Safety Advisory Notice SAN19980090

Safety Advisory Notice issued to: Operators of regional airlines, and maintenance certificate of approval holders

Recommendation details
Output No: SAN19980090
Date issued: 24 June 1998
Safety action status: Closed


Regional Airlines Safety Study

Between October 1995 and July 1997, the Bureau of Air Safety Investigation undertook a study of the safety of Australian regional airlines. The objectives of this study were to:

(a) identify safety deficiencies affecting regional airline operations in Australia; and
(b) identify means of reducing the impact on safety of these deficiencies.

For the purpose of the survey, regional airlines were grouped according to the number of passenger seats fitted to the largest aircraft operated by that airline in January 1997. The groups are defined as follows:

(a) Group 1: 1-9 seats;
(b) Group 2: 10-19 seats; and
(c) Group 3: more than 20 seats.

The study involved analysing data obtained from:

(a) responses to a survey of Australian regional airline employees;
(b) discussions with Australian regional airline employees and managers; and
(c) air safety occurrence reports involving regional airlines over a 10-year period (1986-1995) from the BASI database.

This Safety Advisory Notice addresses one of the safety deficiencies identified as a result of this study.


Some aircraft maintenance workers are not sufficiently prepared for working on their current aircraft as a result of inadequate training.


Survey results

Maintenance staff were asked if the training they received on their most recent aircraft type adequately prepared them for working on that aircraft. While most respondents were satisfied with the training, 28% of maintenance personnel were dissatisfied with the training they had received. Respondents who worked for Group 3 airlines tended to be less satisfied with their training than the respondents who worked for Group 1 or Group 2 airlines.

Inadequate training or lack of knowledge was nominated as a factor in seven maintenance incidents reported to BASI in the regional airlines safety study employee survey. A theme which emerged from the incident reports was the incidence of mistakes being made by new workers and the need for careful supervision and training by more experienced workers. Inadequate technical training was also mentioned in the free response section of the survey and was nominated as a problem by five respondents.

Written responses included the following:

"I have had no training whatsoever in the last 5 years".
- Licensed aircraft maintenance engineer, respondent 384.

"[I witnessed the] incorrect rigging of a [propeller] primary blade angle. [This incident was caused by the worker's] misunderstanding of the particular type of installation and lack of detailed training by the company on the type of aircraft operated".
- Licensed aircraft maintenance engineer, respondent 300.

"An incorrect rig pin hole was used to rig a stabilator, causing the pilot to have very little control on the test flight. [This incident was caused by] lack of training and supervision by licensed personnel".
- Maintenance supervisor, respondent 365.

An incident investigated by BASI involving a regional airline, highlighted the lack of formal training on a particular aircraft type for maintenance personnel. In BASI occurrence number 9403759, a scheduled passenger service aircraft was dispatched with a rudder flight control rod incorrectly fitted to the elevator control system. The fault was only detected in flight when the flight crew noticed an abnormal control column position. A duplicate inspection, carried out by maintenance personnel prior to the incident flight, had also failed to notice the discrepancy.

Current aviation regulations

The Civil Aviation Regulations (CAR) lay down the requirements for training of maintenance personnel by operators. The Aviation Safety Surveillance Program (ASSP) assesses an operator for compliance with the regulation for the training of maintenance staff.

The operator's responsibility with respect to training of maintenance personnel is laid down in CAR 214. This states:

"An operator shall ensure that provision is made for the proper and periodic instruction of all maintenance personnel, particularly in connection with the introduction into service of new equipment or equipment with which the maintenance personnel are not familiar, and the training programme shall be subject to the approval of CASA".

Additionally, CAR 30 details the conditions under which a certificate of approval is issued to allow maintenance of aircraft, aircraft components or aircraft materials. CAR 30 (2C) states:

"A certificate of approval is subject to:

(d) a condition that the holder of the certificate of approval must ensure that each person employed by, or working under an arrangement with, the holder receives adequate training in:

(i) the work performed by the person for the purposes of the activities covered by the certificate; and

(ii) the use of any equipment used in connection with that work".

The Airworthiness Surveillance Procedures contain a checklist - "Training of maintenance personnel" (ASSP362) within the system audit. Completion of the checklist allows Civil Aviation Safety Authority staff to assess an operator for compliance with CAR 214.

Procedures and guidelines for aircraft maintenance engineer (AME) training are contained in the Civil Aviation Orders part 100 and Airworthiness Advisory Circulars part 9. These orders and circulars detail the AME training required for all aircraft types operated in Australia.

Proposed aviation regulations

CASA officers are addressing training of maintenance personnel in their review of the aviation regulations. A survey of maintenance personnel conducted by CASA, highlighted similar problems with training of maintenance personnel. Rules regarding the training of maintenance personnel are contained in the new Civil Aviation Safety Regulations (CASR) part 145 - Approved Maintenance Organisations. This regulation was developed in conjunction with industry, with the latest draft regulation dated 18 February 1998.

CASR part 145.17 addresses the personnel requirements of the holder of a maintenance organisation certificate. This regulation clearly describes the requirement to provide approved training programs (initial, periodic, recurrent, and specialised) to employees. The regulation also requires maintenance organisations to provide sufficient personnel trained in the maintenance function or technique for which the organisation is rated.

CASR part 145.18 addresses the supervisory and maintenance inspection personnel requirements. This regulation clearly and prescriptively details the training required for employees to conduct maintenance inspections, perform maintenance supervisory roles and certify work. The regulation also specifies the qualifications/training needed for supervisory tasks.

Discussions with CASA on this issue indicate that CASR part 66 - Licensing - Maintenance, and CASR part 147 - Approved Maintenance Training Organisations, complement the new part 145. These proposed regulations (due for completion in mid-1998), are meant to provide better standardisation of AME training.


Results from the regional airlines safety study indicate that some maintenance workers (28%) have not been sufficiently prepared for working on their current aicraft as a result of inadequate training. Inadequate maintenance training is cited as responsible for a number of incidents reported in the survey. While current CASA regulations state the training responsibilities of operators and certificate of approval holders and provide guidelines and procedures for AME training, reports indicate that supervisory and inspection maintenance functions may not be carried out adequately at some regional airlines.

The review of the Civil Aviation Safety Regulations part 145, clarifies the requirements of maintenance organisations with respect to training of maintenance personnel. It also details the supervisory and maintenance inspection training requirements. CASA are striving towards clearer instructions and more standardised AME training in their review of the maintenance regulations.

If the proposed regulations are implemented by industry, the Bureau considers that this safety deficiency should be adequately addressed.

Output text

Operators of regional airlines, and maintenance certificate of approval holders, should note the safety deficiency identified in this document and take appropriate action.

Initial response
Date issued:
Response from: Maintenance Organisations
Action status: Not Required
Response text:
Last update 01 April 2011