CASA CEO, Bruce Byron speech at International Society of Air Safety Investigators International Seminar
CEO at the International Society of Air Safety Investigators - International Seminar
Seminar opening speech
31 August 2004
Thank you for inviting me to be with you for what I know is one of the more significant aviation gatherings in the international calendar for 2004. May I welcome you, and for those of you from beyond these shores, welcome to Australia.
I believe the last such seminar in this country was more than a decade ago. As elsewhere, the Australian aviation industry has seen profound changes in that time and I am sure this gathering will be an opportunity for you to gain some insight into those changes and the implications they may have for aviation safety investigation.
As the Chief Executive of Australia’s aviation safety regulator, it is probably sensible that I say a few words about where CASA fits into the aviation safety framework in this country. And to do that I need to say something about the functions we are required to perform by the legislation under which we operate. I would also like to give you some food for thought.
If you ask members of the public or indeed members of the aviation industry what is the role of an aviation safety regulator?, you will never get the same answer. I know – I’ve tried it. Some would have us exercise dominant control of industry organisations whilst others would prefer we leave industry players to get on with it without ‘interference’.
Like most issues where there are a range of opinions, or options, the right answer is somewhere in the middle. A careful look at the legislation that empowers CASA provides that clarity, and in my view, strikes the right balance.
Now, reviewing legislative matters is a dry subject at the best of times, so I promise to be brief, but these are the things we are required to do by law, so they are a proper starting point for an understanding of our place in the aviation safety system. We are required to perform, or take account of, a whole range of statutory functions in pursuing our legal obligations.
Most of them are fairly standard and have parallels in most international jurisdictions, so I won’t subject you to them.
But there are a few that I would like to highlight because it should explain the basis for directions we are planning to take CASA in the near future.
Section 9 (1)(f) of the Civil Aviation Act says we have the function of:
“Conducting comprehensive aviation industry surveillance, including assessment of safety-related decisions taken by industry management at all levels for their impact on aviation safety”
This part of the legislation is where we get our ‘head of power’ to conduct surveillance of the industry. What is particularly noteworthy here is that the only specific item of surveillance activity highlighted here does not target technical areas but asks us to put the spotlight on safety related decisions by management. I’ll come back to this later.
In 9(1)(g) we have the responsibility of:
“Conducting regular reviews of the system of civil aviation safety in order to monitor the safety performance of the aviation industry, to identify safety-related trends and risk factors and to promote the development and improvement of the system.”
Some interesting points of focus here are the need to look at the ‘system’, and specifically, the safety performance of the industry. Again, I’ll talk more on this in a moment, particularly in the context of management’s contribution.
And under 9(3)(a) we have the formal function of:
“Co-operating with the Bureau of Air Safety Investigation in relation to the investigation of aircraft accidents and incidents”.
BASI is of course now the Australian Transport Safety Bureau, and the ATSB’s Kim Bills will be talking to you shortly.
To take this last one first, in one sense it should hardly be necessary for there to be a formal provision in our functions requiring the regulator to co-operate with the independent aviation accident investigator. It just makes good sense and we would be crazy to even think of having some other model. In our case, the co-operative process is facilitated because both organisations operate within the same ministerial portfolio, and at a practical level the relationships between our people are good. But it is important not to get complacent, and we need to regularly review the relationship between the accident investigator and the regulator to make sure it is optimal, while being sensitive to the necessary points of independence within the respective roles.
And in this context, I should recognise that it is not just the relationship between the statutory regulator and the statutory investigator that is important. The industry has significant aviation safety investigation skills and experience, and we need to be sure that arrangements are in place for that knowledge to be part of the overall aviation safety management framework, in other words, part of the system. We have to avoid the idea that only the government-based organisations are the sole repositories of skills and knowledge. We are all in this together.
The other statutory functions I highlighted are interesting in the context of this gathering in that one of them gives us a statutory function or reviewing the overall aviation safety system, and this must include the contributions made to that system by the various players, including, of course, air safety investigators.
What I am clearly saying here is that the task of investigation is unquestionably part of the system – you don’t sit passively outside looking in all the time. In the same way that decisions and actions taken by pilots, mechanics, chief pilots, maintenance controllers, operational managers and CEO’s can affect safety outcomes, so too can the content of an investigation process and the recommendations that flow from that activity. In reviewing the system, we should constantly test each component for the quality of the outcomes, and the contribution made to the full system. In your case, I would encourage you to ask those questions of yourselves during the next few days.
Now this requirement for CASA to review the system has not been an area of our responsibilities that has been front and centre for us in the past, but we are changing that. It is easy for all of us to be focused on the things that are immediately in our face, that come out of left field and have to be responded to. But ensuring that the overall aviation safety system is in the best possible shape is very important, and it is something to which I intend to give some focus.
There have been many accidents and incidents investigated and a lot of very good data has been generated. But we need to be sure the process is not seen as an end in itself, that an accident is investigated, that a complex range of contributing factors are identified, probable cause findings are reached, and we declare victory and ride off to tackle the next investigation. We need to be sure that the results of your work do translate into improved safety, otherwise they become simply interesting technical exercises.
It follows that we need to have an overall safety system in place that ensures that the outcomes of accident investigations do feed into the system, and in particular that conclusions and recommendations that impact on systemic issues are tested, recognised by all those who need to take action, and are in a form that is amenable to action being taken.
Most importantly, it is vital that all the good material that you produce does not fall into some electronic black hole or database – without being used by the decision makers in the system.
Your information needs to be constantly trended, assessed, and compared with data from other sources – not every decade, not every year, but all the time.
At the risk of being controversial, I think we have a bit of work to get this one perfect. A good start would be to ensure that the terms, definitions, parameters, safety measures and health indicators used by operators, manufacturers, regulators and investigators are the same. This is one item of our system, here in Australia that CASA has identified as needing attention.
I am encouraged to see that your code of ethics includes a provision requiring the application of facts and analysis to develop findings and recommendations that will improve aviation safety. A sensible outcome-based approach perhaps, but one that is important not to lose sight of.
And I am further encouraged to see that your seminar papers include titles such as “investigate, communicate, educate: are we doing all three with the same energy?”, and another title, “lessons learned in the investigate, communicate, educate cycle”. These titles suggest to me that the issue of how we go beyond the investigation stage is one that is alive and well in this gathering, and that is a very good thing.
For our part, that is CASA, we have already commenced a review of the system, with modest beginnings, but this will increase as we expand our research capabilities.
I look forward to some of this work being conducted industry-wide, and I hope some will be able to be undertaken in association with the industry and academic bodies, not just within government.
And I should touch on the remaining statutory function I highlighted, the one that mentions looking at safety-related decisions taken by aviation industry management.
This one highlights an issue for us at CASA, and I suspect it may also be one for you. Our people have a lot of good technical skills and experience, and so do you. In your case it particularly relates to the skills and experience needed to analyze accidents and incidents and to come up with sensible conclusions and recommendations. In the last 25 years we have added people with behavioral or human factor expertise to the well-tested group of people with technical background in aviation operations.
But where do we all stand when we push the envelope beyond the immediate technical issues associated with an accident, and start to get involved with an organization’s management processes? In my experience with large organisations, particularly where they have a duty of care for the safety of people, I have seen evidence of potential deficiencies in management decision-making. This is nothing new, but we need to be confident we have the skills to objectively review management processes and procedures that may be somewhat removed from the technical fields with which we are most comfortable.
This may mean we need to involve people with no aviation experience, but who have well developed management systems knowledge. In our case as the regulator, my hope is that we can identify such system deficiencies before they cause problems, not recognise them only once we have started to pick up the pieces, and I hope your outputs will play a part in that process.
We need to be proactive in targeting, for example, management systems. This becomes a real issue for an organization like ours since we are drafting regulations requiring implementation of safety management systems.
In your case, you tend to be involved after the event. You have a tradition or providing excellent technical skills, but I suggest you also need to ensure you have the skills required to assess safety systems, management approaches, and so on.
Again, I see you have a paper “uncovering organizational deficiencies in maintenance operations”, so it would seem systemic and management-related issues are on your radar, and that is a good thing.
So, maybe I am preaching to the already converted.
Thank you for inviting me to be here with you. I wish your seminar the success it deserves and that you will all have an enjoyable and informative time.
It gives me great pleasure to formally declare the 2004 Seminar of the International Society of Air Safety Investigators officially open.
Chief Executive Officer
31 August 2004