Sweeping condemnation of Transport Canada's approach to aviation safety

[dhc2widow]

CNW Newsgroup (http://www.newswire.ca/en/releases/archive/May2008/06/c5515.html)

OTTAWA, May 6 /CNW Telbec/ - In the rush to hand-off responsibility for
air safety to the airlines themselves, Transport Canada failed to assess the
risks inherent in this approach and maintain safety during this transition to
Safety Management Systems (SMS), according to the Auditor General of Canada.
The Auditor General also found that Transport Canada does not know what
is the appropriate mix of proper safety oversight of the industry and how many
aviation inspectors are required to deliver it.
"Transport Canada has thrown caution to the wind when it comes to safety.
For the past 3 years, Transport Canada has reduced safety oversight in favour
of giving responsibility to the industry itself without any knowledge of the
risks involved for the travelling public or ways to mitigate them," said
Captain Greg Holbrook, Chairman of the Canadian Federal Pilots Association.
Sheila Fraser also found that Transport Canada has failed to measure the
impact on safety of the shift of resources to SMS.
"Without understanding the risks, Transport Canada cancelled key
oversight programs like the National Audit Program, and canceled enforcement
actions on serious infractions of safety regulations in order to implement
SMS," Holbrook said.
Sheila Fraser found that Transport Canada's aviation inspectorate of
licenced pilots and engineers has declined by 8% even though the Department
lacks a national human resources plan to ensure adequate staffing, recruitment
and training of safety inspectors.
In her sweeping condemnation of Transport Canada's implementation of
Safety Management Systems, the Auditor General found these shortcomings:
<<
- 15% of Transport Canada inspectors have not received initial basic
inspector training and an additional 15% have not received recurrent
training;
- There is no national data base tracking inspectors qualifications;
- Transport Canada has not identified how many inspectors and engineers
it needs with what skills.
The Auditor General's review of Transport Canada's aviation safety
oversight did not examine the second main pillar of SMS - delegation of
licencing and oversight to industry lobby groups.
The first such delegation occurred in January 2003 when Transport Canada
handed off licencing and safety oversight to the Canadian Business Aviation
Association - a lobby group for business aircraft operators.
A startling review of the CBAA's Safety management System has found that
business aircraft like the corporate plane that crashed last month near
Wainwright, Alberta have operated without any independent safety oversight for
more than five years, according to documents obtained via the Access to
Information Program.
The March 2007 audit found its safety program, known as a Safety
Management System or SMS, "does not provide any planned or structured
oversight of private operators".
The Transport Canada audit and related documents which have only now come
to light also found that the CBAA:
- does not collect and analyze safety data and risk factors
- does not punish private operators for safety violations so there are no
consequences for violating the rules
- lacks procedures for suspending or cancelling an operator certificate
in the event of serious safety problems
- does not track its own safety program to ensure it meets government
standards
>>
The CBAA does not have a team of aviation inspectors which travels to
audit individual operators of business aircraft, as Transport Canada once did.
Instead, the business aircraft operators contract the audit service from a
private supplier, thereby eliminating third party independence in the audit
process altogether.
Transport Canada will soon delegate safety oversight to lobby groups in
the helicopter sector and airports.
"These findings make a mockery of Transport Canada assertion that Safety
Management Systems are an additional layer of safety and their insistence that
this is not a shift to self-regulation of aviation safety," said Holbrook.
Recent revelations of widespread safety violations and maintenance
problems among airlines in the United States and concerns that The Federal
Aviation Administration - the US aviation regulator - has become too cozy with
the industry should give Canadians pause because Canada's regulator is giving
away it responsibility for safety to the industry itself.

What is SMS?
According to Marc Grégoire, Transport Canada's ADM for safety and
security: "SMS is very much based on a partnership between the operator and
the regulator..."(1)
It's a partnership deal in which the airlines and other aviation licence
holders take more responsibility for safety. Determination of acceptable risk
levels is handed off to the airlines which decide what is safe enough for the
traveling public.
In turn Transport Canada agrees to back off direct regulatory oversight
and in some cases delegate licencing and supervision to industry lobby groups.
Transport Canada has already killed key oversight programs and closed
enforcement proceedings for companies with an SMS as incentives to encourage
self-reporting.
In addition, Transport Canada has put in place a number of "incentives"
to encourage the industry to self-report violation of safety regulations.
The deal features a "get out of jail" free provision: airlines which
self-report violations are guaranteed immunity from Transport Canada
enforcement. The airlines are supposed to fix safety problems themselves, with
little intervention from the regulator.
Amendments to the Aeronautics Act which are currently before Parliament
in Bill C-7 would ensure that any violations or problems that are reported to
government will never be available to the public or media for public scrutiny
under the Access to Information Act.
Even thought these "incentives" are intended to encourage operators to
provide Transport Canada more safety information these data will be unverified
because TC no longer has enough inspectors to check-up as they once did.
Under SMS, Transport Canada inspectors become desk-bound system auditors,
inspecting more paperwork than airplanes and relying on information supplied
by the industry.
(1) House of Commons Standing Committee on Transport, Infrastructure and
Communities Transcript, June 15, 2006.


From the AG's Report:
Conclusion
3.57 Transport Canada is the first national regulatory authority in the world to put in place regulations requiring aviation companies to introduce safety management systems (SMS). The Department developed its own approach to implementation and conducted pilot projects with airlines and small operators. It developed appropriate procedures and processes for SMS implementation, and made efforts to apply them consistently. The first two phases of the four-phase approach for SMS implementation in airline operators and associated aircraft maintenance companies are now complete.
3.58 Despite these accomplishments, we found that Transport Canada's management of the transition to the new approach has had several weaknesses. In planning for the transition, the Department did not document risks or suggest mitigating actions, and it did not forecast overall expected costs for the transition. It also had no mechanisms in place to evaluate the impact of SMS activities on the frequency of traditional oversight activities. The Department has not clarified what combination of traditional oversight and SMS-related activity is acceptable as it proceeds through the transition.
3.59 In addition, the Department has not yet identified human resource requirements for Civil Aviation during the transition and once it is complete, or determined how these requirements will be met. There is no integrated human resources plan for the entire Civil Aviation program that addresses these requirements.
3.60 Finally, the performance measurement framework for Civil Aviation does not contain short- or medium-term indicators for measuring performance. These indicators could be used to signal a need for greater attention or action in a particular area.
3.61 The Department was unable to demonstrate to us that it was managing these areas satisfactorily. It is important that Transport Canada address these weaknesses for the transition in the first 74 companies and in the remaining sectors of the industry—comprising more than 2,000 companies—to be successful.

Read it here: http://www.oag-bvg.gc.ca/internet/English/aud_ch_oag_200805_03_e_30699.html

[slip and turn]

Well I feel sure the Auditor General of Canada could write a similar report about many of the first world's aviation regulators, had he the time, the inclination and the invitations to do so :hmm:

They may not contract out their audits (or do they?), but how thin are the CAA's inspectorate spread, for example?

A report like this sounds a bit like the UK's Oftsed reports on individual schools. It doesn't really tell us much we haven't already guessed, and unless numerous disasters occur then I don't suppose anyone will actually achieve much with it, this year, this month or even anytime soon.

The headline says 'Sweeping Condemnation', but will it still be viewed as such in a week's time?

I hate the politics of this stuff. Why can't it just be good and stay good?

Personally I think all Financial Directors in so-called safety critical industries should be knocked down a peg or at least one arm tied behind their backs :ok:to redress the balance of commercial expediency versus the costs of being sure.

[PJ2]

Personally I think all Financial Directors in so-called safety critical industries should be knocked down a peg or at least one arm tied behind their backs :ok:to redress the balance of commercial expediency versus the costs of being sure.
Or stand in the position of "accountable executive". What could be better than being accountable: First in the oak chair and possibly time behind bars if there's an accident - after all, if they're going after crews, why not the executives?

[Eboy]

possibly time behind bars if there's an accident

There is another punishment if there is an accident -- losing money. Passengers go to other airlines. Is this economic incentive effective?

The Auditor General might look at Underwriter's Laboratories of Canada which performs product safety standards development, testing, and certification. It is an independent organization set up by industry. It works. Why?

[Mad (Flt) Scientist]

While I'll happily agree that self-regulation has issues, especially in a financially challenging environment, this piece of logic makes my eyes roll:

Recent revelations of widespread safety violations and maintenance
problems among airlines in the United States and concerns that The Federal
Aviation Administration - the US aviation regulator - has become too cozy with
the industry should give Canadians pause because Canada's regulator is giving
away it responsibility for safety to the industry itself.

Arguing that failure of a non-delegated system to work implies that a delegated system would be weak is, to say the least, a stretch. One might just as easily argue that it proves that the apparent safety provided by an outwardly independent regulation system is, in fact, an illusion.

[slip and turn]

One might indeed, M(F)S ...

Meantime, the Heathrow T5 - Transport Select Committee hearing today in the UK Houses of Parliament did yield one CAA inspectorate snippet - Willie Walsh said the CAA contracted mystery shoppers in the few days after T5 opened to ... ehm, well ...

Anyway, he said they reported no particular problems ... :\

[clevlandHD]

...but a fully goverment regulated system does not make it fail proof: look at any local CAA in Africa! Mrs Fraser just did her job of keeping the gov aware that they are being watch.

True that some regulations should be reviewd at TC but to imply that the system is falling apart is not justified.

[dhc2widow]

Doesn't the Federal Pilots Association (the one's who published this press release) represent the Transport Canada Civil Aviation inspectorate?

http://www.cfpa-apfc.ca/eng/

Ah yes, so it does. Interesting that the inspectors are promoting the idea that the department is not doing it's job ... Rather makes one think there might be something to it ...

[Left Coaster]

How about Union V Management?

[aw ditor]

I hope EASA will not be following the same (Canadian) route in Europe?

[J.L. Seagull]

I believe you will find that the CAA are mandating SMS as from early next year. Whether this is to knuckle to Industry pressure and reduce costs, or because they really believe it will improve things is a potential subject for robust debate.
The bottom line is whether you believe that our employers will be as punctilious as a CAA inspector when auditing themselves is open to question - or at least with a qualifier of whether it affects the bottom line.

I don't believe my own employer necessarily prioritises safety as much as the bottom line, although they would deny it over and over and point out that it says so in the Ops Manual for heaven's sake!

[mates rates]

With the flight and duty time limits in Canada I think it's a long time since TC has been interested in Safety of Aircraft operations in Canada!!

[Spitoon]

There is a problem with being a regulator – you’ll never please everybody.

Regulatory philosophies tend to be cyclic. In many parts of the world we are currently going through a phase of setting regulations by objective which permits operators to determine the best, i.e. safest and most cost-effective way to achieve the objective. This often gives the operator great flexibility in how to work. For those who like to be in control of everything this may be seen as ‘handing-off responsibility for air safety to the airlines themselves’.

On the other hand, if the rules are to be detailed and prescriptive they will usually be criticised for being inflexible and for stifling innovation (often beneficial innovation at that!). Such rules will also need to be regularly reviewed and amended to make sure that they are still valid. And the people writing the rules would need to be completely up-to-date with every new idea that anyone wants to use in order to do this effectively.

So when it comes to writing the rules there needs to be a balance; prescription where it’s necessary and objectives where it’s appropriate. Unfortunately some people tend to be swayed by current fashions that say, for example as they do in Europe at the moment, objective-based regulation is the only way to go, and will use that approach even when it’s really not sensible. Sadly some of these people who go with the current fashion, whatever it is, are highly influential and may lack the professional knowledge to recognise the fact that the rules that they are promoting are not particularly good. Hence we end up with some poorly framed rules that are wide open to interpretation.

To complement the rules we have regulation or oversight. This is the inspectors who are out in the field and can make or break the effectiveness of a regulator. These people can help operators to understand what the rules mean and the latitude that is available in meeting them. Or they can create immense confusion by, for example, each applying different standards and moving goalposts as they speak. Sometimes inspectors have little better understanding of the regulatory philosophy being applied than the operator. Sometimes they have little or no understanding of the skills needed to be an effective regulator. It is quite possible that your friendly inspector was an excellent operational pilot, engineer, controller or whatever, but has had no training in how to be a regulator.

Then there are the CAAs themselves. Often still based around dated civil service systems where grades are more important than competences. Organisations whose roles and functions are not clearly defined; often compounded by the fact that the single organisation has competing responsibilities (which certainly is not understood by the layperson). And these are the organisations that need to manage how the rules are set and how inspectors work in order to have a ‘good’ system in a country.

With this background is it any wonder that a review of Canada’s, or I am sure many other States’ arrangements, would not be seen as satisfactory in a review? I don't know how Canada’s arrangements stack up but I’m guessing that, while not perfect, they are better than many States’.

Ultimately, if you have good management in the CAA, you’ll have a robust regulatory environment in which operators understand what they must do and what minimum standards apply. If you have poor management, who knows what you’ll get. And what proportion of managers are good? And how many of the good ones will be attracted to CAAs?

The people I sometimes feel sorry for are the some of the inspectors themselves (and, no, I’m not one of them). There are some good people out there trying to do a good job; they are not all just supplementing another pension or counting down the days ‘til retirement. But so often they appear to be undermined by those above!

[slip and turn]

Interesting post and observations, Spitoon :ok:

I especially found the following paragraph to be very telling...Then there are the CAAs themselves. Often still based around dated civil service systems where grades are more important than competences. Organisations whose roles and functions are not clearly defined; often compounded by the fact that the single organisation has competing responsibilities (which certainly is not understood by the layperson). And these are the organisations that need to manage how the rules are set and how inspectors work in order to have a ‘good’ system in a country.May I ask whether you were thinking about the UK CAA, and if so which competing responsibilities?

[Spitoon]

I wasn't thinking of the UK CAA specifically but my comments apply here also.

In my particular area of interest the CAA has a responsibility to regulate financial performance of some aspects of ATC service provision and also the safety performance. Similarly, there is often great resistance to the allocation of airspace when it may be appropriate on grounds of safety.

Despite your occasional assertions to the contrary, however, I believe that the UK has a reasonable set of arrangements and, in the main, a responsible and robust regulator managing them.

As I said before, it's not easy being a regulator - and it's very difficult to understand the regulatory framework that is established in a country (or domain) without spending considerable time working within it. A snapshot view, which is all one is likely to get with a government sponsored review, will almost inevitably fail to gain that full understanding.

[Spitoon]

And your point was what, slip and turn?

[MidgetBoy]

TC isn't too bad at covering up stuff either.
When an 80 year old crashes a multi-engine because he was flying low and clipped a fence, that's a pilot error. Though TC claims it was a landing gear collapse (obviously, it wasn't there after it hit the fence) so they can't be responsible for allowing that pilot to go back into the air and end his life days after it was repaired.

Not to mention, TC doesn't exactly have any set standards. Whatever each individual TC inspector says, goes. Rules change on the spot. Especially in the more populated areas of Canada.

[slip and turn]

@Spitoon

Two ears, one mouth and all that, wasn't making any new point IIRC, although it was nearly a week ago :p ... just interesting that you used UK CAA's ERG (financial) and SRG (safety) as examples of potentially competing regulatory devices (in respect of NATS).

From where you sit within NATS, i.e. a particularly and necessarily exacting part of UK aviation, you believe that the UK has a reasonable set of arrangements and, in the main, a responsible and robust regulator managing them.

It's little bite-backs like "in the main" that I wonder about :hmm:

[zalt]

Well UK CAA is following TCCA:
http://www.caa.co.uk/docs/33/FOD200823.pdf

[Spitoon]

The use of a safety management system is not the problem. A weak, incompetent and ineffective regulator is what causes the problems - whatever regulatory philosophy is used.

And, as the FODCOM points out, the requirement for a SMS comes from ICAO so you're going to see a lot of countries going the same way.

[zalt]

Is the UK CAA not the regulator that first published its position on SMS in 1997 yet said that it did not need to be a regulation?

[Shell Management]

Both inside Shell and in the wider industry it is becoming clear that a solidly implemented HSE management system is an essential basis for good HSE performance, BUT that outstanding HSE performance CAN ONLY be achieved if the "culture" is right. The Hearts & Minds culture programme was developed by Shell in 2002, based on research with Manchester, Leiden and Aberdeen universities since 1986, and is being successfully applied around the world. The programme uses a range of tools and techniques to help the organisation involve all staff in managing Health, Safety and Environment as an integral part of their business. This is somthing the aviation industry should do more of.

[alf5071h]

I fully endorse the ‘Hearts and Minds’ programme. Link:- Hearts and Minds. (www.energyinst.org.uk/heartsandminds/)
IIRC the original Shell programme was issued on a CD; if some one has a copy, I would be interested in any comparison between the original content and the web information.

Related Human Factors, SMS, CRM, and TEM materials can be found in the ref links.

Re “This is something the aviation industry should do more of.” I agree; the volume and quality of the work listed below indicates that Aviation has much to learn from the Oil and Gas Industry, particularly where the regulator (HSE) participates in preparation of the ‘know-how’ and guidance information, where an alternative is to stand back and ‘enforce’ regulations (Aviation Safety Agencies/Administrations).
IMHO Transport Canada appears to be on the correct side of the line (at least facing the right direction), but could do more. Elsewhere, aviation is showing signs of complacency.

Refs/related info:-
The Energy Institute, Human Factors. (www.energyinst.org.uk/index.cfm?PageID=811)
Managing human performance. (www.hse.gov.uk/humanfactors/comah/index.htm)
Inspectors Human Factors Tool Kit. (www.hse.gov.uk/humanfactors/comah/toolkit.htm)
Managing human performance - Briefing Notes. (www.hse.gov.uk/humanfactors/comah/briefingnotes.htm)
Step Change in Safety. (http://stepchangeinsafety.net/stepchange/Resources.aspx)
Managing Human Error. (www.parliament.uk/post/pn156.pdf)

[sox6]

Some operators, such as Bristow Helicopters, are making major progress in this direction. See the current cover story of the Flight Safety Foundation's magazine, Aero Safety World, called Beyond SMS, on how to move from just safety management to a more holistic approach including culture:
www.flightsafety.org/asw/may08/asw_may08_p12-17.pdf (http://www.flightsafety.org/asw/may08/asw_may08_p12-17.pdf)

One of the authors, Andy Evans, also presented at their competitor CHC's annual safety summit alongside Leiden's Uniniversities Patrick Hudson in 2007 and 2008 on their Target Zero safety vision - a sign of how respected the Bristow approach is.

[zalt]

Looks like Parker & Evans have something when they talk about leadership and of vision. Have a look at this speech:

Remarks of Robert Sumwalt, Vice Chairman National Transportation Safety Board
to the Regional Air Cargo Carriers Association 7th Anniversary Spring Conference May 22, 2008
Chantilly, VA (http://www.ntsb.gov/speeches/sumwalt/rls080525.html)

Sumwalt talks about three leadership qualities:

Servant leadership - serving the people who follow you (not they you)
Integrity - consistency, courage and humility
Vision - establish a vision, communicate that vision and then motivate others to achieve it


"Leadership is about influence. Your job as aviation leaders is to use your influence to help ensure that bad things don’t happen to your good company. I’ll be the first to admit that it takes a strong commitment for practicing servant leadership, maintaining integrity, and establishing, communicating and achieving a worthwhile vision. But, once you have these, it will be like having a North Star – one that your moral compass can always point to and lead you through tough decisions."

He doesn't bang on about having a documented SMS as the only means to make yourself safe.

His background:

He was a pilot for 24 years with Piedmont Airlines and then US Airways, logging over 14,000 flight hours and earning type ratings in five aircraft before retiring from the airline in 2005. Prior to coming to the Board, he was Manager of Aviation for the SCANA Corporation, a Fortune 500 energy- based company.

He worked on special assignment to the US Airways Flight Safety Department from 1997 to 2004, where he was involved in the development of numerous airline safety programs, including an enhanced crew awareness program and a windshear training program.

He served as a member of Air Line Pilots Association's (ALPA) Accident Investigation Board from 2002 to 2004. He has chaired ALPA's Human Factors and Training Group and was a co-founder of that organization's Critical Incident Response Program, which provides guidance to airline personnel involved in traumatic events such as accidents.

So he probably knows what is talking about.

[Southernboy]

Good post Zalt & so many others - spitoon etc thanks, all v educational. What's clear is that culture is everything.

The NTSB have been trying - in vain - for years to get the FAA to listen to their suggestions. I can see only, "efficiency," IE cost saving as the motivator behind self regulation, nothing else.

Remember the BA 757 that took off with 1/2 the flap system missing? The AAIB report said that the Quality Assurance system had failed because correct procedures had not been followed. That's what a QA system IS -procedures. So it's proof that the man with the clipboard trying to pick holes in what you've done is better, but then he costs more.

[J.O.]

Don't get me wrong, a good QA system is important. But unfortunately, too many organizations have hung their hats on QA rather than putting resources into the development a work force that is adequately trained and given the resources to do their jobs effectively. A little money spent on that side would reduce errors, thus reducing incidents and accidents. It would also reduce the amount of work for the QA folks, maybe to the point of reducing how many of them are needed in the first place.

[geewhizdriver]

Unfortunately, the Canadian media "ran" with a sizzling headline and didn't bother exploring the motives behind those quoted. The Chairman of the Canadian Federal Pilots Association quoted has a direct conflict with regard to statements he makes. Job security has never been compromised within T.C. since the SMS program was instituted, however the damage created to a very effective safe program done by a few sensational unfounded comments is sadly unfortunate. There are inspectors within T.C. who have fought the program since its inception, wrongly believing their jobs were in danger. The CAR 604 sector of Canadian aviation has been statistically the safest. Transport took a major initiative and instituted this program believing in its value. SMS is a proven concept throughout other industries. It is obviously new and there will be skepticism. But like so many media driven frenzies, based on garnering readers with sensational headlines, it should be taken with a grain of salt.

[clevlandHD]

"He touted the country's low rate of commercial aviation accidents, saying travellers have no reason to be worried. Odds are a passenger could make the hour-long flight between Ottawa and Toronto more than 300,000 times before being involved in an accident, he said.

One might opine he means 1 accident per 300,000 flying hours but as stated, assuming 50 pax on board he actually implies 1 per 6,000 flying hours!"

I think he meant 300 000 sectors, so it is still once per 300 000 hrs on a one hour sector.

[Mad (Flt) Scientist]

.... I can see only, "efficiency," IE cost saving as the motivator behind self regulation, nothing else.

Sorry, but "capability" is an important motivator for self-regulation, and there's really no alternative.

Any large OEM, airline or repair organisation has many more people involved in the process of building, repairing, maintaining and operating aircraft than any oversight authority could ever hope for. Therefore it is only common sense that you use that pool of people to help enforce the rules.

Even if by some miracle of funding and personnel availability TCCA were to man up to, say, match Bombardier or Air Canada one-for-one, regulators to regulated, they'd still be worse off than the current approach of co-option and self-regulation. Because there are only two options:

1. The relationship is cooperative. In which case you don't need a TC Jiminy Cricket on everyone's shoulder; or
2. The relationship is confrontational. In which case the simple approach is that you simply don't tell TC. Unless you are actually DOING the work, you always have to place some trust in people anyway.

I have some issues with elements of the way self-regulation is used, but to condemn it unreservedly makes no sense.

Everyone who drives a car practises self-regulation; you get an MoT every so often, but it's up to YOU to make sure your car is roadworthy between those dates. Sure, you can be pulled over by the police, but that's a largely reactive enforcement. By-and-large, people drive safe cars because they do the 'regulation' themselves.

If we can trust the public to monitor their own operation and maintenance of a ton-plus projectile on city streets, I think maybe we can trust aviation professionals to be profesional and ethical in their jobs.

[Chuck Ellsworth]

There is a vast difference between the culture in airline operations and the culture in many of the small airplane operators in Canada.

Without effective regulation does anyone think that SMS will improve safety in the small airplane sector of aviation in Canada?

The fox guarding the hen house scenario comes to mind.

[geewhizdriver]

I am not sure I agree with " Without effective regulation does anyone think that SMS will improve safety in the small airplane sector of aviation in Canada?"
SMS is a guiding fundamental principal behind the concept of CBAA's designation as the organization responsible to administer the CAR604 Private Operator Certificates. Small airplane sector is not covered under CAR 604 operators, unless you suggest a 95,000lb Global Express is small. Turbine powered, pressurized aircraft weighing over 12,500lbs. that are operated under a Private Operator Certificate are only those granted the ability to operate under these provisions. Historically these operators represent major corporations and training as well as operational safety systems are never compromised. Statistically it has been the safest sector of Canada's aviation industry and has been an excellent division to introduce SMS and its guidelines. Canada is being closely monitored by other countries to judge the success of this initiative, and skepticism will take a long time to erode.

[Chuck Ellsworth]

Without effective regulation does anyone think that SMS will improve safety in the small airplane sector of aviation in Canada?

geewhizdriver, my comment was directed to TCCA's expanding SMS into the small airplane sector such as the bush flying operators.

I form my opinions and thoughts on this issue from 55 years in the business and having spent many years working in that culture.

I see you have Ottawa as your location, would you by chance be an employee of TCCA?

In any event, convince me SMS will work in the small airplane sector.

[rob_ginger]

I don't have any first hand experience in the airline industry, but I am a graduate electrical engineer with 30 years working experience while my brother in law is a mining engineer. I think his experience is the most telling.

Initially he worked for a coal mining company as a mine under-manager legally responsibile for safety at his mine. He has a whole raft of stories about how the miners themselves were more interested in their production bonus than their personal safety. My personal favorite is how some of the underground shift would wander away at lunchtime, join their friends in a closely adjoining mine, and light up their cigarettes - in an underground COAL MINE for crissakes !

Then he joined a state mines department, and became a mine inspector. At one coal mine he turned up for an inspection. The mine manager joined him on the inspection tour, and within 10 minutes had volunteered to close the mine down while the obvious (and illegal) ventilation defects were corrected - because it would be less embarassing for the mining company and would involve less paperwork.

Taken along with my own experience in the electrical industry my opinion is this:

If you think self-regulation in ANY commercial venture will work then you are either naive or self-interested - there is no third possibility. The ONLY way you will get adherence to safety standards in any industry is to have a regulator who has the power to halt operations if there are safety issues, and to have independent government inspectors making regular visits to work sites. The employees (sometimes incredibly so) are more interested in earning bonuses or keeping their job than worrying about safety. The managers are more interested in their management bonuses than in "wasting" money on safety. Doesn't matter what industry it is - people are the common factor.

So if Canada thinks self-regulation of the airline industry will work then I won't fly there because people will die before it is recognised as a mistake.

[geewhizdriver]

Chuck, First of all, I definately do not, nor ever have worked for T.C. in any capacity. I fly a corporate jet for a major Canadian Corp. and have been doing so for over 30 years. I completely agree with you regarding bush flying and the potential problems with "self-regulation" in that sector. My only experience with non T.C. intervention is with the CAR604 POC program. Like I mentioned, this sector does not make money with their aircraft. Its sole existence is to provide private transportation for the corporations that operate them. The historical difference with regard to safety statistics is founded in the investment made by these companies to provide the best training, maintenance, and working conditions, which will obviously provide themselves with that safety and security they demand and pay very dearly for.
I have also "payed my dues" in the bush and I know the potential for disaster if left on their own. Anytime there is a potential to cut corners, will probably be seized upon and a regulator is required.
The whole basis for the original media reports was based on the audit by T.C. on CBAA and the fact that certain individuals feel that safety is compromised simply because T.C. no longer administers that sector. CBAA is still responsible to audit, discipline and remove POC's if necessary. A very concise and specific set of standards are to be met, and when they are not policies are in place to deal with it. Although SMS is an integral part of the system it is not the only factor in its operational structure. I think the success of the program will only be proven by time, and there will always be skepticism.

[J.O.]

rob_ginger:

Comparing commercial aviation with mining is quite unfair, IMHO. I am not a regulator, but I work in the airline industry in Canada and I have some involvement with SMS in my company. I am not an expert, but I do have a certain level of insider perspective.

First of all, the term self-regulation is somewhat of a misnomer. No one is suggesting that aviation regulations will go away under SMS. The fact is, the airline industry (at least in most "first world" countries) has been engaged in many aspects of self-regulation for decades. The industry has invested billions of dollars in safety improvements to equipment, support systems and personnel training, not just because of regulations, but because this has been recognized as the best way to assure safety and the longevity of the industry. This is not to say that regulatory oversight can disappear under SMS and self regulation; certainly not in my lifetime. But as Mad (Flt) Scientist said above, no regulator can amass the kind of resources it would take to maintain the level of regulatory oversight that would gaurantee the public safety so that the operators themselves wouldn't need to self regulate.

Miners who display the kind of behaviours you suggest are only doing so because they are part of a culture that does not (so it seems) take safety nearly as seriously as it should. Those miners are lacking in the kind of training, awareness and motivation that would guide them down a safer path. This is not their fault. That fault rests with an industry that seems to have failed in being able to maintain safety to an acceptable level. So instead, a regulatory stick is needed to protect those employees from harm. If the regulators were smart, they would mandate that mining companies maintain much higher levels of safety awareness training and supervisory reinforcement for their employees, so that over time, a learning culture that supports safety would develop.

Another factor, IMHO is that while the mining industry kills alot of people around the world each year, it is extremely rare that someone other than a mining employee is a victim. This is not to say that mining employees do not deserve to work in a system that takes safety seriously, but lets face it, engaging in that activity comes with a certain level of inherent risk that is higher than those faced by people in general. And because the industry does not tend to claim too many collateral victims, it unfortunately doesn't always pay the level of attention to safety that it would if there were a greater risk to the general public and they faced the requisite liabilities that are associated with that exposure.

Commercial aviation on the other hand, has direct exposure to the liabilities that come with failing to provide a safe service to the general public. So the industry has a certain level of motivation to operate safely, because the consequences of a public perception that you are unsafe can lead to the end of the company, such as the TWA800 accident did to that company, among others. Also, pilots, engineers and cabin crew have (at least here in Canada) safety drilled into their heads from the moment they begin their training. They receive ongoing training that reinforces the safety message, and they are guided by detailed operating procedures that are designed to keep risk to an acceptable level. This is not to say that they are infallible, or that regulatory oversight is not needed, but it's been proven in several safety-critical areas (i.e. nuclear power) that the best people to understand and manage risks to an acceptable level are the industry people themselves, with reasonable regulatory oversight and guidance to ensure continuing compliance.

There is no intention to remove government mandates and regulations from the Canadian aviation industry in SMS. The industry is being given the opportunity to accept and maintain a level of accountability that will protect the travelling public, and the legislation has significant penalties for accountable executives who fail in their fiduciary responsibilities to maintain a safe service. Is it perfect? Not hardly. Does the industry need regulatory oversight for the foreseeable future? Absolutely. But it is still a positive step in the right direction, IMHO.

[Big Pistons Forever]

I see no difference in the problems owner operators have in the 703 (small comercial operator) segment as they do in 604 (private/corporate oprators)
The guys operating the big iron and/or multiple types/numbers are doing fine under CBAA. The story for the small one airplane owner operators is a different story. There are many who do it right but a significant number are playing fast and loose with training and maintainance requirements....just like some of the bottom feeders in 703. The problem is the CBAA construct is a paper exercise. Ultimately there is an expectation that the 604 operator will
"paly the game". But if Mr/Mrs 604 doesn't want to, I do not see how anybody at CBAA is going to know, except retroactively by looking at the smoking hole. Taking away the stick is a very risky move.

[carholme]

JO;

Nobody has suggested that regulations or mandates are going to be taken away. You are providing a smoke cover for the issue. I have long maintained that SMS is a valuable business tool but its value is only as good as the credibility of the bean counters and the company's financial status.

Regulatory oversight is the main problem at the moment and is expected to decrease if Bill C-7 is allowed to proceed. Do you think for a moment that if C-7 proceeds, that TC is going to increase their inspector status to cover their existing serious staffing shortfalls?

The AGs most recent reports of Business Aviation and the use of SMS in the rail industry are examples of what lies ahead. "Self Regulation" is not a misnomer by a long shot. Look at the results of the recent activities in the US, the threads on this forum where airlines are being charged for unsafe operations. No matter how you look at it or sugar coat the issue, rising costs will cause more and more bean counters to cut corners and you know exactly what this means.

Safety costs dollars if you embody it and the likliehood is that it will cost dollars if you don't. It is all about dollars when it comes to crunch time and SMS is extremely vulnerable to the financial cycle of any company. As for Accountable Executive, and that person being accountable, you can be guaranteed that there is a long line of positions under his who are already earmarked for blame before he is in a difficult position.

carholme

[J.O.]

carholme:

I think you need to re-read my posting, as I believe I said virtually everything you did, save for the piece about safety, or a lack of it, both costing money. And on that point I completely agree with you.

In effect, rob_ginger said that no money making industry could be trusted to protect the public without a regulator constantly standing over their shoulder making sure they were compliant. I had to challenge him on that because it certainly hasn't been my experience.

I do not view SMS through rose coloured glasses. I see where the warts are, and I have to point them out to my colleagues sometimes. But going back to a prescriptive big brother regulatory environment will not make our industry any safer, IMHO. And that's all I was trying to say.

[Shell Management]

A company with a bad safety culture needs strong regulator.
A company with no clue of risk needs prescriptive detailed regulation.

If you have a strong culture of safety, are mindful of teh hazards, are managing your risks and know what to do; then regulation can be light - better to concentrate scarce competent resources where they are needed.

[20driver]

There is one way SMS could have a positive impact on small bush operations and that is through the insurance industry.
If a safe operation results in a insurance lower cost, which it should, there is a large incentive to get with the program.
Sadly insurance works the opposite way in that the safe operators subsidize the cowboys.

20driver

[sox6]

Read the comments above. If you only have an SMS to save money or to please your national authority you have the wrong culture and your SMS will never be effective.

[PJ2]

One useful site which may help those concerned with their organization's true safety culture and the ongoing implementation project of SMS will find the following Transport Canada site (and others, if the title is Googled), "Score Your Safety Culture", interesting and perhaps helpful as a starting point to see where the weak points are. Here is the URL:

Score Your Safety Culture (http://www.tc.gc.ca/CivilAviation/systemSafety/Brochures/Tp13844/menu.htm)

Obviously, good answers require a brutally honest response. Like investing, it is unwise to confuse affection and loyalty with rationality and "what is".

If the questionaire were evenly distributed throughout management and line crews I wondered if responses would divide along those lines and would such a division reflect the politics of perception or would it reflect how close each group is to the reality of the daily operation and the potential for groupthink within management in terms of how well things are going despite "the data", and within the employee group on how bad things are going, despite the hegemonies? A little of both I suspect, knowing aviation people and safety.

[zalt]

Strangely doing such a test with your employees is not a mandatory part of the TCCA approach. Pity.

[PJ2]

zalt;

A number of factors prevent such an approach, which TC may not be entirely unsympathetic to, especially as SMS is being introduced.

First, management might not get the answers they "like" -

One way to address the matter is to have management's and line employees' responses separated so that the gulf, if there is one, between management's perceptions of their organization's safety culture, and the employees' perceptions, may be seen.

If the gulf is large, there is a credibility problem and likely a safety-culture problem. If the gulf is tiny, likely the company is healthy.

Obviously line employee contentment, state of any negotiations, state of the industry and most of all and mainly for management, the phenomenon of "groupthink" which tends to suppress "bad" news (safety issues) and tout good (shareholder/profit/performance) news, are all factors which may lead to some gulf between the two sets of responses.

I have seen circumstances where the blunt honesty of employees (line and management) in such studies has been not only suppressed but placed beyond all possible access, so damaging was the response. Damaging, that is, in terms of liability - the information may or may not have been used to guide change. Hoping for change is a wasted wish. In this business, "hope" has no place; only confimed and tested results should have currency.

All this said, yes, I think the test should be a yearly, public exercise for all organizations involved in medium to high risk endeavours and not just aviation and the results should be made available to all employees. That would never happen of course for, long before anything was communicated, corporate legal would have prevented it.

And to a very small degree, I can sympathize, knowing that there are elements that would use such information for their own agendas especially if it involved an accident. Honesty is always relative in this and most businesses. SMS however, is not about making public statements about one's level of safety - it is a way of doing business which is recursive, not reactive. It is not a technique for creating a public personna that only legal must be content with.

[J.O.]

You're a wise man PJ2. I hope that you have some involvement in SMS in your company. They can only benefit from your insight and your common sense approach to safety.

Jeff

[zalt]

Every presentation I've seen by TCCA has been very much 'an SMS is about documentation, documentation & documentation'.

One of the European offshore safety agencies, Holland(?), has made a postive safety culture a condition for the continued approval to operate an oil platform.

[J.O.]

Zalt:

Two comments regarding TC and culture:

First, I'm not sure how you legislate or regulate culture. It's tough for rulemakers to create rules that they can't measure for compliance. All you can do is set out guidelines for operators to implement the elements that are common in a safety culture, such as non-punitive reporting, data-driven decision making and a continuous improvement process. It's up to the organization to put them into place and build the right culture around them. If the head shed in the organization isn't committed to culture change, a regulator will have a hard time affecting that change until the operator breaks a safety regulation.

Second, I've asked the question to some acquaintances who are inspectors. While they believe in the concept of SMS, they contend that TC has not spent enough time talking about culture within their own organization. How can they be expected to effectively assess culture change in the organizations they oversee when they don't even see a positive safety culture building in their own house?

[carholme]

J.O.

Sir, you have hit it right on the head. I have always maintained that SMS is a valuable business tool to be utilizrd by a strong company management who are interested in productivity and safety enhancements within their organization.

Anyone who has read the DNR report will see that the inspectorate in TC are a disguntled group, who utilize litttle if any HFT/SMS principles other than paperwork. The experience level of the inspectorate in terms of commercial operations has decreased to the point where they are nothing more than auditors of a vast paperwork regime. Safety is not going to be enhanced by compliance with up to date manuals and paperwork systems just to satisfy regulatory compliance. I feel that we have missed the boat by a large degree in the aftermath of de-regulation and the failure to increase the inspectorate and their level of commercial aircraft operations knowledge and understanding.

A company who sincerely wants to use the benefits of SMS is limited somewhat by the lack of any kind of culture of understanding of the system at TC. I think that the common belief today, is that if your paperwork is up to par, you have achieved a level of safety, satisfactory to TC.

The imbedding of the culture in the lower end of the commercial marketplace cannot be achieved by regulatory demand, it has to come from the operators themselves and any view of what is going on in 703 is enough to realize that the culture is many years away from being an accepted standard to which we all conform.

carholme

[zalt]

Culture in the Australian military being discussed here (http://www.pprune.org/forums/rotorheads/333170-senior-australian-army-pilots-accused-being-cowboys.html) & FAA here (http://www.pprune.org/forums/rumours-news/316850-records-southwest-airlines-flew-unsafe-planes-4.html)

[sox6]

And these for CASA in Australia: http://www.pprune.org/forums/d-g-general-aviation-questions/333946-sms-casa.html and http://www.pprune.org/forums/d-g-reporting-points/295272-casa-then-there-were-none.html

and this: http://www.amroba.org.au/pdf/meetingwithbyron.pdf

"CASA has failed, in all aspects, to meet the needs of the Australian aviation industry, especially the needs of private owners of aircraft. CASA has failed to maintain the safety culture that had been developed over the previous 100 years and has, by its own actions in applying the aviation legislation, alienated the aviation industry that holds responsibility for the aviation safety record. Safety issues are not addressed as a partnership to improve safety. It is this failure to work in
partnership, originally initiated by DCA over 50 years ago, and now adopted internationally to improve safety, that has seen an
upward swing in ATSB incident and accident tables.

This change was initiated and implemented by CASA when it stopped working in partnership with industry in the interest of aviation safety. Government’s application of the criminal code to aviation legislation created a completely different approach to aviation safety that has failed. CASA modus operandi of enforcing safety by strict compliance to known defective legislation has seen safety matters go underground. CASA enforcement policy has had a negative effect on the industry and is the reason most leave the industry. Industry size has been regulatory drastically reduced whilst CASA size has drastically increased. CASA is no longer seen as a competent internationally respected Aviation Regulator.

It is seen as a bunch of individuals that have gone power crazy under the protection of the public service and are out of control because the CASA management cannot control their employees.

[zalt]

From CBC (http://www.cbc.ca/canada/story/2008/09/01/f-secretskies-mckie.html):

Transport Canada's man in charge of aviation safety doesn't like the term SMS, referring to it as a "buzzword." But Merlin Preuss has nevertheless spent a fair bit of time recently defending the concept, which he says will lead to a more accountable aviation industry — and safer skies. Critics such as retired justice Virgil Moshansky, on the other hand, argue that Transport Canada's Safety Management Systems allows the industry to police itself, which is akin to "putting the fox in charge of the hen house."

So as we move into an era of deregulation for many major industries, who are Canadians to believe?

SMS (Safety Management Systems), the shorthand Transport Canada uses to describe its new approach, makes the aviation industry responsible for implementing systems designed to ensure safe air travel in Canada. Under the concept, the federal department will do fewer direct safety audits of air carriers, instead keeping watch over safety checks done by the airlines themselves.

In a spring report, federal Auditor General Sheila Fraser examined Transport Canada's march toward fully implementing its air safety management system. The report uses the following example to define the safety management system:

"For example, instead of conducting an inspection to assess whether the tires in the aircraft landing gear are sufficiently inflated, Transport Canada will assess whether a company has the systems in place to ensure that the tires are inflated, following up if necessary. The goal is to make companies more accountable for the management of risks. Transport Canada will still be accountable for safety oversight. The department maintains that safety management systems will allow more thorough identification and resolution of potential safety problems, making the transportation system safer."

'I would strongly recommend that the federal government assume a proactive approach to taking the pulse of the aviation safety in this country, before another major air disaster occurs, as is being predicted by many responsible and informed individuals in the aviation industry.'
—2007 report by retired judge Virgil Moshansky

SMS is akin to trends in other industrial sectors, such as the food industry. In the wake of a massive meat recall caused by a deadly outbreak of listeriosis in August this year, the Canadian Food Inspection Agency is facing questions about allowing the industry to, in the words of the Agriculture Union of the Public Service Alliance of Canada, "police itself."

Though SMS was introduced in the late 1990s, it was only in 2005 that Transport Canada began asking larger carriers to start developing their own systems. According to the auditor general, the entire airline industry is expected to have safety management systems in place between 2011 and 2013. "Until then, Transport Canada has the task of managing the transition, while continuing its oversight responsibilities," the auditor general's report says.

Assessing SMS
One of the findings after the inquiry into the 1989 crash of an Air Ontario Fokker F-28 jet in Dryden, Ont., in which 24 people died, urged Transport Canada to hire more inspectors. In a 2007 report entitled The Role of the Judiciary in Aviation Safety: The Inside Story and Legacy of Dryden, retired judge Virgil Moshansky, who headed up the Dryden inquiry, repeated a warning that he had issued to parliamentarians months earlier:

"Having regard to the documented systemic problems in the aviation industry which have been surfacing for some time now, I am of the view that, 18 years after the Dryden crash, another wakeup call to Transport Canada is overdue. I would strongly recommend that the federal government assume a proactive approach to taking the pulse of the aviation safety in this country, before another major air disaster occurs, as is being predicted by many responsible and informed individuals in the aviation industry."

Critics like Moshansky argue that Transport Canada is eliminating many of the checks and balances it needs in order to ensure safety, at a time when the department is relying on the industry police itself.

Lack of resources
John Scott, who has been a pilot for 42 years, used to work for the federal aviation safety board as an accident investigator and now speaks for the Retired Airline Pilots Association of Canada. He remembers a time when Transport Canada had more inspectors than it currently employs.

'According to the International Civil Aviation Organization (ICAO), the rapidly expanding aviation industry and the limited resources of oversight authorities make it increasingly difficult to sustain the existing approach to managing safety.'
—Auditor General Sheila Fraser"

They would go to airlines, or flight schools, and they would be the ones conducting the tests. They would do the evaluations and they would give you your ticket," Scott said. "Over time, the number of inspectors has continually decreased. I'm not going to say that Transport Canada has abrogated their responsibility, but the responsibility for checking has essentially devolved to the companies."

In her report, the auditor general pointed out that "in 2006, air transport in Canada carried 99 million passengers, up 6 per cent from 2005, and the number is expected to grow 40 per cent from 2006 to 2015. According to the International Civil Aviation Organization (ICAO), the rapidly expanding aviation industry and the limited resources of oversight authorities make it increasingly difficult to sustain the existing approach to managing safety."

During his appearance before Parliament's public accounts committee this summer, Preuss, Transport Canada's director general of civil aviation, was asked about the number of inspectors. He conceded there were 134 vacancies, but offered little elaboration. In an e-mailed response, Transport Canada explained that 15 of those vacancies are engineers — as opposed to inspectors. The department's inspectorate workforce now stands at 737. Taking the vacancies into consideration, Transport Canada is unable to fill 15 per cent of its inspectorate workforce.

Mike Wing, national president of the Union of Canadian Transportation Employees, which represents the civil aviation safety inspectors who work for Transport Canada, said Preuss's testimony shows the number of people conducting inspections is diminishing. That means there will be increased reliance on the industry to monitor itself with little oversight from Transport Canada, Wing said.

Air transport in Canada carried 99 million passengers in 2006, up 6 per cent from 2005, and the number is expected to grow 40 per cent from 2006 to 2015. (Michael Probst/AP)"This is about changing the type of inspection that we do," he said. "We're going to be primarily just taking a look at safety management. There will be much fewer specialists in the system. There will be people trained on SMS and things to look for in safety management systems, but it doesn't mean that those people have got the technical background that the inspectorate has traditionally had to ensure safety."

While Preuss conceded that the number of inspectors Transport Canada will need under SMS is an open question, he categorically denied that his department is abrogating responsibility for safety. Transport Canada will still conduct its own inspections under SMS, but in addition, it will now monitor the industry's safety systems, which are much better than they used to be, he said.

"No, we're not even asking [the industry] to police themselves. We are asking them to identify hazards before they become big problems … and you break a rule, you've created a hazard virtually by definition," Preuss said. "So one of the things we've asked them to do is put a system in place that shows us that yesterday and today and tomorrow, you're in compliance with the current regulations. And that gets inspected, and we have all the enforcement tools we had yesterday and we will apply them — and we have."

However, an internal memo from November 2006 casts some doubt on the vigilance with which the department will monitor the industry. In his paper, The Role of the Judiciary in Aviation Safety, Moshansky sums up that memo: "Transport Canada instructed its aviation inspectors not to initiate any further enforcement investigations into regulatory contraventions and to close all open cases against SMS certificate holders."

Whistleblower protection
Another important check on the system is protection for employees — whether with the airline industry or Transport Canada - who speak out about safety concerns. The Accountability Act offers some protection, and so, too, does bill C-7, the piece of legislation that gives Transport Canada the legal authority it needs to fully implement the security management system. The bill is currently in its third reading before Parliament and has not yet passed into law.

Charlambe "Bobby" Boutris, FAA aviation safety inspector and Boeing 737-700 Partial Program Manager for aircraft maintenance at the Southwest Airlines (SWA) Certificate Management Office (left), testifies on Capitol Hill in Washington on April 3, 2008, before the House Transportation and Infrastructure Committee hearing on FAA safety oversight of airlines. (Lawrence Jackson/AP)In order to get a sense of how important whistleblowers can be, one need only look at the United States and the experiences of Bobby Boutris and Doug Peters. The two inspectors with the U.S. Federal Aviation Administration spoke out publicly about safety concerns at Southwest Airline after unsuccessfully attempting to deal with the problems internally.

In Canada, bill C-7 does offer some protection, although it has no specific whistleblower protection.

"Although whistleblower protection was not introduced, the House [transport] committee agreed to add a number of new provisions to the bill that provide additional protection for employees who provide information under management systems and voluntary reporting process," states a Library of Parliament summary of the progress of bill C-7.

The summary has this to say about the additional protection: "The House committee further clarified under the new section 5.392(3) that a Canadian aviation document holder shall not use information disclosed under the management system in disciplinary proceedings against the employee who disclosed the information unless sanctioned under the management system. It also added section 5.392(4) to protect an employee who disclosed information in good faith under the management system against reprisals, including measures that adversely affect them, the employee's employment, or working conditions, from the Canadian aviation document holder."

As far as Transport Canada's director of policy and regulatory services, Franz Reinhardt, is concerned, bill C-7 protects employees.

"Transport Canada needs as much safety information as possible, so that's why we encourage employees to report internally through non-punitive, voluntary reporting within the company to make sure the company will have identification of safety hazards and can take corrective measure[s] as soon as possible, even before small incidents evolve into bigger accidents," Reinhardt said. "And in bill C-7, we have drafted the provisions for a whistleblower protection for individuals reporting internally who would be afraid of reprisals … regarding their employment. So if they do avail themselves of that internal reporting system, they may rest assured that, if no followup is made and they report publicly, that they will be protected and there will be no danger for their employment."

Union president Wing disagreed with Reinhardt's assessment.

"I don't see anything in the legislation that says that is the case … the [transport] committee did have an amendment to ensure whistleblower protection within this act. They [parliament] turned down that amendment," Wing said. "So in my mind, this act does not have that protection."

Scott of the Retired Airline Pilots Association of Canada also said there isn't enough protection.

"Until the Canadian government through the legal body produces a very clear whistleblower protection for aviation, then we're not there yet," he said.

"If the Canadian government were to have a look at the whistleblower protection that's been established in the United States, that is as good a founding to use as a premise … because they have done an awful lot of research," Scott added.

In addition to the need for increased traditional inspections and better whistleblower protection, critics such as Scott and Moshansky also feel there should be regular inquiries into air safety, preferably of a judicial nature, where witnesses can be compelled to testify.

They also feel that a third party, much like the office of the federal auditor general, should be set up to monitor whether Transport Canada is doing its job.

Without these checks and balances, the critics charge, Canada is setting itself up for potential disaster.

[Chuck Ellsworth]

They also feel that a third party, much like the office of the federal auditor general, should be set up to monitor whether Transport Canada is doing its job.

Until changes are made in TCCA's top management starting with the DGCA safety will take second place to political expediency.

[remarkablebean]

Whilst TC might hate the term SMS - it's running a seminar in Toronto all about it this month...

And Chuck is right - political expedience rules the roost in Ottawa beyond operational common sense - but name a national transportation body that's different in that respect ?

This ostrich culture also runs through other Federal bodies, and what is regarded as a systemic failure in food inspection, led to many deaths due to a serious listeriosis outbreak. If the same happens due to TC failures leading directly or indirectly to fatalities in an aviation accident, god help them.


Details (English) (http://guest.cvent.com/EVENTS/Info/Custom.aspx?cid=17&e=ba9fc242-3cd1-462f-ae05-aef327fdf2a1) - for the SMS briefing at CYYZ.

[J.O.]

I know one should never let the facts get in the way of a good rant, but there is absolutely no evidence to date to suggest that the listeriosis outbreak had anything to do with government oversight or a lack thereof. In fact, the CEO of the company involved said, and I quote, "The buck stops with us. We failed."

[Chuck Ellsworth]

And Chuck is right - political expedience rules the roost in Ottawa beyond operational common sense - but name a national transportation body that's different in that respect ?

True, on the other hand any country that professes to be a democracy should have the tools to remove people from positions of power who have demonstrated they are unable or unwilling to perform their duties and abide by the very laws, rules and policies their position requires them to abide by.

When does a Canada become a Zimbawbe?

Do the citizens just need to accept corrupt officials until one morning they wake up a to a Bob Mugwabe?

[remarkablebean]

True enough...but McCain admitted Maple Leaf did undertake the inspections themselves, one assumes using the govt. issued loose leaf binder, and look what happened...non-compliance, deaths, massive food recalls and shiny suited Prairies lawyers all over the class action express. Imagine what would happen if an airline was involved in something similar ?

And Chuck - yes. The incompetents in the TC corner offices - get rid of them and no fat payout as they leave head first via the revolving door. Round about now, someone should mention the nuclear watchdog firing and Emperor Harper...

I'm off to have a pork luncheon meat sandwich.

[J.O.]

So, if you get whacked on your way home this evening by a guy who runs a stop sign, are you going to blame the police for failing to have an officer on the scene to stop him?

I'm not trying to say that SMS is a panacea and that we can all sleep soundly with it in place. In fact, effective safety management will always require a healthy level of unease at the senior management level, and a willingness to take responsibility, as the CEO of Maple Leaf has done. But expecting the government to be the primary source of safety assurance doesn't recognize that they are often not in a position to do it effectively. I think it's high time that we stopped being a nanny state and started enforcing credibility and accountability on the people who should be responsible, and that's the people who lead safety-critical organizations.

[Chuck Ellsworth]

But expecting the government to be the primary source of safety assurance doesn't recognize that they are often not in a position to do it effectively.

That is an interesting opinion, are you saying that a regulator can not be aware of how the industry is complying or not complying with the law?

Oh, wait a minute....now I understand, of course they can not when they sit in cubicles and swap make believe paper work with those that are supposed to regulate.

So lets get rid of the police forces as well and turn over the regulating of society to the general population...yeh that would really make it safe for your wife and kids to roam around on their own.

[J.O.]

That's just a little disingenuous, not to mention that it takes my words completely out of context. Last time I checked, criminals and bad drivers were not heavily invested in safety critical enterprises. As the old saying goes, "if you think safety is expensive, try having an accident". A bad accident, particularly in today's challenging airline environment, could easily be the death of an airline. For example, I think that Spanair will be lucky to survive their current situation.

Safety through regulation alone will never achieve an increase in the level of safety beyond where we are today, because organizations that focus on meeting the regulations are, by nature, focussed on meeting the minimum standard. And that's all that TC has ever been able to enforce, because at the end of the day, that's all the regulations can ever be, a minimum standard. My company has policies that are more stringent than the regulations. These have been borne out of our business experiences, and TC has no rules to cover those experiences.

What frequently gets missed in discussions about SMS is that when an organization has an effective SMS, that system will place a heightened focus on the human and organizational factors that contribute to hazards and unsafe events. Many of these factors cannot be controlled by regulation. Fixing them means the organization needs to do alot of navel gazing to fix their internal processes and cultures that contribute to the problems in the first place.

Regulators have a role to play now and in the future. It's their job to ensure that SMS is more than smoke and mirrors, and that the system is not only compliant with the regulations, but that it's effective. But there's nothing wrong with forcing organizations to ensure safety through internal management processes, because when it's done right, that is how it will be effective.

There are also examples of regulatory requirements that are out of touch with the industry, particularly when it comes to technological advances. For example, getting approval to conduct GPS-based non-precision approaches requires an operator to jump through regulatory hoops that were written when GPS was still looked upon as unproven voodoo magic that could be shut off at a moment's notice by the US government. It fails to recognize that many modern aircraft have GPS navigation fully integrated into flight management systems, and that the sum total difference from a pilot's perspective is knowing where the navigation info (raw data) comes from, and what to do about it when the raw data is lost. The rest of the SOP for flying the approach is identical to flying an NDB approach from the nav database. Before SMS, we would have no choice but to jump through those out of touch hoops. But through SMS, an operator should be able to apply for approval to conduct these approaches simply by proving an equivalent level of safety that points out the similarities with what they're approved to do today and that manages the differences to mitigate risk.

[Chuck Ellsworth]

That was an excellent post J.O. and I have no problem with what you said.

However in that I have observed the oversight of the industry by Transport Canada for over fifty years it is my opinion that it has gone from bad to worse.

Also may I suggest that there is a big difference between airline and corporate aviation and the air taxi / bush operators.

There are many examples of companies that not only cut corners and ignore the rules but their company culture is to intimidate their employees to either go along with that culture or be out of a job. Never, ever, have I seen an instance where a pilot or engineer could go to TCCA with evidence of wrongdoing by a company and have TCCA step in and fix the problem and protect the rights of said people......never ever...

It was that way fifty years ago and I see no improvement in today's world, in fact I believe that not only is it worse but with SMS it is letting the fox guard the chicken house in that sector of aviation.

Granted as you describe the vast majority of companies recognize and practice a safety culture in their operations.

It will take a lot more than examples of companies who understand safety to convince me that TCCA is even close to doing an acceptable job of ensuring the rules are being followed, and having more of them sitting on their asses pushing make believe safety on paper is not progress.

Then again maybe I don't know jack sh.t about safety and my 55 years of flying accident free without any regulatory non compliance issues was just blind luck helped by having TCCA in the background beavering away enforcing the law.:suspect:

Anyhow that was a very good post J.O. and I hope SMS will be the magic bullet that makes your world of aviation a better world.....I'm retired and enjoying life after aviation. :ok:

[J.O.]

Thanks Chuck. And I recognize and concur that there are some operators out there who have the bad habits you describe, and that TC has sometimes been ineffective in changing that. No better example exists than the outfit in Winnipeg that had a Navajo run out of fuel. The pilot goes to jail while the company basically gets off scott free, at least from a legal perspective. I knew people who couldn't get away from the place fast enough when they worked there, but so far they seem to have come away realtively unscathed.

And SMS is hardly a magic bullet. It's a tool, and like any other tool, if you use it right, it can be pretty effective at getting the job done. Use it wrong, or use the wrong tool, or ignore the benefits entirely, and bad things can happen.

[Chuck Ellsworth]

The pilot goes to jail while the company basically gets off scott free, at least from a legal perspective. I knew people who couldn't get away from the place fast enough when they worked there, but so far they seem to have come away realtively unscathed.

Exactly, and that is only one of many companies who TCCA turned a blind eye to over the years.

Now may I ask you a question?

Having worked in many many countries all over the world and learned how some them work, you can get approval for most anything with the right amount of money.

How much do you think it takes to pay off some top TCCA official so they go blind?

I am asking because I am curious.

[20driver]

Interesting discussion. Others have pointed out you cannot legislate a corporate culture and enforced standards will always be a minimum.

SMS reminds me of a saying from the old Siberian seal hunting days " God is in heaven and the CZAR is far far away"

For most Canadian bush and small charter operations this is very much the case. They operate on their own. Pretending a system that is designed for companies with long term vested interests in running a safe operation is going to impact them is pie in the sky. A good percentage of these operators are not likely to survive the season, so they are not going to take on a long term expense without a clear financial gain.

At the same time an enforcement regime is what we have. We may see a whiplash spasm to a publicized incident but the trend is going to be less and less "enforcement" because the government does not want to pay for it. A DOT inspector can show up in X lake once a year but everyone knows he is in town and acts accordingly.

There are three forces I can see being brought to bear on operators to get them to behave.

One is insurance providers making operators put effective programs in place. The problem is the insurance companies need the good guys to pick up the tab for the bad guys. The best idea IMHO would be operators starting self insurance pools with admittance limited to those who play by the rules. Keep the bad apples out. Interestingly when this starts to happen the insurance companies suddenly get much more interested in dividing the risk pool to help the good guys.

The second is the public needs to demand something more than right now and the cheapest price. I think people will pay when presented a choice and know one operator in Northern Ontario who has done well by using better equipment and charging more. If I was part of a pool of higher standard operators I'd make sure all my customers knew I was in and encourage buyers to find out who was not.

Third is to start chucking managers and owners in jail. That money saved does you little good when you are in stir. SMS may help by making it more of a company responsibility to operate safely. A very clear statement in the rules that at the end the day safety remains with the company would help. Requiring companies to appoint a named individual to be held liable in case of failures might cause some to think twice about load pushing etc. Requiring directors to post personal bonds could be another step. I cannot believe that in the Winnipeg crash the dispatcher/manager was not charged.

My 2 cents worth

20driver

[Chuck Ellsworth]

20driver, your suggestion re the insurance thing is excellent.

Not only would it work but the good operators would have a vested interest in getting rid of the crooked operators the insurance costs would go down as less losses had to be covered.

I love your suggestion for putting those convicted of operating illegally in jail.

I can think of a few of TC's management who would make good cell mates for them.

[Shell Management]

Similar problems at CASA too:
http://www.pprune.org/d-g-reporting-points/329724-senate-inquiry-into-casa-15.html