Fasten your seatbelts and check your documents
Fasten your seatbelts and check your documents
Bad document management can keep an airline on the ground.
The next time you have to convince a reluctant management team that your business needs an enterprise wide document and records management policy and system, you might like to point out that Ansett was once a strong Australian airline. Now Ansett is dead and as the vultures pick over the bones, bad document and records management proves to be one of the missiles that brought the airline down.
Many parts of Australia are still coming to terms with the loss of the second national carrier. As other airlines pick-up the pieces, the facts behind the Ansett collapse begin appear from behind the clouds. The recently released Australian Transport Safety Bureau (ATSB) report into Ansett having to ground its fleet of Boeing B767s demonstrates the dangers of not having a clear document management policy and system - dangers that threaten your business and the possibly the lives of your customers.
The ATSB is part of the Commonwealth Department of Transport and Regional Services, and is responsible for investigating accidents or serious incidents involving civil aircraft operating in Australia. It began investigating the grounding of Ansett's Boeing B767s after the fleet was grounded twice, firstly in December 2000 and then again in April 2001. By September 2001 Ansett was placed into voluntary administration by its owners Air New Zealand; the ATSB continued its investigation into the grounding because of its importance in Australia and internationally.
The report Investigation into Ansett Australia maintenance safety deficiencies and control of continuing airworthiness of Class A aircraft demonstrates how bad document and information practices led to the aircraft missing service schedules and being grounded, which then impacted on the financial state of Ansett and led to its closure.
GROUNDED
In December 2000 and April 2001 Ansett had to withdraw its Boeing B767s from service. Management at Ansett, in December 2000 had become aware that a mandatory check to an aircraft part known as a Body Station 1809.5 had been revised and had not been incorporated into Ansett's maintenance checks.
The design of the Boeing B767 meant that these checks are of primary importance. Boeing builds the B767 using damage tolerance principals, this means that the structure of the aeroplane is designed to remain sound until fatigue or corrosion can be detected at the scheduled inspections.
"It was critical that there were robust systems to ensure that the required structural inspections were carried out to detect the cracks before they exceeded acceptable limits," the Investigation into Ansett Australia maintenance safety deficiencies and control of continuing airworthiness of Class A aircraft report states.
Boeing and other aircraft and component builders supply users with documented information about the particular aircraft; these include maintenance service bulletins that will require immediate action in the form of an inspection, repair or modification. These bulletins are categorised according to their importance or urgency, typically as; Alert, Mandatory, Recommended and Optional.
In June 1997, Boeing released details of its Airworthiness Limitations Structural Inspections for the B767 to Ansett and other operators. Yet Ansett's Maintenance Development section was not aware that some of the inspections had to be completed when a plane had reached 25,000 flight cycles. Ansett's planes had reached a higher flight cycle as they were early models and had been used for short domestic routes. Ansett discovered in January 1996 that its B767 VH-RMG had a crack in the Body Station 1809.5. Subsequent inspections between 1996 and 2000 found cracks in other Ansett B767s.
"It was reasonable to expect that the Ansett B767 aircraft would be among the first in the world fleet to show evidence of cracking as the Ansett aircraft had accumulated a relatively high number of flight cycles," the report points out.
BREAKDOWN
Boeing sent the Airworthiness Limitations Structural Inspections to Ansett by post in June 1997. The Ansett library passed this document to the Maintenance Development section engineer responsible for the B767. No names of who received this document were marked on the document, breaking down the normal workflow practice.
As a result, engineers were aware that a new program had been released by Boeing, but were unaware that the flight cycle threshold was 50,000. On the 22 December 2000, Ansett informed the Civil Aviation Safety Authority (CASA) and it was agreed that B767s would be grounded before their first flight on the following day. In April 2001 inspections revealed cracks in the wing spars and CASA grounded the four remaining Ansett B767s. CASA issued Ansett with a Notice of Concern that indicated that the conduct of its maintenance was "deficient".
The ATSB investigation found no evidence of deliberate attempts to breach airworthiness regulations at Ansett and there was no accident, but because the airline could not confirm the airworthiness of the planes, there was significant concerns about their safety.
Withdrawing the planes from service also attracted wide media coverage. In its investigations, the ATSB found that central to the breakdown in communications and subsequent maintenance schedule failure and grounding was bad records and information management at Ansett.
"The ATSB investigation found that the Ansett system for the introduction and scheduling of the B767 Airworthiness Limitations Structural Inspections was deficient and vulnerable to human error," the report says.
Three areas of fault were outlined by the ATSB causing the Boeing B767s to be grounded; the organisation structure and change management; systems for managing work processes and tasks and resource allocation and workload.
Airlines have to process a mass of information and the lack of a coherent system to process that information at Ansett led to the breakdown in the maintenance of the service manuals.
"Because there is no authoritative standard for the categorisation of service bulletins, the terms that different aircraft and component manufacturers use to alert operators to the importance and urgency of service bulletins vary greatly. This has the potential to lead to confusion and misunderstanding of the relevance and importance of the information."
The investigation found that there was no formal record of communications occurring between the Maintenance Development section and the Technical Services department. Structural engineers worked for the Technical Services division, an engineer told the investigation that there was no formal procedure for recording and monitoring the workflow between the two work areas, leaving loop-holes open.
"Over a period of four years, the Ansett engineering and maintenance organisation did not incorporate two revisions of BB767 Maintenance Planning Data Document and two revisions of a Boeing service bulletin into the Ansett system of maintenance.
"The Ansett procedures for receiving, assessing and actioning manufacturers' service bulletins and Maintenance Planning Data Document revision were largely informal and lacked many of the safeguards necessary to ensure that tasks were completed in a timely."
Ansett's lack of a coherent document management policy added to a system that was open to problems. The report discovered that the manuals are not stand-alone documents and thus an engineer will have to access information from a variety of sources, which the ATSB felt "increased [the] chance of information being missed or misinterpreted.""Staff reported it was often difficult to determine what documents were important in a particular situation."
TIMS
As well as not having a clear document management policy, Ansett lacked the technology to create a system to equal the demands of the modern airline trade.
"The existing Ansett engineering and maintenance information management system did not have the functionality to adequately safeguard against a breakdown in processing of manufacturer service documentation."
In its report, the ATSB found that document management was over reliant on individuals and if documents were not stamped, as happened with the B767 checks, the system broke down. When a document was taken out by an engineer, there was no record on file when this document would be expected back.
"The Ansett Maintenance Development section received a large number of documents from manufacturers and other sources. However, most of the control of workflow was a manual process. Issues such as applicability and modification status were checked manually and any necessary changes to the maintenance system were also entered manually."
Ansett had begun to fly down the route of electronic document management, in December 2000 a structures engineer from the airline visited IBM in the United States to discuss testing its TIMS document management system, which IBM was developing for Ansett. The ATSB found that TIMS was intended to improve document management and data management and to "enhance airworthiness control by ensuring documentary compliance in areas of potential high risk." Ansett had two legacy mainframe systems, FOCUS and EMIS, both of which had "substantial data management and retrieval limitation."
In July 2000 the management at Ansett's maintenance business ANNZES halted the implementation of TIMS and reviewed the project. Work was to later resume, but with reduced functionality.
Ansett were not the only culprit of bad information management, the ATSB investigation discovered that Ansett were the weakest link in a chain of weak information management links.
Australia Civil Aviation Safety Authority (CASA) was found to have a defective database of reports. Deficiencies in reporting the information received by the authority meant the database was incomplete. ATSB felt that both the Australian and the international system for support continued airworthiness through the supply of information was "not sufficiently robust."
Boeing came in for criticism from the ATSB for the confusion that lays in its reporting system. Boeing documents were referred to by Ansett staff as being a '50 series'. This term does not mean that a report refers to when an aircraft has reached 50,000 flight cycles, but to the last two numbers in the Supplemental Structure Inspection report.
"Staff in the Ansett Maintenance Development section reported that they believed the term '50 series' used in some Boeing documentation indicated that the B767 Airworthiness Limitations Structural inspections would be introduced with 50,000 flight cycle thresholds. However, section 9 of the B767 Maintenance Planning Data document clearly indicated that a number of items had been assigned thresholds of less than 50,000 cycles."
Boeing also failed to consistently label its bulletins. An engineer told the ATSB investigation that that they were not aware that the front wing spar outboard pitch load fitting bulletin was an alert. The first issue of this bulletin, released in March 2000, was marked ALERT, but later revisions to this bulletin did not, other than a letter 'A'
DANGEROUS
Having the Boeing B767s grounded added to the dire situation that Ansett was in and added to its collapse on the 14 September, 2001. An airline cannot operate without its planes, having six aircraft grounded is damaging. Ansett had to cancel 14 flights and borrow much smaller aircraft from other airlines in an effort to carry its passengers.
An airline cannot afford to have a reputation for being unsafe and having its planes grounded by CASA will not have enamoured passengers to the idea of spending money on and flying with Ansett. As a result, it can be argued that Ansett's bad document management played a part in the collapse of the airline. Air New Zealand said it was losing $1.3 million a day on Ansett and that the airline's fleet of aircraft needed an investment of $4 billion. Ansett is dead and Air New Zealand had to right off debts worth NZ$1.3 billion.
Ansett clearly shows that bad document management, when added to a host of other problems, is just another ingredient that will bring a business to its knees. Thankfully there was not accident, but the ATSB report indicates the potential was there: "In both cases undetected fatigue cracking had the potential to eventually lead to structural failure."
"The manner in which events developed highlights the need for organisations to be continually mindful of potential threats to safe operations. Periodic review is needed to ensure that existing systems for maintaining air safety keep pace with the changing environment," the report said of the need to keep all systems up to date.
In its recommendations, following the investigation, the ATSB states that the international process of providing continued airworthiness could be to add quality management to the principals. The investigation found that Ansett and its systems was to blame, not human error.
"If human error on the part of one or two individuals can go unchecked within an organisation and result in a significant breakdown of the workings of the system, then the failure is a system error and not a human error."
Boeing's B767 is a large Class A airliner, and was therefore a pivotal part of the Ansett fleet and business. These aircraft were grounded because Ansett did not have in place the document and records management principals and technology to ensure information that kept these planes safe and in operation.
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