NAS: What went wrong?
As NAS ‘enhancements’ are imminent and the various personalities involved scuttle about trying to make the best of a bad situation, it may be time to quietly reflect on why this attempt at aviation reform went so badly wrong. These are my views.
Firstly, aviation reform was propounded by an individual (Dick Smith) with no clearly defined goal or any cogent reasons offered for the change. The claims of costs as a reason for change were soundly refuted on two fronts. Firstly, the industry did not see cost as a major issue. In fact, an independent Eurocontrol study found that Australia’s costs weer already lower than both Europe and the US. Secondly, the claimed cost savings put forward were found (by the Airservices CEO in evidence to the Senate) to be based upon an erroneous analysis of the financial data provided by Airservices in the first place.
Secondly, but perhaps more importantly, NAS went wrong because of the manner in which the reform was attempted. A telling analogy is the case of the Ansett B743 nose-wheel up landing at Sydney some years ago. This could have been Australia’s first wide-body hull loss.
So, what led to the Ansett incident? Why, when the Boeing 747 has successfully been introduced into airline fleets around the world, did Ansett have an accident on their first revenue flight?
The “can do” culture
According to Ansett’s own analysis, the failure was in part due to the way in which the change (introduction of a new and very different type) was attempted. Captain Trevor Jensen attributed the failure in part to a “can do” culture within the Ansett group. Most airlines attempting the introduction of a Boeing 747 into a fleet like Ansett’s at the time would take approximately 12 months to complete the transition. Because of commercial pressures, Ansett attempted the change in the space of approximately 4 months. This led to serious deficiencies in the change management process, pilot education, training materials, operational documentation etc.
Experience
Ansett found that the experience level of the crew in VH-ING was deficient, particularly in terms of the gradient of experience between the captain, FO and SO. The captain was very experienced on type, but not with Ansett, the FO (or SO) was on his first revenue flight for Ansett and also on type. The CRM aspects of such a steep experience and skills gradient became obvious when a relatively simple engine shut-down led to an approach that was too fast, without the correct flap setting and no nose-wheel. Despite all of this, the approach and landing was continued.
The similarities between this and NAS are startling. It is argued by some proponents that NAS works ‘safely’ in the United States, and they see no difficulty in introducing it into Australia. Leaving aside the issue of ‘how safe is safe?’, let us examine the parallels between the introduction of a new system (NAS) and the introduction of the 747 in Ansett.
”Can do” airspace reform
Airspace reform in the United States has taken many years. The culture and the system have developed in response to many competing pressures, including safety, commercial considerations, effective use of taxpayer funding and the influence of lobby groups such as AOPA (US).
In Australia, the attempted introduction NAS in a short space of time was akin to Ansett’s attempt to introduce a new type in about a third of the average time.
This led to deficiencies in pilot education, training materials, operational documentation etc. Exactly the things that led to a near disaster at Sydney, led to a near disaster at Launceston and Melbourne.
Experience
Like the Ansett flight deck, Australian pilots and controllers have little experience of NAS. Where this situation occurs and cannot be avoided, it can be mitigated by a slow, careful and considered introduction of change. NAS is/was being introduced in stages, but it readily became apparent that the changes were not being absorbed in terms of experience and culture.
So, why did we rush into this? According to Dick Smith, the Minister was frustrated that no reform had occurred over the preceding two years and wanted something done quickly. Mr Smith has previously shown his feeling about safety cases/analyses, when he said:” Is it because you believe safety cases are to be used to stop reform, not support reform. What other reason could there be for your inconsistency? ie, if you or your colleagues personally want the reform there is no need for a safety case, but if you do not want the reform there is the need for such an involved and detailed safety case that it will never be completed.”
What we are left with is a situation where:
1. Public confidence in aviation has been eroded. This cannot have any positive affects on the financial viability of airline and other operators. How many more operators going bankrupt will it take before aviation reform is done properly, by the professionals and with broad consultation and agreement?
2. Further confusion will arise from any ‘rollback’ of NAS, leading to the possibility of further incidents.
3. The chairman of the Airservices’ board has resigned. His talents will no longer be available to benefit aviation reform and aviation safety in Australia.
4. An enormous amount of money has been wasted on now-defunct training, documentation, etc. A further amount of money will be expended undoing the mess.
The costs of NAS, in terms of economic loss, loss of reputation and time are considerable. The people who made these decisions should be held to account. It is incumbent upon all of us who have been affected to support attempts to determine the truth of how NAS was allowed to proceed in the way it did.