The Pacific and Australasian CRM Developers’ and Facilitators’ Forum 2024 (PACDEFF)

Type
Speech
Date
Location
Pacific and Australasian CRM Developers’ and Facilitators’ Forum 2024 (PACDEFF)
MELBOURNE Vic
Speaker
Pip Spence
Director of Aviation Safety

Firstly, I'd like to acknowledge the traditional owners of the land on which we meet, the Wurundjeri (wuh-ruhn-juh-ree) people of the Kulin nation and pay respect to their elders past, present and emerging.

This is my first time at PACDEFF and I'd like to thank Wayne for the invitation and commend him on the interesting program that he's pulled together for the next 2 days.

Phot of CASA CEO/DAS

When Alexander Pope made famous the phrase 'to err is human' in the early 18th century, he was reiterating what people had known for a long time.

Pope was quoting a Latin proverb that has been attributed by some to the Roman philosopher and dramatist Seneca the Younger but which may have had earlier Greek origins.

Seneca's complete quote was 'To err is human, but to persist is diabolical', while Pope opted for a more positive 'To err is human, to forgive divine.'

But both recognised the propensity of humans for making mistakes.

A NASA study of 60 normal flight operations across 3 airlines found 1896 errors, or about 31.6 per flight. The main categories were checklist use, monitoring and primary procedures.

Errors are not always a bad thing – they are often how we learn – but there are some circumstances where they can be fatal, and not just for the people who make them.

Aviation has adopted increasingly sophisticated strategies over the years to address the role played by humans in accidents and I'd like to highlight some of the steps we've taken.

Taking human factors seriously

There's an old aviation adage that says flying is the second greatest thrill known to humanity – landing safely is the first.

Fortunately, that nearly always happens these days but when it doesn't its big news.

The figures vary but it's accepted that the majority of civil and military aviation accidents have a human error somewhere in the chain of events leading up to them.

A NASA study in 2013 suggested human error was the primary cause of 78.6% of fatal general aviation accidents and 75.5% of general aviation accidents.

And the issues don't just occur in the air.

The US Federal Aviation Administration says about 80% of maintenance errors involve human factors such as fatigue, complacency and stress.

Over the years, we've learned that people do not make mistakes in a vacuum – there are social, operational and organisational factors shaping human error.

Today, we examine mistakes in terms of a failure across an entire system.

We look at both the positive and negative contributions people make to the performance of a system – not just their propensity for error but also their resilience, their ability to adapt and their commitment.

Like Seneca, we accept that people make honest mistakes and that being aware of and reporting errors is a positive move that shouldn't necessarily result in regulatory action.

Addressing this is not something regulators can do alone – it requires a cooperative effort between operators, employees, industry associations and experts.

The need to treat human factors and performance in a system-wide way is emphasised in the International Civil Aviation Organization's Manual for Human Performance for Regulators released in 2021.

It observes that human performance 'supports the ability of regulators to make it easy for people in the aviation system to do the right thing and avoid negative safety consequences.'

ICAO highlights the importance of developing expertise and integrating human performance in regulatory practices so that we can recognise the multiple influences across the aviation system that can affect safety during day-to-day operations.

CASA takes human factors seriously and we have embedded the concepts in our philosophy, our educational campaigns and our regulations.

We have our own in-house experts and we participate in the international network of human performance practitioners, researchers and aviation authorities.

We recognise the need to integrate human performance into a range of functions and the need to collect and analyse human performance data.

We've asked scheduled air transport operators to deliver human factors/ non-technical skills training for more than a decade and we're gradually expanding that to include all air transport operators.

This is part of an overall strategy that includes the wider use of safety management systems and training and checking systems and is designed to protect Australia's enviable safety record.

We also use safety and risk analysis to guide our actions and thinking and we are moving towards a system based on improved safety outcomes rather than prescriptive regulations.

It's been a long journey and one that is ongoing as we continue to gather data, build our expertise and find new ways to ensure safe outcomes.

This is all happening in a dynamic environment where the aviation industry – a sector that has always embraced progress – faces some of the biggest changes since the arrival of the jet age.

A quick CASA overview

Safety is always our priority at CASA and we're keenly aware that airline passengers expect us to work with the aviation community to ensure they safely reach their destination.

We have a philosophy that commits us to approaching our regulatory functions consultatively and collaboratively while considering relevant considerations such as cost.

It requires us to communicate meaningfully with stakeholders, build trust and respect and fairly balance the need for consistency with flexibility.

Just culture is built into this philosophy and we encourage and embrace its use by our staff and its development throughout the aviation community.

Communication is a key to this and we're committed to working with the aviation community and addressing the issues raised.

We receive input from the sector through our staff, online consultations, post implementation reviews and regular interaction with stakeholders at all levels, including our executives and board.

I also have the Aviation Safety Advisory Panel, which is made up of individuals with deep and varied aviation experience that provides me with advice – either directly from the panel or when necessary through the establishment of technical working groups which deal with specific projects.

Our full-time staff of about 830 are kept busy across a widening scope of responsibilities ranging from drones, airspace, air traffic control, training and airports to all classes of aircraft operators.

Regulatory reform is a key endeavour and our initiatives are designed to streamline the rules and make them more accessible to industry while maintaining Australia’s high level of safety.

While the shift from the Civil Aviation Regulations to the Civil Aviation Safety Regulations is largely complete (and I'll come back to this), we continue to look for ways to ensure what we are asking of operators is appropriate. In 2022 we published our General Aviation Workplan, which aimed at providing the general aviation community with visibility about what we were doing to safely reduce unnecessary regulatory burdens on general aviation. As set out in the workplan we have delivered improvements to pilot licensing, streamlined maintenance arrangements and aviation medical reform.

Another area on which we've been concentrating is improving service delivery to make dealing with us quicker and more convenient.

We also have an eye on the future and we're collaborating closely with our international counterparts and industry on emerging technology.

We're in the process of updating our Remotely Piloted Aircraft System and Advanced Air Mobility Strategic Regulatory Roadmap.

Built from the ground up in consultation with industry, this outlines our approach for RPAS and AAM regulations over the next 10 to 15 years and outlines how we plan to safely integrate these technologies.

Flight ops and a focus on safety

One of our biggest projects in recent years has been the lead-up and ongoing transition to our flight operations suite.

Coming into effect from December 2021, this is a major milestone in a regulatory reform agenda aimed at improving safety while reducing complexity.

It consolidated hundreds of legal documents into 6 Civil Aviation Safety Regulations (CASR) Parts and their associated Manuals of Standards.

And where appropriate, the rules are outcome-based rather than prescriptive.

We deferred some provisions from the start to ensure we maintained the focus on achieving the safety outcomes we were seeking.

Based on feedback (both internal and external) it became clear as we worked through implementation that we needed to further adjust some timelines to allow everyone to transition to new requirements.

This was because the new requirements will delivery safety benefits, so we did not want to turn this into a 'tick and flick' exercise.

We expect improved safety outcomes once key organisational requirements such as training and checking, safety management systems and human factors/non-technical skills training are implemented and matured by operators.

We're now coming to the end of the third year of the transition with training and checking systems and new rotorcraft performance standards due to be finalised next year.

Our next focus will be looking at the roll out of safety management systems and human factors/non-technical skills training for certain operators and how best to support them while ensuring the safety benefit of these 2 initiatives.

The concept behind mandating SMS is to get operators to think more about improving safety in their organisation and to help them use tools such as human factors to systemically identify and analyse risks.

This has a positive impact on safety management by reducing errors, improving communication, cutting injury rates, reducing costs and boosting employee satisfaction.

Many aviation sectors already have SMS requirements, including flight training organisations, maintenance organisations, aerodromes, large air transport, and self-administering organisations.

Safety will be further enhanced when we expand these requirements to include all air transport operators, and some aerial work operators.

HF/NTS training aims to ensure all operational safety critical personnel have a knowledge of how people react within their environment and strategies for communicating as a team, decision making, maintaining situation awareness and managing stress.

Across all these important initiatives we have been very mindful about the need to ensure what we asking for is appropriate for the size of the organisation, and that we provide clear guidance and best practice examples of what organisations need to comply.

Fighting fatigue

Estimates vary as to how many accidents involve fatigue but studies in the past two decades have identified it as a probable cause in about one in five major aviation accident investigations.

We're keenly aware of the importance of getting people to provide information on fatigue and this was why we formed the human performance team to work with operators to introduce fatigue risk management system programs to their operations.

We know under-reporting is a problem – pilots are worried that if they tell employers they're fatigued, it may have negative consequences.

We've recently added a section to our website confirming our commitment to applying the principles of just culture in our enforcement actions and the use of safety information.

Operators need this information to improve rosters and other aspects under an FRMS and, more broadly, within an SMS.

Under our flight crew fatigue regulations, operators must use the information they gather to continuously improve their management of fatigue risks and we monitor this through de-identified data from fatigue reports, sleep and other surveys.

Civil Aviation Order 48.1 came into effect in 2021. Under the rules there are obligations for flight crew licence holders, air operator's certificate holders, aerial work certificate holders, and Part 141 flight training organisations.

Operators have the option to use a prescriptive or flexible approach but we noted that using a fatigue risk management system provided the most flexibility.

CASA can also approve variations to the prescriptive rules provided they are minor or limited in nature. These may appeal to operators who do not require a Fatigue Risk Management System.

We're currently planning to run a post implementation review of the fatigue management rules, and once that's completed we'll be looking at potential longer-term plans to help support fatigue management practices for cabin crew, engineers and helicopter aircrew.

Upset prevention and recovery training

Of the three broad causes of inflight upsets – aircraft systems, environmental conditions and human error – pilot-induced accidents represent the most frequently identified reason for loss of control.

The training programs developed to counter such upsets – 'undesired aircraft states' we call them – come under the heading of 'Extended Envelope Training' (EET) or, more commonly, upset prevention recovery training or UPRT.

Such accidents mostly result from inappropriate flight control inputs, spatial disorientation, poor energy management, distractions, wake turbulence, icing, and improper training or systems understanding.

Alongside the manual flying skills necessary for recovery, human factors training is an important aspect of a successful UPRT program.

FAA research, for example, shows that in many loss of control in-flight incidents and accidents, the monitoring pilot may have been more aware of the aeroplane's state than the pilot flying. Yet failure to communicate or act properly on a doubt or concern can become a contributing factor of a subsequent accident.

Changes to the International Civil Aviation Organization Annexes 1 (personnel licensing) and 6 (operation of aircraft) prompted CASA to start work on our own UPRT program around 2017. This began with a detailed and extensive program to prepare our own UPRT specialists and continued with several years of intense industry consultation.

We issued an advisory circular on UPRT at the end of 2020 with mandatory UPRT commencing in December 2021 as part of the flight operations regulations.

The UPRT program aligned with the FAA's focus and targeted Part 121 operations (that is, air transport operations involving larger aircraft). CASA refined this focus to cover aircraft of 30 seats and above and a maximum take-off weight greater than 8,618 kgs with the provision to mandate this training for other operations where we thought it necessary.

This meant that by 31 March 2022, all operators of large aircraft needed to have UPRT in their flight crew conversion and recurrent training programs.

Human factors topics covered include situation awareness, startle and surprise response, and threat and error management.

CASA amended flight simulator requirements to ensure adequate fidelity and instructor feedback tools outside the normal flight envelope. Along with this came new standards for instructors and training syllabuses.

Although we've focused on UPRT best practice and compliance for air transport, an interesting development has been the interest in UPRT from general aviation, including the sports and recreational world.

CASA has been closely supporting this work, looking at how we can encourage UPRT by supporting instructors rather than making it mandatory at this level.

One way we're doing this is by awarding grants of $5,000 each; one to develop best instructional technique and the other involving UPRT awareness training for Recreational Aviation Australia pilots. Feedback has been especially useful and will be central to our revised UPRT Advisory Circular.

This more recent 'whole of aviation' UPRT is an industry-driven initiative rather than CASA mandated.

A workshop in mid-November will bring together a range of stakeholder inputs, preparing CASA for the next steps involving instructor and training program standards and training organisations approvals.

Ongoing education

Being an effective regulator requires a lot more than making and enforcing rules – education is key to promoting a successful safety culture.

In fact, safety promotion is often the missing pillar of an effective safety management system!

We offer tools to help people incorporate human factors and performance into their systems.

Resources we offer include best practice consultation, evidence-based specialist advice, information on ICAO human performance guidance and HF safety research.

We've also put together resource kits for pilots and engineers.

The safety behaviour human factors for pilot resource kit covers 10 topics relevant to small operators and individual pilots.

Subjects includes safety culture, human performance, communication, teamwork, situational awareness, decision making, threat and error management and design and automation.

There's also a workbook with practical exercises, discussions and reference material as well as video interviews with industry experts and practitioners.

The safety behaviour human factors for engineering resource kit looks at issues such as error management, human performance and its limitations, decision making, fatigue teamwork and stress, workload and time pressure.

Human factors contributing to safety are also a focus of our successful Pilot Safety Campaign.

It became obvious through our engagement with pilots that making good decisions was a key to avoiding accidents and this is a major focus of this campaign.

It was launched in 2022 in conjunction with the Australian Transport Safety Bureau, Australian Maritime Safety Authority, Airservices Australia, the Bureau of Meteorology (BOM), industry bodies and flying schools.

Under the tag line 'Your safety is in your hands', it encourages pilots to keep up to date with aviation safety developments, refresh their knowledge, invest in their ongoing development and, importantly, stay safe.

We used ATSB data to build our campaign and safety topics based on accident and incident data.

Topics we focus on are non-controlled operations, weather and forecasting, flight planning and controlled aerodromes and operations.

Our pilot safety hub provides a range of safety resources and useful information including webinars, podcasts, videos and products to enhance pilot safety around this topic as well as the others I mentioned.

We also send out targeted newsletters to rotary and fixed wing pilots as well as engineers.

Our pilot safety campaign has resonated with the aviation community and more than 8 in 10 (83%) pilots now recognise the campaign and more than half say they learned something new.

In addition, 67% of pilots who saw the campaign did something as a result and almost 6 out of 10 (58%) report that the campaign made them think twice about the things they do when planning their flight and flying.

Clear communication

In 1883, Pedro Carolino wrote an English-Portuguese phrasebook despite having little or no command of English.

History does not record how many people ended up spouting phrases such as 'the stone that roll not heap up not foam'.

What we do know is that comprehension issues are not limited to owners of what has been described as the worst phrase book ever.

All of us here know that clear communication is key to safety and that ambiguity is its enemy – so we decided to tackle this issue.

The result is a growing series of plain English guides (or PEGs) that explain in an easy to understand but accurate way what members of the aviation community need to do to meet regulatory requirements and remain safe.

So far, we have guides for balloons and hot air airships, flight crew licensing, general operating and flight rules, fatigue management, vertiport design and micro and excluded drone operations.

They join our existing Visual Flight Rules Guide and there are more guides on their way.

The guides can be downloaded free from our website or hard copy versions are available from our online store for a nominal fee plus postage.

Pilot mental health

The current aviation medical system poses a significant barrier to aviation professionals seeking help or disclosing a mental health condition because of the fear of losing their licence.

That's why pilots and air traffic controllers can find acknowledging their own distress and reaching out for help a difficult step.

Mental health issues can impact people in a variety of ways, from sleeplessness or excessive worry, low mood, through to a formal diagnosis of mental illness.

We want the symptoms to be approached by pilots in the same way as other common health issues, such as cardiac problems and diabetes, which can often be managed safely.

An innovative concept presented to ICAO by Australia in 2022 addressed the barriers preventing pilots and controllers from seeking help.

Led by our AvMed team, Australia suggested ICAO develop guidance to help medical examiners and regulators use risk assessments within an SMS approach to decide whether a person's mental and physical state affects their performance and safety.

Similar to the globally proven HIMS program designed to assist pilots with addiction and substance diagnosis, Australia's mental health proposal would involve peer support workers – aviation professionals who understand the pressures and barriers pilots and controllers are experiencing.

In collaboration with qualified mental health care teams approved by the regulator, peers could offer support from within the industry. This would mean pilots and controllers with symptoms that can be safely managed don't need to deny their illness, avoid treatment or potentially not operate at their best.

Since 2022, there have been a number of positive developments in this area in the international arena and CASA continues to be a leader in the implementation of a risk-based, systems-oriented approach to mental health aero-medical assessment.

These include recommendations by the FAA aimed at reducing the stigma associated with mental illness in the aviation community and a framework for mental health risk assessment and support in Europe.

We're working with other organisations in Australia and abroad on the kind of system I've just described and our 'Safe Haven' program is viewed by international regulators and stakeholders as an ideal model for breaking down barriers to seeking help.

Of course, we're not the only organisation looking at pilot wellbeing and I would like to acknowledge The Australian Federation of Air Pilots' Continuous Resilience Development Program for its efforts.

We're looking closely at how we can work with the federation on this program.

Future challenges

It's hard to believe it's been more than 55 years since the saying 'To err is human but to really foul things up requires a computer' appeared in an American newspaper column.

It's a sentiment that has gained greater currency as computers have become ubiquitous in our lives.

One reason for this is that there sometimes seems to be a disconnect between the people who design computer systems and the people who have to use them.

Aviation is no different.

There's no doubt that computer systems designed by aircraft manufacturers and their suppliers to boost safety have made a significant contribution to reducing accidents.

But there have been examples where pilots have been overwhelmed by the information these systems provide or where automation has acted in ways the pilots didn't expect.

Qantas Flight 32, an Airbus A380 crippled by an engine explosion near Singapore in 2010, was a classic example of information overload as was an Airbus A330 that went on a roller-coaster ride in 2008 following a computer fault.

A potential tragedy was averted by experienced pilots in both Qantas cases but there have been others, such as Air France Flight 447 and the Boeing 737 MAX crashes, where this was not the case.

Our industry needs to remain vigilant for unintended consequences as automation becomes more sophisticated and to look beyond the cockpit to the human factors involved in designing, programming and building the technology involved.

Emerging technologies such as advanced air mobility aircraft, remote air traffic control towers and bigger, more complex drones will make this even more important.

Conclusion

I hope I've given you a sense of the importance we place on human factors/human performance and some of the things we're doing.

We've been increasing our capability in this area and we're keen to collaborate with all players to get the best safety outcomes in the most efficient way possible.

We all have an exciting and busy future ahead of us and here at CASA, we're looking at what resources we'll need to cope with new developments.

We want to work with industry and the broader aviation community, and we want various sectors of industry to work together as we face the challenges and opportunities ahead.

As something that touches all facets of aviation, human factors and human performance will be a key part of this process. Thank you.

Online version available at: https://www.casa.gov.au//about-us/news-media-releases-and-speeches/pacific-and-australasian-crm-developers-and-facilitators-forum-2024-pacdeff
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