SMS and Air Taxi Operations
Lessons and Opportunities
Presentation to ATAC
Kathy Fox, Member
Transportation Safety Board of Canada
November 14, 2011
Montreal, QC
Balancing Competing
Priorities
Service
Safety
Why do “safe systems” fail?
Drift into Failure
Dekker, S. (2005) Ten Questions About Human Error
“… Drift is generated by normal processes
of reconciling differential pressures on an
organization (efficiency, capacity
utilization, safety) against a background of
uncertain technology and imperfect
knowledge.”
Challenges Faced by Air Taxi Operations
• Challenging conditions: “on demand”, weather, difficult
terrain, smaller aerodromes with little/no infrastructure.
• Smaller, older aircraft with less sophisticated avionics
and systems: higher crew workloads.
• Flight crews often have less training and experience.
Lack of mentorship available to inexperienced crews.
• 703 a “stepping stone” to a career in larger operations.
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Accidents: 703 vs other categories
Total number of accidents and fatalities from 2001 to 2010, by operator
type.
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Why Change?
Traditional approach to safety management
based on:
• Compliance with regulations
• Reactive response following accidents
• “Blame and punish/ re-train” philosophy
Is insufficient to reduce accident rate
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Safety Management System (SMS)
A systematic, explicit and comprehensive
process for managing safety risks… it
becomes part of that organization’s
culture, and of the way people go about
their work. (J. Reason 2001)
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Desirable characteristics of organizations
effectively managing safety
Westrum Paper, 1998
SMS requirements
(Transport Canada)
Emphasis on organizational safety
Corporate safety policy and goals
Collective Efficacy
Identification of hazards; internal reporting
Task-Resource Congruence
Ensuring personnel are trained and
competent
Free-Flowing and Effective
Communications
Internal reporting
Clear Mapping of Safety Situation
Identification of hazards and managing the
risks; periodic reviews/ audits
Organizational Learning
Identification of hazards and managing the
risks; periodic reviews/audits
Clear Lines of Authority and Accountability
Accountable executive; Corporate safety
policy; SMS documentation
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Elements of SMS
Hazard
Identification
Incident Reporting
and Analysis
Strong Safety
Culture
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TSB Reports
• Observations:
– Inadequate risk analysis
– Employee adaptations
– Goal conflicts
– Failure to heed “weak signals”
– Non-reporting of incidents
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Loss of Control and Collision with Terrain,
Chibougamau, QC, 25 October 2007
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Loss of Control and Collision with Terrain,
Chibougamau, QC, 25 October 2007 (cont.)
Inadequate risk assessment
•
Pairing crew members with limited IFR and multi-crew
experience for flight in IFR conditions.
Goal conflicts
•
Completing flights vs. shortage of experienced pilots –
service vs. safety.
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Controlled Flight Into Terrain
Thormanby Island, BC, 16 November 2008
YVR seaplane dock, clear day
YVR seaplane dock, 16 November
2008. Note occurrence aircraft.
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Controlled Flight Into Terrain
Thormanby Island, BC, 16 November 2008
Weak Signals
•
•
•
Pilot was known for pushing the weather.
Company discussed weather decision making with pilot 3
times but this was not documented (as per company
SMS).
Clients requested this pilot since he flew when others
didn’t in marginal weather.
Goal conflicts
• Overt or passive client pressure to complete flights.
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Controlled Flight Into Terrain
Thormanby Island, BC (cont.)
Inadequate risk assessment/mitigation
•
Training in pilot decision making for departing in marginal
weather not provided nor required.
•
No company procedures to augment pilot’s decision to
depart.
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Collision at Takeoff
DHC-6 Twin Otter, Muncho Lake, BC, 8 July 2007
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Collision at Takeoff
DHC-6 Twin Otter, Muncho Lake, BC, 8 July 2007
Organizational issues
•
•
•
Company also sought approval for 704 operation with
DHC-6.
Significant additional risk assessment and administrative
work required to introduce new aircraft and new
operation.
Challenge of finding/retaining a Chief Pilot for 704
operation.
17
Collision at Takeoff
DHC-6 Twin Otter, Muncho Lake, BC, 8 July 2007
Inadequate risk analysis/mitigation
• Operational control/risk management practices did not
address risks of taking off from this short airstrip.
•
Both Twin Otter crew members new to working in small
seasonal operations.
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Collision at Takeoff
DHC-6 Twin Otter, Muncho Lake, BC, 8 July 2007
Employee adaptations
• Policies and procedures that may have prevented this
occurrence were either violated, not used or missing.
•
Takeoffs only permitted with minimum fuel and only crew
aboard from this airstrip
•
On accident flight, heavy fuel load and passengers.
•
Use of maximum performance STOL techniques without
TC approval.
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Collision with Terrain
Sandy Bay, SK, 7 January 2007
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Collision with Terrain
Beech A100 King Air
Sandy Bay, SK, 7 January 2007
Weak Signals
• Company knew pairing issues between these two crew
members, but unaware of the extent these would affect
safety.
• No CRM training – not required for 703 operations.
Board recommendation
• TC require 703 and 704 operations to provide CRM
training to their pilots (A09-02).
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Lessons Learned
• Goal conflicts, employee adaptations and drift
are naturally occurring phenomena and SMS
can help identify these
• Organizations can learn from patterns of
accident pre-cursors
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What Can Air Taxi Operators Do?
Implement SMS elements
• Hazard identification and analysis
• Internal occurrence reporting system
• Further training for pilots (CRM, PDM, etc.)
• Take time to analyze and re-evaluate hazards, risks,
occurrences, to identify “weak signals” to potential
accidents.
• Re-examine SOPs to remove “grey areas” that might
lead to employee adaptations.
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Conclusion
• Effective SMS depends on “culture” and
“process”
• Successful implementation takes unrelenting
commitment, time, resources and perseverance
• There are business benefits as well as safety
benefits
• Ongoing requirement for strong regulatory
oversight
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