Quality Assurance and Safety Management in GA
Thread Starter
Quality Assurance and Safety Management in GA
Hi all,
Whilst this subject has been bought up a few times on this forum. I would like to open this little chestnut up again for debate/discussion.
If people want to convert the thread into a CASA bashing excercise or make reference to specific accidents, organisations or individuals I will delete the thread. We all have our own individual opinions on the regulator and this isn't the thread to vent you concerns, take them somewhere else or don't put finger/s to keyboard otherwise the thread will disappear.
To open up the forum, what do you as an individual know and think about the subject topic? This question is really directed at the people in the General Aviation side of the business and including private pilots/operators.
😎😎😎😎😎😎😎😎
Whilst this subject has been bought up a few times on this forum. I would like to open this little chestnut up again for debate/discussion.
If people want to convert the thread into a CASA bashing excercise or make reference to specific accidents, organisations or individuals I will delete the thread. We all have our own individual opinions on the regulator and this isn't the thread to vent you concerns, take them somewhere else or don't put finger/s to keyboard otherwise the thread will disappear.
To open up the forum, what do you as an individual know and think about the subject topic? This question is really directed at the people in the General Aviation side of the business and including private pilots/operators.
😎😎😎😎😎😎😎😎
What I THINK, is that - if properly applied - Safety Management and Quality Assurance should be beneficial in any industry.
What I KNOW is that many GA operators treat it as a CASA mandated embuggerance and only pay lip service to it.
Operators put touchy-feely statements in their manuals about how committed the CEO and everyone else is to it. Some even have programs to electronically track every minor incident from initial report to closure. Unfortunately some of these incidents are so minor, and the acquittal process so painful, that they do waste people's time with meetings, investigations and supposed cures. The result is that staff soon regard it as an embuggerance just as much as the CEO. Staff go from initial enthusiasm to report every pissant event to eventually not bothering with the more serious stuff.
CEOs and bean counters are rarely ever willing to actually DO anything if it will take time, effort or money. Which reinforces the staff's jaundiced view.
What I KNOW is that many GA operators treat it as a CASA mandated embuggerance and only pay lip service to it.
Operators put touchy-feely statements in their manuals about how committed the CEO and everyone else is to it. Some even have programs to electronically track every minor incident from initial report to closure. Unfortunately some of these incidents are so minor, and the acquittal process so painful, that they do waste people's time with meetings, investigations and supposed cures. The result is that staff soon regard it as an embuggerance just as much as the CEO. Staff go from initial enthusiasm to report every pissant event to eventually not bothering with the more serious stuff.
CEOs and bean counters are rarely ever willing to actually DO anything if it will take time, effort or money. Which reinforces the staff's jaundiced view.
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Qualified to comment for once!
I run an engineering company. We recently went to the trouble to implement a combined QMS and OHSMS with a "clean sheet"approach.
I would like to report I have 100% engagement (myself included) but I can't. That being said, there is a far greater awareness and we are moving to better adopt the concepts.
What I did do was choose a company to help us implement this who has an aviation background. In fact while they do airlines and foreign ones, they also do aviation support industries.
Why did I take a aviation supper into industrial engineering? Because they really understand how a QMS and SMS (OHSMS) goes hand in hand with a healthy business review and change management culture.
What I have learned is that everyone needs to "own" the system, from the subcontractor to frontline employees, but most importantly the CEO/MD/GM folk.
The down side is somebody has to be responsible for keeping it up and current. It is not a book that you put on the shelf. Everyone has to have it in their blood. From better staff training to suppliers to "office lighting" need to be looked at on a regular basis to see what can be improved, and all of the focus is on the customer. Be they internal or external.
As for a PVT GA operation the same things apply ……. it is just a culture of how we do things.
I am very much against the OHS folk that make it impossible to do anything, but a good QMS&SMS combined is a business improvement tool. The secret is a balance. Many good airlines are very good at this. Some are not. The real secret is weeding out or managing the risks associated with latent risk. It can or may always exist, it is just how you work with it daily.
I am happy to recommend via PM the people we used.
I would like to report I have 100% engagement (myself included) but I can't. That being said, there is a far greater awareness and we are moving to better adopt the concepts.
What I did do was choose a company to help us implement this who has an aviation background. In fact while they do airlines and foreign ones, they also do aviation support industries.
Why did I take a aviation supper into industrial engineering? Because they really understand how a QMS and SMS (OHSMS) goes hand in hand with a healthy business review and change management culture.
What I have learned is that everyone needs to "own" the system, from the subcontractor to frontline employees, but most importantly the CEO/MD/GM folk.
The down side is somebody has to be responsible for keeping it up and current. It is not a book that you put on the shelf. Everyone has to have it in their blood. From better staff training to suppliers to "office lighting" need to be looked at on a regular basis to see what can be improved, and all of the focus is on the customer. Be they internal or external.
As for a PVT GA operation the same things apply ……. it is just a culture of how we do things.
I am very much against the OHS folk that make it impossible to do anything, but a good QMS&SMS combined is a business improvement tool. The secret is a balance. Many good airlines are very good at this. Some are not. The real secret is weeding out or managing the risks associated with latent risk. It can or may always exist, it is just how you work with it daily.
I am happy to recommend via PM the people we used.
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Jaba,
Your post is full of pearls of wisdom. It is logical to increase the efficiency of a company or Organisation to adopt the methods described. Your Organisation will benefit from what you have put in place, I am sure.
One thing that perhaps you have in place is a blame free culture. It is my experience that in the event of a situation arising where there has been a deviation from SOP's, for example, the problem can be identified and resolved in a timely manner if it is known that the penalty, if there is one, is equally distributed.
Nkosi
Your post is full of pearls of wisdom. It is logical to increase the efficiency of a company or Organisation to adopt the methods described. Your Organisation will benefit from what you have put in place, I am sure.
One thing that perhaps you have in place is a blame free culture. It is my experience that in the event of a situation arising where there has been a deviation from SOP's, for example, the problem can be identified and resolved in a timely manner if it is known that the penalty, if there is one, is equally distributed.
Nkosi
SMS
I changed from one GA company with an excellent SMS to another with none
When discussing the SMS with the new Boss he bluntly said its just a pilots way of thinking up another excuse not to go flying. Discussion terminated and not raised again. Of course he also bleated that safety was their first priority. It was a surprise to me that a fairly large company could boast about their safety but totally trash the concept of a SMS
QA
Been there too but after a short improvement in paperwork drowned in its own compliance
I changed from one GA company with an excellent SMS to another with none
When discussing the SMS with the new Boss he bluntly said its just a pilots way of thinking up another excuse not to go flying. Discussion terminated and not raised again. Of course he also bleated that safety was their first priority. It was a surprise to me that a fairly large company could boast about their safety but totally trash the concept of a SMS
QA
Been there too but after a short improvement in paperwork drowned in its own compliance
Last edited by megle2; 19th Jan 2015 at 05:20. Reason: QA comment
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The secret is to not drown in paperwork. We have not set up like that.
We have policy and procedure to follow, and only a few times is there extra paperwork.
We have policy and procedure to follow, and only a few times is there extra paperwork.
It's pretty hard to get clarification on a 100% "anonymous" report.
In my experience a lot of "anonymous" reports (no, no, not all) are less about real company organisational issues, and more about tearing down a workmate or a contractor or deflecting blame for your own f*ckups.
There is a real art to having a JUST culture - a blameless culture will allow the dead****s to get away with murder by simply lodging a report - and a truly just culture will almost obviate the need for "anonymous" reports.
I was employed as safety manager at an organisation where I was told "We have bought a SMS, it's called Air Maestro"
While Air Maestro is not a "SMS" and it is not a cure-all, it does permit smaller organisations a structure around which they can *build* an SMS and put a lot of compliance management tools in place.
A work in progress...
In my experience a lot of "anonymous" reports (no, no, not all) are less about real company organisational issues, and more about tearing down a workmate or a contractor or deflecting blame for your own f*ckups.
There is a real art to having a JUST culture - a blameless culture will allow the dead****s to get away with murder by simply lodging a report - and a truly just culture will almost obviate the need for "anonymous" reports.
I was employed as safety manager at an organisation where I was told "We have bought a SMS, it's called Air Maestro"
While Air Maestro is not a "SMS" and it is not a cure-all, it does permit smaller organisations a structure around which they can *build* an SMS and put a lot of compliance management tools in place.
A work in progress...
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Just culture is difficult to describe but easy to "do".
If you think of a simple example. I dial the wrong phone number. That is an innocent mistake and not intentional so while some kind of non conformance is experienced, I don't cop a reaming or bullied, but we look into why the mistake was made. Maybe poor records, poor lighting or maybe i am a bit dyslexic. (yr right for example).
Deliberately busting minima's or overloading, is another matter. This is serious and I ought to get a reaming of sorts, some retraining, and if I do it again a DCM.
A Just culture is NOT a no blame culture, if you are a deliberate bad boy, then you should be stopped either the easy way or the hard way. A Just culture is one where EVERYONE is held to account for their actions but not punished for genuine and honest mistakes. And open self reporting is encouraged.
Maybe I should change industries?
No jaba…..snap out of it.
If somebody can sum that up better than I have please go for it. I do not claim to be a guru at it.
If you think of a simple example. I dial the wrong phone number. That is an innocent mistake and not intentional so while some kind of non conformance is experienced, I don't cop a reaming or bullied, but we look into why the mistake was made. Maybe poor records, poor lighting or maybe i am a bit dyslexic. (yr right for example).
Deliberately busting minima's or overloading, is another matter. This is serious and I ought to get a reaming of sorts, some retraining, and if I do it again a DCM.
A Just culture is NOT a no blame culture, if you are a deliberate bad boy, then you should be stopped either the easy way or the hard way. A Just culture is one where EVERYONE is held to account for their actions but not punished for genuine and honest mistakes. And open self reporting is encouraged.
Maybe I should change industries?
No jaba…..snap out of it.
If somebody can sum that up better than I have please go for it. I do not claim to be a guru at it.
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OH&S (SMS) and QA considered in the one discussion?
The last company I worked for, SMS was discussed in detail at every monthly staff meeting. QA was only addressed when people weren't ticking the boxes on the QA Sheet. Crossing an item out to say you did not do it (or that it was irrelevant to the work performed) was frowned upon. Putting something bad in your SMS Diary was met with enthusiasm and positive action.
QA, in my industry...and probably the same for AME's means everyone is ticking the boxes to say they did that item. It has little bearing on the quality of the actual work performed.
SMS, in my industry means, everyone is looking out for each other, to make sure we all go home each night, and with all relevant body parts still attatched.
SMS is FAR more important than QA!
The last company I worked for, SMS was discussed in detail at every monthly staff meeting. QA was only addressed when people weren't ticking the boxes on the QA Sheet. Crossing an item out to say you did not do it (or that it was irrelevant to the work performed) was frowned upon. Putting something bad in your SMS Diary was met with enthusiasm and positive action.
QA, in my industry...and probably the same for AME's means everyone is ticking the boxes to say they did that item. It has little bearing on the quality of the actual work performed.
SMS, in my industry means, everyone is looking out for each other, to make sure we all go home each night, and with all relevant body parts still attatched.
SMS is FAR more important than QA!
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What Jaba said.
I am in the process of becoming the Safety Manager for the company where I previously worked as a pilot. It has been an interesting learning curve and I'm still on that curve.
The principles of safety are still the same as they have always been, there is nothing new, its just that they have been formalised and documented. Yes, with a multi-faceted GA company it is a bug-bear of keeping the bookwork current but I can see the benefits of documenting what happens and in taking the whole process beyond being reactive and in trying to be ahead of the game.
The trick with GA is to apply the principles without bogging the company down in unnecessary paperwork and procedures. The "just culture" is really a no-brainer. Mistakes happen because we are human and should not be punished. Violations are deliberate and that is a whole different ball game.
I am in the process of becoming the Safety Manager for the company where I previously worked as a pilot. It has been an interesting learning curve and I'm still on that curve.
The principles of safety are still the same as they have always been, there is nothing new, its just that they have been formalised and documented. Yes, with a multi-faceted GA company it is a bug-bear of keeping the bookwork current but I can see the benefits of documenting what happens and in taking the whole process beyond being reactive and in trying to be ahead of the game.
The trick with GA is to apply the principles without bogging the company down in unnecessary paperwork and procedures. The "just culture" is really a no-brainer. Mistakes happen because we are human and should not be punished. Violations are deliberate and that is a whole different ball game.
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I have been associated with QMS and SMS programs for over 20 years. I use a cricket ball as an analogy for an integrated SMS where the quality system provides the management systems and oversight with the hard outercasing being those elements of an SMS including operational and organisational risk management, a just safety culture and reporting system. The following is the immunity policy I use for a Just reporting culture:
Information for Safety purposes
Information gathered through safety system will be used only for safety purposes, not for personal performance review.
Focus on solutions Safety analysis and corrective action will focus on a holistic assessment of the latent, workplace and active fail points identified in the hazard or event. It will seek solutions, not scapegoats.
Counselling for improvement Where individual safety counselling is required, it will be done to secure required safety improvement, not to punish or blame any individual.
No record on personal file Where individual safety counselling is required, it will not form part of that person’s company employee records or file.
Voluntary submission The above conditions are contingent on the voluntary submission of safety information as soon as reasonably practical.
Conditions of immunity In the case of a hazardous event, the above conditions will be honoured by the company providing the event was not:
• The result of reckless behaviour
• A wilful and deliberate breach of regulatory guidance
• Part of a pattern of previously identified unprofessional,
incompetent or unacceptable conduct.
Above all the success of an SMS/QMS requires total management commitment and walking the talk and all employee engagement and buy in.
PM me if you would like any further information
Information for Safety purposes
Information gathered through safety system will be used only for safety purposes, not for personal performance review.
Focus on solutions Safety analysis and corrective action will focus on a holistic assessment of the latent, workplace and active fail points identified in the hazard or event. It will seek solutions, not scapegoats.
Counselling for improvement Where individual safety counselling is required, it will be done to secure required safety improvement, not to punish or blame any individual.
No record on personal file Where individual safety counselling is required, it will not form part of that person’s company employee records or file.
Voluntary submission The above conditions are contingent on the voluntary submission of safety information as soon as reasonably practical.
Conditions of immunity In the case of a hazardous event, the above conditions will be honoured by the company providing the event was not:
• The result of reckless behaviour
• A wilful and deliberate breach of regulatory guidance
• Part of a pattern of previously identified unprofessional,
incompetent or unacceptable conduct.
Above all the success of an SMS/QMS requires total management commitment and walking the talk and all employee engagement and buy in.
PM me if you would like any further information
All GA operators have a Safety Management System.
All GA Safety Management Systems I have seen appear to reach their limit with discussions surrounding mitigation methods for insect bites, back injury prevention and the hot water temperature at sink.
A proactive SMS in the world of piston ops should result in progressively retro fitting Engine Management Systems, trend logging and training the crews along the lines of Advanced Engine Management.
A reactive system denies the users the information to predict adversity and avoid it, be it absence of radar for night IFR ops or an EMS for engine health. If you are in GA piston ops how many operators do you know who fit the proactive scenario as opposed to the reactive scenario.
I would be impressed if I ever saw a contracted safety auditor identify these items. Typically they seem only interested in seeing a paper work trail. But then again the purpose of the exercise is the exchange of money for the appropriate ticks and an ongoing business relationship.
Here is a sad but true story of SMS.
An operator now since sold, had 3 accidents in short succession, all 3 serious but without injury miraculously. Managements reaction was to bring in a safety system auditor with a national presence and a lot of "heart" for the job.
After an appropriate amount of money was spent (charged) their finding.....and this is truly gold logie stuff...
A more sophisticated comprehensive check list system was identified as being the solution, so the simple and effective military Flight Mate scroll check system was removed from each aircraft. In its place a multi thousand dollar (not including fitment) electronic system with both voice audio and large LCD text display for each individual check was mounted into each aircraft with yoke button advancement through each check, very astronautic indeed.
This large solid alloy rectangular contraption with sharp corners was mounted into the Shrikes at forehead height effectively creating a blind spot and a near certain death scenario should your head impact with it in an accident.
Shortly after installation on a repositioning flight of some duration I counted the number of individual checks incorporated into this state of the art system, there were some 340 individual checks. A simple circuit required 14 minutes to advance and hear all the required checks for the circuit. The complete scrolling of checks including the emergency check list took about 45 minutes to scroll through.
If you have read this far perhaps some of you may be shaking your head and the ineptitude and ludicrousy of all this. Well save some energy for this....the coup de gras....
The audio and text in one of these bizzare check list systems installed into one of the Shrikes was for a King Air.
The outcome to all this was that crews promptly stopped using the new system as it was completely impractical and reverted in the absence of any other functional checklist to individual flow scans and mnemonics. The bottom line likely in the range of 100k plus headaches for engineering while they stopped routine maintenance to deal with the complex fitment process.
Sheer brilliance, a multi national company with a multi billion turnover and 2 dedicated Safety Officers for that particular base operating 9 aircraft. Advised by one of Australia's leading aviation safety auditors, what could possibly go wrong.
A division of that same multi national is at present out there looking for MH370.
All GA Safety Management Systems I have seen appear to reach their limit with discussions surrounding mitigation methods for insect bites, back injury prevention and the hot water temperature at sink.
A proactive SMS in the world of piston ops should result in progressively retro fitting Engine Management Systems, trend logging and training the crews along the lines of Advanced Engine Management.
A reactive system denies the users the information to predict adversity and avoid it, be it absence of radar for night IFR ops or an EMS for engine health. If you are in GA piston ops how many operators do you know who fit the proactive scenario as opposed to the reactive scenario.
I would be impressed if I ever saw a contracted safety auditor identify these items. Typically they seem only interested in seeing a paper work trail. But then again the purpose of the exercise is the exchange of money for the appropriate ticks and an ongoing business relationship.
Here is a sad but true story of SMS.
An operator now since sold, had 3 accidents in short succession, all 3 serious but without injury miraculously. Managements reaction was to bring in a safety system auditor with a national presence and a lot of "heart" for the job.
After an appropriate amount of money was spent (charged) their finding.....and this is truly gold logie stuff...
A more sophisticated comprehensive check list system was identified as being the solution, so the simple and effective military Flight Mate scroll check system was removed from each aircraft. In its place a multi thousand dollar (not including fitment) electronic system with both voice audio and large LCD text display for each individual check was mounted into each aircraft with yoke button advancement through each check, very astronautic indeed.
This large solid alloy rectangular contraption with sharp corners was mounted into the Shrikes at forehead height effectively creating a blind spot and a near certain death scenario should your head impact with it in an accident.
Shortly after installation on a repositioning flight of some duration I counted the number of individual checks incorporated into this state of the art system, there were some 340 individual checks. A simple circuit required 14 minutes to advance and hear all the required checks for the circuit. The complete scrolling of checks including the emergency check list took about 45 minutes to scroll through.
If you have read this far perhaps some of you may be shaking your head and the ineptitude and ludicrousy of all this. Well save some energy for this....the coup de gras....
The audio and text in one of these bizzare check list systems installed into one of the Shrikes was for a King Air.
The outcome to all this was that crews promptly stopped using the new system as it was completely impractical and reverted in the absence of any other functional checklist to individual flow scans and mnemonics. The bottom line likely in the range of 100k plus headaches for engineering while they stopped routine maintenance to deal with the complex fitment process.
Sheer brilliance, a multi national company with a multi billion turnover and 2 dedicated Safety Officers for that particular base operating 9 aircraft. Advised by one of Australia's leading aviation safety auditors, what could possibly go wrong.
A division of that same multi national is at present out there looking for MH370.
Last edited by Obidiah; 25th Jan 2015 at 04:42.
Thread Starter
Good debate and thanks Jaba and others for your constructive input.
Whilst "Just Culture" is a key element of any SMS there are also other important elements such as SMS being built into the organisation's everyday business operations.
The biggest hurdle that I see (and this is the reason why i created this thread) is that a large majority of people in General Aviation are reluctant for any change - especially if they have been in the business for years and haven't been involved in an accident. In retrospect I believe it would be fair to say that just about everyone involved in aviation do actually have a form of SMS in place and have done for years without even realising it. Examples such as defect reporting, pre-flight planning, fuel usage management and flight following are just a few elements of an aviation SMS that I'm sure most small GA organisations are complying with on a daily basis.
One of the main issues in my opinion that is causing grief for people is that the terminology being applied to the new regulations can be a little confusing to understand. The reason behind the terminology changes are due to CASA trying to align the new legislation with the ICAO requirements. A classic example of this is the term "Operations Manual" has now been changed (in most situations) to now being called an "Exposition".
Whilst "Just Culture" is a key element of any SMS there are also other important elements such as SMS being built into the organisation's everyday business operations.
The biggest hurdle that I see (and this is the reason why i created this thread) is that a large majority of people in General Aviation are reluctant for any change - especially if they have been in the business for years and haven't been involved in an accident. In retrospect I believe it would be fair to say that just about everyone involved in aviation do actually have a form of SMS in place and have done for years without even realising it. Examples such as defect reporting, pre-flight planning, fuel usage management and flight following are just a few elements of an aviation SMS that I'm sure most small GA organisations are complying with on a daily basis.
One of the main issues in my opinion that is causing grief for people is that the terminology being applied to the new regulations can be a little confusing to understand. The reason behind the terminology changes are due to CASA trying to align the new legislation with the ICAO requirements. A classic example of this is the term "Operations Manual" has now been changed (in most situations) to now being called an "Exposition".
