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Safety Management System Failure - Australia

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Old 23rd Oct 2005, 11:45
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Lets get on with discussing the systemic failures and lack of project management of Oz Airspace planning and implementation. I don't always agree with Dicks ideas and arguments but it is those ideas and arguments that have led us so far to this point. Whether we like the man or not is irrelevant to the discussion, it is his ideas we are (or should be ) discussing and not his glasses or some other irrelevant personal issue.

I am not defending him, but whilst we discuss him, we are not discussing the current important matter ie " Oz Airspace planning and implementation"


VT
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Old 23rd Oct 2005, 11:59
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Having worked and played in Oz aviation pre- and post- Mr Smith's tenure, three thoughts come to mind -

(a) the then Regulator was more paternalistic than rational thought might consider necessary ... so it might be said that there was a need for a bit of a shake up.

(b) as with many of these sorts of events, the swinging of the pendulum analogy is appropriate

(c) the change to make the Regulator directly and functionally accountable to the Minister caused a great many changes to occur ... but I prefer to keep my views as to whether this might have been a good thing to myself. One needs to keep in mind that, in the days of Donald George, the Head was where the buck stopped .. and I am sure that that probably caused eyebrows to be raised occasionally at political level.

Please don't take my comments either to show support for, or antipathy to Mr Smith's activities. My interest is only to show that someone, such as Mr Smith, was needed for a time to give the old guard a little shake up.

Last edited by john_tullamarine; 24th Oct 2005 at 06:34.
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Old 24th Oct 2005, 03:29
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Wings

Not at all and a very succint summing up indeed.

John_tullamarine

Quite so

That was then and we knew how to work the system.

It was British Post Colonial Australia and across the industry we knew how to "Yes Minister" as well as any Humphrey Appleby.

It would have been easy for any sort of Smith to demonise the system, but at least it worked and had embedded in it many years of experience derived in the unique social, environmental and political context of Australia.

There is no doubt change was in the wind, maybe Mr Smith accelerated it, if indeed he did, then, it was at a terrible cost.

The trail of destruction, the destroyed careers of many highly experienced and competent individuals and the "export" of a significant part of the intelectual property carried in the heads of these people, has left Australia close to being mortally wounded.

Simply, that many internationally respected and highly experienced people can't be wrong.

Any Smith would have had the support of the "chattering classes", but I do not recall the "industry at large", at least the part that was the backbone, he was determined to "save", clamouring for his personal support.

One has to fully understand the events, in the contexts of the times to fully understand the phenomenon.

Overall we are waaaaaaaay past the "time" to which Wings alludes.
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Old 24th Oct 2005, 06:13
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d'accord .
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Old 25th Oct 2005, 04:41
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Management Pt 2

Reading threads of pilots having to write letters to management justifying why they loaded extra fuel strikes a chord that the greatest impediment to further lowering of the accident rate lies in management practices external to the cockpit. One thread quipped that management are the ones who should now be attending CRM courses, and it is hard to argue against. I wonder if marketing have to justify by way of a letter to some bean counter as to why a particular flight departed with less than a profit-making load.

The latest Flight Safety Australia magazine has an article by a pilot under overbearing management pressure as to how a flight was to be conducted Mareeba to Horn Island – a GA operator, and probably a hand to mouth one as a lot are. The article gave me pause to reflect on my own experiences. Let me first say that I’m not out to cast stones or point fingers as I’ve personally made all the stuff ups its possible to make and still be a member of the human race. I merely give it for what it may be worth.

I spent a good part of my aviation career flying offshore for an operation owned and staffed by an oil company (read very deep pockets – not your fly by night GA operation). When I started the pilots were on an award and the manager was staff and as such was subject to a yearly appraisal, which then flowed on as to what his salary might be for the next twelve months. At that time I was flying a Bell 205 and although it was a VFR operation that was in name only. It was nothing to cruise at five hundred feet IMC in cloud, torrential rain, penetrate line squalls or frontal systems, snow or anything else mother nature came up with. Coming home from offshore was simplified if it was strati form type cloud, rather than sweat 35 minutes of IMC hand flying with no stab system we would climb to on top (generally 3,000) and home on the “bubble” in the cloud caused by the heat from a industrial complex located next to the heliport (Alex Henshaw approach). No approach aids were available so approaching the bubble” you let down through the muck till becoming visual (flat terrain so nothing to dodge/hit). Going outbound to a platform (we did have a coffee grinder ADF, but never worked when you needed it most) we navved by watch and compass – remarkable how good you became estimating groundspeed and drift through the chin bubble. In poor conditions it was often only because of a timely tap on the shoulder by a passenger (extra set of eyes) who appreciated the difficulties that you found your destination.

So why did we operate as we did? The aircraft were state of the art for the time in question operating in a geographical area with rapidly changing climatic conditions – blink and the weather could go from CAVOK to where you couldn’t see the water from the platform helideck (100 feet AMSL). They were also pioneering days in that the oil field was in the construction phase and early days of production. The CEO was the original 14 year old mail room boy who worked his way up and knew almost every one of a vast work force by name and thought nothing of passing the time in the crew room to get an insight into how thinks were going – as he did with all sections of the work force. In short, you were an appreciated member of the work force – to the extent that you found your award salary increased because the CEO was of the mind that because group X got a pay rise your group should get one as well.

Then came the rot. A new breed of managers moved in when the oil field was a mature business – all with an MBA in the pocket and focussed entirely on the bottom line. It’s an extreme event for senior and middle level management to venture out of the office – certainly not to talk to the hoi polloi. Every year bought forth-another announcement of an X% cut to the budget – but more expected in productivity. A budget is no longer a tool of management but an impediment to management. The pilots were made staff (willingly I might add mostly at the time) and subject to the appraisal process for salary increases. We then had a manager stand in front of the pilot group and tell us we had it too good because nobody had ever left. Nor did the company honour its undertakings with respect to how the staff system operated (surprise, surprise). Seeing the writing on the wall one of the pilots took to asking questions as to why we kept putting our a55es in a sling vis a vis compliance with the regs when the ops manual stated compliance is mandatory and we had come a long way in terms of equipment capability (autopilots, GPS, radar, no longer single pilot etc) but still operating as if we were still flogging a 205 single pilot. His appraisal for one year from the chief pilot stated “bloggs has out of perspective concerns”. Explanations to various question ranged over “you don’t need to provide for an alternate as the chance of any thing going wrong are infinitesimally small – if we followed the regs we wouldn’t do anything – you will do what you are told – you worry too much – do you want to shut the operation down”. Management seems to have lost sight of the fact that all the regs begin by saying “The PIC (is responsible, shall, will – insert word of choice).” We had fallen into the trap that this was the accepted culture (culture someone defined as its what you do when no one is looking). Was it brought about by a lack of regulatory over sight, close personal relation ship between managers and regulator? A theory I subscribe to is “The Normalisation of Deviance” (do a Google – I wont go into it here). Because the operation had never had an accident or major incident there seemed to be a belief that every thing was AOK. The good fortune had more to do with outstanding maintenance, nothing higher than 225 feet to run into (platform), experienced pilots, well equip aircraft and a healthy dose of luck in that major emergencies always took place in benign circumstances. Because the pilot was not able to push forward on the issues in house he bailed out and is of the thought that perhaps because of his approach to the authorities some ten months ago it may have given some impetus to the REPCON. As to what effect on the company, if any, is clouded by “we can’t tell you” from the authorities.

Off thread a little, but we as aviators I think are often our own worse enemies in as much as judgements we make about the errors made by fellow practitioners (the recent high speed 737 approach comes to mind – see quote of Mike Mullane below). Some of us put ourselves on rather high pedestals, and although the cockpit crew is the last line of defence for every body’s mistakes, none are supermen. Peter Garrison in “Pilot Error” wrote “Again and again, pilots are found to show little sympathy for their colleagues who are hurt or die; some simplifying explanation is immediately hit upon to reassure the others that the same fate will not be theirs”. People are people, fallible despite their best intentions, abilities, training and efforts. There can never be too much humility among those who fly. Following is a selection of quotes apropos I thinks to lessons management could well learn.

What caused both Shuttle occurrences was a confluence of deficiencies in human behaviour; normalisation of deviance, uncritical acceptance of easily verifiable erroneous assumptions, denial, willing suspension of disbelief, rejection of scientific proof, and unalterable commitment to the belief that "it can’t happen here."

Astronaut Mike Mullane commenting on the Shuttle accidents, "NASA managers, engineers and astronauts are not robots. They bring their humanity (egos, ambitions, fears, relationship issues, etc) to work just as everybody else.”

From ‘The Naked Pilot’ by David Beaty
Firstly, there should be an acknowledgment that if and when the pilot makes a mistake, his will probably be the final enabling one at the apex of a whole pyramid of errors down below. This will, in turn, take the heat off investigations – the ‘we intend to find and punish the culprit’ syndrome. Only then can the pilots come forward and admit to mistakes they made or nearly made, and the reasons why can be coolly analysed and lessons learned. [Page 285]

Professor Reason in Human Error (1990) distinguishes between active error, the effects of which are felt almost immediately, and latent error, the adverse consequences of which may lie dormant within the system for a long time. This can clearly be seen in aviation, where pilots at the sharp end make an active error, while latent error lies behind the lines within the management support system. Many of these are already there awaiting a trigger, usually supplied by the pilot. ‘There is a growing awareness within the human reliability community that attempts to discover and neutralise those latent failures will have a greater beneficial effect upon system safety than will localised efforts to minimise active errors.’

As long ago as 1980, Stanley Roscoe wrote that:

The tenacious retention of ‘pilot error’ as an accident ‘cause factor’ by governmental agencies, equipment manufacturers and airline management, and even by pilot unions indirectly, is a subtle manifestation of the apparently natural human inclination to narrow the responsibility for tragic events that receive wide public attention. If the responsibility can be isolated to the momentary defection of a single individual, the captain in command, then other members of the aviation community remain untarnished. The unions briefly acknowledge the inescapable conclusion that pilots can make errors and thereby gain a few bargaining points with management for the future.

Everyone else, including other crewmembers, remains clean. The airline accepts the inevitable financial liability for losses but escapes blame for inadequate training programs or procedural indoctrination. Equipment manufacturers avoid product liability for faulty design,. Regulatory agencies are not criticised for approving an unsafe operation, failing to invoke obviously needed precautionary restrictions, or, worse yet, contributing directly by injudicious control or unsafe clearance authorisations. Only the pilot who made the ‘error’ and his family suffer, and their suffering may be assuaged by a liberal pension in exchange for his quiet early retirement – in the event that he was fortunate enough to survive the accident

Yet it is only recently that very dubious management malpractices are being identified and their contribution to accidents given sufficient weight. For though the pilot’s actions are at the tip of the iceberg of responsibility, many other people have had a hand in it – faceless people in aircraft design and manufacture, in computer technology and software, in maintenance, in flying control, in accounts departments and in the corridors of power. But the pilot is available and identifiable. [Page 221/222]

An incident/accident is generally the result of active failures (pull the trigger) on the part of the cockpit crew, but the stage may have been set by the latent failures (load the gun and put the safety catch to ‘fire’) introduced by others (management practices, certification standards, aircraft design, software, ergonomics etc etc). Put another way, the cockpit crew is the last line of defence for every ones mistakes. As good as you may think yourself, none of us are all knowing.

Capt. Fenwick of ALPA has cautioned. "Pilots will be judged against the perfect pilot flying the perfect airplane on the perfect flight. We all know that no such thing exists.”

PS Thanks for putting up with the rant if you got this far.
PPS One word described our company safety program under the new management style – punitive.
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Old 25th Oct 2005, 04:42
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Management Pt1

CASA Media Release - Thursday, 2 September 2004 Aviation management needs closer scrutiny
A closer examination of management and management systems in aviation organisations is a key to further improving air safety. Management systems should be proactively targeted by both accident investigators and the safety regulator. The call for in-depth scrutiny of the management of airlines and other air operators was made by CASA chief executive officer, Bruce Byron, in a speech to the International Society of Air Safety Investigators.
Mr Byron said accident investigators and CASA may need to bring in people with management expertise even if they have no aviation experience. “Our people have a lot of good technical skills and experience, and so do you,” Mr Byron told the accident investigators. “But where do we stand when we push the envelope beyond the immediate technical issues associated with an accident and start to get involved in an organisation’s management processes.
“In my experience with large organisations, particularly where they have a duty of care for the safety of people, I have seen evidence of potential deficiencies in management decision-making. “This is nothing new, but we need to be confident we have the skills to objectively review management processes and procedures that may be somewhat removed from the technical fields with which we are most comfortable. “We need to be proactive in targeting, for example, management systems.” Mr Byron said scrutiny of management was a real issue for CASA as new regulations were being drafted that would require the implementation of safety management systems by air operators. He told the accident investigators another important issue was making sure the results of crash investigations are actively used to improve safety. “Most importantly, it is vital that all the good material that you produce does not fall into some electronic black hole or database – without being used by the decision makers in the system. “Your information needs to be constantly trended, assessed and compared with data from other sources – not every decade, not every year, but all the time.”
A full copy of Mr Bryon’s speech is at: casa.gov.au/corporat/ceo/04-08-31.htm
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Old 25th Oct 2005, 20:33
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Ahhh Megan, you worked for Esso too did you?

I lasted two years and I wasn't even a pilot.
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Old 26th Oct 2005, 01:15
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Flight Safety First - Cost Last.

Yes business operates for profit. Airlines run very costly businesses. So to improve the bottom line do you:

1) Cut wages,
2) Reduces levels of maintenance,
3) Push flight crews to fly longer hours at less pay.
4) All of the above.

Most airlines do all of the above and more. Bringing in new rules to reduce human oversight of flight operations is not safe. Why change the system? Why should aircraft be able to join on base. You need oversight by radar to control aircraft in a safe manor. Having aircraft fly a pattern before landing enables approach/tower to better control flights. It allows for safe spacing of differing types of aircraft, rather than a cessna 152 and boeing 737-800 fighting it out at the point of joining base.

There should always be separation of light aircraft from the heavy. Having an 'open skies' policy and leaving it up to the pilots is not safe.

The flying public should know that below 10,000ft under this new system it's every pilot for him/her self. It is a cloudy day, with cloud bases around 7,000 your decending at 250kts through fl07 in a 737 and out pops a c152 at 1 mile. No TCAS warning, no radar control for separation, and no requirement for the c152 to call to advise he/she is entering that area, is that safe?
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Old 30th Oct 2005, 12:47
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Cutting wages does not increase productivity.

It gives you the same (if you are lucky) productivity, or (normally) less productivity.

It just reduces the cost base.

It is one of the great myth-management tacthics.

As an experiement - cut your wages cost back to zero - see how productive that makes you.

Or, a case in point around my neck of the woods, reduce the cost base by 10%. (effective pay cut). And watch your productivity soar - backwards (funnily enough, same line graph as morale).

What do they teach in MBA school these days?
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Old 30th Oct 2005, 18:25
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Please go easy on the MBA thing, it might fly in the U.S. but not elsewhere.

The measurement of "profit" itself is problematic.

What you are trying to do is maximise the value of the firm in the long term.

The correct methods of doing this are to focus on long term profitability, which is why smart companies are moving away from "incentivising" managers with short time horizon driven bonuses.

The ultimate measures are return on shareholders funds as well as return on capital employed (which includes debt), the targets for both of these are adjusted for the riskiness (beta) of the associated industry.

The techniques for achieving a good return are:

1. Eliminating waste in all its forms.

2. Doing more with less - finding more customers and also requiring less capital or debt.

"Cost cutting" can sometimes be necessary if the pax are not there to pay peoples wages.
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Old 31st Oct 2005, 14:11
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You are, of course, exactly right, Sunfish - I'm glad to hear there are still such smart companies in Oz, but I can assure you that they're in very short supply in the rest of the world (whether that's because you're behind or ahead of the game here, I can't judge).

In the US and Western Europe, most senior managers operate on a horizon driven by the next quarterly figures. The only exceptions I've seen are companies that are (or effectively are) in private hands, who can afford to view their share price fluctuations with lofty disdain. No decision-taker seriously plans on being in the same job (or even with the same company) in three years time - why should they care about the long-term effect of their decisions so long as they're left covered in short-term glory?
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