SMS and FRMS on way out?

[framer]

The article linked below and the comments on it paint a fairly gloomy picture of the Safety Management Systems in our industry.
Do you think NZ and Aus Airlines are running the same risk?

https://www.linkedin.com/pulse/has-sms-had-its-day-graham-hamilton

[megle2]

Framer, you better recheck link, all I get is
Sorry, this article is no longer available.

[framer]

https://www.linkedin.com/pulse/has-sms-had-its-day-graham-hamilton

[megle2]

Thanks for the link, pretty much agree, in my world the SMS got hijacked. Surprised there has been no comment so far ....

[havick]

Thanks for the link, pretty much agree, in my world the SMS got hijacked. Surprised there has been no comment so far ....

Yep, hijacked by all the snake oil salesmen auditors, various safety foundations that set their own standards (resulting in a tidy little industry for themselves ensuring compliance) etc

[CurtainTwitcher]

Though not directly addressing the concerns of SMS & FRMS a recent monograph published by the US Army addresses many of the organisational cultural issues that lead to the emasculation of control systems by the organisation itself. It's quite short at only 30 pages of actual reading LYING TO OURSELVES: DISHONESTY IN THE ARMY PROFESSION (http://www.strategicstudiesinstitute.army.mil/pdffiles/PUB1250.pdf).

The military has pressure from civilian leadership, commercial aviation has pressure from the financial leadership instead & these pressures can lead to perverse outcomes.

Fatigue is the one of the top issues facing the industry, yet Flight and Duty Time limits appear to have become rostering targets as more blood is being squeezed from the turnip.


Until we as pilots start to be honest with ourselves and no longer justify going on when we are stuffed just to get the job done, nothing will change. Lying is embedded all the way up in many types of organisation, and reading through this document, I can see many similarities and justifications that I hear frequently in my workplace, at all levels of the organisation. Not just with fatigue, but virtually every facet, operational & financial.


Behavioral ethics experts point out that people often
fail to recognize the moral components of an ethical
decision because of ethical fading. Ethical fading
occurs when the “moral colors of an ethical decision
fade into bleached hues that are void of moral implications.”13
Ethical fading allows us to convince ourselves
that considerations of right or wrong are not applicable
to decisions that in any other circumstances would
be ethical dilemmas. This is not so much because we
lack a moral foundation or adequate ethics training,
but because psychological processes and influencing
factors subtly neutralize the “ethics” from an ethical
dilemma. Ethical fading allows Army officers to transform
morally wrong behavior into socially acceptable
conduct by dimming the glare and guilt of the ethical
spotlight.

The upper echelons of the organisation seeks to insulation itself from risk by pushing down onerous regulatory & reporting requirements downwards, leading to then inability to comply, so lying and non-compliance become the norm.

(my bold)
A more recent and significant development concerning
ethical fading is the exponential growth in the
number of occasions that an officer is obliged to confirm
or verify compliance with requirements. When it
comes to requirements for units and individuals, the
Army resembles a compulsive hoarder. It is excessively
permissive in allowing the creation of new requirements,
but it is also amazingly reluctant to discard
old demands. The result is a rapid accumulation of
directives passed down, data calls sent out, and new
requirements generated by the Army. Importantly,
the Army relies on leaders to enforce compliance of
the increasing amount of requirements and to certify
the accuracy


Another interesting aspect is the morality of the leadership. At least in the military, there is the perception that morality & honesty are key personal trait. Would we find such a perception among leaders in a corporate environment?


Before addressing these questions, it should be
noted that U.S. Army officers, and members of the
military profession in general, tend to have a self-image
that bristles at any hint of dishonesty. Consider
that according to a recent survey completed by over
20,000 members of the Army, 93 percent of respon-
dents believed that the Army values of loyalty, duty,
respect, selfless service, honor, integrity, and personal
courage line up well with their own personal values.11

A believe there is a great deal of can be learnt from this information, if nothing else to clearly articulate the unease that the system creates for many of us, without quite being able to put our finger on it.

[Popgun]

^^^^^^^^^^^^^^^^^^^^^^^^^^^^

Yes.

This: Until we as pilots start to be honest with ourselves and no longer justify going on when we are stuffed just to get the job done, nothing will change. Lying is embedded all the way up in many types of organisation, and reading through this document, I can see many similarities and justifications that I hear frequently in my workplace, at all levels of the organisation. Not just with fatigue, but virtually every facet, operational & financial.


There was a time when I just 'sucked it up'.

Not any more.

PG

[PLovett]

Thank you framer for posting that article.

As someone responsible for the SMS where I work, albeit very much at the lower end of the applicability scale for an SMS, I find myself in agreement.

[73qanda]

I agree with the article.
In NZ the regulator has been following the internationally lead line of "Fatigue is one of the challenges our industry must address" for over a decade now. They say that, and look very serious when the subject comes up in conversation, yet they allow greater and greater workloads and duty times as the years roll by. I have serious concerns that there will be a major accident due to fatigue if the current trajectory isn't reversed.
They are revising the fatigue rules as we speak and could do a lot worse than simply reinstating the rules that existed in 1995..... How's that for progress?

[josephfeatherweight]

What is the industry to make of CASA's decision to delay the implementation of 48.1 until 01 May 2018, together with the requirement for an operator to submit their draft operations manual changes, or an application for a fatigue risk management system (FRMS), to CASA by 31 October 2017, whilst at the same time putting out a tender for an independent review of 48.1 - which CASA anticipates (no ****, that's the word they use...) will be complete in September 2017????? So, what are we supposed to do - come up with a plan to implement 48.1 or a full-blown FRMS (at great cost/effort) to discover that the independent review says, "Nah, 48.1 is no good..."
Honestly, WTF is supposed to be the take home message from this situation?

[beany6]

Shoot me down if you like, but in this situation I just wish CASA was a regulator. Imagine if they cancelled all 48 exemptions, then wrote a rule set for all situations. They know what's on their books - they can cover it!
Imagine, the same rule set for all RPT Pax, or for all Charter, or Freight, or survey, or meat bombs. You get the idea.
The issue here is if CASA actually regulated we would have (assuming they follow current guidance..) a much less fatigued and safer industry.
The punters may be paying more- but it would be equally more as everyone would be affected. Net result i think win win.
This is what we should be pushing for!!!

[fl610]

beany6, you are a smart person. :ok:

[CurtainTwitcher]

"It is difficult to get a man to understand something, when his salary depends upon his not understanding it!"
-- Upton Sinclair

It's worth going back to the last time fatigue was really in the spotlight in 2011, and look at what was said and by whom. The links below are to the Hansard for the Pilot training, airline safety and the Transport Safety Investigation Amendment (Incident Reports) Bill 2010.

It is worth carefully reviewing what the complete transcripts, because what has changed since then? Absolutely nothing. Nothing is likely to change, there will be more talk, and more proposals, more reports, more industry feedback, more consultation, more proposed rules. Ultimately the only thing that will be change is the B787 is likely to be granted a specific CAO 48 exemption. That is it, status quo, because the operators are extremely happy with that. Any other system will be more restrictive on them, cost them money and hence ANY changes should be avoided at all costs.

You only need to look at the verbatim quotes from the transcripts to understand that a man understands where his salary comes from...

RURAL AFFAIRS AND TRANSPORT REFERENCES COMMITTEE
18/03/2011 Pilot training, airline safety and the Transport Safety Investigation Amendment (Incident Reports) Bill 2010 (http://parlinfo.aph.gov.au/parlInfo/search/display/display.w3p;db=COMMITTEES;id=committees%2Fcommsen%2F13676%2F 0004;query=Id%3D%22emms%2Femms%2F445004%22)

Senator XENOPHON —Senator O’Brien has asked witnesses today a very pertinent question. The US Congress has passed legislation that has time limits as to whether you are working for a regulator or working for industry. There are different views on that. I think Mr Borghetti from Virgin had a slightly different view to one of his senior executives in maintenance, who thought it was not a bad thing. The civil aviation order 48 is dated 18 September 2009 and it is signed off by Mark Rossiter, who was the manager of CASA operations and air transport for the southern region. Is that your understanding?

Mr McCormick —Yes.

Senator XENOPHON —Mr Rossiter subsequently is now the head of safety at Jetstar. Are aware of when he got the position?

Mr McCormick —As you correctly point out—and thank you for that, Senator—Mark Rossiter was the manager of CASA operations air transport. On 5 October he moved from that position into the safety oversight branch. Then, on 6 December 2009, he left CASA’s employment.

Senator XENOPHON —So within less than three months he had shifted to Jetstar—is that right?

Mr McCormick —Sorry, from September to December?

Senator XENOPHON —Yes, it was a bit under three months.

Mr McCormick —Correct.

Senator XENOPHON —Does CASA have any views on that as a general rule, given what has occurred in the US? There are different views. We have people within Virgin saying something different, but is that something that causes you any concern?

Mr McCormick —Yes. If I can use the vernacular, it is not a good look. We are very cognisant of the fact that the skill set that we need in our senior managers, like Mr Rossiter and others, is very much the skill set that the industry looks for as well. So we are competing for the same people. In a place like Australia it is a very small pool. In fact, even going overseas there are a surprising number of people you know in the industry in other countries, because people tend to move around like that. We saw that earlier today with Virgin Blue’s new AOC responsible person. We are very cognisant from a governance point of view of what people are doing and any time that someone indicates to us that they are going to leave a senior position in the organisation to go somewhere else in the organisation or anywhere that would be a conflict of interest condition—

Senator XENOPHON —So when did Mr Rossiter advise you that he was going to Jetstar, do you know?

Mr McCormick —Me personally or—

Senator XENOPHON —CASA.

Mr McCormick —I do not know whether we have a record of that.

Senator XENOPHON —Presumably he would have given notice that he was leaving?

Mr McCormick —He would have given notice but when exactly he gave us that notice I am not sure.

Senator XENOPHON —Is there a requirement within CASA—or, indeed, the ATSB, Mr Dolan—that if an employee of CASA or the ATSB is going to go somewhere else for employment to advise CASA that they are going to an airline, for instance, from the date that they know that they have got that job?

Mr McCormick —From CASA’s point of view, yes, they would have to declare a conflict of interest.



Rural Affairs and Transport References Committee 31/03/2011 Pilot training, airline safety and the Transport Safety Investigation Amendment (Incident Reports) Bill 2010 (http://parlinfo.aph.gov.au/parlInfo/search/display/display.w3p;db=COMMITTEES;id=committees%2Fcommsen%2F13742%2F 0001;query=(Dataset%3Acommsen,commrep,commjnt,estimate,commb ill%20SearchCategory_Phrase%3Acommittees)%20CommitteeName_Ph rase%3A%22rural%20affairs%20and%20transport%20references%20c ommittee%22%20Responder_Phrase%3A%22mr%20joyce%22;rec=0)

Senator XENOPHON —Sure, and no doubt we will hear from you about that. I want to go to the issue of the CASA audit—and maybe Mr Rossiter can assist us on this. Jetstar out of the Darwin-Singapore flights operates to an exemption to CAO order 48, which relates to flight and duty time limitations. Mr Rossiter, at the time, on 18 September 2009, you were the manager of CASA Air Transport Operations Southern Region—correct?

Mr Rossiter —That is correct.

Senator XENOPHON —And you signed off on this exemption?

Mr Rossiter —Yes, that is correct.

Senator XENOPHON —You commenced work with Jetstar in—what was it?—December.

Mr Rossiter —15 December.

Senator XENOPHON —And just for the record, because it was raised by previous senators—I think I know the answer, but I think to be fair to you: at what stage did you apply for a job with Jetstar?

Mr Rossiter —I did not in fact have a conversation with Jetstar about any potential of even entering into a process until after the time of the signing of that exemption.

Senator XENOPHON —That was in October some time?

Mr Rossiter —The exemption was about—

Senator XENOPHON —The exemption was 18 September.

Mr Rossiter —Yes, 18 September. It was about three weeks after that that I first had a dialogue with Bruce.

Mr Buchanan —Can say a few things on this one?

Senator XENOPHON —Yes, but you can understand why I am raising it—because it was raised by some of my colleagues. I am quite satisfied with that answer, but I think it is important to put that on the record.

Mr Buchanan —But just to give a bit of context around the CAO 48 exemption: that is a document that was renewed for the fifth time by Mark. It is a document that exists for almost all airlines in the world. It is a pretty standard process it goes through. It is really to deal with the flight time duty limitations that were derived back—I don’t know—50 years ago and were not really thought through.

Senator XENOPHON —That is not quite right, though, is it, because there is a difference between international operations and those short-haul international operations? That has been one of the challenges to CAO 48.

Mr Buchanan —I am talking about the original ones. That is why you have the CAO 48 exemption which exist now, which is trying to deal with modern jet operations, RPT services and—

Senator XENOPHON —and the shorter haul international legs?

Mr Buchanan —A combination of both, yes.

Senator XENOPHON —Sure. I accept that.


Review these words in the context of the reference to Lying to Ourselves and you can see just how the system is slanted against those operating the line for a living.

[josephfeatherweight]

Shoot me down if you like, but in this situation I just wish CASA was a regulator.
I shan't be shooting you down - I agree wholeheartedly!

[framer]

Interesting.
Curtain Twitcher that article sums things up very well, thanks for posting it.
From the article
Until a candid exchange begins within the Army that includes recognition of the rampant duplic- ity, the current culture will not improve.
The word Army could easily be exchanged for 'Airline Industry'.
The rampant duplicity I am thinking of is the constant mantra of " safety is our number one priority" all the while cutting training back and increasing duty times and workload within those duties, even though fatigue has been recognised as an Industry issue which needs addressing.

[Falling Leaf]

Having studied CAO 48.1 for a Masters thesis, I can give this word of advice for all pilots out there...

NEVER EXTEND!

The rules are written already beyond the accepted scientific limits for human performance. When you extend you truly go out into no mans land.

[Derfred]

Having studied CAO 48.1 for a Masters thesis, I can give this word of advice for all pilots out there...

NEVER EXTEND!

The rules are written already beyond the accepted scientific limits for human performance. When you extend you truly go out into no mans land.

Interested in the conclusions of your thesis, Leaf.

I operate to the High Capacity CAO48 exemption, and there have been times when I've extended and felt fine, and other times when I have been well inside limits and felt fatigued.

I do feel that the exemption is not very scientific and can lead to fatigue especially when it starts to be regarded as a target rather than a limit (which seems to be a global trend). So far the only effect of FRMS in my operator is that fatique is supposed to be reported and monitored, otherwise it's business as usual. I don't think it's working very well as there appears to be a reluctance from most pilots to report for whatever reason.

Care to share more of your thesis?

[4Greens]

SMS is a cheapskate substitute for a Safety Department.

[framer]

As far as FRMS goes it seems like most of the prescriptive limits of yesteryear have been removed from the rules and individual companies are now required to demonstrate that they have a policy on how a pilot should report fatigue and that they have a 'just culture' that encourages pilots to report fatigue. They can then negotiate duty limits ( in exchange for higher salaries) that are in excess of what the old prescriptive limits used to be.
The policies make it clear that it is the pilots responsibility to call fatigued.
The responsibility used to be on the operator to ensure pilots were not rostered to exceed specific limits, those limits are now higher and the responsibility is on the pilot to report.
It is a bit like the Transport Department telling all trucking companies that they can negotiate their own speed limits with drivers so long as they write a policy on how truck drivers are to report when they get the speed wobbles.

[CurtainTwitcher]

Framer, the "slippery slope (https://yourlogicalfallacyis.com/slippery-slope)" is quite often held up as an example of a logical fallacy. However, that fallacy is related to hypothetical examples. Prior to the introduction of the exemption, that would have been the case. "No, we just need the exemption to do an XXX return, we generally won't roster to those limits"

However I believe there is now sufficient anecdotal evidence to suggest that your comment is perceptive & right on the money. It is now a competitive advantage to have the exemption, because "everyone one else is doing it". Then Jetstar CEO Bruce Buchanan make almost EXACTLY this claim in 2011:

(my highlighting)

Rural Affairs and Transport References Committee 31/03/2011 (http://parlinfo.aph.gov.au/parlInfo/search/display/display.w3p;db=COMMITTEES;id=committees%2Fcommsen%2F13742%2F 0001;query=(Dataset%3Acommsen,commrep,commjnt,estimate,commb ill%20SearchCategory_Phrase%3A%22committees%22)%20CommitteeN ame_Phrase%3A%22rural%20affairs%20and%20transport%20referenc es%20committee%22%20Questioner_Phrase%3A%22senator%20xenopho n%22;rec=2)

Mr Buchanan —But just to give a bit of context around the CAO 48 exemption: that is a document that was renewed for the fifth time by Mark. It is a document that exists for almost all airlines in the world. It is a pretty standard process it goes through. It is really to deal with the flight time duty limitations that were derived back—I don’t know—50 years ago and were not really thought through.


However, operators in many cases have little to no pilot input into the rostering processes, yet make the pilots responsible to not be fatigued. The feedback loop is rarely closed (ie identified poor rostering practices are rarely fed back for the next build. In theory this is precisely what a SMS/FRMS should do however this costs $$.

It is an asymmetric bet, virtually any change to current practice will adversely affect productivity (maximum flight hours possible per crew member) or cost (crew overnight), and so operators are highly reluctant to take any concrete step down this path. Lots of lip service, lots of paper shuffling, reports and committee's, but almost every change & will cost an operator money and thus must be avoided or delayed at all costs.

Mike Mullane - Normalisation of devianceThe Normalization of Deviance (https://www.youtube.com/playlist?list=PL0PabXaxZU03Dxoux9CEuMNY7AOYP38Iy) (NASA Challenger & Columbia Disasters )
PL0PabXaxZU03Dxoux9CEuMNY7AOYP38Iy

[Tuck Mach]

Curtain Twitcher

The amendment to CAO 48 was, following a period of consultation of three years to be introduced this year...Apparently the operators 'needed more time' and so the can was kicked down the road for another year. Interestingly CASA made no reference to the issues that led to the original re-write, it is as though they no longer existed, so the roster practices continued unabated.



Specifically changes were to be made to roster construction where extensions were ONLY granted where the occurrence under consideration had occurred in statistically less than 5% of previous extensions.
'unforeseen operational circumstance' means an unplanned exceptional event that becomes evident after the commencement of the FDP, such as unforecast weather, equipment malfunction, or air traffic delay. Thunderstorms in Sydney in summer are not 'unforeseen' and therefore roster construction would see that 11.40 day reduced so that the TOD woulds be completed by 12 hours.



Rest periods commenced in accommodation not in the taxi and pilots were to be left to rest.
Note When an FCM is interrupted during sleep opportunity, this may affect the FCM’s fitness for duty before the commencement of, or during, the next FDP.

Clearly the poor old operators would be at a financial penalty, so the responsibility for determining fatigue remains with the pilot.Pilots are on their own!..


For a pilot considering an extension, I would recommend and have in a previous life, asked the company for an indemnity in writing for any resulting accident or incident were I to extend. Any company unwilling to indemnify a FCM to step outside the legislated rules that protect the FCM and the traveling public, is not a company I will risk my licence for. Naturally as a junior pilot I was on my own. The other guy wanted to get home to bed... I expected a call from a fleet manager, but it never eventuated and having independent legal representation is always money well invested. http://cdn.pprune.org/images/smilies/evil.gif



.The Senators last year paid a little attention, but lacking a headline (and for some a camera) they moved on..CASA could quietly kick the can down the road. Union representatives were late to the party..



As a wise man once said to me, 'you are only a doormat if you lay down'. Collectively pilots do themselves a disservice. As Diane Vaughan said cultural drift occurs in which circumstances classified as “not okay” are slowly reclassified as “okay.


The problems CASA were going to address in the CAO 48.1 have not gone away http://cdn.pprune.org/images/smilies/sowee.gif

[Blitzkrieger]

There is no problem here though. If you look at it from the other side there is no credible evidence of a fatigue issue in the industry. The only ones complaining are the flight crews, and traditionally we are all overly industrialized lazy so and so's.

The airlines cry poor and CASA in their eternal spinelessness capitulate by allowing the (yet to be proven unsafe) fatigue management systems to continue. Nobody has factored the latency of an industry wide, and growing fatigue problem.

[Tuck Mach]

An astute observation Blitz...

Generally everything is alright until it isn't...

[KRUSTY 34]

A senior management pilot once remarked to me "We do not have any fatigue issues here." How can you be sure of that?" I asked. He looked me straight in the eye and said, "Because we do not have any fatigue reports!"

There it is, in a nutshell.

[73qanda]

That is it in a nutshell but why ?
The word 'fatigue' and the stigma/ feelings / opinions it conjures is part of the problem.
At one stage a year or so ago if you went to the main offices of my outfit people didn't say the word fatigue, instead they said "the F word". If you were a pilot and you went in there to visit the rostering team or pay clark, safety team, you were guaranteed to receive disparaging remarks about how little you worked and how soft you are ( complete with expletives) regardless of how friendly and cordial you were when you approached the office.
This even extended to the senior ' leaders ' (cough cough) although I admit they steered clear of the expletives. I haven't been into the main offices in a long time so I am not sure if the same culture still exists there.
Allowing a culture like that to develop and then continue to exist in an Airline is a failing of senior management. It results in pilots disengaginging from the safety process and actively reducing communication and contact with the safety department and management in general.
As long as childish management sit atop an organisation SMS and FRMS will fail quietly and steadily until the latent threats reveal themselves in a way nobody can ignore.
SMS and FRMS rely on mature and sensible leadership to work as advertised.

[Tuck Mach]

Self regulation rarely achieves anything, the finance 'industry' a case in point.
The only way to has always been effective regulation and enforcement. Australia has neither.

With management pilots working to keep the corner office and protect KPI bonuses nothing will be pushed up the line, ultimately the pilot is all alone...

[PLovett]

As Diane Vaughan said cultural drift occurs in which circumstances classified as “not okay” are slowly reclassified as “okay.

She went on to give it its name, "normalisation of deviance" and it is probably the biggest danger in aviation, that and the accountant mentality among management.