Audit

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 areas

The 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”