Air France Safety Culture Study

[Don Hudson]

I think there are lessons here for other carriers which have been fortunate enough not to have suffered major accidents. Whether the industry is truly a "learning culture" and whether the the laudable intent of a functioning SMS approach can demonstrate a pro-active rather than, as the article states, a far-to-often reactive stance.

Don

Air France Told To Upgrade Safety Culture

Aviation Week & Space TechnologyFeb 7, 2011

By Jens Flottau

Frankfurt

"Air France needs to significantly alter its safety organization and culture to be able to improve overall safety levels, according to recommendations made by a mandated independent panel of experts.

The Independent Safety Review Team (ISRT) of eight leading authorities in the field was set up in December 2009 by the airline. Air France had just suffered the loss of Flight 447 on June 1 in which all 228 people onboard were killed. The review is not meant to identify causes and factors in that particular accident, but is studying the airline’s overall performance in terms of safety. The review has not been made public, but Aviation Week obtained a copy of the findings and recommendations.

"The ISRT found that Air France’s safety governance structure is “overly complex, leading to an overlap and blurring of the lines of responsibility.” Stating that the airline needs to change the “governance arrangements starting at the top,” the panel recommends the introduction of a board subcommittee for safety. “In general there is an absence of the strong safety leadership at all levels of management needed to guide proper consideration to safety in daily actions and decision-making.”

"Senior managers emphasized that they are committed to safety as a top priority. “However this message does not appear to have penetrated the workforce. This may lead some employees to believe that safety considerations are secondary to commercial considerations,” according to one insider at the airline. Therefore, the ISRT finds, the CEO and senior management should display more visible leadership.

"AF447 was the third major accident involving an Air France aircraft since 2000, when Concorde F-BTSC crashed shortly after takeoff at Paris Charles De Gaulle Airport. In 2005, an Airbus A340-300 had to be written off after a severe landing incident at Toronto Pearson International Airport. While the events are not linked, they have had a deep psychological impact on the organization and have raised awareness that the company should look at its performance in a more structured way. Following the 2009 crash, the airline’s management determined that something concrete had to be done, and quickly.

"The review found that in many departments the safety culture is mainly event-driven, being reactive where it should be proactive. They recommend critically analyzing individual events with an eye to what these could mean on a broader level.

"Also, some aspects of pilot behavior were criticized. Flight data monitoring analysis, introduced in 1974, is “seen by some pilots as a policeman and not as a proactive tool to improve procedures and safety.” Also, while Air France allows pilots to deviate from established procedures when necessary, “there is a small percentage of captains who abuse this general guidance and routinely ignore some rules.” According to the ISRT: “Maintenance and cabin crew expressed a difficulty relating to pilots, noting that some treated them in an autocratic and arrogant manner.” Once again this may be a small percentage of pilots, but the effect on morale, discipline and crew resource management is entirely out of proportion to the number of offenders.” One recommendation is that “a review of initial pilot selection and training programs may provide an opportunity to develop a more team-oriented, less elitist pilot workforce.”

"As to individual responsibility, the review notes that “the culture at Air France does not reflect the level of trust and cooperation . . . that is typically seen at best-performing carriers.” The panel encouraged team-building exercises.

"The ISRT presented 35 detailed recommendations to Air France, many of them organizational changes, though some address training and operational policies. The group believes that it may take Air France up to a decade to implement them all. One of the biggest challenges cited involves redefining “the relationship between management and the unions, particularly the pilot unions.” Also, the airline is urged to jettison a project-based approach in favor of a more long-term view. “Major safety improvements are possible, but if, and only if, they are driven from the top.”

"Air France says it has already instituted preliminary recommendations such as the creation of the safety subcommittee and a line operations safety audit. Most of the other recommendations will be “rapidly implemented.”

[Specs]

I think there are lessons here for other carriers which have been fortunate enough not to have suffered major accidents. Whether the industry is truly a "learning culture" and whether the the laudable intent of a functioning SMS approach can demonstrate a pro-active rather than, as the article states, a far-to-often reactive stance.

Don

The problems at Air France were known long ago. A decade later an outside report just re-states the obvious.

In the end, left to deal with it on their own, Air France and I would venture to say most airlines, are incapable of affecting the type of pro active culture change you're talking about Don. The same individuals who created the problem or excelled under it can't be expected to change it, especially when there is no personal upside, lots of downside, and corporate imperatives are brought to bear.

[Don Hudson]

Hi Specs;

Within the boundaries of rationally balancing profitability with safety, I think progress can be made.

Large and small organizations alike will not be perfect of course - human error is not limited to the cockpit, nor to pilots.

If we take an example like Colgan, your assessment of how proactive an organization can be might be true - I'm almost certain that they still don't have a FOQA program on their Q400s even though they "promised" they would after their February 2009 fatal accident in which serious organizational shortcomings became obvious.

The FAA is reluctant to enforce more than minimum standards because of the outcry from operators working on the thinnest of financial margins. There are broader fundamentals at the seat of this problem, including de-regulation and the price of a ticket, but we've been over that ground many times - passengers complain over a ticket price difference which is often the price of a designer-coffee at Starbucks; - they get what they pay for, ultimately...minimal training, little oversight, and to focus on their recent accident, a First Officer being paid $16,000/year, living at home with Mom and Dad just to help make ends meet, going to work sick and fatigued from commuting and no rest facilities.

I know some of the people involved in the Air France audit and they know what they're doing and know the challenges of cultural change and of organizational complexity; - I suspect the report will provide a roadmap forward. So I think there is good reason to be optimistic and to be at the same time realistic concerning the short-term, and the long-term results.

The industry will monitor changes at Air France, which will be again under the spotlight as the search for AF447 resumes in March of this year, until July. These problems are not limited to AF but remain latent elsewhere.

Don

[J.O.]

I wonder how their partner (KLM) feels about this audit. They have a steep cultural mountain to climb and it will be interesting to watch how they get through it.

[Lakelad]

Large and small organizations alike will not be perfect of course - human error is not limited to the cockpit, nor to pilots.

True enough

"Weak internal governance, including unclear lines of responsibility and accountability, lack of incentives to work across units and raise contrarian views, a review process that did not `connect the dots' or ensure follow-up, and an insular culture also played a big role.''