CONTEMPORARY ISSUES

IN AVIATION

A discussion of Flight Crew Training and the

role of Safety Management Systems in aviation
operations

Daniel Quinn z3462434

INTRODUCTION
The multitude of airline accidents in recent years have placed the spotlight onto how airlines
approach the issue of accident prevention. As technology has advanced over the years, the root of
such accidents have evolved from technical weaknesses, to causes largely preventable through
improved flight crew training and robust systematic frameworks. This report seeks to discuss the
current state of Safety Management Systems and in greater detail, risk management and flight crew
training, in relation to the topic of accident prevention.

SAFETY MANAGEMENT SYSTEMS

With increasing pressure from the community for airlines to operate under a well-defined Safety
Management System (SMS), the International Civil Aviation Organisation (ICAO) has set out the
global standard for aviation management. Preceding this discussion, three key words must be
defined as set out by the Australian Government Civil Aviation Safety Authority:

Safety: is the state in which the probability of harm to persons or property is reduced to,
and maintained at, a level which is as low as reasonably practicable (ALARP) through a
continuing process of hazard identification and reduction
Management: requires planning, sources, directing and controlling
System: a coordinated plan of procedure

Combining the three components together, the role of a SMS is to serve as an organised approach
to managing safety, including the necessary organisation structures, accountabilities, policies and
procedures. Under ICAOs framework, a SMS is scalable to any organisation size and is comprised of
four components:

SAFETY POLICY AND OBJECTIVES

The first step of SMS implementation is the to establish policies and objectives, which dictate the
intended safety outcome, the steps management are required to take to achieve them and how the
organisation as a whole will work to support such policies and objectives. As a part of this process,
key safety personnel such as a Safety Manager (to oversee and drive SMS implementation) and
Safety Committee and Action Groups (to monitor and review safety performance and outcomes)
must be appointed with well-defined accountabilities and knowledge requirements. These roles are
critical and must be appropriately suited to the size of the aviation organisation in question. In a
large organisation, an entire Safety Department with a Head of Safety Manager and several support
groups may be required, whereas a less complex organisation may only require one Safety Manager

CONTEMPORARY ISSUES IN AVIATION | Daniel Quinn

with one or two support groups. Ultimately, the implementation of safety policy and objectives
should define the organisations culture of safety. While one may argue that any aviation operation
would inherently uphold a culture of safety, a strict way of doing business is still necessary to
guide day-to-day actions as well as having tangible, measurable goals to work towards.
SAFETY RISK M ANAGEME NT

In achieving the aforementioned policy and objectives, an organisation must then work to identify
the relevant hazards, assess their associated risks and mitigate their potential to cause harm. The
diagram below illustrates the steps required in this process.

The collapse of effective risk assessment and management has been the root of several high profile
accidents. For example, the crash of the Air France 447 Airbus A330 over the Atlantic, which resulted
in the deaths of all 228 passengers and flight crew, was likely due to the freezing of the planes pilot
tubes (BEA, 2012). The Bureau of Enquiry and Analysis for Civil Aviation Safety (BEA) noted that
the pilot tube failures were well known on the Airbus long-range fleet yet the significant risk of these
hazards did not appear to be recognized. Such negligence in risk management is not a rare
occurrence, as aircraft operators can often expect approximately 1,000 operational safety reports
per year, of which less than 5% would be considered anything beyond low probability of risk. The
critical, yet highly difficult, step in risk management is to correctly identify the hazards which could
cause a catastrophic outcome. Tools such as risk ratings currently exist to help categorise reported
hazards but they too, are often open to interpretation.
Another perspective from which we can examine the issue, is the to focus on the fact that there are
an overwhelming number of reports. The Transport Safety Bureau (ATSB) is the governing body for
safety investigations in Australia which has a mandatory reporting requirement. All serious incidents
as defined by ICAO Annex 13 are immediately reportable to the ATSB (Office of Parliamentary
Counsel, 2003). However, several other events fall into a category called Routine Reportable,
which typically have no cause for alarm. As a result, the ATSB received approximately 15,000 reports
between 2014 15 (Australian Transport Safety Bureau, 2015), of which only approximately 0.2%
were investigated. As a result, the Australian Civil Aviation Safety Authority (ACASA) has begun
taking a greater role in the process of safety investigation as the ATSB can no longer be relied upon
to observe all hazards which warrant investigation due to the sheer number of reports. This is a

CONTEMPORARY ISSUES IN AVIATION | Daniel Quinn

positive step towards a more effective SMS by facilitating a more robust safety investigation
capability.
Once a risk is identified, it should be managed to the extent it is ALARP, whereby the cost of further
prevention measures be significantly larger than the subsequent increase in safety. This definition
however, is once again subjective and a misinterpretation could have far reach consequences. For
example, The American Eagle flight 4184 in 1994 crashed after ice on its right wing caused the plane
to spiral and kill all 68 people on board. In the aftermath, a whistle-blower revealed longstanding
problems with the ATR aircraft under freezing conditions. The National Transport Safety Board later
determined that the Federal Aviation Administration (FAA) was a direct contributor to the incident
as its aircraft icing certification requirements failed to consider the hazards to a sufficient degree
(National Transport Safety Board, 1994). It was later revealed that for thirteen years prior to this
accident, the FAA consistently fought against the NTSB on changing its icing certification
methodologies as it would be excessively penalising and economically prohibitive. In 1998, the FAA
finally implemented several proposed rules and directives which are intended to reduce icing
hazards. It is clear that the interpretation of ALARP by the FAA was clearly insufficient, and that
the potential increase in safety, in fact, far outweighed the increase in cost. Hence, diligence in
assessing the extent of risk management and agility in responding to risk assessments are critical in
the effective implementation of SMS.
SAFETY ASSURANCE AND PROMOTION

Effective SMS implementation in the long run requires ongoing and systematic monitoring of safety
performance as well as constant reviews of processes and practices. The scope and complexity of
assurance measures should be congruent with the scale of the aviation organisation, and can range
from effective hazard reporting systems to front-line supervisors who report day-to-day activities
and daily inspections of safety-critical areas. Further, the service provider should establish a formal
process to evaluate changes, whether organisational or operational, which could impact its net level
of risk. One example may be ensuring the rapid expansion of an airline does not undermine the
allocation of resources to maintaining its safety standard. In response to such changes, the
organisations SMS must be amended accordingly. Overall, this process should result in a continual
improvement of the SMS.
Once all elements of a SMS are in place, the last step is to ensure the system is thoroughly promoted
to every corner of the organisation, ensuring it reaches employees of all positions, from executive
management to engineers. A constant effort must be made to ensure the various SMS processes are
communicated, and that staff are properly trained to carry out the required tasks.

FLIGHT CREW TRAINING

In addition to a robust SMS, there is now increasing public scrutiny on flight crew training and
whether it sufficiently prepares them for catastrophic circumstances. It will also be apparent
throughout the discussion, that a well-equipped and capable flight crew should is a natural
consequence of a robust SMS. A flight crew comprises of the pilot and the cabin crew. Set out below,
are the three stages of training required to hold a commercial pilot licence.

CONTEMPORARY ISSUES IN AVIATION | Daniel Quinn

On the other hand, there is no official regulation with regard to cabin crew training, only
recommendations from various governing aviation bodies. Central to the recommendations is Crew
Resource Management (CRM), which has become a global standard in training programs. CRM
training was initially created for pilots but was then extended to encompass all crew members. The
concept is to enhance situational awareness, planning and decision making, communication and
teamwork skills, and stress management, in order to manage flight safety under all circumstances
(Royal Aeronautical Society, 1999).
In addition to the required training, Regulation 217 of the Civil Aviation Regulations 1988 (CAR)
requires all operating flight crew of training and checking organisations undergo two checks of a
nature to test the competency of each member every 12 months (Civil Aviation Safety Authority,
2014). There has been an increasing focus on training and checking organisations in recent years, as
accidents repeatedly appear to have been caused by pilot failure to manage basic, textbook
situations. Such examples include, the Colgan Air Bombardier Q400 at Buffalo, New York, Turkish
Airline Boeing 737- 800 at Amsterdam and the FedEx Boeing MD-11F landing accident at Narita,
Tokyo. There is an increasingly prevalent school of thought which believes pilots are no longer as
diligent or skilled in their aircraft operations in the face of increasing technological advancement and
automation. It should be apparent that the need to reinforce basic flying skills in response to the
complacency caused by automated flight decks would have been easily identified under a robust
SMS. In carrying out Safety Assurance, a diligent organisation would have presumably identified
technological advancement and automation as a material change to the airlines operating
environment and evaluated any changes to its current processes necessary to maintain its standard
of safety.
Recent commercial airline crashes such as the intentional crashing of Germanwings Flight 9525 into
the French Alps by the co-pilot in 2015 has also placed a spotlight on the emotional stability of pilots.
As illustrated by the timeline below, possible pilot suicides in airline crashes are infrequent, but still
concerning.

CONTEMPORARY ISSUES IN AVIATION | Daniel Quinn

While most jurisdictions require regular testing of a pilots psychological condition, increased efforts
may be necessary as part of the core training program in order to prevent incidents initiated by
unstable pilots. Note that once again, the emotional health of pilots is a hazard which should be
easily identified as part of a SMS Safety Risk Management process.

CONCLUSION
It is evident that a robust Safety Management System is a necessity in modern aviation, commercial
airlines face increasing public pressure to demonstrate their commitment so safety. Further, the
recent occurrences of accidents caused by pilot actions have also reignited debates about flight crew
training and whether it is sufficient in preventing catastrophic consequences. Ultimately however,
the successful implementation of an effective Safety Management System should work in tandem
with other aspects of the organisation such as Flight Crew Training and ensure they are adequate in
maintaining the required level of safety.

CONTEMPORARY ISSUES IN AVIATION | Daniel Quinn

REFERENCES

Australian Government Civil Aviation Safety Authority, (2014). SMS 1: Safety management system
basics. Canberra.
Australian Government Civil Aviation Safety Authority, (2014). SMS 2: Safety policy and objectives.
Canberra, Australia.
Australian Transport Safety Bureau, (2015). ATSB Annual Report. 2014 - 15. Canberra.
BEA, (2012). Final Report On the accident on 1st June 2009 to the Airbus A330-203 registered F-GZCP
operated by Air France flight AF 447 Rio de Janeiro - Paris. France.
Civil Aviation Safety Authority, (2014). Civil Aviation Advisory Publication. CAR 217 Flight
CrewTraining and checking organisations. Canberra.
International Civil Aviation Organization, (2013). Safety Management Manual (SMM). Montreal,
Canada.
National Transport Safety Board, (1994). AIRCRAFT ACCIDENT REPORT. IN-FLIGHT ICING ENCOUNTER
AND LOSS OF CONTROL SIMMONS AIRLINES, d.b.a. AMERICAN EAGLE FLIGHT 4184.
Washington.
Office of Parliamentary Counsel, (2003). Transport Safety Investigation Regulations 2003. Canberra.
Royal Aeronautical Society, (1999). Crew Resource Management. London.

CONTEMPORARY ISSUES IN AVIATION | Daniel Quinn