Sweeping condemnation of Transport Canada's approach to aviation safety

[dhc2widow]

CNW Newsgroup

OTTAWA, May 6 /CNW Telbec/ - In the rush to hand-off responsibility for
air safety to the airlines themselves, Transport Canada failed to assess the
risks inherent in this approach and maintain safety during this transition to
Safety Management Systems (SMS), according to the Auditor General of Canada.
The Auditor General also found that Transport Canada does not know what
is the appropriate mix of proper safety oversight of the industry and how many
aviation inspectors are required to deliver it.
"Transport Canada has thrown caution to the wind when it comes to safety.
For the past 3 years, Transport Canada has reduced safety oversight in favour
of giving responsibility to the industry itself without any knowledge of the
risks involved for the travelling public or ways to mitigate them," said
Captain Greg Holbrook, Chairman of the Canadian Federal Pilots Association.
Sheila Fraser also found that Transport Canada has failed to measure the
impact on safety of the shift of resources to SMS.
"Without understanding the risks, Transport Canada cancelled key
oversight programs like the National Audit Program, and canceled enforcement
actions on serious infractions of safety regulations in order to implement
SMS," Holbrook said.
Sheila Fraser found that Transport Canada's aviation inspectorate of
licenced pilots and engineers has declined by 8% even though the Department
lacks a national human resources plan to ensure adequate staffing, recruitment
and training of safety inspectors.
In her sweeping condemnation of Transport Canada's implementation of
Safety Management Systems, the Auditor General found these shortcomings:
<<
- 15% of Transport Canada inspectors have not received initial basic
inspector training and an additional 15% have not received recurrent
training;
- There is no national data base tracking inspectors qualifications;
- Transport Canada has not identified how many inspectors and engineers
it needs with what skills.
The Auditor General's review of Transport Canada's aviation safety
oversight did not examine the second main pillar of SMS - delegation of
licencing and oversight to industry lobby groups.
The first such delegation occurred in January 2003 when Transport Canada
handed off licencing and safety oversight to the Canadian Business Aviation
Association - a lobby group for business aircraft operators.
A startling review of the CBAA's Safety management System has found that
business aircraft like the corporate plane that crashed last month near
Wainwright, Alberta have operated without any independent safety oversight for
more than five years, according to documents obtained via the Access to
Information Program.
The March 2007 audit found its safety program, known as a Safety
Management System or SMS, "does not provide any planned or structured
oversight of private operators".
The Transport Canada audit and related documents which have only now come
to light also found that the CBAA:
- does not collect and analyze safety data and risk factors
- does not punish private operators for safety violations so there are no
consequences for violating the rules
- lacks procedures for suspending or cancelling an operator certificate
in the event of serious safety problems
- does not track its own safety program to ensure it meets government
standards
>>
The CBAA does not have a team of aviation inspectors which travels to
audit individual operators of business aircraft, as Transport Canada once did.
Instead, the business aircraft operators contract the audit service from a
private supplier, thereby eliminating third party independence in the audit
process altogether.
Transport Canada will soon delegate safety oversight to lobby groups in
the helicopter sector and airports.
"These findings make a mockery of Transport Canada assertion that Safety
Management Systems are an additional layer of safety and their insistence that
this is not a shift to self-regulation of aviation safety," said Holbrook.
Recent revelations of widespread safety violations and maintenance
problems among airlines in the United States and concerns that The Federal
Aviation Administration - the US aviation regulator - has become too cozy with
the industry should give Canadians pause because Canada's regulator is giving
away it responsibility for safety to the industry itself.

What is SMS?
According to Marc Grégoire, Transport Canada's ADM for safety and
security: "SMS is very much based on a partnership between the operator and
the regulator..."(1)
It's a partnership deal in which the airlines and other aviation licence
holders take more responsibility for safety. Determination of acceptable risk
levels is handed off to the airlines which decide what is safe enough for the
traveling public.
In turn Transport Canada agrees to back off direct regulatory oversight
and in some cases delegate licencing and supervision to industry lobby groups.
Transport Canada has already killed key oversight programs and closed
enforcement proceedings for companies with an SMS as incentives to encourage
self-reporting.
In addition, Transport Canada has put in place a number of "incentives"
to encourage the industry to self-report violation of safety regulations.
The deal features a "get out of jail" free provision: airlines which
self-report violations are guaranteed immunity from Transport Canada
enforcement. The airlines are supposed to fix safety problems themselves, with
little intervention from the regulator.
Amendments to the Aeronautics Act which are currently before Parliament
in Bill C-7 would ensure that any violations or problems that are reported to
government will never be available to the public or media for public scrutiny
under the Access to Information Act.
Even thought these "incentives" are intended to encourage operators to
provide Transport Canada more safety information these data will be unverified
because TC no longer has enough inspectors to check-up as they once did.
Under SMS, Transport Canada inspectors become desk-bound system auditors,
inspecting more paperwork than airplanes and relying on information supplied
by the industry.
(1) House of Commons Standing Committee on Transport, Infrastructure and
Communities Transcript, June 15, 2006.

From the AG's Report:

Conclusion
3.57 Transport Canada is the first national regulatory authority in the world to put in place regulations requiring aviation companies to introduce safety management systems (SMS). The Department developed its own approach to implementation and conducted pilot projects with airlines and small operators. It developed appropriate procedures and processes for SMS implementation, and made efforts to apply them consistently. The first two phases of the four-phase approach for SMS implementation in airline operators and associated aircraft maintenance companies are now complete.
3.58 Despite these accomplishments, we found that Transport Canada's management of the transition to the new approach has had several weaknesses. In planning for the transition, the Department did not document risks or suggest mitigating actions, and it did not forecast overall expected costs for the transition. It also had no mechanisms in place to evaluate the impact of SMS activities on the frequency of traditional oversight activities. The Department has not clarified what combination of traditional oversight and SMS-related activity is acceptable as it proceeds through the transition.
3.59 In addition, the Department has not yet identified human resource requirements for Civil Aviation during the transition and once it is complete, or determined how these requirements will be met. There is no integrated human resources plan for the entire Civil Aviation program that addresses these requirements.
3.60 Finally, the performance measurement framework for Civil Aviation does not contain short- or medium-term indicators for measuring performance. These indicators could be used to signal a need for greater attention or action in a particular area.
3.61 The Department was unable to demonstrate to us that it was managing these areas satisfactorily. It is important that Transport Canada address these weaknesses for the transition in the first 74 companies and in the remaining sectors of the industry—comprising more than 2,000 companies—to be successful.

Read it here: http://www.oag-bvg.gc.ca/internet/En...3_e_30699.html

[slip and turn]

Well I feel sure the Auditor General of Canada could write a similar report about many of the first world's aviation regulators, had he the time, the inclination and the invitations to do so

They may not contract out their audits (or do they?), but how thin are the CAA's inspectorate spread, for example?

A report like this sounds a bit like the UK's Oftsed reports on individual schools. It doesn't really tell us much we haven't already guessed, and unless numerous disasters occur then I don't suppose anyone will actually achieve much with it, this year, this month or even anytime soon.

The headline says 'Sweeping Condemnation', but will it still be viewed as such in a week's time?

I hate the politics of this stuff. Why can't it just be good and stay good?

Personally I think all Financial Directors in so-called safety critical industries should be knocked down a peg or at least one arm tied behind their backs to redress the balance of commercial expediency versus the costs of being sure.

[PJ2]

Personally I think all Financial Directors in so-called safety critical industries should be knocked down a peg or at least one arm tied behind their backs to redress the balance of commercial expediency versus the costs of being sure.

Or stand in the position of "accountable executive". What could be better than being accountable: First in the oak chair and possibly time behind bars if there's an accident - after all, if they're going after crews, why not the executives?

[Eboy]

possibly time behind bars if there's an accident

There is another punishment if there is an accident -- losing money. Passengers go to other airlines. Is this economic incentive effective?

The Auditor General might look at Underwriter's Laboratories of Canada which performs product safety standards development, testing, and certification. It is an independent organization set up by industry. It works. Why?

[Mad (Flt) Scientist]

While I'll happily agree that self-regulation has issues, especially in a financially challenging environment, this piece of logic makes my eyes roll:

Recent revelations of widespread safety violations and maintenance
problems among airlines in the United States and concerns that The Federal
Aviation Administration - the US aviation regulator - has become too cozy with
the industry should give Canadians pause because Canada's regulator is giving
away it responsibility for safety to the industry itself.

Arguing that failure of a non-delegated system to work implies that a delegated system would be weak is, to say the least, a stretch. One might just as easily argue that it proves that the apparent safety provided by an outwardly independent regulation system is, in fact, an illusion.

[slip and turn]

One might indeed, M(F)S ...

Meantime, the Heathrow T5 - Transport Select Committee hearing today in the UK Houses of Parliament did yield one CAA inspectorate snippet - Willie Walsh said the CAA contracted mystery shoppers in the few days after T5 opened to ... ehm, well ...

Anyway, he said they reported no particular problems ...

[clevlandHD]

...but a fully goverment regulated system does not make it fail proof: look at any local CAA in Africa! Mrs Fraser just did her job of keeping the gov aware that they are being watch.

True that some regulations should be reviewd at TC but to imply that the system is falling apart is not justified.

[dhc2widow]

Doesn't the Federal Pilots Association (the one's who published this press release) represent the Transport Canada Civil Aviation inspectorate?

http://www.cfpa-apfc.ca/eng/

Ah yes, so it does. Interesting that the inspectors are promoting the idea that the department is not doing it's job ... Rather makes one think there might be something to it ...

[Left Coaster]

How about Union V Management?

[aw ditor]

I hope EASA will not be following the same (Canadian) route in Europe?

[J.L. Seagull]

I believe you will find that the CAA are mandating SMS as from early next year. Whether this is to knuckle to Industry pressure and reduce costs, or because they really believe it will improve things is a potential subject for robust debate.
The bottom line is whether you believe that our employers will be as punctilious as a CAA inspector when auditing themselves is open to question - or at least with a qualifier of whether it affects the bottom line.

I don't believe my own employer necessarily prioritises safety as much as the bottom line, although they would deny it over and over and point out that it says so in the Ops Manual for heaven's sake!

[mates rates]

With the flight and duty time limits in Canada I think it's a long time since TC has been interested in Safety of Aircraft operations in Canada!!

[Spitoon]

There is a problem with being a regulator – you’ll never please everybody.

Regulatory philosophies tend to be cyclic. In many parts of the world we are currently going through a phase of setting regulations by objective which permits operators to determine the best, i.e. safest and most cost-effective way to achieve the objective. This often gives the operator great flexibility in how to work. For those who like to be in control of everything this may be seen as ‘handing-off responsibility for air safety to the airlines themselves’.

On the other hand, if the rules are to be detailed and prescriptive they will usually be criticised for being inflexible and for stifling innovation (often beneficial innovation at that!). Such rules will also need to be regularly reviewed and amended to make sure that they are still valid. And the people writing the rules would need to be completely up-to-date with every new idea that anyone wants to use in order to do this effectively.

So when it comes to writing the rules there needs to be a balance; prescription where it’s necessary and objectives where it’s appropriate. Unfortunately some people tend to be swayed by current fashions that say, for example as they do in Europe at the moment, objective-based regulation is the only way to go, and will use that approach even when it’s really not sensible. Sadly some of these people who go with the current fashion, whatever it is, are highly influential and may lack the professional knowledge to recognise the fact that the rules that they are promoting are not particularly good. Hence we end up with some poorly framed rules that are wide open to interpretation.

To complement the rules we have regulation or oversight. This is the inspectors who are out in the field and can make or break the effectiveness of a regulator. These people can help operators to understand what the rules mean and the latitude that is available in meeting them. Or they can create immense confusion by, for example, each applying different standards and moving goalposts as they speak. Sometimes inspectors have little better understanding of the regulatory philosophy being applied than the operator. Sometimes they have little or no understanding of the skills needed to be an effective regulator. It is quite possible that your friendly inspector was an excellent operational pilot, engineer, controller or whatever, but has had no training in how to be a regulator.

Then there are the CAAs themselves. Often still based around dated civil service systems where grades are more important than competences. Organisations whose roles and functions are not clearly defined; often compounded by the fact that the single organisation has competing responsibilities (which certainly is not understood by the layperson). And these are the organisations that need to manage how the rules are set and how inspectors work in order to have a ‘good’ system in a country.

With this background is it any wonder that a review of Canada’s, or I am sure many other States’ arrangements, would not be seen as satisfactory in a review? I don't know how Canada’s arrangements stack up but I’m guessing that, while not perfect, they are better than many States’.

Ultimately, if you have good management in the CAA, you’ll have a robust regulatory environment in which operators understand what they must do and what minimum standards apply. If you have poor management, who knows what you’ll get. And what proportion of managers are good? And how many of the good ones will be attracted to CAAs?

The people I sometimes feel sorry for are the some of the inspectors themselves (and, no, I’m not one of them). There are some good people out there trying to do a good job; they are not all just supplementing another pension or counting down the days ‘til retirement. But so often they appear to be undermined by those above!

[slip and turn]

Interesting post and observations, Spitoon

I especially found the following paragraph to be very telling...

Then there are the CAAs themselves. Often still based around dated civil service systems where grades are more important than competences. Organisations whose roles and functions are not clearly defined; often compounded by the fact that the single organisation has competing responsibilities (which certainly is not understood by the layperson). And these are the organisations that need to manage how the rules are set and how inspectors work in order to have a ‘good’ system in a country.

May I ask whether you were thinking about the UK CAA, and if so which competing responsibilities?

[Spitoon]

I wasn't thinking of the UK CAA specifically but my comments apply here also.

In my particular area of interest the CAA has a responsibility to regulate financial performance of some aspects of ATC service provision and also the safety performance. Similarly, there is often great resistance to the allocation of airspace when it may be appropriate on grounds of safety.

Despite your occasional assertions to the contrary, however, I believe that the UK has a reasonable set of arrangements and, in the main, a responsible and robust regulator managing them.

As I said before, it's not easy being a regulator - and it's very difficult to understand the regulatory framework that is established in a country (or domain) without spending considerable time working within it. A snapshot view, which is all one is likely to get with a government sponsored review, will almost inevitably fail to gain that full understanding.

[Spitoon]

And your point was what, slip and turn?

[MidgetBoy]

TC isn't too bad at covering up stuff either.
When an 80 year old crashes a multi-engine because he was flying low and clipped a fence, that's a pilot error. Though TC claims it was a landing gear collapse (obviously, it wasn't there after it hit the fence) so they can't be responsible for allowing that pilot to go back into the air and end his life days after it was repaired.

Not to mention, TC doesn't exactly have any set standards. Whatever each individual TC inspector says, goes. Rules change on the spot. Especially in the more populated areas of Canada.

[slip and turn]

@Spitoon

Two ears, one mouth and all that, wasn't making any new point IIRC, although it was nearly a week ago ... just interesting that you used UK CAA's ERG (financial) and SRG (safety) as examples of potentially competing regulatory devices (in respect of NATS).

From where you sit within NATS, i.e. a particularly and necessarily exacting part of UK aviation, you believe that the UK has a reasonable set of arrangements and, in the main, a responsible and robust regulator managing them.

It's little bite-backs like "in the main" that I wonder about

[zalt]

Well UK CAA is following TCCA:
http://www.caa.co.uk/docs/33/FOD200823.pdf

[Spitoon]

The use of a safety management system is not the problem. A weak, incompetent and ineffective regulator is what causes the problems - whatever regulatory philosophy is used.

And, as the FODCOM points out, the requirement for a SMS comes from ICAO so you're going to see a lot of countries going the same way.