Aviation Voluntary Disclosure Programs in High Growth Markets
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Transcript of Aviation Voluntary Disclosure Programs in High Growth Markets
Running Header: Aviation Voluntary Disclosure Program Use in High Growth Markets 1
Aviation Voluntary Disclosure Program Use in High Growth Markets
Joshua Hjemvick
Florida Institute of Technology
AVS5207 – Safety Management Systems
Aviation Voluntary Disclosure Program Use in High Growth Markets 2
Abstract
Voluntary disclosure programs, VDP, in aviation applications have helped safety professionals
accurately detect hazards and manage operational risk. Programs such as the FAA’s Aviation
Safety Analysis Program, ASAP, have been incorporated by a number of aviation service
providers including airlines. More importantly ASAP has been embraced by a number of
aviation professionals, including pilots, flight attendants, mechanics, dispatchers, ground
personnel, as an effective means for detecting and communicating operational hazards to
organizational leadership. One vital component in the non-punitive terms provided by regulators
on operators if the error reported was not due to direct negligence or illegal activity. The end
desire is the development of risk mitigation mechanisms, or controls, that minimize the potential
risk of a detected hazard within the system. ASAP is only one example in a sea of many
voluntary disclosure programs used by aviation professionals. Voluntary disclosure programs
may come in different names and in varying degrees of interaction by actors who use the system.
This paper will focus on VDP use in the growing aviation market that exists in the Asia-Pacific
region. Significant trade liberalism and economic growth has aided in expanding many country’s
aviation, specifically commercial airline travel, industries. This growth must be properly
managed in the realm of safety management. While taking the posture of evaluating the VDP in
the Asia-Pacific markets, the use of the VDP will be analyzed in an overall concept of safety
management systems in use and how well the various actors have embraced a positive safety
culture that protects resources and provides a safe operating environment.
Aviation Voluntary Disclosure Program Use in High Growth Markets 3
The ICAO each year publishes a safety report that discusses overall safety trends and
provides analysis of the current global aviation sector’s overall safety health. Unfortunately at
the time of this writing the 2015 report, covering the data and trends for the 2014 year, was not
available. Accordingly the statistics that follow are derived from ICAO’s 2014 safety report that
details the most recent aviation safety statistics available, statistics for 2013. In its 2014 Safety
Report the ICAO remarked on the growth occurring within the global air transport industry by
spotlighting that a total of 3.1 billion passengers were transported throughout the year. Also
reported was a decrease of accidents from 2012 by ten percent. ICAO further remarked that the
global accident rate involving scheduled commercial operators decrease by thirteen percent, to a
derived value of 2.8 accidents per million departures in 2013. Additionally, the 173 fatalities that
occurred in 2013 represent the lowest number of fatalities in commercial schedule air transport
since the year 2000. (ICA0, 2014).
The trends are quite clear (Fig 1), global aviation is becoming an increasingly more safe
operation, the real question though is why, and what processes has the global community
embraced to help build awareness of potential hazards and risks related to commercial air travel?
ICAO, the aviation arm of the United Nations, promotes the safe and orderly development of
international civil aviation throughout the world. Accordingly it sets Standards and
Recommended Practices, or SARPs, necessary for aviation safety, security, efficiency and
environmental protection on a global basis. Through the collaborative process of the 191 member
states of the United Nations taking part in ICAO, it is able to meet its most fundamental strategic
goal of improving the safety of the global air transport system.
Aviation Voluntary Disclosure Program Use in High Growth Markets 4
Fig. 1 - ICAO Accidents / Fatalities - (ICAO, 2014)
The trend is certainly, without question, moving in a positive direction due to the clear
reduction in total accidents and the clear decrease in fatalities from years prior. ICAO, together
with commercial industry leaders and individual states’ aviation governing bodies, has embraced
a new philosophy on addressing aviation safety. The phrase Safety Management System, or
SMS, is becoming a household name throughout the global aviation industry as the leading
approach to managing safety, including the necessary organizational structures, accountabilities,
policies and procedures (ICAO, 2013). The SMS philosophy requires the clear establishment of
the following four pillars, as indicated in ICAO’s Safety Management Manual, 3rd edition:
1. Safety Policies and objectives;
2. Safety Risk Management;
3. Safety Assurance; and
4. Safety Promotion.
Without spending too much time discussing each of the four pillars, the following is an
overview of each pillar’s overall purpose. Ultimately each pillar must be effectively deployed
and managed to allow for a mature SMS to deliver full safety benefits to an operator. Safety
policies and objectives that encompass an organization’s policies and procedures that explicitly
Aviation Voluntary Disclosure Program Use in High Growth Markets 5
describes the responsibility, authority, accountability and expectations of its safety infrastructure.
Safety risk management details an organization’s processes and tools used to identify hazards,
analyze consequences, and ultimately evaluate the level of risk associated within its overall
operation. The next pillar is safety assurance, which includes the regular management review of
safety policies, procedures, tools, and risk mitigation controls to assure safety goals are being
achieved. Also included within safety assurance is an effective process that allows the safety
infrastructure to evolve to changing operational landscapes or even organizational challenges.
Finally the last pillar, safety promotion, is quite simple: the organization, and organizational
leadership, must emphasis safety as a core value with practices that support a sound safety
culture (Stolzer, et. al, p 25-29).
Of the four pillars, two specifically – Safety risk management and Safety Assurance,
provide the overall operational tools necessary to improve global aviation safety. Safety risk
management, highlighted above, is an extremely crucial element to a successful safety
management system. Additionally, safety risk management serves the vital role of hazard
identification and risk analysis. Through SMS, the global community has embraced a proactive
safety outlook. Contrary to a reactive outlook, SMS delivers to the aviation community an
opportunity to analyze safety in a manner that requires forward thinking rather than waiting for
accidents or incidents to occur. Proactive safety looks to transform organizational cultures by
encouraging safety professionals to look forward in an effort to detect hazards before they impact
the operation (Zahn).
Recognizing the changing philosophy of safety management, SMS second pillar – safety
risk management, encourages a proactive safety philosophy that welcomes reporting of potential
Aviation Voluntary Disclosure Program Use in High Growth Markets 6
hazards and concerns from employees to appropriate agencies / authorities. Wittmer, et. al.,
discusses risk management as:
Risk management means the permanent and systematic recording of all kinds of risks
with regard to the existence and the development of the enterprise. It involves analyzing
and prioritizing recognized risks as well as defining and implementing adequate strategic
or surgical measures to minimize non-tolerable risks (2011).
Discussing risk management in the context of aviation also requires a brief overview of
various organizational cultures that may be found within aviation firms. Specifically with safety
cultures in an aviation context, the optimum desired culture is a “just culture.” Just culture is
defined by Wittmer, et. al. as incorporating the reporting culture elements of an atmosphere of
trust, where people are encouraged to report their errors or near misses. Such reports provide
essential information that can be used to avoid the same mistakes being repeated (2011). Taking
in the elements of a reporting culture, Just Culture reflects an organizational standpoint from
leadership that offers a “blame-free” culture where employees are supported by providing
essential safety related information. Additionally, a clear line is drawn between acceptable and
unacceptable behavior, and when unsafe acts call for disciplinary action (Wittmer, et. al., 2011).
Embedded within a Just Culture environment are processes that allow for the free flow of
safety related information from all levels of an organization to safety professionals who analyze
the information within the context of risk management. Within the United States two programs,
one ran by a government organization and another ran collaborative between company,
regulatory, and employee groups, allow for the sharing of safety related information. NASA’s
Aviation Safety Reporting System, or ASRS, collects voluntary submitted aviation safety
incident/situation reports from pilots, controllers and other actors within the United State’s
Aviation Voluntary Disclosure Program Use in High Growth Markets 7
National Airspace System, or NAS (National Aeronautics and Space Administration, n.d.).
ASRS allows for the reporting of information in a confidential and non-punitive environment,
where even if errors occur, the pilot responsible for highlighting the error may be protected from
Federal Aviation Administration, FAA, administration action against their pilot certificate.
Aviation safety, in prior years, use to rely on the analysis of accidents and incidents after the
accident or incident occurred, potentially with a significant loss of life. Partially thanks to the
advancement of a proactive safety management system, aviation safety professionals recognize
the enormous benefit of receiving hazard related information directly from the operators (pilots,
controllers, mechanics, dispatchers, flight attendants) prior to an accident or incident occurs.
This process aids in the hazard identification process embedded within safety risk management
in an evolving SMS.
The second voluntary disclosure program many professional aviators in the United States
will be familiar with is the FAA’s Aviation Safety Action Program, or ASAP. ASAP is a
globally recognized safety program that strives to receive voluntary reported safety issues and
events that come to the attention of employees of certain certificate holders. A certificate holder
being a certificate aviation service provider, but predominately recognized as a Part 121 airline
in the United States. ASAP is based on a proactive and just culture safety partnership that
includes the FAA, the certificate holder, and may include a third-party, such as an employee
group’s labor union (Federal Aviation Administration, 2013). Both of these examples of
voluntary disclosure programs highlights how well the United States has moved from a reactive
safety philosophy to one that is proactive and asks the front-line operator to provide content,
context, and specific hazard identification to organization leadership in an effort to target, and
trap, threats before they become such a risk to the operation that an accident or incident occurs.
Aviation Voluntary Disclosure Program Use in High Growth Markets 8
These two examples however come from a very developed country with a stable aviation
infrastructure that has grown through the problems a young aviation industry tends to encounter.
Considering the success of voluntary disclosure programs in highly developed aviation
markets, to what extent do voluntary disclosure programs exist in the developing world’s
aviation segments? If they exist, what level of non-punitive protection do they provide to
suppliers of information and what organizations are parties to the process? What will follow is a
recap of voluntary disclosure programs in use throughout the international community, but
especially those in high growth aviation markets such as in the Asia Pacific region.
Boeing, a world leader in commercial aircraft manufacturing, publishes a current market
outlook every year detailing the changing trends in global aviation, specifically aircraft demands
and expect passenger growth. In its 2014-2015 Current Market Outlook, Boeing continues to see
the Asia Pacific region as the highest growth environment over the next twenty years,
specifically to the tune of over 13.4 thousand aircraft deliveries over the same time period
(Boeing, 2015).
Fig. 2 - Aircraft deliveries 2014 to 2033. (Boeing, 2015)
Aviation Voluntary Disclosure Program Use in High Growth Markets 9
What exactly is triggering this explosive growth? Forbes magazine, recognizing the
overall economic growth that is occurring in the region, recently highlighted a few contributing
factors to the growing aviation marketplace in the region. Following stable economic growth
over the previous few years, the Asia Pacific region is expected to maintain such growth through
trade liberalization and improved trade agreements on the global marketplace. Additionally,
access to cheap air travel has helped to develop a strong low-cost carrier aviation marketplace
(Forbes). Boeing, in its Current Market Outlook, even expressed the reality of increased personal
incomes as a factor in the upcoming explosive growth. Citing a GDP growth rate of 4.4%
annually over the next twenty years, Boeing expects Asia Pacific to become the largest air travel
market in the world. The real expectation is 100 million passengers entering the marketplace
annually (Boeing, 2015). This explosive growth will not be free of challenges. Tony Tyler,
International Air Transport Association’s Director General and CEO remarked, “Aviation is an
industry with tremendous potential. Asia-Pacific is leading the industry’s growth. But there will
be challenges to become ever safer, to provide cost-efficient infrastructure and to ensure
environmental responsibility” (International Air Transport Association, 2014).
Unfortunately a few of the more noteworthy aviation accidents have come out of
countries in the Asia Pacific region, including for example Air Asia Flight 8501, Malaysia Flight
370 and 17, TransAsia Airways Flight 435. Now, certainly, each of the mentioned accident
flights are unique in their own right, but the number of fatalities associated with these four
accidents alone are quite staggering when compared to the total number of fatalities in 2013.
These four accidents alone, starting from March 2014 to February 2015, yield a total fatality
figure in excess of 750. The similarity of the four accidents is also important in the context of
Aviation Voluntary Disclosure Program Use in High Growth Markets 10
hazard identification in a SMS due to each of these accident aircraft were operated by an
organization calling the Asia Pacific region home.
Without speculating on the causes of the four referenced accidents, there are a number of
facts that surround each accident. For example, early factual findings for TransAsia Airways
Flight 435 reflect the crew improperly shut-down an operative engine following an engine
shutdown shortly after takeoff which contributed to a loss of power and a loss of control,
resulting in the death of 43 of the 58 occupants (Polek). TransAsia, an airline that calls Taiwan
home, operates a fleet of ATR-72 aircraft flying routes between Taiwan and mainline China,
with a number of routes to a number of Japanese cities or other Southeast Asia cities (Finamore).
TransAsia Airways’ safety record is not necessarily the best. As an organization it has had a total
of five ATR-72 accidents in the past twenty-one years (TransAsia Airways). The focus on
TransAsia Airways has not been without purpose. Taiwan, as a member of the high growth
aviation market analyzed by Boeing, will face unprecedented aviation growth over the next two
decades. Accordingly, this high growth will come with varying levels of aviation professional
experience levels. For the same twenty-year period that Boeing analyzed in regards to aircraft
growth, it also determined that the Asia Pacific region would need a total of 216,000 new pilots
in the region to help with the growing aviation market place. This growth represents a 41% share
of new pilots worldwide over the next twenty years (Boeing). For a region that is expected to see
such significant growth, how then does it expect to maintain, or honestly improve, its safety
record as new aircraft and new crews are brought into the landscape?
NASA’s ASRS program is one of thirteen confidential aviation safety systems that is part
of the International Confidential Aviation Safety System, or ICASS, group. ICASS strives to
promote confidential reporting system as an effective method of enhancing flight safety in
Aviation Voluntary Disclosure Program Use in High Growth Markets 11
commercial air transport and general aviation operations. Recognizing the benefits of a just,
reporting, culture, ICASS’s principle objectives are to:
Provide advice and assistance in the start-up and operation of a confidential reporting system.
To facilitate the exchange of safety related information between independent confidential aviation reporting systems., and
To identify solutions to common problems in the operation of such systems. (CHIRP)
In the case of Taiwan, its confidential and voluntary safety reporting systems, Taiwan
Aviation confidential Safety Reporting System, or TACARE, has been a participating reporting
system in ICASS since 2000 (CHIRP). TACARE, originating in 1999 from Taiwan’s Aviation
Safety Council, encourages the reporting of actual or potential threats involving the safety of
aviation operations, inviting flight crew, maintenance personnel, air traffic controllers, flight
attendants, or any other person to report to the system. Recognizing the power of confidential,
voluntary and non-punitive report acceptance, TACARE strives to elevate Taiwan’s aviation
safety by obtaining, distributing and analyzing safety-related reports while keeping the reporter’s
identity confidential at all times (TACARE, n.d.).
TACARE is operated by a specific work group that is specially trained in handling the
reports in a manner that protects the confidentiality and integrity of the reports. The following
graphic highlights TACARE’s report processing flow:
Aviation Voluntary Disclosure Program Use in High Growth Markets 12
Fig. 3 - TACARE Reporting Processing Flow. (TACARE)
Having a reporting mechanism is not the same thing as having a robust, widely used,
reporting system. Taiwan’s TACAR, for instance, was recently found to lack the safety
promotion processes to effectively encourage report submittals from potential reporters,
specifically maintenance professionals in Taiwan (Chen). Even a recent TACARE newsletter
remarked at the challenges the program faces in regards to the volume of reports received
(TACARE, 2013). Chen, in a combination of survey and interview data, found that Taiwanese
mechanics were overwhelming unfamiliar with the safety culture philosophy of “Just Culture” (p
60). When only 18.3% of mechanics are familiar with the very safety culture philosophy that
encourages a non-punitive environment for the reporting of safety related issues, there is little
doubt as to why TACARE has not been more successful. Chen’s research is actually quite
impressive in recognizing the power of TACARE in Taiwan’s overall aviation safety
environment. Of the 601 participants in Chen’s research, only 22, or 3.7%, were familiar with
TACARE and have used it. Compared to the 349 people who were familiar with it, but have not
used TACARE. The success of a non-punitive reporting system requires the input of individual’s
Aviation Voluntary Disclosure Program Use in High Growth Markets 13
errors and near-misses (Reason). Without the data there is very little opportunities for an
organization to adjust its safety posture from a reactive to proactive safety posture. Taiwan’s
Aviation Safety Council appears to have a safety promotion problem in fully implementing its
state Safety Management System due to the clear lack of awareness of a vital safety risk
management tool. TACARE makes an effort on its website to project its ultimate desire by
encouraging aviation personnel to take part in the program. The desire is to upload an open
forum where information can be freely exchanged and without an active participation base the
system will not be effective and successful (TACARE). TACARE’s success will certainly
require aviation professionals, from organizational leadership figures to frontline operators,
embracing a just culture philosophy throughout all levels of its aviation segment.
The downfalls of TACARE awareness highlight the importance of all facets of a safety
management system. While safety risk management and safety assurance are largely regarded as
to the two most important elements of a SMS, the example of TACARE highlights how safety
promotion is extremely important in building awareness of the safety processes, procedures,
programs, and controls necessary to improving an organization’s, or state’s, safety trend.
While Taiwan’s TACARE has received a fair amount of attention, additional confidential
safety reporting programs in Asia include Japan’s ASI-NET, Korean’s KAIRS, China’s SCASS,
and Singapore’s SINCAIR – all of which are all parties to the International Confidential Aviation
Safety Systems Group. Each of these programs provides regular newsletters or publicly posted
reviews of de-identified reports covering aviation safety issues as supplied by reporting
individuals. These reports are accessible predominately online through the respective program’s
website.
Aviation Voluntary Disclosure Program Use in High Growth Markets 14
Voluntary disclosure programs provide access to otherwise unknown safety issues that
may go unnoticed until the unfortunate event of an accident or incident. Through the full
development of state sanctioned safety management systems, underlying aviation organizations
will establish an improved proactive, and even predictive, safety philosophy that strives to
minimize hazard impacts on the state’s aviation industry. Widespread development, and
deployment, of confidential and non-punitive voluntary reporting programs will only help aid in
timely and targeted detection of hazards in a highly dynamic aviation environment. Voluntary
disclosure programs are an important element in successful hazard identification in an effective,
and mature, safety risk management element for a state or aviation firm’s safety management
system. Without strong safety promotion, as was seen in the case of TACARE, the ultimate
success of any voluntary disclosure program may be ineffective in providing the necessary
amount of data that can truly help safety professionals in recognizing unknown hazards. It is with
this acknowledgement that each pillar of a safety management system requires each other pillar
to be appropriately built and managed. Consider for a moment each pillar’s role in protecting a
voluntary disclosure program.
First with safety policy and objectives, organizational leadership must clearly define the
roles of leadership and the various authority figures that will provide oversight and quality
control management of the voluntary disclosure program’s systems, data, and analysis.
Additionally the organization must make clear the objectives of the voluntary disclosure
program. If written appropriately, the clear description of the objectives of the program can even
serve as the initial safety promotion for the voluntary disclosure program.
The next pillar, safety risk management, houses the voluntary disclosure program itself.
Analysts, information gatekeepers, processors, the electronic infrastructure, and many more
Aviation Voluntary Disclosure Program Use in High Growth Markets 15
elements that must exist for the actual program to be effective must be constructed in a way that
encourages the seamless input of information. The program must be accessible by potential
reporters through various means of report submittal, including electronic, telephone, or even
paper form. By having multiple means of data submittal, the program offers an increasing
number of data entry points.
With safety assurance, the third pillar in a safety management system, quality control
measures will be utilized to analyze the effectiveness of the program’s use. Errors in form
submittal may be caught, improved language in the forms instructions, ample space for reporters
to provide enough detail regarding the hazards identified, a feedback system for operators to
provide additional comments or advice regarding the systems effectiveness must all be available
otherwise the program may fail to gain support by the very individuals necessary to its success.
This is only a small list of potential pitfalls but the example still stands in regards to safety
assurance. It is the organization’s job to make sure the safety tools that are in place within its
safety risk management system are operating effectively and with the level of participation
desired. Otherwise changes must be made so as to improve the control’s effectiveness or to
maximize participation to the desired levels.
In regards to maximizing participation, even with very mature voluntary disclosure
programs, it is necessary to promote the voluntary disclosure program through every medium at
an organization’s disposal. By promoting the program’s use, with clear language reinforcing the
program’s objectives, and with the publication of after-the-fact analysis the voluntary disclosure
program is capable of receiving increased attention from targeted audiences. These very same
targeted audiences are liable to receive a number of new found information regarding their
Aviation Voluntary Disclosure Program Use in High Growth Markets 16
organization’s operation, improved awareness of safety hazards, and will be more aware of how
to thoroughly protect themselves and organization’s resources.
Ultimately voluntary disclosure programs provide a unique opportunity for safety
professionals by uncovering unknown hazards to an organization’s operation. Through
successful use of the four pillars of a safety management system, any risk mitigation tool, not
just a voluntary disclosure program, can be effectively deployed to meet the needs of the parent
organization. The program gains legitimacy through effective safety promotion. With strong
safety assurance processes in place the program can be improved or modified to meet the
evolving needs of the organization. A proactive, eventually predictive, safety philosophy will
lead to the construction of strong safety risk management processes and tools. And of course, a
positive safety culture that is embedded in clear safety policy and objectives will greatly allow
for the embrace of whatever safety program is in use at an organization. Predictive safety is the
future of aviation safety. Organizations that embrace the necessary cultural changes required and
the development of tools required to foster such a safety philosophy (such as voluntary
disclosure programs and other hazard identification tools) will be well positioned to evolve
smoothly from an infant safety management system into one that can be very mature and even a
model for other organization’s.
Aviation Voluntary Disclosure Program Use in High Growth Markets 17
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Aviation Voluntary Disclosure Program Use in High Growth Markets 19