Bristow Norway AS
|
Report No.
|
1809 |
|
Type of audit
|
External Audits |
|
Auditee/Customer
|
Bristow Norway AS |
|
Date
|
2020/10/21 |
|
Findings
|
14 |
|
Status
|
Closed |
Audit Report – Bristow Norway AS
Summary
audit report, to verify Bristow’s compliance with requirements. Several pre-audit planning meetings were
arranged to clarify the operator’s expectations, and requirements for the audit. The audit covered a review of
some of the management control framework in place to ensure compliance; and the audit team visited
Bristow’s offices, and conducted interviews with relevant personnel, accompanied by verifications of applicable
documentation. Spot-checks and reviews of the current management system reveals significant challenges and need for
digitalization, and effective systems for all disciplines. Processes appear labor intensive and dependent on
individuals, with several manual processes using Excel spreadsheets. However, the quality of these appears
sound. KPIs are processed manually, with significant use of resources utilizing Bristow’s “home-made” systems,
with limited support. The audit team note that management indicates willingness to introduce industry
recognized IT solutions.
Findings
-
The Bristow Norway Management review (MR) for 2019 appears to be noncompliant with requirements in ISO
9001 standard. Top management shall review the organization’s suitability, adequacy, effectiveness, and
alignment with strategic directions of the organization, and the MR shall contain inputs and outputs.
Bristow Norway’s MR appears inadequate with regards to structured identification of opportunities for
improvement, and requirements for changes. The MR does not include documentation of decisions and actions
related to the processes. Furthermore, the auditors note the following:
MR for 2019 was completed in October 2020, untimely to ensure continuous improvement processes
to be included in annual action plans.
• Actions resulting from the review are not documented in Q-pulse, and there is no evidence to suggest
that these are subject to a systematic follow-up during the next review.
• Repetitive observations from 2018
• The process of measuring Goal attainment appear inadequate
• MoM and relevant documentation missing, Date for MR indistinct, participants not registered -
Admission management
Management of company identification (ID) cards, including responsibility for all processes related to
admission control and issuance of Airport Access badges, are the responsibility of the Facility Manager;
however:
• Management of ID cards and admission cards are administered by Approved Training Organization
(ATO) planner
• Several employees discovered without required valid Avinor ID & access card
• Employees without valid Avinor ID & access card discovered with provisional access to facilities with
• Use of Bristow company key card for access at Sola
• Use of Bristow temporary visitor cards for access
• Note: Validity of time for keycards and visitor cards and follow up processes appear unclear
• No evidence of a formal procedure for removing access privileges, relies on the annual review of access
holders carried out by Avinor
• Security personnel manning the reception counter issues visitors’ cards
• Lack of coordination with facility management
• Indistinct criteria and requirements for issuing visitors cards
• Ambiguous management of Avinor driving licenses at Airside -
Health and Usage Monitoring System (HUMS) management
HUMS management is described in Continuing Airworthiness Management Exposition (CAME). The Job
description for the HUMS administrator incorrectly describe the HUMS administrator as reporting to the
Technical Manager in CAME 0.3.3.7. However, the auditors note that the HUMS administrator is appropriately
not included in the Organization Charts for Part M in CAME 0.4.2. The HUMS service is subcontracted to
Bristow Limited in Aberdeen. -
Competency management
Spot-checks reveal lack of required competency in accordance with requirements in the Management System
Manual (MS)for Nominated Postholders, furthermore:
• Nominated Postholder Flight Operations lacks documented training for Human Factor and Dangerous
Goods.
• Nominated Postholder Ground Operations / Service Delivery Manager lacks documented training for
Investigation Techniques, including Human Factor investigations.
Additionally, the auditors note that competency for management personnel appears complicated to manage,
in order to ensure compliance with requirements in MS. -
The audit team, based on feedback from customers and Bristow personnel regarding variable quality of
reports, and limitations in standardized processes, reviewed the current Investigations management processes.
The review of Management System Manual Chapter 13 “Safety Investigations” and relevant appendixes reveal
the following weaknesses:
• Vague requirements such as “Are always carried out” and practice – “Terms of reference” – Unclear
mandate
• Ambiguous requirement for use of limited technical Bristow Event Analysis Tool (BEAT) and full BEAT
• Vague requirement for use of initial checklists
• Unclear formalities for involvement and support of Event Review Group (ERG) using FAiR® system and
Just culture process versus investigation team’s intentions of independency, objectivity & integrity
• Unclear role of Safety Action Group (SAG), and Safety Review Board (SRB) responsibilities
• Unclear customer involvement and participation in investigation teams such as observer role
• Unclear involvement of employee representatives and protocols to ensure compliance with legislations
• Limited descriptions of formal hearing processes and involvement of relevant stakeholders
• Limited descriptions of formal processes and requirements for QA/QC of investigation report, review
board, document control and final approval
• Limited requirements and processes for presentation, and “hand over” of investigation report to
management
• Unclear processes for follow up after the report have been issued and adequate documentation
• Note: Flow chart in Management System Manual is describing a process with limited
compliance with text in Management System Manual
• Lacking requirements for confidentiality, and sharing of experiences with customers and stakeholders
• Definitions of competency requirements for investigation team, and approved training providers -
Delays and technical issues in May 2020 at Florø and Hammerfest were reviewed, and spare part stock levels
and availability were highlighted as a possible contributing factor. Spare part management at remote bases
appears to have potential for improvement including need for the following actions:
• Review stock levels, assortment, and availability for spare parts for local bases to ensure optimal
management of spare parts and performance
• Optimize logistics for spare parts -
Management and responsibilities in Ground Operations Manual (GOM) appears indistinct for the following:
• 2.1.1 Ramp Safety Audits
• Defined as the Bristow internal audit by Ground Operations. However, management and
responsibility for these audits appear ambiguous. Ground Operations could not document
compliance with this requirement, and it was unclear if the activities were conducted by
Ground Operations or Safety & Compliance departments.
• Ramp safety risk assessment during regular safety inspections
• Requirements and practice should be reviewed– Last “quantification” 05.04.2018
• “Quantification” terminology and method should be defined
• Accident and incident procedure are incorrect and not aligned with Emergency Response Plan (ERP) -
Management of quarterly Safety Review Board (SRB) appears to have potential for improvement and the
auditors note the following:
• SRB for Q1 were conducted 30.04.2020. SRB for Q2 have not been issued, and 3 meetings have taken
place since.
• Inadequate terminology and requirements, such as “no significant comments”, “SMS is working
satisfactory” and “all members of SRB are obliged to keep themselves updated on regulatory news …”
• Several relevant issues noted as information, which would be relevant for implementation of follow-up
and mitigating actions.
• Actions and responsibilities are not defined for areas such as high sick-leave KPI, increase of
fatigue, and significant use of overtime.
• Lack of follow up from previous meetings, defined actions, and responsible person
• Actions not recorded in Q-pulse, or other management systems
• Impression of “copy & paste” in several areasThe audit team recommend reviewing processes for aligning SAG and SRB meetings for content and
purposes. -
The sick leave rate for Q1 2020 were 5,4 %, which appears high, given Bristow’s target of not exceeding 3 %.
Sick leave rates are differing between bases and professions, with identification of causes, and mitigating
actions appearing inadequate. The audit team note a concern that the pilot group appear to experience
challenges for Sick leave and “loss of license”. Feedback received from Operators voices concerns for work
environment and sick leave ratio for pilots. -
The audit team conducted reviews of documents and manuals, and several versions of designation for the
Safety and Compliance Manager were found. Correct title must be used to avoid confusion and incorrect
compliance with responsibilities for the CAA-N approved position. -
Chapter 26” Virus and pandemic strategy” refers to World Health Organization (WHO) and lacks references to –
and alignment with Norwegian Health Authorities requirements and recommendations, including risk levels -
Documentation and action logs for ConocoPhillips incident “Mayday call” LN ONQ 25.09.2020 were reviewed,
revealing inadequate documentation of notification processes.
• Hard copies of action logs contain handwritten information and documented information appear to be
inadequate compared with requirements and expectations for level of details
• Online incident documentation contains limited information, and is possible to edit post incident
• Interviews reveals challenges related to decisions if Bristow should inform customer when incidents
take place.
• Processes for clear and concise information to customer appear ambiguous
• Positions and personnel in Bristow responsible for information appear indistinct – Operations Centre,
Nominated Postholders, Accountable Manager or ERP Team
• Reviews reveals that checklists should be revised, to simplify terminology and identify relevant
information to be documented.
• Content and details of checklists appear extensive and overlapping
• Note: Bristow should encourage Operators to standardize bridging documents and notification charts
to ensure equal level of information and simplify processes if an emergency occurs -
The audit team note that several Air Safety Reports (ASR) are registered, challenges identified in Management
review and responses among personnel in interviews related to the E-Flight Management system. The E-Flight
system appears somewhat to be inadequate for its purpose, and dependent on quality of manual inputs,
including several time-consuming processes related to quality control associated with input of data. -
Bristow Norway “Industrivern Manual” appears unaligned with relevant manuals and requirements, such as:
• 2. “Mål og handlingsplaner”
o Lack of Risk assessments of Facility management, and not reviewed 4 times annually as
required.
• 8.1 “Internt tilsyn”
o Incorrect terminology, undefined requirements for Housekeeping
• 9.1 “Alarm og varslingsplaner”
o Not in accordance with Emergency Response Plan
o Unclear requirements and criteria for Notification to Police if fatality or “spinal cord injuries”
Additional Documentation
New Audit Report
\n
Bristow Norway AS
|
Report No.
|
1809 |
|
Type of audit
|
External Audits |
|
Auditee/Customer
|
Bristow Norway AS |
|
Date
|
2020/10/21 |
|
Findings
|
14 |
|
Status
|
Closed |
Audit Report – Bristow Norway AS
Summary
audit report, to verify Bristow’s compliance with requirements. Several pre-audit planning meetings were
arranged to clarify the operator’s expectations, and requirements for the audit. The audit covered a review of
some of the management control framework in place to ensure compliance; and the audit team visited
Bristow’s offices, and conducted interviews with relevant personnel, accompanied by verifications of applicable
documentation. Spot-checks and reviews of the current management system reveals significant challenges and need for
digitalization, and effective systems for all disciplines. Processes appear labor intensive and dependent on
individuals, with several manual processes using Excel spreadsheets. However, the quality of these appears
sound. KPIs are processed manually, with significant use of resources utilizing Bristow’s “home-made” systems,
with limited support. The audit team note that management indicates willingness to introduce industry
recognized IT solutions.
Findings
-
The Bristow Norway Management review (MR) for 2019 appears to be noncompliant with requirements in ISO
9001 standard. Top management shall review the organization’s suitability, adequacy, effectiveness, and
alignment with strategic directions of the organization, and the MR shall contain inputs and outputs.
Bristow Norway’s MR appears inadequate with regards to structured identification of opportunities for
improvement, and requirements for changes. The MR does not include documentation of decisions and actions
related to the processes. Furthermore, the auditors note the following:
MR for 2019 was completed in October 2020, untimely to ensure continuous improvement processes
to be included in annual action plans.
• Actions resulting from the review are not documented in Q-pulse, and there is no evidence to suggest
that these are subject to a systematic follow-up during the next review.
• Repetitive observations from 2018
• The process of measuring Goal attainment appear inadequate
• MoM and relevant documentation missing, Date for MR indistinct, participants not registered -
Admission management
Management of company identification (ID) cards, including responsibility for all processes related to
admission control and issuance of Airport Access badges, are the responsibility of the Facility Manager;
however:
• Management of ID cards and admission cards are administered by Approved Training Organization
(ATO) planner
• Several employees discovered without required valid Avinor ID & access card
• Employees without valid Avinor ID & access card discovered with provisional access to facilities with
• Use of Bristow company key card for access at Sola
• Use of Bristow temporary visitor cards for access
• Note: Validity of time for keycards and visitor cards and follow up processes appear unclear
• No evidence of a formal procedure for removing access privileges, relies on the annual review of access
holders carried out by Avinor
• Security personnel manning the reception counter issues visitors’ cards
• Lack of coordination with facility management
• Indistinct criteria and requirements for issuing visitors cards
• Ambiguous management of Avinor driving licenses at Airside -
Health and Usage Monitoring System (HUMS) management
HUMS management is described in Continuing Airworthiness Management Exposition (CAME). The Job
description for the HUMS administrator incorrectly describe the HUMS administrator as reporting to the
Technical Manager in CAME 0.3.3.7. However, the auditors note that the HUMS administrator is appropriately
not included in the Organization Charts for Part M in CAME 0.4.2. The HUMS service is subcontracted to
Bristow Limited in Aberdeen. -
Competency management
Spot-checks reveal lack of required competency in accordance with requirements in the Management System
Manual (MS)for Nominated Postholders, furthermore:
• Nominated Postholder Flight Operations lacks documented training for Human Factor and Dangerous
Goods.
• Nominated Postholder Ground Operations / Service Delivery Manager lacks documented training for
Investigation Techniques, including Human Factor investigations.
Additionally, the auditors note that competency for management personnel appears complicated to manage,
in order to ensure compliance with requirements in MS. -
The audit team, based on feedback from customers and Bristow personnel regarding variable quality of
reports, and limitations in standardized processes, reviewed the current Investigations management processes.
The review of Management System Manual Chapter 13 “Safety Investigations” and relevant appendixes reveal
the following weaknesses:
• Vague requirements such as “Are always carried out” and practice – “Terms of reference” – Unclear
mandate
• Ambiguous requirement for use of limited technical Bristow Event Analysis Tool (BEAT) and full BEAT
• Vague requirement for use of initial checklists
• Unclear formalities for involvement and support of Event Review Group (ERG) using FAiR® system and
Just culture process versus investigation team’s intentions of independency, objectivity & integrity
• Unclear role of Safety Action Group (SAG), and Safety Review Board (SRB) responsibilities
• Unclear customer involvement and participation in investigation teams such as observer role
• Unclear involvement of employee representatives and protocols to ensure compliance with legislations
• Limited descriptions of formal hearing processes and involvement of relevant stakeholders
• Limited descriptions of formal processes and requirements for QA/QC of investigation report, review
board, document control and final approval
• Limited requirements and processes for presentation, and “hand over” of investigation report to
management
• Unclear processes for follow up after the report have been issued and adequate documentation
• Note: Flow chart in Management System Manual is describing a process with limited
compliance with text in Management System Manual
• Lacking requirements for confidentiality, and sharing of experiences with customers and stakeholders
• Definitions of competency requirements for investigation team, and approved training providers -
Delays and technical issues in May 2020 at Florø and Hammerfest were reviewed, and spare part stock levels
and availability were highlighted as a possible contributing factor. Spare part management at remote bases
appears to have potential for improvement including need for the following actions:
• Review stock levels, assortment, and availability for spare parts for local bases to ensure optimal
management of spare parts and performance
• Optimize logistics for spare parts -
Management and responsibilities in Ground Operations Manual (GOM) appears indistinct for the following:
• 2.1.1 Ramp Safety Audits
• Defined as the Bristow internal audit by Ground Operations. However, management and
responsibility for these audits appear ambiguous. Ground Operations could not document
compliance with this requirement, and it was unclear if the activities were conducted by
Ground Operations or Safety & Compliance departments.
• Ramp safety risk assessment during regular safety inspections
• Requirements and practice should be reviewed– Last “quantification” 05.04.2018
• “Quantification” terminology and method should be defined
• Accident and incident procedure are incorrect and not aligned with Emergency Response Plan (ERP) -
Management of quarterly Safety Review Board (SRB) appears to have potential for improvement and the
auditors note the following:
• SRB for Q1 were conducted 30.04.2020. SRB for Q2 have not been issued, and 3 meetings have taken
place since.
• Inadequate terminology and requirements, such as “no significant comments”, “SMS is working
satisfactory” and “all members of SRB are obliged to keep themselves updated on regulatory news …”
• Several relevant issues noted as information, which would be relevant for implementation of follow-up
and mitigating actions.
• Actions and responsibilities are not defined for areas such as high sick-leave KPI, increase of
fatigue, and significant use of overtime.
• Lack of follow up from previous meetings, defined actions, and responsible person
• Actions not recorded in Q-pulse, or other management systems
• Impression of “copy & paste” in several areasThe audit team recommend reviewing processes for aligning SAG and SRB meetings for content and
purposes. -
The sick leave rate for Q1 2020 were 5,4 %, which appears high, given Bristow’s target of not exceeding 3 %.
Sick leave rates are differing between bases and professions, with identification of causes, and mitigating
actions appearing inadequate. The audit team note a concern that the pilot group appear to experience
challenges for Sick leave and “loss of license”. Feedback received from Operators voices concerns for work
environment and sick leave ratio for pilots. -
The audit team conducted reviews of documents and manuals, and several versions of designation for the
Safety and Compliance Manager were found. Correct title must be used to avoid confusion and incorrect
compliance with responsibilities for the CAA-N approved position. -
Chapter 26” Virus and pandemic strategy” refers to World Health Organization (WHO) and lacks references to –
and alignment with Norwegian Health Authorities requirements and recommendations, including risk levels -
Documentation and action logs for ConocoPhillips incident “Mayday call” LN ONQ 25.09.2020 were reviewed,
revealing inadequate documentation of notification processes.
• Hard copies of action logs contain handwritten information and documented information appear to be
inadequate compared with requirements and expectations for level of details
• Online incident documentation contains limited information, and is possible to edit post incident
• Interviews reveals challenges related to decisions if Bristow should inform customer when incidents
take place.
• Processes for clear and concise information to customer appear ambiguous
• Positions and personnel in Bristow responsible for information appear indistinct – Operations Centre,
Nominated Postholders, Accountable Manager or ERP Team
• Reviews reveals that checklists should be revised, to simplify terminology and identify relevant
information to be documented.
• Content and details of checklists appear extensive and overlapping
• Note: Bristow should encourage Operators to standardize bridging documents and notification charts
to ensure equal level of information and simplify processes if an emergency occurs -
The audit team note that several Air Safety Reports (ASR) are registered, challenges identified in Management
review and responses among personnel in interviews related to the E-Flight Management system. The E-Flight
system appears somewhat to be inadequate for its purpose, and dependent on quality of manual inputs,
including several time-consuming processes related to quality control associated with input of data. -
Bristow Norway “Industrivern Manual” appears unaligned with relevant manuals and requirements, such as:
• 2. “Mål og handlingsplaner”
o Lack of Risk assessments of Facility management, and not reviewed 4 times annually as
required.
• 8.1 “Internt tilsyn”
o Incorrect terminology, undefined requirements for Housekeeping
• 9.1 “Alarm og varslingsplaner”
o Not in accordance with Emergency Response Plan
o Unclear requirements and criteria for Notification to Police if fatality or “spinal cord injuries”
Additional Documentation