Safety Management Systems-Raising the Bar on Aviation Safety
by Jean-François Mathieu, LL.B., Chief, Aviation Enforcement, Civil Aviation, Transport Canada
A safety management system (SMS) is a structure of systems designed to identify and eliminate risks and improve the safety performance of air operators. SMS is intended to increase industry accountability, and to nurture and sustain a safety culture, whereby employees can confidentially report safety deficiencies without fear of subsequent punitive action. Regulation will eventually require all Transport Canada operating certificate holders to implement an SMS.
The following event illustrates the value of an SMS in advancing aviation safety when there has been a contravention of the regulations.
On a clear January morning, an Airbus 310 departed Halifax, N.S., for Calgary, Alta., and climbed to a cruising altitude of 34 000 ft. After completing the routine cruise checks, the crew settled back and the 256 passengers relaxed and enjoyed a light breakfast. As they were approaching Montreal, Que., the captain checked the en-route weather while the first officer took fuel quantity readings and compared them with the flight plan figures required to complete the flight to destination. The first officer suddenly realized that they had not taken on enough fuel prior to their departure from Halifax. After confirming the readings and manually recalculating the minimum required fuel to complete the flight to Calgary, he informed the captain. They both double-checked the fuel remaining against the fuel required. The insufficient fuel state was confirmed and they agreed to plan an unscheduled refuelling stop in Toronto, Ont. Montreal Centre and company dispatch were both advised of the fuel condition and they respectively authorized and concurred with the revised routing.
From a regulatory standpoint, the pilot-in-command and the operator, contravened Canadian Aviation Regulation (CAR) 602.88(2) for not carrying sufficient fuel for the planned route. The enforcement process initiated following this contravention is typical of what would happen within any aviation company that operates in accordance with an SMS.
The Aviation Enforcement Division became aware of the event through an occurrence report in the Civil Aviation Daily Occurrence Reporting System (CADORS), and notified the Transport Canada principal inspector responsible for the operator. The principal inspector confirmed that the crew had, as required under SMS, internally reported the incident to the operator.
In line with SMS philosophy, the operator developed and submitted a corrective action plan (CAP) to the principal inspector, outlining a systematic approach to address the fuel mismanagement and to prevent a recurrence. The CAP included revised pre-flight and in-flight standard operating procedures (SOP) designed to ensure accurate flight-planned fuel calculations and accurate fuel-on-board monitoring prior to, and during, flight. These procedures for proper fuel management were incorporated into a mandatory training seminar for all flight crew members. The principal inspector reviewed the CAP and was confident that it addressed the issues that led to the initial contravention. In consultation with the principal inspector, the Aviation Enforcement Division could have reactivated the investigation at any time during the process leading up to the acceptance of the CAP, and would have, if:
the contravention had been intentional;
the incident had not been internally reported; or
the principal inspector had found the CAP to be unacceptable, and the operator had refused to address the issue.
Had the decision been to continue the investigation, a letter of investigation would have been sent directly to the operator, and the principal inspector would have been notified. In this specific case, the investigation was closed without further enforcement action.
Although the story in this article does not depict an actual event, it does serve to illustrate a typical SMS response, designed to raise the bar on aviation safety following a regulatory contravention.
For further clarification, we invite you to consult the Aviation Enforcement Policy and Procedures-Safety Management Systems Web site at http://www.tc.gc.ca/eng/civilaviation/standards/sms-menu-618.htm.