Aircraft defects were not written on the maintenance release, leading to several defects not being rectified or managed.
Broome Aviation has implemented a revised defect reporting system with specific requirements. In addition to regular safety meetings to review aircraft defects and ensure pilots are adhering to the defect reporting procedure, this safety action adequately addresses the identified issue.
The new head of flying operations (HOFO) at Broome Aviation has overhauled the defect reporting process.
The organisation now has both a full-time HOFO and an alternative HOFO, who is also the Safety Manager. The revised procedure requires that all defects are reported to either the HOFO or the alternative HOFO and, where required, noted on the MR. The notified HOFO will then discuss the issue with the engineer and arrange for any necessary maintenance to be conducted.
Specific detail of the revised procedure included:
The pilot will inform the HOFO as soon as possible, any abnormal instrument indication, flight conditions, aircraft behaviour, operating limit exceedance or defect that occurs on a flight.
On return to base, the post flight documentation should include an email to the HOFO, MM and Chief Engineer of Broome Air Maintenance with a detailed description of the defect and any relevant photos of the item.
Flight crew procedures were also updated to include:
Pilots must record any defect on the MR in accordance with sub regulation 50(2) of CAR.
If an endorsement on Part 2 of the MR is a major defect or major damage, the MR becomes invalid until such time as the major defect or damage is rectified and the endorsement cleared by an appropriately authorised or licenced person.
Defects that are not major defects or damage may not render the MR invalid. The pilot in command will assess whether any such defect is in an item of equipment that is required for the particular flight. For example, if a night flight is planned and instrument lighting is unserviceable, the flight must not be commenced until the lighting is rectified. However, a day VFR flight would not be affected. Some defects may render the aircraft unserviceable as the component or equipment is required by type certification. Where the pilot is unsure, maintenance matters will be referred to the Maintenance Manager for consultation with the maintenance provider or suitably qualified maintenance engineer. Operational matters relating to the suitability of the aircraft for the intended flight will be referred to the HOFO.
Broome Aviation also provided 3 current maintenance releases to the ATSB that illustrated the revised process in use.
The ATSB has reviewed the maintenance releases submitted by Broome Aviation and acknowledges the operator is now leveraging maintenance releases to systematically document defects, ensuring that issues with aircraft in the fleet are properly tracked and addressed. While not specifically submitted as a response to this safety issue, the ATSB has noted that meeting minutes from recent safety meetings show an open dialog between the HOFO and pilots surrounding issues with aircraft in the fleet.
