Sweeping condemnation of Transport Canada's approach to aviation safety

[zalt]

Is the UK CAA not the regulator that first published its position on SMS in 1997 yet said that it did not need to be a regulation?

[Shell Management]

Both inside Shell and in the wider industry it is becoming clear that a solidly implemented HSE management system is an essential basis for good HSE performance, BUT that outstanding HSE performance CAN ONLY be achieved if the "culture" is right. The Hearts & Minds culture programme was developed by Shell in 2002, based on research with Manchester, Leiden and Aberdeen universities since 1986, and is being successfully applied around the world. The programme uses a range of tools and techniques to help the organisation involve all staff in managing Health, Safety and Environment as an integral part of their business. This is somthing the aviation industry should do more of.

[alf5071h]

I fully endorse the ‘Hearts and Minds’ programme. Link:- Hearts and Minds.
IIRC the original Shell programme was issued on a CD; if some one has a copy, I would be interested in any comparison between the original content and the web information.

Related Human Factors, SMS, CRM, and TEM materials can be found in the ref links.

Re “This is something the aviation industry should do more of.” I agree; the volume and quality of the work listed below indicates that Aviation has much to learn from the Oil and Gas Industry, particularly where the regulator (HSE) participates in preparation of the ‘know-how’ and guidance information, where an alternative is to stand back and ‘enforce’ regulations (Aviation Safety Agencies/Administrations).
IMHO Transport Canada appears to be on the correct side of the line (at least facing the right direction), but could do more. Elsewhere, aviation is showing signs of complacency.

Refs/related info:-
The Energy Institute, Human Factors.
Managing human performance.
Inspectors Human Factors Tool Kit.
Managing human performance - Briefing Notes.
Step Change in Safety.
Managing Human Error.

[sox6]

Some operators, such as Bristow Helicopters, are making major progress in this direction. See the current cover story of the Flight Safety Foundation's magazine, Aero Safety World, called Beyond SMS, on how to move from just safety management to a more holistic approach including culture:
www.flightsafety.org/asw/may08/asw_may08_p12-17.pdf

One of the authors, Andy Evans, also presented at their competitor CHC's annual safety summit alongside Leiden's Uniniversities Patrick Hudson in 2007 and 2008 on their Target Zero safety vision - a sign of how respected the Bristow approach is.

[zalt]

Support from NTSB

Looks like Parker & Evans have something when they talk about leadership and of vision. Have a look at this speech:

Remarks of Robert Sumwalt, Vice Chairman National Transportation Safety Board
to the Regional Air Cargo Carriers Association 7th Anniversary Spring Conference May 22, 2008
Chantilly, VA

Sumwalt talks about three leadership qualities:

• Servant leadership - serving the people who follow you (not they you)
• Integrity - consistency, courage and humility
• Vision - establish a vision, communicate that vision and then motivate others to achieve it

"Leadership is about influence. Your job as aviation leaders is to use your influence to help ensure that bad things don’t happen to your good company. I’ll be the first to admit that it takes a strong commitment for practicing servant leadership, maintaining integrity, and establishing, communicating and achieving a worthwhile vision. But, once you have these, it will be like having a North Star – one that your moral compass can always point to and lead you through tough decisions."

He doesn't bang on about having a documented SMS as the only means to make yourself safe.

His background:

He was a pilot for 24 years with Piedmont Airlines and then US Airways, logging over 14,000 flight hours and earning type ratings in five aircraft before retiring from the airline in 2005. Prior to coming to the Board, he was Manager of Aviation for the SCANA Corporation, a Fortune 500 energy- based company.

He worked on special assignment to the US Airways Flight Safety Department from 1997 to 2004, where he was involved in the development of numerous airline safety programs, including an enhanced crew awareness program and a windshear training program.

He served as a member of Air Line Pilots Association's (ALPA) Accident Investigation Board from 2002 to 2004. He has chaired ALPA's Human Factors and Training Group and was a co-founder of that organization's Critical Incident Response Program, which provides guidance to airline personnel involved in traumatic events such as accidents.

So he probably knows what is talking about.

[Southernboy]

Oversight

Good post Zalt & so many others - spitoon etc thanks, all v educational. What's clear is that culture is everything.

The NTSB have been trying - in vain - for years to get the FAA to listen to their suggestions. I can see only, "efficiency," IE cost saving as the motivator behind self regulation, nothing else.

Remember the BA 757 that took off with 1/2 the flap system missing? The AAIB report said that the Quality Assurance system had failed because correct procedures had not been followed. That's what a QA system IS -procedures. So it's proof that the man with the clipboard trying to pick holes in what you've done is better, but then he costs more.

[J.O.]

Don't get me wrong, a good QA system is important. But unfortunately, too many organizations have hung their hats on QA rather than putting resources into the development a work force that is adequately trained and given the resources to do their jobs effectively. A little money spent on that side would reduce errors, thus reducing incidents and accidents. It would also reduce the amount of work for the QA folks, maybe to the point of reducing how many of them are needed in the first place.

[geewhizdriver]

Unfortunately, the Canadian media "ran" with a sizzling headline and didn't bother exploring the motives behind those quoted. The Chairman of the Canadian Federal Pilots Association quoted has a direct conflict with regard to statements he makes. Job security has never been compromised within T.C. since the SMS program was instituted, however the damage created to a very effective safe program done by a few sensational unfounded comments is sadly unfortunate. There are inspectors within T.C. who have fought the program since its inception, wrongly believing their jobs were in danger. The CAR 604 sector of Canadian aviation has been statistically the safest. Transport took a major initiative and instituted this program believing in its value. SMS is a proven concept throughout other industries. It is obviously new and there will be skepticism. But like so many media driven frenzies, based on garnering readers with sensational headlines, it should be taken with a grain of salt.

[clevlandHD]

"He touted the country's low rate of commercial aviation accidents, saying travellers have no reason to be worried. Odds are a passenger could make the hour-long flight between Ottawa and Toronto more than 300,000 times before being involved in an accident, he said.

One might opine he means 1 accident per 300,000 flying hours but as stated, assuming 50 pax on board he actually implies 1 per 6,000 flying hours!"

I think he meant 300 000 sectors, so it is still once per 300 000 hrs on a one hour sector.

[Mad (Flt) Scientist]

Originally Posted by Southernboy

.... I can see only, "efficiency," IE cost saving as the motivator behind self regulation, nothing else.

Sorry, but "capability" is an important motivator for self-regulation, and there's really no alternative.

Any large OEM, airline or repair organisation has many more people involved in the process of building, repairing, maintaining and operating aircraft than any oversight authority could ever hope for. Therefore it is only common sense that you use that pool of people to help enforce the rules.

Even if by some miracle of funding and personnel availability TCCA were to man up to, say, match Bombardier or Air Canada one-for-one, regulators to regulated, they'd still be worse off than the current approach of co-option and self-regulation. Because there are only two options:

1. The relationship is cooperative. In which case you don't need a TC Jiminy Cricket on everyone's shoulder; or
2. The relationship is confrontational. In which case the simple approach is that you simply don't tell TC. Unless you are actually DOING the work, you always have to place some trust in people anyway.

I have some issues with elements of the way self-regulation is used, but to condemn it unreservedly makes no sense.

Everyone who drives a car practises self-regulation; you get an MoT every so often, but it's up to YOU to make sure your car is roadworthy between those dates. Sure, you can be pulled over by the police, but that's a largely reactive enforcement. By-and-large, people drive safe cars because they do the 'regulation' themselves.

If we can trust the public to monitor their own operation and maintenance of a ton-plus projectile on city streets, I think maybe we can trust aviation professionals to be profesional and ethical in their jobs.

[Chuck Ellsworth]

There is a vast difference between the culture in airline operations and the culture in many of the small airplane operators in Canada.

Without effective regulation does anyone think that SMS will improve safety in the small airplane sector of aviation in Canada?

The fox guarding the hen house scenario comes to mind.

[geewhizdriver]

I am not sure I agree with " Without effective regulation does anyone think that SMS will improve safety in the small airplane sector of aviation in Canada?"
SMS is a guiding fundamental principal behind the concept of CBAA's designation as the organization responsible to administer the CAR604 Private Operator Certificates. Small airplane sector is not covered under CAR 604 operators, unless you suggest a 95,000lb Global Express is small. Turbine powered, pressurized aircraft weighing over 12,500lbs. that are operated under a Private Operator Certificate are only those granted the ability to operate under these provisions. Historically these operators represent major corporations and training as well as operational safety systems are never compromised. Statistically it has been the safest sector of Canada's aviation industry and has been an excellent division to introduce SMS and its guidelines. Canada is being closely monitored by other countries to judge the success of this initiative, and skepticism will take a long time to erode.

[Chuck Ellsworth]

Without effective regulation does anyone think that SMS will improve safety in the small airplane sector of aviation in Canada?

geewhizdriver, my comment was directed to TCCA's expanding SMS into the small airplane sector such as the bush flying operators.

I form my opinions and thoughts on this issue from 55 years in the business and having spent many years working in that culture.

I see you have Ottawa as your location, would you by chance be an employee of TCCA?

In any event, convince me SMS will work in the small airplane sector.

[rob_ginger]

Dracula in charge of the blood bank

I don't have any first hand experience in the airline industry, but I am a graduate electrical engineer with 30 years working experience while my brother in law is a mining engineer. I think his experience is the most telling.

Initially he worked for a coal mining company as a mine under-manager legally responsibile for safety at his mine. He has a whole raft of stories about how the miners themselves were more interested in their production bonus than their personal safety. My personal favorite is how some of the underground shift would wander away at lunchtime, join their friends in a closely adjoining mine, and light up their cigarettes - in an underground COAL MINE for crissakes !

Then he joined a state mines department, and became a mine inspector. At one coal mine he turned up for an inspection. The mine manager joined him on the inspection tour, and within 10 minutes had volunteered to close the mine down while the obvious (and illegal) ventilation defects were corrected - because it would be less embarassing for the mining company and would involve less paperwork.

Taken along with my own experience in the electrical industry my opinion is this:

If you think self-regulation in ANY commercial venture will work then you are either naive or self-interested - there is no third possibility. The ONLY way you will get adherence to safety standards in any industry is to have a regulator who has the power to halt operations if there are safety issues, and to have independent government inspectors making regular visits to work sites. The employees (sometimes incredibly so) are more interested in earning bonuses or keeping their job than worrying about safety. The managers are more interested in their management bonuses than in "wasting" money on safety. Doesn't matter what industry it is - people are the common factor.

So if Canada thinks self-regulation of the airline industry will work then I won't fly there because people will die before it is recognised as a mistake.

[geewhizdriver]

Chuck, First of all, I definately do not, nor ever have worked for T.C. in any capacity. I fly a corporate jet for a major Canadian Corp. and have been doing so for over 30 years. I completely agree with you regarding bush flying and the potential problems with "self-regulation" in that sector. My only experience with non T.C. intervention is with the CAR604 POC program. Like I mentioned, this sector does not make money with their aircraft. Its sole existence is to provide private transportation for the corporations that operate them. The historical difference with regard to safety statistics is founded in the investment made by these companies to provide the best training, maintenance, and working conditions, which will obviously provide themselves with that safety and security they demand and pay very dearly for.
I have also "payed my dues" in the bush and I know the potential for disaster if left on their own. Anytime there is a potential to cut corners, will probably be seized upon and a regulator is required.
The whole basis for the original media reports was based on the audit by T.C. on CBAA and the fact that certain individuals feel that safety is compromised simply because T.C. no longer administers that sector. CBAA is still responsible to audit, discipline and remove POC's if necessary. A very concise and specific set of standards are to be met, and when they are not policies are in place to deal with it. Although SMS is an integral part of the system it is not the only factor in its operational structure. I think the success of the program will only be proven by time, and there will always be skepticism.

[J.O.]

rob_ginger:

Comparing commercial aviation with mining is quite unfair, IMHO. I am not a regulator, but I work in the airline industry in Canada and I have some involvement with SMS in my company. I am not an expert, but I do have a certain level of insider perspective.

First of all, the term self-regulation is somewhat of a misnomer. No one is suggesting that aviation regulations will go away under SMS. The fact is, the airline industry (at least in most "first world" countries) has been engaged in many aspects of self-regulation for decades. The industry has invested billions of dollars in safety improvements to equipment, support systems and personnel training, not just because of regulations, but because this has been recognized as the best way to assure safety and the longevity of the industry. This is not to say that regulatory oversight can disappear under SMS and self regulation; certainly not in my lifetime. But as Mad (Flt) Scientist said above, no regulator can amass the kind of resources it would take to maintain the level of regulatory oversight that would gaurantee the public safety so that the operators themselves wouldn't need to self regulate.

Miners who display the kind of behaviours you suggest are only doing so because they are part of a culture that does not (so it seems) take safety nearly as seriously as it should. Those miners are lacking in the kind of training, awareness and motivation that would guide them down a safer path. This is not their fault. That fault rests with an industry that seems to have failed in being able to maintain safety to an acceptable level. So instead, a regulatory stick is needed to protect those employees from harm. If the regulators were smart, they would mandate that mining companies maintain much higher levels of safety awareness training and supervisory reinforcement for their employees, so that over time, a learning culture that supports safety would develop.

Another factor, IMHO is that while the mining industry kills alot of people around the world each year, it is extremely rare that someone other than a mining employee is a victim. This is not to say that mining employees do not deserve to work in a system that takes safety seriously, but lets face it, engaging in that activity comes with a certain level of inherent risk that is higher than those faced by people in general. And because the industry does not tend to claim too many collateral victims, it unfortunately doesn't always pay the level of attention to safety that it would if there were a greater risk to the general public and they faced the requisite liabilities that are associated with that exposure.

Commercial aviation on the other hand, has direct exposure to the liabilities that come with failing to provide a safe service to the general public. So the industry has a certain level of motivation to operate safely, because the consequences of a public perception that you are unsafe can lead to the end of the company, such as the TWA800 accident did to that company, among others. Also, pilots, engineers and cabin crew have (at least here in Canada) safety drilled into their heads from the moment they begin their training. They receive ongoing training that reinforces the safety message, and they are guided by detailed operating procedures that are designed to keep risk to an acceptable level. This is not to say that they are infallible, or that regulatory oversight is not needed, but it's been proven in several safety-critical areas (i.e. nuclear power) that the best people to understand and manage risks to an acceptable level are the industry people themselves, with reasonable regulatory oversight and guidance to ensure continuing compliance.

There is no intention to remove government mandates and regulations from the Canadian aviation industry in SMS. The industry is being given the opportunity to accept and maintain a level of accountability that will protect the travelling public, and the legislation has significant penalties for accountable executives who fail in their fiduciary responsibilities to maintain a safe service. Is it perfect? Not hardly. Does the industry need regulatory oversight for the foreseeable future? Absolutely. But it is still a positive step in the right direction, IMHO.

[Big Pistons Forever]

I see no difference in the problems owner operators have in the 703 (small comercial operator) segment as they do in 604 (private/corporate oprators)
The guys operating the big iron and/or multiple types/numbers are doing fine under CBAA. The story for the small one airplane owner operators is a different story. There are many who do it right but a significant number are playing fast and loose with training and maintainance requirements....just like some of the bottom feeders in 703. The problem is the CBAA construct is a paper exercise. Ultimately there is an expectation that the 604 operator will
"paly the game". But if Mr/Mrs 604 doesn't want to, I do not see how anybody at CBAA is going to know, except retroactively by looking at the smoking hole. Taking away the stick is a very risky move.

[carholme]

JO;

Nobody has suggested that regulations or mandates are going to be taken away. You are providing a smoke cover for the issue. I have long maintained that SMS is a valuable business tool but its value is only as good as the credibility of the bean counters and the company's financial status.

Regulatory oversight is the main problem at the moment and is expected to decrease if Bill C-7 is allowed to proceed. Do you think for a moment that if C-7 proceeds, that TC is going to increase their inspector status to cover their existing serious staffing shortfalls?

The AGs most recent reports of Business Aviation and the use of SMS in the rail industry are examples of what lies ahead. "Self Regulation" is not a misnomer by a long shot. Look at the results of the recent activities in the US, the threads on this forum where airlines are being charged for unsafe operations. No matter how you look at it or sugar coat the issue, rising costs will cause more and more bean counters to cut corners and you know exactly what this means.

Safety costs dollars if you embody it and the likliehood is that it will cost dollars if you don't. It is all about dollars when it comes to crunch time and SMS is extremely vulnerable to the financial cycle of any company. As for Accountable Executive, and that person being accountable, you can be guaranteed that there is a long line of positions under his who are already earmarked for blame before he is in a difficult position.

carholme

[J.O.]

carholme:

I think you need to re-read my posting, as I believe I said virtually everything you did, save for the piece about safety, or a lack of it, both costing money. And on that point I completely agree with you.

In effect, rob_ginger said that no money making industry could be trusted to protect the public without a regulator constantly standing over their shoulder making sure they were compliant. I had to challenge him on that because it certainly hasn't been my experience.

I do not view SMS through rose coloured glasses. I see where the warts are, and I have to point them out to my colleagues sometimes. But going back to a prescriptive big brother regulatory environment will not make our industry any safer, IMHO. And that's all I was trying to say.

[Shell Management]

Its Culture, Stupid

A company with a bad safety culture needs strong regulator.
A company with no clue of risk needs prescriptive detailed regulation.

If you have a strong culture of safety, are mindful of teh hazards, are managing your risks and know what to do; then regulation can be light - better to concentrate scarce competent resources where they are needed.