APPENDIX II
INTRODUCTION
AUSTRALIA
NEW ZEALAND
CONCLUSION
APPENDIX III
INTRODUCTION
The
Role of the US State Department in Foreign and Domestic Aviation Disasters
The Twa Flight 800 Disaster
Accident Information Data
Management Systems
The Cornerstone of Family
Assistance Programs
Report By Chair and Deputy Chair on Transportation Safety Management Systems in
Australia and New Zealand
INTRODUCTION
In October 1998 the Chair and Deputy Chair of the Special Committee on Transportation Safety and Security were on a fact finding mission to Australia and New Zealand. The transport sector in Australia and New Zealand to a large extent is privatized (commercialized) and as such these countries have been managing safety under a some what different regime that is the case I Canada. This is especially true of New Zealand where "out sourcing" of transportation safety has been taking place over the last few years. Both countries provide insight into how a deregulated safety environment operates and how it can be applied to the Canadian situation.
In Australia most safety regulation is conducted at the state level with the exception of civil aviation which is regulated federally. Australia has been attempting to harmonize regulations among the states, especially in the area of trucking and automobile safety. The Federal Government is commencingsome initiatives with the States towards harmonization but more work appears to be required in this area.
A. Transportation Safety Bureau
The Transportation Safety Bureau (TSB) in New South Wales (NSW) is the State agency responsible for rail accident investigations. The TSB sets up the criteria under which the accident investigation takes place. However, the investigation itself is conducted by the railroad involved. Once the accident report is completed, it is submitted to the TSB for review and acceptance and then sent to the CEO of the railway. The TSB monitors the implementation of the report’s recommendations and, if it is not satisfied, it can withdraw its accreditation of the railroad.
At the present time, the accident reports are not published because there is a concern that they could be used in litigation. However, this could change. There is a review of the legislation covering the TSB and this may result in the reports being published in the future.
An area of concern with regard to the TSB’s operations is that of the having the railroads conduct the accident investigation. It would seem, from the Canadian point of view, that the railroads that were involved in the accident may not be able to take a totally objective view of the situation when they are investigating the accident.
B. State Railway Authority
The State Railway Authority operates all passenger train services in New South Wales. On average, there are 800,000 passenger journeys per day (this includes commuter trips into and out of Sydney), on 1,680 railcars generally running as eight car sets with an average train journey of 160 kilometres.
The Authority stated that there is a major review taking place of safety management in New South Wales. It will look at the effects of rail crew reductions, one person train operators and the operations of the TSB. Once this is completed there may be changes to the way railroad safety is managed in NSW. At the present time, railway safety is not perceived as a significant problem since there have been relatively few major accidents.
C. Roads & Traffic Authority (RTA)
The RTA of NSW is a State government entity responsible for providing major road infrastructure, driver and vehicle policy and regulation, and road safety and traffic management.
The RTA is attempting to get uniformity of standards and regulations across Australia. In the area of trucking the RTA is working towards uniform licensing, standards and hours of work. This is a slow process but the RTA believes they are making some progress in this field.
The major issue facing the trucking sector in NSW is the move towards increasing axle weights. The RTA believes this will have a significant impact on transportation infrastructure – especially bridges. Truck driver fatigue is also an issue and new regulations will come into effect this November outlining new hours of work and rest periods for truckers.
The trucking association in NSW is establishing a self-accreditation program to get rid of unsafe truckers. This is in the early stages, but the program is attempting to put the onus on safety on truck owners rather than on just the driver. If owners do not adhere to the safety regulations then the trucks are taken out of operation thereby placing a financial penalty on the truck owner.
The RTA believes that the keys to enhanced safety are advertising (stressing the social and criminal consequences of drunk driving), education and random alcohol testing of drivers.
D. National Roads and Motorist Association ( N.R.M.A.)
The NRMA began in 1920 as a group lobbying for improved roads and has since grown to be Australia’s largest motoring organization. Its functions and services are similar to those of the CAA in Canada. The NRMA exercises influence on all levels of government, in road infrastructure planning, traffic and accident research, and matters relating to all modes of ground transportation.
NRMA believes that one of the key factors in maintaining and improving road safety is having good road infrastructure – properly built and maintained. They conduct highway audits and label poor parts of the roads as ‘black’ sections.
E. Air Round Table
Representatives from the Department of Transport and Regional Development, the Civil Aviation Authority (CASA) and the Bureau of Air Safety Investigation (BASI) provided an in-depth briefing on air accident investigation procedures, air safety regulation, International safety issues, security and, victim assistance.
The Bureau of Air Safety Investigation (BASI) is the unit that is responsible for aviation accident investigation in Australia. While BASI is part of Government, it conducts an independent investigation process with sole responsibility for the investigation with its draft reports distributed for comment to interested parties prior to being made public. BASI does not play an adversarial role; rather, it is looking for the cause of the accident. The bureau is faced with many of the same issues as the TSB in Canada. Namely, the length of time it takes to produce reports and the fact that they take a system’s approach to accident investigation which adds time to the investigation process.
BASI believes that human factors are the key element in aviation accidents and we must look to this in terms of a system’s approach to safety management.
The Civil Aviation Authority (CASA) regulates air transportation in Australia. At the present time they are rewriting their regulations using ‘world’s best practices’ trying to select the best rules for their airline industry. CASA is also involved in trying to develop a regional safety culture in Asia. It assists poorer countries in upgrading airports, air traffic control and safety investigation capability through MOU’s with the country in question.
With regard to airport security services, CASA contracts these out and audits the performance. There is a mandatory training period for airport security staff and security personnel must go through a pre employment screening process. However, CASA did point out that employee security checks are not full proof and are seen as a weak link in the security system.
CASA stressed that credibility is a key issue in safety management and in order for this to occur, proper risk analysis must be undertaken so that the regulating authority properly regulate and audit the safety systems. Basically, the civil aviation safety management system in Australia appears to be moving towards a form of self regulation with the government body performing an audit system to ensure the program works.
F. Maritime Transport Safety Management
There is a Marine Incident Investigation Unit in Australia responsible for investigating marine incidents. The unit investigates the cause of the incident and its findings cannot be used for litigation purposes. As with the air mode, the draft reports are sent out to the interested parties for comments and then published. The reports’ findings are used for risk analysis to improve marine safety. Officials believe that lack of a safety culture in the marine industry is a major cause of accidents.
Round Table Briefing: Transportation of Dangerous Goods,
Trucking, and Drug and Alcohol Policy,
1. Transportation of Dangerous Goods
Australia has a uniform regime for moving dangerous goods over the roads. It is based on the UN code for dangerous goods transport and the Australian States are adopting legislation to adhere to it. They are moving from a prescriptive code to a performance-based system. As far as rail is concerned, the regulations for rail also adhere to the UN code but are controlled by the individual states. The big challenge for Australia is to harmonize safety regimes throughout the country.
2. Trucking
There has been much discussion in Canada about the large truck/road – trains that operate in Australia and they are often cited as a reason for increasing our truck sizes and load limits. In point of fact, for the most part, these units operate mainly in remote areas and not on busy highways. Their operation is highly regulated with strict permit conditions imposed on this segment of the industry. Road trains are restricted to 90 kph in most jurisdictions where they operate except in New South Wales where the limit is 85 kph. In addition, normal truck speeds are regulated in Australia by means of governors that are set 100 kph. This not only provides for enhanced safety but also lowers fuel and maintenance costs for the operator.
3. Drug and Alcohol Policy
Random alcohol testing is conducted by the states. This is seen as a major deterrent in stopping people from drinking and driving and is very popular politically. The testing program coupled with a strong advertising campaign is seen as an extremely effective method for reducing drinking and driving. The incidence of positive tests for general drivers is at approximately 1%, while for professionals it is very low – well below 1%.
In the rail industry, alcohol use on the job is not perceived as a problem and there is a zero tolerance policy for train operators and people in safety sensitive positions. In addition, all railways must have a drug and alcohol program in place to receive accreditation to operate.
Drug and stimulant use does not appear to be wide spread in Australia. When it does arise, officials believe that this is an issue of fatigue management. In other words, if you properly manage hours of work and rest periods, a reduction in stimulant use will follow. As was the case with the air mode, human factors were seen as the key component in accidents.
A. Ministry of Transport
1. Safety Policy – The Safety Audit
Since 1980 there has been a period of fundamental transport reform in New Zealand. Changes have included: the corporatization, deregulation and/or privatization of many transport operations, the transfer of ports to new companies and the opening of the coast to foreign shipping, the deregulation of domestic air services and the privatization of Air New Zealand, the liberalization of domestic air services, the liberalization of all forms of road transport regulation, and the privatization of New Zealand Rail.
In conjunction with this, there has been a comprehensive refocusing of the role of the central government in the transport sector and a fundamental change in the way the New Zealand government approaches safety management. Civil aviation underwent a fundamental re-evaluation out of which developed the concept of ‘safety audit’, which is now gradually being applied to all modes.
Safety audit is not self-regulation, if that term is taken to mean the transfer of all interest in safety away from the public sector. Safety audit takes long term view of safety, focusing on entry and exit procedures in a particular sector, while clearly spelling out the ongoing safety accountabilities of each operator in that sector. The administrative emphasis moves of the public interest moves from spot checks on particular components of the system to the impact of the whole safety management system, as this is audited on a regular basis. All such audits are at the operator’s expense, so that the most cost effective outcome for the operator is to ensure that safety management systems are fully operational, and additional audits following required corrective action are not necessary.
Safety audit is a change of culture as much as a change of system, and will take several years to fully implement. To manage the transition to safety audit, and to clearly identify the costs of any particular level of safety intervention, three new modal safety agencies were created, taking over functions formerly in the Ministry of Transport. These agencies are: the Civil Aviation Authority; the Land Transport Safety Authority; and the Maritime Safety Authority.
Given the safety audit approach, and the highly technical nature of transportation safety, the New Zealand government felt that tightly focussed, stand alone agencies operating in partnership with each of the transport sectors was more appropriate than the traditional Government department approach.
Legally defined as ‘Crown entities’, these agencies are responsible to the Minister of Transport, in terms of a formal Performance Agreement. These Agreements set out safety outcome targets and provide appropriate measures of accountability. Each agency has a board appointed by the Minister to represent the public interest, with two of the five members coming from the sector involved. Each agency CEO has their powers and responsibilities for the safety of the industry set out in legislation, and is independently responsible for the issuing of all safety documents, as well as having the power to institute appropriate prosecutions. Agency staff are not part of the Public Service. The agencies are expected to recover operating costs from direct charges on the industry for which they are responsible.
There is also a general statutory requirement on agencies to tender out activities where this can be shown to be cost-effective. Audit and inspection services are increasingly being transferred to appropriately qualified private sector operators, so that the agencies are more able to focus on operator and sector safety outcomes.
The New Zealand approach to transport safety moves away from massive, high cost intervention into each transport mode. The new safety authorities must work within an overall framework of safety at ‘reasonable cost’. Reasonable cost is defined in legislation as a situation where the costs to New Zealand of any safety intervention are exceeded by the benefits to New Zealand of any such intervention. Since the safety authorities are responsible for developing safety standards and proposing safety rules to the Minister of Transport, the ‘reasonable cost’ approach effectively means that all future safety interventions will only proceed subject to positive cost benefit analysis results at every stage of their development.
Agencies have extensive powers of intervention in cases of urgent public concern. For example, the Director of Land Transport Safety, can require any or all railway vehicles on a particular railway immobilized if there are grounds to believe there is any threat to personal safety arising from continued operation.
A small separate entity, the Transport Accident Investigation Commission has been established to provide independent investigation of serious accidents.
The New Zealand approach to safety is designed to clearly identify the costs of safety in each sector, to relate these costs to the benefits to be derived from particular levels of intervention and to ensure that the particular transport sector, as the ‘consumer’ of safety services has the opportunity to ensure that the safety authorities are giving value for money.
In discussions with Ministry officials regarding the operation of this new safety management system, it was pointed out that they do not impose regulations that result in unnecessary costs to the industry. In practice, the industry establishes a safety regime and submits it to the government for approval. The regime is then audited by the agencies to ensure the safety management system works properly.
One caveat regarding this new approach that was put forward by officials was that with commercialization, the government does lose some of its database for monitoring safety systems. What was once run by the government, is now provided by the private sector and with this goes the control over the data that is part of each transport sector. To be able to effectively monitor safety, you must have a through knowledge of the information database. Without this you cannot accurately assess safety compliance and risk to the transport consumer.
B. Transportation Accident Investigation Commission ( TAIC)
The TAIC is a body corporate consisting of not more than five, nor less than three, members appointed by the Governor General on the advice of the Minister of Transport. Members hold office for a term not exceeding five years. There are no statutory qualifications for Commission members except that one shall be a barrister or solicitor. The Commission meets six to eight times per year or as the workload requires.
As is the case in Canada, TAIC is a multi-modal board. Unlike Canada however, it does not do proactive studies – it investigates after an incident/accident occurs. TAIC’s preliminary reports are sent to interested parties for comment prior to finalization. On average, it takes nine months for a final report to come out. The Commission has a good acceptance (approximately 80% are accepted ) rate for its recommendations but has no enforcement powers to make operators comply.
C. Land Transport Safety Authority (LTSA)
According to the LTSA New Zealand’s road safety record is not as good as it should be. The major reasons are alcohol and poor highway design. To address the issue of alcohol use New Zealand has random mandatory roadside alcohol testing and a graphic advertising campaign against drunk driving. This has reduced accidents to a degree but the government still believes the levels are too high. With regard to the road network, the government recognizes that the country requires better road infrastructure to improve safety. This, however, will require a large investment and the challenge for the government is how to fund it.
Truck accidents in New Zealand are mainly caused by automobiles and driver fatigue (although fatigue is very difficult to assess accurately). There is a lot of commercial pressure on drivers to work long hours without rest and the government is looking at ways to manage fatigue.
With regard to rail, the LTSA has some concerns that safety standards may be slipping. Under the current system, the LTSA approves the safety regime developed by the railroad and then audits it to ensure the standards are adhered to. The concerns centre on the fact that the railways believe, that under the current legislation in New Zealand they do not have to notify the LTSA of variations to their safety regime. The LTSA believes that this could result in deficiencies in safety standards for the railways.
A final caution was raised by the LTSA regarding the commercialization of the transportation sector. This was the same concern raised by Ministry of Transport officials and has to do with the loss of control over safety management when you out source safety activities. The LTSA stressed that you must have good contract management capability if you out source. You must retain the intellectual capital and information database when you out source the delivery of the services. If this does not occur, you lose control over the safety audit function because you are not able to ask the right questions with regard to meeting the desired safety standards.
D. Civil Aviation Authority (CAA)
As is the case in the other modes, the CAA approves and audits the airlines safety management systems. With a new operator there is a six month entry period where there is of surveillance of its safety program by the CAA.
Much like other countries, the CAA believes that the major cause of aviation accidents is due to human factors. System stress on flight deck crew is an issue that will have to be addressed in the future.
Airports in New Zealand must be certified by the CAA and have a security plan in place that is subject to CAA audit. Passenger and baggage screening at airports is provided by the Aviation Security Service, a Crown Agency.
In relation to airline and airport facilities in southern-hemisphere countries, the CAA assists them in upgrading these facilities and systems. The concept is that aviation safety is a global issue and in order to ensure that the consumer has access to a safe airline system the total system must be safe. In this regard, the CAA had some concerns with code sharing. In some cases, because of code sharing, the consumer does not know on which airline he or she is flying. A passenger may think that the airline he is flying on has a spotless safety record, when, in fact, the operator of the code share is a different carrier. In New Zealand, passengers must be told who the operator of the flight is.
In terms of the future, the CAA believes that changes in corporate culture must take place to advance aviation safety. For example, cockpit crew management must evolve to the point where there is a collegial approach rather than a ‘chain of command’ approach to flying an aircraft. For some cultures this can be a problem but it will have to addressed if flight safety is to advance in the future. In conjunction with this is the issue of fatigue. With longer international flights, there will have to be more emphasis placed on fatigue management and how to keep flight crews alert for longer periods of time.
Throughout the Committee’s study of transportation safety it has examined safety management systems in a number of countries. For the most part, they are structured along the same lines as Canada – with varying degrees of control by the federal/national government. In the case of Australia and especially New Zealand, a different approach has been taken.
In Australia, much of the safety program, apart from aviation, is handled by the State governments. New Zealand has taken a radically different approach with regard to safety management. It has gone from a government owned and controlled transportation system, to a private, market driven industry. From a regime that prescribed safety regulations to one of auditing safety management programs developed by the private sector. There are valuable lessons here for Canada as we move into an era of less regulation and government involvement in the transportation sector.
Family and Victim Assistance for Transportation Disasters
When the U.S. Congress passed the Aviation Disaster Family Assistance Act in 1996, it directed the Secretary of Transportation to convene a task force on how to better help families of the victims of aviation disasters. The task force worked for eight months and produced a report in October 1997 containing 61 recommendations to ensure that the families of the victims of aviation disasters receive prompt and compassionate assistance.
The recommendations concentrated on the needs of families after an aviation disaster and how organizations (e.g., the Red Cross) interact with family members. The Act also designated the National Transportation Safety Board (NTSB) as the lead US federal agency in addressing the needs and concerns of aviation accident victims and their families. In this role, the NTSB hosted an international symposium to discuss the role of government and industry in the care of victims and their families following major transportation disasters.
The symposium covered a variety of topics including: the role of the US State Department in foreign and domestic aviation disasters, the TWA Flight 800 disaster, accident information data management systems, and essential elements in accident response. These are summarized below.
The Role of the US State Department in Foreign and Domestic Aviation Disasters
The U.S. State Department is the lead federal agency with respect to the assistance to families of US citizen victims in all instances involving an aviation disaster outside the United States. There is a Memorandum of Understanding between the State Department and the NTSB setting the responsibilities and procedures to be followed in an aviation disaster outside the United States. This is to ensure that there is no unnecessary duplication and a streamlining of efforts to assist families.
In its lead role, the Department notifies the families when an aviation incident occurs outside the United States and assists in making arrangements after the death of an American citizen abroad. It also helps in ensuring ease of travel for families who wish to travel to the scene of the incident.
What has been evolving over the past few years, is a greater degree of co-ordination and co-operation between all the stakeholders in foreign aviation incident. The State Department as the lead agency, co-ordinates efforts with the NTSB, the airlines and foreign governments to ensure that families are provided with the best possible assistance.
Perhaps the major incident that ‘sparked’ changes to the way families are treated after an aviation disaster was the downing of TWA Flight 800 on July 17, 1996 off the shore of Long Island with the loss of 230 people. There was criticism of the airline company for how long it took to inform the families of who was on the flight and for the general confusion and lack of co-ordination in dealing with the victim’s families in New York.
Participants at the symposium were given a somewhat different account, from what appeared in the media, as to what occurred at the trauma centre in New York. The Co-ordinator of TWA’s Trauma Response Team, Johanna O’Flaherty, underlined the fact that along with herself there were 30 members of TWA’s trauma response team (comprised of both active employees and retirees of TWA) working with the families of the victims within hours of the crash. What hampered their efforts was the lack of co-ordination among the 22 or so agencies involved in the aftermath of the disaster and the apparent territorial battles being fought amongst different levels of government in the region. Once these tensions were resolved, the process worked fairly well.
Critical to the success of assisting families is the need for highly trained trauma personnel to be in place. Airlines must be prepared to invest the time and money in training employees for this task. TWA has developed training programs for this type of personnel and readily makes it available to other airline companies.
Accident Information Data Management Systems
At the core of the debate that arose after the TWA Flight 800 tragedy and other aviation disasters was the slowness in releasing the passenger list/manifest to the families of the victims. Family members often complained of phone calls not answered or returned and the general lack of information surrounding the victims of an aviation disaster. Because of this, the Department of Transport adopted the Enhanced Passenger Manifest Rule which requires all US and foreign airlines to collect the full name of each US citizen travelling on flights to and from the United States and to request a contact name and phone number from those passengers. This rule came into effect on October 1, 1998, and it is hoped that it will make the compilation of passenger lists and notification of next of kin a more efficient and humane process.
In conjunction with this, the airlines are developing more sophisticates systems for managing information regarding customers and family members affected by an aviation disaster. Continental Airlines for example, has developed the Incident Centre Activity Reporting Database (ICARE Database) to maintain customer information regarding: the customer’s name, next of kin, physical description of the customer, list of hospitals where customers have been taken, and the name of the family escort assigned to the customer and/or family member. In addition, the names of the emergency response volunteers are maintained in the database to ensure the best match between the volunteer and the survivor/family member (e.g., language, religion). Such a database tool is designed to manage information received about an aviation disaster to better assist in the provision of prompt and compassionate services to family members.
The Cornerstone of Family Assistance Programs
What is critical to the success of any family assistance program is preparedness. We were told throughout the symposium that without a proper response plan in place with highly trained personnel, families of victims would not receive adequate assistance after an aviation disaster. The federal government in the United States has taken the initiative and moved to have American air carriers put such plans in motion. How effective they are will depend upon how much time, money and effort the airlines are willing to devote to such an enterprise.
A final note of caution was raised at the symposium concerning two questions. The first was how do you ensure that smaller air carriers with limited financial resources and a small employee base will be able to develop an adequate an adequate family assistance program? And second, was with the airline business being a truly global industry, how do you get the world airline community to adopt similar programs to deal with aviation disasters?
These two challenges will have to be addressed if we are going to attain the goal of providing prompt and compassionate assistance to families after an aviation accident.