ASSIGNMENT
COVER SHEET
GRIFFITH AVIATION
COURSE CODE
3515NSC
COURSE NAME
Safety Management
ASSESSMENT ITEM NUMBER
WRITTEN ASSIGNMENT (REVIEW) 1
ASSESSMENT TITLE
A REVIEW OF THE SMS PROCESSES
THAT COULD HAVE IDENTIFIED,
AND POSSIBLY PREVENTED, THE
F-28 ACCIDENT OF AIR ONTARIO
DUE DATE
15th May 2015
STUDENT NAME
REBECCA SPENCER
STUDENT ID NUMBER
S2942503
COURSE CONVENOR
Peter Bryant
WORD COUNT
1997
Self-Assessment
Grading
5

1
Criteria
2


3
4
4

3
2
1
Assigned
Total
grade
available
Weighting
%
4
/5
x 60
48
5
/5
x 15
15
4
/5
x 15
12
5
/5
x 10
10
TOTAL
85
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0.0
Executive Summary
In March 1989, flight 1363 of Air Ontario crashed after take-off from Dryden Municipal
Airport, Canada. This report aims to review the factors contributing to this preventable
accident, relying mainly on the Honourable Virgil Moshansky’s report. After categorising key
deficiencies of the air carrier into organisational, flight operations and maintenance, it was
found that numerous latent conditions could have been rectified through a Safety
Management System (SMS). Many of these conditions were found to be due to poor
management throughout the organisation. By following the ICAO SMS Framework
(Appendix A), this report considers the factors essential for identifying the latent conditions
contributing to deficiencies. The processes which achieve these outcomes would have
identified and possibly rectified the general failures leading towards the accident of flight
1363, had Air Ontario implemented an SMS.
Through a top-down approach analysis, one sees that in order for Air Ontario to achieve their
safety goals, the airline needed greater focus on their written safety policy and objectives,
after defining implementation methods, with secured compliance. This report found that
implementation of clear policies, ensuring standardisation and explicit documentation would
have clarified the understanding of all involved in flight 1363. When making operational
decisions under times of stress, maximum support is to be afforded to the flight crews.
Through Hazard Identification (HID) processes and Internal Reporting Systems (IRS), Air
Ontario would have identified deficiencies proactively, leaving time for active corrections to
be made. These methods of Safety Risk Management (SRM) can assist in the assurance of
safety for any organisation.
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Table of Contents
0.0
Executive Summary ......................................................................................................... 2
0.1 List of Figures ....................................................................................................................... 5
0.2 Glossary ................................................................................................................................. 5
1.0 INTRODUCTION .................................................................................................................... 6
2.0 DEFICIENCIES WITHIN AIR ONTARIO ............................................................................... 7
GENERAL FAILURE TYPES ............................................................................................... 7
1.
Communications .................................................................................................................. 7
2.
Error / Violations ................................................................................................................ 7
3.
Defences .............................................................................................................................. 7
4.
Procedures and Policies ..................................................................................................... 8
5.
Management ........................................................................................................................ 8
6.
Organisation ........................................................................................................................ 8
3.0 SAFETY POLICY AND OBJECTIVES ................................................................................... 9
3.1
Appointment of Safety Roles and Accountabilities ........................................................ 9
3.2
Organisational Processes .............................................................................................. 10
3.2.1
3.3
Resource Allocation ............................................................................................... 10
Explicit Documentation .................................................................................................. 11
4.0 SAFETY RISK MANAGEMENT AND SAFETY ASSURANCE ........................................... 12
4.1
Internal Reporting System ......................................................................................... 12
4.2
Investigations and Documentation ............................................................................ 12
4.3
4.4
Defences to Accident Causation ................................................................................... 13
Management of Change ............................................................................................. 13
5.0 SAFETY PROMOTION ........................................................................................................ 14
5.1
5.1.2
6.0
Safety Culture ................................................................................................................ 14
Safety Culture Index .................................................................................................. 14
CONCLUSION ................................................................................................................. 15
7.0 REFERENCE LIST: .................................................................................................................. 16
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Appendix A – ICAO SMS Framework ....................................................................................... 18
Figure B – Air Ontario Inc. Flight Operations Organisation (March 1989) ............................ 19
Appendix C – Ideal Management Structure for a Safety-Conscious Organisation ................ 20
Appendix D – Effective Safety Reporting – Five Basic Characteristics ................................. 21
Appendix E – Accident Causation ............................................................................................. 22
Appendix F – CASA Safety Culture Index ......................................................................................... 23
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0.1 List of Figures
1 - ‘The Organisational Accident’
2 – The Safety Space: Balance of the 2 P’s
3 – Levels of Efficiency for Hazard Intervention
0.2 Glossary
ALARP
As Low As Reasonably Possible
APU
Auxiliary Power Unit
CASA
Civil Aviation Safety Authority
CRM
Crew Resource Management
HID
Hazard Identification
ICAO
International Civil Aviation Organisation
IRS
Internal Reporting System
MEL
Minimum Equipment List
SOC
Systems Operational Control
SMS
Safety Management System
SRM
Safety Risk Management
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1.0 INTRODUCTION
This report reviews deficiencies noted in Air Ontario in the lead up to the accident of
flight 1363. Though Canadian regulation did not require SMS implementation at the time,
this report considers elements which would have identified key deficiencies, had an SMS
been in place. Processes to achieve these elements are discussed, highlighting how they could
have rectified the deficiencies and potentially prevented the avoidable accident of flight 1363.
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2.0 DEFICIENCIES WITHIN AIR ONTARIO
This report makes regular reference to the six groups of general failure types listed
below, listing key deficiencies noted throughout Air Ontario. These issues have been
numbered individually and are categorised further as organisational, flight operations or
maintenance (represented by colour).
GENERAL FAILURE TYPES
1. Communications
1.1 Lack of information exchange during and between flight operations
1.2.1 Use of sticky notes
1.2.2 Limited communication between cabin/flight crew and also with maintenance/
dispatchers
1.2 Pilots’ failure to report deficiencies/incidents  leaving next crew in the unknown
1.3 Relied on “verbal interim” from Transport Canada as approval for MEL draft
1.3.1 Decisions based on assumption and second hand information
2. Error / Violations
2.1 Regulatory standards not abided to
2.2 Mishandling flight operations
2.3 Improper operational control of dispatch function and maintenance practices
2.4 Erroneous flight release
3. Defences
3.1 Did not employ pilots with previous experience on the F-28 or transport category jet aircraft
3.2 Failed to employ additional aircraft/crew as backup
3.3 Lack of resourcefulness (little involvement with Air Canada – the parent airline)
3.4 Limited training:
3.4.1 Ground-handling staff: lack of resources/facilities to support F-28 at Dryden
3.4.2 CRM: pilots not taught to share workload nor cross-check
3.4.2.1 Did not involve flight & cabin crew and maintenance & dispatchers
3.4.3 Flight attendants never received practical training for emergency procedures on F-28
3.4.4 Dispatchers lacked adequate job training and personnel qualification
3.4.5 SOC dispatch personnel did not appreciate importance of their function
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4. Procedures and Policies
4.1 Maintenance problems noted in aircraft journey log continuously deferred, based on MEL
4.2 Pilots deferring maintenance, based on aircraft’s turn around period
4.3 Lack of airline’s own F-28 operations manual
4.4 Self-dispatch system, which lacked supervisions, developing into a hybrid system
4.5 Improper reporting and investigation systems
4.6 Safety operations procedures not written clearly for pilots
5. Management
5.1 Resource allocation  balance of protection and production
5.1.2 No ground start facilities at Dryden to support the F-28 aircraft
5.2 Little commitment to and promotion of safety practices
5.3 Prioritising of key issues
5.3.1 Operational supervisors preoccupied with matters regarding labour relations
5.4 Managerial staff
5.4.1 Lacked experience (i.e. Tom Syme appointed director of maintenance but had no
technical background or proficiency)
5.4.2 Numerous positions/roles appointed to individuals (e.g. Joseph Deluce concurrently
held managerial roles as: F-28 chief pilot, chief instructor, check pilot and manager of Air Ontario
F-28 program
6. Organisation
6.1 Policy making  lack of standardisation
6.1.1 Prevention of pairing of two pilots with low experience
6.1.2 Lacking standardisation for training and competencies
6.2 Culture lacked safe practice emphasis
6.3 F-28 program needed greater project coordination
6.4 Absence of strong ‘interface’ with the regulator (Transport Canada)
6.5 Weak supervision procedures in place
6.5.1 Absence of monitoring for maintenance practices and competence
6.6 Delineated working conditions
6.6.1 Few interactions between top/middle management and staff
6.6.2 Weak relationship/support between management and staff
6.7 Prioritisation
6.7.1 Competition driven  ‘jetitis’
6.7.2 Management team assigned “low priority” over filling vacant safety positions
6.7.3 Rushed acquisition of the F-28
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3.0 SAFETY POLICY AND OBJECTIVES
Figure 1 - ‘The Organisational Accident’
(Source: ICAO SMM, p 2-4).
Safety improvements and identification of deficiencies must be completed simultaneously, in
order to prevent accident causation. Risks arising from workplace or latent conditions can be
mitigated via SRM and HID, which will be discussed in section 4.0. Figure 1 above
emphasises monitoring of organisational processes, with methods to achieve this being
outlined throughout the report.
3.1
Appointment of Safety Roles and Accountabilities
The appointment of key safety roles is one of the first steps any safety-conscious
organisation considers, showing commitment from top management and developing safety
accountabilities (Appendix A). Though Air Ontario had a range of personnel appointed to
organisational roles, no positions were safety specific1 (noted in Appendix B). Any successful
SMS starts with top management and includes personnel on all levels, which is why each
department must involve representatives with the ‘safety action group’ (refer to Appendix C
for ideal structure). Had department representatives been involved in regular board meetings,
this would have presented the opportunity for hazards to be addressed.
1-
Captain Ronald Stewart was appointed as the safety officer, but this position was left vacant from 1987
until February 1989, leading into the F-28 accident. Furthermore, the management team “assigned a low
priority” (p876) over filling this vacant position.
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As this group includes representatives from senior management to staff, this generates
clear communication throughout the entire organisation, also improving supervision. With a
team solely responsible for safety, a board representing all departments can meet frequently
for continuous monitoring and review of safety procedures.
This proactive approach could have identified hazardous factors leading to general
failures noted under: 1.1, 4.3, 4.4, 5.1 and all under category 6 (‘organisation’).
3.2
Organisational Processes
Had safety management been a “core business function” (Bryant, 2015, Module 3) of
Air Ontario, organisational processes would have achieved effective SMS through a topdown effect. This then affects the workplace conditions, influencing active failures (i.e. errors
and violations) and addressing all deficiencies noted in Section 2.0.
3.2.1 Resource Allocation
Lacking balance between resource input for protection and production causes
deviations in an organisation’s safety space, as seen in Figure 2 below. Through IRS and
continuous monitoring, management would have noted the need for greater resources for
protection needs, maintaining appropriate balance of the “2 P’s” (Bryant, 2015, Module 3).
For instance, had maintenance reported the lack of spares to supervisors, management could
have sourced equipment necessary to enable aircraft operations (rectifying deficiencies 2.3,
2.4, 5.1, 6.5 and 6.7). Additionally, management should have seen the need for greater
training, improving flight crew experience and the level of expertise among
maintenance/dispatch personnel (addressing deficiencies 3.1, 3.3, 3.4, 5.4 and 6.1.2). A
‘bottom-up’ approach should have been employed, with improved training syllabuses
eliminating latent conditions.
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Figure 2 – The Safety Space: Balance of the 2 P’s
(Source: ICAO SMM, p 2-14).
3.3
Explicit Documentation
SMS must be explicit, ensuring all organisational activities are well documented and
accessible. This is where the airline could have recorded (once creating) relevant flight
operations manuals, training procedures and supervision reports. Explicit documentation
improves communication across all departmental levels and achieves standardisation
(through appropriate written policy). As seen in deficiencies 1.1 and 1.3, greater inter and
intra correspondence was needed to avoid ambiguity. Improved communication alongside
clear policy offers maximum support to flight crews when making difficult operational
decisions, such as when operating with an unserviceable APU.
With clear and accessible information, the following deficiencies would have been rectified:
2.1, 2.3, 3.3, 3.4, 4.3, 5.1, 5.3, 6.1 and 6.3.
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4.0 SAFETY RISK MANAGEMENT AND SAFETY ASSURANCE
4.1
Internal Reporting System
Strong HID processes, such as successful IRS, were needed throughout all levels of
Air Ontario, identifying deficiencies noted under categories 1, 2 and 3 (Section 1.0). An
effective IRS reflects organisations’ culture, with positive safety cultures eliminating
reluctant attitudes towards honest and timely self-reporting, with emphasis placed on
accountability and willingness (Appendix D). With an IRS identifying hazards, the airline
could have become more proactive and taken corrective actions to eliminate their risks to at
least a tolerable level. Additionally, Air Ontario could have adopted more in-depth pre-flight
procedures, to account for unreported incidents in previous journey logs.
4.2
Investigations and Documentation
Air Ontario needed to document safety risks and make the investigation accessible to
relevant personnel via suitable collection/storage of incidents. As Air Ontario only
investigated as a reactive response, risks developed without intervention. Greater use of a
database alongside flight data analysis and continuous monitoring would have identified
latent conditions actively, enabling corrective actions to minimise failures.
Addressing deficiencies 1.1, 1.2 and 4.5, the monitoring of an investigation database can
make an organisation predictive, becoming a highly efficient defence for SRM (Figure 3).
Had Air Ontario been more predictive than reactive, the airline would have noted that two
reported incidents before the Dryden crash showed commonalities with the serious F-28
accident. With similar adverse weather conditions, any pilot or supervisor should have
foreseen the risk of continued flight operations in such circumstances, something which could
have been easily prevented.
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Figure 3 – Levels of Efficiency for Hazard Intervention
(Source: Bryant, 2015, Module 3).
4.3
Defences to Accident Causation
Proactively implementing effective defences (Appendix D) creates a safer operating
environment. As noted in category 3 of general failures (‘defences’), it is evident that the
airline failed to make proper use of all three intervention platforms, which would have
rectified the following deficiencies:

REGULATION  2.1, 2.2, 2.3 and 4.3

TRAINING  3.4 and 5.4

TECHNOLOGY  1.2.1 and 6.1
Despite emphasis for training improvement, many mistakenly place an over-reliance on
training “as a means to improve safety” (Course notes, 2015), hence the need to combine
training with safety practices under regulation and technology also. Continuous amendments
to training and technology applications needed reference to previous experience/incidents,
which standardisation (through policy making) and an investigation database would assist in.
4.4
Management of Change
Air Ontario failed to see the importance of HID during their internal organisational
changes, when introducing new equipment and management structure. These changes needed
to be treated with their potential to introduce new hazards, hence why implementing the F-28
program during this time was risky and something to be avoided. SRM is associated with the
apex of safety (Appendix A), highlighting that mitigation, alongside risk defences, can
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“avoid, reduce [or] segregate” risks (Bryant, Module 5, 2015, p32), capturing deficiencies
3.3, 5.1, 5.3, 5.4, 6.3, 6.4 and 6.7. In terms of avoidance, the airline needed to rethink their
operational priorities and resourcefulness, indicating the necessity for greater interface with
the parent (and experienced) company.
5.0 SAFETY PROMOTION
5.1
Safety Culture
Poor safety culture saw to violations, combined with error, leading to a disastrous
outcome. Violations were executed by personnel on all levels (2.1), including a pilot of the
Captain rank, showing poor role model qualities from the experienced. Poor practice was also
seen in the cockpit, with flight crews responding to a cabin smoke problem by simply
deactivating the smoke detector (2.2). Safety culture is paramount in creating an
environment which encourages safe practices, such as cross-checks throughout all operations,
to eliminate error to an ALARP level (6.1 and 6.2). Culture can be used to develop
unquestionable standards of practice, making correct actions appear obvious to all personnel,
guiding them to appropriate responses to hazards (Pidgeon, 1991).
5.1.2 Safety Culture Index
Findings from the Moshansky Report have been used with CASA’s Safety Culture
Index to determine that the airline had a ‘bureaucratic’ safety culture. With a safety score of
64 points (Appendix F), Air Ontario was below the minimum threshold for a positive safety
culture, which requires a score of 93 (CASA, 2014). Air Ontario’s culture leading into the F28 accident saw to maintenance supervisors deferring problems, which had been logged by
flight crew, due to aircrafts’ short turn around periods (2.3, 2.4, 4.1, 4.2, 5.3, 6.5 and 6.7).
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6.0
CONCLUSION
After reviewing the deficiencies noted through Air Ontario, it was found that most general
failures occurred through management operations. Management, upon appointing key safety
people to roles, needed to include safety representatives from all departments and clearly
defined accountabilities. Further hazards would have been identified through an IRS and
stronger investigations. These needed to be stored on a suitable database to be accessible by
all relevant personnel. That would enable the air carrier to become predictive about flight
operations. As well, improved resource allocation and training procedures are two processes
which would have rectified many latent conditions. However, these decisions come down to
the management team and policies of Air Ontario.
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7.0 REFERENCE LIST:
Bartsch, R. I. C. (2013). Aviation Law in Australia. Sydney, New South Wales,
Australia: Thomson Reuters (Professional) Australia Limited
Bryant, P. (2015). 3515NSC Safety Management Module 1: Course Introduction &
Overview. Retrieved from Griffith University, School of Natural Sciences,
Learning@Griffith website:
https://bblearn.griffith.edu.au/bbcswebdav/pid-1211368-dt-content-rid3674264_1/courses/3515NSC_3151/Course%20Content/Module%201%20%20Course%20Introduction%20%26%20Overview%20ICAO%20SMS%20Template%20IC
AO%20SMS%20Template/ICAO%20SMS%20Framework.pdf
Bryant, P. (2015). 3515NSC Safety Management Module 2: Basic Safety Concepts.
Retrieved from Griffith University, School of Natural Sciences, Learning@Griffith website:
https://bblearn.griffith.edu.au/bbcswebdav/pid-1389403-dt-content-rid4162354_1/courses/3515NSC_3151/ICAO%20SMS%20Module%2002%20%20Basic%20Safety%20Concepts%20Part%201%282%29.pdf
Bryant, P. (2015). 3515NSC Safety Management Module 3: Introduction to Safety
Management. Retrieved from Griffith University, School of Natural Sciences,
Learning@Griffith website:
https://bblearn.griffith.edu.au/bbcswebdav/pid-1408063-dt-content-rid4245830_1/courses/3515NSC_3151/ICAO%20SMS%20Module%2003%20%20Introduction%20to%20Safety%20Management%282%29.pdf
Bryant, P. (2015). 3515NSC Safety Management Module 5: Risks. Retrieved from
Griffith University, School of Natural Sciences, Learning@Griffith website:
https://bblearn.griffith.edu.au/bbcswebdav/pid-1413903-dt-content-rid4290069_1/courses/3515NSC_3151/ICAO%20SMS%20Module%2004%20%26%2005%20%20Hazards%20%26%20SRM.pdf
GU | 3515NSC | NSC| Written Assignment 1 | Rebecca Spencer | s2942503 | Page 16 of 23
Bryant, P. (2015). 3515NSC Safety Management Module 8: SMS Planning. Retrieved
from Griffith University, School of Natural Sciences, Learning@Griffith website:
https://bblearn.griffith.edu.au/bbcswebdav/pid-1431645-dt-content-rid4415160_1/courses/3515NSC_3151/ICAO%20SMS%20Module%2008%20%20SMS%20Planning%283%29.pdf
CASA (Civil Aviation Safety Authority). (2014). SMS for Aviation – A Practical
Guide: Safety Assurance.
http://casa.gov.au/wcmswr/_assets/main/sms/download/2014-sms-book4-safetyassurance.pdf
Commission of Inquiry into the Air Ontario Crash at Dryden, Ontario (Canada), &
Moshansky, V. P. (1992). Final report. Ottawa: The Commission.
https://bblearn.griffith.edu.au/bbcswebdav/pid-1336051-dt-content-rid3984476_1/courses/3515NSC_3151/Moshansky%20Vol%201%20Dryden%20Report%281%
29.pdf
ICAO (International Civil Aviation Organisation). (2013). Doc 9859 Safety
Management Manual (SMM).
http://www.icao.int/safety/SafetyManagement/Documents/Doc.9859.3rd%20Edition.alltext.e
n.pdf
Pidgeon, N. F. (March 1991). Safety Culture and Risk Management in Organizations.
Journal of Cross-Cultural Psychology, 22(1). doi: 10.1177/0022022191221009
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Appendix A – ICAO SMS Framework
(Source: Bryant, Module 1, 2015).
Figure B – Air Ontario Inc. Flight Operations Organisation (March 1989)
(Source: Moshansky, 1992, p419)
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Appendix C – Ideal Management Structure for a Safety-Conscious Organisation
(Source: Bryant, 2015, Module 3)
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Appendix D – Effective Safety Reporting – Five Basic Characteristics
(ICAO, 2013, p33).
Appendix E – Accident Causation
(Source, ICAO, 2013, p19).
Appendix F – CASA Safety Culture Index
(Source: CASA, 2014, p41)