The insight into reported apparent safety deficiencies within Airservices by ABC News represents a worthy raising of potential issues with Australia’s air navigation services provider. But it also warrants at a closer look at balance that needs to be applied in such matters.
Headlining the exposé, it should first be noted that the “internal report” referred to is not internal – it is a properly independent review of Airservices conducted by the air safety regulator, the Civil Aviation Safety Authority (CASA). A standard routine between regulator and operator.
Having been both an aviation safety regulator and an operator of air traffic services in an overseas jurisdiction, first-hand experience tells me that an audit with 35 recommendations is not in itself a demonstration of a serious dereliction of maintaining safety standards.
It is the severity of those recommendations and whether they have the potential to constrain – or in the worst case close – an operation that is the vital aspect of audit findings. Air safety regulators such as CASA have a job to find areas for improvement, just as organisations themselves have a duty to implement continual improvement in safety.
The 35 recommendations, which are the distillation of hours of surveying records and practices, are the crucial outcome of any audit.
An aspect of the ABC report that seems to hold true is CASA’s apparent frustration with lack of progress on these findings. It would be normal and right for a regulator to escalate issues that were findings in previous audits. CASA’s frustration in this instance has been in the form of not giving an indefinite approval to Airservices, instead limiting that to three year. It is a signal of concern, but if there were serious safety deficiencies, the regulator by law would have acted with far more urgency.
The decision to award a time-limited approval was one of a number of options open to CASA that ranged from the one it has chosen at the less urgent end of the scale to reovoking approval altogether with at least another three steps in between. A time-limited approval was in effect the lightest. It does, however, send a clear signal that in a year’s time, Airservices must be able to demonstrate that across the breadth and depth of the organisation, safety-related processes and resources have been improved markedly.
Indeed the audit conclusion itself noted withdrawal of Airservices’ approval does remain an option. And under law it clearly is. It was the regulator putting in front of Airservices the simple fact that option remains is systemic deficiencies persist, as one would hope the regulator would.
However, in his letter of January this year to Airservices CEO Margaret Staib, CASA’s Director of Aviation Safety John McCormick wrote: “You will recall that in my letter of 18 December 2012 I gave an undertaking to provide detailed comments on Airservices’ Action Plan. I now consider it better to advise you that although there may be matters of detail that emerge, in general the actions you outlined therein appear responsive and appropriate.”
On balance, therefore, taking into account the reduction of the period to which operating approval applies to three years, and McCormick’s comments about Airservices’ responses, the situation may not be as dire as reported.
In an interview with Airservices’ Staib in late 2012, she told Australian Aviation that she had identified areas for improvement, just as one would hope she had.
A CEO that had not found room for improvement would be derelict in their duties.
None of this means Airservices does not have some serious problems, though. Staff and union unrest in the years leading to Staib’s appointment would appear to have come to the surface again. That, in addition to concerns expressed by aircrew at delays caused by apparent air traffic controller staff shortages at critical hubs such as Sydney has been vindicated by one of the CASA findings, which noted: “Airservices staffing plans have failed on occasion, as evidenced by the inability at times to provide ATS at some locations…”.
Frustrating and costly as delays may be, a lack of staff on duty is not an inherent safety issue unless the safety system they operate in is deficient.
It is this area of the CASA audit findings that presents arguably the greatest cause for alarm.
“The review identified deficiencies in Airservices’ SMS and ATS supervision. An element of the Airservices’ SMS is the identification and management of incidents, such as the BOS (breakdown of separation) and loss of separation assurance (LOSA) occurrences. During late 2011 and early 2012 there was a spike in the number of ATS-attributable BOS and LOSA occurences which resulted in increased public concern and media exposure,” the CASA report stated.
According the audit report sourced by the ABC under freedom of information, Airservices’ target enroute BOS rate per 100,000 flight hours is less than 1.25. In 2008/09 the target was exceeded, reaching 1.31. In 2010/11, the rate was 1.26.
The report continued: “The BOS occurrences in high level enroute Class A airspace are a matter of concern as the consequence of these can be high and they indicate failures within the national ATS system. As Airservices has rarely been able to determine the root cause(s) of the increase… , more definitive investigation by Airservices in this area would assist safety in the provision of ATS.
“CASA has detected ongoing problems with the practical application of Airservices’ SMS as it applies to ATS.”
A safety management system (SMS) is the glue that holds together both the safety philosophy of an aviation operation’s staff and management, and which guides an organisation’s processes and procedures.
In dissecting this apparently alarming finding, one must apply the same balance with which an SMS itself should be applied.
A SMS is a complex, resource-intensive but vitally important asset to, in this case, Airservices, but to all aviation organisations. It is no surprise that Airservices has not been able to find the root cause of every BOS or LOSA, but it is worrying that CASA has found that rarely has Airservices been able to find the cause. That does indicate systemic failure of the SMS within the organisation’s ATS activities.
And that this is a repeated concern of CASA is again worrying. It implies rather clearly that Airservices is having trouble managing SMS within its hierarchical structure and within the departments that use and manage the SMS.
In finding the balance between the SMS running the organisation and the organisation running the SMS, an organisation and its CEO must also weigh a balance between those aspects of the daily routine (or that should be part of the daily routine) and the myriad of other operational and business imperatives. And Airservices has plenty of the latter at the moment, having just gone to tender for a new air traffic management system jointly with Defence and the implementation of flow control measures at the ever-increasingly congested major hub airports.
However, it is here that the CEO must ensure adequate resources – people – are applied to SMS. Having the right number of appropriately qualified personnel within the ATS section of Airservices has to be a priority. From experience, SMS eats into other daily routines, so it is easy for compromises to occur in one area or another, and often that is SMS. The application of additional people to undertake the duties compromised by SMS is the only assurance that a CEO can have that SMS is functioning as it needs to.
The same has to be said about the conduct of internal audits and reviews, another area of concern for CASA. Alongside SMS, indeed they should be a fundamental part of it, internal audits are a vital – and healthy contribution to safety improvement. Importantly, they also give an indication of the health of an organisation’s safety culture.
In summary, is Airservices in danger of imminent closure? No.
Has it room for improvement? Absolutely. But just as all complex organisations have. CASA is doing its job with Airservices. If nothing comes out of a safety audit, either the auditor is not doing its job or something’s being covered up.
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