[Peetwo]

FRMS/SMS a lip service exercise - Part VII

While we wait for the answers to my QON to come back from the Senate Secretariat I thought now might be a good time to start joining a few more FRMS dots...

Excerpt from BC & MC LinkedIn profiles:

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Manager Human Factors
Company Name: Civil Aviation Safety Authority
Dates Employed: Oct 2007 – Jul 2010  Employment Duration: 2 yrs 10 mos
- Led and managed the HF section including development of a HF strategy to provide pragmatic, pro-active systems enhancements.

- Developed and managed an annual work program, including financial management of a $1.0+ million budget.

- Led and managed projects/tasks to provide strategies, tools, and policies to support the practical integration of HF within the Australian aviation industry.

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Human Performance Specialist
Company Name: Civil Aviation Safety Authority
Dates Employed:2008 – 2010  Employment Duration 2 yrs

Provided advice on human factors and human performance matters in the preparation of aviation regulations.

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"...Coincidentally (or not) Mal Christie left CASA and started employment with the ATSB in February 2010..."

Other than being part of the PelAir special audit team and coincidentally the co-author of the PelAir FRMS SAR, it would seem that MC was the CASA officer tasked to co-ordinate the original CASA project for implementation of mandatory FRMS for certain airline/operator pax carrying operations. Here is a MC update to the Operational Standards Subcommittee meeting on 24 March 2009 (note the reference to ICAO):

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 4.17 Fatigue Risk Management Systems (FRMS) Update

4.18 Mal Christie, Human Factors Specialist advised that the FRMS is a two phase
project. He advised that Phase 1 includes amendments to Civil Aviation Order
(CAO) 48 covering flight and duty times and guidance material implementing FRMS
for pilots. Mal advised that Phase 2 is due to commence soon for operational safety
critical personnel, and will include cabin crew, ATC, engineers, ground support and
other safety critical personnel. Mal advised that the working group is scheduled to
meet on 8 April to review the working groups proposed changes to the documents.
Mal advised that he hopes he will be able to release the NPRM in the near future
but did advise that this may not occur until we are across the ICAO FRMS SARP
update. He advised that he will be calling for nominations for Phase 2 shortly. Mal
was asked if the working group would be reviewing the ICAO documentation. Mal
said yes and subsequently advised there would be a lengthy three (3) month
consultation period due to the complex nature of the subject matter. He also
confirmed in response to a question from the SCC chair, that the Operational
Standards Sub-committee is being kept up to date on the progress by regular
briefings at its meeting.

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As we now know it took a further 4 years before the CAO 48.1 (FRMS) amendment was officially written into law and even then it was subject to an attempted disallowance motion by former Senator X.

Ironically the MC update was included in the minutes of an SCC 2 day meeting that was also utilised as the unofficial welcoming/coming out of the then new CEO/DAS John McCormick.

List of attendees (note the 3rd name ): SCC 32

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Attendance:

Rob Graham SCC Chairman
John McCormick CASA CEO
Shane Carmody DCEO, Civil Aviation Safety Authority-Strategy & Support
Peter Boyd Civil Aviation Safety Authority
Melinda Evans Airservices Australia
Phil Hurst Aerial Agricultural Association of Australia
Phil Gornall Airborne Law Enforcement Agencies
Tim Blatch Aircraft Owners and Pilots Association
Marjorie Todd Attorney Generals Department
Bill Hamilton Australian Association of Flight Instructors
Torben Petersen Australian Airports Association
David Bell Australian Business Aircraft Association
Brian O’Dea Australian Federation of Air Pilots
John Alldis Australian Licensed Aircraft Engineers Association
Colin Adams Australian and International Pilots Association
Bob Hall Australian Sport Aviation Confederation
John Hodder Australian Defence Force
Ken Cannane Aviation Maintenance Repair and Overhaul Business Association
John Guselli Aviation Safety Foundation Australasia
Ritchie Hollands Department of Infrastructure, Transport, Regional Development & Local
Government.
Leanne Dalton Flight Attendants Association of Australia
Pine Pienaar Flight Training Adelaide
Merv Fowler Guild of Air Pilots and Navigators
Peter Docking National Jet Systems
Mark Wolny Qantas Airways Ltd
Warwick Walesby Qantaslink
Phillip Stacy QBE Aviation
Keith Jobson Raytheon Australia
Lee Ungermann Recreational Aviation Australia
Paul Tyrrell Regional Aviation Association of Australia
Ian McIntyre Royal Aeronautical Society
Allan Bligh Royal Federation of Aero Clubs of Australia
Alan Benn Royal Flying Doctor Service
Peter Jolly Sports Aircraft Association of Australia
Paul Machin-Everill Virgin Blue
Grant Mazowita Civil Aviation Safety Authority
Greg Hood Civil Aviation Safety Authority
Peter Cromarty Civil Aviation Safety Authority
Clive Adams Civil Aviation Safety Authority
Richard Farmer Civil Aviation Safety Authority
Megan Barby Secretariat - Civil Aviation Safety Authority

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Yes a veritable whose who of aviation safety stakeholders...   

In hindsight I wonder how many of those well known Alphabet identities now cringe or have nightmares when they reflect on the following passages off the McCormick brief... :  

  

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4.23 CEO Briefing

4.24 John McCormick, CASA’s CEO attended the meeting and introduced himself to
industry members of the SCC. He added that today he had signed off an AOD
exemption (which had been discussed earlier under Brenda Cattle’s Alcohol and
other drugs update). John added that he has recently approved the MOS concept
for the Maintenance suite of regulations, and whilst he is philosophically opposed to
a 3 tier regulatory framework, he does understand that the OLDP drafting of a 2
tier framework would not have matched the industry expectations for the
Maintenance suite. John referred to consultation, including CASA’s requirement to
consult under the Civil Aviation Act, and how CASA will try to take the industry
along with it on its regulatory proposals, but in the end the regulatory decisions are
CASA’s to make. He encouraged industry to let him know of their ideas via the CEO
feedback available on the CASA website.

4.25 John referred to the Aviation Green Paper, which sets the target of 2010 for the
end of regulatory reform. This may be very difficult and he sees regulatory reform
as an ongoing process. In relation to regulatory reform John added that Australia
does control a lot of airspace, has a thriving industry and a strong military. He
added that taking on another countries regulations style can often also mean taking
on that countries social standards, which can present other difficulties in the
Australian context. He advised that at this stage it is ‘business as normal’ and that
CASA will try to move the regulations forward, take input and consult, once again
as required under the Civil Aviation Act. He also advised that he wanted to
encapsulate a review of the enforcement regime, though this may not be a high
priority but does need to be addressed at some stage. John then went onto speak
about the structure of CASA and how with any organisation working through a
reform process there is always some reworking required, particularly in relation to
how CASA works with industry. John was very mindful of having a single point of
contact as he is aware that often industry may liaise with several offices with
possible varying outcomes. John then added that he saw the Australian aviation
industry as robust and expressed support for the GA sector of industry within
Australia, as it is the backbone that must not be left behind. John also mentioned
that he intends reviewing the oversight of different sectors of industry.

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What I find passing strange is that in the next SCC meeting on July 29 2009 there was no further update on the FRMS project, this was despite the fact ICAO were ramping up their campaign to mitigate fatigue risk in the aviation industry. (This included the establishment of a FRMS taskforce in November 2009)

However I guess we shouldn't be surprised when we saw McCormick's attitude to FRMS and the input to fatigue oversight from certain former CASA HF experts..

One area of interest from the July SCC meeting was this:

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6.1 ICAO Audit Findings PEL/02 - ALAEA

6.1.1 John Alldis representing ALAEA spoke to this item questioning what action CASA had taken to address the issues raised in the ICAO Audit in relation to CASA surveillance of delegated licensing activities and approved training organisations also taking into account the proposed implementation of competency based training in relation to licensing. John also questioned how CASA’s timetable was progressing on the ICAO findings and the recommended actions. Peter Boyd advised that CASA has already made a move on this issue, given the implementation of the new rules, he advised there are some synergies, but CASA has a comprehensive surveillance plan in place. Peter reassured members that CASA does have adequate resources and the transition will be properly managed, and resources appropriately applied. As part of CASA’s realignment it is also looking at resourcing on these transition type activities. John reiterated ALAEA’s concern given his quoted drop in numbers of Airworthiness
inspectors (AWIs) from 100 to 60. Peter undertook to confirm numbers and come
back to the SCC on this issue. In relation to the ICAO Audit findings Peter confirmed
that CASA has provided its response in relation to the Corrective Action Plan in late
2008, and is currently monitoring the implementation of the corrective actions within
CASA, as part of this plan.

Action Item: July 09-1. CASA to report back on AWI numbers in relation to CASA
being able to effectively implement and oversight delegated licensing activities and
approved training organisations.

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Fast forward that to 7 December 2009 when this WikiLeaks cable was revealed: https://www.wikileaks.org/plusd/cables/0...081_a.html

Two weeks later Ben Cook and Mal Christie submitted their PelAir FRMS special audit report which I can now confirm they were tasked to complete as part of the PelAir special audit.

However on returning from leave the two CASA HF experts were informed that the report would no longer be included as part of the final audit report...

Fast forwarding again, to 30 June 2013 the following are quotes from a AIPA Parliamentary Brief in support of the NX proposal to disallow CAO 48.1: https://www.aipa.org.au/sites/default/fi...3a_002.pdf

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From pg 2 of the brief:

In summary, the Instrument is a step in the right direction but is unfinished business. There are serious concerns about the application or otherwise of the body of fatigue science and research and the preservation or extension of existing provisions already challenged by parts of the industry as unsafe.

CASA has an abysmal record of regulatory oversight of fatigue management, even without the pressure of trying to get some serious traction on the Regulatory Reform programs that have diverted them for the last 17 or so years. Parts of the industry believe that CASA has seriously underestimated the resources required to implement these new rules and that there will be an inevitable trade-off in surveillance activities of flight operations.

If not disallowed now, this legislation will continue with no incentive for improvement unless and until the inherent risk crystallises into an undesirable outcome. That is not a possibility that this Parliament should allow to persist.
 

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From pg 5:

ICAO recognises the importance of “operational experience”, but that is a tainted concept if it merely reflects what operators have been doing or what the regulator thinks they are doing.

In Australia, we have already seen how this concept is tainted - recent Senate inquiries that have touched upon Jetstar, Pel-air and Avtex/Skymaster fatigue management processes and largely exposed the gulf between sound fatigue risk management, what operators have really been doing and what the regulator didn’t really bother to see what they were doing. The CASA Special Audit conducted after the Pel-Air ditching revealed all three of those propositions, while explaining a lack of pilot complaints:

…The short planning period, lack of knowledge of possible destinations and lack of support provided by operations staff once doors closed appears to add to this fatigue. All crew interviewed stated that they felt there would be no issues in stating that they were fatigued and pulling out of duty but also felt that they had limited opportunities to fly and had to take these opportunities when they arose… 8

… Most crew interviewed stated that they had been part of a duty that was greater than 15 hours in length but evidence could not be identified that showed fatigue related extension of duty processes had been followed, safety reports had been written following the duty or that management follow-up was conducted as is required in the company FRMS manual. Several interviewees believed that there is a lack of management adherence to safety management requirements and the fatigue risk mitigation strategies as laid down in the company's FRMS manual…9

When CASA was asked about the significance of Jetstar requiring crews on the Darwin-Singapore-Darwin night flight to extend beyond their normal flight duty period (FDP) limits on 12 of 21 flights in January 2011, they responded:

CASA does not consider that these extensions require continual monitoring.
The duty extensions recorded in January 2011 by Jetstar were a result of flight crew agreeing to operate beyond the standard 12 hour initial limits as provided for within Civil Aviation Order 48 Exemption. No breaches of the 14 hour condition were recorded.10

Undoubtedly that is how CASA will regulate operations under the SIE until they expire in 2016, despite the fact that the same flights could not even be contemplated under The Instrument! Finally, from evidence given to the UK Parliament Transport Committee Inquiry into Flight Time Limitations in February 2012 (which we believe to be replicated in parts of the Australian industry):

7.6. More importantly: fatigue is significantly under-reported by the pilots themselves. This is because pilots do not file reports on an aspect that has become a ‘normal’ part of their daily work. Many are afraid their fatigue reports could have negative consequences for their professional future (i.e. reprisals by management) – a phenomenon that is growing – particularly when pilots refuse to fly because they are too fatigued. Indeed UK polling results show that 33% of pilots would not feel comfortable refusing to fly if fatigued, and of those who would, three quarters would have reservations. Once a pilot has decided they have no option but to fly, a fatigue report would be tantamount to writing the evidence for their own prosecution…11

This under-reporting by pilots is exacerbated by CASA being widely seen by the aviation community as having actively disengaged in any intelligent discussion about fatigue regulation for many years. It is highly unlikely that CASA has any defensible
‘regulatory experience’ other than superficial ‘tick and flick’ audit activities and, as such, cannot and should not rely on its perception of the current state of fatigue management to set aside the science or to replicate current rules.

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Spot the FRMS dots & dashes? If you have any remote interest in the subject I recommend taking the time to read the AIPA Parliamentary brief in it's entirety...


MTF...P2

Ps Caught this in my recent internet trolling...

Via 7:30 Report 16 December 2009:

https://sleepnosleep.wordpress.com/2009/...o-fatigue/

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Automatic pilot - series of fatal accidents linked to fatigue[/b]
 
Posted Wed 16 Dec 2009, 8:48pm
Updated Wed 16 Dec 2009, 8:49pm

A series of fatal accidents around the world over the past decade have been linked to pilot fatigue, in response the International Council of Aviation will put in place new rules next year, to manage pilot exhaustion, in one of the biggest shake-ups in 50 years of commercial aviation.

Transcript

KERRY O'BRIEN, PRESENTER: The Federal Government has set out its vision for the aviation industry over the next 20 years in a white paper dealing with issues from in-flight security to the seemingly endless quest for a second Sydney airport.

But there's another big issue looming for the aviation industry: pilot fatigue, which has been linked to a series of accidents around the world over the past decade.

The International Council of Aviation will put in place new rules next year to manage pilot fatigue in one of the biggest shake-ups in 50 years of commercial aviation.

In 2001, Australia was ahead of the game, introducing a five-year study into the issue. It recommended a whole new approach to the management of pilot fatigue.

But many of those who took part are now musing as to why Australia is still waiting to see what the rest of the world will do.

Thea Dikeos reports.

RICHARD WOODWARD, AUSTRALIAN & INTERNATIONAL PILOTS ASSN: Someone said to me once, "If you want to think about what we do, sit in front of a fish tank at 4 o'clock in the morning and stare at the fish for two hours and see how you feel."

THEA DIKEOS, REPORTER: It was the close call that shocked the Flying Kangaroo's renowned safety record. In 1999, a Qantas 747 overshot the runway at Bangkok, injuring 38 of the 400 passengers on board.

The Australian Transport Safety Bureau investigated the incident and revealed the pilot had been awake for 21 hours and the first officer 19 hours. But the incident report found there was insufficient evidence to conclude fatigue was the cause.

JOHN GISSING, SAFETY MANAGER, QANTAS: We took action after those findings. Fatigue risk is one of the mentions in that report. In the mix of our safety improvement strategy was clearly something that we were very keen to learn more about.

THEA DIKEOS: 10 years on, pilot fatigue is at the forefront of the international air safety agenda. Next year, the global body responsible for air safety standards, the International Civil Aviation Organisation, will announce one of the most significant shake-ups in 50 years of commercial aviation.
It's expected to issue guidelines requiring member countries to incorporate scientific analysis to assess pilot fatigue. Australian airlines will also need to comply.

RICHARD WOODWARD: They'll be the biggest single change in flight time limitations and the risk management of those since the 1950s.

THEA DIKEOS: Last year, the UN body detailed 26 accidents around the world since 1971 in which fatigue was a factor. Here in Australia, the Transport Safety Bureau has investigated six air safety breaches which have been identified as fatigue related in the past 10 years.

JOHN MCCORMICK, CIVIL AVIATION SAFETY AUTHORITY: If I was to turn around and say can point to an accident where it 100 per cent was the cause of fatigue, I think I would struggle to find one. Would I turn around and find that fatigue has been a factor in many incidents that have happened, yes, it has been. So fatigue is on our list. It is a high priority.

RICHARD WOODWARD: The standard answer you get in every accident is 60 per cent or 70 per cent of the accident's caused by the pilots. Well, pilots are human beings; human beings make mistakes, and human beings make lots of mistakes when they're tired.

THEA DIKEOS: With more than 20 years military and commercial flying experience, Qantas pilot Richard Woodward is providing input for the proposed new international standards. On the ground, he likes to race vintage Monaros.

RICHARD WOODWARD: I've been flying long haul aeroplanes for 24 years or so and, yes, there's times when you feel terrible when you're sitting in an aeroplane, you're just so tired that you feel physically ill.

THEA DIKEOS: Almost 10 years ago, pilot fatigue was on the radar of the Australian aviation industry. It was the subject of a landmark multi-million dollar study funded by Qantas and supported by the Civil Aviation Safety Authority, Australia's International Pilots' Union and the University of South Australia.

RICHARD WOODWARD: At the time it was world's best practice research.

THEA DIKEOS: More than 260 volunteer pilots took part in the study.

DREW DAWSON, SLEEP RESEARCH, UNI. OF SA: We wanted to know how much sleep people were getting as pilots out on the line and we also wanted to know what was the effect of sleep loss on cockpit performance.

MATTHEW THOMAS, SLEEP RESEARCH, UNI. OF SA: I have been have on a flight deck where both pilots have been asleep.

THEA DIKEOS: It was this experience years earlier on another research project which prompted Matt Thomas' interest in pilot fatigue.

Can you understand from a person who flies who's in the passenger seat that that might be a bit alarming?

MATTHEW THOMAS: Absolutely. Fatigue is a very real issue in aviation, without a doubt.

THEA DIKEOS: Over 50 years, a complex formula has been used to determine how long pilots can work and how much rest they should have. The Qantas study found that didn't tell the whole story.

DREW DAWSON: We collected data that said even though pilots are compliant with the rules, there are a small number of occasions when they aren't actually getting sufficient sleep to be safe.

MATTHEW THOMAS: The roster simply does not predict at all well a crew's performance. We saw that in the simulator very clearly.

THEA DIKEOS: Disturbingly, the researchers found pilots who had less than five hours' sleep were twice as likely to make safety errors.

MATTHEW THOMAS: Incorrect calculations is a classic example, well known to cause accidents internationally, errors in decision-making.

THEA DIKEOS: Are there many pilots in Australia flying under those circumstances?

MATTHEW THOMAS: The broader studies which show us that it's a small percentage, but every day there would be some. It's in the magnitude of five to 10 per cent who are operating at the five to six hour sleep in the prior 24 hours. So maybe one in 10, maybe one in 20 pilots.

THEA DIKEOS: This year, Virgin Blue introduced a new fatigue risk management system. Pilots are now trained to assess their own fatigue.

ANDREW DAVID, VIRGIN BLUE: How many hours have you been awake before you start this tour of duty, verses how many hours you've slept in the last 24 and 48 hours. So a simple report card and a mechanism to be able to report fatigue.

THEA DIKEOS: Richard Woodward and the South Australian researchers say they're disappointed that Qantas and CASA didn't move quickly to address all the recommendations in the South Australian report.

RICHARD WOODWARD: We fully expected the airline to move ahead and implement that. We also expected the regulatory authority to move ahead and change the rule-making process. They did start to do that and I participated in that as well and we drafted a set of rules, but then the program basically ceased until we see what happens at ICAO.

THEA DIKEOS: Qantas rejects the criticism and says it's implemented 15 of the 30 recommendations from the report and says it's well placed when the new regulations come in 2010.

JOHN GISSING: We'll be well ahead in terms of the full implementation of our further improvements that we're planning at the moment.

THEA DIKEOS: CASA says it's already approved 70 fatigue risk management plans for various airlines, but prefers to wait for the global regulator to define the standard.

JOHN MCCORMICK: We don't want to make industry or individuals be placed in a situation where this year, say, we mandate something and then find next year the international standard is something different.

DREW DAWSON: I think we know enough about what's likely to come out of the draft regulations and proposed rule-making initiatives to say we could have a pretty fair guess on how to move forward.

THEA DIKEOS: Professor Drew Dawson says it's time for the aviation industry to act.

DREW DAWSON: I think the important issue is to acknowledge the level of risk that fatigue poses and to take an appropriate level of response to it. That is, you don't wanna shut down the industry, but where there is risk, and we know that there are on occasions a low number of events that carry a high level of risk with them, that we should be able to intervene and manage those in a highly targeted way.

KERRY O'BRIEN: That report from Thea Dikeos.