On the 10th of April 2018, both COMPANY Management and COMPANY Contractor personnel (10 pax plus 3 aircrew) boarded a charter flight in Accra, Ghana, to travel to the COMPANY mine site in Mali. This fight took approximately 3.5 hours which included an immigration stop in Sikasso, Mali.
The charter flight for that day was operated and crewed by the Malian Aero Company (MAC). MAC had been audited on a number of occasions by a COMPANY-contracted aviation safety specialist, (Pinpoint Aviation) in 2012, 2014, and 2016. The Audit Reports issued to COMPANY, advise that MAC had been classified as an EXTREME OPERATIONAL RISK, with the most recent Audit Report of 2016, recommending to COMPANY, “Due to significant and serious deficiencies noted, the Malian Aero Company (MAC) should NOT be used to provide personnel transport services to COMPANY.”
Upon boarding and whilst traveling on the aircraft, one of the passengers (myself – a qualified private pilot) noted that the aircraft both externally and internally, was in extremely poor condition and that there were also a number of significant ‘safety’ related issues that had been observed. These were: 1. Seat belts not working (3 in total), 2. An aircrew member standing, un-restrained during take-off and landing, 3. No rear bulkhead separating the luggage from the passenger cabin and 4. The luggage was un-restrained.Prior to this flight, on the 28th of February 2018, a number of discussions and email exchanges took place between COMPANY corporate management and COMPANY site management, regarding COMPANY air charter operations. Sahel Aviation Services (SAS), is the approved and Contracted air charter operator to COMPANY. These discussions were due to the recent discovery, that the Contract between COMPANY and SAS, had expired.
Included in these discussions, were the increasing operational demands that COMPANY was placing on SAS due to an increase in operational activity at the COMPANY mine. SAS, due to external, unscheduled flight demands and an unserviceable aircraft in their fleet, was finding it increasingly difficult to meet the charter flight demands being placed on them by COMPANY.The following investigation was undertaken to identify the cause/s as to why a non-approved air charter operator, that had been classified as an EXTREME OPERATIONAL RISK, was used for 6 COMPANY, charter flights in Mali, West Africa.
Although the aviation infrastructure has improved over the last 10 years in Africa, the quality and safety of operations, particularly for smaller, charter operators, is still quite a long way behind that of Australia, North America, and Europe, as highlighted in several key International Aviation Safety publications and Regulatory Authority statistics, such as ICAO and the Aviation Safety Network.
As part of its risk management responsibilities, utilizing air charter services in Africa, COMPANY have a significant duty of care in regard to the risks their people are exposed to. It is of paramount importance, that the business has effective people, systems, and organizational structures in place, to manage those operational and third-party risks that exist.
This event, which could have resulted in a catastrophic outcome, has provided the business with a significant opportunity to identify improvements to its systems and its effective management and control of risk, due to the multi-faceted nature of this event and the type of findings it presented. The consequences of an air-related incident, would not only have impacted the lives of those involved and their families, but also the business in regard to it compromising the company’s, reputation and insurance commitments.
As a result of an extensive examination of this event and analysis of the contributory factors, the root cause in this instance is apportioned directly to “A failure to effectively apply and monitor the management system standards and supporting controls, designed to minimize, reduce and manage risk”.
Notably, however, the key stakeholders involved did NOT act to rectify the situation as would have been expected. This lends itself to the very manner in which the systems, failed.
The recommendations contained within this investigation, have yet to be applied.