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.


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.


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


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


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


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.


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)


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


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


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:


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


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.


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


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


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.


References

Boeing. (2015). Current market outlook, 2014-2033. Retrieved from http://www.boeing.com/assets/pdf/commercial/cmo/pdf/Boeing_Current_Market_Outlook_2014.pdf

Chen, Y. T. (2010). Taiwan civil aviation safety reporting (TACARE) system in aircraft maintenance: An evaluation of the acceptance of voluntary incident reporting programs for maintenance personnel in taiwan (Order No. EP31991). Retrieved from http://search.proquest.com/docview/878698428?accountid=27313

CHIRP. (n.d.). The international confidential aviation safety systems group. Retrieved from https://www.chirp.co.uk/what-we-do/icass

Federal Aviation Administration. (2013). Aviation safety action program. Retrieved from https://www.faa.gov/about/initiatives/asap/

Finamore, E. (2015). Taiwan plane crash: who are transasia airways – and what is their safety record. The Independent. Retrieved from http://www.independent.co.uk/news/world/asia/taiwan-plane-crash-who-are-transasia-airways--and-what-is-their-safety-record-10022132.html

Reason, J. (1997) Managing the risks of organizational accidents. Aldershot: Ashgate.Trefis Team. (2014). Asia-Pacific will be the largest market for boeing’s commercial

airplanes. Forbes. Retrieved from: http://www.forbes.com/sites/greatspeculations/2014/02/13/asia-pacific-will-be-the-largest-market-for-boeings-commercial-airplanes/

International Air Transport Association. (2014). Preparing for growth – challenges for asia pacific [Press Release]. Retrieved from http://www.iata.org/pressroom/pr/Pages/2014-11-19-01.aspx

International Civil Aviation Organization. (2013). Safety management manual. (3rd ed.). Montreal, Quebec.

International Civil Aviation Organization. (2014). Safety report. Montreal, Quebec.Müller, R., Wittmer, A. and Drax, C. (2014). Aviation risk and safety management:

methods and applications in aviation organizations. Cham New York: Springer.National Aeronautics and Space Administration. (n.d.) Program briefing. Retrieved from

http://asrs.arc.nasa.gov/overview/summary.htmlPolek, G. (2015). TransAsia pilots undergo retesting for engine-failure response. AIN.

Retrieved from http://www.ainonline.com/aviation-news/air-transport/2015-02-11/transasia-pilots-undergo-retesting-engine-failure-response

Stolzer, Alan J., Carl D. Halford, and John Joseph Goglia. (2010) Safety management systems in aviation. Farnham: Ashgate,

TACARE. (n.d.). About TACARE. Retrieved from http://www.tacare.org.tw/sub_en/docDetail.aspx?uid=401&pid=396&docid=32

TACARE. (2013). TACARE Newsletter. Taiwan Confidential Aviation safety Reporting System. 30th Edition. Retrieved from http://www.tacare.org.tw/upload/message_files/4ccc5dfc-ef05-42de-b1cf-9aee9659f041.pdf

TransAsia Airways. (n.d.). In Wikipedia. Retrieved April 4, 2015, from http://en.wikipedia.org/wiki/TransAsia_Airways

Wittmer, A., Bieger, T., and Müller, R. (2011). Aviation Systems. Heidelberg: Springer.


Zahn, J. (2010). Proactive safety management. Professional Safety, 55(9), 50-51. Retrieved from http://search.proquest.com/docview/755053794?accountid=27313

aviation voluntary disclosure programs in high growth markets

Documents