Following a relatively minor accident, Ansett Australia recently set about overhauling the way the whole company looks at its safety task. This was not done in isolation - there is a growing understanding, manifested at recent air safety forums, that some traditional industry practices, and even early human factors initiatives, are no longer advancing airline safety.
Nowhere are human factors matters aired more diversely than in the Asia-Pacific region, where rapid airline growth has, until recently, brought record levels of fleet expansion, placing heavy demands on the recruiting, training and safety education of pilots, cabin crew, maintenance and other support staff, and all levels of management. The current economic slow-down could provide useful thinking time in which to assess the reasons for the region's rather dire safety record in recent years.
Australia has been given a significant role in improving regional air safety because its Asia-Pacific peers have noted that, uniquely, its airlines have not suffered a jet transport hull loss. Unusually, Australia's airline industry is also willing to acknowledge and discuss safety events and deficiencies. Australia's Bureau of Air Safety Investigation (BASI) assists in regional accident investigations as well as in safety systems education, and has helped to cement close ties throughout the region's air safety community.
At the annual "Safeskies" conference in Canberra last November, Capt Trevor Jensen, Ansett Australia's general manager of operations, revealed his company's rationale for a range of initiatives over the previous 12 months - in effect a total overhaul of the carrier's organisational approach to safety. Jensen, until recently a senior Qantas management pilot, was recruited to overhaul the Ansett system.
This change in thinking was sparked by a relatively minor accident in which a Boeing 747-300 on a flight to Kansai, Japan, turned back to Sydney and landed without its nosewheel extended, says Jensen. The event, almost unnoticed elsewhere, came as a shock because of Australia's history of freedom from jet airliner accidents. The publicity hit Ansett in the early stages of its first major venture into virtually deregulated overseas operations.
BASI's comments on the role of organisational factors were blunt: it found that commercial pressures to arrive at Kansai on its opening day had resulted in the "accelerated introduction" of the 747 into Ansett's operations. "Planning, implementation and management of the operational aspects of the aircraft introduction were deficient, particularly with respect to manuals and procedures, indoctrination and training of contract crew members, crew resource management training, and flight training to the line," said BASI.
Following that experience, Jensen has overseen the creation of a company safety system that could be a working model for the management of any carrier emerging from a regulated environment to find itself under new competitive pressures. Warning other airlines of what he calls "the comfort factor", Jensen reminds them that Ansett's management environment at the time of the event bore a striking resemblance to that of other carriers in the region that have yet to to embrace organisational reform.
"The culture at Ansett was that of a strong and pre-eminent centralised senior management," he says. "This was partly rooted in practices and traditions which had been successful during the prolonged decades of closely regulated domestic aviation before the 1990s."
Geographical remoteness had impelled Ansett to develop high levels of in-house technical expertise in areas which airlines in North America or Europe might have outsourced. "So," Jensen notes, "there was a cultural combination of centralised management and a sense of technical and operational esprit de corps. This tended to see people down the line either obey commands without challenge, or convince themselves that everything must be in order, despite private misgivings.
"Unfortunately, as the external realities were unfolding, specifically the introduction of new aircraft within the airline, the learned ways of doing things, or the 'comfort factor', became a major block in properly managing the change. There was also another factor at play - lowered risk appreciation," he says.
Jensen urges all airline managements to recognise that "key to the establishment of any culture is the fact that change emanates from the core corporate values of the organisation". A potential reaction to the Ansett incident, says Jensen, "-could have led the company to systematically scour the whole organisation of misfits. An inquisition could have effectively got rid of the flaws and carried a message of fear across the ranks". Such a purge would have had unfortunate effects, he warns, adding: "Many sociological studies on group behaviour explicitly demonstrate that a divide and conquer approach achieves just that - a divided workforce mistrustful of one another. What Ansett developed, however, was a full departure from punitive disciplinary measures. It saw the value of spreading the responsibility and accountability for safety across large sections of the company. In effect, the whole organisation is being transformed into a safety organisation."
BOARD SAFETY COMMITTEE
Jensen says the Ansett board is now supported by a board safety committee which meets quarterly, headed by Ansett International's chairman. This monitors all aspects of flight and industrial safety, compliance with legal and regulatory requirements, and takes responsibility for clearing preventative procedures.
A step further down the management chain, safety is reviewed in closer detail, says Jensen. "To ensure that safety pervades through the first-line management at Ansett, a senior managers' safety and security panel [which Jensen chairs] is convened monthly to review the safety/security status of the company." This panel includes the directors of safety, security, flight operations, maintenance and engineering, airport operations, medical, service delivery, human resources and Ansett's regional airlines.
The senior line managers from cabin crew, overhaul and maintenance, freight, aviation insurance, environmental affairs, dangerous goods compliance and the corporate counsel are also represented, says Jensen, "to ensure that safety issues are actioned by the airline at a high level where-the company safety culture is most able to be effected".
Specialised safety committees, including flight and cabin safety, chaired by managers from the safety department, are drawn from the respective line areas across all ports and bases. Again, safety and security information is shared, enabling solutions within the committee's scope to be developed and tracked. Core operations staff have analysed the company's current safety competencies, documented procedures to bring them in line with corporate values, positioned a non-punitive and self-correcting reporting system, and established a system-wide "safety net" to capture latent error causes.
Focusing on flight operations, Jensen plans to extend and unify cockpit resource management (CRM) as a critical intervention tool. "I don't believe that CRM should be a non-assessed activity," he says. "The time has come when the fact of CRM and the practice of human factors must be assessed. You can't have a situation where you say 'I'm sorry, your practice of human factors wasn't so good, but we're still going to pass you'. Those days are over, and CRM will be an assessed element of any training in any part of our checking procedures. If somebody fails to demonstrate the appropriate level, it will be a fail, just as it would be if they flew outside their tolerances on an instrument landing."
Ansett Australia has appointed Joey Anca, a human factors specialist formerly with Philippine Airlines, as its manager of human factors. Anca, who has been involved in the Ansett reform process, advocates a culture in which only the active endorsement of safety policy and practice by corporate heads will suffice. "In this state, the chief executive officer is the chief safety officer, or otherwise there is an assignment of such a position into top management levels," he says. "Safety is viewed as an inextricable partner of production and the service culture."
The core safety structure need only be a small but highly specialised group of professionals because safety committees and safeguards are spread through the whole organisation. "Safety pervades all levels of the organisation because everyone is convinced that safety is a part of doing excellent business," says Anca. "The company's corporate manuals are continually reviewed to include safety imperatives. There is a culture of collective participation in terms of hazard reporting and the culture of 'blame' is replaced by problem-solving techniques and potential hazard identification."
Ansett is now introducing a flight operations quality assurance programme based on flight data from aircraft-installed quick access recorders, a system that Jensen helped develop at Qantas. It also plans a revised training and checking programme that will direct more training resources towards individuals whose greater need is identified in the simulator.
"We're also putting BASI's 'INDICATE' [identifying needed defences in the civil aviation transport environment] programme into our regional carriers," says Jensen. "We have appointed a director of regional airlines and an operational adviser to assist them. It's no use 'Big Brother' having all the knowledge and saying when [the regionals] make a mistake: 'We could have told you that'."
Unusually, the company has set up its own internal air operator's certificate (AOC) audit programme as a safety system measure. Jensen explains: "We're moving slightly away from surveillance because I believe more in compliance than surveillance. You can go and sit on flight decks and watch people do things, but we need to be sure that the whole system is complying, and that, as a consequence, we meet all the requirements of our AOC."
Source: Flight International