Evolving Systems Safety 2006 Symposium
Keynote address, 9 November 2006
I am very pleased to be with you to present the keynote address for today's proceedings and to talk about safety systems, a topic that I am passionate about.
As an aviation safety regulator, CASA's primary focus is ensuring that the aviation industry has the competence and capacity to manage their own safety risks. It is not the job of CASA to do it for them. Having spent a number of years in the Air Force as a pilot and manager, in private enterprise as a safety consultant, airline operations manager and safety manager, and now operating at a senior government level in the highly political world of aviation, I have managed to develop both a practical and operational view about safety. This is what I want to share with you today.
I am sure that throughout this conference you will hear from some highly qualified international and home grown experts about the latest developments in safety systems and human factors. Forums like this are valuable for sharing this information.
But in my experience, I have found that safety management is a “hearts and minds exercise” in which the right attitude and behavior is crucial to sustained safety performance. It is not about just following regulations, having all the right manuals, and ticking the box that you have a safety department or safety officer. Don't get me wrong, following the regulations is an important part of the safety equation, but it is not the whole story.
It is my intention today to provide an Australian perspective on how the aviation safety regulator is striving to take a greater leadership role in espousing the “right” safety behavior and attitude. After all, if you think about it, CASA is representative of the very same safety problems that continually test the organisations it oversights. For instance, when conducting surveillance we don't always pick up all the safety risks, we don't have all the right safety data and we struggle at times to recruit and maintain the right people. I am sure that those here today from airlines, flying schools, maintenance organisations etc, will recognise the very same challenges as their own.
I want to talk about some recent and ongoing reforms in CASA that I feel are very necessary to better meet the changing demands of industry. Let me be clear that this is not just another change exercise. I hope that you will see that these changes are positive, I know I do.
Firstly, let me talk about the key principles that underpin the relationship between the regulator and industry.
There must be a shared responsibility for safety
An operator will always be better placed than the regulator to know and understand the safety risks they face in their particular circumstances. It is obvious that CASA does not fly or maintain aircraft, manage aerodromes or train pilots and engineers.
Yet in the past there has been a mindset, both within CASA and some people in the industry, that the delivery of safety outcomes was primarily the concern of the regulator and the regulations. This blinkered view grew up in the early days of aviation when the regulator did indeed hold-the-hand of industry whenever safety issues had to be addressed.
However, CASA does not hold the monopoly on risk management. For example, Qantas knows the detail related to the risks they face in ultra long haul operations (crew fatigue, engine efficiency, maintenance etc). Moreso than we do. It is not the job of CASA to tell Qantas what all the risks are in flying across the Pacific. However, it is our job to scrutinise the process that Qantas use to identify and mitigate their risks - in other words is their risk management process sound, thorough and systematic.
The word shared in this relationship does not mean that CASA is in partnership with operators. In order to stand back, remain objective, and add value to safety we need to remain fiercely independent and be able to go from encouragement to enforcement as the need arises.
Regulations do not ensure safety
Something I am keen to see an end to, is the philosophy that ‘as long as we meet the requirements of the regulations we will be safe'. Not so. The regulations can really only seek to cover what we believe are the minimum necessary requirements, and they can never hope to cover all situations and circumstances. What CASA really looks for in operators, and really is encouraged by, is where an organisation is able to demonstrate that they have gone beyond the regulations and have looked for more innovative ways to manage their risks, particularly those not covered by regulation.
A good example of this is the management of fatigue. For many years CASA has had in place CAO 48 which prescribes flight and duty time limitations for pilots. Despite not originally being based on any science, CAO 48 has largely stood the test of time. But increasingly, operators are looking for more flexibility. As a result CASA has issue a myriad of exemptions to CAO 48. More recently the authority has allowed operators (about 47 organisations at last count) to trial the implementation of Fatigue Risk Management Systems. You will hear more about the FRMS approach throughout the conference, so I will not go into any great detail – suffice to say, similar to an SMS an FRMS approach provides operators with more flexibility to manage crew working hours, provided the risks are identified and addressed.
Surveillance by the regulator will not identify all safety risks
Those of you that have ever done audits, know that they simply provide a snapshot view of a part of your operation at a given time. Similarly, regulatory surveillance is subject to the same pressures – our inspectors come and have a look at part of an operation in a short space of time and form an impression that the operator may or may not always agree with.
If an operator relies only on the regulator to identify safety cracks in their system, then they are sticking their head in the sand. CASA's surveillance program should be complementary to an operators own regular systems checks.
CASA is going through a fundamental period of reform to its surveillance system that involves changes to audit methods, but also to the individuals that make-up its audit teams. We are conscious of the fact that we need to be much smarter about surveillance and focus on systemic risk issues as well as some micro details. A large part of our current workforce has not traditionally operated this way, so that involves CASA making some fundamental changes to it's workforce capability. I will talk about this in more detail a little later.
Effort where it is most needed – focus on air transport operations
Historically CASA has tried to be all things to all parts of industry. However, this is flawed thinking if we consider what the travelling public rightly demand. A safe and sustainable passenger carrying air transport system. CASA has always devoted a fair bit of effort to the air transport sector – but it is now explicitly stated in our corporate plan.
Ironically, it is the air transport sector that enjoys the best safety record in Australia. In our GA industry, the fatality rate has remained fairly static over the last few years with recent figures from the ATSB indicating that between 1995-2004 at least, the average annual number of fatalities sits somewhere in the low 30's. And I am pleased to report that these figures are showing a downward trend.
Any fatalities in our industry are tragic, but the focus of any safety regulator must be to prevent those low probability but highly catastrophic events, involving multiple fatalities. In CASA's case this means the travelling public who pay good money and expect high safety standards. This approach is supported by a recent survey of public attitudes to air safety.
Challenges and Risks
There is no doubt that the increased focus on transport security worldwide is here to stay and a layered approach to security in aviation will be with us for the foreseeable future. If you had told me 2 years ago that CASA would have to devote significant resources to security related activities, I would have been sceptical. But that is just what we did early this year, when CASA had to issue thousands of aviation security identification cards (ASIC's) to pilots. We now are in the business of issuing about 20,000 ASIC's annually.
Drug and alcohol testing
The Minister for Transport announced earlier this year that regulations to require mandatory alcohol and drug testing would be introduced. This will see people working in safety sensitive jobs (pilots, aircraft engineers, air traffic controllers, cabin crew, refuellers, baggage handlers etc) subject to a range of testing requirements.
CASA has just completed a comprehensive series of workshops around the country, highlighting to industry the need for this testing regime and the basics on how it might work. Regulations are currently being developed, and are intended to be finalised by the end of the year, which will set out how the alcohol and other drugs testing regime will operate.
In my view, the aviation industry has lagged behind other transport modes such as road and rail, who have had drug and alcohol monitoring regimes for some time. It's about time we caught up, and it will be a challenge for CASA to ensure that whatever regime is introduced it achieves it's aim of protecting the travelling public.
The Federal Government recently announced that CASA would be the home for a new Office of Airspace Regulation. This Office will manage and implement the national Airspace plan. Like many countries, the management of Airspace has had political overtones, with various sectors of the industry lobbying from their own perspective. The challenge for CASA is to keep the discussion firmly centered on safety and to ensure that any changes address genuine needs.
Introducing Safety Management Systems
Air operators, maintenance organisations, aerodromes and training organisations – large and small – must identify their own safety risks and develop systems to manage those risks. This is part of introducing a Safety Management System. Many organisations already do this, some better than others, while there are others that have yet to fully understand and accept this responsibility. While CASA cannot manage the day-to-day operational safety risks of industry, there is, of course, much we can and will do to support and foster risk management across the various sectors of aviation.
Most of you will of course know that anything you read about safety management systems talks about the importance of (1) top-level management commitment and (2) having effective communication initiatives in place to ensure that people report safety issues, know about them and know what action to take. Having spent a few years working in an airline environment as an operational manager and also a safety manager, I know that these 2 things are harder to achieve than they look. It really comes down to management creating the right work environment for safety issues to be aired and this can only be done with the right behaviour and attitude, as I mentioned in my opening remarks.
Variable Approach to Safety Management
CASA is quite prepared to help operators foster or reinforce this attitude and behaviour, but there are some that will never come to the party. So what do we do about them? Well recently, I asked some of our human factors people to look into how our inspectors try and identify and detect poor safety attitudes amongst industry players. This arose out of some concern I had with several recent accidents highlighting pilots and others not following or ignoring established procedures. What our human factors people found is that in some cases CASA inspectors suspect who these people are, suspect that they are not doing the right thing, but there is often no real evidence that can be a basis for enforcement action.
One of the things from this review is that we will be taking a closer look at our expectations about key accountable persons. For example, when we approve Chief Pilots we check to ensure they have the right flying experience, number of hours etc, but we don't scrutinise their knowledge of safety management, including SMS principles or their understanding of the safety risks of their operation. If we can make it harder for people with the wrong attitude to safety to get in, we will do this through stricter entry control.
Significant Industry Change
Increasing financial pressures, such as aviation fuel, cost of labour and demands from the market are resulting in significant operational changes in all large airlines. In Australia, most of our established airlines are introducing new complex aircraft, our low cost carriers are exploring international operations, as well as the rapid expansion and the introduction of progressively larger aircraft in the regional airline sector,
This is a great deal of change in not a lot of time and may potentially represent an increased risk to passenger safety if the changes are not managed well.
In the past, CASA has tended to scrutinise traditional organisational wiring diagrams showing key accountable persons, and based on this gave a green light for operations. There is now significant departures from “traditional” carrier structures, with leaner and more streamlined management structures being adopted. Accordingly, CASA's focus must also shift to an emphasis on the effectiveness of both management and systems within these carriers, rather than simply the layout of their wiring diagram. This requires a different approach by our inspectors and a shift from a purely technical view to a broader systems perspective in addition to the technical approach.
Changes at CASA
I would now like to say something to you about the big changes that are happening in CASA. I should emphasise that what we are doing is not just change for the sake of change. Our guiding principles are clear. Achieving better safety outcomes is the prime goal of our operational changes. We are changing to meet the requirements of our passenger priority policy, with more resources channeled to the oversight of the passenger carrying sector.
CASA has always had good people, many of them highly professional, well qualified, with long experience in a wide range of aviation disciplines. But I had questions about how we used our people.
When I first joined CASA 2 and a half years ago I found an organisation dominated by process – fill in the forms, tick the boxes, without a lot of thought as to what that meant in terms of actual safety outcomes. There were a lot of people, highly competent in their technical fields, who had risen up the hierarchy to management positions, but were simply out of their depth as managers. Not necessarily their fault. Rather a problem of the system that placed them there. And that is a management issue that is not uncommon in the aviation industry more broadly.
So what changes to the workforce are we making?
Currently there is only one member of the senior management team that was at CASA when I arrived. That is over a period of two and a half years, so no slash and burn, but a much changed and refreshed team that brings new talent and enthusiasm and broad based experience from the aviation industry as well as the wider private sector. And to strengthen that team even further, I have recently appointed a new Deputy CEO Strategy and Support, with a key responsibility of getting CASA's service delivery up there with the best.
System Safety Specialist
We have recently recruited a new type of CASA inspector, the safety system specialist. Three are already in place. Their job is to oversight the safety performance of operators, their safety management systems and the operator's senior management responsible for those systems. These specialists compliment our technical inspectors and bring more of a focus on systems. I expect to recruit more of these system safety specialist over time. This is an example of the need for a regulator to adapt to a changing environment. If we are going to put emphasis on SMS to better manage safety risks, we need people specialising in that field.
Field Safety Advisors
We believe we can give better support to the industry by the way we deliver safety education and training. This is very important because I believe safety education and training, in some industry sectors is the best way to achieve safety outcomes. Our traditional approach to education has been to host large scale safety seminars at various locations and invite people to attend to hear whatever message. If you ever went to these seminars you typically saw the same faces and I always used to wonder about those that never turned up – these were the ones that probably needed to hear the message the most.
Our approach now is to take our educational programs to where aviation people work. We have appointed 6 Field Safety Advisors who are assigned particular geographical areas initially on the east coast and their job is to conduct regular site visits with “their” operators. This activity is clearly separated from surveillance.
These people are expected to spend their days out of the office, working hand-in-hand with industry to achieve positive safety outcomes by addressing real, not imagined risks which have been identified through objective research and analysis. Our hope is to be able to give industry, where they need it, the tools and knowledge to improve safety in their own organisations, as well as opening up and maintaining direct communications between CASA and industry outside the surveillance/audit structure.
Outcome focused regulations
CASA is also making fundamental changes to the way it formulates its new regulations. The new regulations will focus on safety risks and safety outcomes and will be supported by, for example, Acceptable Means of Compliance, written in non-legal language. This is a very different approach to the past. It will mean regulations which are simpler, shorter, outcome-based, and easier to comply with, although the regulations themselves will not detail how to achieve compliance. This approach is based on the European model which not only works but produces results consistent with CASA's goals. This year we are close to finalising the maintenance rules, and also finish the rules relating to aerial work applications and the sports aviation suite. The majority of the remaining rules will be processed next year.
In 2002, CASA decided that operators should be required to have Safety Management Systems to enable them to manage their own risks and hazards. Guidance material was produced in advance of a regulatory requirement. This comprised a series of booklets describing an SMS, and detailing how to go about introducing it. These education booklets have received wide praise and were used by ICAO in their recent education material on SMS, and indeed other transport modes and high risk industries.
It is now time for CASA to update this SMS material, in line with our new outcome based regulatory approach. You will see our new SMS education material rolled out in the second half of next calendar year.
Other priorities for education will be advisory material on FRMS, Flying Training Instructor competencies, GNSS and well as continuing our focus on the role and safety accountabilities of key position holders such as AOC holders, Chief Pilots, Maintenance Controllers etc.
Systems approach to Surveillance
In terms of our approach to surveillance we are implementing a targeted, focused approach, based on a serious assessment of risk, rather than random audits, or surveillance on some arbitrary cycle. For example, low capacity RPT and charter operations have been shown to have higher safety risks, so they are under increased scrutiny, with special teams formed for that purpose.
We have moved the bulk of our Air Transport and General Aviation operational positions out of Canberra to our new operational headquarters in Brisbane, and to our regional offices around Australia.
We are moving our own surveillance and audit of the industry away from a focus on scheduled audits assessing compliance with the regulations- what I call the ‘tick-the-box' approach, to a fully risk-based approach. In other words , if we have an operator who has a really pro-active approach to safety, has robust systems in place to identify potential safety problems and do something about them, who is always up to speed on the latest training of pilots and maintenance staff, why would we devote the same number of resources to them as to someone who is operating at the margin, who seems to do the bare minimum, and who seems to like to cut corners?
We are still doing regular audits, and we will still look at all operators. But there will be much more focus on risk assessment and devoting our resources to where they will have the greatest benefit to the traveling public.
What will the future CASA look like?
In short, the CASA of the future will not focus on digging around until breaches of the regulations are found.
When the CASA carries out on an audit or other surveillance the focus will be on an operator's safety systems and how they manage their risks. Confirming regulatory compliance will be part of, but not the whole story
We will be located closer to major industry centres, have a more diverse workforce and we will focus where the risks are greatest.
CASA will be taking a far more sophisticated approach to achieving safety outcomes, one that will reduce unnecessary burdens on the aviation industry, while working towards an even better air safety record for Australia in general, and for the traveling public, in particular.
The Future of SMS
A key part of our activities will of course be the introduction and oversight of Safety Management Systems.
Our approach to SMS will be to ensure that it is not an appendage to other systems but an integral part of the management and oversight of operations.
Our focus will be to test how well these systems are functioning, not just that they exist, and we will be looking for continuous improvement.
I am glad to have had the opportunity to speak with you today. The conference program contains an impressive line up of international speakers, so I sincerely hope that at the end of the meeting that you will be able to return to your respective workplaces having learned something new. I hope that you enjoy the rest of the conference, and for those international visitors you take the time to experience the beauty of Manly and our “harbor city”.
Finally, the title of my presentation included the words ‘ Emerging Risks to Aviation Safety' and I have spoken about some of the changes happening in the industry that must be managed carefully to avoid increasing risk. But I have mainly looked at it from the point of view of the regulator – how we must adapt to a changing environment if we are to be relevant.
But there is a broader risk that is not just for the regulator. For at least 15 years I have worked with like minded people and attended conferences, like this one, where, over time, we have developed the approach that I have talked about today - and I'm sure others will talk over the next few days. The development of SMS is the classic example. But the broader risk is that all this good work will be held in too small a circle - that we all will have convinced ourselves - but not the prime stakeholders - the traveling public.
An unsettling trend in some quarters is for a purely punitive approach following an aircraft accident rather than a safety benefits approach where lessons learned can prevent a reoccurrence. There is no question that if someone deliberately breaks the law there must be consequences but we all know that the right approach is to achieve improved safety outcomes and that's not always a simple right or wrong issue.
The challenge - as I see it - if we all believe that addressing systemic issues, including the complexity of human factors in aviation, is a vital part of improving safety outcomes, then it's time to stop just convincing ourselves - and start telling the broader community.
Bruce Byron AM
Chief Executive Officer
9 November 2006