Appendix 10 - Audit Report

Acme Aero Limited Audit
June 5 - 23, 2000

Audit Report

This report consists of four parts:

Part I - Introduction

Objective and Scope

This routine conformance audit was conducted on Acme Aero Limited during the period of June 5-23, 2000. The audit covered the period from June 20, 1997 to June 5th, 2000 and included reviews in the following areas:

  1. maintenance (AMO and air operator programs);
  2. flight operations;
  3. cabin safety;
  4. the transportation of dangerous goods; and
  5. aviation occupational safety and health.

Company - General

Acme Aero Limited is an aviation company formed in 1984. It offers both a scheduled and non-scheduled domestic air service from the main base at Macdonald-Cartier International Airport, with sub-bases in Toronto/Lester B. Pearson International Airport and Montreal International (Dorval).

Acme Aero Limited operates one PA31 and two DA20 aircraft from its main base, one HS-748 from each sub-base, plus one PA31 from the sub-base in Toronto. The HS-748s offer a scheduled service between Toronto and Windsor, Ontario and between Montreal and Val D'Or, Quebec. The PA31s operate on a charter basis and are available for med-evac under a standing offer with the Ministry of Health for the Province of Ontario. The DA20s have been added to the Air Operator Certificate since the previous audit in June 1997 and operate under contract to a major courier company. The operator transports dangerous goods by air.

Aircraft maintenance is performed in-house at all three bases. There is a full-time staff of eight Aircraft Maintenance Engineers, five apprentices and two technicians. The Aircraft Technical Records are kept at the main base in Ottawa.

The company has experienced steady growth and now employs over one hundred people.

Audit Synopsis

Mr. R. Jonson, Regional Director Civil Aviation, Ontario Region, convened Acme Aero's 2000 audit under the provisions of the Inspection and Audit Manual (IAM). The audit assessed Acme Aero's level of conformance with the regulatory requirements governing operations of Canadian air operators. The audit was conducted in accordance with policy and procedures detailed in the IAM employing standard, industrial auditing techniques. These techniques included interviews with key personnel, review of approved documents, sampling of relevant files, and random inspections throughout Acme Aero's system.

The audit entry meeting was held in Acme Aero's executive offices at Ottawa's Macdonald-Cartier International Airport on June 12th, 2000. During this meeting, the audit manager briefed the operator's management on the general audit process and the team's specific plans for the audit of Acme Aero. Throughout the audit, team leaders kept Acme Aero's officials informed of the audit progress and of all audit findings submitted. During the audit, Maintenance and Operations team members inspected specialty areas within the main base in Ottawa as well as Acme Aero's route structure. The audit was completed and the exit meeting held at Acme Aero's executive offices on June 23rd, 2000 with Acme Aero's President and Chief Executive Officer, Mr. Ian Stravinski, and the Convening Authority in attendance.

Audit Team

Position Name Region Phone Cell/Pager
Convening Authority R. Jonson Ont 416-952-0001 416-987-6542
Audit Manager T. Smith Ont 416-952-0002 416-987-6543
Administration S. Brown Ont 416-952-0003 416-987-6544
Team Leader (Ops) J. Reynolds Ont 416-952-0004 416-987-1234
Flight Ops K. McLean Ont 416-952-0005 416-987-1235
Flight Ops M. Michaels Ont 416-952-0006 416-987-1236
Cabin Safety V. Bruce Ont 416-952-0007 416-987-1237
Dangerous Goods P. Gagnon Ont 416-952-0008 416-987-1238
AOSH N. White Ont 416-952-0009 416-987-1239
Team Leader (Maint) F. Lalonde Ont 416-952-0010 416-987-2345
Maintenance D. Jacobson Ont 416-952-0011 416-987-2346
Maintenance W. Preston Ont 416-952-0012 416-987-2347
Maintenance S. Wallace Ont 416-952-0013 416-987-2348
Maintenance J. Black Ont 416-952-0014 416-987-2349

Company Management

Name Title Telephone No.
I. Stravinski President, Acme Aero Limited (613) 974-2300
J. Anderson Director, Maintenance (613) 974-2306
T. Baynes-Armstrong Quality Assurance Manager (613) 974-2307
B. Mathers Director, Flight Operations (613) 974-2301
N. Schaffer Chief Pilot (HS748, PA31) (613) 974-2302
F. Duquette Chief Pilot (DA20) (613) 974-2402
M. Tellier Chief, Dispatch (613) 974-2304
S. Lavallee Director, Inflight Services (613) 974-2305
D. McIntyre Manager, Dangerous Goods (613) 974-2308
C. Roberts Safety Officer (613) 974-2303

Corrective Action Plan

Audit Findings identify a situation where an Acme Aero policy, procedure, or activity does not conform to an approved company manual or to the applicable regulatory standard. The company must respond in writing to each audit finding, detailing short term corrective action to correct the specific examples listed, and long term systemic corrective action to prevent recurrence of similar situations. Transport Canada Civil Aviation will monitor implementation of Acme Aero's Corrective Action Plan through the audit follow-up process described in the IAM.

Review of Findings by Aviation Enforcement

Aviation Enforcement routinely reviews all audit findings after an audit and will advise Acme Aero through normal channels if it proposes to take action concerning any finding(s).

Part II - Executive Summary

General

The audit examined Acme Aero's Maintenance and Operations Divisions using applicable Maintenance and Operations checklists referenced from the Inspection and Audit Manual (IAM). A total of 10 Maintenance and 17 Operations audit findings were submitted. These findings identified examples of non-conformance to the Canadian Aviation Regulations (CARs), standards or Acme Aero's policies or procedures. A number of the findings were administrative in nature and can be easily corrected, whereas others were systemic and will require particular attention to ensure that corrective actions are effective in addressing the identified system faults.

Maintenance

The Transport Canada maintenance team reviewed all of the specialty areas applicable to Acme Aero Limited. The Acme Aero maintenance requirements and system was assessed to the Canadian Aviation Regulations (amendment 20-1) and individual Maintenance Control (Original May 31, 1997) and Maintenance Policy (Rev. 3, dated August 13, 1999) Manuals. The Maintenance Policy Manual (MPM) was approved October 16, 1996. Items that failed to conform to the above documents were recorded as audit findings.

The audit team sampled two HS74, one PA31 and two DA20 aircraft. Notice of Inspection forms were issued for two aircraft that had minor discrepancies. During aircraft inspections the absence of exterior placards on some aircraft resulted in the company completing an immediate fleet wide campaign to insure all safety placards were in place. Overall, the quality of the aircraft inspected was found to meet the applicable standards. Company facilities were found to be adequate for the scope of work and are well maintained.

The greatest areas of concern were found in the areas of the Maintenance Control Manual (MCM), Airworthiness Directive compliance and Technical Records. In addition to this, the maintenance evaluation program and quality assurance system require enhancements to achieve full functionality. Company management have demonstrated a positive attitude towards the audit and have acted proactively towards findings that have been identified.

Operations

The Operations Team audited 21 specialty area elements in accordance with the provisions of the Inspection and Audit Manual to ensure that Acme Aero operations conform to the requirements of the Canadian Aviation Regulations (CARs), associated standards and company control manuals. In addition to a comprehensive review of company documentation, control procedures and management personnel qualifications, the audit team conducted a series of in-flight and ramp inspections.

Deficiencies were noted in nine specialty areas resulting in sixteen audit findings. Most of these represent deficiencies in administrative procedures and guidelines that are to be specified in the company control manuals, specifically the Company Operations Manual, the Flight Attendant Manual and the HS-748 Minimum Equipment List.

The areas requiring immediate attention are: the flight crew training programs, which currently lack some essential elements; flight crew training records, which require a detailed system to ensure flight crews have met all training requirements; and procedures to monitor and report on CCP activities. The company will also want to review the HS-748 MEL and the MCM which currently contain conflicting procedures.

The above deficiencies notwithstanding, the review revealed that Acme Aero Limited is conducting a safe operation and that a knowledgeable, competent management team has been assembled to oversee a staff and crews that have the ability and desire to operate within the regulatory framework. The company's response upon learning of any deficiency was immediate and indicative of Acme Aero's focus on safety.

Part III - Maintenance Specialty Area Summaries

The audit focused on 26 areas relating to Air Operator Maintenance Requirements and 17 areas attributed to that of the Approved Maintenance Organization. A brief description of the areas where findings were made is provided.

Air Operator Maintenance Requirements

AOC - 01 Maintenance Control Manual

The company utilizes individual Maintenance Control and Maintenance Policy Manuals. A discrepancy relating to policy and procedures for the control of maintenance/service instruction information was raised. The responsibility for obtaining and making technical information available resides with the Air Operator, whereby MCM policy and procedures must specify how the operator will ensure that publications are available and current. Other minor deficiencies were noted in the MCM; these are documented under a separate finding.

AOC - 04 Technical Records

Conformity Certificates providing the details of maintenance performed were not generated as required or were found to be incomplete. In other instances, the company did not always comply with requirements to transcribe maintenance details into the permanent technical record.

AOC - 05 Evaluation Program

Audits are generally completed as indicated in the MPCM and follow up procedures have been completed, or are in the completion process. Independent Inspection anomalies, illegible entries and data entry errors and omissions were identified during this audit indicating that the daily sampling of log books and weekly surveillance is not being accomplished as required.

AOC - 11 Defect Control (Deferral)

A review was conducted on a sampling of each type of aircraft in the Acme Aero fleet. Findings indicated recurring defects are not identified as such because the company definition differs from the Canadian Aviation Regulations.

AOC - 12 Airworthiness Directives/Service Bulletins Compliance

On one occasion the company permitted the operation of an aircraft for up to 43 hours with an outstanding Airworthiness Directive requirement. In addition, this aircraft was operated while a particular Airworthiness Directive was not fully complied with. The company immediately removed the aircraft from active service while a follow up review with the AMO that completed the work was conducted.

Approved Maintenance Organization

AMO - 04 Maintenance Training

The maintenance training requirements of CAR 573.06 and 706.12 are being met, although no formal procedures for the planning and control of maintenance training have been developed. The company indicated that an amendment to the MPM is underway and will resolve this deficiency when completed.

Part IV - Operations Specialty Area Summaries

The audit focused on 21 areas of company operations resulting in 17 findings. Specialty area elements not mentioned below were found to meet regulatory requirements.

FO-3 Company Manuals

During the review of the company manuals, several areas were identified where procedures were either not linked from one manual to another or were lacking elements needed to fully comply with regulatory requirements. These, as well as shortcomings in the Dispatch Manual (see FO-9) and the Flight Attendant Manual (see CS-2), were identified under a single audit finding to simplify preparation of the corrective action plan and subsequent post-audit follow-up. A finding was also assigned to the Company Operations Manual for the lack of any mention of the Flight Safety Program, a requirement for all 705 operations.

FO-6 Company Check Pilot (CCP) Program

Acme Aero has three Type A CCPs and one Type B CCP. One of the Type A CCP's was found to have conducted 2 PPCs while his authority had expired due to a monitor ride not being done. This resulted in the company removing two pilots from flight status until such time as their PPCs could be renewed by a qualified CCP. It was also noted that the company had not implemented the required monitoring system to ensure that a CCP's authority is valid prior to scheduling the CCP to conduct a flight check. In addition to this, the monthly schedule of proposed flight checks was not being submitted to Transport Canada, nor was notification of CCPs who were no longer with the company.

FO-7 Flight Crew Training Program

The company flight crew training programs were reviewed and a number of deficiencies were identified. These resulted in three audit findings being assigned. A number of training programs were missing essential elements, the most important of which was the lack of night flying training during HS74 initial flight training, and emergency procedures practical training that is not being conducted in accordance with the standard. In addition to this, joint CRM training is not being conducted with flight attendants. It was also noted that some training programs were lacking the training examinations that are to be used to confirm that the candidate has grasped the required training.

FO-8 Flight Crew Training Records

The training records of 19 pilots were reviewed and a number of errors and omissions were noted. In one case, Acme Aero was requested to provide documentation indicating that the annual technical ground training for three HS74 flight crew had in fact been completed. The company was unable to do so. Further to this, company senior management were unaware that training had not been completed and that extensions had been granted by the TC Regional office. The reason for this was that the extensions had not been placed in the appropriate training files.

It was also noted that the company does not maintain a record of all required training elements where those elements are imbedded in other training programs (ex., CRM, HAI and MEL training are part of the annual ground training program and therefore not identified individually in the training records).

FO-9 Operational Control System

The flight dispatch office consists of a manager, two duty managers, 4 dispatchers and crew scheduling and operations co-ordination staff. The workings of the operational control system is well-organized with only a few areas in the Dispatch Manual requiring clarification. One Finding was made that pertained to the reporting relationships of the flight dispatch duty managers. They should not report to the Vice President, Operations on operational matters, since that position is not required to be filled by a certified flight dispatcher.

FO-13 Minimum Equipment List

A review of the company's Minimum Equipment List manuals and procedures resulted in two audit findings. These pertained to MEL procedures that were in conflict with maintenance procedures specified in the MCM, and out-of-date amendments.

CS-2 Flight Attendant Training Program

Although some discrepancies between the Initial Flight Attendant Program and the Flight Attendant Manual were noted, the overall Flight Attendant Program was being well maintained under the guidance of the Company's Learning and Development Co-ordinator. The variances were recorded under Company Manuals (finding FO-3-2).

DG-1 Dangerous Goods

The dangerous goods program at Acme Aero is satisfactory and company personnel are knowledgeable and professional in the conduct of their assigned tasks. One shortcoming was noticed where training records for two individuals did not contain a copy of the required training certification.

AOSH-1 Aviation Occupational Safety and Health (A-OSH)

Acme Aero's A-OSH program is maintained by two conscientious officers who exhibit support for the safety and health of employees. Through co-ordination and co-operation between the offices of Safety and the Facilities Environment and Site Safety, the appropriate occupational safety and health reports are provided in accordance with the standard with one exception that pertained to incomplete documentation and follow-up to an on board flight attendant injury.

Appendices - Findings

  • Maintenance Audit Findings
  • Operations Audit Findings
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