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Administration of the Civil Aviation Safety Authority

CHAIR —Welcome. Do you have any comments to make on the capacity in which you appear?

Mr Klein —I am here as a recently retired airworthiness inspector from CASA. The basis of my submission is some concerns I have with the oversight of Qantas.

CHAIR —Thank you. Would you like to make a brief opening statement?

Mr Klein —I think the submission is fairly specific, so I will just leave it at that.

CHAIR —We will go to questions.

Senator O’BRIEN —The nub of your concern is that CASA is not applying the resources it should be to the airline that you used to work for in terms of its regulatory role?

Mr Klein —Yes, that is part of the concern. I think the other part is the fact that the audit regime that has been put in for Qantas is not realistic. It is nowhere near enough—

Senator O’BRIEN —Has that changed in the last five years?

Mr Klein —No. The SPM has not changed in that regard in the last five years, and that is the bible; that is the document you work to.

Senator HEFFERNAN —What is the SPM?

Mr Klein —That is the surveillance procedures manual. It calls for one audit per year for Qantas.

Senator HEFFERNAN —Per plane?

Mr Klein —Per year for Qantas—one organisation. It has as many technical staff as the rest of the certificate approval holders combined. It probably has about a third of the LAMEs, and it is in the same bracket for an audit as an organisation with over 50 staff.

Senator HEFFERNAN —The same time is put into the audit as would be put in for Rex airlines or the like?

Mr Klein —Not the time. It just calls for the audit for airline aircraft with certain levels of staff. In the case of Qantas it does not even get a specific requirement. It just says ‘organisations over 50 staff, one audit per year’.

Senator HEFFERNAN —By the way, are you a licensed engineer?

Mr Klein —Yes.

Senator HEFFERNAN —Right. What does that audit involve? What are they looking for?

Mr Klein —The regime of audits has got to be constructed. In 10 years of oversighting Qantas I constructed quite a lot of them, and they vary. The focus was mainly systems based rather than product based. The previous regime of audits had a mix of a once-a-year systems based audit and a cyclic, product based audit, which I helped develop—I was on the project team for that. When this concept was produced and the development team for the SPM came around, as the senior Qantas airworthiness person I challenged it straightaway and said: ‘There is no way. I don’t care if you put 50 people in one audit; you’re not going to cover anything the scale and size of Qantas to any effect.’

Senator HEFFERNAN —But I still do not quite get it—I mean, it was £4.10 an hour when I learnt to fly. With the two systems, can you just say what they are rather than describing them—can you put a name to them? What are the two systems?

Mr Klein —With the predecessor of the existing system, you had a number of cyclic audits.

Senator HEFFERNAN —What is a cyclic audit?

Mr Klein —So many audits to cover off certain elements that you wanted to look at: management responsibility, facilities, structure, licensing, training, all those different things.

Senator O’BRIEN —They were separately audited?

Mr Klein —Yes. It is just a breakdown. You go in to do a major audit of the systems, on the management control aspects—

Senator HEFFERNAN —That is an administrative audit.

Mr Klein —Yes, and then following audits you would go in and do ramp checks. You go and look workshops, you go and look at different things—and that gave you a presence factor across the organisation. With the change to a systems based audit, focusing on the systems, the management philosophy, it has come away from a product based audit and it is nearly all focused on the top level.

Senator HEFFERNAN —So does the systems audit—as opposed to the product audit—mean that, rather than look at the workshop, if you look at the bloke who is the supervisor of that particular workshop and think, ‘Well, he’s qualified to look at the workshop,’ you will give him a tick?

Mr Klein —It is almost getting to that. It is saying, ‘Look at their documentation, make sure that procedures and processes are in order and focus on that side of it,’ and the product outcome basically became a secondary consideration.

Senator NASH —So in layman’s terms it is hands-on checking?

Mr Klein —Yes, going on to the hangar floor.

Senator NASH —Yes, hands-on stuff.

Mr Klein —A heavy check. Still, even with this new system, with the one check per year, I have put a little bit of my own interpretation on that. The last one I did—I remember well, in October in Brisbane—I went in on a heavy check, and that is where you can get some results. You have just got to go up to the guys working on the aircraft and ask, ‘Where’s your data? What are your qualifications? Do you consider these sufficient?’ That sort of drilling down is what is necessary to get the result.

Senator HEFFERNAN —And that doesn’t happen now?

Mr Klein —That happens now, right, but the main focus is still on the top level, on management responsibility and the systems in place. But I had to fudge a little bit to do what I want to do; that is what I am saying.

Senator HEFFERNAN —So you rely more on the paper trail rather than the practical?

Mr Klein —Yes, that is right.

Senator HEFFERNAN —So, if the paper trail was run by someone who like me had become worn out, or someone had got bad social habits or something and came to work with a hangover et cetera, the systems would fail.

Mr Klein —Yes. Another big focus, of course, is on internal auditing. If the internal audit is okay—and that is the way it is heading in the future, I think—and they set up the systems management approach, make sure they have got their own risk analysis, make sure they have got all these things in place, then you can draw back on your own inspection criteria.

If you look at Qantas right now, basically, it has massive resources in that area. It has its own human factors people, it has its own safety department, it has the risk department with lots and lots people there already, which will basically almost give them a tick in the box for the new way forward—and yet, even with that, you can still go in and find issues.

Senator FISHER —So, Mr Klein, are you saying there is no examination of the outcomes—there is a focus on systems and process to the exclusion of outcomes achieved?

Mr Klein —No.

Senator FISHER —So can you break it up percentage wise?

Mr Klein —I have been going in and getting findings. You act on your findings. I guess a lot of the action we have had to take with Qantas is not from our findings from audits as much as from triggers that have come in from other aspects. But we have had some findings from audits which have led to certain actions having to be taken.

Senator FISHER —Sorry; I should perhaps have clarified my question. To the extent that you are saying there is a focus on processes and systems rather than, in Senator Heffernan’s terms, on the practical, layman, hands-on-deck stuff, I have translated that as not looking at the outcomes that need to be achieved. So are you saying that, when the audit is done, there is no regard to safety outcomes but rather there is total regard to systems and processes? Or are you saying there is some regard to outcomes but it is insufficient?

Mr Klein —There is still regard to outcomes.

Senator FISHER —Do you want to indicate to what extent you think there is a regard, and then why you think that extent is insufficient?

Mr Klein —I am not saying that the regard to outcomes or the actual process and procedures are not appropriate. What I am saying is: the number of times we have a presence in the organisation, the number of times we would look at them, regardless of what is put in place—whether it is a systems based or a product based audit—is not enough.

Senator HEFFERNAN —Are you implying, though, that because some of the auditing is internal, as it were—so, for instance, would it not be in the interests of Billy Bloggs Airlines, an international carrier, that the internal certification and inspections were up to standard to keep their good flying record intact?

Mr Klein —Yes. Like I say, they put a lot of resources into that. I think they have 40 or 40-plus staff in their quality risk department; about half of those are internal auditors and they continually do a cyclic audit. Yet you could still go in and find problems which they do not find.

Senator HEFFERNAN —Can I ask a pretty dumb question? We had the earlier witnesses saying that a lot of this is outsourced overseas and that the planes come back with faults.

Mr Klein —Yes.

Senator HEFFERNAN —In your experience, when a plane goes through the same process in Australia, do they still come out and find some faults?

Mr Klein —Yes. In fact, some of the interest we have had—or I should say, I used to have—was particularly in Avalon. There is a lot of heavy maintenance in Avalon. And there have been a lot of human factors problems et cetera down there which have led to a lot of mistakes.

CHAIR —Would you find serious faults, such as the bolts not being properly done up in the galley?

Mr Klein —I would say equivalent to that, yes, for sure—if not worse.

Senator O’BRIEN —So, from your experience of the two different audit systems, you clearly believe that the current audit system does not reveal shortcomings that might exist in the process—is that what you are saying?

Mr Klein —I am saying that you can make the current system, the way it is now, work, to get product audit into it. It will work, but you need more of it. Take the case of Qantas. You are talking about three major heavy maintenance facilities; at least 40 or 50 component workshops; about 12 or 13 line stations around Australia, and a lot of those are international and domestic; and about 24 ports that they have maintenance conducted at, and at about half of those, I think, they have got Qantas engineers. You are looking at that spread, plus you have authorised persons who have their own delegations, and the delegates themselves, like us. They are supposed to be audited as well. But in the time that I have been trying to rationalise it all and get some means of at least getting a realistic sample—and that is what it is about—those people have virtually had very little audit. So it is the scale of the organisation.

Look at the Sydney office, for example. When the Sydney office was first put together many years ago, it was designed for Qantas as an international operator only. There was no domestic. When they took over Australian Airlines, it basically more than doubled in size and responsibility. How big did the Sydney office get? It probably had about the same level of inspectors as it has today—it has not developed. It has all been catered for, to my mind, by the audit frequency being reduced to meet the resources rather than the other way around. Why else would you put one audit a year in for Qantas? It just does not make any sense.

Senator HEFFERNAN —If you were in charge, what would you do?

Mr Klein —If I were in charge, I would make the audit regime—even the existing one, as it stands—meet a three-year cycle, so that every maintenance facility that Qantas has would get at least one visit from a team of auditors in a three-year cycle. In some areas you might ramp that up to a two-year or one-year cycle. Over a three-year cycle there should not be anywhere that Qantas conducts maintenance that CASA has not visited.

Senator HEFFERNAN —Does that also apply to Virgin or whoever else?

Mr Klein —Yes. Virgin have outsourced most of their’s—there is no comparison with Qantas. It is just mega.

Senator HEFFERNAN —Chair, perhaps I should declare an interest at this stage. I have a daughter who works for Qantas and I learnt to fly in 1965 at the Wagga flying school, which later became Kendall Airlines, which became Rex Airlines. Maybe I am conflicted, but I think this committee knows that I was in the previous government and if I had needed to give them a hard time I did, regardless of the fact that I was part of them.

Senator O’BRIEN —I think everyone at this table and many in this room have a vested interest in aviation safety. That is probably a given for everyone sitting around this table. The extent of your concern about CASA is that you believe they do not adequately perform their safety regulation function of Qantas because their audit system is inadequate in your experience.

Mr Klein —I would not say the audit system; I would say the audit frequency. There is no way you can make one size fit all and that is what they are trying to do. You have to have a discrete regime of audit for Qantas.

Senator O’BRIEN —The staff who conduct the audits—

Senator FISHER —Sorry, Senator O’Brien. Mr Klein, in terms of frequency or content of the audit? I am not convinced we have the final answer.

Mr Klein —What I said before was that because we had a cyclic system we had more of a presence. We can use the existing system but we need to do it more often to get the presence.

Senator FISHER —So you are saying that the difference for Qantas should simply be more often.

Mr Klein —More often.

Senator O’BRIEN —And drilling down to different sites, I think you are saying.

Mr Klein —To drill down, yes.

Senator O’BRIEN —You were talking about a three-year rotation, drilling down to all of the sites where the maintenance was conducted, so that there is a presence and understanding of the operation and scrutiny everywhere that the maintenance was performed.

Mr Klein —That is correct. Overseas, as I said, there is very little other than Singapore, Los Angeles and Hong Kong that have had any CASA presence at all.

Senator O’BRIEN —Do you know how that would compare to the scrutiny of airlines in other parts of the world?

Mr Klein —Yes. Wherever there is a N-registered aircraft, FAA will sight it. Qantas have what they call contracting state arrangements, say, in Mumbai in India. If you turn up at Mumbai, Air France will be turning their aircraft around. Air France might have one or two Air France specialists there and the rest will be from the local area.

Senator HEFFERNAN —What would you do if you were in charge in Mumbai? Would you have Australian people there supervising them?

Mr Klein —They still work to the Qantas system of maintenance, but that is the key issue: somebody should be going over there. I talked to the internal audit people at Qantas recently about how many times they go in because we are not going in. I cannot remember, but it was not very often. I said, ‘What did you think of Mumbai?’ because that concerns me, you know. I think they pick the grottier areas and try to look at those and see how they shape up. The response I got was not that impressive. You need to be there and say: ‘That is Qantas’s regime of audit. How do you people interpret this? You are the contractor’—they have the agreement. ‘When you do your turnaround inspections, what levels of supervision do you have? How do you coordinate your technical data? How do you get the information back to Qantas?’ You have to ask all those sorts of things just to make sure you have a foothold on it and you can do a baseline of risk. For years, when I kept complaining about not seeing enough of the organisation, they kept saying, ‘We’re going to do a risk model and do it all by risk model.’ They came up with some risk model that was never going to meet Qantas’s requirements. Even now, the last report I read on the Transport Canada introduction of the safety management system, which is the new way forward for CASA, was not very impressive at all.

Senator HEFFERNAN —Have you retired?

Mr Klein —Yes, I retired at the end of February.

CHAIR —That is in Mr Klein’s submission.

Mr Klein —I keep saying ‘we’ because I still think I am working for CASA.

Senator O’BRIEN —After a while it would be second nature that you would say that. I am interested in your reflections on the Canadian experience of the similar system. What do you know about that?

Mr Klein —I can give you a copy of the quotations that I have said that I have.

Senator O’BRIEN —Where from?

Mr Klein —I am not sure. It came through the net from somebody, but I am not sure. It was one of those things that appeared on my screen one day. It indicates the implementation was done and the Canadian auditor general went in, after three years I think it was, and it got the worst rap I have ever seen.

Senator O’BRIEN —So presumably that is in the Canadian system. Their auditor general audited the system, which was called what?

Mr Klein —It is the safety management system approach. You set up a safety management system within an organisation. Like I said before, Qantas has got just enough to give a tick in every box on that. You set it up and, in theory, the authority, once it is set up and they can do their own risk base assessments, can step back.

Senator O’BRIEN —So that system was put in place in Canada. After its operation for three years, to your knowledge, the auditor general in that country reviewed it and found serious shortcomings with the system?

Mr Klein —Yes, very much so.

Senator O’BRIEN —And that is the system that CASA applies to Qantas?

Mr Klein —That safety management system is the philosophy that is being pushed now as the panacea to fix our system. I think a lot of it is resource focused. CASA talks about limited resources so we can deal with the industry and let them become responsible for their own risk assessment, but the report I read indicated it was almost a quasi-self-regulation. Transport Canada pulled back too far, to the point they lost a business aircraft or something, which could almost be attributed to it.

Senator HEFFERNAN —But do you think in time, by erosion, it will be less safe to fly under what we are doing? I am wondering if it is not in the airlines’ interests to keep up the standards, even if CASA has not as much input.

Mr Klein —My main focus to come here today was Qantas. I do not want to diverge into general aviation, please.

Senator HEFFERNAN —You stick with what you want to stick with.

Mr Klein —As far as a safety culture goes, you cannot get much better than Qantas. The safety culture is there and they throw a lot of money at it. They have huge resources pumped into safety culture, but you have human factors impacting on that. Right at this point in time, to my mind, you have a morale problem.

Senator O’BRIEN —With Qantas or CASA?

Mr Klein —Qantas—very much so.

Senator HEFFERNAN —They can come and join us farmers.

Mr Klein —LAMEs are under threat, as you know. They shut down Sydney heavy maintenance and they put the threat over their head that, if they do not produce, they are going to look at the rest. So there is low morale and, at the same time, there is the introduction of the A380—coming in in August—involving a massive amount of training requirements and a lot of people tied up in that project. I used to be the coordinator for that project before I retired. Another aspect is commercial pressure.

Senator HEFFERNAN —They might call you back.

Mr Klein —After today, I will not be called back. When you look at heavy maintenance, the commercial pressure aspects are quite interesting. A heavy check on a 747 involves 45,000 or 50,000 man-hours, and that is projected out over about six weeks. As they get to the sharp end of it, invariably they have made commitments for that aircraft that, in most cases, it is not going to come out before the six weeks—it is going to be a little bit over that. With a lot of my heavy maintenance—well, not a lot; I did not have that many—I deliberately planned at least one aircraft towards the end of its check, so I could see how much commercial pressure was involved.

Senator NASH —Mr Klein, can you outline for me as a layman what a heavy inspection actually entails?

Mr Klein —It can vary, but in most cases you have to strip the aircraft right out and remove all the panels. There is normally a significant inspection for corrosion and inspection of a lot of areas that you normally cannot access at other times. It is mainly based on calendar time and not hours—or pressure cycles. In most cases with Qantas, their heavy check comes up every 18 months. A lot of them end up in that calendar cycle so tight, and that is the reason that they are now looking at offshore to get them out of the commitments they have—because they tend to bunch up.

Senator NASH —On average—as I am sure it varies—how long does the actual inspection itself take?

Mr Klein —Between 45,000 to 55,000 man-hours over about six weeks.

Senator NASH —How many people would work on that?

Mr Klein —They rotate shifts around the clock, but with most shifts you are looking at about 40.

Senator NASH —You were saying before that you would tend to come in towards the end of that period.

Mr Klein —I tried to look at the heavy maintenance schedule and see what aircraft were going through. Normally, in Qantas, they would have a couple in the one hangar. I would try to get at least one of those that was towards the end.

Senator NASH —As an inspector, how long would you spend on site doing your job?

Mr Klein —I used to plan it so that I was on the floor for at least a full day. I would try to cover off one full shift and then look at a transition of a shift coming in the other way to see what the shift changeover was like. So there was one full day on the floor for at least each aircraft that was in the hangar. I also spent a lot of time in the supervisors area, where they have all the planning documents and the sign-off documents. I would then look at the full trail from there.

Senator NASH —You mentioned earlier that you had to fudge.

Mr Klein —The surveillance procedures manual has a hybrid section in it for airlines and there are all these elements that you can choose from. For instance, you will not find one element that says ‘ramp inspection’. It will say ‘continuing airworthiness’. So I made ‘continuing airworthiness’ fit a ramp inspection. That is the sort of thing that I am talking about. You do not necessarily find what I consider is needed to do a proper drill-down audit the way I would want to do it.

Senator NASH —Would you say that you felt that you were limited by what your job description actually was, compared to what you really thought needed to be done?

Mr Klein —Yes, I would say that to some degree.

Senator NASH —Going on from that, what specific things did you see that were not in your job description that would have benefited the process had you been able to do them?

Mr Klein —I guess, from a job description point of view, it was mainly the flexibility to be able to look a bit further, past the systems element, and go more into the product element side of the audit. That was mainly it. I would like to be able to look at that. A lot of the triggers came from the other end. You will not find a better set of documents around than the Qantas procedures manuals. They are massive, and they cover just about everything, but it does not mean that the guy at the other end understands or follows them. In most cases, when we had findings it was that issue—failing to follow their own procedures. At the top end, you are looking at documentation that is great—it is fantastic. They have risk assessment. Everything at the top end is there. But when you get down and check the process at the other end that is where you make the finding.

Senator NASH —On that follow-through, surely if that process is not appropriate all the way through then it does not matter how good the systems are at the top. I think you mentioned human error before. They are human beings and, if there is not a check on what the human beings are doing at the end, it does not matter how much good stuff you have at the top. It is the delivery that has to be checked as well.

Mr Klein —Yes, the delivery as well, and it is the attitude. That is why I am saying the—

Senator HEFFERNAN —Would it be fair to say, finally, that if you have whatever it is—what is the plane that is coming in?

Mr Klein —The A380.

Senator HEFFERNAN —Righto. We live in a global environment. Would you like to see a global standard to look after an A380?

Mr Klein —The A380 is an interesting one because, I believe, Qantas will be able to do all the maintenance themselves anyway, but they obviously want to try and be able to do maintenance overseas. If you are looking at overseas maintenance—I did not want to divert to that because of the previous one—doing it becomes very complex. It is a separate regulation set that you work to.

Senator HEFFERNAN —Thank you very much.

CHAIR —Thank you, Mr Klein, for your assistance to the committee.

[10.02 am]