TSB Canada concerned that Sunwing failed to report serious incident

[rotornut]

Transportation safety watchdog raises concerns after charter airline incident | Toronto Star (http://www.thestar.com/news/canada/2013/03/09/transportation_safety_watchdog_raises_concerns_after_charter _airline_incident.html)

[Blind Squirrel]

I'd be concerned too. This sort of thing has AF 447 written all over it (though perhaps Sunwing teaches its pilots how to cope with stalls). Presumably TSB Ca. will now have to rewrite its reporting requirements.

[west lakes]

Incident occurred 2 years ago so I suspect procedures have changed!

[Spitoon]

Some very important things can be drawn from even this lightweight news report. I haven't read the full report yet but
Presumably TSB Ca. will now have to rewrite its reporting requirements.isn't one of them - the report suggests that Transport Canada's procedures were good, it's just that the operator didn't follow them.
This sort of thing has AF 447 written all over itNot sure that I see the link quite as clearly as you.

But for everyone who has to run an SMS there looks like this event highlights a very practical problem. Any SMS will require an occurrence to be assessed and certain actions to be taken depending on the results of the assessment. By its very nature, an assessment will be based on the views of a group of experts within the organisation. The problem is, what if another group - say the TSBC - would have come to a different conclusion? Does it mean that the SMS is wrong? Does it mean that the SMS has failed?

The rather glib comments reported of the airline's president don't sound like someone who's been closely involved in an in-depth review of SMS processes but, who knows, maybe the words have been presented out of context.

But for anyone who is critical of SMS, ask yourself, what do you think TC would have done if a report had been sent to them? And if it's not to your satisfaction, what would you expect them to have done? And how would have things have been different?

Ho, hum - must go and get the report now.

[PJ2]

Link to the TSB Report (http://www.tsb.gc.ca/eng/rapports-reports/aviation/2011/A11O0031/A11O0031.pdf).

[westhawk]

Thanks for posting the link to the report PJ2.

I continue to admire the work product of the Canadian TSB.

So it looks as though both members of the flight crew performed as expected during a situation with a potential for trouble by applying good airmanship and good crew coordination, bringing the flight to a relatively uneventful conclusion. Just exactly what every pro in the flying business would expect of them because that is the standard pro pilots work to meet and exceed. Even so, good job guys! :ok:

Yeah, if the PIC would have recognized the lack of correlation between what triggers required TSB reporting and the declaration of an emergency, he'd have most likely filled out a report for them too, to go along with all the others submitted following this event. From there, I find it distressing that the company SMS failed to flag this event as being worthy of further investigation and that the worldwide reporting of UAS events along with the Boeing bulletin didn't trigger a threat assessment as per the "proactive" component of the SMS concept. It's fortunate for everyone concerned that the failure mode and the circumstances under which it occurred were such that the crew were able to deal with it easily. Alter the circumstances or the failure mode and maybe the outcome is altered as well. That's where the "proactive" threat assessment is supposed to pay off isn't it? But maybe not so much if a SMS fails to identify or acknowledge a threat which is widely known throughout the industry.

So in conclusion, while SMS may be a step towards effective self assessment and safety enhancement within an organization if properly employed, glaring holes are possible if it is not. And if regulatory bodies like TC are now tasked primarily with SMS enforcement rather than direct safety inspection and enforcement, then the potential for glaring holes in the Swiss cheese model going unaddressed is more than likely until such time as the "system" is perfected and the "system" for inspecting and testing the "system" is just as perfect! Until then, perhaps it'd be wise to maintain some good old fashioned human accountability in these organizations rather than allowing an inadequately implemented "system" to fail the humans it's supposed to protect.

So before I'm accused of being an organizational management "Luddite", I'll just admit that I am. Good management is smart people doing the right things. "Systems" are just sets of tools to be used by competent individuals in order to more reliably achieve consistent results. At no time can they replace human leadership, judgment or vision. In order for a SMS to be used effectively, someone still needs to be minding the store, maintaining an awareness of the threats and ensuring they are addressed. I think that could have been done allot better here.

[J.O.]

Those are some of the wisest words ever written on this forum. :D

[telecaster]

Forgive me if I have missed something but if the monitoring pilot had been monitoring BOTH ASIs during the T/O roll, the ASI discrepancy would have been recognised earlier and no later than the 80 knot call? Surely this would warrant a RTO? This would have prevented the Bergenair and Peruvian disasters

[HyFlyer]

Westhawk......

The blatantly obvious stated in a very eloquent way. Well done Sir.


...of course, when I say blatant, what I mean is blatant to those with the experience and intelligence to realise just how obviously you are correct.

Sadly there are increasingly few who fulfil those two criteria simultaneously and are in a position to influence events....

[Rabina]

Don't like the contradiction of the NFF in the safety report and the Sunwing boss man stating that "all the parts were changed". What was the write up after landing and what did maintenance do exactly and was the Quality Manager informed? There are a bunch of parts to be replaced depending on how you interpret the quote.

[westhawk]

Thanks for the complimentary remarks HyFlyer and J.O.

Easy to say on the internet under a pseudonym, probably less so for people actually in a position to make a difference! I've worked through TQM, Six Sigma, ISO 9000, CRM, SOPs... SMS is just one more...

That's all I have to say about that! :)

[GlueBall]

Surely this would warrant a RTO? This would have prevented the Bergenair and Peruvian disasters

The Aero Peru B757 static ports were taped, but pitot systems showed correct airspeed during ground roll. There was no anomaly during ground roll. :{

[Denti]

If discovered in the high speed regime (according to boeing thats above 80kts) it is not considered to be a reason for an aborted take off.

We had something like that around 2 years ago with a crew that aborted close to V1 due to speed disagree (in this case caused by an alpha vane failure) and the aircraft subsequently left the paved surface and came to a stop on the grass. Thank god nobody was hurt and nothing was bent.

[nwesterntown]

Jet ignored order to abort landing after driverless van rolled across Pearson runway | Toronto Star (http://www.thestar.com/news/canada/2013/03/14/jet_ignored_order_to_abort_landing_after_driverless_van_roll ed_across_pearson_runway.html)

From the article.....
"Air traffic controller orders arriving jet to abort landing as empty van rolled across a runway threshold and nearby taxiway."

“The tower controller requested an inspection and an unoccupied Sunwing Airlines van was found with the engine running, engaged in gear,” according to a preliminary Transport Canada report."

[J.O.]

Westhawk:

I'm sure we could have an interesting conversation over coffee (or something stronger). I'd invite PJ2 and HyFlyer as well to bring their perspective.

It's interesting that most of the programs you've "worked through" have their roots in QA. In Canada, the regulations don't require CAR 705 (your FAR 119) certificate holders to have operational QA programs. I'm a firm believer that if they'd have been required to certify a QA program to a standard such as ISO, they'd have been well on their way to having an effective SMS.

[westhawk]

Well J.O., that would be an interesting discussion I'm sure. I'd be representing the viewpoint that these "process control" centered programs work only as well as the people on front lines make them work.

The last airplane management and charter outfit I worked for was working on SMS compliance when the economic downturn sent it to bankruptcy. Ours would have probably been better than most since it was being done with the full participation of actual line pilots like me rather than just hiring it done from an outside agency or buying a canned SMS to be implemented in typical corporate top down fashion.

I'm not going to be very surprised by failures in SMS design and implementation being associated with aviation incidents and accidents. But I still find it distressing because it's really a failure of leadership.