Griffith Aviation Assignment: 3515NSC Safety...
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Michelle Shiels S2942509 3515NSC Safety Management Written Assignment Page 1 of 15
Griffith Aviation
Assignment: 3515NSC
Safety Management
Due:1700 015 May 2015
Assignment: Air Ontario Written Assignment
Weight: 30%
Word Count: 1982 words
Student Name: Michelle Shiels
Student Number: S2942509
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Abstract
On March 10, 1989 an Air Ontario Fokker F-28 Mk1000 (registration C-FONF) crashed on take-
off from Dryden Municipal Airport, Canada, at 12.11pm Central Standard Time. Flight 1363 had
been travelling from Thunder Bay to Winnipeg via Dryden. Of its 65 passengers, 21 died, as well
as Captain George Morwood, First Officer Keith Mills and one of two flight attendants aboard.
The initial cause found for the incident was ice contamination which led to a loss of lift. Previous
incidents of a similar nature had attributed sole responsibility to the captain of the aircraft;
however the report issued by Virgil Moshansky (1992) identified a complex system with failures
on many levels, each of which contributed to the accident. As a result, the Dryden incident has
become a study in how to create, implement and monitor an effective Safety Management
System (SMS).
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Table of Contents
1. INTRODUCTION .................................................................................................................................. 4
2. IDENTIFIED SAFETY DEFICIENCIES AT AIR ONTARIO ......................................................................... 5
2.1 Incompatible Goals.................................................................................................................... 5
2.2 Organisational Deficiencies ....................................................................................................... 5
2.3 Poor Communications ............................................................................................................... 6
2.4 Poor Defences against Design Failures ..................................................................................... 6
2.5 Poor Defences against Hardware Failures ................................................................................ 6
2.6 Poor Training ............................................................................................................................. 6
2.7 Poor Procedures ........................................................................................................................ 7
3. HAZARD IDENTIFICATION AND MITIGATION .................................................................................... 8
3.1 Safety Policy and Objectives ..................................................................................................... 8
3.2 Safety Risk Management ........................................................................................................... 9
3.3 Safety Assurance ....................................................................................................................... 9
3.3 Safety Promotion .................................................................................................................... 10
4. CONCLUSION .................................................................................................................................... 11
References ............................................................................................................................................ 12
APPENDICES .......................................................................................................................................... 13
A: Example of a Safety Policy Statement ...................................................................................... 13
B: Example of key safety personnel placement within an organisation ....................................... 14
C: Risk Management Process and Risk Analysis Matrix ............................................................... 15
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1. INTRODUCTION
“When anyone asks me how I can best describe my experience in nearly forty years at sea I merely
say uneventful… I have never been in an accident of any sort worth speaking about… I never saw a
wreck and have never been wrecked, nor was I ever in any predicament that threatened to end in
disaster of any sort.”
Captain John Edward Smith, H.M.S. Titanic (New York Times, 1912)
The statement above derives its poignancy from the fate of its author, which was to become a part
of one of the greatest disasters in history. It highlights that a period of time without accidents does
not necessarily indicate an absence of hazards. The system approach to safety management
recognises that humans make mistakes, and plans for multiple levels of redundancy to prevent a
single error from causing catastrophic consequences (Reason, 2000, p.768). The system will only fail
when it is neglected to the point of failure occurring on multiple levels, as was the case with Air
Ontario. The Reason model of General Failure Types (Figure 1.1) depicts how process failures in
various areas of an organisation contribute to error-enforcing conditions. There is considerable
overlap, and it is important to note
that failures at the top of the
organisation filter down to other
areas. In the case of Air Ontario,
latent failures as high as goals of the
organisation affected error-enforcing
conditions. This filtered down to
affect the company’s organisation,
communications, design, hardware,
training and procedures. This report
will identify deficiencies that existed
at Air Ontario and then outline how the
implementation of an SMS could have
avoided the accident.
Figure 1.1: The relationship between General Failure Types, Safety Management System Processes and Error Enforcing Conditions. (Reason, 1997, p.136)
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2. IDENTIFIED SAFETY DEFICIENCIES AT AIR ONTARIO
2.1 Incompatible Goals
2.1.1 Air Ontario was a growing company, making its first movements into jet operations.
Productivity was seen to be more important than protection due to economic pressure. The conflict
is evident in Air Ontario’s mission statement (June 17, 1988):
“The creation of a safe and reliable diversified Air Transportation system serving Central Canada and
Northern United States, whose primary goal is the maximisation of profitability and return on its
shareholders’ investment while optimizing feed traffic to and from the Air Canada network.”
2.2 Organisational Deficiencies
2.2.1 Safety audits were not conducted in an effective manner. Air Ontario did not conduct internal
audits, although Air Canada did perform an audit on the company via a contractor as part of its
operational review when it obtained controlling interest in the company. William Rowe, member of
the Board of Directors for Air Canada expressed dissatisfaction with the audits conducted on Air
Ontario, as logbooks, aircraft and maintenance records were not examined as thoroughly as he
would have expected them to be. It did not assess Air Ontario’s new F-28 jet program and the fact
that Air Ontario had no Flight Safety Officer (FSO) was not reported.
2.2.2 For a period of more than 12 months leading up to Dryden Air Ontario did not have an FSO.
This is particularly significant as a new aircraft type, the F-28, was being introduced to the fleet. In a
reactive measure, Air Ontario appointed Captain Ronald Stewart as FSO to head their internal
investigation into the incident.
2.2.3 The role of the project manager for the F-28 jet program was not formally defined, and was
carried out by the Chief Pilot in addition to his regular duties, overburdening his workload.
2.2.4 The position of F-28 project manager was filled by an individual without the necessary
experience.
2.2.5 No supervision of the F-28 project manager was in place.
2.2.6 Check Captains received inadequate company support, as cited by Check Captain Castonguay,
who resigned in 1988 after just 6 weeks.
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2.3 Poor Communications
2.3.1 Reporting systems lacked confidentiality. Air Ontario FSO Captain Ronald Stewart initially set
out to conduct a phone survey of F-28 pilots, however he discontinued the survey after just 5 calls
because a pilot in a position of superiority became emotional about the possibility of incrimination.
2.3.2 Reporting systems lacked documentation, accountability or assurance of feedback. Two
incidents of a similar nature had occurred prior to Dryden, involving Air Ontario F-28s in icing
conditions. Causal investigations were not conducted, and information was passed onto other pilots
in the form of a bulletin containing generalised information.
2.4 Poor Defences against Design Failures
2.4.1 The aerodynamic design of the F-28’s wings makes it extremely intolerant to even a small
amount of ice accretion. Previous reports of icing incidents had not been acted upon in an effective
manner.
2.4.2 Two previous incidents of a similar nature had occurred, which Air Ontario had failed to
investigate and learn from.
2.5 Poor Defences against Hardware Failures
2.5.1 Air Ontario did not have a Minimum Equipment List (MEL) in place for the F-28.
2.5.2 Smoke was reported in the cabin of the F-28 four days prior to the accident. This was found to
be caused by oil leakage from the APU. The APU was not fixed. The APU was not working on the day
of the accident.
2.5.3 Air Ontario had a history of deferred maintenance due to a shortage of parts.
2.6 Poor Training
2.6.1 Air Ontario did not have any pilots who were experienced with the F-28, and outside resources
were not utilised. Management determined that flying the aircraft more would solve this problem.
2.6.2 F-28 training manuals and training syllabi had not been developed by Air Ontario at the time
the aircraft began operations.
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2.6.3 The Systems Operational Control (SOC) dispatcher for Air Ontario in London dispatched a flight
release containing numerous errors. SOC provided no training on the F-28 to dispatchers when the
aircraft was introduced to the fleet.
2.6.4 There was a low level of F-28 expertise in Air Ontario Maintenance Operations.
2.7 Poor Procedures
2.7.1 A survey revealed that Air Ontario pilots felt that Safety Operating Procedures (SOP) were not
written or controlled well enough.
2.7.2 Policies were not in place to prevent the operation of the F-28 without a standard operating
procedures manual (SOP) or Minimum Equipment List (MEL).
2.7.3 Policies were not in place requiring Air Ontario to have scheduled internal audits.
2.7.4 No policies were in place to require pilots to de-ice a second time before departure. Some Air
Ontario pilots were not even aware that de-icing was available at Dryden. The Route Manual did not
contain these services.
2.7.5 No procedures were in place to assist pilots with dealing with the fuel load/pax last minute
changes (as per Dryden) that were common with Air Ontario.
2.7.6 Captain Morwood was forced to refuel at Dryden with one engine running due to the broken
APU. No operational guidance was provided for refuelling/de-icing procedures with the engines
running.
2.7.7 The first officer observed snow on the wings prior to take-off (looking out the cockpit window).
A flight attendant observed a thick layer of clear ice on the wings prior to take-off (looking out the
cabin window). No procedure existed instructing the pilot to observe the wings from the cabin.
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3. HAZARD IDENTIFCATION AND MITIGATION
“We cannot change the human condition but we can change the conditions under which humans
work.”
James Reason, 2000, p.769
If we are to accept that humans will always make mistakes, then it is necessary to implement an
effective Safety Management System (SMS) to provide redundancies as a safeguard against human
error (Simmons, 1989, p.13). The Australian Civil Aviation Safety Authority defines SMS as “a
systematic approach to managing safety, including the necessary organisational structures,
accountabilities, policies and procedures,” (CASA, 2009, p.8).. The 12 Elements of SMS (categorised
under 4 Elements) provide a sound guideline for the creation of such a system (ICAO, 2013, 5.3).
What follows is an outline of SMS features that Air Ontario could have implemented, which would
have spared them the Dryden occurrence. Specific deficiencies that would have been addressed by
these measures are listed at the conclusion of each section.
3.1 Safety Policy and Objectives
3.1.1 Development of a Safety Policy Statement which explicitly detailed the company’s SMS (and
how it conformed to regulations), committed management to achieving high safety standards, and
described how safety would be monitored and improved upon (Appendix A).
3.1.2 Communication of the Safety Policy Statement and associated safety goals to staff.
3.1.3 Appointment of key safety personnel, who were qualified, trained, dedicated to their
respective areas and exercised a degree of independence from management (Appendix B).
3.1.4 Creation and communication of clear definitions of the safety responsibilities and
accountabilities for each role within the company.
3.1.5 Development of an Emergency Response Plan delegating personnel and resources to specific
areas in the event of an emergency.
3.1.6 Development of an SMS manual containing the Safety Policy Statement, legislated SMS
requirements, policies and procedures related to SMS, accountabilities and responsibilities of
personnel and company SMS goals.
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3.1.7 Development of safety policies to address known issues encountered within the company, such
as de-icing procedures, fuel load/passenger last minute changes and standardised icing check
procedures.
3.1.8 Development of a Minimum Equipment List for each aircraft type held by the company,
specifying who was accountable for ensuring parts were available.
Deficiencies Addressed: All deficiencies are directly affected by safety policy and objectives and
management’s commitment to safety.
3.2 Safety Risk Management
3.2.1 Utilisation of a standardised risk management process involving identification (linked to
reporting systems and audits), analysis of probability and severity (Appendix C), assessment and
mitigation.
3.2.2 Regularly scheduled safety meetings for each sector of operations as well as meetings between
safety officers and management to pass on safety critical information and discuss safety data
collected in safety assurance processes.
Deficiencies Addressed: 2.2.2, 2.2.3, 2.2.4, 2.2.5, 2.3.1, 2.3.2, 2.4.1, 2.5.2, 2.5.3, 2.7.3.
3.3 Safety Assurance
3.3.1 Implementation of a
voluntary reporting system
that was confidential, non-
punitive and accessible. The
Head of Safety could have
been responsible for
reviewing data, implementing
appropriate actions, providing
timely feedback to the
reporting agent and
documenting the process in a
Figure 3.1: Characteristics of an effective reporting system (ICAO, 2013, Figure 2.7)
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centralised data base.
3.3.2 Development of a policy outlining occurrences for which it would have been mandatory that
employees report.
3.3.3 Development of a policy which mandated a schedule for comprehensive internal and external
safety audits (which included contractors). These audits would have gathered information to drive
continuous improvement of the SMS.
3.3.4 Appointment of a qualified project manager who was dedicated to overseeing any major
change implemented by the airline and who was supervised by and accountable to the Head of
Safety.
3.3.5 Development of a policy which mandated minimum requirements for training, documentation
and resources (e.g. manuals, training materials, spare parts) prior to the introduction of a new
aircraft type, and which spanned Systems Operation Control, Flight Operations and Maintenance
Operations.
3.3.6 Development of a policy which mandated compulsory safety reviews upon the introduction of
any significant change. Checklists, surveys and confidential interviews could have formed part of the
review.
Deficiencies Addressed: 2.2.1, 2.2.2, 2.2.5, 2.3.1, 2.3.2, 2.4.1, 2.5.1, 2.5.2, 2.5.3, 2.6.1, 2.6.2, 2.6.3,
2.6.4, 2.7.1, 2.7.2, 2.7.3.
3.4 Safety Promotion
3.4.1 Development of a Safety Induction Manual for each operational sector, which would have
contained a checklist of safety items for new employees to be introduced to upon entry to the
company, and specified who was accountable for inducting new employees. It could have included
company safety policy, roles and responsibilities, details of the reporting system and general SMS
principles.
3.4.2 The provision of ongoing safety training (professional development) specific to each
employee’s role within the company (including senior management).
Deficiencies Addressed: 2.2.6, 2.3.1, 2.3.2, 2.4.1, 2.7.4, 2.7.5, 2.7.6, 2.7.7.
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4. CONCLUSION
Although companies place
strong focus on profitability,
nothing should be more
important that creating a
culture of safety in an
organisation, bearing in mind
the adage, “If you think
safety is expensive, try an
accident,” (Chamberlain,
1996, p.20; Peterson, 1996,
p.65). Air Ontario stands as a
poignant example of this. For it to be effective, safety culture needs to filter down from the top of
the organisation to permeate every level (ICAO, 2013, 2.6.5). “Practical drift” occurs from baseline
safety in any system, and so the company must commit to undertaking continual SMS monitoring,
measurement and improvement (ICAO, 2013, 2.3.15). Had Air Ontario implemented the SMS
features outlined in this report, the deficiencies that were contributory factors at Dryden would not
have cumulated in such a catastrophic event. If anything positive has emerged from Dryden, it is the
opportunity to learn from the mistakes that were made, and recognise the critical nature of SMS in
any organisation.
Figure 4.1: James Reason’s Safety Space Model (ICAO, 2013, Figure 2.6)
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REFERENCES
Civil Aviation Safety Authority (CASA) (2009). Safety Management Systems for Regular
Public Transport Operations. Civil Aviation Advisory Publication (CAAP).
Chamberlain, H. Dean (Sept 1996). “Thinking Safety” in FAA Aviation News. U.S.
Department of Transport, Washington. (Pp.20-24)
Commission of Inquiry into the Air Ontario Crash at Dryden, Ontario (Canada), &
Moshansky, V. P. (1992). Final report. Ottawa: The Commission.
Hudson, Patrick. (2014). “Accident Causation Models, Management and The Law” in the
Journal of Risk Research. Vol.17. No.6. (pp.749-764)
International Civil Aviation Organization (ICAO). (2013). Document 9859 Safety
Management Manual (SMM) – Third Edition. Published by the International Civil Aviation
Organisation, Montreal, Quebec, Canada.
New York Times (16th
April, 1912). Disaster At Last Befalls Capt. Smith. [online resource].
Retrieved 4th
May, 2015 from http://www.encyclopedia-titanica.org/disaster-at-last-befalls-
capt-smith.html
Peterson, D. (1996) “The Management System to Build Culture” in Analysing Safety System
Effectiveness – 3rd
Edition. Van Nostrand Reinhold, New York. (pp.65-88)
Reason, James. (1997). Managing the Risks of Organisational Accidents. Aldershot: Ashgate
Publishing.
Reason, James. (2000). “Human Error: Models and Management” in BMJ: British Medical
Journal. Volume 320, Issue 7237. (Pp.768-770)
Simmon, David A. (April/June 1989). “Model Airline Safety Program” in Airliner
Magazine. Pp. 13-16.
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Appendix A – Example of a Safety Policy Statement (ICAO, 2013, Figure 5.1)
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Appendix B – Example of key safety personnel placement within an organisation.
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Appendix 3 – Risk Management Process and Risk Analysis Matrix (ICAO, 2013, Figures 5.2 and 5.5)