Note: Couple of PMs have expressed their opinions that my post #
789 from Truss thread would be better represented on this thread...so here it is..
Mayday..mayday..mayday!
Top catch SIUYA at post #
782 & #
785….
“..SUMMARIES OF DISCUSSIONS
Topic 2.5: Implementing new safety management process
44. There was unanimous support for the establishment of a new Annex [19] to the Convention dedicated to safety management responsibilities and processes..”
Meanwhile, in Fort Fumble’s parallel universe, the middle management minions were busy enacting their MAP to roger DJ and the ATsB, while attempting to cover up their obvious shortcomings to properly oversight the PelAir operation.
Anyone else see the irony in the two universes?
List of Participants
AUSTRALIA
MCCORMICK J. CD
FARQUARSON T. ACD
TIEDE A.H.R. ANC
ALECK J. D
BOYD P. D
BROOKS L. D
DOHERTY J. D
EVANS P.K. D
MACAULEY K. D
Looking at all the participants from Oz, I also find it more than ‘passing strange’ that Beaker’s crew did not get a look in?? After all the principle body that is fundamental to a successful State SSP is it’s fully independent AAI.
Oh well perhaps bean counter Beaker’s budgetary constraints couldn’t stretch to paying a couple of economy class airfares to Montreal…
In regards to Annex 19 & in the context of the WLR panel report, unlike CAsA, hopefully the panel will have not missed the significance and importance that ICAO place on Annex 19 as the lynch pin that ties all the other ICAO SARPs together. This significance was certainly not missed by several of the submitters to the WLR, who have asked for the Govt to seriously consider reviewing/updating our version of the SSP (State Safety Program i.e. Annex 19).
Examples…
Sports Aircraft Association of Australia (SAAA) submission:
2) The Government review the State Safety Program (SSP)
a) The SSP concept as articulated in Annex 19 is the basis of how a State administers aviation oversight and reporting at the state level and internationally to ICAO.
b) Recommend the Government overhaul the SSP and use it to administer all aviation activities in Australia not as a spectator role it takes at present.
Australian Lawyers Alliance (ALA) submission:
5. In light of the Pel-Air and Transair air disasters, Australia should update its State Safety Program in recognition and reflection of Australia’s adherence to safety management standards set out in Annex 19 to the Chicago Convention which entered force on 14 November 2013, to assure the public of confidence in future regulator oversight and surveillance of operators.
It is worth reflecting on the ALA submission because the main author of their submission was Joseph Wheeler from Shine Lawyers. This bloke has a real handle on our obligations, as a signatory state, to the ICAO SARPs and in particular Annex 19. Couple of quotes from the ALA submission…
“…Despite Australia’s admirable domestic and international air safety record, and its respected place among International Civil Aviation Organisation (ICAO) States, Australia does not occupy as high a place as it should in terms of international adherence to ICAO standards and recommended practices (SARPs) – the principal measure of a nation’s air safety oversight obligations…”
And from Part ‘5. Systemic oversight issues following Lockhart River crash in 2005’…
“…In the aftermath of the Lockhart River crash it is recognised that the broader trend worldwide towards risk assessment and management led to the development and approaches being implemented at the operational level by CASA. See for example, the publication “SMS for Aviation – A practical guide: Safety Management System Basics”.51
The ALA’s submission is that while there is now a proactive aviation atmosphere with respect to safety risk management for aviation service providers, as evidenced by CASA’s reliance on such principles in preparing its own responses to SARPs on fatigue risk management and drug and alcohol risk management in aviation, these principles should also not be forgotten in the broader context of the results which can eventuate in the absence of such principles in guiding surveillance or oversight of AOC holders (such as the crash at Lockhart River).
Thus, the ALA recommends and endorses updating of the Australian State Safety Program, as published on the Department of Infrastructure and Regional Development’s website, as this was last considered in April 2012, well before the commencement of Annex 19.52 The benefit of this would be to demonstrate to the public the Government’s continuing adherence to regulatory oversight and surveillance at a national level and inspire confidence in smaller air operators to embrace safety risk management principles in the management of their aviation businesses…”
Joseph Wheeler has also produced some excellent articles, published on the Shine Lawyers blog site, on the MH370 search and accident investigation:
MH370 investigation: roles, responsibilities and rule changes
MH370 Preliminary Report released
But his latest article perhaps best highlights the essential role that ICAO play in governing how a signatory state must predictively act after a tragic air disaster has occurred.
MH370 search for answers and ICAO work to track airliners
One rule in Annex 13 is that countries which have a special interest in an accident by virtue of fatalities or serious injuries to its citizens are entitled to “have access to relevant factual information which [are] approved for public release by the State conducting the investigation, and information on the progress of the investigation”: Ch 5.27 at 5-8 – 5-9. While it has been argued that no-one knows better than accident investigators the importance of their role (to make aviation safer) we maintained (less than 2 weeks after the aircraft’s disappearance) that:
… passengers’ families need to be represented within investigations, both during the search phase and during the investigation phase. … It is only these people, with their human feelings and passionate concerns for answers (owing to their unique losses and experience), which can serve to remind investigators of the reason they are doing what they are doing – to prevent the suffering which has been caused to family members – not the lofty ambition of “making aviation safer” (a trite comment in the context of the shared global pain of those hoping with the families of MH370 passengers to get answers).
We do not depart from those views.
In this case the ICAO SARPs, along with international community, has helped remind the Malaysians of their obligations to the victims and their families of flight MH370.
Joseph Wheeler’s article also displays how all the ICAO SARPs are intrinsically linked. If you follow the JW Annex 13 reference (i.e. Ch 5.27):
5.27 A State which has a special interest in an accident by virtue of fatalities or serious injuries to its citizens shall be entitled to appoint an expert who shall be entitled to:
a) visit the scene of the accident;
b) have access to the relevant factual information which is approved for public release by the State conducting the investigation, and information on the progress of the investigation; and
c) receive a copy of the Final Report.
This will not preclude the State from also assisting in the identification of victims and in meetings with survivors from that State.
Note.— Guidance related to assistance to aircraft accident victims and their families is provided in the Guidance on Assistance to Aircraft Accident Victims and their Families (Circ 285).
Link for Circ 285 HERE & ICAO Annex 9, Chapter 8, Section (I) can be viewed HERE
yr right’s comments…
“…SMS what by any other name is basic common sense. Same as Human factors is. But oh gee we now all have to do it or we are all unsafe. Its these extras that at the end of the day don't really amount to anything but are costing industry heaps…”
“…At the end of the day ICAO whilst it sounds good…”
yr right is right that SMS & Annex 19 is yet another impost to industry stakeholders and is largely based on ‘common sense’. yr right is not right when it comes to ICAO and their SARPs.
Since the Chicago Convention 1944, the ICAO SARPs have been evolving and are produced from over a 110 years of collective (some tragically) international air safety lessons learnt. Those bothersome Human Factors experts may have had a large part in the writing and design of Annex 19, however their combined efforts are not just based on a whim. HF experts in aviation basically study why it is we humans continue to make fundamental errors while committing aviation. They also look at ways to lessen the occurrence & severity of these errors. Annex 19 is a reflection of HF expert research over a good 50 or so years.
That is why it is a total abomination that our numb nuts in CAsA and the Dept (there are Dept names in that list) have the audacity to spend untold millions of taxpayer monies going on junkets to Montreal to show, on paper at least, that we are an ICAO compliant State. But in reality we are merely paying lip service to the ‘Spirit & Intent’ of over 70 years of collective ICAO wisdom…
One can only hope that the ALA recommendation 5 features somewhere near the top of the list of WLR recommendations and the miniscule takes heed, hopefully sometime before Mr ICAO eventually comes knocking…
TICK bloody TOCK!
Comment: Have also been doing some research on the history of CAIR/REPCON because it disturbs me how this, ICAO endorsed, essential safety information source, has evolved and been diluted to the current WOFTAM system we have today. Effectively submitting a REPCON is nothing more than a signed, sealed confession open to future exploitation (rogering) by Fort Fumble.
In the course of my research I came across a paper from the then ATSB CAIR manager (2001), the paper was titled
"Who Cares About CAIR?" Here is a part of that paper reproduced:
Successes, failures and challenges
How do you measure success? How do you ever know if a report of a
notification of a system deficiency subsequently prevents an accident? An
identified system weakness, knowledge of a violation, limitations in training are all factors - known as .holes in the cheese. - and defences are then developed and put in place to limit the risk and improve safety.
Several outcomes can be identified from CAIR reports where action has been taken to make the system safer, such as CASA.s withdrawal of the AOC of shonky operators, changes to inadequate or inaccurate documentation, navigation aids or procedures. But how many accidents has the CAIR system prevented? No one knows. The CAIR office received numerous reports of alleged maintenance deficiencies with a major airline last year. Was it a coincidence that the regulator CASA grounded a number of an operator's aircraft earlier this year? It would be drawing a long bow to say that an aircraft did not crash or have an accident because the early warning system had raised an awareness of deficiencies and action was taken to prevent such an outcome.
What about the recent accident in Bangkok? Were flight crews concerned about deficiencies with training or procedures? Were flight crews aware of the potentially increased risk with the flaps 25 approach, in particular, a high and fast approach to a wet runway - at night. If they were concerned about any of these matters - why was no report submitted to the CAIR system? Are the flight crews of airlines persuaded to not submit reports to the CAIR system because of a negative event that had occurred to one their members in the past?
The greatest concern, and what is considered to be a failure of the safety system, are those occasions when an operator or an organisation seeks to find out who submitted a CAIR report.
If you were the head of an airline, of course you would want your own systems in place to capture any information that identified deficiencies in your defences. For public relations reasons, you would not want these deficiencies known by the public - its bad for business. But it is not as bad as having an aircraft slide off the end of the runway or having large cracks found in the wings or engine pylons, or having a large portion of your fleet grounded.
If you were the head of an airline and one of your employees was aware of a safety hazard but was uncomfortable with the internal reporting system, you would want that person to tell someone, especially someone that had a system in place that would alert you to the hazard. Any attempt to identify the reporter of a CAIR report does make the CAIR manager’s job harder and has the potential to weaken the whole system. A system that was solely developed to protect our industry by improving flight safety.
The history of flight was in its infancy at the beginning of the last century. Thus, the contemporary air safety investigation practices of the 21st century are, by definition, in their infancy. So what are the challenges for confidential incident reporting. First and foremost is the maintenance of the viability and integrity of the confidential program. The demise of the various confidential programs of other countries has resulted from a lack of commitment, funding and the rigid application of robust procedures.
In Australia, the three pillars of CAIR are:
• The maintenance of the confidentiality of the reporter
• The willingness of industry to use the system, and
• The provision of feedback to the reporter and industry.
While the program manager has a degree of control over the first and last of the three pillars, the willingness of industry to use the program can be destroyed in a moment. The CAIR program needs the support of all facets of industry: flight crew, operators, engineers, regulators and managers.
Everyone committed to safety should promote and support the reporting of
incidents through both the open and confidential incident reporting systems...
So who..
Cares about CAIR (REPCON)? Well quite obviously, through the abrogation of our obligations to ICAO Annex 19, our executive management of the Dept, FF & the bureau don't CAIR..
