Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
ENG770
Initial Report
I raised a safety report within our company’s SMS after an aircraft was flown twice with open Tech Log defect entries. As this was an incident involving 2 sets of flight crews, the report was handed over to the CAMO Safety team for investigation. Subsequent action from the CAMO Safety team was to ask both crews of their recollections of the event. Following on from this, the CAMO Safety team have not addressed any of the issues these events brought forward: a) a cultural lack of awareness and bad practice from both sets of crews admitting not to normally check the Tech Log for open entries; b) an assumption that a manned base would have corrected any defects; c) a lack of recognition to the potential dangers of flying with open Tech Log entries by not carrying out any remedial action to raise awareness; and d) a lack of any response other than showing they asked the crew for their perspectives. There is also evidence to show an historic lack of confidence in the CAMO safety team coming from the Part-145 Safety Manager because previous issues seem to not be actioned.
Operator Comment
Thank you very much to the reporter for submitting their concerns. As an airline, we take pride in ensuring every report is processed, categorised, and risk assessed before they are shared with the relevant stakeholders and investigated or closed for trending as required. Reports are handled in accordance with our Just Culture, and those that are investigated focus on the systemic aspects as we believe errors and mistakes are a symptom rather than a cause.
On this occasion, we accept that the report could have been investigated further. This was missed due to a number of factors, including but not limited to the volume of reports we receive, requiring a level of prioritisation. Administrative changes have been taking place, while risk assessed accordingly, still increased the likelihood of mistakes.
Having said that, defect status management by flight crew is an issue that was identified as a trend by our SMS and, as a result, addressed as a wider organisational concern. It has been discussed at key safety meetings such as Safety Action Group and Safety Review Board and a dedicated Operations Notice will be published to the crew community in the next few weeks. This has highlighted a gap in the way we provide feedback to our contracted services also, which we are looking to address.
We would like to encourage all colleagues to continue to report safety occurrences, hazards, near misses and safety concerns.
CHIRP Comment
Quite apart from the report’s subject matter and the issue of why the Tech Log had open defects in the first place, this is not the first organisation to recently admit to experiencing issues in their respective safety departments. It may be that the shortcomings on the Ramp or Hangar floor are becoming the norm, but perhaps support departments are still, or suddenly, also feeling the squeeze.
Operating an aircraft without consulting the Tech Log concerns us. Engineers must consult the Tech Log prior to carrying out many tasks: applying Ground Power, starting an APU, applying hydraulics, commencing fuelling, and most certainly prior to starting an engine (plus a full sweep of the panel) for example. How prepared were the flight crew if they were unaware of open and/or carried forward items (especially those that require operational action (O))? Not to mention any Line Maintenance that might have taken place on the turnround (chip-plugs for example). We assume that this was a paper-based Tech Log rather than the increasingly common electronic versions because the crew would not have been able to accept the aircraft without acknowledging the electronic Tech Log, and the engineers would not have been able to hand the aircraft to the crews with open entries.
One question is what human factors issues were at work? The Dirty Dozen would point us towards complacency! Why was that the case? Is it ‘familiarity breeds contempt’? Flight crew walk-rounds concerned many engineers when they were introduced several years ago. There have been cases where flight crew who were expected to do their own walk-round never even left the flight deck. More accurate to describe such activities as heedless rather than complacent one might think.
The importance of the Tech Log and ensuring that it has been properly checked cannot be overstated; it is not something that should be taken for granted or paid lip-service to. It has been the case where an aircraft arrived at an outstation and it came to notice of someone in the organisation that the aircraft had departed with another registration’s Tech Log. Not only does this raise questions as to lack of awareness about the state of the aircraft concerned, but there are enormous legal ramifications as an illegal operation with potentially invalid insurance had something gone wrong; the potential consequences of which are unimaginable. CHIRP have received a number of reports recently from flight and cabin crew where reporting times have been reduced, even to the point of pre-flight briefings being carried out on the moving crew bus. Whilst not suggesting for a moment these pressures were taking place in this report, could time pressure be a causal factor for why two separate crews did not look at the Tech Log?