Safety issue

Safety issue description

Malaysia Airlines’ processes for the management of change did not follow recommended industry practices, and its risk and change management processes were not detailed and clear enough to assure:

  • the appropriate level of involvement of subject matter expertise and safety groups
  • that risk controls were implemented and monitored.
Issue number AO-2018-053-SI-05
Issue owner Malaysia Airlines
Transport function Aviation: Air transport
Issue status Closed – Adequately addressed
Date issue released 16/03/2022

Safety action

Action type Proactive action
Action number AO-2018-053-PSA-07
Organisation Malaysia Airlines
Action date 16/03/2022
Action description

Malaysia Airlines amended the change and risk management processes to add:

  • an initial change process step to notify corporate safety oversight of the change
  • a final change process step for the safety risk oversight committee (the renamed safety risk assessment team—SRAT) to monitor and manage residual risks identified during the change process
  • a dedicated risk management process flowchart (that is, separate to the safety report process flowchart), including steps for a dedicated committee to conduct risk assessments, risk assessment validation and approval, and consolidation of risk registers
  • risk treatment methods
  • detail on triggers for risk assessment activities in addition to change management triggers.

After further discussion with ATSB, Malaysia Airlines undertook to revisit the following items:

  • elements of change management, specifically: the definition of change, the definition of relevant stakeholders, the development of action and assurance plans, and change approval
  • guidance on the identification of risk stakeholders
  • the risk management element of the safety report process, with regard to assuring the appropriate level of involvement of subject matter expertise and safety groups.