Scandalously competent
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It is twice as safe to fly on a scheduled flight in Australasia as
it is in the two next safest regions of North America and Europe. Forget the
rest of the world. These statistics come from the Flight Safety Foundation,
a world-renowned independent body whose aim is the improvement of safety in
aviation.
A recent overseas study, using a system developed and adopted by the Association of Oil and Gas producers in conjunction with Shell and the European Bank for Reconstruction and Development, placed Ansett as the second safest, and Qantas as third safest of all the major airlines in the world.
Australian Transport Safety Bureau statistics show that total aviation accident rates in Australia declined by 42% from 1990 to 1999. Improvements were seen in every sector except flying training during the last decade.
Against that background one of the Sydney talkback radio hosts recently described CASA in a newspaper commentary as scandalously incompetent. We have been described as being in meltdown, as a basket case. Certainly CASA has historically come under criticism for over a decade in its present guise or as the Civil Aviation Authority, which preceded it until 1995. The criticism continues today.
How can we explain the contradiction that suggests we have an outstanding safety record in the skies and an incompetent, or at best troubled, regulator?
Today I would like to explain why I believe CASA is a competent regulator. A scandalous suggestion for the media who tend not to report on how well we do. Certainly my views are supported internationally, where CASA and Australia are highly regarded technically by ICAO, the International Civil Aviation Organisation, which is the United Nations body responsible for all aviation. Australia is ranked in ICAO in the top ten aviation nations in the world
Before you can judge us in CASA, we really need to understand the role of the regulator that we are required to fill. The Government in 1995 decided to split the CAA and to separate the service provider, of air traffic control mainly, from the rule-maker and enforcer. Thus CASA, the regulator, and Airservices Australia, the service provider, were born. This was an unusual concept at the time, but one that is increasingly being recognised as the best way to avoid a conflict of roles within the one organisation. The Civil Aviation Act defines what CASA must, and can, do.
In brief the Act says that we have to establish a regulatory framework, secure compliance with the regulations, issue certificates, licences etc., assess (and this is a direct quote from the Act), assess 'safety-related decisions taken by industry management at all levels for their impact on aviation safety', monitor the performance of the industry and keep a watch on international safety developments. We are expected to educate, advise and to foster awareness in management of the importance of safety, and compliance with legislation, and to promote consultation and communication
This defines our role and in fulfilling it we 'must regard the safety of air navigation as the most important consideration'. In practice the Act, and the Regulations that sit below it, impose substantial legal duties on CASA. In fulfilling these duties we are occasionally required to take strong action against businesses, be they operators or maintenace organisations. We have a wide range of enforcement powers but there are some gaps in our tools which need to be filled. In particular we have not had a more serious tool than a formal counselling until we reach the suspension or cancellation of a certificate, which threatens the livelihood of a business. We are currently introducing a system of administrative fines, and a scheme for voluntary enforceable undertakings is before Parliament. While not a sweeping change, this will be a useful additional enforcement tool which, I believe, will be warmly welcomed by industry.
Let us not for one second suggest that this is an easy role. One of the world's leading experts on human factors and particularly in aviation, Professor James Reason of the University of Manchester, wrote an important book entitled 'Managing the Risks of Organisational Accidents'. One chapter of the book is 'The Regulator's Unhappy Lot' and he has a section in that chapter which is dear to my heart, and explains the predicament we face frequently. It is called "Damned if you do, and damned if you don't'. I don't need to remind you of the fact that in the recent past we have faced criticism for being too tough on Yanda Airlines, Aquaflight, Sydney Harbour Seaplanes and Ord Air Charter but not being tough enough on South Pacific Seaplanes, Whyalla Airlines or even Ansett or Qantas. In my job you need broad shoulders, a philosophical expectation of criticism whatever you do, and a resilient nature.
In the light of this brief explanation of our role, let us look at some
of the criticisms that have been publicly voiced of CASA recently, both in the
context of what our job is defined to be, and also what it could be if changes
or improvements can or should be made. During discussion
of the Ansett maintenance matters of recent months, one phrase seemed to take
hold in the public debate, self-regulation by the airline. Let me make it very
clear today: There is no self-regulation by any sector of aviation, and particularly
not by any airline, large or small. There can only ever be one set of regulations,
and therefore by definition one regulator. Sports aviation, where the degree
of risk is understood by the participants who are fully aware of those risks,
is allowed a degree of self-administration. That is appropriate. But self-regulation....no
way.
So what led to this misconception? I believe the confusion arises from two important cogs in the wheel of safe aviation. First, CASA must, out of necessity, delegate various regulatory powers to industry. This is not self-regulation however. The delegates become representatives of CASA and are required to act as though they were CASA employees. These people are periodically examined on their performance for us, and the ultimate regulatory control over these delegated activities is retained by CASA. Delegations can be, and are, revoked. This is standard practice in many, if not most, countries, and particularly the more mature aviation nations.
The second point which has led to this misunderstanding is the move towards a systems audit approach. This was started nearly two years ago with the large airlines, and is now being rolled out in varying forms to all segments of industry. In the old days of the Department of Civil Aviation in its heyday, the approach to regulation was totally prescriptive and totally hands on. Operators were told exactly what they had to do, exactly how to do it, and Examiners of Airmen and inspectors checked that it was done the 'right' way. This was fine in a small and developing industry, but aviation grew very quickly and no Government could afford to continue this total 'hands on' approach. The system evolved into one of product auditing, where inspectors sampled industry's performance by visiting the hangar or sitting in the cockpit during flights. It was even laid down how often they had to fly, and where, such that the inspectors looking after Qantas managed trips to London, Los Angeles, Honolulu, Tokyo, Bangkok, Hong Kong, Bali as well as Melbourne and Brisbane. And these had to be done a number of times every year. Nice Job! But sitting in a cockpit for hours does not tell you much about the overall health of the airline. Neither does walking round the hangar tell you the weaknesses in a maintenance organisation. There is a school of thought that much was learned in the tearoom, and the importance of informal intelligence cannot be underestimated today. As an example a disaffected work force will act as a quality informant for the Authority. But more was needed than the sampling of the product that was the mainstay of our auditing or the benefits from intelligence sources.
Business entered the era of quality management, ISO accreditation, and the concept of systems auditing took hold. Systems auditing is the best tool we can use for ensuring that operators perform their functions and embrace their responsibilities properly. It is about reviewing the systems in place to ensure there is not a single point of failure. It is about heightening the awareness of companies, and particularly of Boards, of the necessity for such systems. Good systems produce good results. Weak systems increase the likelihood of bad results. In practice, we are finding that we are learning far more, as are the management teams who hold the responsibility. We don't hold hands. We also ensure that we sample an adequate number of results of the systems to validate their effectiveness. We encourage an adoption of a safety culture which ensures the defence mechanisms are in place to minimise failures. We audit the systems which create that culture.
It was asked at the time, validly, how come we did not pick up that Ansett had failed to comply with an important maintenance requirement? The answer to this again goes back to the matter of operator responsibility which is required by the Regulations. Let me give you a simple example. I own an aircraft. The maintenance period, a bit like a car's service interval, is the earlier of 100 flying hours or twelve months. When the aircraft goes in for its service, if I can use that word, there are around half a dozen Airworthiness directives that must be complied with, a number of other service bulletins to be actioned, as well as the requirements of the standard schedule of maintenance. And that is for a fairly simple privately owned aircraft. Clearly the responsibility must lie with me as the owner, not CASA as the regulator, to ensure these things are done. Otherwise just start to calculate what CASA's work force and budget would need to be to know everything that was happening, and to ensure everything that needed to be done was done, and was done correctly. We would need to duplicate the operator's workforce. Think of it as a policeman sitting in the cab of every long distance truck to ensure speed limits are observed! The fact that we leave the responsibility where it is accepts that mistakes will be made, let us not deny it. The human is normally the weakest link in the process as we all make mistakes. What CASA has to do therefore is emphasise the criticality of having checks and balances within each system to ensure that mistakes are discovered before anything untoward happens and that there is not a single point of failure.
The regulatory system ultimately and essentially is linked to, and aims to build up, the professionalism, integrity and honesty of everyone involved in the aviation industry.
How do we compare with our international regulatory colleagues, particularly in times of stress? I have been reflecting on the reaction to the tragic Concorde crash last year. The French authority immediately grounded the Concorde, the UK CAA did not. Neither was criticised for their actions. Evidence was produced of a number of previous incidents of tyre failure causing wing puncture. The aircraft had not been grounded, nor was it suggested that it should have been. What would have happened if that had been a Qantas Concorde in similar circumstances, or the Concorde had been certified in Australia? I have a suspicion that we would have lost a Director of Aviation Safety, a CASA Board, and possibly even a Minister.
I believe there is a well recognised problem confronting regulators, worldwide and in many industries. If a problem exists because someone in industry makes an error, the regulator, not the regulatee, tends to get the blame. "It's you're fault, you should have known". Yet clearly this is wrong. It dilutes the sanctions on the regulatee, someone else is getting the blame, and reduces the pressure on them to lift their game. Why should they if the spotlight will fall on the regulator for their transgressions.
Another criticism laid on us is are we fair? Do we treat the big airlines in the same way as the small airlines? The answer is a categorical yes, although the circumstances can appear different. Yes, we take action which means that each year one or two small airlines are forced to close. No, we have not to date closed down any of the major airlines, though if their continuing operation is considered an immediate threat to safety, then I assure you that we would.
In broad terms we are looking for a capability and a willingness on the part of every airline or maintenance organisation to operate safely. Capability can easily be improved when weaknesses are discovered, either by employing the right people, amending systems, or in the simplest of cases, by suitable training. Willingness is a state of mind.
Small airlines tend to be dominated by a single owner or a Chief Pilot. There is nothing inappropriate in this, and some of our best small airlines are at the pinnacle of the industry because they are dominated by such a person with a fanaticism for safety and quality. But if you have an owner who talks the talk but does not walk the walk, or one who deliberately flaunts the Authority or at best meets the regulations in a minimalist way, then clearly the willingness is missing. The only way to achieve a change to safety when it reaches such an unacceptable level is to take action strong enough to force a change of attitude. Sometimes this is just not feasible and stronger action against the operation is taken.
Bigger companies with active independent Boards of directors, aware of their corporate governance responsibilities, and particularly their responsibility to shareholders and customers, are clearly always going to be more receptive to the need for improvement when a denial of the need would pose a threat to the business. Their willingness is driven by the commercial imperative to be safe or lose the goodwill of their passengers, staff and business associates.
The FAA in the US has talked about a partnership approach between the regulator and industry. I have a concern that this is open to misinterpretation of an excessive closeness to the industry, and particularly to the big airlines. Clearly everyone in the industry should share the same goal of the highest possible level of safety. CASA as the regulator must work with the industry whenever it can to achieve this goal. We recognise this in our Corporate Plan's vision of safe skies for all. We recognise it in our Corporate Plan's enunciation of our challenge, which is 'to lead the aviation community in providing Australia with a world class air safety environment which has public trust and confidence'. Leadership requires a supportive collaboration with those you are trying to lead. The end result is that we must have a sensible working relationship with the aviation community, but we must also know when to draw the line and take disciplinary action or initiate legal action through the processes available to us under the law. For this reason CASA does not use the word partnership in describing its approach.
So to go back to where I started. Is CASA competent, do we have an air safety record to be proud of? The answer to both these questions is a firm yes. The safety record figures speak for themselves. Aviation, like all other forms of transport, will never be totally safe. Accidents will happen. Interestingly, twice as many people die each year in small boat accidents as do in aviation accidents. And our standards are still producing a safety record which is the envy of the rest of the world.
CASA is a young organisation, born into a turbulent environment. In the past two years we have put together a comprehensive strategic view of what is needed to keep Australia at its pinnacle in aviation safety. We have recruited a large number of staff with recent industry experience: 89 new technical specialists have joined CASA in the past 24 months with an average of nearly thirty years working in the industry, This, when combined with those with many years of regulatory experience, allows us to put together strong teams for audits and inquiries. It is also the backbone of the cultural changes we are making in the organisation. We have set about a significant internal review of our business practices, with the intent of focussing our resources where they do the most good, and doing what we do in as efficient and as simple a way as possible. There are improvements under way, and more planned and we have been in a state of change, and change cannot be rushed. But they are sensible measured improvements which add to our ability to fulfil our difficult role.
Equally, organisational stability is vital to securing reform. We need continuity at the leadership levels. We cannot live under threat of sacking the board or senior executives when things go wrong if serious efforts are to be made to fix problems.
We have a number of critics, mainly individuals with their own strong ideas. Some are pushing an agenda loudly that is inconsistent with our statutory obligations. It is easy to criticise, it is much harder to be accountable and to deliver.
We have a great story to tell as an aviation nation. Let's not treat aviation as a tall poppy, but support and encourage what is one of our most successful, vibrant and important industries. The future of the industry in Australia is dependent on encouraging and enthusing a new generation in the way my and previous generations were enthused. Schoolchildren need to be encouraged to enjoy the same thrill and excitement that came from the Smith brothers, Hinckler, Kingsford-Smith, and still enrapturing audiences today with her tales of the pioneer days, Smithy's most vibrant pupil Nancy Bird-Walton.
My goal is that aviation safety should generate as little interest in the media as, say, boating or shipping does today, because the success of our safety regime is recognised and supported by all its participants, be they industry, politicians, passengers or the non-flying public. It's time to be proud of what we are achieving as a great aviation nation.
Thank you.
Mick Toller, Director of Aviation Safety
Media contact
Peter Gibson
ph 02 6217 1015
mobile 0419 296 446