Stress caused by the handling by management of major changes within

[noclue]

REPCON: AR201400015 (http://www.atsb.gov.au/repcon/2014/ar201400015.aspx)

[bazza stub]

Bravo, should be more of it!

Standard BS from "the operator"

[ALAEA Fed Sec]

Regulator's response (Regulator 1)

CASA has reviewed the REPCON and the response by the operator. CASA recognises that the significant change being undertaken by the operator and the associated uncertainty this creates for staff is a risk factor to the organisation. Consequently CASA has increased its oversight of the operator during this period of change to ensure that the required safety standards are maintained.

Increased oversight activities includes assessment of their risk assessments and change management plans; monitoring of safety data including Airservices Australia Cirris reports, ATSB reports, CASA surveillance results, and internal safety data; increased surveillance on the ramp, terminal area, line and base maintenance, and domestic and international flight operations; increased engagement with staff including senior management, operations management, safety department, and line staff including pilots.

Funny that overtime in some Line Maintenance departments (Syd DOM a prime example) regularly exceeds FRM principles yet they will allow this company to reduce numbers by 30%.

CASA's engagement with senior management appears to be continuing though. We note that the EGM of Engineering attended a Sydney Surveyors retirement function gifts in hand. If only he knew the name of some of his own staff......

Oversight activities have confirmed that the operator has identified the risks associated with the current change and is managing the change appropriately. CASA engagement with the operator’s pilots has confirmed there is concern about the uncertainty however flight deck surveillance has also confirmed that the pilots continue to undertake their responsibilities to the safety standards expected by CASA and the airline.
CASA continues to focus oversight activities on identified areas of change.
Minimum Engine Oil levels were managed well. Pilots having active advice to depart with less oil than is required.

[SeldomFixit]

The implication there being that said Pilot's are doing so willingly. Very helpful to the big picture, indeed :ugh:

[ALAEA Fed Sec]

Just reading through the REPCONs generally. What concerns me is the way CASA seem to just fob everything off and the ATSB accept that. Have a look at some of these responses to fatigue and other raised issues.

Regulator's response (Regulator 1)

CASA has reviewed the REPCON and the response by the aerodrome operator. CASA regularly conducts surveillance of both the relevant aircraft operators and the aerodrome and will follow up on any issues.

Regulator's response (Regulator 1)

CASA is aware of the operator's fatigue risk management policy and monitors the system in respect of fatigue risk management objectives. Risk mitigators observed include regular monitoring of roster pattern performance by the airline, adjustment of rostering rules, the ability for a crew member to opt out of a duty when fatigue is anticipated or experienced and the provision of company transport or accommodation in order to limit the fatigue effects following duty.


Under the proposed flight and duty rules which are expected to be in force from this year, it will still be up to the individual to determine fitness for duty and to make a report via the safety management system (SMS) where this is indicated under company procedures. CASA strongly recommends airline employees report potential fatigue events through the SMS, in order to identify areas where the company should focus resources to reduce operational risk, including fatigue risk.


If the reporter has evidence of the reporting culture being compromised by management actions they are invited to make a report to CASA detailing any concerns.


Regulator's response (Regulator 1)

CASA has reviewed the REPCON and notes Airservices response. CASA will include the information provided in the REPCON in planning and prioritisation of surveillance activities relating to Airservices.

Regulator's response (Regulator 1)

CASA has reviewed the REPCON and will monitor Airservices post implementation review of the new STAR procedures.

Regulator's response (Regulator 1)

I refer to your email of 22 November 2013 and 3 December 2013 requesting further information in respect of the Australian Transport Safety Bureau REPCON AR201300081 and AR201300089 about concerns regarding the proposed transition of operations from the old Melbourne Control Tower to the new Air Traffic Control tower.


Since the reporter's comments in October 2013, Airservices have rolled out the full mimic program of at least 8 shifts per controller and have issued AIC 124/13 regarding 'Implementation of interim ground delay program for Melbourne' that will be one of the mechanisms for limiting the amount of traffic at Melbourne during the first 2 weeks after cutover. Airservices have issued a number of ATC local instructions and Group Circulars, including TLI 13/0266 'Old Melbourne Tower-Cutover and Ghost Procedures'; TLI 13/0268 'New Melbourne Tower-Traffic Management Procedures'; TLI 12/0269 'INTAS Operations-Cab Procedures'; Group Circular 13/0438 'Melbourne Tower INTAS Commissioning'; and Group Circular 13/0457 'Support for the commencement of services from the new Melbourne Tower'.


CASA has reviewed Airservices' supporting Safety Case and associated documents and is of the opinion that the transition risks, including ensuring ATC competencies and ATC support arrangements, are being managed in accordance with Airservices' Safety Management System. CASA is aware that the Melbourne Surface Movement Control (SMC) position is a complex and high workload area. CASA has recommended that Airservices conduct a review of the SMC position post INTAS transition. CASA will be monitoring the results of this review.



Regulator's response (Regulator 1)

We note that there was no loss of separation and CASA does not intend to take any direct safety action with regard to this matter; however CASA will use this information to complement other information that informs us of Airservices Australia safety risk profile.



Regulator's response (Regulator 1)

CASA has reviewed the REPCON and has referred the matter to the regulator in question, as they have responsibility of oversighting the operator.





They simply never do anything.

[Australopithecus]

Seldom Fixit: Emphatically NO.

Pilots will not knowingly depart with insufficient oil. He problem is that the pilot manuals do not specify the minimum dispatch oil qty, nor do they adequately explain the correct time window for performing a qty check.

This information was not needed until now as engineering was on the job. The company has since changed the procedure while not ensuring that the pilots were adequately trained and informed on their new task.

QF has failed utterly by uaing wishful thinking as a management tool, and CASA has failed utterly to oversee this process change.

[emergency000]

"Operator 1" The organisational transformation is being undertaken through established change management processes to ensure that ongoing safety assurance is being maintained.

Gee, that wording sounds like a lot of the company emails I was receiving up until around August last year...

[004wercras]

What an absolute load of Regulator ****e."CAsA is aware", "CAsA has reviewed", "activities have confirmed" blah blah blah.
CAsA does nothing but 'talk'. Of course it is a different story when what could be construed as a 'small operator' makes a mistake - Friday faxes, special audits, robust pineapples, show causes and a process designed to send the operator bankrupt.
But oh no, not the mighty 'Q'. Could you imagine CAsA so much as finding a pimple on the ass of 'Q's illustrious operation? Heavens above, impossible, it's just impossible!

[The Banjo]

Austraopithecus,

A few B737 FACTS:

Boeing: Boeing 737 Facts (http://www.boeing.com/boeing/commercial/737family/facts.page)

I would be delighted and enlightened if you would point out to me to an incident or accident report in the:

1. past 40+ years of global B737 operations - 7,500+ airframes
2. by the hundreds of "far less capable" operators than the encumbent under discussion......
caused by the low oil situation that you so desperately allude to :ugh:

[Chris2303]

This reminds of the good old days in NZ when the CAA would say yes to anything that TE asked.

[Australopithecus]

The Banjo.

Can you play "the love theme" from "Deliverance?

That's about as erudite as your submission is. I was answering another member who thought that perhaps there might be some pilots who would be willing to dispatch with less than sufficient oil.

Now you chime in with the erroneous supposition that I am claiming pilots are unable to competently judge oil quantity to be within limits.

My post was to emphasise that QF has not provided a definitive source of critical pre-flight information. Specifically: what constitutes minimum oil quantity for the planned flight, given minimum dispatch oil qty and the (usually cryptic, likely unique) , exact hourly oil consumption such that the planned flight, including any diversions, will be completed while maintaining minimum oil quantity.

Finally: I am not desperate by any means, instead relying on cold facts to ascertain the suitability, or otherwise, of an aircraft and its planned fuel/oil to meet my requirements.

I will spare you the insulting little emoticons. Feel free to bang your head against the wall all you want. It may result in some small improvement in your cognitive ability. Or not. Whatever.

[Australopithecus]

Oh, by the way Banjo, while I am compiling data, do you wish me to exclude the JT-8 in its many variants which powered the first part of your 40+years of operation?

Since oil is common to all engines, and hence all airliners, why don't I perform a search of all aircraft run to oil exhaustion? Why narrow your inquiry to one type?

(These are rhetorical questions, by the way, since I have zero intention of performing the alleged regulator's tasks pro bono. But feel free to answer in a considered fashion, with footnotes.)

[Prince Niccolo M]

Hey Banjo,


I guess what you are saying is that nobody has to check the oil levels because it has never previously been a problem - that must be evidence-based decision-making...

[gordonfvckingramsay]

Banjo, not a QF stooge are you?

Since when is the absence of accidents/incidents been proof of a safe system?

I have to say, the sudden decline in standards around the place (driven by the top brass) makes me wonder if we have even a couple of years before the big one.

[Kharon]

ALAEA #5 –"Just reading through the REPCONs generally. What concerns me is the way CASA seem to just fob everything off and the ATSB accept that".
If you go the Repcon link on post #1 in the left hand panel there's a black rectangle, marked Repcon, this will take you to three pages, containing 45 Repcon; most of which are aviation related. As Steve says, the responses are well rehearsed, smoothly executed excuses which make it look, through the smoke and mirrors, as though something is actually be done (disgusting).

If you can find the time have a look at the responses from the 'other' domestic transport agencies and compare them; then, if you want to get serious, have a look at the Canadian or USA authorities responses to similar 'safety reports'. I found an hour last evening to do this, not to make it a project, but to 'test' differences. I'm still shaking my head, well at least we can still drink most of the water in Australia.

If the Repcon in #1 achieves nothing else it has served well to highlight the appalling, self evident condition to which the official attitude on safety concerns has degenerated.
ALAEA "They simply never do anything".

Wrong Steve, they spend the entire day and budget making sure they cannot be held responsible or accountable for anything, while ensuring maximum control and kudos. It's an art form; deeply entrenched, fully supported and set to endure. The really 'nasty' part is they steal all the accolades for 'safe transport' from those who are at the coal face, keeping the public safe even while under the incredible pressure of work place uncertainty, mismanagement and not too much protection.

[Snakecharma]

And this is why a lot of good points are lost.

People try and play the safety card and use hypothetical's to illustrate something that "might" happen.

It has all been trotted out before - when they got rid of radio operators and navigators, again when they got rid of the FE, when they went from four and three engines to two - and yet the predicted rain of aluminium from the sky has not eventuated.

The arguments that management understand are related to cost and commercial issues.

Lets face it, no sane professional pilot is going to depart with really low oil. It doesn't really matter what the "official" minimum level is, a quart or two below that level isnt going to cause an engine to run dry unless the engine is using an abnormal amount of oil - in which case the engine has a bigger problem than can be found on a pre dispatch inspection.

Make that argument about OTP and cost then you are going to get their attention. It might not change their mind as they are driven by different imperatives than the operational people including the threat that if they dont "perform" they are out (obviously at levels below the CEO because it seems that threat doesnt exist at that level).

Emotional arguments and those with hypotheticals are easy to ignore and often lead to good points being lost.

Figure out what is driving the management and frame your arguments accordingly.

[Kharon]

Snakecharma - The arguments that management understand are related to cost and commercial issues.

Agreed and that's fine for Qantas 'financial' management when the 'operational' protection is (was) built in down the line. There is no doubt that economies of scale and adaptation to changing environments is a prerequisite of a modern era. Fine with that and I would support it; but, the current situation raises doubt. Checks and balances are required; if only to 'externally' prove that the 'internal' safety net is properly maintained. That check comes from external oversight (CASA), the balance, if you like, is the ATSB.

But when the safety 'authorities' simply accept 'management' predictions of equivalent safety without a proper 'look-see', the holes can, do and have in the past aligned. When the CASA only appears (seen) to be doing and ATSB are prepared to allow it, then things can become potentially grim indeed. How is operational 'sanity' to balance management 'madness', or vice versa.

But yes agreed, the faux 'safety' card has been played much too often, much to the detriment and devaluation of potential real ones. Is that enough excuse though for the authority to simply ignore, waive off or pay lip service to any or all concerns; no matter how fatuous? They are paid to provide a full service to the public.

[IsDon]

If we are not informed what the minimum oil level should be on preflight, the simple solution to me would be to not depart until all engines are topped up to full.

A few delays put down to oil servicing that wasn't required will soon get their attention. I can see the FSO now.

[Sunfish]

Snakecharma:

no sane professional pilot is going to depart with really low oil. It doesn't really matter what the "official" minimum level is, a quart or two below that level isnt going to cause an engine to run dry unless the engine is using an abnormal amount of oil - in which case the engine has a bigger problem than can be found on a pre dispatch inspection

If the sane professional pilot isn't trained to know what "really low oil" means then of course he can depart with insufficient oil.

"Abnormal" oil consumption can only be determined by long term statistical studies of engine oil consumption per hour and per cycle. From that you develop a standard for what "Abnormal" means at the particular stage of life of the componentry.

You then plot engine oil consumption for each engine per hour and per cycle and do it daily. There used to be people who did that stuff. Pilots can't.

[itsnotthatbloodyhard]

A suggestion would be to mind your own business, fly your roster and go home at the end of your shift to the wife and kids. Smile and be happy.

Mate, do you understand here that a lot of pilots are facing demotion? That quite a few may soon be looking for the nearest Centrelink? And that the remainder are contemplating the fact that the company they were working for ten or twelve years ago, when it was one of the most profitable (if not the most profitable) airlines in the world, may soon cease to exist in any recognisable form?

And your suggestion is to "mind your own business, smile and be happy"? Seriously?

[FYSTI]

If you as a pilot can not help but get involved in the company politics then it probably will cause you stress. A suggestion would be to mind your own business, fly your roster and go home at the end of your shift to the wife and kids. Smile and be happy. The issue with this is that it was a deliberate campaign engineered to *maximise* publicity over an extended period of time to influence the employeess, public & politician. This was a textbook propaganda campaign designed to appeal to emotion & bypass reason to generate an ACTION. QF deliberately maximised the pain of "the sky is falling in", designed to generate a political outcome. This the key, to generate an ACTION. (Jaques Ellul Propaganda (http://www.pdfarchive.info/pdf/E/El/Ellul_Jacques_-_Propaganda.pdf) provides all the guidance needed)

It was virtually impossible to shut out this level of company generated hysteria. Short of telling wives, friends & family to also avoid reading the newspaper & watching TV, it was impossible to avoid. The campaign was deliberately designed to inflict & maximise emotional pain & distress. This was the desired outcome.

So to say, simply fly the roster & go home is naive. Sure plenty of other operators have had issues. However, I wonder how many other airlines ran a fully blown propaganda campaign to convince everyone (except selected insiders) that the company was about to fail unless an action was taken. it was always smoke & mirrors, and I said so at the time (http://www.pprune.org/australia-new-zealand-pacific/528014-merged-alans-still-not-happy-31.html#post8192482), however, the vast majority were convinced by narrative. It takes a lot of strength & knowledge about how "the game" is played to see beyond the newspaper & TV spin and avoid emotional engagement.

[Sunfish]

Australianguy:

Running around saying that safety is affected by change management within the company is a bit of a stretch. These activities go on all the time all over the world. Do you think this situation is unique to Qantas?


You obviously have no experience whatever on which to base your worthless opinion.

I have participated in many restructures over Forty years both as the consultant, restructurer and the restructuree.

Let me explain that Qantas is using the worst of all possible techniques to restructure its business and that it is causing stress because it is maximising Fear, Uncertainty and Doubt, causing misery among its employees, as far as I can tell purely for the emotional gratification of management.

There are Three ways to do a restructure.

1. The "quick and dirty" way when the business requires an immediate reduction in costs. This is planned in secret by a very small group and employees are told on Friday as their pink slips are handed out and told "don't come Monday". On Monday the survivors are given a pep talk and resume business. I've had to fire 30% of staff once that way. You provide support services etc. to try and minimise the pain. There is no "working out notice" and suchlike. One minute you are happy and productive, the next you are on the street.

2. The "slow and clean" way. You announce that there needs to be a cutback. You explain the reasons in detail. You explain the targets. You call for voluntary redundancy. You consult, you report back regularly, you keep people informed, you hold job fairs, give counselling, etc/ and you take at least six months to implement it

Qantas has chosen the worst way : "Slow and dirty". Maximum Fear Uncertainty and Doubt. One day somone tells you you have a job, next day maybe not. Strange looking consultants prowl the place talking in whispers. Rumours abound - fantastic rumours thrive in the absence of hard information. Some people purport to know whats happening but withold information to settle old scores - "if you are going to be kept, they will send you a letter next week" yadda yadda..

In this fertile hothouse evil flourishes. Where are Alan Joyces Five Thousand victims? Are you going to be one of them? Alans not telling. Stress multiplies unchecked.

[Captain Nomad]

A suggestion would be to mind your own business

I would suggest ensuring his aircraft is airworthy with sufficient fuel and oil for the job he is paid do is indeed a critical part of a pilot's business:

CAR 234 "Fuel requirements (1) The pilot in command of an aircraft must not commence a flight within Australian territory, or to or from Australian territory, if he or she has not taken reasonable steps to ensure that the aircraft carries sufficient fuel and oil to enable the proposed flight to be undertaken in safety." (italics added)

CAR 224 (2) (b) (b) "A pilot in command of an aircraft is responsible for:
the operation and safety of the aircraft during flight time;"

CAR 233 (1) (g) "The pilot in command of an aircraft must not commence a flight if he or she has not received evidence, and taken such action as is necessary to ensure, that: the aircraft is safe for flight in all respects;"

The just 'do your job and go home' approach reminds me of those I have come across over the years who have been fortunate that others do the right thing which so happens to save their 'couldn't care less' backsides...

[Australianguy]

Ok, granted that many are nervous. And while I certainly feel terrible for those pilots that may or may not be facing the axe, the issue here is if change management is affecting safety. Perhaps I could have been more delicate in my approach.

[The Banjo]

No, I am not a management stooge, however, this oil scenario has been topical for a number of weeks now.

Perhaps a better way to resolve the issue would be a professional internal email query to the fleet manager rather than plastering emotional crap on an electronic graffiti board for ALL to see....:=

[ALAEA Fed Sec]

Letters over the oil issue have formally gone to CASA. CASA must have acted because the Fleet Manager issued guidance for Pilots to use to ensure enough oil was in the tanks for safe flight. The guidance was wrong.


Change Management is something covered by the CASA Regs and it is an integral part of the now required Safety Management Systems. It must also include provision for consultation with users of the amended system. By not advising Pilots of their minimum oil requirements before the change and then getting it wrong after, breaches countless principle of the SMS.


Oil is just one of many changes though that have not been communicated, consulted or considered IAW mandatory Change Management rules. As this thread is about the interaction of CASA and the ATSB, it will be interesting to see how they react and what they do because of these alleged breaches.


From reading the REPCON outcomes, one could easily come to the conclusion that submitting a report is pointless because there is never any resulting fix to identified problems. I think someone needs to talk to the good Senator before he goes into the next estimates hearings.

[Paragraph377]

One could also include 'just culture' as an argument in this case. Just culture is also an element of the safety management system, and it has been heavily promulgated by ICAO and CASA. I would argue that in the case of QF management their just culture process is in breach of their safety management system because a just culture is not being fostered, promoted or complied with. Anybody at the company been issued a NCN for that yet? That's right, I didn't think so.

[Angle of Attack]

The minimum oil quantity was published last week for the 737 and with my own extra research it seems entirely correct. I don't watch TV and only read the odd paper so maybe it insulates me but I just go to work and after that go home to the wife and kids. There's no point worrying about stuff you can't change anyway.

[Hempy]

Tell me if this is a plausible scenario.

A/c has an engine burning abnormal levels of oil. A/c starts the day 'topped off'. A/c flies short sector. A/c oil levels now at 'normal'. New crew 'check oil' is at 'normal levels' and depart on long sector.....

[Angle of Attack]

As long as the oil is at the minimum required it would be more than enough for the maximum endurance of the aircraft, even if it was burning abnormally high levels. It would need to be burning extremely high levels to cause any issues. Regardless of that hypothetical would you refuse to go because the Oil quantity was at a minimum for a long sector? Unless you were going to a port with no engineers then possibly, otherwise I wouldn't think so. At the end of the day the 737 minimum is still 75% of capacity anyway, it's not that low.

[Australopithecus]

Angle of Attack...the minimum is 60%, not lower. We as a group have to rely on those pesky engine designers for a definitive oil quantity. Being ignorant of the geometry of the oil reservoir, the pick-up location, the minimum mass for thermal stability, the behaviour in turbulence, etc, I have to rely on published data.

As someone else mentioned, you could surely operate the engine safely with a bit less than minimum. But is something happened, even unrelated, they would be looking for a scapegoat. Guess who?

The published figures differ from those in the maintenance manual as mentioned in the other thread. You are apparently supposed to have 12 plus the anticipated consumption.

[ALAEA Fed Sec]

12 plus consumption is correct. The Fleet Manager put out information that the minimum oil was 12. period. no calculation for consumption.

[Angle of Attack]

In that case if the figure is 12 plus consumption that is concerning. The trouble is we can only go on what we are told. As usual we are left to take responsibility with no further guidance...oh yeah that is SOP I guess...

[HeSaidWhat]

Back to the topic - change and the stress it brings


In a way the 'safety card' has its place here. There is an old adage in Risk Management that says "Wherever their is change or growth, there is risk". This holds true because change can bring additional hazards in the operational space, or additional threats in the business sense.


So safety may well be in play here. That is, of course, if the risks associated with the change are not mitigated. Have QF put controls in place? Have those controls been implemented? Seems at the very least they haven't been communicated well, hence the REPCON.