Monday, February 25, 2008
Safety Management Systems: The Future of Air Safety – Part I
The Safety Summit, held at the National Transportation Safety Board Academy near Washington, emphasized not only the changes necessary for operators but those for regulators as well, with Transport Canada being on the leading edge of a new surveillance trend which departs from record audits to assessing a company’s safety management system and whether or not it is meeting expectations. But that new surveillance requires a reassessment, and in some cases, a rewrite of regulations and even legislation to ensure they can accommodate the differences in safety management systems.
While the National Transportation Safety Board has yet to publish its 2007 statistics, those for on-demand operations in 2006 showed 54 accidents, 10 of which were fatal, killing all 16 passengers and crew on board. However, the industry had 1.50 accidents per 100,000 flight hours and 0.28 fatal accidents per 100,000 flight hours. This compares with 1.071 accidents per 100,000 flight hours for Part 135 commuter operations which had a 0.357 rate for fatalities. Scheduled operations had 0.132 accidents for 100,000 flight hours, and a fatal rate of 0.011. (continued below)
The safety emphasis is critical since such operations are growing at a dramatic rate. The FAA, which is expected to come out with its 2008 forecast shortly, said in its 2007 forecast that general aviation fleet will increase 1.4 percent annually over the next 13 years to 274,914 aircraft by 2020. The agency also said that Very Light Jets – expected to have a greater share of the on-demand, air taxi market than traditional turbojets – will fly 1,500 per year, while fractionals will be at 1,300 per year and non-VLJ 407 hours annually, all by 2020.
The summit opened with National Air Transportation Association President Jim Coyne noting that safety for air taxi and on-demand operators is very different than the commercial environment because of the equipment flown, destinations, and the on-demand nature of operations.
At a time when the emphasis for all aviation involving paying passengers is moving toward the so-called single level of safety, ACSF Chair Charlie Priester told the 100 in attendance, that an effective safety culture starts at the top with management not only paying lip service but devoting the dollars necessary to establish a safety culture.
NTSB Vice Chair Robert Sumwalt, who was keynote speaker, devoted his day to last week’s event beginning with his experience at improving safety at US Airways and for a Part 91 operator. He has also taught aviation safety programs at a leading university.
“The safety board is interested in the safety culture of operators because we see, time and time and time again that, when there is an accident, it is too easy to blame the dumb mechanic or pilot,” he said. “When we peel back the layers we find there are systemic safety issues within the company.” He noted that his Former NTSB Chair Jim Hall often said that the most common link in accident investigations is the attitude of corporate leaders.
He questioned whether participants thought they had a strong safety culture. “If you are convinced you do, you are likely wrong,” he said. “Safety culture is not an end state. It is a process constantly striving to do things better. Corporate safety culture is triggered at the top and measured at the bottom. It permeates the entire organization. It is about managing risks. Establishing an effective safety culture means your employees do the right thing even when no one is watching. You need integrity, within organization and within yourselves and with the people who work for you. You don’t have to balance profitability with safety; you can use safety to your corporate advantage. It can become a profit center for you.”
He cited the Lautman-Gallimore Study that tracked the Boeing fleet between 1975 and 1984. The 12 top-notch carriers, said the study, had four attributes including a high management emphasis on safety, standardization of all procedures and a disciplined adherence to a single way to do things. They also had a strong quality control system using both external and internal audits to assess the effectiveness of their safety programs. This included a confidential, non-punitive reporting system for hazards which allowed for trend monitoring. He recommended offering incentives for those who adhered to company standards and procedures and basing it on the entire team’s performance rather than on a single individual.
“A safety culture is one in which constructive criticism and safety observations are encouraged and acted upon in a positive way,” Sumwalt quoted Dr. James Reason, who cited four components of a safety culture – an informed culture, a reporting culture, a learning culture and a just culture. “Key to this is the collection and analysis of data and dissemination to all employees. Employees must be able to report safety problems and know their confidentiality will be maintained. They must also know the information will be acted upon. They must know that everyone is responsible for safety, not just management. As part of a learning culture they must know and learn from mistakes. Finally there must be a just culture in which employees know they will be treated fairly; that mistakes will not be punished unless they are intentional. There is no benefit to punishment when it is a mistake made in good faith.”
Finally he quoted NTSB Board Member Deborah Hersmann who said during the Pinnacle Airlines accident hearing: “Safety culture is about having the will to do something – not the money. It doesn’t cost a lot of money to implement a safety culture.”
Pete Devaris, manager FAA Office of Accident Investigation Safety Analysis Branch, discussed the warning signs of what he called rogue operations or pilots as one which does not follow the type of culture outlined by Dr. Reason. He illustrated the importance of data analysis in finding the root cause of accidents, that often go beyond the pilot, and recommended TapRoot analysis software.
He noted the worst thing a company could do is to fire a single pilot after an accident. “The problem does not go away, it needs to be analyzed to reveal what could be systemic operational problems that makes the entire company culpable, not just the pilot,” he said.
“Running the operation right, saves money,” he said, adding while insurance may pay for mistakes, settlement money from accidents and higher premium payments can be better used to improve the safety of an operation. “A company has to have internal enforcement of policies and procedures, they should have safety stand downs and, if something happens, they must get to the root cause of failures rather than just blaming the pilot or mechanic. Companies striving for safety must also have accountability which reaches to the top. A safe company is one in which they make going beyond the regs a competitive sport.”
Devaris also said the culture inside the FAA has changed to be less tolerant of problems. He also said the agency is moving toward self oversight for operators in favor of doing global analysis of problems to establish new safety initiatives.
Next Week – SMS Forces Changes for Regulators