Three airlines drop self-reporting safety program

[Shell Management]

boofhead - You are right that ASAP is not and should not be a get out of jail card. But without it the FAA can still take certificate action for unintended actions and genuine mistakes. The continuing FAA attitude is very unproductive and unfair and totally against best practice.

tbavprof - you are 100% wrong. What is happening in Singapore is seperating the activity (running an airport) from the regulator. This is a GOOD thing as it makes the regulator independent.

Nick NOTOC and Roadtrip - I agree US aviation managers often show poor leadership - which results in a poor culture.

Nick NOTOC - the need to rely totally on a confidential reporting system is really a sign of a bad culture - it is simply a work around. They are fine if they are designed to cope with just a small percentage of reports.

PJ2 - The structure you suggest is what all airlines should have but too many Directors of Ops fear being made to look bad rather than welcoming the benefit. It is also the way to foster open rather than confidential reporting.

There is a very good and popular article on SMS and going beyond the system to get a culture of safety here:
SKYbrary - Popular pages

[lomapaseo]

I see that we have garnered some important opinions about how a safety culture should work, BTDT. But still no clear sign of why a working ASAP program is no longer working at these major airlines.

I begining to suspect that the problem is not in it's origination but in the user. So what and how is this obvious diminishing in safety going to be fixed?

[PJ2]

Shell Management;

The structure you suggest is what all airlines should have but too many Directors of Ops fear being made to look bad rather than welcoming the benefit. It is also the way to foster open rather than confidential reporting.

Having the Flight Safety Department controlled by and reporting to the VP of Flight Operations only works if the Flight Operations VP and his/her organization wants to know about flight safety issues. At present, they seem satisfied with the operation, we haven't had any accidents and therefore have no need for a flight safety program that may impede commercial priorities.

We collect all kinds of FOQA data but do nothing with it - nothing that is effective anyway. We even have to wrangle an invitation to training and standards meetings because we're often "forgotten".

I can tell you from personal experience that getting a FOQA Program going without the support and buy-in of Flt Operations or the CEO, (even getting the CEO's awareness, let alone buy-in, is a significant problem here) is simply a complete waste of time, human and technical resources and the organization's money. We have been beating our heads against the office refrigerator for ten years and it's a lost cause.

So, no, I don't think that "reporting to Flt Ops" is a good idea if they don't want to know. I think the CEO needs to know how close his/her airline came to an accident, (we can show at least a dozen "events") so he can comprehend the notion that the airline business is about more than marketing. Then, just maybe, he might kick some ass down below and get his people onside because right now it doesn't "hurt" for people to ignore the data.

If there is a healthy, knowing safety culture which has an appropriate level of intervention as per previous discussion and a good agreement with the association, (and we have an excellent one that is respected by both sides) where flight safety has both independance from operations and the ability, with teeth, to intervene where the data indicates, (I fully realize the problems in this requirement but expect that a healthy safety culture is one that doesn't ground every 767 no matter where it is around the world with a 5kt flap overspeed!, etc, etc), then a working relationship with Flt Ops which respects and asserts the requirements of both departments so that commercial and safety interests are intelligently balanced through the use of data and not just opinion or politics, can work effectively for the organization.

Anyway, enough. I guess we're going to learn the hard way.

[dhc2widow]

In 1977, the Washington based Institute for Policy Studies launched the Government Accountability Project (GAP) in an effort to support individuals who come forward, risking their jobs and careers, by challenging wrongdoings for the benefit of public safety. The following is an excerpt from “The Whistleblower’s Survival Guide: Courage Without Martyrdom”, first printed in 1997.

“Structurally, corporate voluntary disclosure programs are vulnerable to the now-familiar conflict of interest inherent when an institution is responsible for disclosing its own misconduct. To illustrate, the investigations often are conducted by attorneys whose professional duty is to the client corporation – rather than to the public. The same attorney who interviews whistleblowers and serves as a liaison between the corporation and the government during a voluntary disclosure may later act as counsel for the defense in the event of enforcement action.

As a result, voluntary disclosure programs have failed to serve as an effective substitute for external oversight, and too often serve as a shield for liability.”

and

“The GAP has identified six basic principles that we believe are needed for any meaningful system of whistleblower protection and corporate and government accountability. Whistleblowers must:

1. Have a legal right to protection against discrimination for challenging illegality or violations of the public trust through lawful disclosures, without having to obtain advance permission, as well as the same protection for refusing to violate the law;
2. Have access to courts in which the decisionmakers have judicial independence from the political process, and be entitled to a jury trial;
3. Have remedies that hold individual harassers personally liable and subject to discipline, so that an employer or supervisor has something to lose by retaliating;
4. Gain access to legal shields for following government or professional codes of ethics;
5. Have the ability to go on the attack against lawlessness by restoring citizen standing to challenge fraud and enforce the law; and
6. Restore substantive and procedural due process rights for all violations of constitutional rights, even when the government asserts a conflict with national security.”

Have any of these principles been incorporated into the ASAP?

Also curious, what labour associations are available to non-airline pilots? (I know the answer for Canada)

Are there any countries that have a mandatory Professional Pilots Association for all working pilots, and if so, how is that working?


P.S.

dch2 widow...interesting name...I hope it doesn't mean what I think it means

... yes, I'm afraid it does.

[Shell Management]

P2 - I may not have been clear - I was advocating an independent safety director reporting to the CEO with the budget and resources required NOT safety officers subordinate to directors of ops and maintenance.

dhc2widow - your GAP example relates to reporting of misconduct. That is not what ASAP or any of theother equivalent schemes are aimed at. If it is a case of misconduct then most national aviation authorities have a means of such reporting. However as you are aware, reporting to TCCA, for example, does not always results in a comprehensive investigation or enforcement if required. But that is a failure in regulation not reporting.

[PJ2]

Shell Management;

Ah, ok, thanks for the clarification. The key is, the CEO "knows", so there is no denial possible and those down below get an earful if they don't do the right thing when things that are done wrong are reported directly to the accountable executive. Our safety people are under Flt Ops so the CEO only knows what's been sanitized through the bureaucracy and no department is going to report on itself.

I'm not fed up or at the end of my wits - that's inappropriate for safety people who are at times, accustomed to such treatment but I am deeply frustrated because it IS after all, my company's health. Thanks for the feedback.

[Mark in CA]

Japan Air Lines seems to be moving in the opposite direction, not only encouraging voluntary, non-recriminating pilot error reporting and continuous black-box data analysis, but they're also showing in-flight videos to passengers that illustrate how the airline is learning form its mistakes.

http://www.nytimes.com/2008/12/16/business/16box.html

[Intruder]

I was advocating an independent safety director reporting to the CEO with the budget and resources required NOT safety officers subordinate to directors of ops and maintenance.

They exist in many airlines and military air organizations. Still they are only as effective as the CEO/CO/Commander allows them to be. In my military and airline experience, operations still "wins" the arguments most of the time, because the CEO wants the airplanes moving.

Our current "Safety Director" is a do-nothing.

[Shell Management]

Only back in October NTSB Board Member Robert Sumwalt said the following to the Regional Airlines Association's Presidents Council Luncheon:

Following a fatal regional airline accident a few years ago, the Safety Board issued safety recommendations calling for air carriers to implement Aviation Safety Action Programs (ASAP) and Flight Operations Quality Assurance (FOQA). Almost two years after those safety recommendations were issued, I did some research to see how many carries had implemented them.

ASAP programs encourage employees to report safety concerns in a non-punitive environment, which allows the air carrier to act on the information before an accident or incident occurs. I found virtually no difference between regional and major carrier in implementation of ASAP. 93 percent of 14 major carriers in my survey had ASAP programs, whereas 91 percent of the 21 regional carriers had these programs. I applaud major and regional carriers alike in their efforts to implement ASAP.

Now:

NTSB weighs in on US carrier suspension of voluntary reporting

US safety officials are publicly expressing their concern over the suspension of voluntary safety reporting programmes by four of the country's airlines.

The Aviation Safety Action Programme (ASAP) has officially been suspended at Delta Air Lines and its wholly-owned regional Comair, American Airlines and US Airways.

An Aviation Safety Action Programme (ASAP) is an agreement between an airline labour group, FAA and carrier management that generally frees employees from penalties when they report incidents or safety concerns.

[The National Transportation Safety Board (NTSB) today said: "These programmes identify and correct safety issues before they cause accidents."

NTSB believes the information provided by ASAP is used in developing methods to improve safety, and "their elimination could put aviation safety at risk".

In 2007 the board said it issued a recommendation to FAA strongly encouraging ASAP adoption among US regional carriers.

Delta pilots suspended the carrier's ASAP programme in December 2006. Both American and US Airways pilots allowed their progammes to lapse this year.

American pilots suspended ASAP after determining a proposal offered by management in the renewal process would put the carrier's pilots at greater risk for discipline.

US Airways this month terminated the carrier's 10-year ASAP programme after pilots failed to expand immunity to events not previously covered under the agreement.

Recently Delta's branch of the Air Line Pilots Association (APLA) said it hoped to reach an agreement with management regarding ASAP soon.

NTSB, meanwhile, "strongly urges all parties to do what is needed to reinstate proactive safety programmes and keep existing programmes viable and fully functioning," says board Chairman Mark Rosenker.
Source: Air Transport Intelligence news

[timbob]

The High Ground

At play is the longterm competition between the management safety organization (Vice-President of Safety, XYZ Airlines) and the pilot union's traditional role as safety watchdog. At some airlines, it becomes apparent to the line pilots that neither talk to each other very much, each publish periodic safety booklets and letters that appear to have no coordination in content or emphasis. Given the choice, most would probably favor full disclosure in the interest of safety, but the competition between the two elements for moral preeminence (management vs pilot association) can be a distraction. (Note to Both; publishing some joint blather in the Flight Operations Manual is viewed with suspicion by most flight crews as nice words with no specific meaning. Pilots strongly prefer independant reporting to third party for confidentiality.) "Do I confess here, or at the church across the street?"

[None]

IOSA audit?

Can an air carrier pass an IOSA audit without an ASAP-type of program?

IATA Operational Safety Audit (IOSA)


[Safety] Programme Elements
ORG 3.3.10 The Operator shall have a process for the investigation of aircraft accidents and
incidents, to include reporting of events in accordance with requirements of the State. (GM)
ORG 3.3.11 The Operator shall have a process for identifying and investigating irregularities or other
non-routine operational occurrences that might be precursors to an aircraft accident or incident.
(GM)
ORG 3.3.12 The Operator shall have an operational reporting system that:
i) encourages and facilitates feedback from personnel to identify deficiencies, expose
hazards and raise safety concerns;
ii) includes analysis and management action to address operational deficiencies, hazards
and concerns identified through the reporting system. (GM)
ORG 3.3.13 The Operator shall have a flight data analysis programme that is non-punitive and
contains adequate safeguards to protect data sources. The programme shall include either:
i) a systematic download and analysis of electronically recorded aircraft flight data or
ii) a systematic acquisition, correlation and analysis of flight information derived from a
combination of some or all of the following sources:
a) aircraft FDR readouts;
b) confidential flight and cabin crew operational safety reports;
c) flight and cabin crew interviews;
IOSA Standards Manual
Part One
ORG 6 ISM Ed 2 Rev 1, April 2007
d) quality assurance findings;
e) flight and cabin crew evaluation reports;
f) aircraft engineering and maintenance reports. (GM)
(Note: this is a Parallel Conformity Option effective until 31 December 2009.)
ORG 3.3.14 The Operator should have a programme for the systematic acquisition and analysis of
data from observations of flight crew performance during normal line operations. (GM)
ORG 3.3.15 The Operator should have a confidential human factors reporting system. (GM)
ORG 3.3.16 The Operator should have a database to ensure effective management of data derived
from the flight safety programme.

[AirRabbit]

The ASAP program, as I understand it, accepts voluntary reports of facts that may have led (or if allowed to continue, might lead) to an unsafe circumstance or it reports something that was or is not in compliance with existing rules, regulations, policies, or procedures. Filing such a report insulates the reporters from any further action being taken against the one doing the reporting and others involved. But I also understand that if it is found that the facts of the circumstance lead to a conclusion that the claimed “error” involves criminal activity, substance abuse, the use of controlled substances, alcohol, or intentional falsifications, an enforcement action may be pursued whether or not an ASAP report has been filed. I also understand that if an ASAP report is filed, and the unsafe practice was found to exist through some alternative investigation NOT USING the information provided by the offending party(ies), where there is sufficient evidence found through another means that would have justified processing a corrective action, including an enforcement action, that corrective or enforcement action may be taken.

I also understand that if an accident or incident occurs, and no ASAP report has been filed, whatever is found can be used in any potential corrective or enforcement action. Noticeably, however, the fact is the voluntary reporting program was designed to highlight and, hopefully, correct the situation before an accident, incident, or another rule violation occurs. Without such information, there is little hope that the circumstance that might lead to such an outcome will ever be known. Believing that a rule requiring the reporting of such violation of rules, practices, or procedures will lead to their being reported is simply naive. If the “offenders” would be subjected to punitive or embarrassing actions if they reported the incident, wouldn’t the motivation be largely to hide the evidence, stay quiet, and hope that no one found out … thereby hopefully avoiding any kind of punitive or embarrassing actions being taken?

In this case I agree with Sturgell … the best course of action is to urge the airlines and the labor unions to resolve their differences. The name of the operation should be PREVENT … not PUNISH. I think there are adequate caveats with the existing program to take necessary punitive or corrective action when someone criminally jeopardizes safety – and I think that operating an aircraft while impaired is at least as bad as operating a motor vehicle under the same circumstances. This industry is currently enjoying one of the safest times in its history. For one, I think that the ASAP program can claim at least some part of that safety record. I would hate to see it removed because of “in-fighting.” I may be all wrong, but I would think that companies would much prefer to re-train a handful of crewmembers … and that labor organizations would rather see their members re-trained … than to have the continuing viability of the operation jeopardized by an accident.

[llondel]

I think the other aspect of all of this is that the lawyers, having saturated the medical profession, have turned to aviation, so that any admission of a mistake could be the one that invites a lawsuit (costing time, money and giving bad PR). Some management types have obviously decided that the best way to safeguard the company is to act on reports by 'retraining' crew or firing them, showing by their actions that it was individuals at fault and not the company should it come to court.

Ultimately it's going to cost them more - how much does a hull loss with fatalities cost a company if it turns out later that similar incidents had occurred previously but avoided the fatal outcome? Some time in the next few years it'll happen, and the fatal event would have been avoidable if only there had been a sensible mechanism for reporting the first.

Unfortunately there isn't really a good method of anonymous reporting because for many incidents enough detail is needed that the flight in question can be identified.

[dhc2widow]

Updated: January 29th, 2009 09:46 AM GMT-05:00
Home > Top News
NTSB Pleased With Delta's Decision to Reinstate ASAP
NTSB

WASHINGTON, D.C. -- The National Transportation Safety Board is pleased that Delta Air Lines has reinstated its Aviation Safety Action Program (ASAP).

Under ASAP, pilots, mechanics, and dispatchers receive immunity from disciplinary action when they voluntarily report any safety-related incidents.

"ASAP is a major component to aviation safety," says NTSB Acting Chairman Mark V. Rosenker. "We are hopeful that other carriers, who have recently suspended their ASAP will also see the importance and value of these programs and quickly reinstate them."

The Safety Board believes that proactive safety programs, which encourage voluntary disclosure of safety issues, are critical to ensuring aviation safety and identifying problems before they lead to accidents.

The memorandum of understanding signed between the carrier, the Air Line Pilots Association and the Federal Aviation Administration will identify and correct safety issues, and prevent accidents.

AMTonline

[kappa]

Now all major U.S. carriers again have ASAP programs.

Yesterday American Airlines announced that their pilots had agreed to again participate in an ASAP program. Previously the U.S. Airways and Delta programs had been reinstated.

[manrow]

Is this another sign that these days the FAA is no longer proactive?

[Roadtrip]

The FAA is a joke. When they proposed new rest rules for long haul flying, they quickly retracted them when their defacto bosses in the airline executive boards rooms gave them "guidance."

Defined rest periods required for domestic reserve pilots, but international reserve pilots are available 24 hours a day. And the beat goes on.