SCENARIO FOI WS on RCA CAPABILITIES

Scenario 1:
Training Division audit of an large aircraft operator is scheduled (the company was notified 2 weeks
in advance by mail and official letter)

CAA team is composed of 2 FOI, a team leader, POI and a Junior FOI

Objective of this audit to Training division organization, the training program implementation and the
training management,

For preparation, documents available are Training Manual of the Operator (PART D), Safety & Quality
Manual, General Organisation Manual (PART A)

To welcome the FSSD Team just the Quality Manager was present. Neither a Manager nor a Deputy
was working in the office, the Chief Pilot, the Training Manager and the DFO are absent.

The operations are scheduled with 2-night standby outside the country 6/7 day a week.

Have been identified:

 The pilot training files are not updated, difficult for the FSSD team to be sure that the Pilots
are in conformity,
 The Instructor report (forms) are not well filled, are not reflecting the OMD and are leading
to certain ambiguities on the result,
 The annual training program on SIM is not updated, there is no SIM reservation, knowing
that 3 to 6 months are required to book a SIM cession,
 The QAM insisted on the importance of the Safety in this Airline despite all nonconformity
noted.

Scenario 2:
CAA, through airworthiness department, was informed of a possible excess of Pilot’s monthly flight
time in a small Airline,

Based on this information a random Surveillance Plan audit was scheduled (in emergency)

A team of 2 FOI was designated to conduct audit

CEO and QAM welcomed the FSSD team, the other Managers were not in the office.

The FSSD Team presented the purpose of the audit.

Have been identified:

 The CEO explained this nonconformity by a lack of Pilots and confessed that this event was
not a big issue due the high experience of his Pilots,
 No one in the company was able to present the operations daily planning,
 Evidently, the CEO was not aware of the procedure in use under his responsibility,

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SCENARIO FOI WS on RCA CAPABILITIES

 The QA Manager took about the Quality in place for the aircraft maintenance only,
 The forms were well filled, the follow-up of each Pilot was done as mentioned in the OM and
appeared clearly the excess (22 and 31 hours in excess) for the past 2 months of the total
flight hours for 2 Captains,
 No trace of a Safety specific meeting on this issue was found by the FSSD team.

Scenario 3:
A SANA out of KTM was scheduled for a week. Was targeted the small Operator operating high
altitude airfields.

Organization was conducted by the Chief of FSSD due to the administration’s procedures in use in
CAAN. 3 FOI were involved in these tasks, 2 Senior experimented and 1 Junior.

3 Operators were audited including 1 Helicopter Operator.

The bad weather conditions made the audit difficult.

Living conditions were summary.

Have been identified:

 Immediately, the team observed a relaxed ambiance, the Operator’s staff did not wear
uniforms within all other people, expect 2 Pilots out of 6,
 Absence of the Chief of the remote Base during the operations, only ACFT maintenance,
handling staff and Pilots,
 Poor communications between the main base and the remote place,
 Operations data not updated per flight and dispatch to the main base once a week during the
staff permutation,
 Weight and balance not strictly done,
 Use of O2 not well understood, Oxygen equipment unserviceable on 1 ACFT
 Safety culture is evidently not anchored among this environment while exceedingly difficult,
 A feeling of routine emerged more than a professional attitude,
 The official information to the pilots (weather, traffic…) is poor, leaving the Pilots on their
own devices.

Scenario 4:
During and audit on KTM apron, the FSSD team observed a large aircraft landing after the touch
down point. This landing was followed by a long stopping distance and the aircraft finish its landing at
the end of the runway. Due to event, KTM TWR ordered to next aircraft on approach to perform a go
around.
After 72 hours, neither the Operator nor the TWR have been send an occurrence report to the FSSD
office.
The FSSD Chief decided an investigation.

Have been identified:

 The DFO and the SMS Manager of the Operator were not able to present an FDA analysis
thinking this landing did not falling in this process,

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SCENARIO FOI WS on RCA CAPABILITIES

 The Crew declared a normal landing admitting a bit longer than another,

Scenario 5:
FSSD received an occurrence report from the Cabin Crew chief of an operator performing
international flights.
This occurrence report notified the non-respect of the Safety procedures during a departure
flight after a night stop outside KTM due to a malfunction of an automatic system
deployment of an emergency exit .
The Captain decided to continue the flight with the same number of passengers.
Have been identified:

 No communications between the Captain and the OCC (including MCC) in KTM due
the office closed (while the departure scheduled at 2 am)
 Non-respect of the procedures described in the OM,
 Role and responsibilities of the Chief CC during the flight
 Safety culture implementation while SMS publication are covering the wall in the
company.

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