Aviation safety issues and actions

Chief Engineer and Business Quality Director review of retrospective concessions

Issue number: AO-2010-089-SI-09
Who it affects: Rolls-Royce plc
Issue owner: Rolls-Royce
Transport function: Aviation: Air transport
Background: Investigation Report AO-2010-089
Issue release date: 27 June 2013
Current issue status: Adequately addressed

Safety issue description

The engine manufacturer's process for retrospective concessions did not specify when in the process the Chief Engineer and Business Quality Director approvals were to be obtained. Having them as the final approval in the process resulted in an increased probability that the fleet-wide risk assessment would not occur.

Proactive Action

Action number: AO-2010-089-NSA-051
Action organisation: Rolls-Royce
Date: 27 June 2013
Action status: Closed

On 25 May 2011, Rolls-Royce advised the ATSB that a major corrective action, which arose from an internal major quality investigation, was to remove the existing retrospective concession procedures from their quality system, and replace them with a new Global Process titled Management of Undeclared Non-Conformance in Delivered Product.

The global process was developed to ensure an improved and more consistent approach across the company when it is identified that parts containing undeclared and non-conforming features have been released to the customer for entry into service. The global process requires the Chief Engineer and the Business Quality Director to be involved in the process at a much earlier stage to ensure that the fleet-wide risk assessment is conducted.

The global process was incorporated into the engine manufacturer’s quality management system on 4 July 2011.

Additionally, Rolls-Royce carried out an independent audit and review of the retrospective concession activity for the 2009 to 2011 period. The review revealed that only 7 out of 138 retrospective concessions that had been raised within the Civil Large Engine business unit were compliant with the engine manufacturer’s procedures.

All non-compliant retrospective concessions that had been raised since 2009 were subsequently identified and revalidated by the appropriate Chief Engineer and Business Quality Director. Other than the retrospective concession regarding the misalignment of the oil feed stub pipe counter bores, no safety concerns were identified and no in-service activity required.

ATSB comment:

The ATSB is satisfied that the actions taken by Rolls-Royce adequately addresses this safety issue and therefore makes no recommendation.

Last update 08 January 2014