Mode Aviation
Reference No. AR201700015
Date reported 16 February 2017
Concern title The recent management and oversight practices of the operator
Concern summary

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

Industry / Operation affected Aviation: General aviation
Concern subject type Aviation: Maintenance

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.

Operator's response (Operator 1)

In respect of the allegations in the report made by the reporting party I completely refute the assertions. I note the report only provides an opinion without reference to any incident or example. In response, I have provided some general observations then added more detail of the organisation, Safety Management System and agency actions to continuously improve safety and operations within [operator] for the necessary consideration.

[Operator] (fixed wing operations) is currently in the process of organisational change. This change is in relation to fixed wing operations moving from a private operator category to operations conducted under an air operator certificate (AOC) governance structure involving a more comprehensive operations system. It has been my observation that within the staff group, individuals have differing levels of personal resilience when dealing with this type of organisational change. This is further compounded by varying levels of understanding around what the role and functions of each management level are and the level of engagement of staff in safety related resolution strategies.

There is a management focus on this change to the AOC structure due to the benefits it will bring across the operation including to safety and flying operations. Part of this process has been the review of organisational governance structures relating to planning, budget and human resource management. This has resulted in the detection of gaps and non-compliance issues with appropriate state policies and directives. Management has taken change actions to enhance structural governance.

Structurally, the organisation has only had one change to decentralise management with senior managers now located within the operations group rather than being located away from the operations. I do not agree with any assertion this change is detrimental to safety within [operator]. The change has resulted in higher levels of supervision within the fixed wing business units including reviews of current processes and procedures, which may cause some staff concern.

The fixed wing maintenance model is currently under review after it was identified the current service delivery model was not sustainable. While I am unable to comment on previous management strategies, distrust has resulted with some staff making the decision to leave the organisation due to the review and possible change of direction. I suspect this review of maintenance delivery within [operator] to be the motivating factor behind the report in this instance.

I acknowledge some staff anxiety could be contributed to a lack of certainty around the future ownership of the aviation operations but this is an executive decision and the timeframes for that decision is largely outside the control of management at [operator]. Communication regarding the decision process is provided to staff however, this is not the provision of an answer that they seek.

There has been no change to any reporting or investigation process in the [operator] safety system and I find the allegations an unfair assessment of the dedicated team who work in this area with a genuine commitment to safe practices within [operator]. The time and depth of investigation conducted into reported matters is directly related to the circumstances of the report. We have systems to separate high risk from low risk matters and investigation timeframes can be extended due to many operational or staff related events. Without specific examples provided in the allegation this aspect of the report challenges a comprehensive response. I have provided a general overview of the system further within this response.

I welcome any quality inspection of the [operator] safety system that is considered necessary as a result of this report and would consider any recommendations or enhancements provided. In the below section I have provided some further background and explanation of the organisation and systems to support this response.

Safety Management within [operator]

[Operator] operates with an organisational safety management system documented in a manual format. Our manual is based on the CASA/ICAO suggested framework and investigations follow the principles of a ‘Just’ reporting culture and assessed levels of culpability. Investigations follow the aviation industry’s organisational and individual human factors taxonomy to establish root causes and contributing systemic or individual factors.

The system consists of an IT safety and hazard reporting system (Air Maestro) that allows any member within the organisation to report any safety concern.

  • The reports are assessed by the safety team and given a rating based upon the report. Reports are then either forwarded to responsible managers or investigated by the safety team with reports generated, consulted with subject matter experts (SMEs) and Director level. Completed investigation reports are then filed and can be accessed by members if required. (Confidential reporting is protected and requires different access levels).
  • Monthly safety meetings are conducted by the safety team and involve responsible managers or SMEs where all reports are viewed, discussed and actioned as required. Minutes are kept of these meetings.
  • Safety meetings are divided with dedicated meetings for health and safety reports and one meeting for aviation related reporting.
  • Monthly safety meetings are also conducted with the (AOC) holder, to ensure organisational awareness of medium and high risks reported and the mitigation/resolution actions undertaken.
  • The current safety system has not changed and provides a robust method of reporting matters across eight bases situated throughout [State].

While the system for fixed wing operations is still maturing, data identifies that from commencement of [operator], 51 reports were lodged in the first year of [operator] and reporting increased by 72 per cent the following year with a further slight increase this year to date.

[Operator] Operational Structure

The operational structure has changed recently. The structure has moved from a centralised management located away from the operational units to a decentralised model with directors moved into the operational units. The aim of this change was to provide a level of appropriate management into the business unit to coordinate the different sections that are required to deliver the service. The directors can take immediate action to identify, resolve or rectify hazards or safety issues within their unit using the relevant SME. This level of oversight by a senior manager has also limited flexibility or ineffective work practices by those who previously worked without oversight.

Management actions taken to date to improve safety and governance of [operator].

  • Open meetings conducted with staff to address service delivery models and concerns.
  • Staff engagement program to seek feedback from all members within [operator] both face to face and computer based.
  • Creation and funding of a Responsible Manager Position and Heavy Maintenance control position.
  • Employment of a quality manager.
  • Trial structure of Director Fixed Wing and Director Rotary Operations to lead and coordinate sections.
  • Expenditure of $800K per annum on training for staff members.
  • Additional funding request (2017-18) for safety training to enhance investigation methods and reporting, and increase organisational capacity.

Regulator's response (Regulator 1)

CASA has reviewed the REPCON and notes that the operator is currently undertaking work to improve their organisational structure. CASA is assessing their operations to ensure compliance with applicable civil aviation legislative requirements as the organisation changes. In this instance, CASA is satisfied with the operator’s response and will continue to monitor their operations as part of ongoing regulatory activity.

Last update 12 July 2018