SMS on CTV - March 15, 2009 - Moshansky speaks out

[sprayrail]

Interesting comments on the whole SMS theme. I can tell you that my experience implementing SMS for an AMO has been a positive experience for the most part with the technical staff embracing it 100%. The upper management team however has been a challenge and slow to come around, however with the realization that they cannot just be seen to participate but must promote it, we're finally making some headway.
Regards

[Chuck Ellsworth]

and therefore would withdraw my comment to Cat about it being the PIC`s ultimate decision to go/nogo. There is obviously much more to the Dryden incident then I had ever been told. I do know one user on this board whos opinion would be very valid as he worked with this Captain. Ill be interested to see if he wades in.

Fly Safe all.

No need to withdraw your comment flynthebug as George did make a very fatal mistake.

The Moshansky report however digs deep into the culture that grew over time and was a contributing factor to Georges fatal mistake.

I do not wish to discuss this accident in any more depth because I was very closely associated with both George Morewood as we learned to fly together and some of the principals in Ontario.

I was chief pilot for one of the Deluce family's companies and am oh so familiar with the culture of the time and thus do not wish to offer any further comments about that sad episode.

When you come out here to visit I shall tell you the whole story and it is not pretty.

. .:

[Lastcat]

x2 - What Cat said. I knew and worked with the F/O.........

[Prairie Chicken]

Code: Select all

I think the overall consensus is that SMS is good, but not without real - hands on - oversight (not just auditing paperwork). 

If you read Moshansky's paper, he doesn't suggest throwing the baby out with the bathwater, but rather cleaning the tub periodically to make sure the rime has been removed before the baby is put back in. The regulatory authorities need to be tested for the efficacy of their own safety management systems. He doesn't just suggest it for Canada either, but that it should be an ICAO regulation in respect of the importance of SMS.

Well put Widow. I’m a big believer in SMS, but also in the concept of “trust but verify” ... at least for the next 10 years or so until SMS has become an entrenched part of the culture. Then TC can start backing off on their regulatory oversight if & when warranted.

What really bothers me just now is that even a good, functioning SMS (or ISO, or IMS, or whatever you call it) isn’t always enough. I know a certain East coast operator was ISO certified in order to satisfy their off-shore, oil-patch customers. They are a good, safe company. And still they recently had a very tragic accident. I know a management system can’t eliminate all of the risks, but it is just so very sad to see a tragic accident strike a good operator. We all seem to expect it of the bad operators, but it just shouldn’t happen to the good guys. (Yeah I know, I’ve been called that before.) Anyhow, it bothered me last evening to see a news interview of an NL politician who raised valid concerns of SMS & quoted Moshansky. Sadly, he did so while discussing the recent accident of that same operator, leading the interviewer to ask if self-regulation was a factor in the accident.

OK, I had to get that off my chest.

[flyinthebug]

Prairie Chicken.. We are not that far apart..but what id like to know is how do you oversee SMS with the "bad" operators? We can all agree that we have a rash of "bad" operators..How is it that SMS works for the good guys..but also licences the bad ones? I sincerely do not see SMS being sucessful on the 703/704 level. Please show me where im wrong!?
How will these "bad" companies even be identified, when they are self policing?

Maybe indeed SMS can work.. But it will only be as effective as the management and team that implement it within their op. When I step back and look at the big picture, I see a HUGE loophole that will keep allowing small unscrupulous operators to rebuild their superchargers at Joes diesel shop, create a green tag, and voila.

How do you propose we will police these types of ops? And we ALL know they exist as we all knocked on their doors with 200 hours, a float rating and a dream. PC, i`ll look fwd to your input.

Fly safe all.

[Widow]

I feel the same way, in some senses P.C., but also understand why it happens. I didn't see/hear/read the interview with the NL politician ... how did he respond to the question? I was impressed that the CTV article/newsclip, while coming on "the eve" of this latest tragedy, did not make a *clear* link between the two stories.

It is very difficult for me to watch what is happening on the other coast right now ... it is bringing up a lot of memories, again, and they aren't the good ones. The last three, terribly tragic accidents ... the two Pasco's (also viewed as a top notch op) on this coast and this latest on the other coast ... all three have had their survivor(s). Dave was supposed to be our survivor. Watching the TSB bring up the bodies, the wreck next (I've never understood how the officials managed to miss the aircraft down there, and we found it using the same info they'd had since day 2 - nor the fact that we, the families, paid for the majority of search/recovery costs after the "official" search stood down - not to mention the engine two years later) ... it all seems very unfair.

Whether we like it or not, fatal accidents like these are the only times when aviation safety is brought to the public's attention. So this become a time when activists for safety, like Danford and Moshansky, speak up about what is happening in the system - because it is now, and only now, that the public WILL pay attention. Down in the US, the National Air Disaster Alliance has launched a suit over the NY accident - rightly or wrongly, using the accident to bring the failures of the FAA to the attention of the American public.

Right now, we just don't know what the findings will be from the TSB about any of these three accidents. We might have suspicions, but until the reports come out and are published, we won't know with certainty what combination of mechanical, operational and regulatory issues will be found to have contributed to the accidents. The lack of investigation and public reporting on "my" accident was an aberration of the norm. That being said, those that are made public have generally been vetted between draft and final stage to such an extent that the TRUE root cause has been obfuscated. Moshansky identified this as being a problem when he headed the Dryden inquiry. It hasn't changed, for the most part. Even when recommendations are made, they end up being either refuted or delayed to such and extent, I personally begin to question why we even have a TSB.

So Prairie Chicken, although I too find it sad that these tragic - with cause yet to be determined - accidents should be used to voice industry concerns, I also believe it to be something of a necessary evil.

[Prairie Chicken]

Fly, before I try to respond, let me ask you to clarify.

Do you agree with & believe in the philosophy of SMS? If the answer is yes, you and I likely are not at odds at all.

OR, is your issue that you disagree with TC's approach to implementing SMS & depending solely on SMS to regulate good and bad, large and small operators alike? If this is your issue, again, you and I are not at odds.

So, disagree with SMS? Or, disagree with the manner and extent to which it is being implemented? Or, I suppose, both (a) & (b).

[Widow]

I like you P.C.

[flyinthebug]

Prairie Chicken...We are indeed not far apart at all. It is the implementation that I have a problem with. The lack of oversight by our regulator. The lack of accountability. So many other factors. SMS as an ideal is a positive one..However, it must be regulated much closer before it has any chance of sucess. At least on the level of aviation that I am familiar with. I cautiously "assume" that SMS functions much better on a 705 level.

Its not the larger ops im concerned with. They have enough bright people around that they will ensure SMS is functioning at an acceptable level. Its the smaller guys that concern me..and the abuse of the system PRIOR to SMS was rampant.. Im sure you would agree PC that SMS on that level will only enhance the ability of the "shady" operators to conduct business IMHO. So how do we fix the cracks in an overall positive system such as SMS?

I guess the big question remains, if TCCA refuses to accept responsibility anymore..then WHO is truly regulating our industry?

Fly safe all.

[Cat Driver]

.then WHO is truly regulating our industry?

Money, as in the profit margins.

[Driving Rain]

.then WHO is truly regulating our industry?

Money, as in the profit margins.

Cat you'd really like John Raulston Saul.
Here are three of his quotes that I think are quite important to the discussion at hand.

Money is not real. It is a conscious agreement on measuring value.

The evolution from the $1 category to the $2 category might mean a marginal improvement or nothing at all or a worsening in poverty.”

If allowed to run free of the social system, capitalism will attempt to corrupt and undermine democracy, which is after all not a natural state.

[Prairie Chicken]

Yes fly, we’re on the same page. Ok, here are my thoughts, for what they’re worth.

SMS can ONLY work if the most senior levels of management have fully bought into the philosophy. I’m not sure any amount of TC regulation can force an operator to operate IAW SMS. It has to originate with the executive, or better yet—with the customer. That was the case with the off-shore oil industry. ISO was the ticket to the game ... you couldn’t even bid a job without proof of ISO, and submitting to frequent audits both internally and externally. In our case, the regulator is forcing the adoption of SMS. I’m not sure it will work. IMHO, if it does work, it's best chance is if the new DGCA takes a different approach to regulatory oversight. As I understand it, Merlin Preuss directed no enforcement action be taken against an SMS enterprise except in the extremely rare circumstance of wilful or intentional disregard for regulation—and even then it spooked him. He apparently believed that confidential reporting, a cornerstone of SMS, would be used or perceived to be used by TC against the company or individual. While I agree this is a concern, I do believe it could be managed.

I think Merlin put the cart before the horse. Inspectors should be assessing the risks of their SMS enterprises, and where risk factors are identified, increase regulatory oversight & take action as warranted. But, and again I think the DGCA is responsible, TC has been reluctant both to allow inspectors to inspect, and to take action when risk factors are identified. Effectively, companies enjoy the benefits of self-regulation without having earned it.

Yes, we do have some “bad” operators out there. Here I’ll refer to those that have bothered to obtain an AOC. These are the ones that will require a lot of TC oversight. Yes, they’ll need to adopt SMS, but with TC looking over their shoulders. Eventually, even SMS may look good to those “bad” operators if they have an inspector watching their every move. As one Air Transat manager said when they moved to SMS: “The management will change, or the management will change.”

I believe SMS can work at any level, from 703 to 705. Remember, in the simplest terms, SMS is only process management—what do you do, and how do you do it? Write that down, follow the process you wrote down, and maintain records that you are doing so. Adjust as necessary to continually improve the process. TC &/or other auditors confirm that your processes address key management areas & meet regulatory requirements, then confirm through documentary evidence the processes are being followed. With that in mind, a small Mom & Pop operator could have a simple yet effective SMS. The “good” 703’s were probably applying the concepts of SMS intuitively, and because they were so small, could get away with doing so. That wouldn’t be possible for a larger organization. You were thinking SMS may work better on the 705 level than at the 703 level. I’d suggest it becomes more important in a larger organization, but doesn’t actually work “better”.

You asked how we should fix the cracks. I think both you & I would have implemented SMS differently. I believe TC should ‘trust but verify’ for both small & large operators. By that I mean inspectors should be are out inspecting, doing check rides, and all the things they used to do pre-SMS. As SMS matures & proves itself, less regulatory oversight is required. Enforcement should be used as a tool when SMS isn’t being effectively applied. (Of course, oversight does cost money ... our tax dollars ... but that is a whole other discussion.) Finally, TC really does need to reach down into their pyjamas & find the courage to suspend or cancel AOCs when an unsafe operation is identified.

You asked what we can do about the current situation. Well, complaining on this forum won’t help. C-7 hasn’t passed yet so perhaps political pressure can make some changes. I have faith that Justice Moshansky is getting some traction with his efforts. Perhaps a petition, well worded and thought out, could be circulated & submitted to politicians and the media. (Not an on-line click-to-sign petition—we know politicians don’t pay attention to those.) The CFPA is making the same arguments we are here. I wish we had a professional association now that could speak with a credible & united voice on this issue. Widow is on the case but she’ll need all the help we can give her. Perhaps we should be raising our concerns on other forums ... those populated by the travelling public. We do need to keep pushing TC for action against the “bad” operators, and keep pushing, and keep pushing. Squeaky wheels do get attention. We have a new DGCA coming soon, but I’m not overly optimistic on that front.

What I`d like to know is why SMS appears to be replacing regulatory oversight. Where did this impetus come from? Was it Merlin Preuss`s idea, or was he reacting to direction given by his political masters?

You asked who was in charge .... this chicken thinks it`s the fox.

[jeta1]

Fly, before I try to respond, let me ask you to clarify.

Do you agree with & believe in the philosophy of SMS?

Here's a Breeze presentation which some may never have seen. Worth watching. The presenter has left TC since and now works at the TSB.

http://www.tc.gc.ca/civilaviation/SMS/B ... viewer.swf

[flyinthebug]

jeta1.. Thanks for the link. It is a very informative video.

PC.. Ty as well for your reply. The bottom line is we are asking the exact same question.. just you are doing it much more eloquently and with more experience then I. Cheers!
Who knows, maybe Moshansky & Danford will get someones attn. The fox is indeed runnin the henhouse!

Fly safe all.

[hydraulic fluid]

When will sms be law for the 703 operator,and how long after till the 703 operator have to get theres up and running

[CD]

CAR Part
702, 703, 704

Gazette I Publication
Forecast - July 2009

Gazette II Publication
Forecast - September 2009

Planned In-Force
September 2009

SMS Implementation

[Prairie Chicken]

Tx for that link JetA1. Bryce did a good job for TC. I didn't know he had left. That's TC's loss & TSB's gain.

[flyinthebug]

CD.. Ty again for the link!

Greg87.. I am not "against" SMS.. I echo your feelings almost exactly Greg. Its not SMS as an ideal im against.. Its the implementation and lack of oversight by our regulator that is at issue.

Letters to TCCA will not always fall on deaf ears. Widow is currently in Ottawa hand delivering a few as we speak I wish her the very best!

1 voice may not be heard.. but many voices will carry!

Fly safe all.