Recently, Australia's CASA released a document "An Assessment of Trends and Risk Factors in Passenger Air Transport". This document is one of CASA's initiatives to identify risk and address it, thereby enhancing aviation safety. The notion of data gathering and analysis is not new and is contemplated in section 9(1)(g) of the Australian Civil Aviation Act, which obligates CASA to conduct regular reviews of the system of civil aviation safety. Indeed, similar exercises have been undertaken in the past, so in my opinion, this is a good second step in an eternal process; however I found the assessment a little superficial. I think that it could have been more comprehensive. Click here to read the report.
The US FAA established the Aviation Safety Information Analysis and Sharing intitiative (ASIAS) a few years ago with some success. Apparently, the keys to the success of this initiative are information sharing, analysis and trust. Clearly a high level of trust is required to enable useful information to be gathered and shared by the regulator and other relevant stakeholders (including global stakeholders). This requires a higher level of maturity on behalf of the regulator, industry and other stakeholders.
In a speech recently, the FAA Associate Administrator, Nick Sabatini stated inter alia, that the aviation community is on the threshold of reaching the next level in aviation safety, and the key to higher levels of safety is using safety data to identify remaining or previously undiscovered risk. Click here to read Mr. Sabatini's speech.
In the speech he gave an example of how data had been used to increase understanding and make a difference in aviation safety. Following an accident in August 2006 in Kentucky where an aircraft took off from the wrong runway, the ASIAS undertook a examination of 116 wrong runway departures over the past 20 years. In the study, they found that there were common physical characteristics that could lead to pilot confusion and result in a departure from the wrong runway. This is very powerful information.
Understandedly, many aviation safety initiatives have involved addressing some active failure in a system. For example, a wrong runway departure may be addressed by providing better familiarization training, documentation and signage for pilots; and once this is done, little more examination is undertaken to reveal latent failures in the system which may have also contributed to the incident.
In my opinion Mr. Sabatini has hit the nail on the head when he uses the phrase, "previously undiscovered risk.". Possibly, the low hanging safety fruit has been harvested, and the hard work is just starting. Industry and the regulator are now required to dig deeper to look for hitherto undiscovered active and latent failures. The latent failures are generally well hidden and some considerable trust, patience and energy is required to identify and address them.
Our challenge is to engender trust between industry and government agencies, encourage information sharing and find previously undiscovered aviation risk in all areas of the system of aviation safety.
As a former aviation safety regulator, I read with interest an article which appeared in Flight International magazine recently. Entitled, F
AA Oversight Role Slammed, the article outlined some of the issues facing the FAA as it evolves from being a forensic to a prognostic aviation safety agency.
FAA Associate Administrator, Nick Sabatini was quoted as saying that (inter alia), the days of randoming touching an airplane and hoping to find somthing are long gone; this was on the eve of a US congressional hearing called, "Critical Lapses in FAA's Safety oversight of Airlines". Apart for the usual change management issues, the problem appears to be the FAA's reliance with the Air Transportation Oversight System (ATOS) which relies heavily, but not entirely upon voluntary reporting mechanisms by the airlines themselves.
Alegations of "cosy" realationships, and matters appropriately raised by FAA whistleblowers have fueled the current round of dissatisfaction with the oversight arrangements. The FAA have countered with a plan to address perceived deficiencies. Of interest, is a restriction that will prevent Inspectors being recruited to an airline which they are or were responsible for oversighting. Other initiatives include regular rotation of Supervisory Inspectors, the establishment of a national review team to look into safety issues raised by FAA staff, and periodic reviews of the FAA Oversight functions.
Having been involved in this type of change, I see many similarities in what has occurred in Australia over the past 15 years or so. I have come to realise that law makers like the concepts (often because it saves money - and most can see sense in a holistic and scientific oversight strategy), but quickly get nervous and may revert to a preference for a simplistic objective oversight approach preference when the going gets tough (something significant occurs).
All common sense, research and experience indicates that a safety oversight strategy which relies heavily or entirely on "touching the airplane" (commonly called product audit), is at best lucky to find significant issues before they become failures. Conversely, a sytem that relies entirely on a systems methodology is also not fully effective. A good system relies on both, competent Inspectors, an analytical capability, good management and sound governance.
The lawyers who prosecute or defend play a deft hand in assessing the role of the regulator; on one hand they are critical of simplistic and unscientific approaches, and on the other, are also critical of what may be characterized as an over-zealous regulatory approach. The perspective is often determined by the circumstances of their client.
Notwithstanding all of the above, often this sort of change is not well managed and goes too far too quickly, or implodes into an incompetent mess. I guess the system is working when someone identifies the problems and adjustments are made, so that eventually a better system is established.
The role of the safety regulator is not an easy one; there is no need to articulate the reasons for they are well known. Their role is more difficult when change is required, and someone has the fortitude to implement them.
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