Address by Nick Sabatini at 1st Global Aviation Safety Conference
February 18–19 2009
Abu Dhabi UAE
Nick Sabatini at www.nicksabatini.aero
Good morning and thank you for that kind introduction.
It’s a privilege to be here to speak to you on behalf of Bill Voss, President and CEO of the Flight Safety Foundation. Bill extends his sincere best wishes for a very successful safety conference and wishes he could have been here.
I would like to thank the organizers of this event. A safety seminar is a wonderful idea. The Flight Safety Foundation held its first one in 1947 and eight people showed up. That seminar is still going strong with hundreds of attendees each year. I look around this room and must say that you are off to a great start.
When offered the opportunity to be here with you, a group who engages in a great humanitarian cause, I jumped at the chance to do so because I believe in what you do.
What you do must be done with great care and the highest degree of safety. Aviation safety is the number one priority for the global aviation community. The people you serve are, at that moment in time, the most vulnerable among us. They are highly dependent on your services. And you face unique challenges as you transport food and aid workers for emergency relief actions to the most difficult areas.
You are trying to save people from man-made and natural disasters, while ensuring safe air transportation. And when something goes wrong with the aviation side of a humanitarian mission, its effects ripple out and harm people who are least able to withstand another challenge.
Remember the incident after the tsunami in Banda Aceh? A cargo plane hit a water buffalo on the runway and suffered such terrible damage that it took a day to bring in specialists to remove the aircraft.
Of course this is an extreme example, but how many people suffered even more because of the airport’s closure?
Relief efforts are obviously going to be limited by airport capabilities, so they can’t be limited even more due to an aviation incident.
Conferences like this are key to the exchange of information. And that exchange can minimize aviation accidents and incidents.
If you were to read my personal biography, you would learn that for a period of time in my life, I was a New York City police officer.
First among the duties and responsibilities of a police officer is the “Protection of Life and Property.” We were taught how critically important it was when responding to an emergency call that we operate our police vehicles with the utmost care and safety. We had to get there safely and provide whatever that person in distress needed.
Having an accident on the way would cause us to fail in the discharge of that duty … the protection of life and property.
Humanitarian air operators like the World Food Program face that same challenge. You must get to the site of the disaster as quickly and safely as you can.
Global aviation is experiencing the safest period in the history of aviation. Yet, we never rest. We’re always striving to improve. We do this because of the inherent trust the public places in us and because of the very real costs of accidents. But more than anything we strive to improve because our important safety work saves lives.
Today, however, as a subset of the global community, operators involved in humanitarian operations do not enjoy a similar safety record.
Every one of us is here at this conference because we know we still have opportunities to enhance safety.
Traditionally, the flight crew is a focal point in accident investigation. As the saying goes, “they are the first ones at the scene of an accident.”
We have given pilots extensive crew resource management training. We have given them advanced technologies, including electronic flight bags, enhanced vision systems, improved warning systems, and more. These efforts have helped reduce the classic “pilot error” causes of events and accidents.
Yet, flight crews are but one part of the larger system. What about other critical parts of the system?
Do you know about the hazards and risks impacting engineering departments or maintenance shops or dispatch?
How about in the hangar or on the ramp? Do you have methods to systematically identify and control the hazards?
Attention to human performance in maintenance, engineering and on the ramp holds the promise for enhanced safety. We must offer those other personnel improved information systems and procedures, as well as increased training on human performance issues.
We must support efforts to report and analyze human error with voluntary reporting systems.
Conferences like this one, and the professional activities in which most of you are engaged, are excellent steps in the right direction. Our growing and evolving industry requires that we remain unrelenting AND laser sharp in our efforts to maintain pressure on preventing accidents. The evolution of the safety equation takes us from prognostics to pre-emption of accidents.
We must use every tool at our disposal and, we must use the sharpest tools in our safety toolkit.
What is the sharpest tool?
Let me give you a three-word answer to that question. Safety Management Systems.
A SMS enables an organization to identify and manage risk. Managing risk is of fundamental importance, and an SMS enable us to manage risk far better than before. With this formalized approach, we can identify issues and fix them and ensure that they stay fixed.
Operating under a Safety Management System assures a disciplined and standardized approach to managing risk. The best part is we can review past experience and address known hazards. At the same time, we can look ahead and rigorously apply these principles to any changes or introduction of new elements.
Furthermore, under an SMS, the whole process of identifying potential problems and putting corrections in place is ongoing and the procedure is continuously assessed to make sure it is working.
SMS is rigorous. It is measurable. And it is repeatable.
In this era of competing demands, tight budgets, and high expectations, SMS enables all of us to focus our limited resources on the highest priority hazards. It will help us fix problems early when it is less expensive in both lives and dollars.
I have described Safety Management Systems in terms of process. Yet, what is equally important is that this disciplined approach goes hand in hand with a safety culture.
Organizations that operate under an SMS are committed to safety. They know that success requires more than procedures, more than mitigations, and more than measurement. It requires that safety be a way of thinking — a mindset. SMS is a system but systems are only as good as the people who use them. Systems are tools. To be truly successful in the safety business, it is essential to have a culture of safety.
Getting the culture right is as important — perhaps more important — than the systems you use. An organization with a safety culture is always striving to achieve maximum attainable safety, regardless of commercial pressures or who is in the executive suite.
An organization with a safety culture recognizes and expects people and equipment will fail. It develops defenses and backup plans.
Professor James Reason has characterized a safety culture as one that is also a reporting, just, and learning culture.
To be a “reporting culture” requires an atmosphere of trust. Employees at all levels need to be willing and able to admit errors. These are the organizations with active Aviation Safety Action Programs. Here, reporting mistakes is the norm. Voluntary reporting is not only accepted — it is expected. Nor is it punitive. Yet, in a “just culture” employees acknowledge the distinction between blame-free and culpable acts. Responsibility for seriously unsafe acts is understood. Lastly, Professor Reason reminds us that a safety culture is characterized by continuous learning.
How do you achieve a safety culture? You start with the processes, the structure, and the procedures. These will enable the beliefs and attitudes and values to follow.
The regulator will look to you to operate with a Safety Management System. They expect you to operate with a safety culture.
What are the consequences for an air operator who does not proactively conduct their operations at the highest levels of safety? The answer to that question I believe is obvious.
I’d like to briefly touch on a subject which is of great concern to me, and others in the aviation community, the criminalization of aviation accidents.
There is substantial concern that the increased involvement of criminal investigators in aviation accidents may actually be detrimental to aviation safety. As I look out at the prestigious group before me, I see people who have others’ lives in their hands — in more ways than one.
But what about your lives?
How many of you would look forward to being prosecuted as potential criminals for manslaughter? My guess would be none. I’m sure you all know that in many countries around the world you could be prosecuted as criminals. So could your co-worker or boss.
Just ask the mechanics from Continental Airlines who are being prosecuted in France for the part that dropped of their plane and allegedly contributed to the Concorde accident.
Just ask the pilots from Excel Air who survived the mid-air collision with GOL over the rainforest of Brazil.
Just ask the former regulators from the DGAC in France who retired 15 years prior and were prosecuted for the Mount Saint Odile crash.
If you don’t think this can happen to you, think again.
If you were to ask me, as a former regulator, what can I, as an Air Carrier, do to protect myself against such actions? I would tell you that you must embrace and implement SMS and all its tenets.
Those who did have been successful in mitigating criminal prosecution.
Air carriers who cannot face great liability.
As a former regulator I can tell you this…I could come into your organization and do an analysis and see in a VERY short period of time what type of an organization you are.
Many organizations are talking about safety management systems. Does your organization REALLY have a safety management system? How can one tell? The regulators can tell and if they can tell, the investigators from the criminal courts of the world can tell.
The first thing they will ask is “was there something this organization could have done to prevent this” and “whose name is on the document that might have prevented this but didn’t.”
Safety management systems are all about minimizing risk. One of the most important ways to minimize risk is to proactively examine data from normal operations and see if there are any trends that could be an early precursor to a big problem.
Let me offer a real-world example of how the analysis of data made a big difference in safety.
After the August 2006 accident when an airplane took off from the wrong runway at Lexington, Kentucky, the FAA’s newly formed Aviation Safety Analytical Services staff reviewed 5.4 million records from a number of databases. This examination uncovered 116 wrong runway departures involving commercial air carriers over the previous 20 years. They dug deeper.
In a Wrong Runway Study, they found that certain airports had common elements and/or physical characteristics that could lead to confusion. For example, runway thresholds that terminate in a large apron area can be confusing to pilots.
Other common elements that can contribute to crewmember misunderstanding include a short distance between the airport terminal and the runway, or a complex airport design, or the use of a runway as a taxiway. Or, all of the above.
They used these findings to call the aviation community together for last year’s FAA Call to Action on Runway Safety. At that session, after seeing the findings and recognizing the safety implications, various elements of the community stepped up to make voluntary — not Government-mandated — safety improvements.
This is a key point. Although this effort was led by the FAA, ultimately it was the industry that got together, looked at the data and determined what they needed to do.
The World Food Program does not need government oversight to implement its own ASAP-type program, the Aviation Safety Assessment System.
It doesn’t need the involvement or permission of the owners of the aircraft to continue the Line Operational Safety Assessment.
I must applaud the work of Cesar Arroyo here. His actions in implementing the Continuous Monitoring Approach will pay dividends in making aviation safer. He is serving as a regulator.
This is not an easy undertaking. It requires a commitment from everyone involved in the WFP. And Cesar deserves all of our thanks and appreciation for developing this program and bringing us all together today.
As I mentioned earlier, I’m here representing the Flight Safety Foundation. I’m sure that many of you are familiar with the work of this Foundation. It is a non-political, non-profit international organization with members from more than 150 countries.
It truly is an independent and international group that wants to help and is in a unique position to do so.
The Foundation can be seen as a social network. Take a look at their board list or who serves on the advisory committees. You’ll know those names and you can see that they are from every continent and many different countries.
These people are volunteering their time to spread the message of aviation safety through the best-equipped group out there, the Foundation.
And they are willing to help.
It may be an exchange of information or a review of best practices, or someone may be able to spend a few weeks working with you to implement a new program.
Cesar has outlined the aviation safety priorities and we can say with confidence that the plan he has developed, the CMA, is strong.
As has been evident over the past decade or so, it is more important than ever to take a proactive approach to safety such as the WFP’s ASAS and LOSA.
Let’s find the problems before we lose more lives. This approach is being used very successfully in the commercial airline industry and it will work for WFP. And here’s something that you may not have thought about. There is no airline in the world that has more on the ground knowledge of Africa than the pilots of WFP.
You are the eyes and ears on the ground there.
The information you all develop through ASAS and LOSA would be vital to any airline that serves that continent.
Your experiences and knowledge can help.
This is an industry that sets the standard for cooperation in safety matters. WFP’s commitment to aviation safety, under some of the most trying situations imaginable, is admirable and the major players want to help.
I would like to close be thanking you again for the opportunity to speak with you all today. This is an important seminar and I hope it is the first of many.
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