When will airlines start preparing safety cases?

[Shell Management]

When will airlines start preparing safety cases?

[forget]

Safety cases, as invented by the oil industry, have been shown to be the best way to manage high risk industries.

BP? .............................

[forget]

Cliff (?), I suspect that, as 'Shell Management', the Governors of Louisiana and Florida would welcome you standing up in court and saying that. :hmm:

[forget]

I don't understand what prompted you to start this thread, other than the righteousness of the converted - although I doubt you could 'convert' in three years.

Royal Dutch Shell safety concerns.

An article titled "Sharpening Shell’s safety culture" was published on 10 August 2007 on the web portal website of the energy multi-national Royal Dutch Shell. Authored by James Schofield, an editor and speech writer at Shell, the article concedes in the sub-headline: "There are many examples of successful safety programmes in Shell but overall its safety record doesn’t measure up to other major oil and gas companies. Each fatality is one too many, so Shell is launching new initiatives to build a stronger safety culture." The Schofield article provides an informative overview of Shell safety issues on a global basis and it is recommended that it be read in conjunction with this article, which currently focuses mainly on Shell North Sea operations.

Are you really trying to tell us that Shell has something to teach aviation at large about safety?

[Spitoon]

Strictly speaking, ICAO does not require aircraft operators to prepare a safety case; only to use a safety management system. Some may argue that this inevitably will result in a safety case of some sort, but it is not required.

You ask why operators do not prepare safety cases. I don't work in flight operations (but in ATC) and my experience would suggest such documents or arguments are seen as providing little benefit. Regulators are not skilled in using safety assurance documentation as a basis for oversight. Often the regulator seems to use 'Send us a safety case...' as a means to avoid a having to make a decision, and then, when it receives a safety case, doesn't know what to do with it.

From the service provider's perspective, safety management seems to be yet another opportunity for the few skilled (and semi-skilled) safety management practitioners to sell their services, and write a pretty document that no-one in the SP reads, or understands, or believes in.

Do I sound cynical? Maybe it's because after 10 years I've seen lots of SMSs, and quite a few safety cases - heck, I've even written some - but all we seem to have done in the vast majority of cases is produce piles of documents with very little demonstrable improvement in safety. And, in most cases, good, experienced, professional decision makers can still knock spots off someone who is given the job of 'looking after the SMS'.

Want to fix it? First, start by getting the regulators to understand how a good SMS will work and what a safety case really is; second, get them to explain what they need to the operators.

And the (admittedly limited) exposure that I have had to SMSs/safety assurance in other industries suggests to me that effective implementation is patchy at best and is handled by the respective industries in much the same way as it is in aviation today. I'd be glad to be shown to be wrong because I'm a believer in the SMS approach, but I'm yet to be anywhere near to being convinced.

[forget]

Shell Management, I wrote earlier – “I don't understand what prompted you to start this thread”. I’m still baffled. I’ve read the paper referenced by you in Post 1. My conclusion – the author shows almost no understanding of what’s required, by law, to maintain and operate public transport aircraft.

The paper says ‘Development of an aviation safety case is essential as it focuses a company's top management and staff on the real risks that need to be managed and ensures that every reasonable effort is taken to provide safe operations’.

The last few words are an absolute give away that aircraft hangars and Flt Ops are completely foreign to the author. What’s described is an airline accountants dream. “OK guys, from now on just make every reasonable effort to provide safe operations’.

But I’m still baffled. What does this mean? “It became clear that the means of controlling a hazard varied depending on whether the aircraft was in flight, undergoing maintenance or moving on the ground”. Became clear? Was this a lightning bolt revelation; or perhaps a slow dawning.

Your post above ‘One only has to look how few threads are started on this Safety, CRM, QA & Emergency Response Planning part of this site to realise the lack of interest the airline industry really has in safety’.

Eh? Could it be that aviation has reached levels of safety, control and regulation such that anonymous forums, and your opinions, don’t really have a lot to offer?

Please tell us what aviation qualifications you hold, we’d maybe form a better picture of your motives. And please learn to spell ‘amateurs’. Only amateurs get it wrong. (Also, you may want to correct your today’s – ‘the Super Puma is obselete.)

My bafflement has now got the better of me and I’ve looked at some of your recent posts. How about this;

One has come to expect such small minded envy from hired hands who will never rise to the exulted (sic) aviation pinacle (sic) of being a Shell Aviation Advisor. :p

http://www.pprune.org/rotorheads/145176-whats-new-west-africa-nigeria-post5780158.html#post5780158

Do your bosses read your literary pearls? Did Walter M have bosses?

[onetrack]

Is it that well known pig-headed arrogance that most airline pilots promoted to management postions have?

I think this little hand grenade (along with the abysmal spelling), thrown in amongst a group of those very same people, makes Mr Shell Management a troll??... :suspect:

Either that, or he has a very large axe to grind with those same people he is out to aggravate?? Lost his job from his desk-bound position, due to those same people, perhaps??... :suspect:

[forget]

I asked - 'Please tell us what aviation qualifications you hold, we’d maybe form a better picture of your motives'. You didn't answer, which speaks volumes. We now have the answer.

Your juvenile postings throughout this forum do nothing to enhance the standing of Shell Aircraft, and I'm sure that Shell Aircraft value their reputation. I don't think you work for Shell. I don't believe that Shell would hire anyone so naive.

Easy fix. This chap can confirm, or otherwise. I'm sure you won't mind if I point him in the direction of some of your fruitier missives and ask. I'll let you know how I get on.

About Aviation Safety Consulting Limited (http://www.asc-limited.co.uk/id1.html)

On a more benevolent note, I've seen people crack before, and I just wonder .....

[Spitoon]

I offered a serious response to the original question. I can assure you that my reply is based on professional experience and I believe that I have a good understanding of both the aviation industry and of SMS.

I am not inclined to rise greatly to your assertions of amateurism, save to offer the view that your view that '...safety case is an essential part of an SMS' demonstrates a rather blinkered view of how safety can be managed in an organisation. Of far more importance is whether the organisation actively manages its activities in order to achieve an acceptably safe standard of operation; what it calls its documents and how it conducts/records hazard analysis is of little matter.

[PEI_3721]

SM, “Safety cases, as invented by the oil industry, have been shown to be the best way to manage high risk industries.” Really?
Safety Cases were intended to be an aid to thinking about risk, not an end in themselves. Haddon-Cave? Also, a hazard of claiming invention is that someone will probably cite earlier work, e.g. Patrick Hudson of Leiden University who was contracted by Shell.

The oil and gas industry do appear to have taken a lead with safety initiatives; see:-
Hearts and Minds - Home (http://www.eimicrosites.org/heartsandminds/)
OGP Risk Management Homepage (http://info.ogp.org.uk/RiskManagement/main.html)
(which I suspect that SM is well aware of)

A weakness in aviation could be in not having a centralised coordinator (other than a regulator) for this type of work; cf ‘The Energy Institute’. Thus there may be material ‘knowledge’ gaps between what is published by regulators – the minimum requirement, and what should be used as best practice.

How can the investigators (NTSB / AAIB) be responsible (“their backward ways”) for regulation. Its not their mandate. Investigators are faced with the facts after an event, the regulators, as with operators, have to promote safety beforehand, and if found wanting, implement the investigators findings.

“BP failed to use a safety case in the US. Just proves the point.
A bit presumptions; lets wait for the full story.
Whilst in this instance BP might not have used industry best practice, it appears that they provided sufficient safety / risk information for an operating licence to be granted. This implies that the ‘regulator’ (and government) knew what was happening; now reconsider the share of responsibility.
Aviation (every industry) should be able to learn from the BP’s problems, but learning requires understanding and application.

”This is something the airline industry doesn´t do.”
Again presumptuous. Just because a process is not visible it doesn’t imply that SMS / risk assessments in some form are not in use.
The aviation industry (with a few exceptions) is recognised as a high reliable industry – an ‘ultra safe system’ (Amalberti); the oil and gas industry is not always associated with this category.
With high levels of safety, an industry requires new and often novel ways of thinking just to maintain the status quo.
Thus heed “Safety Cases were intended to be an aid to thinking about risk, not an end in themselves,” the important issue is to think about risk; how the thoughts are acted on – safety case, SMS, or otherwise – is of lesser importance.

[forget]

I do believe we've been had. Shell Management's profile shows his Home Page as the Shell web, which worked yesterday. Today there's a little exclamation mark icon and access is blocked. Oh dear. Shell Management persona non grata at Shell. Surprise surprise. :hmm:

Home Page:
The Shell global homepage - Global (http://www.shell.com)

[squib66]

Flight International claimed this week that airline safety performance has levelled off at 2003 levels so perhaps we all have something to learn from other industries.

However a sign that Shell don't have much to crow about is that Shell, BP & Total were fined over £5 million this week for their parts in the massive Buncefield explosion.

Buncefield companies fined £5.35m for oil depot blaze | UK news | guardian.co.uk (http://www.guardian.co.uk/uk/2010/jul/16/buncefield-companies-fined-fire-oil)

forget - I'm suprised you have not posted that already - you were pretty quick with this http://www.pprune.org/rotorheads/412839-g-m-oil-rig-explosion.html !

I don't understand the point of your last post. The Shell WWW link certainly works today.

[forget]

forget - I'm suprised you have not posted that already - you were pretty quick with this.

I was 'pretty quick' with that because, at the time, it was breaking news.

I don't understand the point of your last post. The Shell WWW link certainly works today.

Think it through, squib, think it through. :rolleyes: ( Clue. Again, it has something to do with time.)

[Burr Styers]

Hallo Shell Management,

I have had experience/exposure to the "Shell" Hazreg/Bowtie/Safety case ensemble, in both rotary and fixed wing environments, and with the Job title of Safety Manager.

My experiences.............

Shell appeared once a year, gave you a sack load of material, and then expected full implementation by the time they re-appeared the following year - Not much in the way of product support, mentoring, training etc etc.

Retro fitting a Safety Suit(e) might work when placed on a oil rig, it works far less well when draped over an airline - irrespective of its aircraft type.

It will, (probably does) work for Shell - congratulations on designing a bespoke safety system. But that is in "Shell world" only, the rest of us inhabit a somewhat different corporate environment.

I now know that "over -complicated- trying- to- solve all -the- worlds-problems", via an excel spreadsheet (which is what the Shell Hazreg was) is not a winning strategy.

In recent years I have found the ICAO guidance (9859 et al) to be the guidance which gives the most clarity, and actually gives one something to work with.

You may want to consider that when you want to engage with other like minded people, to either share a problem, or request their indulgence, that using an accusative style will do you absolutely no favours in life whatsoever.

Over the years I have got to know people who inhabit the Shell Aviation dept, gotta say,............ none of them sound or act like you.

B rgds

BS

[sox6]

The problem is that Shell insist on imposing their own system because nanny Shell knows best and I'm afraid I have seen this level of agressive, arrogance before!

[Gentleman Jim]

Shell Management

I find the tone of your communications quite shocking really. Aggressive, arrogant and lacking any knowledge of aviation matters.

An interesting statement you made was
It is SO frustrating to spend so long devising and promoting the only clear way to protect yourself from a court case to see others ignorantly fail to take up best Shell practice.perhaps that is the fundamental difference between our professions. In aviation we devise safety and training systems designed to protect us from loss of life and loss of aircraft, and any impact on the earnings of the legal profession is an aside and of no consequence to our primary safety aim.

You are procedure driven, indeed apparently procedure mad. The problem with procedures is that you can write them, reams of them for everything, yet people still break them, and as a result an incident may occur. The trick is understanding, truly understanding the reasons WHY people break procedures and then working with that and your most important asset, your people.

I have worked in the aviation safety industry for over 12 years, prior to a full career as a pilot, and one of the reasons I believe there are so few inputs on this particular thread is that the whole aviation attitude to safety, CRM and Human Factors has become embedded in to our everyday professional lives. I would not say we sit back on our laurels, far from it, but we have got the major part of the problem licked, and we strive to continually improve that.

In the future of aviation the only logical path forward will be that the percentage of accidents caused by Human Error will increase. There can be no other conclusion as the machines are becoming more reliable, our understanding of material science more thorough and our maintenance and NDT procedures more trustworthy with components being replaced before any predicted failure can occur. So the only weak link in all of that is the Human machine interface. Our aim in the short term should be to strive for scientific and engineering excellence with the machine, and we will be in the situation where almost 100% of aircraft accidents will be caused by Human Error. Whilst that may sound alarming, what we have also done is to reduce significantly the physical 'number' of accidents. In the 1950's there were hundreds/thousands of aircraft accidents every year, but for all the reasons stated above that number has now reduced to a handful effectively.

We have done well to eradicate the very aggressive self righteous attitudes from our Pilots on an inflated driver´s salary or perceived status. that used to exist in the 60's and 70's that you so magnificently display in your posts. You really really need to start working on 'the people' because if your attitude is representative of those in your industry then you still have massive problems that lie ahead.

You state that your concern is The safety of the travelling public well if that is truly the case then relax! Aviation is the safest form of travel on the planet today, and it has never been safer, testimony to the excellent work done by our pilots, and flight crews, maintenance technicians and support staff world-wide. We have tried to encourage the rail industry for a long time to adopt similar training of key staff as in aviation. Well you inform us that the rail industry has adopted 'safety cases' and whilst that is delightful news, it does not address the individuals understanding of why they will fall asleep at the controls, or the cognitive failures that will result in the driver seeing a 'green light' when it was infact 'red'. Safety cases are but one piece of armour that can be put in place to prevent a life critical or business critical failure, but rather like the knight on the battlefield who only wears a steel boot and nothing else, whilst his foot will stay safe the rest of him is somewhat exposed to danger.

I have worked with the largest off shore aviation companies in the world, and the picture is not as rosy in your industry as you paint it to be. Your industry is system mad and study mad and it shows from what you have said. A friend of mine had £60K to spend on safety training of teams for exploration rigs in the icy north. We sat for hours looking at the lessons from aviation and what he could achieve with some communication training and looking at the effects of fatigue on Human performance and decision making etc. Seventeen years of work already carried out by the aviation industry with the lessons there to be plucked for free, and what does the PhD Geophysicist do? Correct he spends £55K on an academic study from a University on why Human Error occurs. He still admits today that his decision to do that was a human error.

We do not continually discuss all of this SM because as said before it is now embedded in our culture.

You may also wish to reflect upon your 'style'. Their are many many definitions of Leadership, but in its simplest form it could be said to be 'the ability to get the best out of your people for any given situation'. I absolutely assure you that if your 'style' is as we see here on this forum, then on a day to day basis you will never get the best out of people.

Anyway, enough said. Perhaps you ought to look seriously at the cracks in your own industry before trying to fix ones in another. People who live in glass houses and all that.

Of course if you need assistance with implementing these wonderful strategies from aviation then you can always pm me:E

By the way just as a point worthy of note. The article you link to (you're not cliff are you?) says
Unless significant
changes are made to improve the nearly
flat accident rate, by 2010 there could be
an average of one airline accident per
week.


Well it is in fact 2010, and I appreciate I may not have my ear close enough to the ground in my own industry, but I don't think we are having on 'average' one airline accident per week. Mind you as I have experienced for years it is only such alarmist BS that the magazines deem fit to print.

[Burr Styers]

Well put and heartily agree GJ.

It appears common to me, that management in the oil industry is "Testosterone led", and that there is very little (if any) inter company initiatives wrt safety. Why, because they are so bound up in their corporate competitiveness, that it is a complete anathema for them to consider asking a competitor for help, or to share something that their industry as a whole could benefit from.

Witness the BP leak in the Gulf, first oil company on scene stated "Well we wouldn't have done it like that" - just says it all really.

Fortunately commercial aviation takes a more mature view, and Safety Information Exchange (SIE) and many other initiatives, is alive and well, and benefiting many companies and individuals. Blatant plug for the UKFSC by the way.

No doubt the oil industry is a high risk industry, that requires its own unique ways of solving its problems. But it is a mistake for that industry to think that just because they have come up with a "Killer App", that it uniformly reads across to many other risk industries.

Anyway, back to the day job, - "People Centric Safety Management" :ok:

BS

[Gentleman Jim]

'Gentlemen' Jim

Shell misManagement, it is awfully rude to play with names to gain a particular effect is it not?

‘safety is embedded’. Do you not mean ‘unconscious’?

I believe that is a misquote, and no I wrote 'embedded' and mean 'embedded.

You quote a number of incidents and yet with 17 Million air movements a year you would have us believe we have a major problem. We had a major problem a long time ago and we addressed it. The major problem was made worse by self righteous attitudes and a belief that 'my way is the only possible correct way of doing something', a little bit akin to the attitudes and beliefs you display in your posts SM. As you do not appear to have addressed anything I actually said in my post then the 'reams and reams' fell on deaf ears, but that is clearly only to be expected.

Please be happy and content with your zealous support of the Shell Safety System but it is very fallible believe me, and as for this

Shell Alaska’s VP, told the BBC: "The Gulf of Mexico may have been a wake-up call for some, but not for Shell."

That is not only one of the most crass bits of commercial point scoring but also indicates an over-confident and therefore dangerous approach to the whole issue of safety.

I could go on, but you won't read it, answer it or consider it, another major trait in those whose safety systems ultimately fail, often with tragic results.

The author of the article you linked to may well have won awards, and I am happy for him, but the awards were certainly not for the accuracy of his scaremongering predictions were they.

So, back to Shell La La land, and when you have your next major incident perhaps you can come on here and explain why your 'safety case' failed.

[john_tullamarine]

Two points, please, ladies and gents -

(a) let's not push the bounds of polite discussion TOO much lest censure be invoked

(b) some folk stir the pot a tad to get reactions. We have a number of such folk within the PPRuNe family. Best not to rise too much to the lure.

[Gentleman Jim]

Fair Point John.

[Rigga]

I think Shell Management's complaint equates to the same issue in the perceived lack of ISO9001 in the airline indutry too -

ISO9001 just doesn't fit into what happens to an airline either. Sure, some administrative areas can make it fit and do operate on an ISO system, but it's essentially a production or manufacturing system that can't really cope with the intricacies of airline maintenance without getting complicated, costing time (and yes, money too) that is needed to meet timelines.

In my view a good SMS is far better than an SCS, it is flexible to the type of operation and easier to maintain. An SMS can be as complicated or as simple as the operator requires.

To be honest, an SCS is just another system that depends on the indivudual working it, and the managers reponses to it. It is no better and no worse than an SMS.

This is not about a lack of an airlines/operators safety for personel, pax, property and the environment - but about the use for a reasonable method of controlling what is going on for each company, being aware of the real issues and avoiding or mitigating their effects effectively until a permanent fix can be made, if at all possible.

Maybe ICAO will make it a mandated system, but only when it been proven to work - when there's no more ships sinking, oil fires or nuclear leaks, for instance.

[Rigga]

"The chhanged ICAO annex do require the management of hazards and prioritising them needs to be done on a risk basis."

...and thats exactly what goes on!

Full agreement at last that the addition of another level of beaurocracy isn't needed.

...the end of this thread then?

[john_tullamarine]

ISO9001 just doesn't fit into what happens to an airline either.

Can't agree with that observation.

A 9000 management system can be very simple or highly complex according to the needs of the entity (and the understanding of the folk putting it together). Problems arise when the activity tries to map itself to a pre-ordained system (failure in the making) rather than developing a compliant system to suit the requirement .. not much different to the basic philosophical problems in aircraft design, I suggest. If the operation basically is sound, the bulk of 9000 considerations will ALREADY be in place.

but it's essentially a production or manufacturing system that can't really cope

9000 started life in Industry to address the problems and difficulties associated with customer audit. It is just a codification into a commonsense system of important considerations when it comes to "ways of doing things".

I'm involved with a high end corporate operation and the whole engineering and maintenance activity is 9000 compliant - nothing in that causes us any significant problems. Coincidentally, I have been involved extensively with design and manufacturing in previous lives and the same applied.

without getting complicated, costing time (and yes, money too) that is needed to meet timelines.

Unless you are making paddlepop stick models with a pot of glue in your backyard, all activities involve resource costs. The system need only be as complicated as you want to make it .. complexity for complexity's sake is a waste of time.

[Piltdown Man]

Why does the airline industry fail to adopt them after 10 years even though the nuclear, rail and ANSP industries and the RAF have all adopted them?

The industry may not have adopted Shell's onerous approach but will have instead implemented their own, simpler, easier to understand and more effective procedures. Fancy diagrams, long buzzwords and management-speak phrases and other such marvellous things does not improve safety. If Also the processes, if followed in the way the article suggests, will add little to safety but very nicely nail some poor sod who might step out of line. An outcome hardly conducive to safety as too many will start fiddling (or shredding) paperwork or stories. Additionally, the departments who cook up this guff are consuming scarce resource which could be put to better use, like QAR data processing, training, communications etc. Safety programs do not have to have bloody diagrams to work.

And have you ever wondered why not everyone jumps to bid for Shell's outsourced corporate aviation work? The article only explains half of the hoops a bidder has to hop through. I understand that you have to buy into this process to be able to bid for the work. So I'm sure many companies decline to even read the bid offer let alone put any effort into it (I know of a couple for a start).

On a more positive note, I'd suggest that the main reason Shell's aviation department has an enviable safety record is that it has well trained and above all, very experienced operators. With or without your "safety" guff, it would still be safe.

PM

[Brian Abraham]

Shell Management, with your supposed contacts you should have an insight into what happened with the Nigerian Puma ditching. When might we see a factual report of cause etc? Had it been any airline the general public, let alone aircrew, would already have a fair notion as to what happened. This one seems to sit under a cloak of secrecy, not even people within the company have any idea, despite an excellent video on Youtube.GLplm2nYyis

[Brian Abraham]

If only every Bass Strait occurrence was in the public domain eh my friendYou are quite right, and I did whilst there, in some small way, to attempt a more open acknowledgment of cause and effect, but to no avail. Lack of compliance was the name of the game, as with all oil companies.

Everyone who needs to know about this Super Puma (not Puma) ditching does BTWSeems to be a pretty closed shop. As I previously said, even some of the company offshore pilots don't know. So what happened with the Nigerian SUPER Puma? I have my own ideas, having been party to a what I think is a similar scenario, only did not get quite so far through the layers of swiss cheese.

And no more of the condescending "my friend". That I ain't, but never say never. :ok:

[PBL]

I find the thread a bit odd, although the topic interests me. Indeed, professionally I have quite a lot to do with safety cases and safety case requirements.

The subject is very broad, so here just a couple of pertinent comments.

First, Safety Cases are by no means the province of the oil and gas industry. Safety Cases are required by many national and international standards for various parts of safety-critical system lifecycles, under this or other names. For example, the international standard on functional safety for systems - any systes- which include electrics. electronics or programmable electronics, IEC 61508, requires a written document equivalent to a safety case. They are used extensively in UK MoD technical projects, and a recent set of observations on their use and misuse occurs in the report of Charles Haddon-Cave into the Nimrod accident and the history of the technical developments which led to it. That report illustrates quite clearly that safety cases are not a panacea, but that they can be misused just as any other tool. My colleagues at Adelard have a SW tool, ASCE, for safety case preparation, which is the result of nearly two decades of work and which is increasingly being used by UK MoD contractors. For a good introduction to the technicalities of safety case preparation, the Adelard Safety Case Pages (http://www.adelard.com/web/hnav/ASCE/) are amongst the very best available. (GenghisE, that is, John_T, I think (again), I hope you agree with me that this is an important reference, and not a commercial citation.)

The quick answer to "why don't airlines use safety cases?" is that the aviation industry has its own operational equivalents. In the case of an airline, it is the documentation required to obtain and maintain its AOC. ATC organisations increasingly use safety cases, labelled as such. Airplane manufacturers produce equivalent written documentation during certification.

So on one view, it is just not true that airlines don't use safety cases. They just don't call them that and it may be that the required arguments for safety in operations are spread over many documents rather than just one. Whether that is a good idea or not rather depends on how big the documentation is, and on whether the existing regime more or less works satisfactorily. Looking at the safety records of many of the world's better airlines, one would have to conclude that it does work pretty well.

All this is of course independent of what someone self-identifying as "Shell Management" might write on an anonymous public forum. My guess is that heshe is a poseur, but the issues raised, though provocatively, include good ones to which there are answers. More publicity about safety cases is in any case a good thing, and you know what they say - no publicity is bad publicity!

PBL

[Genghis the Engineer]

(GenghisE, I hope you agree with me that this is an important reference, and not a commercial citation.)

I do, but am not a moderator in this bit of Pprune - I only moderate flight test (out of fascination for the subject) and ground ops (out of public duty because somebody had to, and there weren't any ground handlers amongst the Pprune mods).

G

[Treg]

http://www.nopsa.gov.au/document/QandA%20-%20Safety%20Case%20in%20Context.pdf

May offer some differing perspective

[SNS3Guppy]

This is something the airline industry doesn´t do.

You present a paragraph waffling on about realistic flight simulation, then make the statement that the airline industry doesn't do this? Clearly you have no idea whence you speak.

You assert that the airline industry doesn't do realistic risk assessment? Clearly you have no concept regarding that which you attempt to speak.

You assert that no case-based scenarios and prepared responses exist? Can you really be that clueless?

I don't think so. Someone pegged you correctly early-on. You're here as a troll.

[forget]

SM. Could you please override your obvious modesty and tell us who you are? And please don't claim that you work for Shell.

[SNS3Guppy]

I am a highly experienced aviation safety consultant and safety auditor with over 40 years in the aviation industry. If acilitated and directed the development of thea complete hazard analysis for operating and maintaining aircraft before ICAO had even heard of hazard management. I am currently busy assessing corporate culture, developing assessments for continuing airworthiness of ageing aircraft, life cycle cost models and aircraft replacement strategies.

No you're not.

You're not familiar with the industry language that already addresses the issues you raise. This information is already a regular part of training, and is old hat. That you're not familiar with this clearly demonstrates your fraud.

[PBL]

On the basis of what the contributor calling himself Shell Management has written, I wouldn't advise anyone interested in safety management to pay him much attention.

If we want to talk about the assurance of safety, including the construction of safety cases, let's go ahead. I keep coming back here because of contributions from others, but those contributions appear mostly (still) to be reactions to what he has said. Please let's not orient the discussion solely around his commentary, because it won't get us anywhere useful.

PBL

[sox6]

Shell Managemnt is known for being arogant, demanding, over confident in their own knowledge, with a tendancy to lecture (both the PPRuNe callsign and as collective group). Shell's recent high risk behaviour in Nigeria shows that much of their bluster is not backed with action.

PBL is right that the future of safety management is important. What is ironic is that the relative lack of interest here AND some of the responses do seem to reinforce one of SM's apparent points, that the aviation industry does sometimes seem to be a little too smug in resting on its laurels.

[Brian Abraham]

He who knows, and knows he knows, is wise ---- follow him (JT, Old Smokey, 212man)

He who knows not, and knows he knows not, is worthy ---- teach him (most of us)

but

He who knows not, and knows not he knows not, is a fool ---- avoid him (Shell Management, SSG)

[PBL]

SH, I dearly wish you would say something worth discussing on this most important issue, and try to discuss it as if you were interested in resolving it.

PBL

[SNS3Guppy]

Brian thanks for your valuable contribution to this safety debate.

He's contributed more in post than you'll contribute, by far. You've been called out. Slink away.


SH, I dearly wish you would say something worth discussing on this most important issue, and try to discuss it as if you were interested in resolving it.

He or she really can't. SM has already revealed that he or she knows nothing about the industry, or safety management for that matter.

I'm only familiar with one poster who keeps returning with new identities from time to time, posting the same kind of language as SM, who proves conclusively every time from the language that they use, that they know absolutely nothing about their subject matter. This poster, "shell management," is that same person. Whether he calls himself ssg, shooter, tank whatever, or any of the other names under which he or she keeps crawling back, it's the same troll, incapable of making an intelligent post, with nothing of substance to offer, and a refusal to learn.

[forget]

Here's one back. Do a Google on "Shell fined" with quotation marks. 4,010 hits. There'll be many duplications but even so 4,000+

Some very interesting tales.

“It is impossible to reconcile Shell’s continuing participation in price fixing cartels and other unlawful market manipulation activity, with its claimed business principles pledging honesty, integrity and transparency in all of Shell’s dealings.”

PS. Even better, these guys have done all the work.

Mission – Royal Dutch Shell plc .com (http://royaldutchshellplc.com/mission-statement/)

[Helen49]

Unless there is an intent and culture of safety at the 'top' of the organisation, all the systems, documents, safety cases etc in the world will not help you. If the culture is there, the simplest of documents and systems will go a long way towards enabling a safe operation. Simple!

Helen

[PEI_3721]

SM, within this thread, are you suggesting that this is due to the lack of SMS, or is SMS proposed as the solution?

Stalled – at what level. The fatal accident rate appears to remain low, hull losses similar, but at a higher rate. Of concern (Boeing Stat Sum) is that the overall accident rate shows a slight increase, but all of these values are ‘relatively’ low. Naturally, rates depend on how they are defined, and that their relative success (acceptability) depends on what minimum might be achievable (ALARP).

If the very low accident rate is an indication of an ‘almost totally safe transport system’ - The paradoxes of almost totally safe transportation systems (http://www.ida.liu.se/%7Eeriho/SSCR/images/Amalberti%20_%282001%29.pdf) (Amalberti) (http://www.ida.liu.se/%7Eeriho/SSCR/images/Amalberti%20_%282001%29.pdf), then the safety task has to adapt from improvement to containment.

SMS might target those areas with less than the general standard of safety - improvement, but those operations which have achieved an acceptable level should focus on safety programs for containment, if not already done so. Will SMS contain what is already achieved; not necessarily so?

A counter view is that SMS auditing and monitoring will help containment, but only if the key safety items are identified. Many audits (SMS activities) only see what is looked at: – in how many of the recent accidents were the major contributors identifiable by conventional SMS auditing – beware hindsight bias.
Instead of looking for hazards, we should look for the changes in operation; look at the difference between how the tasks are undertaken vs how management thinks they are (perhaps these are the real hazards).
Improving safety culture is a good idea, but it is a lengthy process and success is not assured.

Many interpretations of SMS see it as an idealized concept (ICAO SMM Chapter 1); it is guidance to be built upon.
Many airlines have good systems; these are containing the accident rate at low levels. The important item which has to be identified - avoided - is the ‘big one’.
Thus why not look at the successes in the industry, how the successful (safe) operators achieve containment both with management and in practice at the workface, as opposed to how the regulators think that safety should be achieved in concept

[Piltdown Man]

SM - you can wind your neck in now. You personally have saved the world and there will now be no more incidents or accidents because every airline will now have their SMS boxes ticked by 8 April, 2012 as required by ICAO Annex 6 Part 1. So you can now have a proper sleep. You'll also find that since the start of this month, every airline will have started spending millions putting yet another system in place, the specification of which will undoubtably change because plonkers keep meddling with the specs.

And I really wouldn't start suggesting that the failure of Qantas's A380 engine and associated damage was due to a lack of SMS systems without understanding how either Qantas or Rolls Royce operates. I wouldn't be the least surprised if they had already had highly credible and efficient safety systems in place.

PM

[forget]

.... from the succesful concept Shell launched in 1999!

Are you now saying that, prior to 1999, Shell was operating worldwide without your 'SMS'?

[forget]

Shell invented these techniques in the early 1990s in response to Piper Alpha.

You mean like this?

The Herald: Shell failed to learn Piper Alpha lessons – Royal Dutch Shell plc .com (http://royaldutchshellplc.com/2006/07/19/the-herald-shell-failed-to-learn-piper-alpha-lessons/)

[PEI_3721]

SM, “Since that Flight article was published their have been yet more fatal accidents and a series of engine accidents with Qantas, so the rate is worsening.” (#57)

You appear to misunderstand the term ‘rate’; in the same period there have been vastly more successful operations; rate depends on the ratio.

“SMS is the solution that will get the airline industry again making year on year safety improvements.” (#57)

You avoid or fail to comprehend the point in my post #56 – “If the very low accident rate is an indication of an ‘almost totally safe transport system’”
If so, then ‘SMS’ or any other ‘conventional’ safety system is unlikely to achieve a measurable year-on-year improvement.
A risk of applying a rigid SMS to a operational system in equilibrium (almost totally safe) is that it will be disturbed. See Amalberti‘s conclusions –
“… it is also important to recognise that these systems are nearing the end of their life and should not be placed off balance by requiring operations to take place within unreachable performance and safety objectives.”

Thus an innovative view should consider how much if any of current SMS thinking should be applied (a flexible response), and if SMS’s are at the end of their life, what should replace them.

[Brian Abraham]

Your pretty little graph shows how little an understanding you have. Statistics can be massaged to prove any argument a person wishes to put. The records are for aircraft certified to carry 13 or more passengers. You don't need to be an Einstein to understand how the number of wide body versus Beech 1900 type aircraft accidents in any one year can skew the data.

Aviation Week & Space Technology, Monday, March 19, 2007
Making "Safe" Safer
The NTSB Relishes The Recent Air Record

The unfortunate fact of our existence upon this good earth is that there will always be accidents -- otherwise, they could stop building trauma centers in hospitals. Some years ago, an ICAO official was asked by a reporter (when a zero rate in some aviation accident statistic had been reached): "I guess you'll be breaking out the champagne then?"

The ICAO official's cynical (albeit ungrammatical) retort: "No. We consider it to be a statistical aberration that we don't ever expect to see repeated again." Perhaps he was just trying to emphasize the fickle nature of statistical conclusions.

From the Report Card submitted by the National Transportation Safety Board last week, the industry as a whole has an outstanding record of which we can all be proud, but that doesn't mean we can rest on our laurels and not strive for that elusive zero rate in spite of the ICAO assessment.

After all, the oft-repeated "that could've easily been me" runs through our minds each and every time we turn on the television and see the ruinous aftermath of yet another seemingly inexplicable accident. The other sobering aspect of any such record is that it's necessarily historical and that the only thing that counts for you, and those you hold dear, is what's coming down the pike to change it all -- "for better or for worse" as they say in that other commonplace disaster. More on that gloomy perspective later.

So what was good in that NTSB summary? First, the overall accident rate dropped again in 2006, although marginally. Passenger and cargo carriers operating larger aircraft under 14 CFR Part 121 continued, as expected, to have the lowest accident rates in civil aviation. In 2006, they carried 750 million passengers more than 8 billion miles while logging more than 19 million flight hours.

The cost was 31 accidents, a more than 20 percent drop from 2005. Only 2 of those 31 accidents were fatal, resulting in 50 fatalities. It equals .01 accidents per 100,000 flight hours or .018 accidents per 100,000 departures. For those who like their statistics mirror imaged, this translates to, on average, only 1 accident every 266 million miles, 630,000 hours flown, or 368,000 departures. The odds are that everybody has a much better than even chance of not making one of those unfortunate TV appearances.

On-demand part 135 operators had 54 accidents, down almost 20 percent from 2005, with 10 of those accidents resulting in 16 fatalities (or 1.5 accidents and .28 fatal accidents for every 100,000 hours flown). Part 135 covers air taxi, air tour and air medical operations. Scheduled Part 135 (commuter) operators experienced only 3 accidents, one of them fatal, resulting in two fatalities.

In General Aviation there was a total of 1,515 accidents, 303 of them fatal, resulting in 698 fatalities. Even though GA accounts for half of all civil aviation flight hour activity, it should be noted that the claimed drop-off in accidents is partly related to a decline in GA activity. Since 1990, according to NTSB, GA activity has declined by 20 percent and the rate has thus remained stable at 7.5 accidents per 100,000 flight hours.

What are the factors in the looking glass that could reflect or inflict future changes in our presently stable stats? Disregarding security concerns, there are a dismal myriad of these:

a. Looming pilot shortages and some of the measures being taken to address the situation (ICAO's MPL or Multi-crew Pilot's License).

b. Outsourcing of maintenance as driven by the need to pare costs and boost profit margins.

c. New technologies (including the next generation air traffic control system).

d. The rise in low-cost minimalist operations under deregulation worldwide.

e. Directly related to d., a marked trend toward tasking pilots up to the legal limits.

f. The Very Light Jet swarm (and the manning of those fleets).

g. The increasing popularity of sports aviation.

h. A denser air traffic environment.

i. Diminishing experience levels among air traffic controllers, some of which will be related to their perceptions of their longer term prospects in a different ATC environment (NextGEN).

We've not mentioned the new age limit of age 65 retirement, because that is extremely unlikely to blip any statistic anywhere. And we'll not even stand by to eat our words on that claim. To borrow a phrase from that well-known non-aviator Forrest Gump: "Safety is as Safety Does". Only the really dumb take chances.

[Brian Abraham]

Organizations that are focused on the next quarter’s results must somehow find the time and energy to deal with these long-term challenges.

And therein lies the problem.

It is clear we lack the systems to prevent hiring the wrong people, and to remove them when they can’t perform.

That be the management who persist in selling a product for less than it costs to produce, which then results in maintenance short cuts, lack of training for crews, hiring unqualified people (or lacking experience), fatigued crews etc etc, and nearly all those factors present in the Coglan accident. Not issues crews can address, rather it falls into the laps of incompetent management that are focused on the next quarter’s results

You're talking to the wrong people, you need to get on a management/beancounter forum.

[SNS3Guppy]

This message is hidden because Shell Management is on your ignore list.

SM is a troll. The above works well. He or she can prattle on all they wish and not be heard. It's for the best.

[Brian Abraham]

Fully agree with your sentiments SNS3Guppy, but some of us do like a dose of comedy in our lives. I think I'll refrain from eating any more bait though, communicating with idiots in the end only drags you down to their level.

[camel]

'safety is our biggest priority' bla bla bla ....

does anyone seriously believe this rubbish any more?

$$$$$$$$$$$$$$$ is the number 1 priority!

How many more innocent people have to die ??????????

:ugh::ugh::ugh:

[forget]

Today's News. Drilling company Transocean had an incident on one of its North Sea rigs similar to that which caused the biggest oil spill in US history earlier this year, it emerged today.

An internal company report obtained by the BBC shows that four months before the US disaster the Sedco 711 rig in the North Sea, which is leased by Shell and operated by Transocean, experienced similar problems.

In this case, however, the blow-out preventer – which is believed to have failed on the Deepwater Horizon – worked effectively, preventing oil and gas from spurting uncontrolled up the rig's pipe.

Transocean oil rig suffered blow-out in North Sea | Environment | guardian.co.uk (http://www.google.co.uk/url?sa=t&source=web&cd=1&ved=0CBYQFjAA&url=http%3A%2F%2Fwww.guardian.co.uk%2Fenvironment%2F2010%2Fd ec%2F07%2Ftransocean-oil-rig-north-sea-deepwater-horizon&ei=_UP-TNvcNs25hAeGyaSgCw&usg=AFQjCNFSo2dNruf2-4EMVkMGerZLSXJc7Q)

Over to you SM. :hmm:

[Sir Niall Dementia]

Hey SM;

As a pilot who has flown all over the world on Shell contracts can you tell me why Shell spout safety and then behind the scenes bully and cajole aircraft operators?

Can you tell me why when Shell moved a North Sea contract in the mid '90s the pilots "losing" the contract sent a condolences card to the pilots "gaining" it?

Can you tell me why after the Cormorant crash of 1992 Shell introduced a "no deck landings with windspeeds over 50 knots" rule and then quietly made it go away when it caused logistical problems? In fact I was called in to fly some freight to a Shell platform after the rule was introduced and the windspeed on the deck was 72knots. During planning we quoted the rule and were told, by Shell "its not a passenger flight so there's no risk to human life. Weren't my co-pilot and I humans?

Where do Shell get off demanding to lisen to CVRs after minor incidents, when they have absolutely no right to?

I haven't flown for Shell for 10 years and don't miss them one iota. The staff offshore were great and some are still friends, Shell Management? a bunch of hypocritical, pious people, and you come across as one of the worst (if you even work for Shell)

This is a forum for Professional Pilots, I suggest if you aren't one, and with you obvious ignorance of aircraft operation you aren't then disappear !

SND

[forget]

Another success for the Shell safety case methodology in ensuring the hazard controls worked. Hence a non-incident.

That says it all. :rolleyes: The whole idea is to prevent these cock-ups occurring in the first place - in which Shell, once again, has failed. If you believe that relying on rescue from cock-ups by third party equipment is acceptable then Shell deserves every word of bad press it gets.

[Capot]

As a one-time contractor for provision of fixed and rotary aircraft to Shell, in the form of one of its national oil companies managed 100% by Shell, although they did not own 100%, I can add a comment that my experience over 8 years was that they would demand trunkfuls of paper responding to Shell's "safety management" directions, but when operational necessity meant picking up a load (people or freight or both) and carrying it to somewhere else that operational necessity overcame all other considerations, repeat "all".

Perhaps things have improved, but I wonder. Cultures take a lot of eradicating and the oil exploration and extraction industry is not run by people who let caution and "bureaucracy" stand in their way.

[Brian Abraham]

As you seem a little bitter and are ignorant of Shell EPE's AWP I don't feel the need to respond to you diatribe in detailYou really must be in management SM. Typical myoptic management response to real world facts.

[SinglePilotCaptain]

Want to reduce accidents?

Hire from the top of the resume pile not the bottom.

What a revelation huh?

[Sir Niall Dementia]

SM;

I'm not in the slightest bitter, I don't have to contract to Shell anymore. As for the initials/acronyms, frankly I couldn't give a s***. I'm currently involved in writing an AOC SMS and we are working to the best available material under the guidance of the CAA.

Whatever works for a company like Shell will probably not work in aviation, especially as Shell will probably ignore it as soon as it impinges on their "operational requirements"

I now don't believe you either work for/have ever worked for Shell, otherwise there is no way a man of integrity could claim that they are so perfect, and I am assuming you are a man of integrity and not a troll or dishonest.

Working on the oil patch across the world I was left amazed at the safety policies of all oil companies when they thought no-one would notice.

SND

[PBL]

I keep hoping for some reasonable commentary on this thread, because safety cases, arguments for attainment of the safety goals of a critical installation, are a key part of modern safety practice. So I keep coming back when a new post shows from someone other than the most frequent contributor.

I have pointed out that aviation does have safety cases. For aircraft, they are the documentation that justifies the airworthiness certificate. For airlines, they are the documentation that justifies the operators certificate.

The person called "Shell Management" is unfortunately providing a lot of misleading information on safety-case matters. I do suggest that the best way to find out about safety cases is reading up on them oneself, or corresponding with someone like me who really knows.

Just to show my point, let us take: safety case methodology and SMS ...... Shell invented these techniques in the early 1990s in response to Piper Alpha.

A quick look at the Cullen report, and consequent legislation, will show that companies started performing safety cases because that was recommended by Cullen and turned into UK law.

Cullen's recommendation did not come out of nowhere. It is not true that Shell invented safety-case techiques. Question, for those really interested in serious discussion of these matters: who (which organisation or organisations) did?

BTW, loci classici for safety-case methodology are to be found at the UK MoD, at the company Adelard, and at the University of York computer science department.

PBL

[PBL]

I do suggest that the best way to find out about safety cases is ... corresponding with someone like me who really knows.

How modest and self-deluded of you.

Thanks, my friend, I didn't realise it was going to be so easy.

For people who had thought about maybe paying attention to some of what our friend says:

I was invited by the German standards committee on functional safety of systems with programmable components last year to prepare guidelines for Germany on software assessment and documentation regarding such systems, in other words guidelines for software safety cases.

I have been invited to talk about this work at the 16th International Conference on Reliable Software Technologies, otherwise known as Ada-Europe, which is meeting jointly with the Ada-UK conference in Edinburgh in June 2011.

Suffice it to say that, if the person self-identifying as "Shell Management" really had much to do with safety cases, heshe would likely have known. Certainly none of my real colleagues would think of abusing me in public quite like this.

PBL

[Brian Abraham]

myoptic??
I think you meant myopic.
I'm glad to say by eyesight is 20/20!Just love it when one points out a spelling mistake by providing his own..........spelling mistake. Best get those eyes checked buddy.

Also you might do a bit of background checking on folks such as PBL before taking to them with a cane. You have NO credibility on these pages, despite your continued advancement of how Shell has lead the way in the cause of safety. Which it hasn't.

That funding did also help invent the swiss cheese model too!You have a habit of making claims about what Shell invented. As far as I'm aware James Reason developed the Swiss Cheese Model without any help from Shell. He certainly gives no credit or attribution to Shell. If you want to stand by your claim I say prove it. Else it's filed in your bull****e file, which is getting crowded.

[zalt]

SM

How do you explain Shell's poor safety record in your own back yard (Sumburgh BV234, Brent Spar S-61, Cormorant Alpha AS332L [mentioned above] and Leman S-76 to name just 4 Shell fatal accidents in the last 25 years in the North Sea resulting in 73 deaths)? In fact, in the last 30 years in the UK, 5 of the 7 fatal offshore accidents have involved Shell contracted aircraft AFAIK.

A crude estimate is that Shell fly 12,000 hours in the North Sea (UK, No, Dk, Nl) each year (out of 80-90,000 hours per annum worldwide). So with a fatal accident on average every 6 years or so, thats a fatal accident rate of about 14 per million flying hours, which is pretty dreadful.

[Rigga]

I've seen safety cases and can confirn that, in my opinion (given free to all readers), they are the largest waste of money ever given to so-callled safety engineers.

Safety cases are an over-rated system of ever decreasing argument against any action anyone would want to make to improve an operation. The series of nit-picking and smugness from said SE's is astounding and unbelieveable. And their wages are unsustainable considering the profit they rob from the company.

It is the one "standard" that everyone should rightly ignore until it goes away.

[PBL]

Rigga,

you cannot judge the worth of a safety case from an experience of reading only bad ones.

As I have pointed out, the certification documents for all commercial transport aircraft contain one large safety case. The regulations define a risk matrix for single-point failures (although it is not called that; it is called a "relationship between probability and severity of effects" in Table 4-1 of Lloyd and Tye's Systematic Safety, CAA Publications, 1982). There is a systematic hazard analysis of every system on board and it is accompanied by a demonstration that the requirements of the risk matrix are satisfied.

Airworthiness certification is obviously very effective. Commercial air transports are amongst the most trustworthy artefacts subject to dangerous failures which have ever been built.

So much for your contention that safety cases are mostly rubbish.

PBL

[Rigga]

"Rigga,

you cannot judge the worth of a safety case from an experience of reading only bad ones.

If "Bad" Systems are all that I see I cannot make another judgement against the evidence present - Show me a good one.
As I have pointed out, the certification documents for all commercial transport aircraft contain one large safety case. The regulations define a risk matrix for single-point failures (although it is not called that; it is called a "relationship between probability and severity of effects" in Table 4-1 of Lloyd and Tye's Systematic Safety, CAA Publications, 1982). There is a systematic hazard analysis of every system on board and it is accompanied by a demonstration that the requirements of the risk matrix are satisfied.

Airworthiness certification is obviously very effective. Commercial air transports are amongst the most trustworthy artefacts subject to dangerous failures which have ever been built.

If this is so good then why is there a need to have another level of safety bureaucracy inside the airline itself?
So much for your contention that safety cases are mostly rubbish.

See my earlier answer.

PBL,
I have checked out your website (because I used to live in Avenwedde) and I have downloaded and read your department missives on safety analysis systems - I have even used my interpretation of "Why-Because" in a recent MEDA investigation (and I thought it worked well, too) but a university position and membership of glorious societies does not a perfect solution make!

I believe that the theory of mandating everyone has a set of tools to self-assess for perfection is flawed in its concept.

I believe that theory emulates the ISO9001 theory of perfection, in that it becomes a beast of horror and self-destruction if allowed to consume more and more effort to achieve the "perfect" status.

You find the best ISO9001 company and I'll show you a very large and very expensive QA dept with a low reputation.

By the way - I do like your published theories and tools, especially the Why-Because thing. But I think they may not aptly apply in all the areas you think.

[PBL]

Show me a good one.


If you now live in Anglia, I recommend you call up my colleagues at Adelard in London. They have devised plenty of very good safety cases. Whether they have one to show you is likely a matter of your justifiably professional interest.

I am rather surprised, since you have to do with safety cases, that you don't appear to know of them. They provide the software with which most of the MoD safety cases are nowadays prepared.


Airworthiness certification is obviously very effective.

If this is so good then why is there a need to have another level of safety bureaucracy inside the airline itself?

Because, as you will know, not speaking entirely from within your hat on safety case matters, operational safety is a different matter from fit-for-purpose certification. I wonder why you even asked the question?

To your comment on WBA:

...a university position and membership of glorious societies does not a perfect solution make!

You imagine you can infer someone's capabilities from their day job? Maybe you can. BTW, I am curious to know which societies I belong to you think are "glorious".

The industrial users of WBA are very happy with it. That's good enough for me (and the tech-transfer company's pocketbook).


I believe that theory emulates the ISO9001 theory of perfection, in that it becomes a beast of horror and self-destruction if allowed to consume more and more effort to achieve the "perfect" status.

How insightful! Can we cite you as a reference?

PBL

[squib66]

PBL

As you have said:

As I have pointed out, the certification documents for all commercial transport aircraft contain one large safety case.

There is a systematic hazard analysis of every system on board and it is accompanied by a demonstration that the requirements of the risk matrix are satisfied.

Airworthiness certification is obviously very effective.

I'd welcome your views on this where those practices seem to have been less effective: http://www.pprune.org/safety-crm-qa-emergency-response-planning/442489-cougar-s-92-accident-case-study-safety.html

Plus I really would love to know what Shell Management will do in his Safety Cases in regard to this recommendation:

...prohibit commercial operation of Category A transport helicopters over water when the sea state will not permit safe ditching and successful evacuation.

[Sir Niall Dementia]

Squib;

Surely Shell management will do what Shell management (and all the other oil companies) do whenever that recommendation is made; They'll ignore it. (Or follow it until it causes production or exploration delays).

There are lies, damn lies and oil company safety cases.

Shell management I do wonder if you realise just how many of us involved in commercial avaition and aviation safety cases think what a total c*** you are. Lets face it all of our ops manuals, AFMs and certification standards are there for safety, not decoration.

Personally I also add the proviso "would I let my family fly with that operation?" Trust me if the operation had any form of Shell input there would be no way.

[PBL]

Squibb,

Neither I nor my colleagues are familiar with oil rig helo operations. I am not familiar with helo certification requirements. If I were/if we were, I would be more than glad to answer your question. But I ain't, so I can't.

PBL

[Rigga]

PBL,

Please do quote me! - probably my first time in university publications.

...and not all of anglia is run by MOD. Some of us have to work for a living!


I'll carry on with the WB thing - I like it.

Und Tchuess!

[Spitoon]

I just know I'm going to regret this, but.....
Simple, as I've already discussed the Adverse Weather Policy Shell introduced nearly 20 years ago, which is a risk based approach to controlling the hazardAn Adverse Weather Policy sounds simply like professional common sense. There is no need to wrap it up in some form of mystique and call it safety management.

And, by the way, a policy is not a safety case, nor is it a safety management system. It's a policy. This one, perhaps, crossing the line into an operational procedure. A safety case will present an argument for why the policy will assure an acceptable level of safety and evidence to show that the arguments are valid.

But, hey, what do I know? I don't work for Shell.

[Spitoon]

I knew I was going to regret it.

Thanks SM, now I understand that point. I hope I've got enough time on this Earth to understand the whole safety management thing as well as you do.

[Olive61]

Hi Shell Management

For what it's worth ....

I work for a relatively small operator in Australia and I can assure you that we are frequently required (by our own internal policies) to develop safety cases for significant changes to our MO, and in nearly all submissions made to our Regulator, a safety case is required. Our compliance and methodology is at least IOSA standard, and our Safety and Quality objectives and requirements are an integral part of all Flight Crew Operating Manuals. Maybe it's not the same in other parts of the world, but we would not contemplate a significant change to our MO without a safety case examination - we would never pass the most fundametal business risk assessment (our own internal policies) without it. Kind Regards

[Brian Abraham]

Spitoon and Olive, don't fall into Shellies web of professed expertise in safety. He knows zip, narda, nix, zero - well you get the idea. He claims that he invented the Swiss Cheese Model of accident causation and as yet has failed to provide proof to back up his claim. Which is a shame, because all in the professional safety field and aviators believe Professor James Reason was the originator. Shellie might be missing out on a medal.

But, hey, what do I know? I don't work for Shell. You're vastly over qualified for a role in Shellies organisation, for a start you ain't brain dead. ;)

[Brian Abraham]

Brian, it pays to read what is written closelyThat I did and you said "Shell invented the Swiss Cheese Model". You made no qualification as to Shell funded Prof Reason's work and allied programmes in the Netherlands that formed the basis of a lot of modern safety theoryYou have been asked to provide evidence to support Shells association with Reason and the Swiss Cheese Model but so far have failed to do so.

[theficklefinger]

Brian, your trying to be the expert that you aren't. Go have a Fosters and ponder the Felonious DNA that cripples your logic.

[Brian Abraham]

your trying to be the expert that you aren'ttheficklefinger, you're new around here so your ignorance is excused. You will find NO WHERE where I have pretended to be an expert, quite the reverse. For your edification Shellie has a well earned reputation here on Pprune for being the self appointed expert. Unfortunately he has always been found wanting by, not only real safety professionals, but the run of the mill aviators like me. That is quite apart from his troll reputation, which has been recognised, and commented on, by the Mods.

Get in out of the cold and revive yourself with a Schnapps before Felonious DNA cripples your logic.

[PBL]

tff,

the person self-identifying as "Shell Management" has, over time produced a number of what Flying Lawyer has termed "extreme views", and also misinformation concerning matters on which he self-presumes to be knowledgable, such as safety and organisational safety.

Brian Abraham is just one of the people who have become publically fed up with SM's facile and misleading interventions. I understand Brian's exasperation very well, and sympathise. I am also grateful that he flags the distortions so that people who don't know that much about safety are not misled.

SM's interventions do have a plus side, however. Occasionally I feel the need to correct a particularly egregious misreprentation, and so I can write a few paragraphs summarising some aspect of the history of safety which I may not have written on before. Then a couple people here might be grateful to read it, and I myself have text I can use again when the need arises.

So here are a few paragraphs on some of Jim Reason's work (which I will be able to use again). I follow these with a couple of comments on SM's misrepresentations.

The so-called "Swiss Cheese Model" is a picture which appears in Reason's book Human Error (Cambridge U.P. 1990) as Figure 7.5. in Chapter 7, "Latent Errors and Human Disasters", in which Reason considers various well-known accidents. The caption is "The various human contributions to the breakdown of complex systems are mapped onto the basic elements of production. It is assumed that the primary systemic origins of latent failures are the fallible decisions taken by top-level plant and corporate managers. These are then transmitted via the intervening elements to the point where system defences may be breached." In order to interpret this diagram, one needs to know what the "basic elements of production" are (they are given in a similarly layered diagram, with feedback loops, in Figure 7.4). One must also buy the assumption of whence the "primary systemic origins of latent failures" derive. Reason was talking specifically about complex human organisations and complex accidents. TNI, Bhopal, Challenger, Chernobly, Herald of Free Enterprise capsize at Zeebrugge, King's Cross station underground fire.

One thing Reason does not explicitly say is that his conceptualisation in Figure 7.5 is based on a barrier-analysis conception of accidents. An aviation accident to which barrier analysis is obviously well applicable is 1988 A320 Habsheim, which involved a lot of failures in the corporate and institutional controls over the pilot's planning and behavior beforehand. An aviation accident to which it is not very well applicable is 1992 Warsaw, which was a combination of what I call a "requirements failure" (namely, the systems worked as designed, but in circumstances in which one would have preferred rather than they had done something else), and physical barrier built at the end of the runway, making the consequences of any overrun very severe.

In the intervening twenty years, most of the context (and content) of Figure 7.5 seems to have disappeared. The picture gets reproduced as the "Swiss Cheese Model" and, for example, pilots all over PPRuNe talk about "the holes in the cheese lining up" without often having the slightest idea of the analysis technique to which they are ultimately referring, or even the labels on the various "slices" of "cheese" whose holes line up.

Reason's model was specifically designed for analyses in which human error and organisational missteps and holes play a large role. I don't believe it is a general model of accident causation and as far as I know Reason has not promoted it as such. But sometimes things take on a life of their own.

The work reported in Chapter 7 of his book, including this diagram, is his own work, which has been informed by projects with many clients. Reason's group at the Uni Manchester worked with the Uni Leiden on Tripod-Delta for Shell Internationale Petroleum Maatschappij (now Shell International Exploration and Production BV). The project started in 1988. The technique was developed in various Shell operating companies in 1989-92, rolled out across Shell in 1993 and generally in 1996. The methods were developed later in REVIEW, for British Rail Research, and MESH, for British Airways Engineering, also at the Uni Manchester. The main programmer of REVIEW and MESH also wrote Tripod-Beta, which is also marketed by a Dutch firm with a similar name.

SM has suggested in previous notes here that, after Piper Alpha, other oil companies followed Shell's "lead" in developing safety cases, and has even suggested that safety cases derive from Shell's work. All of this is just wrong. I have asked him to correct himself (assuming SM is male), but he declines to do so. That may be because he simply doesn't know. He doesn't appear to know, for example, whence safety cases derive. And he doesn't appear to know who the main players in the safety-case development field are.

He seems in his latest note to be suggesting by implication that Reason's main intellectual work was also paid for by Shell. That is not what I understand. I think grants for this work, in so far as additional money was needed, came from the usual sources.

SM also presents himself as someone who knows about safety. But he doesn't know who I am, and replied rather rudely when I suggested that I know quite a lot about it.

So I wouldn't pay a whole lot of attention to what SM says, if I were you, without checking out what he says very carefully. I wish he would stop distorting matters and start producing worthwhile contributions to the ongoing safety discussion. On the other hand, if he did, then I might not have so many notes I can use again....

PBL

[Ghostdancer]

I have followed this thread with a lot of interest over the last few weeks and would now like to throw my own thoughts into the pot with regard to Shell Managements view below.

Quote:

"The steps are:

Top management commitment
Prepare a safety case
Define accoiuntabilities
Implement an SMS
Hold people accountableIf you do that the workers will follow the right culture."

No problem with this as a general approach.

My view of SMS is that it is a very simple concept; it is the proactive management of safety. The pillars of a good SMS are already established as concepts, and much is Regulated for; a Flight Data Monitoring Programme, a good open reporting system, a method of risk assessment and analysis off the results, implementation of recommendations out of that programme, an appropriate management system, and an independent quality system to monitor the whole operation.

Let’s look at the steps quoted above in a little more detail. I think Helen49’s remarks have been overlooked during the debate:

Quote:

"Unless there is an intent and culture of safety at the 'top' of the organisation, all the systems, documents, safety cases etc in the world will not help you. If the culture is there, the simplest of documents and systems will go a long way towards enabling a safe operation. Simple!"

The most important element of a good SMS is getting the right culture, on that I hope we can all agree? The problem we now face as an industry is that “top management” now see SMS as another Regulatory hurdle to overcome. Talking in broad terms, very few senior managers appear to understand the importance of the cultural aspects and grasp that they already possess the basic building blocks for an SMS within their organisations. Senior Management perception in my recent experience is that their commitment ends with a signature to a safety policy.

Safety Case: has anyone ever thought to consider that the initial safety case for a start up organisation is the manuals suite which has to be accepted by the Regulator? These manuals have to meet the minimum standards, set and define the scope of approval/areas of operations, along with Accountability, Responsibility and the procedures within an organisation to support those elements. I raise this as a discussion point for debate and learning, because the original question was “when will airlines start producing safety cases”. The answer could be maybe they have produced the vast majority of this work prior to start up?

Implement an SMS: I believe the basic pillars have already been outlined earlier. The implementation is about top management/senior management being seen to say and do the right things, and allowing a just and learning culture through the application of continual improvement techniques and the proactive management of risks. This should be simple and understood by all. The “holding people accountable” element should extend to the top management of an organisation, as actually they are the ones who are accountable. Top management need to understand they can delegate responsibility, not accountability.

Ultimately SMS is all about getting the right culture into an organisation. Don’t let anyone fool you otherwise. How you choose to do this is largely down to you, no one model fits all, it is the ability to take elements from many different ideas, concepts and models and make them work for you that is important. The SMS should ultimately be tailored to the needs and complexity of your organisation and your employees will judge your success through playing their part in the culture. We need to learn from one another, are all in this together, and should respect one another’s opinions. I fear sometimes we are all in extreme danger of losing sight of common sense during the SMS debate.

[sox6]

Talking of culture, what should we really make of this story:-
United’s 757 Grounding: What It Really Says About Airline Safety | BNET (http://www.bnet.com/blog/airline-business/united-8217s-757-grounding-what-it-really-says-about-airline-safety/3397)
A 5 year delay in acting or a sound culture when a problem found?

[PBL]

A 5 year delay in acting or a sound culture when a problem found?

Recall we have recently had two US airlines fined by the FAA because they did not keep up with ADs concerning structural problems.

I would say that US airlines have been on notice for some time that some lax safety practices, in particular AD compliance, will no longer be tolerated by the regulators, and the "culture" is adapting to the "new" (actually old, but now more actively enforced) reality.

I do applaud the action by UA to declare and fix. I am told almost all aircraft were back in the air within 24 hours.

PBL

[Safety Concerns]

I have to side somewhat with shell management. The united case is shocking for many reason. It isn't just about missing an AD.

I still owe PBL an explanation as to my concerns but safety is talked about and nothing more. A serious approach to operational safety at least is more than lacking. Managers are extracting urine for want of a better word.

[What Limits]

Top management need to understand they can delegate responsibility, not accountability.

With respect, you cannot delegate responsibility or accountability, only authority.

[Brian Abraham]

Whilst we don't have an explanation as yet for the 757 incident it may be timely to revisit an old incident which on the face of it seemingly has parallels. And it shows the difficulties to be had in managing safety. Bear in mind when reading, the Broome S-92 incident, and the failure to adequately investigate, which had they done so, may have prevented a catastrophic accident.

Investigation into Ansett Australia maintenance safety deficiencies and the control of continuing airworthiness of Class A aircraft

Summary

Australia has an excellent air transport safety record. Major Australian airlines have long been regarded as being among the world's safest, and there have been no fatalities involving an Australian high capacity jet aircraft. This enviable record is due, in part, to an aviation safety culture that recognises the need for constant safety awareness.

Given the commercial pressures facing international aviation, the events described in this report should be seen as a learning experience for the aviation industry, regulatory bodies, and all organisations concerned with continuing airworthiness assurance.

In December 2000 and in April 2001, a number of Ansett Australia (Ansett) Boeing 767 (B767) aircraft were withdrawn from service because certain required fatigue damage inspections of the aircraft structure had been missed. As a result there was uncertainty as to the continuing airworthiness status of the aircraft. In December 2000 the concerns related to possible fatigue cracking in the rear fuselage of the aircraft, and in April 2001 the concerns related to possible fatigue cracking of the engine strut fitting on the wing front spar.

On 11 January 2001, the Australian Transport Safety Bureau (ATSB) commenced an investigation into the circumstances surrounding the withdrawal from service of the Ansett B767 aircraft as the situation was regarded as indicative of a potential safety deficiencyi. On 10 April 2001 the ATSB investigation was extended to include an examination of the continuing airworthiness system for Australian Class Aii aircraft such as the B767.

Action by Ansett and the Civil Aviation Safety Authority (CASA) addressed the potential risks to fare-paying passengers. Although Ansett was subsequently placed into voluntary administration in September 2001, the ATSB continued a detailed systemic investigation because of the importance of the issues involved, both in Australia and internationally.

The international continuing airworthiness system, like all complex and safety-critical activities, is dependent on robustiii systems to maintain high reliability. The circumstances surrounding the withdrawal from service of the Ansett B767 aircraft revealed, among other things, that the reliability of the continuing airworthiness system was threatened by a number of weak defences.

The B767 aircraft type was among the first in the world to be designed and certified under damage tolerance principles. Damage tolerance certification relies heavily on scheduled inspections to ensure continuing airworthiness. The aircraft structure is designed to maintain integrity until any fatigue or corrosion damage can be detected at a scheduled inspection, and appropriate action taken. Therefore, in itself, the presence of fatigue cracks in the Ansett B767 aircraft was not necessarily a cause for undue concern. However, it was critical that there were robust systems to ensure that the required structural inspections were carried out to detect the cracks before they exceeded acceptable limits.

Withdrawal from service of Ansett B767 aircraft in December 2000

Ansett was the sixth airline worldwide, and the first airline outside North America, to operate the B767. Of the nine Ansett B767-200 aircraft, five were first flown in 1983 and two in 1984. The aircraft accumulated a high number of flight cyclesiv because they were mostly flown on comparatively short domestic sectors. Ansett had been working with Boeing on fatigue cracking in the area of the Body Stationv 1809.5 bulkhead outer chord since 1996.

In June 1997, Boeing introduced the Airworthiness Limitations Structural Inspection programvi for the B767. The program was an essential part of the damage tolerance requirements and was designed to detect fatigue cracking in susceptible areas that had been identified through testing and in-service experience. Ansett staff did not initially recognise that some Airworthiness Limitations Structural Inspections were required by 25,000 cycles and a period of almost two and a half years elapsed before that error was identified. At the time that the inspection program was introduced, some Ansett B767 aircraft had already flown more than 25,000 cycles. In June 2000, further 25,000 cycle inspections were introduced, including in the area of the Body Station 1809.5 bulkhead outer chord. Ansett did not initially act on this.

In December 2000, Ansett senior management became aware of the missed inspections and the aircraft were withdrawn from service on 23 December 2000, despite the high commercial cost to the company. At that time, both Ansett and CASA were of the belief that compliance with the missed inspections was mandatory. Subsequent legal advice indicated that the regulatory basis for mandating compliance with the Airworthiness Limitations Structural Inspections for Australian operators was unclear. On 29 December 2000, CASA issued a direction to Ansett specifically mandating the inspections for the Ansett B767 aircraft.

The ATSB investigation found that the Ansett system for the introduction and scheduling of the B767 Airworthiness Limitations Structural Inspections was deficient and vulnerable to human error. A mistake or omission by one or two people could potentially result in continuing airworthiness assurance being compromised. In addition, deficiencies existed in resource allocation and in the supporting information management systems.

From October 1998, Boeing also issued a series of service bulletins in relation to fatigue cracks in the area of the B767 Body Station 1809.5 bulkhead outer chord. Service bulletins are issued by aircraft, component, or engine manufacturers to provide operators with relevant service information. Not all service bulletins are safety-related, and compliance with a particular service bulletin can only be mandated by the State of Registry of an aircraft.

Boeing initially notified operators that the service bulletin requirements were primarily commercial in nature. It was not until November 2001 that Boeing indicated that the service bulletin dealt with a potentially major safety issue. The FAA had mandated action by US operators in relation to the service bulletin in April 2001.

Any action to be taken by Ansett in relation to the Body Station 1809.5 service bulletins issued by Boeing was complementary to requirements under the B767 Airworthiness Limitations Structural Inspection program. It was the failure by Ansett to appropriately incorporate the required Airworthiness Limitations Structural Inspections, issued in June 1997 and updated in June 2000, into the B767 system of maintenance that led to the withdrawal from service of six Ansett B767 aircraft in December 2000.

Withdrawal from service of Ansett B767 aircraft in April 2001

In March 2000, Boeing issued an Alertvii service bulletin to detect and repair fatigue cracks in the wing front spar outboard pitch load fitting of the B767 engine mounting strut. Boeing recommended that the work be carried out within 180 calendar days. A revision to the service bulletin was issued in November 2000. In March 2001, Ansett became aware that they had not acted on either the original or the revised service bulletins.

During the period from 7-9 April 2001, inspections revealed cracks in the pitch load fittings of three of the Ansett B767 aircraft and they were withdrawn from service. On 9 April 2001 CASA required that a further four Ansett B767 aircraft be withdrawn from service, pending inspection. Those inspections were subsequently carried out, and the aircraft were cleared to fly.

Deficiencies in the Ansett engineering and maintenance organisation

The ATSB investigation found that similar deficiencies within the Ansett engineering and maintenance organisation led to the withdrawal from service of the B767 aircraft in December 2000 and April 2001. Those deficiencies were related to:

* organisational structure and change management
* systems for managing work processes and tasks
* resource allocation and workload.

However, the investigation found no evidence to suggest that Ansett had deliberately breached airworthiness regulations.

Ansett had undergone considerable change over a number of years. Many of the Ansett systems had developed at a time when the company faced a very different aviation environment. Over time, efficiency measures were introduced to improve productivity but the introduction of modern robust systems did not keep pace with the relative reduction in human resources and loss of corporate knowledge.

Risk management and implementation of change within the Ansett engineering and maintenance organisation were flawed. Inadequate allowance was made for the extra demand on resources in some key areas during the change period.

The Ansett fleet was diverse and the point had been reached where some essential aircraft support programs were largely dependent on one or two people. Hence it was possible for an error or omission by a particular specialist to go undetected for a number of years.

Resource allocation and workload issues had been evident within some areas of the Ansett engineering and maintenance organisation for a considerable period of time. The investigation found that measures aimed at achieving greater productivity had been introduced throughout the organisation without sufficient regard to the different circumstances and criticality of the different work areas. Insufficient consideration had been given to the possible consequences of resource constraints on the core activities of some safety-critical areas of the organisation.

People and robust systems are two of the prime defences against error. Therefore, a combination of poor systems and inadequate resources has the potential to compromise safety. If a failure by one or two individuals can result in a failure of the system as a whole, then the underlying problem is a deficient system, not simply human fallibility.

The Australian continuing airworthiness system

The ATSB investigation found that based on the Ansett B767 experience, the Australian system for continuing airworthiness of Class A aircraft was not as robust as it could have been, as evidenced by:

* uncertainty about continuing airworthiness regulatory requirements
* inadequate regulatory oversight of a major operators continuing airworthiness activities
* Australian major defect report information not being used to best effect.

The investigation identified a need for the regulatory basis for continuing airworthiness requirements of Class A aircraft to be better defined and disseminated to operators.

No evidence was found to indicate that CASA had given formal consideration to monitoring the introduction of the B767 Airworthiness Limitations Structural Inspection program by Ansett from 1997 onwards.

Prior to December 2000, there was apparently little or no awareness among Ansett senior management or within CASA of the underlying systemic problems that had developed within the Ansett engineering and maintenance organisation. The presence of organisational deficiencies remained undetected. In addition, there were delays in adapting regulatory oversight of Ansett in response to indications that Ansett was an organisation facing increasing risk.

The decision by the then Civil Aviation Authority in the early 1990s to reduce its previous level of involvement in a number of safety-related areas did not adequately allow for possible longer-term adverse effects. This included reducing the work done by Authority specialist staff in reviewing manufacturer's service bulletins relevant to Australian Class A aircraft, and relying on operators' systems and on action by overseas regulators in some airworthiness matters.

CASA's central database for major defect reports was incomplete, partly due to deficiencies in reporting, and the information received was not always fully analysed. In addition, feedback to the initiators of major defect reports, and to other operators, was limited. As a result, the potential safety benefit of the major defect reporting system was not fully achieved.

The FAA and ICAO

Delays by the US Federal Aviation Administration (FAA) contributed to a lack of awareness by Ansett and CASA of required B767 Airworthiness Limitations Structural Inspections. This breakdown in FAA process was acknowledged by the US Secretary of Transportation in August 2001. The FAA did not issue airworthiness directives in relation to the June 1997 Airworthiness Limitations Structural Inspection program, or the service bulletins for the Body Station 1809.5 bulkhead outer chord and the wing front spar outboard pitch load fitting, until after the second Ansett groundings in April 2001.

Different views within the FAA as to the importance of airworthiness directives to mandate continuing airworthiness requirements for damage tolerance aircraft types contributed to a lack of timely action by the FAA. The ATSB report includes recommendations that the FAA ensure that such airworthiness directives are processed and released without undue delay, and that affected parties should be informed when delays do occur. The report also recommends that the FAA ensure that the process for determining grace periods for aircraft to comply with airworthiness directives is both systematic and transparent.

The ATSB report outlines where the existing international continuing airworthiness system, as defined by International Civil Aviation Organization (ICAO) standards and recommended practices, could be enhanced by the application of quality assurance mechanisms to the processing and distribution of safety-related information.

The events outlined in this report indicate that there was a breakdown in the continuing airworthiness system within Ansett, the FAA, and CASA. In addition, the possible safety significance of cracks in the area of the B767 Body Station 1809.5 bulkhead outer chord was not initially highlighted by Boeing.

Safety action

On 12 April 2001, the ATSB released two safety recommendations to CASA. The intent of these recommendations was to enhance the robustness of the systems used to manage the continuing airworthiness of Australian registered aircraft such as the B767 by ensuring that:

* action, or lack of action, by another State did not adversely affect the safety of Australian Class A aircraft
* all service bulletins relevant to Australian Class A aircraft were received, assessed and implemented or mandated as appropriate.

CASA subsequently initiated a comprehensive review of its systems to monitor, assess, and act on service bulletins, to ensure that those critical to safety could be readily identified and acted upon appropriately. Recommendations from that review were addressed in an associated implementation plan that detailed the nature and timing of the actions that CASA would take in response to the recommendations. The ATSB is monitoring the implementation of this important safety action.

In response to the circumstances of the events of December 2000 and April 2001, the FAA has included further checks and balances designed to ensure that all service bulletins issued by US manufacturers are properly reviewed and addressed. In addition, the FAA has established an 'early warning system' to provide non-US airworthiness authorities with information on pending occurrence investigations that may result in mandatory action by the FAA.

The manner in which events developed highlights the need for organisations to be continually mindful of potential threats to safe operations. Periodic review is needed to ensure that existing systems for maintaining air safety keep pace with the changing environment.

Implementation by the relevant organisations of the recommendations made by the ATSB as a result of this investigation should help to ensure that aviation systems, both within Australia and internationally, are strengthened and that air safety for Class A aircraft is enhanced.

Investigation into Ansett Australia maintenance safety deficiencies and the control of continuing airworthiness of Class A aircraft (http://www.atsb.gov.au/publications/2002/sir200211_001.aspx)

[Safety Concerns]

Lets be clear on one thing here as there are no parallels with the above.

United DID NOT miss or overlook an AD. They only half implemented it. Yes we should perhaps wait for a proper explanation however it is incredibly serious that the AD was detected, scheduled to be performed within the allowable time frame. yet not fully embodied.

There are a number of failures there which are a cause for serious concern.

If this was simply an AD oversight issue I would have fewer problems with events.

[Brian Abraham]

Lets be clear on one thing here as there are no parallels with the above.I'm amazed that you can be so self assured. Certainly it was not because they over looked an AD, but I'll bet a penny to a pound that the failure to implement it fully will be found to have some parallel with the above failures. As I hinted at earlier, some of the failures raised have a direct connection with the Cougar fatal S-92 accident.

[PBL]

Brian,

I've lost your point in the extensive quote. Is it that communications about complex matters such as the quality of safety-mandated inspections in airlines are less good than they should be?

Frankly, I find the UA event puzzling. Clearly, someone inside the airline detected something of which no one else there had been aware, namely that a certain step, a check step, in an AD had not been complied with. Good for them!

And someone else decided that a very public grounding of all their airplanes of a particular type was the appropriate response. The check step was trivial; it was all over with very quickly and the airplanes were back flying. There had been no in-flight incidents in half a decade related to the AD (this is very different from previous incidents with other airlines, in which the safety of flight was a real consideration). So why not spread the checks over a few days and minimise the disruption?

PBL

[Safety Concerns]

Brian, the work (the SB/AD) was in the hands of maintenance. Now it is not feasible that any qualified individual would perform only half the work and release the aircraft as serviceable due to an oversight.

Even less so on an RVSM aircraft. If I am now to believe that 96 aircraft had their air data hardware modified without tests being performed afterwards that is an extremely serious WHY NOT?

As I doubt very much that only one individual was involved with all 96 aircraft this indicates an extremely serious culture issue.

That is why there are no parallels.

It is also worthy of note that some operators complained to the FAA that the original AD was too work intensive resulting in expensive long ground time. I wonder whether that operator was United.

This AD was deemed as necessary as safety was affected. Either the industry is serious about safety or its serious about making huge sums of money. You can have both but not when tickets are being sold for a few dollars.

It is time for all involved with aviation to wake up. Safety has been eroded due to commercial pressure and it has been going on for some time. The cracks have been ignored and those raising the alarm have been ridiculed.

We are now slowly entering the Payback era. I wish it was otherwise.

[Safety Concerns]

The check step was trivial

Sorry PBL disagree. The check step was vital in ensuring airworthiness was maintained. Without this critical step one can only assume airworthiness was maintained. The check step as far as I am aware was to test the Air data system. The AD itself states:

A persistent erroneous warning could confuse and distract the flightcrew and lead to an increase in the flightcrew's workload. Such a situation could lead the flightcrew to act on hazardously misleading information, which could result in loss of control of the airplane. This action is intended to address the identified unsafe condition.

United got lucky nothing more nothing less and trivia belongs elsewhere.
Had an aircraft had an accident immediately after the modification because they were distracted by a persistent erroneous warning the attitude towards that trivial matter of testing the system would be totally different.

System integrity is fundamental to airworthiness after a modification. United have a duty to fare paying passengers to ensure that to the best of their ability the aircraft they are flying in is safe. They failed in 96 cases X number of flights.

I hope this is one of the largest fines ever.

[PBL]

SC,

there are different meanings to the word "trivial". I meant it in the good old mathematical sense of "easily fulfilled" and I think you took me to be meaning "unimportant". I definitely don't think the verification step is unimportant!

PBL

[Safety Concerns]

yes I did take the latter. Probably because I have heard it said so often by so many maintenance managers.

"Maintenance is trivial"

[john_tullamarine]

the work (the SB/AD) was in the hands of maintenance

My comments are not directed, specifically, to the present discussion but are somewhat generic -

(a) having, at various times, had backgrounds in several bits of the game - design, manufacture, certification, fleet support (both in the [OEM and operator tech services] design and [operator] maintenance areas), and flying - one of the significant things which has become apparent relates to competent assessment of airworthiness documentation.

(b) we all come to the assessment table wearing glasses which are coloured by our particular skill and experience bases. Furthermore, we all tend to have some difficulty with defining the fence location around the paddock which represents our quantitative expertise. As a consequence, to a greater or lesser extent, a small group (often an individual in a small organisation) may run a higher incidence of interpretative errors than that associated with a larger group covering a wider competence base.

(c) provided the small group is conservative, we get away with the deficiency for much of the time. However, if the documentation is not explicitly clear, the risk of inappropriate interpretation can bite us on the tail.

(d) my view is that a multidisciplinary tech information review process generally will come up with a better assessment decision than that arrived at by the one-man band operation - a bit like the CRM principle that the commander is better served by utilising all pertinent resources during the assessment and management of an emergency/abnormal situation.

Some f'instances -

(a) OEM optional SB provided a comparatively low cost option to retract the landing gear doors following an alternate extension. Standard fit presumed that the (hanging) doors would abrade safely during the subsequent landing.

Operator maintenance organisation was a bit parochial and didn't discuss much with either flight standards or the two Industry engineering consultants retained (of which I was one). Maintenance assessment was that the cost/benefit wasn't warranted so the mod was declined without the knowledge of the other groups.

As Murphy would dictate, the abnormal situation arose but, during the recovery landing, the door decided to depart rather than wear down .. BRT overhaul cost was disproportionately higher than the mod cost ...

The CP, following the event, opined that, had he known of the mod, it would have been incorporated at flight standards direction to guard against just this risk....

(b) OEM parts organisation. Reviewed the warehouse stockholdings and decided that it would be a good accounting idea to scrap everything which had not moved during the past five years. This occurred during a period of several months between the previous fleet support manager's leaving to go to a far more interesting overseas flying task (he is a regular in PPRuNe and a fine chap) and my taking up the reins on a fill-in contract position. Pity that a large number of big ticket items, stocked for a mandatory SB coming up not all that far down the calendar path, were destroyed .. and had to be remanufactured to suit the mod requirements..

In that contract role, due to having to fund the design support but having no effective input into design output, I regularly was faced with enquiries from the fleet operators in respect of confusing aspects of SBs etc. Murphy dictates that the guy in the field will often read something the wrong way (ie not as intended) unless all the i's are dotted and t's crossed in a painstaking way.

(c) in my current day job, one of the sideline tasks is to do the final review of documentation relating to maintenance planning. Not infrequently, I reject documents back to the design group for clarification - they hate me but it comes with the territory.

.. and so it goes on. I'm sure that most here within the nuts and bolts fraternity can come up with a host of additional examples.

[Safety Concerns]

having reviewed this SB today, one cannot miss the clearly stated required tests.

As I said previously, I feel sure one man did not cover all 96 aircraft so there are a number of serious unanswered questions here

[4dogs]

Ghostdancer said it all in one sentence:
Ultimately SMS is all about getting the right culture into an organisation.

Exactly the same could be said for ISO 9000 et seq. In fact, if you look at it with an open mind, both approaches share a great many practical similarities as plain old "good business sense", certainly enough to be considered siblings.

Unfortunately, the implementation of SMS is likely to suffer the same birth defects as was the case for the ISO 9000 family - it was hijacked by commercial interests that turned it into the greatest paper consuming exercise of all time, so focused on minutiae that the strategic gains were obscured or lost. Both of these babies were conceived in simplicity as good management practices and are best born at home with loving parents, not forcibly extracted by huge surgical teams of self-professed experts trying to outdo the annual cost of Medicare/National Health!

Please, let's not miss the point...

Stay Alive,

[Brian Abraham]

Meanwhile this story shows the poor and complacent state of aviation safetyNo it doesn't. It shows the complacent state of management, but not of the people at the sharp end.

[smallfry]

@ SM.
You are trying to get an audience about this even when you have been proven to be economical with the facts. (See the Ash thread in R&N)
No Airline has submitted a case for flying in the high concentration ash, but have for flight in the lower concentration areas.
See this CAA document
CAA issues update on Volcanic Ash Arrangements | CAA Newsroom | CAA (http://www.caa.co.uk/application.aspx?catid=14&pagetype=65&appid=7&mode=detail&nid=1996)
Where they say 'many airlines have submitted cases'
Nobody has submitted a case for high concentrations because they cannot prove it is safe to do so.
Stop exaggerating the case.

[Francis Frogbound]

smallfry;

SM loves to exagerate a case he/she knows nothing of. On another thread on this forum a pilot asked for SM to be banned, I agree with that pilot. The media read these pages and SM's complete unfamiliarity with aviation practises will eventually cause a surfing journo to take SM's word as gospel.

Like many pilots here I've flown on Shell contracts. The sheer dishonesty of Shell safety beggars belief, the fact that SM thinks it is the worlds greatest tells me that he is as intellectualy dishonest as the real Shell.

SM, I've read the drivel about your "occupation" thankfully my company never wastes money on snake oil salesmen with great buzz words, we prefer to spend it on safety.

Oh, and by the way SM. The ash cloud case was a CAA requirement, most companies who COULD have a problem have applied, how many have the overworked FOIs approved?

Please MODs ban this fool before someone outside aviation takes him seriously.

[Brian Abraham]

Are you really sure you want to take such a generalised and unsupported swipe at one of Europe's largest, most profitable and respected corporationsIf Francis wishes to reneg I'll take his place. As someone once posted on these hallowed pages,

I would like to say a word on behalf of all the oil companies I've flown for, British and others. Without exception, they all stick absolutely rigidly to each and every safety rule - to the letter.

Until it becomes inconvenient.

This guy is headed in the right direction.

http://i101.photobucket.com/albums/m56/babraham227/shll-1.png

[Sir Niall Dementia]

Brian;

I'll stick by FF's words (he and I share an office and I know how angry SM's sort of stupidity makes him), after all I once told the head of Shell what I thought of Shell safety procedures.

I also stick by the request to ban the ridiculous, pilot hating creature who calls himself Shell Management, lets face it, if he knew anything about aviation he would realise that in this case the CAA decided to put the ash cloud scenario in the safety case because most companies were doing just that and that by making it a regulation standardisation could be achieved rather than an alphabet soup of different ideas.

SND

[john_tullamarine]

Just a point on moderating, banning etc.

We don't set out to censor discussion just because we might not agree, like, etc,. the tone or content of a given poster's commentary.

If, however, posts get into overt nastiness, venture into potential legal minefields, have utterly no connection with aviation, etc., then we revisit.

On the positive side, inaccurate, careless, stupid, etc., posts challenge the reader to test his/her own knowledge base and, hopefully, encourages gentle criticism to divert the overall discussion along more appropriate pathways. Doesn't always work but that's the idea ...


However, at the individual's level, one can filter out posts by any other poster as one sees fit so that one's sensibilities are not assaulted by said poster's posts ...

[verticalhold]

Shell Management;

Like the coroner in this case you have confused an operations manual (and therefore mandatory requirement) with SMS. The crew were not correctly rested, and would have been in breach of European AOC requirements. The only SMS points in these findings were in reality against the airport.

The withdrawl of an AOC for lack of financial means can be taken against any European carrier who does not have the required funds which are mandated to cover maintenance etc.

An airline SMS is a very small document. Nearly everything an AOC holder does is covered by legislation and is in the holder's operations manual, the rest scheme which the coroner discussed will be OPs Manual section 7 (in Europe) and is roughly 30 pages of stringent regulations, before every flight both the ops department and the pilot must ensure he is legal to fly and at the end of every month the ops dept will raise a full record of pilots duty hours. These records are then audited regularly by the controlling authority and the AOC holders quality department.

In certain parts of SE Asia such controls may not exist (I know from personal experience) and the result can be very fatigued crews.

To ask "when will airlines start preparing safety cases?" is the wrong question. Airline safety management has been an organic, growing thing for more years than I care to remember, and certainly for far longer than the 25 years my career has so far lasted, and certainly pre-dates every other SMS out there.

Reading some of your comments you have a serious misunderstanding of us and what we do. An operations manual is mandatory, it cannot be more relaxed than the standards set down by the controlling authority, but can be stricter. When a company puts a requirement in to its' manual that requirement effectively becomes enshrined in law because it is in the manual, and woe betide the person who tries to go against it. Sir Niall Dementia of these pages is well known to some of us as a very knowledgable Head of Flight Safety and has long been involved in keeping people and aircraft in one piece as a union rep and in company management, I would strongly urge you to take heed of people like him and VeeAny who runs a superb safety website before trying to tell us where we are going wrong. The CAA asked carriers to work out a plan on how to deal with volcanic ash the carriers did knowing that the plans would go into the ops manuals and so become mandatory, you appeared to suggest that we were forced into it by legislation, we are never forced, in fact we often lead the push for safety as we are the people who understand our operating environment the best.

[galaxy flyer]

SM

I've been aviation, civil and military, for 35 years; I have acted as a safety officer, a commander, now a professional pilot. You seem to believe that aviation, at all levels, refuse to believe in safety management; that pilots and operations managers ignore risk management; and that upper level management lets it happen.

Have you stopped to consider the relentless reductions in safety performance? Have you considered that there are continuing safety audits and programs like IOSA? SMS requirements by ICAO?

Do you think that the safety record of the airline is an accident despite the idiocy of management and the regulators?

Once, please post some record of your experience in aviation management and operational line performance, just to show some credibility.

GF

[verticalhold]

Shell Management;

As usual your blind arrogance has led you to not read a post correctly. Re-read my post and you will see that often the airlines lead the regulators on safety.

I formally and publicly invite you to come and see all of my company operations manuals and to see just how they cover so much of the SMS case, from how engineers should work at height, how operations must plan and prepare a flight and how the pilots must fly it, I think you will be amazed at just how the safety case is covered.

A condition of my invitation is that you fulfil Galaxy Flyer's request and reveal on this forum exactly what your aviation experience and background is.

VH

[stuckgear]

Ref: VH

As usual your blind arrogance has led you to not read a post correctly. Re-read my post and you will see that often the airlines lead the regulators on safety.


Indeed, within the FAA system, many AD's and SB's have derived from operators concerns over certain issues, which the regulator has looked into and conferred and presented an NPRM, enabling those affected to address the variances in certain issues. many NPRM's have as such provoked further revision of NPRM's in the name of safety.



Ref: SM

Cyprus decided on 26 November 2010 to suspend the Air Operator Certificate (AOC) of the air carrier Eurocypria Airlines following the stop of operations and the lack of financial means of the air carrier to operate in safe conditions;

Italy decided to suspend on 24 October 2010 the air transport licence held by the air carrier Livingston and that held by the air carrier ItaliAirlines on 11 March 2011;

Lithuania decided to revoke the AOC of the air carrier Star 1 Airlines on 11 November 2010;

following the liquidation of the air carrier Blue Line and the subsequent suspension of its operating licence, France decided to suspend the AOC of this air carrier on 6 October 2010. Furthermore, France decided not to renew the AOC of Strategic Airlines on 16 September 2010;

Greece decided to revoke the AOC of Hellas Jet in November 2010, had suspended the AOC of Athens Airways in January 2011, and had placed Hellenic Imperial Airways under heightened surveillance;

Sweden decided not to renew the AOC of the air carrier Viking Airlines AB on 31 December 2010 and the




as VH points out the withdrawal or suspension of an AoC may not necessarily be due to safety issues in relation to the operation or maintenance of the fleet, indeed when this is the case, the AoC holder would have been subject to an inspection and been provided notices of it's failings with requirements to meet regulatory standards or face re-percussive actions. (namely suspension of the AoC)

Economic safety is also a prime driver in the suspension of the AoC and the largest cause of AoC revocation or suspension due to the failings of providing 'economic authority'. Again the AoC holder will be advised of the concerns and given rectification demands or re-percussive actions, at which point the need for funding is required and if not achieved in the capacity required, revocation will follow.

so your presentation is actually disingenuous SM.


Ref: SM

Again you confirm the fundamental lack of risk awareness of many in the airline industry. ICAO are trying so hard to get airlines to think for themseleves and take a risk based approach but again are foiled by those stuck in the past.


do you have case to substantiate that claim or is that personal conjecture ?

[squib66]

Shell certainly makes this claim in the bochure above, dated June 2010:


Process safety in Shell
Our assets are safe and we know it Given the nature of the risks involved, ensuring the safety and integrity of our assets is paramount to Shell. For us, process safety means making sure our facilities are well designed, safely operated, and properly inspected and maintained.


SM may want to consider these words in relation to the fact Shell were fined over £1mn this week for an explosion in the Bacton gas plant in the UK that would probably have killed 10 people if they were not doing a shift change in the admin block.

BBC News - Gas terminal blast: Shell fined £1m plus £242,000 costs (http://www.bbc.co.uk/news/uk-england-norfolk-13805763)

See also this article from earlier in the week on the death of a worker on Shell's Brent C after a fall overboard:
BBC News - Brent Charlie oil platform death fall man named (http://www.bbc.co.uk/news/uk-scotland-north-east-orkney-shetland-13865222)

The same complex was shut down earlier in the year after a large piece of Brent B fell into the sea at the start of this year:
Brent fender falls off - Offshore.no International (http://www.offshore.no/international/article/Brent_fender_falls_off)

Brent B has a fatal history and another record fine:
Shell Brent Bravo deaths 'preventable' | Business | The Guardian (http://www.guardian.co.uk/business/2006/jul/18/oilandpetrol.news1)

See also this:
Shell Brent Bravo Deaths: Criminal Investigation uncovers lies, deceit and potential corruption – Royal Dutch Shell plc .com (http://royaldutchshellplc.com/2011/03/04/shell-brent-bravo-deaths-criminal-investigation-uncovers-lies-deceit-and-potential-corruption/)

Shell have also picked up record breaking HSE fines at their Stanlow refinery after an oil spill and even their head office (after a fire).

What is the real outrage, that people listen to Shell Aircraft's nonsense.

[Brian Abraham]

What is the real outrage, that people listen to Shell Aircraft's nonsenseNo they don't squib (if they have half a brain). SM has the Pprune contract for the provision of comidic relief. :ok: Thanks for the links of Shell showing we peons the way forward safety wise.

[Spitoon]

The really sad thing is that occasionally SM may have something useful to offer but it's likely to be overlooked because it's lost in the rest of the uninformed detritus.

[verticalhold]

Okay I'm lost now. Where in hell did Squib "drag up anti-capitalist nonsense?"

All he showed were facts about Shell fouling up on safety and getting fined for it.

Quite frankly SM if you think they are the safety experts its a bloody good job that aviation isn't following them. With leadership like that it would be raining aircraft, and it would always be someone else's fault.

SM you do write some good posts (I'm thinking the Africa thread on Rotorheads) Please tell me, whisper it into my perfectly formed porcelain ear if you have to, are you really on here to take the piss out of Shell by winding the rest of us up? If you are its working, if not then somewhere (Den Hague apparently, but I have doubts) there is a seriously delusional fantasist on the loose with access to the internet and possibly Shell labs. Its beyond the scope of most nightmares:eek:

[5711N0205W]

SM reminds me of an ex senior figure in Shell Aircraft Services who served in (to my knowledge) Africa and Aberdeen who had an innate ability to wind up everyone he came into contact with, was a master pedant and who left the organisation a number of years ago to the relief of many and probably not at his planned exit point.

In the Oil & Gas food chain the operator is king. In the UK both Shell and BP have long histories of dictatorial practices of safety management systems to subcontractors often at the expense of common sense while sadly suffering the consequences of failures in those systems within their own organisations.

One thing this forum is good at is attracting these characters with oblique viewpoints who usually manage a fairly decent sustained run before finally being found out. :)

[The Tox]

SM, who are the 'experts' you are referring to?:hmm:

[Saint Jack]

Shell Management: Please respond to Galaxy Flyer's Post #126 and Vertical Hold's Post #127 by stating your experience and qualifcations to make the many statements you have made regarding safety throughout PPrune. If you choose not to do so you will certainly have lost all credibility and, as Brian Abraham states in his Post #130, you'll simply be regarded as 'comic relief'.

[The Tox]

Hello Saint Jack et al,
I see we and others are still waiting for SM to answer those questions put to him/her. I was interested (at one stage) to see if SM would/could back him/herself but his/her opportunity has well & truly passed now and it's time to move on.......

My thanks to the thread contributors for their interesting and valuable input arguing the points that SM contrived and used to try and mislead us into thinking he/she knew something of what he/she was on about. Clearly this individual didn't and doesn't.

Have a great day & Stay safe........ :ok:

[verticalhold]

Tox;

I reckon that SM is so vastly qualified that its' taking him/her nearly a month to remember all his/her safety qualifications and years of experience in the business, after all its 26 days since post 127.

Wow! Imagine being such an expert:E

VH

[Sir Niall Dementia]

Exactly a month since galaxy Flyer and VerticalHold asked Shell Management to state his/her qualifications to make the kind of statements he/she does, and oddly no reply.

Shell Management you are obviously a fake, so do us all a favour now and stay away from anything to do with aviation.

Aviation professionals offered you the chance to prove yourself, as they would to anyone wanting to enter the field. You have been found wanting, in aviation there is rarely a second chance, you have failed, leave aviation to those who know it, understand it, and fight to keep stupidity out of it.

SND

[Safety Concerns]

shell where can I find the report you quote from? The bit about extra surveillance on JET2 AND TITAN:

[jumpseater]

SM
how rude it is for people hiding behind an anonomous non de guerre

Whiule I could boast of my years of hands-on experience implementing advanced safety thinking and the awards I have recieved for that,

Well it is rather odd, or to put it another way blatant hypocracy, to accuse people of hiding when that is exactly what you are doing. Of course we only have your word that you are an expert.

Personally I doubt it, because if you haven't seen the elephant in the room in that link you provided above, you're the last person I'd take any advice from. That's not a personal attack, just a statement of fact purely on the basis that you obviously can't see an issue when its written down in front of you.

[Spitoon]

Mmmmmmm..........

BBC News - Ogoniland oil spills: Shell admits Nigeria liability (http://www.bbc.co.uk/news/world-africa-14391015)

[Pukka]

XXXXXX, sorry I mean SM, why do you waste your time in this playgound? You have the ear of management.

ID deleted - JT

[Burr Styers]

All

heres a link to a presentation given by a representative from the oil and gas industry, to CASA, back in 2001. The subject was "When will aviation start preparing safety cases"?

Clarified a few things for me.

B rgds

BS

Civil Aviation Safety Authority - Professor Patrick Hudson video (http://www.casa.gov.au/scripts/nc.dll?WCMS:STANDARD::pc=PC_91440)

[Safety Concerns]

pukka whether it is XXXXX or not your post is in bad taste.

Shell expresses his/her opinion just like everyone else. take it or leave it but outing is a no go

Thanks - I missed that first time around - JT

[zalt]

Nice video, making some good points.

It is a pity that 'certain' posters here do not display the clear knowledge, balance and good humour by that presenter.

[Avionker]

Shame that the name is still in the link to the video though.....

[Brian Abraham]

Anyone who is familiar with the postings of Shell Management on Pprune will know that he, and Professor Patrick Hudson, are not one in the same person,

[Neptunus Rex]

Whiule (sic) I could boast of my years of hands-on experience implementing advanced safety thinking and the awards I have recieved (sic) for that,That explains it. SM is an Elf 'n' Safety Guru.

[Brian Abraham]

Where is Shell Management? He is quick to lambaste any one else who happens to stub a toe, even sugesting in a now removed post in Rotorheads, that a particular accident would not have happened had the operator been subject to Shell oversight. Seems here the emperor has no clothes, to the extent of being both reluctant to report the event and then economical with the truth when reporting.

The Courier - Shell Gannet Alpha North Sea oil spill confirmed as biggest in a decade (http://www.thecourier.co.uk/News/National/article/16500/shell-gannet-alpha-north-sea-oil-spill-confirmed-as-biggest-in-a-decade.html)

Shell Gannet Alpha North Sea oil spill confirmed as biggest in a decade

A North Sea oil spill 112 miles from the Scottish coast is the biggest leak in a decade.

By Stefan Morkis

The Department of Energy and Climate Change said on Monday that "hundreds of tonnes" of oil has leaked out from a flow line at Shell's Gannet Alpha platform.

The firm has been heavily criticised for not divulging details of the leak until the company had closed the subsea well. Despite this the firm is still trying work to prevent further leaks.

A DECC spokesman said: "Although small in comparison to the Macondo, Gulf of Mexico, incident, in the context of the UK Continental Shelf (UKCS) the spill is substantial — but it is not anticipated that oil will reach the shore and indeed it is expected that it will be dispersed naturally.

"The UK Continental Shelf oil spill record is strong, which is why it is disappointing that this spill has happened. We take any spill very seriously and we will be investigating the causes of the spill and learning any lessons from the response to it."

However, if the DECC's estimates are correct then the spill is greater than the combined total of leaks in the North Sea since 2001.

The spokesman added: "Current estimates are that the spill could be several hundred tonnes. However, it is always very difficult and takes time to get an accurate assessment of the size of a spill and this is subject to ongoing revision.

"So these estimates are subject to continuing analysis and change. The Maritime and Coastguard Agency are making twice-daily flights to monitor the situation."

Dr Richard Dixon, director of WWF Scotland, said: "Shell have managed a second press statement six days into this substantial oil spill — they have even managed to put some figures in this one.

"However, you are still left with the impression that they would rather not be saying anything at all in public. Their message concentrates on the single tonne of oil that has ended up on the surface but says nothing about the fate of the other 210 tonnes that they admit has leaked.

"It's time they came clean and released their video footage which will reveal the extent of oil contamination on the seabed."

The oil field is operated by Shell and is co-owned by the company and Esso.

Stuart Housden, director of RSPB Scotland, called for assurances from Shell that the spill has completely stopped as it threatens thousands of sea birds.

He said: "We know oil of any amount, if in the wrong place, at the wrong time, can have a devastating impact on marine life. Currently thousands of young auks — razorbills, puffins and guillemots — are flightless and dispersing widely in the North Sea during late summer. So they could be at serious risk if contaminated by this spill."

Shadow Scottish secretary Ann McKechin said: "There is clearly a distinct lack of information flowing from the Scottish Government and a lack of dialogue between them and the DECC.

"I have written to the Scottish secretary of state for details of what discussions he has been having with the Scottish Government and colleagues at the DECC regarding the spill, and to ask what he is doing to facilitate a dialogue between them and environmental groups who are rightfully concerned about a lack of clarity regarding when the spill happened and how big the problem is."

The oil company said: "Shell takes all spills seriously, regardless of size and we have responded promptly to this incident."

Scottish environment secretary Richard Lochhead said the spill is being taken "extremely seriously".

"As is standard practice in incidents such as this, the UK Government, which has responsibility for the pipeline system, will be taking forward an investigation and I will be pressing for the Scottish Government to have a full and formal role, given our responsibilities for the marine environment," he said.

"The Scottish Government's primary role is to advise on the impact any spill might have on the marine environment. Marine Scotland aircraft are currently involved in surveillance work over the affected area. Fishing vessels in the area have also been made aware of the incident."

[whenrealityhurts]

This from the guy that doesn't understand why helicopter manufacturers design the blades to rotate right or left...just sayin...

[Brian Abraham]

I see SSG is back under a new guise. The postings are all too familiar.

[Hedge36]

Oil companies are truly high reliability organisations.


As one who spent a considerable portion of his fourteenth year cleaning up after the Valdez mess, I'd take issue with that notion.

[Brian Abraham]

The fact that this tiny spill is the worst is just a sign of the SUCCESS the oil industry has had Has Shell patented that mealy mouthed management excuse, or is it available for all? As in, this is the first time we've dinged an aircraft in X years so it's a sign of our SUCCESS.

Certainly no where near the 5,300 ton spill Shell had on the Río de la Plata, Buenos Aires. Notable that the Supreme Court of Justice ordered Shell to carry out a 35-million dollar coastline cleanup, not least because it impacted a valuable wildlife area that is considered a biosphere reserve by UNESCO. Last heard was Shell was still avoiding its responsibility and the effects of the oil spill continue causing damages in the coastal ecosystem and in the local community. And you had the hide to take a stick to BP.

http://www.petroleomagdalena.com/wp-content/uploads/2008/11/costa-empetrolada-i.jpg
http://www.petroleomagdalena.com/wp-content/uploads/2008/11/trabajadores.jpg
http://www.petroleomagdalena.com/wp-content/uploads/2009/01/enero-1999-petroleo-recogido-en-baldes-de-albanil.jpg
http://www.petroleomagdalena.com/wp-content/uploads/2009/01/enero-1999-ave-empetrolada-en-magdalena-republica-argentina.jpg

[Brian Abraham]

Plus it takes substance abuse abuse seriouslyIs that indicative of substance abuse?

drunk mariners running aground in AlaskaFar be it from me to defend Exxon because I know what a bunch of barstards they are, but should you read up on the NTSB report, the state of the Captains sobriety had absolutely nothing to do with the event. In fact it doesn't even get a mention.

So what your saying is the size of the spill is the determinant, not the fact that it happened.

PS When the hell are you lot (Shell) going to clean up your act in Nigeria? Once you have achieved that then you can lecture others.

[Brian Abraham]

Oil spill investigation begins as Shell plugs North Sea leak | Environment | guardian.co.uk (http://www.guardian.co.uk/environment/2011/aug/22/shell-north-sea-oil-leak)

An investigation by the Sunday Herald found that Shell had been officially censured 25 times in the past six years for breaking safety rules, giving it one of the worst safety records of any major oil company in the UK. Infringements by Shell include repeatedly failing to maintain pipelines - similar to the one that gave rise to the Gannet leak - as well as for failing to report a dangerous incident, and failing to protect workers from hazardous chemicals. The revelations cited come from records held by the government's Health and Safety Executive (HSE), and include incidents in which Shell was fined or received an official reprimand.

Since 2005, Shell has been prosecuted four times: for an explosion at Bacton gas terminal near Norwich; an accident at Ellesmere Port in Cheshire; a collision at the Mossmorran gas plant in Fife; and a fatality on the Clipper rig in the North Sea. The company has been forced to pay out nearly £1m in fines and legal costs. No other major oil company has faced as many prosecutions in the last six years, according to the HSE. Talisman was prosecuted twice in the period, while BP, Total, Amec and Nexen were each prosecuted once, the Sunday Herald reported.

Oil Company Score Card (UK)
Oil company / prosecutions since 2005 / enforcement notices since 2005

Shell / 4 / 21
Maersk / 0 / 33
BP / 1 / 20
Talisman / 2 / 12
Petrofac / 0 / 15
Total / 1 / 7
Chevron / 0 / 9
Nexen / 1 / 5
Rowan / 0 / 8
Amec / 1 / 4
Amoco / 0 / 7
Esso / 0 / 6
Conoco / 0 / 5
Marathon / 0 / 5

Keep up the good work SM. At least you're a leader in the UK.

[stuckgear]

Most leaks are due to theft of oil by tapping into pipelines, both by poor individuals and on an industrial scale by well organised criminal bunkering gangs.http://images.ibsrv.net/ibsrv/res/src:www.pprune.org/get/images/smilies/boohoo.gif


So what you are saying is that the risk factors are known, both on the small and large scale, both disorganised and organised and the problems continue? That could be considered a significant failure in addressing the risk analysis.