- ISSUE 4/2007
- Copyright and Credits
- Guest Editorial
- To the Letter
- Winter Operations
- Flight Operations
- Maintenance and Certification
- Recently Released TSB Reports
- Accident Synopses
- Regulations and You
- The Civil Aviation Medical Examiner and You
- Flight Crew Recency Requirements — Self-Paced Study Program
- Full HTML Version
- PDF Version
- The Canadian Business Aviation Association Column-Success Through Safety
- COPA Corner-Runway Incursions-Your Part
- Does Your Group Think Safety?
- A Just Culture-Enhancing the Reporting of Safety Information
- Be Prepared: What If an Emergency Happened to You? Part II
The safety culture of an organization is the product of its values, attitudes, competencies and patterns of behaviour, which determine the commitment to, and proficiency of, its safety programs. An organization that is infused with the safety mentality will have a positive safety culture, characterized by communication founded on mutual trust, shared perceptions of the importance of safety, and confidence in the efficacy of preventative measures.
If safety culture is to be successfully implemented in an organization, certain factors will always present themselves. Foremost among these factors is the leadership and commitment of the chief executive, complemented by the involvement of all employees in the organization. The success of a safety management system (SMS) rests on how well it is understood, and if everyone in the organization consistently incorporates it into day-to-day operations. Every employee will have an understanding of the safety guidelines, and will accept the responsibility of providing input to create change where improvements can be made and safety promoted.
In a strong safety culture, safety information is disseminated throughout the organization. Everyone has a responsibility for safety and should be willing to identify unsafe conditions or behaviours, and confident to correct them without fear of reprisal. This necessitates effective communication and a responsiveness to change in order to meet changing safety attitudes. Good safety culture implies a constant assessment and re-assessment of the safety significance of events.
Establishing and developing positive attitudes toward safety culture in an organization is cost effective. An organization with a strong safety culture will experience few at-risk behaviours. Consequently, they will experience low accident rates, low turn-over, low absenteeism, and high productivity.
Creating a safety culture takes time and effort by everyone in the company. To achieve a comfort level so that all employees are part of proactive change, senior management needs to be an active participant in promoting safety culture and embracing the processes established in the company SMS manual. Employer and employee commitment are hallmarks of a true safety culture where safety is an integral part of daily operations.
To be successful, every employee of an organization has to contribute. The first step in developing a safety culture may be to raise the level of safety awareness, and later, to address specific hazards. Contributions and suggestions for change or amendments to the SMS should be solicited and should be assessed equally and fairly, capturing as much input from all employees as possible. Through daily activities, everyone should be encouraged to report their observations of situations where increased safety is required, which processes are not implemented effectively, and how increased safety could be more effective.
Over time, the norms and beliefs of the organization will shift focus from eliminating hazards to eliminating unsafe behaviours, and building systems that proactively improve safety conditions. Safety and doing things the right way begins to take precedence over short-term pressures. The result is an enhanced level of excellence developed within the organization.
Successful implementation of a change process for safety will focus on the process rather than individual tasks. The initial phase of implementation entails ensuring that top management fully understands the need for change, and is willing to support it. The direct or indirect costs of accidents affecting bottom-line costs to the organization will more than pay for the needed changes. The next obvious step is creating a partnership between management and the employees. Everyone in the organization should have a clear understanding of what changes are needed, why they should be implemented, and how the proposed actions will affect them.
Accountability for safety should become the responsibility of everyone in the organization. With identification of safety items, and a shared responsibility within the organization, no restriction should be placed on who initiates the SMS change process. Suggestions for change should be assessed on individual merit and its impact, if the issue had not been identified. Everyone should have a voice; otherwise, there will be a reluctance to "buy in" to the process.
There is also a need for a clear distinction between data collection of incident reports and the reporting of unwarranted risk-taking that might produce avoidable errors and trigger disciplinary proceedings. The value of non-punitive reporting is that it encourages everyone to raise safety-related issues. Analysis of near-miss and incident reporting and the remedial actions becomes lessons learned company-wide. Failure to mitigate the risks is kept to the level that is as low as is reasonably achievable.by everyone in the organization. Positive communication in the form of feedback from senior management to employees instills a sense of value and accomplishment, while promoting continued growth in company safety culture. An organization’s SMS will continually measure performance, communicate the results, and celebrate the successes. Anticipating possible errors and rehearsing appropriate recoverable actions at all levels is a hallmark of a high-reliability operation.
It is clear that basic faults in organizational structure, climate, and procedures may predispose an organization to an accident. Human fallibility is an inescapable reality. Safety culture is an on-going evolution of rules that change as the operational requirements change. It is a convergence of attitudes, beliefs and behaviours subject to human influences, best described as the things you do when no one is watching. It is not just making safety a priority, because priorities change. It is making safety a value, as values are less likely to change.
The year 2007 marks the 30th anniversary of the Tenerife disaster-the worst runway incursion accident in aviation history, when two Boeing 747s collided at Los Rodeos Airport in the Canary Islands. It was the worst aviation accident of any kind, resulting in 583 deaths. Good progress has been made in reducing runway incursions in Canada, but there is further room for improvement.
One situation that leads to a runway incursion is when an aircraft enters the protected area of a runway when it is not authorized to do so. Separation is lost and there is the potential for a serious accident.
The two most common elements in runway incursions are runway layouts that the pilot is not familiar with, and inadequate communication. Different scenarios happen at airports of different sizes. At large airports, with complex layouts, lots of taxiways and runways, and air traffic control (ATC), a pilot typically becomes uncertain of where they are while taxiing, and ends up being somewhere they shouldn’t be.
Small, uncontrolled airports, with simple runway layouts, typically require aircraft to backtrack after landing or to position for takeoff. Incursions can happen when landing traffic and backtracking aircraft don’t know about each other, or misjudge the speed and time it will take to get where they are going, and get too close for comfort.
So, as a pilot, what can you do to avoid these situations? The answer is simply airport layout familiarity and communication. How do you familiarize yourself with an airport layout when you have never been there before? There are lots of tools to help you. The runway diagrams in the Canada Flight Supplement (CFS) and the Canada Air Pilot (CAP) can be a great starting point. NAV CANADA also distributes airport diagrams under the title Canadian Airport Charts (available on NAV CANADA’s Web site: http://www.navcanada.ca/). This Web-based publication is available free to everyone for download, and contains the airport diagrams for every airport that has IFR procedures available. You can simply print the charts in advance for the airports you plan to visit.
Another great source of runway orientation information is COPA’s Places to Fly. Found on the COPA Web site (http://www.copanational.org/Placestofly.cfm), this publicly-available, user-editable, airport directory has information on almost 800 airports, and is growing quickly as pilots and airport managers add information daily. The features of Places to Fly are designed to increase airport orientation and reduce runway incursions. Many of the airports listed have aerial photos of the airport that COPA members have taken and posted on the Web site. Some are vertical photos that show runway layout, while others show the point-of-view from an aircraft on final approach. In many cases, a second version of the photo is posted with the runways, taxiways and other features, such as the location of the fuel pumps, labelled. These are great tools to show what you will see from the circuit, where the taxiways are, and where you will ground manoeuvre your aircraft.
Many of the Places to Fly airport pages also have links to satellite photos that show good vertical photos of the airport layout. Many of these are high-resolution so that lots of detail is available. A few minutes reviewing the aerial photos and satellite photos should give most pilots the knowledge needed to avoid runway incursions, even at airports they have never been to before. Best of all, the photos can be printed and carried in the aircraft.
The second part of the equation is communication. If you are at a small, uncontrolled airport, make sure you are on the right frequency, make the required calls, and communicate with all other aircraft to work out your separation. Always watch out for no radio (NORDO) traffic at uncontrolled airports-they can be there too.
At controlled airports, you have help available-don’t be afraid to ask ATC ground control for vectors to the runway or ramp to avoid ending up in the wrong place.
By working together and doing our part, we can make 2007 the year that we really make a marked decrease in runway incursions. COPA can be found at http://www.copanational.org/.
This runway incursion prevention poster is one of six full-size posters produced jointly by Transport Canada and NAV CANADA. The six posters were widely distributed and can still be ordered through our order desk at 1-888-830-4911, or online at http://www.tc.gc.ca/eng/civilaviation/standards/systemsafety-posters-menu-723.htm.
Most of us fly as part of a group. This group might be a flying club, a soaring association, a group of people who share an airplane, or a commercial flying operation. Regardless of what it is called, or how big or small it is, any group will establish a set of norms that serves to provide a code of behaviour for people in that group. I’m not saying that people sit down and decide how they will behave in the group. Normally, this is something that develops as the various people relate together; some behaviour is accepted and works, while other behaviour doesn’t work very well within that group. This set of norms or behaviours is sometimes called the group’s culture, and can have a profound effect on the safety of that group.
In the last issue of the Aviation Safety Letter (ASL), I looked at some of the ways that we humans tend to think. I talked about hindsight bias, attribution error and invulnerability. By way of review:
- Hindsight bias refers to our tendency to believe that what has already happened was more or less inevitable and should have been predicted by people beforehand. We all have 20/20 hindsight, and this makes is easy to be critical of other people’s decisions, when we know they didn’t work out very well.
- Attribution error refers to our tendency to attribute the errors of other people to their own personal shortcomings rather than to the situational factors that often play a major role in producing an error.
- Invulnerability refers to our tendency to believe that accidents happen to other people, but not to ourselves.
Because all humans are susceptible to these patterns of thinking, it is common for them to find their way into the beliefs and norms of a group of people. I would like to look at a few areas of aviation culture in this article, and would ask you to consider your own group to see if your norms contribute to safety, or work against it.
Human error-how does your group respond to human error? People often respond by being critical of the person making the error. Error is believed to be evidence of incompetence. When someone in your group makes an error, are they subject to ridicule? When you discuss accidents that have happened to others, are you very critical of the people involved? This kind of attitude will drive errors underground. People will hide their errors. As a result, systemic conditions that lead to errors will never be brought to light.
Human error is most often the result of systemic conditions, and if one person can make the mistake, any other person in the same set of circumstances could do the same thing. If your group can accept this notion, error will be seen as a potential symptom of a problem in the system, and the group will want to identify errors in order to fix potential problems. The group will need to make a conscious effort to avoid criticism of people making errors, and learn how to look for systemic issues within, and beyond, the group.
Expecting the unexpected-how does your group plan? Do you expect everything to go pretty much as expected, or do you build in some margin for unexpected things to happen? Remember that the aviation industry is working to maintain an accident rate of 1 in 1 million. Therefore, we have to be ready for any event that could happen, even when the probability is low. Sometimes safety measures seem extremely conservative. People might take issue with a regulation or safety advisory, pointing out that the events at issue are so unlikely that it seems silly to pay money to prevent them. However, we need to consider how best to prevent events, even if they are only remotely probable.
Risk management-this leads naturally to a discussion on the best way to control risk. In your group, if someone mentions a potential hazard, how does everyone else react? All too often, people are reaching for the nearest piece of wood to touch, as if simply talking about a hazard is bad luck. People are often uncomfortable with an honest discussion of the hazards in a given operation. However, it is important to consider hazard scenarios and calculate the probability and severity of those scenarios, in order to make intelligent choices on how best to keep risks to a minimum.
A group that works towards safety views human error as a symptom of a deeper problem. The group tries to learn from error, and make changes when appropriate. When making plans, the group thinks about unusual events, as well as the everyday, and tries to build in resilience to error and other unexpected events. The group also considers what could go wrong, and tries to build in safeguards to keep risk to a level as low as reasonably possible. How does your group measure up?
In any industry, the effectiveness of a safety reporting system relies on the willingness of front-line workers to provide essential safety information-and that often means reporting their own errors or mistakes.
The quantity and quality of information is directly influenced by a country’s legal framework, organizational policies and procedures, the availability of feedback to the reporting community, and a common understanding of the purpose of the safety information.
These factors can work constructively to foster a "just culture," which Professor James Reason has described as "an atmosphere of trust in which people are encouraged, even commended, for providing essential safety-related information, but in which they are also clear about where the line must be drawn between acceptable and unacceptable behaviour."
In recent years, a number of different industries and organizations have been exploring the benefits of a "just culture." NAV CANADA recently undertook an initiative toward formalizing a just culture policy in air traffic services (ATS), and this article provides an overview of some of the questions that arose during the initial steps of the project.
Who should be part of the Just Culture Working Group?
In January 2006, a Just Culture Working Group was formed to develop a framework for the assessment of human behaviour or events that may have contributed to an air traffic control (ATC) operating irregularity.
An operating irregularity is a situation in which ATS are being provided and a preliminary investigation indicates that safety may have been jeopardized, less than minimum separation may have existed, or both.
The scope of the Working Group was limited to operating irregularities where it was determined that ATC services contributed to the negative outcome.
Establishing credibility and trust in a framework to assess acceptable and unacceptable behaviour requires working in a collaborative environment with members of the organization directly affected by the framework. Given the focus on ATC services, the members of the Working Group at NAV CANADA consisted of three representatives from the air traffic controller union (the Canadian Auto Workers/Canadian Air Traffic Control Association [CAW-CATCA]); three management representatives; and a chairperson.
The Working Group’s mandate was threefold: first, to propose a just culture policy statement; second, to establish criteria for acceptable versus unacceptable behaviour; and third, to develop procedures for determining culpability.
How do current practices compare to recommended practices?
One of the first steps undertaken by the Just Culture Working Group was to conduct a gap analysis of recommended practices and current policies, procedures, and practices regarding aviation occurrence reports in general, and more specifically, the operating irregularity process.
The gap analysis revealed target areas where enhancements could be made to further support the principles of a just culture, and potentially enhance the quantity and quality of the safety information provided by controllers.
For example, a target was set pertaining to aviation occurrence reports to increase education, awareness, and feedback to controllers regarding why their reports are important, who sees the reports, and how the information in the reports is used by NAV CANADA, Transport Canada, and the Transportation Safety Board of Canada (TSB).
Important targets regarding operating irregularities were to:
- change the perception that a controller involved in an event is a "bad" controller, and instead create an environment where operating irregularities are seen as a tremendous opportunity for individual and organizational learning;
- increase education of managers and controllers on human error, and what constitutes acceptable and unacceptable behaviour;
- increase understanding by controllers on what to expect when they are involved in an operating irregularity; and
- develop procedures for consistent and transparent handling of individuals involved in events.
How do we get "there"?
A six-month trial period commenced in the summer of 2007 at one area control center (ACC) and one tower to test the recommendations from the NAV CANADA/CAW-CATCA Just Culture Working Group. This trial period will be used to collect feedback from controllers and managers regarding the just culture policy, principles, and procedures.
Following an assessment of the trial feedback, consideration will be given to a broader implementation of the just culture.
What are the expected benefits of a just culture?
The collective experience of a number of organizations has demonstrated three key benefits of a just culture, when compared to a culture of blame or a culture of no accountability.
It is anticipated that the just culture initiative at NAV CANADA will improve performance in all three areas-namely, increased safety reporting, trust building, and more effective safety and operational management.
GAIN Working Group E and Flight Ops/ATC Ops Safety Information Sharing, A Roadmap to a Just Culture: Enhancing the Safety Environment, Global Aviation Information Network (GAIN), 2004.
Reason, J., Managing the Risks of Organizational Accidents, Ashgate Publishing Limited, Hampshire, England, 1997.
It happened so quickly
We were taking off at night, and I was sitting on my jump seat at the front of the DC-8 aircraft. It was winter, and the departure was from what is now called the Montréal/Pierre Elliott Trudeau International Airport. As the aircraft rolled down the runway for takeoff, I remembered feeling that something just wasn’t right when the aircraft began to lift. Then I felt the aircraft start to sink when it should have been climbing. Looking to my right, I saw the lights of homes along the shore of the West Island of Montréal, Que. The next thing I remembered was sudden darkness, getting out of my jump seat to look out the window, and seeing water. We had crashed into the river. I began yelling to the passengers to put on their life preservers and get out of the aircraft. I opened the aircraft door and couldn’t believe the sight. There were large chunks of ice floating on the water and the sound of metal rubbing and groaning. People were screaming. I could hear other crew members yelling commands and I could smell fuel. I hated telling people to jump into the dark cold water, but I knew we had to get out. Then the moment came when I had to leave the aircraft. My heart was pounding and I held my breath as I jumped. The shock of the icy cold water as it soaked through my uniform was numbing. I was grabbing for something, anything, to hang on to-a piece of metal, broken ice- I was desperate. Then I woke up. Yes, it was a dream.
I have been told that many crew members have dreams related to crashes because they spend so much of their life on aircraft. That dream was back in 1988, but I can still remember the details so vividly, and how jumping into the cold water took my breath away. Of course, luckily for me it was only a dream, but it certainly made me wonder what a real crash would be like, and how I would react. I think, as crew members, we like to believe that we would perform as expected, and that our training would come through and make for a successful evacuation. But, how would you react? Would you be prepared?
In the last issue of the Aviation Safety Letter (ASL), the article "Be Prepared: What If an Emergency Happened to You? Part I" examined the procedures in place to prepare an aircraft for a flight, and how the preparations that are made prior to every takeoff have an impact on the outcome of a survivable crash. This article looks at the crash scenario, the types of emergencies
- prepared and unprepared
- and the post-evacuation duties of crew members.
Prepared or not prepared: that is the question!
Basically, there are two types of evacuations: prepared and unprepared. Either the crew has sufficient warning of an emergency and they are able to prepare the passengers, or the emergency is so unexpected that the evacuation is called without preparation.
In a prepared evacuation, the crew has some advance warning. It could be as little as 10 min, or it could be hours. The flight attendants will follow their established procedures and begin to ready the passengers and secure the cabin for the evacuation. These procedures, or steps, are arranged in order of priority to allow the more important duties to be completed first. During this time, flight attendants will brief and assist passengers, and ensure passengers know how to take a brace position. The proper brace position can minimize injuries during impact due to flailing and secondary impact. Flight attendants will verify that seat belts are tightly fastened across the hips, baggage is securely stowed, life preservers are properly donned (if necessary), infants are secured, and if time permits, flight attendants will answer questions and calm passengers. Some passengers may have started to panic and others may be in denial and unwilling to cooperate. Flight attendants must deal with the human and procedural aspects of the evacuation preparation and maintain control of the situation. This is multi-tasking at its maximum! If, during any of the steps, the situation dictates that the preparations must cease, or that there is no time left available, then the flight attendants will immediately ready themselves by going to their jump seats and taking a brace position. Once seated, they will start their silent review and go through the mental checklist of procedures as they wait for the signal from the flight deck to evacuate.
An unprepared evacuation does not automatically mean disaster. The evacuation can still be successful, depending on whether there is damage to the aircraft structure upon impact, the conditions inside and out of the aircraft, and the readiness of the flight attendants. If the passengers have been well briefed prior to takeoff with a thorough pre-flight safety briefing, and more importantly, if they were paying attention to the information provided, they have the knowledge necessary to help them evacuate an aircraft. In interviews with passengers who have survived aircraft evacuations, many comment on how they wish they had paid closer attention to the safety briefing prior to takeoff.
The unprepared evacuation scenario can be one of the most difficult for crew to manage, as everyone is taken by surprise. Time management is critical and affects survivability in accidents, so proper training and knowing procedures are essential. In the end, whether the crew is faced with a prepared or an unprepared evacuation, the task remains the same-to get everyone out as quickly as possible.
Whether the crew is faced with a prepared or an unprepared evacuation, the task remains the same-to get everyone out as quickly as possible.
The real thing
Once an evacuation begins, quick and precise actions by the crew are required. Is the exit usable and safe? Should the passengers be redirected to another exit? The environment inside the aircraft cabin during an evacuation can best be described as chaotic. Passengers may need to climb over seats or crawl to exits in order to get out, the fuselage might be ripped open and seats may no longer be attached to the floor. People may become jammed at exits trying to get out, and others may bring baggage with them in attempt to save precious items; all this can seriously affect the evacuation flow. In other situations, once at the aircraft exit, some people freeze. The height of a door from the ground can be daunting for many people, especially if they are being told to jump out into the unknown, or worse, are surrounded by smoke and flames. Flight attendants must be assertive and forceful in order to keep the evacuation flow moving, the tone of voice and words used have a big impact on getting passengers to exit. A flight attendant will shout, use body language, push and pull, if necessary-whatever it takes to evacuate an aircraft-and all this with a cabin possibly filling with smoke. Flight attendants will shout commands to give directions in the cabin and to tell passengers to move away from the aircraft after they have exited. Once all passengers have been evacuated, and if conditions inside permit, the flight attendants will run through the aircraft, checking that nobody is left inside. They verify that lavatories are empty, and check the flight deck and any other areas that passengers may have gone to in a state of panic. At this time, they may come across injured people who were unable to move, or people who may be unconscious or frozen with fear and in need of assistance to evacuate. Flight attendants will check if other crew members need assistance and then they will exit last.
The next step-post evacuation
For a flight attendant, the evacuation does not end with clearing the aircraft. If the accident has occurred at the airport, help may arrive within minutes from local authorities and rescue services. If, on the other hand, the crash site is in a remote area, assistance could take hours, or even days. In this case, flight attendants will usually grab emergency and survival equipment, such as first aid kits, blankets, water, and then exit the aircraft. Some passengers may have injuries that will need to be attended to immediately; others may be in a state of shock or confusion. Some will be separated from family members and desperate to find their loved ones, they may even try to re-enter the aircraft to look for other passengers or to retrieve belongings. Flight attendants will use their crowd control skills to keep people calm and from potentially injuring themselves. Grouping people away from the aircraft and upwind from smoke is the next step. A passenger count will be taken, if possible, in order to establish if all passengers and crew have been evacuated.
As a passenger, you can increase your chances for survival in an accident by being informed. Pay attention to the pre-flight briefing, be aware of your surroundings, and follow the directions of the crew. Travel by air is one of the safest modes of transport, but it never hurts to be prepared.
- The lesser of the height above ground or water of the base of the lowest layer of cloud covering more than half the sky or the vertical visibility in a surface-based layer which completely obscures the whole sky.
- Land and Hold Short Operations
- Key the activating sequence when commencing your approach, even if the airport lighting is on.
- unreliable; it transmits
- Advise ATS, and, if necessary, revert to using traditional aids for navigation.
- 20 miles north of Toronto; 20 DME north of Toronto.
- readable with difficulty
- follow normal communications failure procedures; 7600
- NAV CANADA flight information centres (FIC)
- To notify pilots of potentially hazardous weather conditions not described in the current graphic area forecast (GFA).
- 200 ft overcast
- After 1300Z.
- Greater than 6 SM.
- When there are lower sector visibilities, which are half or less of the prevailing visibility.
- en-route; is not
- is not; the target will be lost on the ATC radar screen
- the current altimeter setting of that aerodrome; if the altimeter setting is not available, to the elevation of that aerodrome; standard pressure (29.92 inches of mercury or 1013.2 mbs)
- 45; normal cruising speed; 20; normal cruising speed
- FISE; SAR action
- 1-888-226-7277; 2; 48
- 5; UTC; 5
- A replacing or a cancelling NOTAM must be issued.
- NAV CANADA; Transport Canada
- a maintenance schedule, approved by the Minister
- Bonding prevents sparks by equalizing or draining the electric potentials.
- 3 000 ft
- refraction error
- at or above; beyond
- Identify themselves as the holder of a pilot’s licence.
- night vision; reaction time
- 48 hr