Safety Management System Failure - Australia

[Voices of Reason]

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

[Woomera]

For anyone wanting to get the Australian perspective on this very important issue go here;

Safety Alert for Australian Airspace Dunnunda & Godzone (http://www.pprune.org/forums/showthread.php?s=&threadid=194085)

We have never seen anything quite like in any other First World country.

Be careful out there.

[Dick Smith]

No doubt all PPRuNe readers are very aware of the disclaimer stated very clearly by the organisers of PPRuNe:

As these are anonymous forums the origins of the contributions may be opposite to what may be apparent. In fact the press may use it, or the unscrupulous, to elicit certain reactions. I believe I can see evidence that a number of PPRuNe posters are trying to undermine Australia in relation to aviation. Many of the posters give the impression that they are Australians but could actually be from overseas – say, countries that don’t want Australia to succeed in aviation.

For example, it is fantastic to see that a substantial part of the NAS 2c changes have now been signed off and are going ahead. However it is disappointing to see that one of the cost savings and improvements to safety has been deleted after a campaign by people I can only believe are traitors to Australia.

Under the US system that we should be following, any aircraft can join on base provided it can be done safely. This saves the airlines in the USA hundreds of thousands, if not millions of dollars per year.

This was to be part of our Aussie NAS 2c, however due to a campaign by a number of people, even Qantas will not be able to join directly on base (as the US system allows), save money and improve safety. Under the new system they will either have to do 3 legs of a circuit or head out and do a 5 mile straight in approach. This will add tens of thousands of dollars (if not more) to Qantas costs and will not improve safety in any way.

Possibly other PPRuNe readers may like to comment. I just wonder how many traitors (as far as Australia is concerned) post here to try to do as much damage to our aviation system as possible so their own country has a competitive advantage.

By the way, if it is not a traitor from another country or from an overseas airline influencing this, what could it be? Why would anyone want to prevent (by law) Qantas and other operators doing a sensible approach and joining on base when aviators all around the world can do this? Does anyone have an answer to this?

[Sunfish]

Seems someone removed a post about who the culprit was on this affair.

[multime]

Didn,y you used to own or have something to do with electronics?
or Food Products.
Your rants are not relevant and stirring the pot (AGAIN) doesn,t help.
Stick to what you know.
DICK

[nafai]

Sounds like cheap shots and sour grapes after losing the debate a couple of months ago with a certain navaid on this forum. Maybe biscuit man you can help an old lady across the street or fly in to free a few more immigrants to help boost your diminishing public profile.

[blueloo]

Dick, surely any airport where an aircraft of 717/ 146/ 737 size operates should either have a manned tower with radar coverage, or at least radar coverage tied into TAATS with control/advice from an operator.

(Maybe someone should also come into modern times an install some new navigation equipment at these aerodromes too, but thats another issue, and if a major international airport like YMML cant have an ILS on 34 then what hope do these others have!)

I think radar coverage will happen - but only after a light a/c has plowed into a 737. QANTAS certainly won't demand or pay for it. Qantas only reacts after the fact. The government wont act either until thepublic demand it. So unfortunately what we need is a prang to bring about change. Touch wood a prang doesnt happen.

[DeBurcs]

Hi Dick,

1. Would you explain how joining the circuit on base increases safety? What basis do you have for that conclusion?

I can see that it might be neutral on the effect it has on safety, at best.

2. How does a foreigner working against us from outside the system qualify as a "traitor"?

3. On a slightly different topic, was it you who systematically disbanded all the remote Flight Service Units and merged all the CTA and OCTA area frequencies? We now have airliners outside RADAR coverage at flight levels in the high 200s, 300s and low 400s and light aircraft taxiing at dirt runways or reporting at altitudes below 10 000, all on the same frequencies.

Does this relaly makes sense to you? Where did you plan to stop with cost-cutting?

I'm sure you're good with business, electronics and food but this does not make you necessarily qualified to tamper with aviation.

Good luck with your other ventures.

[CaptainMidnight]

Gawd, it's conspiracy theories now ........

To quote Mike Smith at an industry meeting:The worst thing that could have happened to NAS is for Dick Smith to become involved ..........

[Wizofoz]

Mr Smith,

Just to confirm-
a)Nobody with a contrary view to you could POSSIBLY have a genuine concern that the reforms you advocate are wrong.

b)Anybody expressing a view not in concert with you own has a sinister hidden agenda inspired by union concerns or (and I'm REALLY scatching my head over this one!!) a desire by foreiners for Australian Aviation not to succeed.

c) Following your initiatives will, in isolation, revitalies the entire aviation industry and create "Tens of Thousands" of pilot jobs (in a country which has approx. 9000 aircraft in total.)

Dick, I am going to make a sober, serious suggestion to you. get one of your staff to print off all your entries here and on Dick Smith Flyer. Get them to be examined by a mental health care professtional.

Identifying anyone who dissagrees with you as a traitor or conspiritor shows distinct signs of a developing paranoia, and you really should seek help.

[triadic]

No Dick, you are wrong.


You are trying to change a culture without a change management project, and you wonder why it keeps falling over.

There are no traitors in our midst, just a lot of folk who have been not sold the reason/s for the changes either safety or financial.... and hence they don't support it for whatever reason.

If you don't sell and manage the change/s properly, then how can you expect to succeed??

:( :(

[Tacan400]

Traitor? VOR posts from New York apparently. How can it/she/he/they be a traitor?

But Dick, it's actually the Transport Minister that has or is about to sign your damn CAS 2c regulations, which apparently you now find deficient. That means you are accusing him of being a traitor for apparently implementing a 'Cabinet decision'! How does that figure???? You'd better get in quick and stop them before they're made into law then if you think our Nation is being betrayed.

Hopefully Truss will now tell you to bugger off out of aviation like Anderson did.

Hopefully you will be carted off by little men in white coats before I am.

[Sexual Chocolate]

Personally I think there are two main reasons why people don't agree with you or like you.

1) You made a heap of money, bought into aviation and have never known what's it's like to struggle through the industry, try and make a career work or deal with the real life day to day pressures of commercial aviation. Realistically, you're nothing more than the equivalent of a pivate pilot with more expensive toys than the average boy and a few adventures that this money's bought you. Yet you feel your opinion to be worth something, not because you're an expert but because you're well known. We don't have any wealthy businessmen-come-yachties who feel themselves qualified to comment on the future of the maritime transport industry. So please, why can't you just stop ridiculing and patronising us, put your coke-bottle glasses back on and go back to fiddling with circuit boards?

2) Really, every time I see you in the media I keep wondering when your nose will start running and your mother will run out to wipe it with a tissue, tell you to tuck your shirt in and ask you if you're wearing clean underwear.

[Binoculars]

Well, this is going well, isn't it Dick?

Never mind, mjbow and the rest of your sycophants will be along shortly. It must be hard for you becoming an increasingly irrelevant fish in a small pond.

[TROJAN764]

Dick

Not my quote, I'm afraid - tho' I wish it was - but one which I feel is appropriate to repeat:

"You don't have to be smart to make money - just remember Forest Gump!"

In the same vein, your NAS is 'like a box of chocolates' - 'we really don't know what we are going to get!'

[Ex FSO GRIFFO]

Dick,

Just G O A W A Y and leave us alone!!!!!!!!!!!!
Haven't YOU done enough damage already??????

An Ex Flight Service Officer, current CPL, and proud of it !!!!!!
And, before you start your rantings again, I was just about due to retire anyway, so YOU actually did ME a huge financial favour!!!!

Now, I think I am going to VOMIT!!!

THERE!!:yuk: :yuk: :yuk:

(I (I feel betttteeer now...)

[Woomera]

In case anybody in Rumour and News is confused, the above poster Dick Smith is the designer and sole promoter of the Australian National Airspace System the subject of this thread.
Safety Management System Failure - Australia

If there is indeed a conspiracy as Mr Smith suggests he;

can see evidence that a number of PPRuNe posters are trying to undermine Australia in relation to aviation. Many of the posters give the impression that they are Australians but could actually be from overseas – say, countries that don’t want Australia to succeed in aviation.
I just wonder how many traitors (as far as Australia is concerned) post here to try to do as much damage to our aviation system as possible so their own country has a competitive advantage.

we would appreciate your immediate help in identifying them to Mr Smith.

Clearly, Australian aviation is in urgent need of your help.

[Jerricho]

Ladies and Gentlemen, I believe it a waste of time and bandwidth calling Mr Smith to task over his outrageous comments regarding "traitors" and other subversive tactics. As always, he has said his bit, stuck his fingers in his ears and will not listen to anyone else's opinion because that's all it really is, isn't Dick, your opinion. Something you are perfectly entitled to have, however lacking and wrong it may be.

[Wings]

Hello everyone,

I am an Oz pilot who has lived and worked overseas since before 1989. I have never worked for an Australian Airline and probably never will. That's a personal choice.

Having got my Oz licence in the ealy 80's I can remember the Absolute Monarchy that the DCA, Dept of Transport, Transport Australia or what ever else they wanted to call themselves had.

Anybody who wanted to do anything in aviation wasn't allowed to do it because ANR this or ANO that forbade it.

The only way you could do anything was with major @rse licking to the regional branch of the DCA who would then give you a one off concession. Of course you now lived with the constant threat that if you upset the department in any way, your concession would be revoked and you would be sunk. If you had to make your living out of Aviation you were literally at the mercy of the omnipotent Gods in regional Office who knew it.

The only way this would ever change was if someone who was interested in aviation, had a stack of money and didn't rely on the mercy of the DCA, stood up and shouted.

That's what Dick Smith did.
In the very public way that only a high profile person can

His book 'Two Years in the Aviation Hall of Doom' was a real eye opener and hopefully a major embarrassment to the department. As a consequence of the book, a Federal enquiry was held into civil aviation and major changes to the industry began.

It was about then thatI left Oz and went overseas to work. I haven't worked back there since.

My point from all of this is that it appears that Dick Smith's original strength is now his ultimate weakness.

Because he didn't earn a living from aviation, the DCA couldn't really hurt him.

But because he didn't earn a living from aviation, he can never really know what the real stresses of earning a living from aviation are.

From what you all say, it appears that the time has come (perhaps passed already) to say

"Thank you for your help, but your abilities have now been fully utilised and we can no longer consider you a useful resource, please step away from the controls".

The problem then becomes
' Who will replace him and will they be any better ?'.

Cheers:ok:

P.S. Does this make me a traitor ???

[Sunfish]

Gee Wings, I don't make my living from aviation either and I have exactly the opposite view.

[Vacant Towers]

Lets get on with discussing the systemic failures and lack of project management of Oz Airspace planning and implementation. I don't always agree with Dicks ideas and arguments but it is those ideas and arguments that have led us so far to this point. Whether we like the man or not is irrelevant to the discussion, it is his ideas we are (or should be ) discussing and not his glasses or some other irrelevant personal issue.

I am not defending him, but whilst we discuss him, we are not discussing the current important matter ie " Oz Airspace planning and implementation"


VT

[john_tullamarine]

Having worked and played in Oz aviation pre- and post- Mr Smith's tenure, three thoughts come to mind -

(a) the then Regulator was more paternalistic than rational thought might consider necessary ... so it might be said that there was a need for a bit of a shake up.

(b) as with many of these sorts of events, the swinging of the pendulum analogy is appropriate

(c) the change to make the Regulator directly and functionally accountable to the Minister caused a great many changes to occur ... but I prefer to keep my views as to whether this might have been a good thing to myself. One needs to keep in mind that, in the days of Donald George, the Head was where the buck stopped .. and I am sure that that probably caused eyebrows to be raised occasionally at political level.

Please don't take my comments either to show support for, or antipathy to Mr Smith's activities. My interest is only to show that someone, such as Mr Smith, was needed for a time to give the old guard a little shake up.

[gaunty]

Wings

Not at all and a very succint summing up indeed.

John_tullamarine

Quite so:ok:

That was then and we knew how to work the system.

It was British Post Colonial Australia and across the industry we knew how to "Yes Minister" as well as any Humphrey Appleby.

It would have been easy for any sort of Smith to demonise the system, but at least it worked and had embedded in it many years of experience derived in the unique social, environmental and political context of Australia.

There is no doubt change was in the wind, maybe Mr Smith accelerated it, if indeed he did, then, it was at a terrible cost.

The trail of destruction, the destroyed careers of many highly experienced and competent individuals and the "export" of a significant part of the intelectual property carried in the heads of these people, has left Australia close to being mortally wounded.

Simply, that many internationally respected and highly experienced people can't be wrong.

Any Smith would have had the support of the "chattering classes", but I do not recall the "industry at large", at least the part that was the backbone, he was determined to "save", clamouring for his personal support.

One has to fully understand the events, in the contexts of the times to fully understand the phenomenon.

Overall we are waaaaaaaay past the "time" to which Wings alludes.

[john_tullamarine]

d'accord .

[megan]

Reading threads of pilots having to write letters to management justifying why they loaded extra fuel strikes a chord that the greatest impediment to further lowering of the accident rate lies in management practices external to the cockpit. One thread quipped that management are the ones who should now be attending CRM courses, and it is hard to argue against. I wonder if marketing have to justify by way of a letter to some bean counter as to why a particular flight departed with less than a profit-making load.

The latest Flight Safety Australia magazine has an article by a pilot under overbearing management pressure as to how a flight was to be conducted Mareeba to Horn Island – a GA operator, and probably a hand to mouth one as a lot are. The article gave me pause to reflect on my own experiences. Let me first say that I’m not out to cast stones or point fingers as I’ve personally made all the stuff ups its possible to make and still be a member of the human race. I merely give it for what it may be worth.

I spent a good part of my aviation career flying offshore for an operation owned and staffed by an oil company (read very deep pockets – not your fly by night GA operation). When I started the pilots were on an award and the manager was staff and as such was subject to a yearly appraisal, which then flowed on as to what his salary might be for the next twelve months. At that time I was flying a Bell 205 and although it was a VFR operation that was in name only. It was nothing to cruise at five hundred feet IMC in cloud, torrential rain, penetrate line squalls or frontal systems, snow or anything else mother nature came up with. Coming home from offshore was simplified if it was strati form type cloud, rather than sweat 35 minutes of IMC hand flying with no stab system we would climb to on top (generally 3,000) and home on the “bubble” in the cloud caused by the heat from a industrial complex located next to the heliport (Alex Henshaw approach). No approach aids were available so approaching the bubble” you let down through the muck till becoming visual (flat terrain so nothing to dodge/hit). Going outbound to a platform (we did have a coffee grinder ADF, but never worked when you needed it most) we navved by watch and compass – remarkable how good you became estimating groundspeed and drift through the chin bubble. In poor conditions it was often only because of a timely tap on the shoulder by a passenger (extra set of eyes) who appreciated the difficulties that you found your destination.

So why did we operate as we did? The aircraft were state of the art for the time in question operating in a geographical area with rapidly changing climatic conditions – blink and the weather could go from CAVOK to where you couldn’t see the water from the platform helideck (100 feet AMSL). They were also pioneering days in that the oil field was in the construction phase and early days of production. The CEO was the original 14 year old mail room boy who worked his way up and knew almost every one of a vast work force by name and thought nothing of passing the time in the crew room to get an insight into how thinks were going – as he did with all sections of the work force. In short, you were an appreciated member of the work force – to the extent that you found your award salary increased because the CEO was of the mind that because group X got a pay rise your group should get one as well.

Then came the rot. A new breed of managers moved in when the oil field was a mature business – all with an MBA in the pocket and focussed entirely on the bottom line. It’s an extreme event for senior and middle level management to venture out of the office – certainly not to talk to the hoi polloi. Every year bought forth-another announcement of an X% cut to the budget – but more expected in productivity. A budget is no longer a tool of management but an impediment to management. The pilots were made staff (willingly I might add mostly at the time) and subject to the appraisal process for salary increases. We then had a manager stand in front of the pilot group and tell us we had it too good because nobody had ever left. Nor did the company honour its undertakings with respect to how the staff system operated (surprise, surprise). Seeing the writing on the wall one of the pilots took to asking questions as to why we kept putting our a55es in a sling vis a vis compliance with the regs when the ops manual stated compliance is mandatory and we had come a long way in terms of equipment capability (autopilots, GPS, radar, no longer single pilot etc) but still operating as if we were still flogging a 205 single pilot. His appraisal for one year from the chief pilot stated “bloggs has out of perspective concerns”. Explanations to various question ranged over “you don’t need to provide for an alternate as the chance of any thing going wrong are infinitesimally small – if we followed the regs we wouldn’t do anything – you will do what you are told – you worry too much – do you want to shut the operation down”. Management seems to have lost sight of the fact that all the regs begin by saying “The PIC (is responsible, shall, will – insert word of choice).” We had fallen into the trap that this was the accepted culture (culture someone defined as its what you do when no one is looking). Was it brought about by a lack of regulatory over sight, close personal relation ship between managers and regulator? A theory I subscribe to is “The Normalisation of Deviance” (do a Google – I wont go into it here). Because the operation had never had an accident or major incident there seemed to be a belief that every thing was AOK. The good fortune had more to do with outstanding maintenance, nothing higher than 225 feet to run into (platform), experienced pilots, well equip aircraft and a healthy dose of luck in that major emergencies always took place in benign circumstances. Because the pilot was not able to push forward on the issues in house he bailed out and is of the thought that perhaps because of his approach to the authorities some ten months ago it may have given some impetus to the REPCON. As to what effect on the company, if any, is clouded by “we can’t tell you” from the authorities.

Off thread a little, but we as aviators I think are often our own worse enemies in as much as judgements we make about the errors made by fellow practitioners (the recent high speed 737 approach comes to mind – see quote of Mike Mullane below). Some of us put ourselves on rather high pedestals, and although the cockpit crew is the last line of defence for every body’s mistakes, none are supermen. Peter Garrison in “Pilot Error” wrote “Again and again, pilots are found to show little sympathy for their colleagues who are hurt or die; some simplifying explanation is immediately hit upon to reassure the others that the same fate will not be theirs”. People are people, fallible despite their best intentions, abilities, training and efforts. There can never be too much humility among those who fly. Following is a selection of quotes apropos I thinks to lessons management could well learn.

What caused both Shuttle occurrences was a confluence of deficiencies in human behaviour; normalisation of deviance, uncritical acceptance of easily verifiable erroneous assumptions, denial, willing suspension of disbelief, rejection of scientific proof, and unalterable commitment to the belief that "it can’t happen here."

Astronaut Mike Mullane commenting on the Shuttle accidents, "NASA managers, engineers and astronauts are not robots. They bring their humanity (egos, ambitions, fears, relationship issues, etc) to work just as everybody else.”

From ‘The Naked Pilot’ by David Beaty
Firstly, there should be an acknowledgment that if and when the pilot makes a mistake, his will probably be the final enabling one at the apex of a whole pyramid of errors down below. This will, in turn, take the heat off investigations – the ‘we intend to find and punish the culprit’ syndrome. Only then can the pilots come forward and admit to mistakes they made or nearly made, and the reasons why can be coolly analysed and lessons learned. [Page 285]

Professor Reason in Human Error (1990) distinguishes between active error, the effects of which are felt almost immediately, and latent error, the adverse consequences of which may lie dormant within the system for a long time. This can clearly be seen in aviation, where pilots at the sharp end make an active error, while latent error lies behind the lines within the management support system. Many of these are already there awaiting a trigger, usually supplied by the pilot. ‘There is a growing awareness within the human reliability community that attempts to discover and neutralise those latent failures will have a greater beneficial effect upon system safety than will localised efforts to minimise active errors.’

As long ago as 1980, Stanley Roscoe wrote that:

The tenacious retention of ‘pilot error’ as an accident ‘cause factor’ by governmental agencies, equipment manufacturers and airline management, and even by pilot unions indirectly, is a subtle manifestation of the apparently natural human inclination to narrow the responsibility for tragic events that receive wide public attention. If the responsibility can be isolated to the momentary defection of a single individual, the captain in command, then other members of the aviation community remain untarnished. The unions briefly acknowledge the inescapable conclusion that pilots can make errors and thereby gain a few bargaining points with management for the future.

Everyone else, including other crewmembers, remains clean. The airline accepts the inevitable financial liability for losses but escapes blame for inadequate training programs or procedural indoctrination. Equipment manufacturers avoid product liability for faulty design,. Regulatory agencies are not criticised for approving an unsafe operation, failing to invoke obviously needed precautionary restrictions, or, worse yet, contributing directly by injudicious control or unsafe clearance authorisations. Only the pilot who made the ‘error’ and his family suffer, and their suffering may be assuaged by a liberal pension in exchange for his quiet early retirement – in the event that he was fortunate enough to survive the accident

Yet it is only recently that very dubious management malpractices are being identified and their contribution to accidents given sufficient weight. For though the pilot’s actions are at the tip of the iceberg of responsibility, many other people have had a hand in it – faceless people in aircraft design and manufacture, in computer technology and software, in maintenance, in flying control, in accounts departments and in the corridors of power. But the pilot is available and identifiable. [Page 221/222]

An incident/accident is generally the result of active failures (pull the trigger) on the part of the cockpit crew, but the stage may have been set by the latent failures (load the gun and put the safety catch to ‘fire’) introduced by others (management practices, certification standards, aircraft design, software, ergonomics etc etc). Put another way, the cockpit crew is the last line of defence for every ones mistakes. As good as you may think yourself, none of us are all knowing.

Capt. Fenwick of ALPA has cautioned. "Pilots will be judged against the perfect pilot flying the perfect airplane on the perfect flight. We all know that no such thing exists.”

PS Thanks for putting up with the rant if you got this far.
PPS One word described our company safety program under the new management style – punitive.

[megan]

CASA Media Release - Thursday, 2 September 2004 Aviation management needs closer scrutiny
A closer examination of management and management systems in aviation organisations is a key to further improving air safety. Management systems should be proactively targeted by both accident investigators and the safety regulator. The call for in-depth scrutiny of the management of airlines and other air operators was made by CASA chief executive officer, Bruce Byron, in a speech to the International Society of Air Safety Investigators.
Mr Byron said accident investigators and CASA may need to bring in people with management expertise even if they have no aviation experience. “Our people have a lot of good technical skills and experience, and so do you,” Mr Byron told the accident investigators. “But where do we stand when we push the envelope beyond the immediate technical issues associated with an accident and start to get involved in an organisation’s management processes.
“In my experience with large organisations, particularly where they have a duty of care for the safety of people, I have seen evidence of potential deficiencies in management decision-making. “This is nothing new, but we need to be confident we have the skills to objectively review management processes and procedures that may be somewhat removed from the technical fields with which we are most comfortable. “We need to be proactive in targeting, for example, management systems.” Mr Byron said scrutiny of management was a real issue for CASA as new regulations were being drafted that would require the implementation of safety management systems by air operators. He told the accident investigators another important issue was making sure the results of crash investigations are actively used to improve safety. “Most importantly, it is vital that all the good material that you produce does not fall into some electronic black hole or database – without being used by the decision makers in the system. “Your information needs to be constantly trended, assessed and compared with data from other sources – not every decade, not every year, but all the time.”
A full copy of Mr Bryon’s speech is at: casa.gov.au/corporat/ceo/04-08-31.htm

[Sunfish]

Ahhh Megan, you worked for Esso too did you?

I lasted two years and I wasn't even a pilot.

[738Capt]

Yes business operates for profit. Airlines run very costly businesses. So to improve the bottom line do you:

1) Cut wages,
2) Reduces levels of maintenance,
3) Push flight crews to fly longer hours at less pay.
4) All of the above.

Most airlines do all of the above and more. Bringing in new rules to reduce human oversight of flight operations is not safe. Why change the system? Why should aircraft be able to join on base. You need oversight by radar to control aircraft in a safe manor. Having aircraft fly a pattern before landing enables approach/tower to better control flights. It allows for safe spacing of differing types of aircraft, rather than a cessna 152 and boeing 737-800 fighting it out at the point of joining base.

There should always be separation of light aircraft from the heavy. Having an 'open skies' policy and leaving it up to the pilots is not safe.

The flying public should know that below 10,000ft under this new system it's every pilot for him/her self. It is a cloudy day, with cloud bases around 7,000 your decending at 250kts through fl07 in a 737 and out pops a c152 at 1 mile. No TCAS warning, no radar control for separation, and no requirement for the c152 to call to advise he/she is entering that area, is that safe?

[Frank_Sources]

Cutting wages does not increase productivity.

It gives you the same (if you are lucky) productivity, or (normally) less productivity.

It just reduces the cost base.

It is one of the great myth-management tacthics.

As an experiement - cut your wages cost back to zero - see how productive that makes you.

Or, a case in point around my neck of the woods, reduce the cost base by 10%. (effective pay cut). And watch your productivity soar - backwards (funnily enough, same line graph as morale).

What do they teach in MBA school these days?

[Sunfish]

Please go easy on the MBA thing, it might fly in the U.S. but not elsewhere.

The measurement of "profit" itself is problematic.

What you are trying to do is maximise the value of the firm in the long term.

The correct methods of doing this are to focus on long term profitability, which is why smart companies are moving away from "incentivising" managers with short time horizon driven bonuses.

The ultimate measures are return on shareholders funds as well as return on capital employed (which includes debt), the targets for both of these are adjusted for the riskiness (beta) of the associated industry.

The techniques for achieving a good return are:

1. Eliminating waste in all its forms.

2. Doing more with less - finding more customers and also requiring less capital or debt.

"Cost cutting" can sometimes be necessary if the pax are not there to pay peoples wages.

[Pax Vobiscum]

You are, of course, exactly right, Sunfish - I'm glad to hear there are still such smart companies in Oz, but I can assure you that they're in very short supply in the rest of the world (whether that's because you're behind or ahead of the game here, I can't judge).

In the US and Western Europe, most senior managers operate on a horizon driven by the next quarterly figures. The only exceptions I've seen are companies that are (or effectively are) in private hands, who can afford to view their share price fluctuations with lofty disdain. No decision-taker seriously plans on being in the same job (or even with the same company) in three years time - why should they care about the long-term effect of their decisions so long as they're left covered in short-term glory?