Safety Management System Failure - Australia
SAFETY ALERT – AUSTRALIA
Many readers of PPRuNe, whether based in Australia or elsewhere, will be aware of a heated and protracted debate about airspace reform in low level airspace.
To the non-Australian readers it may not appear a particularly relevant thread for this forum; nevertheless, it is important to understand the massive safety management implications – or the precedents being set, which may ultimately have a catastrophic safety effect.
The reforms proposed and/or implemented, in and of themselves, are relatively innocuous. Whilst applying to large areas of Australia, they principally affect general aviation users, and smaller link-airline and charter operators. In some cases, the changes proposed do/will affect larger passenger carrying operations, including Dash-8 and even B737 operations.
It is our considered opinion that the changes, if implemented safely and effectively, will have relatively little risk affect on the operation of the airspace concerned.
That said, it has been evident through the last two years, that there is an aggressive campaign to “crash or crash through” the airspace reform agenda, with no regard for established safety and change management systems and practices.
Indeed over this period we have been supplied with large quantities of information that would indicate, if not a deliberate attempt to circumvent those processes, then at the very least a level of naïveté of the processes.
In the last 12 months, the Australian chapter of PPRuNe has been the only effective forum for informed debate on this issue.
We had been mildly satisfied that the tremendous debate that took place over reforms to Australian airspace last year had had the effect of raising awareness of proper change management processes, and at the very least had set in place an environment where those change management processes would be applied in all future initiatives.
All of the key management staff that had been involved in the previous implementation processes – including the Australian Government’s Transport Secretary, the head of the Australian Air Force, and the heads of both the service provider and regulator – were replaced.
All of their respective replacements provided “assurances” that the long established and very robust change management processes – in most cases as good as any in the world across any industry – would be reinstituted and applied for all future changes.
We have been watching the recent developments - and we are now of the opinion that there is a deliberate attempt in Australia, once again, to override proper change management processes to achieve a target implementation date - come "hell or high water".
It is evident that not only is senior management of Airservices Australia involved, but also very senior management of the regulatory arm - the CASA - and once again, the political office of the Australian Transport Secretary.
The changes proposed are scheduled for implementation on the 25th of November – just 6 weeks away – and yet the Design and/or Implementation Safety Case have not been completed and promulgated publicly, training and education material has not been distributed, program staff have refused to provide briefings to pilot meetings, meetings are being scheduled without distribution of invitations, and no cost benefit analysis or business case has been produced.
The production of the Safety Case Hazard Log has been deliberately skewed so that transition hazards are either ignored - or worse – incorrectly categorized and mistreated.
Review of previous Safety Cases produced by the project team - and what little has been made available regarding the Safety Case for the current changes – shows a level of incompetence that if it were not so serious, would be slapstick.
It has been brought to our attention that the internal debates are so substantial within both Airservices Australia and the CASA, that multiple versions of charts, AIP amendments, and training material, have been produced and stockpiled, to allow decisions on implementation to be withheld until the absolute last minute.
It has also been brought to our attention that ultimate implementation decisions are being delayed to a “point of no return” - that is, to a point where the responsible agencies can claim that a recall would create more harm than the actual implementation.
It is our considered opinion that THE CHANGE PROCESS BEING APPLIED IN RELATION TO THE CURRENT AIRSPACE CHANGE PROPOSALS IN AUSTRALIA WILL DEGRADE SAFETY.
As we stated earlier in this post, the changes to be implemented will not, in themselves, substantially alter risk levels in the affected airspace.
However, the means of implementation, and the blatant disregard for proper change management processes and compliance with mandated regulatory requirements for Safety Case, not only increases the safety risk, it establishes a dangerous precedent that will question EVERY safety and change decision taken in Australia in the recent past, and from this point on.
One would have to question whether or not the much vaunted ADS-B implementation has been properly validated through Safety Case.
One would have to question the haste with which new separation minima were developed for use with ADS-B in Australia, and how robust was the supporting safety analysis.
One would have to question the recent implementation of flex-tracking across Australia, and whether or not the Safety Cases were adequate or robust.
THIS is the danger of ignoring established processes – a flaw in one process will naturally call into question all other such processes. You CANNOT choose where to apply safety processes, and where not to apply them – they must be applied uniformly.
We have urged all participants in the Australian debate to "step away" from this safety abyss, and manage this change in accordance with the published safety management processes of both Airservices Australia and the CASA.
We have urged them not to risk the life of one single pilot or one single passenger simply to be able to say "we got it through".
Through this broader forum, we are urging readers to use whatever means they have available to call attention to this travesty, and to challenge the Australian authorities to STOP… THINK…and ACT to reverse this ridiculous situation.
Voices of Reason