Stress caused by the handling by management of major changes within
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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.
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.
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.
CASA continues to focus oversight activities on identified areas of change.
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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.
They simply never do anything.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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"Operator 1" The organisational transformation is being undertaken through established change management processes to ensure that ongoing safety assurance is being maintained.
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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!
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!
Austraopithecus,
A few B737 FACTS:
Boeing: Boeing 737 Facts
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
A few B737 FACTS:
Boeing: Boeing 737 Facts
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
This reminds of the good old days in NZ when the CAA would say yes to anything that TE asked.
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.
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.
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.)
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.)
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why check the oil at all?
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...
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...
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.
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.
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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 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".
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.
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.
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Checks and balances.
Snakecharma - The arguments that management understand are related to cost and commercial issues.
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.
Last edited by Kharon; 4th May 2014 at 23:26.
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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.
A few delays put down to oil servicing that wasn't required will soon get their attention. I can see the FSO now.
Snakecharma:
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.
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
"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.
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.
And your suggestion is to "mind your own business, smile and be happy"? Seriously?