Nippon Cargo Airlines Co., Ltd. (NCA), submitted the preventive measures on 17August, 2018 for the Business Improvement Order received from the MLIT on 20th July 2018, after analyzing the background, problems and factors that contributed to the issues.
We sincerely apologize for the inconvenience that we caused our customers from the grounding of the aircraft and the suspension of the flights. We also apologize for the loss of trust as a result of the Business Improvement Order.
The outline of business improvement order and its preventive measures are as follows.
- Contents of the business improvement order that NCA received on July 20, 2018
(1) Assurance of awareness of safety consciousness and compliance training
(2) Appropriate formulation of the safety management system
(3) Appropriate records of maintenance
(4) Appropriate maintenance related to the aircraft structure
(5) Appropriate operations for damages potentially corresponding to aircraft accidents
(6) Confirmation for soundness of aircrafts
(7) Suspension of maintenance operations, etc. to the aircraft structure
- Contents of factors and preventive measures that NCA submitted to the Minister of Land, Infrastructure, Transportation and Tourism
I. Main factors and issues in this matter
(1) Insufficient countermeasures to the causal background in maintenance department (Increased business volume and insufficient of personnel)
Though B747-400F aircraft had been operated since the establishment of its own maintenance system in July 2007, the business volume has increased to deal with multi-model maintenance compared to one model as B747-8F was introduced in succession from 2012. In addition, the number of aircraft operated was approximately 1.6 times higher in FY2016 than in FY2011, while the number of personnel in the maintenance division has only slightly increased. As a result, it is considered that the number of employees in the maintenance department was getting gradually insufficient compared to the size of flight operations.
(2) Shortage of support for maintenance department
Against the background of this increase in business volume, the management and staff departments of the maintenance division became unable to provide adequate systematic support to the actual maintenance operational division, creating an environment in which the maintenance operational division can make own decisions and interpretations as well as opinions could not be expressed to persons in charge with long experience and much knowledge, which led, as a result, falsification of the maintenance records and concealment.
(3) Insufficient countermeasures for case of strict precautions
The causes of the failure of the measures taken by the Minister of Land, Infrastructure, Transportation and Tourism to take strict precautions for inappropriate maintenance work effectively in October 2016, were the fact that the measures were not properly implemented based on the understanding of the background of the occurrence of the problem and the introduction of specific cases of strict precautions was not disseminated throughout the company to prevent specifying individual. As a result, information about the strict precautions was not shared and opinions were not heard within the company.
II. Contents of preventive measures
(1) Measures to deal with background factors in the maintenance department
(a) The size of flight operations will be revised in accordance with the number of personnel, including consideration of the adoption of only one model for B747-8F aircraft.
(b) Based on the “Strategic Business Alliance” concluded with All Nippon Airways Co., Ltd. (hereinafter “ANA”) in March this year, five personnel support from ANA were received in April 2018 to strengthen the maintenance staff department and the maintenance operational division. Furthermore, from September 1, 2018, NCA will receive additional three personnel support from ANA to strengthen the management of the quality assurance, technical, and operational divisions, thereby strengthening the structure of the entire maintenance group.
(2) Measures to cope with insufficient support for maintenance department
(a) Each person in charge of technical management, production control, and quality control, which are the maintenance-indirect departments, will be stationed in the maintenance operational division to strengthen support systems for each function.
(b) In order to support the maintenance of airports other than Narita during the flights peak hours, the number of managers in departments providing 24-hour maintenance support will be increased from one to two.
(3) Measures against the failure in implementation of countermeasures for case of strict precautions
(a) The details of inappropriate maintenance, falsification of maintenance records, and concealment will be shared throughout the company, and group discussions are to be held in each department to share information and hear opinions throughout the company.
(b) Opportunities of direct conversation between all departments and the president/the general safety manager will be provided to foster awareness of safety and compliance.
(c) Training on safety and compliance awareness, including stratified education training, will be provided for all executives and employees. In addition, in order to firmly establish these awareness, managers should monitor and provide guidance on a daily basis, and external experts should provide opportunities of checking the status of each workplace and having discussion.
(4) Changes in valid period of airworthiness certification
Establish a system to ensure the airworthiness certificate renewal and the airworthiness test of all aircraft (change from continuous type to one year of validity) shall be promptly implemented.
(5) Consignment system of aircraft structure repairs
Until completing the restructure of the company's own maintenance system, the company will continue to consign maintenance companies in Hong Kong (HAECO) and Taiwan (EGAT), and plans to receive support from ANA from the perspective of timely action in the future.