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ATSB says it supports safety management systems it ignored in Pel-Air crash inquiry

An ATSB review of the effectiveness of safety management systems in Australia completely contradicts the position in took its its much criticised final report into the crash of a Pel-Air medical flight near Norfolk Island in 2009.

The ATSB this morning published a review of the effectiveness of the safety management systems that it insisted were irrelevant considerations in framing a final report into crash of a Pel-Air Careflight air ambulance jet into the sea near Norfolk Island on 18 November 2009.

The crash report is the subject of an unfinished Senate inquiry which is itself due to report by the end of February. It is controversial because of evidence that alleges that the ATSB conspired with CASA, to frame all of the cause of the crash on the pilot to the exclusion of substantial failures by the air safety regulator to properly audit the operator Pel-Air and meet its obligations to exercise oversight of the carrier, and its pilots, among other matters.

This is what the ‘independent’ safety authority, the ATSB says as to why it commissioned “a systemic review of the effectiveness of safety management systems”.

Why have we done this report?

Australian aviation, marine and rail industries have all recently incorporated safety management systems into regulations and operations as a required way of managing safety. Safety management systems (SMS) refer to organisations having a systematic approach to managing safety, including organisational structures, accountabilities, policies and procedures. They generally include several common elements such as explicit management commitment to safety, appointment of key safety personnel, hazard identification and risk mitigation, safety investigations and audit, and safety performance monitoring. Although Australia’s transport industries’ SMS approach is following world’s-best practice, little empirical research evidence has been presented to determine the impact on safety of a structured SMS. The objective of this research investigation was to examine the published research literature into the efficacy of safety management systems, safety programs and related management processes that is applicable to high-reliability transport operations. The examination also aimed to identify which characteristics of these systems, and/or other organisational characteristics or external influences, are most related to the quality of an organisation’s safety management.

The outcome of this review may help organisations and regulators prioritise their efforts on those areas most likely to improve safety performance, and provide guidance for reviewing, auditing or investigating an organisation’s safety management processes.

This is the ‘safety message’ at the end of the summary.

Safety message

Incorporating safety management systems into normal business operations does appear to reduce accidents and improve safety in high-risk industries. At present, there have only been a small number of quality empirical evaluations of SMSs and it is unclear as to whether any individual elements of a SMS have a stronger influence on safety over other elements, although management commitment and appropriate safety communications do affect attitudes to safety. Transport organisations that provide an appropriate investment and commitment to a safety management system should receive a positive return on safety.

The fact is that nowhere in the controversial and abruptly rewritten final version of the ATSB report into the accident is the term SMS or safety management system used, never mind discussed or examined in relation to the operations of Pel-Air, which were found widely unsafe in a CASA audit the safety regulator had suppressed at the time, and which was not referenced anywhere by the ATSB document eventually released on 30 August this year.

The Pel-Air report raises extremely serious issues about the administration of air safety in Australia, and has seen CASA and the ATSB take positions completely at odds with the standards and expectations of the international air safety community, as represented by ICAO.

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    David Klein
    Posted December 11, 2012 at 11:17 am | Permalink

    Introduction of Safety Systems Management by CASA has placed all the emphasis on operators keeping their own house in order with structured accountability and has reduced the frequency of audits and oversight that were provided in the previous surveillance system. Unfortunately some operators lift their standards to receive a CASA tick for Safety Systems Management introduction, then it degrades significantly due to cost implications and the reduction in effective regulatory oversight does not pick up the numerous safety breaches that follow.

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