[Peetwo]

PelAir MKII & the quest for IP: SMS a lip service exercise -  

From P7's pointed post...

...We can let this all pass, for the while, as insignificant in comparison to some of the ‘glossed over’ major items which have been given a PC ‘tick-a-box’ treatment from the invisible Manning. Small items, of a ‘psychological nature’ which have been ignored. Like feeling that the SMS is a lip service exercise; or, fatigue is only a figment of imagination; or, that company culture has no effect on the ‘upright’ pilot. There is more, lots more which, in the BRB opinion, shows clearly the deeply flawed approach ATSB is taking – without going into the Mildura bun fight or even the ATR events (now plural) and, heaven forbid we ever mention Essendon...

Now to join the dots - from page 353 under 'Contributing Factors':

Although the operator’s safety management processes were improving, its processes for identifying hazards extensively relied on hazard and incident reporting, and it did not have adequate proactive and predictive processes in place. In addition, although the operator commenced air ambulance operations in 2002, and the extent of these operations had significantly increased since 2007, the operator had not conducted a formal or structured review of its risk controls for these operations. [Safety issue]

  
Extracts from under Safety Management and management oversight (page 337-341):

Hazard identification processes

The operator had a safety management system (SMS) in some form for several years prior to it being formally mandated in regulatory requirements for Australian RPT operators in 2009. Although ideally an SMS will allow an operator to identify and address hazards in its operations, the effectiveness of these processes can be affected by many factors.

The operator’s processes to identify hazards in its flight operations relied heavily on flight crew submitting incident, hazard and fatigue occurrence reports. If a report was submitted, it could then be assessed and considered by personnel other than those involved in the relevant fleet’s operations. However, the reporting culture within the operator was such that flight crew were generally only submitting reports when requested or for incidents that external parties had already reported. There were minimal voluntary or discretionary reports submitted. Although the available evidence indicates this situation was improving in the operator’s other fleets during 2009, this did not appear to be the case in the Westwind fleet...


...The primary task of the Westwind fleet was traditionally night freight operations. It commenced air ambulance operations with the air ambulance provider in 2002, and the extent of these operations significantly increased from 2007 to 2009, and by 2009 it was the main activity undertaken by the Westwind fleet. During 2007–2009, the number of bases routinely conducting air ambulance operations increased from one to four, and there was a significant turnover of flight crew, particularly with the captains based in Sydney.

Despite these changes, the operator’s formally-defined risk controls, particularly for training and checking, still appeared to be better suited to routine freight operations. There also appeared to be a significant reliance on the informal transfer of essential knowledge to flight crew regarding international operations and operations to remote islands, and an assumption flight crew would acquire the knowledge and skills appropriate for their tasks.

Given the expansion of the operator’s air ambulance operations, and the inherent nature of international ad hoc air ambulance operations, there was a need for the operator to closely monitor and review the conduct of operations to assure itself they were being conducted to an appropriate standard, and that the implemented risk controls were suited to the nature of the tasks being conducted. As indicated above, the processes used to identify hazards and monitor operations were not adequate to achieve this purpose.

Safety management is an evolving discipline, and it is undoubtedly difficult for a relatively small air transport operator to conduct hazard identification activities to the standard expected of major airline operators. There were indications the operator was taking positive steps to improve its hazard identification processes during 2009. However, these efforts had limited effect on the Westwind fleet’s operations up until the time of the accident.

In summary, the operator’s processes for identifying hazards extensively relied on hazard and incident reporting, and it did not have adequate proactive and predictive processes in place. In addition, although the operator commenced air ambulance operations in 2002, and the extent of these operations had significantly increased since 2007, the operator had not conducted a formal or structured review of its risk controls for these operations. Overall, had the operator adopted more thorough proactive and predictive hazard identification processes, it is likely at least some of the inadequate risk controls associated with its air ambulance operations would have been identified, particularly in terms of flight/fuel planning and in-flight fuel management.

 
On reviewing the various ATSB identified PelAir SMS preamble and deficiencies (above), it is very hard to go past the very disturbing parallels to the tragic Lockhart River investigation, with familiar issues like lack of proper CRM training and obvious deficiencies in the CAR 217 organisation.

The following is some quoted extracts from an excellent 2008 ASASI presentation by former ATSB Executive Director Kym Bills...

...All these factors strongly indicate to an industry where experience levels are reducing dramatically. Add to this the financial pressures of rising fuel costs and rapid growth, and we are starting to paint a picture of an industry that will need to withstand increasing stress in the future. In Australia in particular, there will be significant challenges for the industry to meet societal and political expectations that rural and regional Australian air services will be maintained to a high standard. We face an environment where resistance to pressures to cut corners in training will be paramount; where real and meaningful safety management systems need to be integral to an organisation’s operation. It would come as no surprise to you I am sure that the ATSB has seen many examples during investigations of safety management systems that are little more than a book on a shelf, or loose words that are readily bandied about. Hand in hand with this is the need for commitment to the establishment of strong safety cultures. Again, while we see excellent examples of such strong cultures, we see many examples where translation of the words into action and reality is far removed, and it is clear that manager lack of awareness of human performance remains an issue in this regard...

It is a matter of some frustration that we continue to see the same types of fatal accidents, particularly controlled flight into terrain, VFR into IFR conditions, fuel exhaustion/starvation, wire strikes and needless and indeed reckless high risk GA behaviour. While, some are what I would describe as the unfortunate result of innocent human fallibility, we continue to see too many of these accidents that are clearly avoidable and the result of poor preparation and decision making, and what it seems can only be described as a disregard for the lessons of the past. Learning from others and mindfulness of past lessons are crucial to curbing the continuing trend of avoidable accidents. Understanding of the limits to human performance and organisational behaviour, risk analysis, and threat & error management will need to feature more so than ever in the future.... 

---

...While the need for timeliness in investigation has always been important (if not always achieved), media, political and societal expectations have certainly changed, and there is a need more than ever to strive for better timeliness. (P2 -How's that working out Kym, Beaker err Hoody - ) Careful consideration is needed as to what trade-offs might be made between investigation timeliness and thoroughness, but the greatest challenge is probably how we achieve both.

A prime example is the ATSB’s Lockhart River investigation report. I believe the quality of this 500-page report into the worst civil aviation accident in Australia since 1968 is first rate, but more problematic was that the final report took almost two years to be released. (P2 - Duck me 2yrs that's good) While there were several interim reports and the investigation was complicated by an inoperative CVR, no witnesses and the extent of destruction of the Metroliner 23, two years is a long time. The ATSB is examining ways that this could be improved, which may require directing fewer resources to other lesser priority investigations.

I suspect that the ATSB is not alone in battling with this problem, and while there will always be exceptions, getting the balance right between professionalism and timeliness and explaining any need to take longer than societal expectations, will be an increasing challenge if safety investigations are to remain relevant.

The other matters that featured strongly in the responses from my colleagues when questioned on challenges for the future, were the need to strike the right balance between no-blame and culpability in a ‘just culture’, and the need to strike the right balance between the need to protect safety data and the demands of legal systems. (P2 - "..let's do the timewarp again.." )  

The confusion or industrial agenda that ‘just culture’ means no blame or liability, even in instances of serious and deliberate wrongdoing by aviation industry practitioners is an issue that needs to be addressed. As James Reason has argued, engineering a ‘just culture’ in which the 10 per cent or so of wilful and culpable actions do not escape sanction, while encouraging reporting and learning from the other 90 per cent of actions that lead to accidents and incidents is ‘the all-important early step’. But there are those who would suggest that a just culture involves only ‘no-blame’ investigation and who seek protection for 100 per cent of behaviours. Meanwhile, we have seen judicial systems imprison crew members who have done little more than be involved in an accident because of actions and omissions that were the types of error expected among all humans. Closer to home we are seeing safety investigations becoming increasingly subject to external scrutiny. On one level, such external scrutiny should be welcome and investigations should withstand reasonable objective scrutiny. Significant scrutiny of ATSB investigation reports is applied through coronial inquests. However, while technically inquisitorial in nature, such forums are in reality often adversarial as our increasingly litigious society has led to parties attempting to divert attention from, and dilute important safety issues in pursuit of their own agendas. This unfortunately often leads to protracted proceedings and results in a significant drain on ATSB investigative resources. 

The desired implementation of the Global Aviation Safety Roadmap in terms of protecting safety data to enable its wider and timelier sharing is predicated on robust legislation in member states. This is a great challenge for many poorer ICAO states, but also for some of the otherwise best practice members. For example, the US NTSB is required to make available much sensitive data it holds, including CVR transcripts, in a public docket even where it is sourced from another state of occurrence, and France’s BEA has similar challenges because of the power of its judicial system. The new Attachment E to Annex 13 seeks to provide guidance with respect to some of these legal difficulties but serious tensions remain in the Annex itself.

In Australia, the ATSB has not been immune from legal and regulatory pressures. The Transport Safety Investigation Act 2003 mentioned earlier, protects safety information obtained and analysed by the ATSB as a ‘no-blame’ safety investigator. As an example, the TSI Act recently stood up to legal challenge, in what became known as the Elbe shipping case, where a party in a civil case relating to the leakage of oil from a ship in Gladstone harbour sought to obtain the ATSB’s investigation evidence. The Executive Director refused to issue a certificate for the release of the evidence and the party challenged the TSI Act as being unconstitutional, as it claimed such decisions should reside with the courts. The Federal Court upheld the legitimacy of the TSI Act and the party was ordered to pay costs.

That is not to suggest that the ATSB doesn’t recognise the need for a just culture. A just culture is preserved through the ATSB taking a cooperative approach to any required parallel investigations by regulators, police or other bodies, which must be entirely separate and gather their own data and evidence. This is particularly important because the ATSB can compel evidence that may otherwise incriminate and ATSB reports are unable to be used in criminal or civil courts. However, as I mentioned earlier, they can be used in a coronial inquest. In addition, Australian legislation provides for a CVR to be used in cases of severe criminality unrelated to normal crew duties, such as in the case of drug running or terrorism.

Accident investigation by safety investigators remains essential, if only to remind us of the continuing need for vigilance to avoid the human and other factors that have led to so many unnecessary accidents and fatalities in the past. In many cases, professional investigations do much more than just remind us of past lessons. There are new and novel twists based on differing organisational cultures and pressures, regulatory environments and human interfaces with other humans and with changing systems and technologies.

In closing, it is clear that using all available means to avoid a major accident is a primary challenge. This includes good safety management systems among all key players, understanding of the limits to human performance and organisational behaviour, risk analysis, data collection and analysis, threat & error management, and excellence in regulation. Human factors will without doubt continue to dominate as a key element of safety investigation. It is crucial that we learn the lessons from the past and the experiences of others. Close cooperation within the aviation community is essential to ensure that those lessons that will benefit safety are shared openly.

Please someone bring back Kym Bills - ASAP
 
Next from another 2008 Kym Bills presentation: https://www.atsb.gov.au/media/24560/sia121108.pdf

Safety Management Systems

• Before looking at methodology and aviation

examples, I want to reinforce that robust

safety management systems (SMS) can

make a major difference to safety

• The ATSB often finds poor SMS and weak

safety culture contributes to accidents

• SMS compulsory among aviation operators

from 2009 (aerodromes already)

• An International Civil Aviation Organization

(ICAO) Manual published in 2006 is a key

document and is to be updated with cases.

---

&..

Lockhart River and SMS

• Among the many contributing safety factors

the ATSB Lockhart River investigation

found Transair’s SMS to be poor

• Poor company organisation structure, weak

Chief Pilot commitment to safety, and

inadequate risk management processes

• Other factors included Ops Manual,

variable training including HF/CRM, poor

supervision of flight ops, TAWS not fitted.

---

Transair’s SMS

• Chief Pilot was also MD & head of Check &

Training and regularly in PNG – overloaded

& poor organisational structure back-ups

• He did not demonstrate a high level of

commitment to safety, eg Cairns base

largely unsupervised and checked itself,

reported pilot hazards not addressed, etc

• SMS largely in manuals not reality - virtual.

---

Transair’s SMS

• Transair did not have a structured process

for proactively managing safety-related

risks associated with its flight operations

• This included the move from charter into

RPT with passengers in QLD, & expansion

of operations in QLD and NSW to 25 pilots

with new ports such as Lockhart River

• Training was variable and sometimes

entailed little more than an open book exam

---

Transair’s SMS

• Transair’s Operations Manual involved a

mass of Word documents slapped onto a

CD with no indexing or version control

• Manual requirements for human factors

training, like crew resource management for

multi-crew operations, did not happen

• Transair appeared to have a SMS and a

commitment to best practice but actual

practice reflected a poor safety culture

driven from the top (cf ICAO 2006 Manual).

 
Hmm...see what I mean?


MTF...P2