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Ben Cook PelAir revisited - Part V (PDF)

Via AA magazine:

BRIGH T S P O T S
DELIVERING BETTER OUTCOMES AND OTHER LESSONS OF THE PEL-AIR DITCHING
Pel-Air
revisited
Part 5
WRITER: BEN COOK

This is our final in a series of five articles where human factors expert Ben Cook has revisited the ditching of the Pel-Air aircraft off Norfolk Island on November 18 2009 – looking at the numerous human factors that influenced the tragedy. In this article, Ben explores the failings of key organisations and the importance of them rebuilding trust within the aviation community and the broader flying public.

Where are we now?

As noted in previous articles, the failure of the Civil Aviation Safety Authority (CASA) – including the impact of personal bias and ego – adversely affected the accident investigation process for the Pel-Air ditching. The CASA special audit conducted after the accident also highlighted inadequate regulatory surveillance.

Now add to this the inability of the Australian Transport Safety Bureau (ATSB) to remain independent of the influence of strong personalities within CASA. It was unable to genuinely consider all the facts available, including the findings from the CASA special audit, and it failed to conduct a timely and thorough first investigation.

The result: devastating consequences for the accident survivors.

Moreover, the total cost to the taxpayer, via Senate enquiries, an independent review of the ATSB by the Transportation Safety Board of Canada, a second accident investigation and more, has been exorbitant – and for what gain? Some suggest, including the survivors, that even today there has been little to no safety improvements as a direct outcome of these processes.

And while you’ve gained further insights into the horrific impact for some of the crew members, namely Dom (the aircraft captain) and Karen (the flight nurse), it is important to remember that the passenger requiring medical assistance was confronted with ongoing post-traumatic stress and a fight for basic medical compensation, which she could not cope with and ultimately lost her will to live. A terribly tragic outcome for her family and friends.

Timeliness and surveillance

Timeliness is a critical factor still impacting on investigative processes.

Even today I am personally aware of several families and organisations still experiencing the same slow response from the ATSB. For instance, I attended a major safety forum where an aviation small business owner, post-accident, openly discussed their case with a presenter as part of the forum. The business owner spoke about how they were repeatedly told by members of the ATSB that the final report would be ready in another month.

Unfortunately, this was the same response received every month for many months.
Eventually, they were told the ATSB investigator had taken stress leave. You could hear the trauma in the voice of this person as they articulated their story to the forum; the tremor in their voice and the visible stress on show due to the uncertainty about insurance and the viability of their family business – all dependent on the timely outcomes of the ATSB investigation to assist with resolution.

Then, there is regulatory relevance.

From my personal experience working for CASA, surveillance remains a challenge. Ensuring you have adequate time to find the real systemic factors impacting an organisation takes time.

Many years ago, CASA employed systems safety specialists to gain a better balance around such issues, including access to adequate data (safety intelligence) to enhance the ability to conduct risk-based surveillance.

The aim was to avoid the ‘old school’ tick-and-flick checklists and a generally shallow audit response (covering too much too quickly) to better focus and spend more time on those areas that genuinely impacted individual and organisational behaviour.

Ultimately, good surveillance helps organisations improve their own standards for continued business success.

It was a good attempt to enhance CASA processes and worked well in some offices and less so in others due to a lack of clarity around the new role. The net outcome was enhancements for CASA but this still has further room for improvement.

What’s your experience with regulators? Are they helping you identify important issues that are making a positive difference? For some the answer is yes, and that’s a great outcome.

For others, you may receive corrective action that leaves you wondering why you should invest resources into something that you don’t believe will enhance your operations, where the costs potentially outweigh the benefits gained.

So where does this leave CASA and the ATSB today?

My view is the Pel-Air ditching had a significant impact on the trust relationship between local aircraft operators and members of the Australian public. It also led to significant questions about the professional standing of the ATSB.

And that impact continues today.

Why is that trust so important and what’s required to rebuild it?

Trust – the one thing that changes everything

From the work of Stephen Covey, the author of The Speed of Trust, society is experiencing a crisis of trust that always affects two outcomes: speed and cost. Covey cites numerous examples of changes within society and organisations, with research from many companies and broader society indicating a sharp decline in trust, which continues today.

If you consider relationships with low trust what are the typical behaviours you might see within an organisation? Let’s consider writing an audit report involving a highly competent and experienced inspector that requires review by a team leader and a regional manager where there is a low trust relationship at all levels.

Some outcomes could include unnecessary questioning, seeking further evidence to substantiate findings and asking for sections to be re-written; initially by the team leader and again by the regional manager. For the inspector it feels like micro‑management and leads to frustration.

Low trust slows down the process – unnecessary additional administration for potentially no gain. Speed goes down and the cost to the organisation and industry (lost time) goes up.

If we consider something critical to aviation operations, such as effective communication and linking this back to trust, Covey says:

“In a high-trust relationship, you can say the wrong thing, and people will still get your meaning. In a low trust relationship, you can be very measured, even precise, and they’ll still misinterpret you.”

It’s a good reminder that trust is hard, real, quantifiable, and can provide significant enhancement to efficiency and cost within any system.

Leaders must address trust as part of a strong culture. As Covey says, “Leadership is getting results in a way that inspires trust”. It also means that leaders must provide opportunities for personnel to learn from their mistakes and to provide a culture that makes it safe for that to happen.

A starting point for CASA and the ATSB is to be more transparent when they get things wrong. They must be upfront, accept all organisations make mistakes, and provide clear evidence that they themselves are making improvements from the lessons learnt. It’s role-modelling the culture expected of operators as part of applied safety management systems for continuous improvement.

As part of my work with organisations to review their ability to achieve and sustain operational and business excellence, I spend time investigating trust through the lens of ability, character and truthfulness.

When considering this from a CASA and ATSB perspective:

>> Are CASA and ATSB personnel technically competent and do they deliver outcomes consistent to an agreed standard?

>> Do you get a consistent response from CASA or ATSB personnel from different geographical regions?

>> Is there a strong customer focus or do members hide behind a veil of bureaucracy?

>> Do staff have the interpersonal skills to deal with difficult issues while upholding a professional relationship with industry clients?

>> Do the words of employees and the broader organisation match the realities of what is delivered?

For every government employee that sits in bureaucratic, semiretirement mode, where they’re not held accountable, they’re letting down those hard-working, passionate employees performing a competent, professional role.

For every service response that demonstrates disrespect to industry customers, it tends to negate the 10‑20 professional and positive services delivered by those other personnel who are respected and trusted by industry.

Empowered accountability for any organisation means you weed out underperformers to protect your brand and industry reputation – and enhance trust.


Good surveillance helps

organisations improve their
own standards for continued
business success. casa

Now apply these concepts of ability, character and truthfulness to you.

Are you as technically competent as you could be? Do you actively seek feedback to make sure you’re not getting overconfident or complacent?

Do you understand the pros and cons of your character (the mental and moral qualities distinctive to an individual) and seek to modify your attitudes and behaviour to better manage your own personality traits?

Ask yourself and others whether you’re honest, candid, and frank? If you say you’re going to deliver something by a certain time, do you deliver it?

All these elements help to build and instil ongoing trust.

So how does CASA and the ATSB rebuild trust with the industry?

Rebuilding trust – future solutions

The ATSB and other investigatory bodies have a challenge, which was summarised nicely in a statement made by Deborah Hersman, a former chairman of the National Transportation Safety Board (NTSB):

Looking beyond its core mission to investigate accidents, the National Transportation Safety Board also is seeking a major role identifying aviation hazards before they can cause crashes…a departure from the board’s traditional job of dissecting the causes of fatal plane accidents and serious incidents, and then months – or years – later recommending ways to prevent repeats.

In today’s fast-paced society, by the time recommendations are presented, particularly if the timeline is 18-24 months post-accident, an organisation has already moved on. Many of the successful programs I’ve worked with across different industries have only met stakeholder needs if they’ve delivered timely outcomes.

I also propose the premise of proactive hazard identification is a missing link for regulators. They too need to move well beyond traditional surveillance to consider new models for enacting their requirement to regulate industry and to ensure operators have the capacity to deliver the standards necessary to provide safe, effective operations required by the fare-paying public.

Another solution is bright spot thinking. The aim is to avoid focusing on the negatives and to instead look for solutions that could be in plain view, including the opportunity to innovate better ways of doing business. It’s about spending more time identifying, cloning and sharing good industry standards and practices.

I believe it’s time to have an independent group perform a complete review of the existing practices of CASA and the ATSB – with a view to looking at opportunities for innovation.

This could help to identify what’s working well and why; to better understand and consider industry needs from a business perspective. Perhaps it’s about creating enhanced efficiency and effectiveness for business success or the re-alignment of existing resources to deliver enhanced outcomes for the benefit of the whole of industry.

Time and again we’ve heard the same promises: the regulatory reforms will be prioritised, accident investigations will be completed faster, but little has changed.

So isn’t it time for an independent and innovative review of how to get the best we can from both the ATSB and CASA?

Consider this: Some regulators establish relationships with airlines to rotate personnel through inspectorate roles, with clear policy and procedures to avoid conflicts of interest.

The benefit is access to industry personnel with recent, relevant experience for a two to four year placement. Aircrew and engineers gain valuable insights into the role of the regulator, with an ability to transfer those skills back to the airline. This could equally be applied by investigatory bodies. This may not be the correct answer for our industry, but it demonstrates how we can think outside the box.

Some other suggestions for rebuilding trust include:

>> Delivery: Deliver what you say you’re going to deliver and performance manage personnel who cannot demonstrate a genuine contribution to your core business, particularly those lacking trust or respect by industry. They tarnish brands. Meet industry expectations and hold your own personnel accountable.

>> Industry risk profiles: Establish industry risk profiles (work is ongoing in this space) and reconsider the classification of various operations to ensure CASA and ATSB resources are utilised for best effect. With limited resources, they must be utilised across sectors that will genuinely enhance and protect the broader population.

This also allows regulations and acceptable means of compliance to be tailored to match the nature of the industry profile, and for some sectors the outcome might even be enhanced through self-regulation.

>> Regulatory reform: Keep the rules simple and aligned to industry risk profiles. The regulatory requirements considered suitable for high capacity organisations such as Qantas and Virgin Australia need to be much different to those that will support smaller family businesses, such as aerial application and flying training organisations.

>> More safety promotion: Both CASA and the ATSB have delivered outstanding proactive support to industry including the establishment of aviation safety advisors, the delivery of safety promotion products (eg Safety Behaviours Human Factors for Pilots) that have received international praise, and training courses (eg ATSB Human Factors for Transport Safety Investigators) that are recognised and oversubscribed by industry seeking placement. It’s time to take this model to the next level.

>> Collaborative investment: Promote high training standards and outcomes, rather than every operator trying to deliver a minimum standard. Why not establish larger training centres within regions of high training activity (Moorabbin, Parafield, Bankstown, Jandakot etc) focused on delivery of modules such as non-technical skills training, accident investigation, human factors for operators, and applied fatigue management? This could be achieved through use of Aviation Safety Advisors, ATSB investigators, industry experts and aviation universities working in collaboration with a focus on train-the-trainer. Some of our smaller organisations, particularly the flying training industry, require greater assistance to keep their businesses viable. While a one-hour presentation at a local flying club on situational awareness by an Aviation Safety Advisor might be interesting, wouldn’t it be better to deliver longer courses that genuinely upskill future trainers to allow them to deliver enhanced standards and professional practices?

It’s back to bright spots – taking what we’ve already got and delivering better outcomes aligned with industry needs. This will help build a more trustworthy, collaborative and reliable industry.



Timeliness is a critical factor

still impacting on investigative
processes. atsb

In conclusion

I would like to thank you for taking this journey with me. For those who have read all five articles, we’ve covered much ground including the impact of egos, trust, professionalism, fatigue, inconsistencies with systemic investigation, and the powerful impact of organisational culture.

I hope you’ve gained some practical tips that you can apply within your own aviation operations.

MTF...P2