (aided & abetted by the ATSB) go to such extraordinary lengths to cover-up the non-compliances and dysfunction of the PelAir FRMS/SMS dating back to at least 2004?

&..

Q/ Why did the previous CASA identified safety concerns with the PelAir FRMS that led to issue of several RCAs and even a 'safety alert' (Ref - Malcolm Campbell signed letter here: foi-ef12-10004.pdf) seemingly have no effect in addressing the systemic deficiencies identified in the - supposedly 'unauthorised' - Cook PelAir FRMS SAR?

&..finally

Q/ Within the ToR for parallel investigations - of either the 2004 or 2010 MoUs - why didn't CASA share their findings on the PelAir FRMS with the ATSB?

Excerpts from CAIR 09/3

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P2 comment - Note that MALIU White refers to the FRMS 'Cook' report. This would appear to contradict the former DAS McCormick's statement (sup submission) that BC was not authorised to produce the PelAir FRMS SAR?  

Ironically there is not one mention of the deficiency findings of the FRMS in either the 'causal factors' or 'findings' of the CAIR 09/3 report:

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To set the scene for answering my (above) QON, here is some document links for the 9 (anonymously provided) Senate AAI inquiry documents, that were received by the RRAT committee Secretariat on the 10 October 2012 i.e. 12 days before the first public hearing:    

11
Internal CASA report titled "Oversight Deficiencies- Pel-Air and Beyond" also known as the Chambers report (dated 1 August 2010), received 10 October 2012;(PDF 6210KB) 
12
Internal ATSB email regarding the ATSB and CASA's approach to the Pel-Air investigation (dated 9 February 2010), received 10 October 2012;(PDF 1093KB) 
13
Internal CASA email regarding the discussion with the ATSB over the content of the ATSB report (dated 18 August 2010), received 10 October 2012;(PDF 1193KB) 
14
Internal CASA email (dated 4 February 2010) ATSB identification of a 'critical safety issue' may have ramification for CASA actions in relation to Mr James, received 10 October 2012;(PDF 913KB) 
15
Advice from the UK Civil Aviation Authority to CASA providing an assessment of the fatigue scores for the accidental flight (dated 11 December 2009), received 10 October 2012;(PDF 881KB) 
16
Internal ATSB email- reviewer wanting to look more closely at FRMS and re-interview pilots (dated 24 May 2012), received 10 October 2012;(PDF 535KB) 
17
Internal ATSB email- reviewer indicating they can't deviate at this point and they have to work with what they have (dated 24 May 2012), received 10 October 2012;(PDF 360KB) 
18
Internal ATSB email regarding the inconsistency in safety knowledge of ATSB staff (dated 6 August 2012), received 10 October 2012;(PDF 1597KB) 
19
CASA Special Audit of Pel-Air Fatigue Risk Management System, received 10 October 2012;(PDF 5428KB)

Hint: Refer to docs 15 to 19 and see if you can spot the FRMS dots...


Time has beat me, so I'll definitely have MTF...P2