There was a routine CASA audit of Pel-Air scheduled for October 2007. This audit had to be terminated as the majority of pilots did not submit their logbooks and Pel-Air therefore could not provide sufficient paperwork to allow this 2007 audit to proceed.
http://www.casa.gov.au/wcmswr/_asset...ef12-10004.pdf Page 3.
This rescheduled CASA audit took place on 12-13 March 2008. This audit was damning, finding multiple defects. Among the most serious was that the training records of 20 pilots were seriously deficient (for example, 80% of these records contained no evidence of training in emergency procedures), and there were irregularities in the renewal of instrument ratings. Odd that paperwork would still be so deficient give 6 months notice of a rescheduled audit.
http://www.casa.gov.au/wcmswr/_asset...ef12-10004.pdf Page 4.
Most serious of all was the issue of fatigue management. Pel-Air had been operating under a Fatigue Risk Management System (FRMS) for 11 months. However pilots had not received training in FRMS. This non-compliance was considered by CASA to be an imminent safety threat. On 12 March 2008, CASA issued an immediate “Safety Alert”, which precluded further operations under the FRMS until this training was undertaken. On 17 March 2008, Pel-Air advised CASA the required training had been completed. On 18 March 2008, CASA approved Pel-Air to resume operations under the FRMS - possibly a record turnaround by CASA.
http://www.casa.gov.au/wcmswr/_asset...ef12-10004.pdf Page 3.
On 11 October 2008, CASA formally documented that all active pilots had been trained in the FRMS (page 45 of above 2008 audit). Which would be all well and good – but for future events.
Roll forward 13 months....
Following the crash, CASA conducted a special audit between 26 November – 15 December 2009. This was much more in depth than the routine March 2008 audit. What had been wrong in March 2008 was still wrong. Furthermore, additional serious problems came to light. This audit found fault with the pilot, fault with Pel-Air, and fault also with CASA itself. The report is truly shocking - it too is in the public domain. But it nearly wasn’t – until someone leaked it to 4 Corners.
http://www.abc.net.au/4corners/docum...Audit_2009.pdf
The 2009 (post-crash) special audit report is as long (> 100 pages with appendices) as it is damning. There are far too many deficiencies to cover here.
But the issue of fatigue does make an interesting sideline. Remember that poor fatigue management and training in the FRMS system were the major concerns of the March 2008 audit, and led to an immediate “safety alert.” Pel-Air quickly attended to these deficiencies, and CASA (very) quickly accepted that all pilots were suitably trained. But this does make you wonder why the 2009 CASA special audit 12 months later again found ongoing serious issues with fatigue and the FRMS. Four pages (22-25) of this 2009 audit deal solely with fatigue management deficiencies. Strange given this had all been efficiently resolved in 2008.
¥ "Most crew identified a lack of understanding of the FRMS processes, and crews regarded the training as inefficient and ineffective." Page 22.
¥ There was an "FRMS knowledge gap displayed by the pilots." Page 22.
¥ "PelAir have not managed fatigue risk to a standard considered appropriate..." Page 23.
¥ No evidence was found that supported the claim that Pel-Air FRMS had ever managed fatigue risk to a standard considered appropriate, particularly for an operator conducting adhoc, back of the clock medivac operations.
¥ It is evident the fatigue reporting culture within Pel-Air is deficient. This cannot be fixed quickly, and will require a number of months to determine whether this reporting culture has improved. An open and honest reporting culture is critical to the success of any FRMS and there is evidence to suggest one or two key personnel may be the root cause of this cultural problem.