Management Processes Need Safety Scrutiny

Management and company processes should be proactively targeted by accident investigators and safety regulatory agencies, according to the Australian Civil Aviation Safety Authority (CASA), as one key to further improving air safety. At the annual International Society of Air Safety Investigators (ISASI) seminar held in Australia in August, Bruce Byron, chief executive officer for CASA, said that accident investigators may need to bring in people with management expertise to evaluate a company's processes. "In my experience with large organizations, I have seen evidence of potential deficiencies in management decision-making," said Byron.

Byron also stressed that although the members of the ISASI organization tend to become involved in evaluations of incidents and accidents after the event, as promoters of safety, regulatory agencies should have the skills to assess safety systems and systemic management related problems.

Scrutiny of management is a real issue for CASA, according to Byron, and new regulations are being drafted in Australia that would require the implementation of safety management systems. Another issue is making sure the results of crash investigations are actively used to improve safety. "It is vital that all the good material that [investigators] produce does not fall into some electronic black hole or database--without being used by the decision makers in the system," said Byron. He stated that investigation information needs to be constantly trended, assessed, and compared with data from other sources.

Section 9 (1)(f) of the Australian Civil Aviation Act states that the agency has the function of conducting comprehensive assessment of safety-related decisions taken by industry management at all levels for their impact on safety. Byron said, "What is particularly noteworthy here is that the only specific item of surveillance activity highlighted here does not target technical areas but asks us to put the spotlight on safety-related decisions by management."

One accident that highlights the need for intense maintenance management scrutiny is the Alaska Airlines MD-83 crash in January 2000. All aboard were killed when the jackscrew that runs the pitch trim system for the horizontal stabilizer failed, causing the stabilizer to flip up and separate from the airplane. Out of control, the aircraft then tumbled into the Pacific Ocean. During the investigation, FAA inspectors uncovered deficiencies in 79 of Alaska Airlines's 89-aircraft fleet requiring all 79 to be re-inspected. The pervasive nature of these problems is certainly indicative of the need for management philosophies to be inspected along with the technical facts. --By Joy Finnegan