Transcript to see PowerPoint Presentation
SMS and Air Taxi Operations
Lessons and Opportunities
Presentation to ATAC Kathy Fox, Member Transportation Safety Board of Canada November 14, 2011 Montreal, QC
Balancing Competing Priorities
Service Safety
Why do “safe systems” fail?
Drift into Failure
Dekker, S. (2005) Ten Questions About Human Error
“…
Drift is generated by normal processes of reconciling differential pressures on an organization (efficiency, capacity utilization, safety) against a background of
uncertain
technology and imperfect knowledge
.”
Challenges Faced by Air Taxi Operations
• Challenging conditions: “on demand”, weather, difficult terrain, smaller aerodromes with little/no infrastructure.
• Smaller, older aircraft with less sophisticated avionics and systems: higher crew workloads.
• Flight crews often have less training and experience. Lack of mentorship available to inexperienced crews.
• 703 a “stepping stone” to a career in larger operations.
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Accidents: 703 vs other categories Total number of accidents and fatalities from 2001 to 2010, by operator type.
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Why Change?
Traditional approach to safety management based on:
• Compliance with regulations • Reactive response following accidents • “Blame and punish/ re-train” philosophy
Is insufficient to reduce accident rate
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Safety Management System (SMS)
A systematic, explicit and comprehensive process for managing safety risks… it becomes part of that organization’s culture, and of the way people go about their work
. (
J. Reason 2001
)
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Desirable characteristics of organizations effectively managing safety Westrum Paper, 1998
Emphasis on organizational safety Collective Efficacy
SMS requirements (Transport Canada)
Corporate safety policy and goals Identification of hazards; internal reporting Task-Resource Congruence Free-Flowing and Effective Communications Clear Mapping of Safety Situation Organizational Learning Clear Lines of Authority and Accountability Ensuring personnel are trained and competent Internal reporting Identification of hazards and managing the risks; periodic reviews/ audits Identification of hazards and managing the risks; periodic reviews/audits Accountable executive; Corporate safety policy; SMS documentation 8
Elements of SMS
Hazard Identification Incident Reporting and Analysis Strong Safety Culture 9
TSB Reports
• Observations:
– Inadequate risk analysis – Employee adaptations – Goal conflicts – Failure to heed “weak signals” – Non-reporting of incidents 10
Loss of Control and Collision with Terrain, Chibougamau, QC, 25 October 2007
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Loss of Control and Collision with Terrain, Chibougamau, QC, 25 October 2007 (cont.)
•
Inadequate risk assessment
Pairing crew members with limited IFR and multi-crew experience for flight in IFR conditions.
•
Goal conflicts
Completing flights vs. shortage of experienced pilots – service vs. safety.
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Controlled Flight Into Terrain Thormanby Island, BC, 16 November 2008 YVR seaplane dock, clear day YVR seaplane dock, 16 November 2008. Note occurrence aircraft.
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Controlled Flight Into Terrain Thormanby Island, BC, 16 November 2008
• • •
Weak Signals
Pilot was known for pushing the weather.
Company discussed weather decision making with pilot 3 times but this was not documented (as per company SMS).
Clients requested this pilot since he flew when others didn’t in marginal weather.
Goal conflicts
• Overt or passive client pressure to complete flights.
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Controlled Flight Into Terrain Thormanby Island, BC (cont.) Inadequate risk assessment/mitigation
• Training in pilot decision making for departing in marginal weather not provided nor required.
• No company procedures to augment pilot’s decision to depart.
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Collision at Takeoff DHC-6 Twin Otter, Muncho Lake, BC, 8 July 2007
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Collision at Takeoff DHC-6 Twin Otter, Muncho Lake, BC, 8 July 2007 Organizational issues
• • • Company also sought approval for 704 operation with DHC-6.
Significant additional risk assessment and administrative work required to introduce new aircraft and new operation. Challenge of finding/retaining a Chief Pilot for 704 operation.
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Collision at Takeoff DHC-6 Twin Otter, Muncho Lake, BC, 8 July 2007
•
Inadequate risk analysis/mitigation
Operational control/risk management practices did not address risks of taking off from this short airstrip.
• Both Twin Otter crew members new to working in small seasonal operations. 18
Collision at Takeoff DHC-6 Twin Otter, Muncho Lake, BC, 8 July 2007
•
Employee adaptations
Policies and procedures that may have prevented this occurrence were either violated, not used or missing.
• Takeoffs only permitted with minimum fuel and only crew aboard from this airstrip • On accident flight, heavy fuel load and passengers.
• Use of maximum performance STOL techniques without TC approval.
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Collision with Terrain Sandy Bay, SK, 7 January 2007
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Collision with Terrain Beech A100 King Air Sandy Bay, SK, 7 January 2007 Weak Signals
• Company knew pairing issues between these two crew members, but unaware of the extent these would affect safety.
• No CRM training – not required for 703 operations.
Board recommendation
• TC require 703 and 704 operations to provide CRM training to their pilots (A09-02).
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Lessons Learned
• Goal conflicts, employee adaptations and drift are naturally occurring phenomena and SMS can help identify these • Organizations can learn from patterns of accident pre-cursors 22
What Can Air Taxi Operators Do?
Implement SMS elements
• Hazard identification and analysis • • • Internal occurrence reporting system Further training for pilots (CRM, PDM, etc.) • Take time to analyze and re-evaluate hazards, risks, occurrences, to identify “weak signals” to potential accidents.
Re examine SOPs to remove “grey areas” that might lead to employee adaptations.
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Conclusion
• Effective SMS depends on “culture” and “process” • Successful implementation takes unrelenting commitment, time, resources and perseverance • There are business benefits as well as safety benefits • Ongoing requirement for strong regulatory oversight 24
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