158034.ZIRP_Dario

							Dario Fakleš, B. Sc.
Tomislav Gradišar, B. Sc.
Croatia Airlines
Zagreb, Savska c. 41, Croatia
Sanja Steiner, D. Sc.
University of Zagreb
Faculty of Transport and Traffic Engineering
Zagreb, Vukelićeva 4, Croatia


  IATA Operational Safety Audit (IOSA) in function of
                       safety

ABSTRACT:
        Reaching uttermost system enhancements, traditional approach to
safety assessment has drained its abilities. Imperative of safety, with stress
on costs reduction and production increase, leads to development of a
process model that leads to development of new tools used for data
acquisition on information about safety and efficiency of flight operations. One
of the most important tools for evaluation of flight operations safety and
efficiency is auditing. Inter-auditing of airlines that was first started as tool for
verification of service level and risk control, is now becoming significant tool
for safety improvement. Sustained level of increasing code-share agreements
accompanied with significant expansion of number of airline operational audits
similar by intent and content, have led to unnecessary waste of resources.
The solution to this problem, with improvement of audit process itself, was in
global standardization and unification of the audit process. Therefore, IATA
took the lead to develop IOSA. Even still imperfect, IOSA programme might
become the most significant mean of safety assessment of flight operations.


KEY WORDS
Aviation Safety, Safety Culture, Error (Risk) Management, Flight Operations
Safety, Safety Audit, IOSA (IATA Operational Safety Audit)


1. INTRODUCTION
        Transport system such as aviation has become ultra-safe without
having such explicit models of how they achieve this. Aviation is very
vulnerable to the sorts of organizational and technical change which is
flooding over it at present. One of the biggest challenges in the next century of
flight will be improving on the already very low accident rates of major air
carriers. On the other hand, an international trend of aviation markets is the
creation of larger, more cost-efficient airline business structures where
economies of scale can operate. An example is the growth in global airline
alliances and code-share agreements in recent years. The question that
arises is can cost efficiency come without expense of safety? What tools are
efficient enough to verify safety standards of airline carriers on world-wide
scale? A promising step in that direction is being taken by IATA with
development and implementation of IOSA programme.


2. QUALITY ASSURANCE IN THE SERVICE OF SAFETY


2.1. Process approach in the assurance of air safety
        Various socio-technological systems have advanced to be so vast and
complex that the traditional methods of safety and accident prevention have
lost their efficiency. Additionally, the public perception of organisation's safety
has evolved and become an integrated value. Therefore, isolated
interventions to safety become obsolete. As safety is now an integrated value
of an organisation, safety management needs to be process oriented.
        Each manufacture, service or sale can be disseminated to processes
that can take place in parallel or one after another. These processes can often
surpass organisation’s boundaries, which differentiate this model from the
traditional and static vertical organisational model.
        With its global growth, the system of air traffic is growing more
complex. Changes are prompt and forceful, demanding the airlines to respond
swiftly or disappear from the market. Amongst the most frequent changes are
amendments of legislative, escalation in worldwide competition, development
of the new technologies, upsurge of mergers and alliances etc.
       These developments require increased productivity and efficiency
bringing up the risk of reduced safety margins and necessitating better
understanding of safety investments. While production processes are well
defined and explicable, safety measures are more subtle and difficult to
distinguish. The balance between profit and safety is constantly fluctuating
and is more often than not altered towards production increase and cost
reduction, leaving the organisation exposed to (never absent) threats. Also,
safety developments are used not to reduce risks but to increase production,
leaving the risk at level perceived as acceptable. This process is known as
“risk compensation” Moreover, long periods with absence of an accident or
incident can often result in slow degradation of safety levels in ever-present
strives for production increase.
        Better understanding of accident prevention and risk management
requires the recognition of safety tools and levels of protection, which can be
identified using the process approach.


2.2. Latent Errors
        The necessary condition for an organisational accident is the rare
conjunction of a set of errors in successive defences, allowing hazards to
come into damaging contact with people and assets. The most obvious errors
would be the ones performed at the “sharp end” of the system – by pilots, air
traffic controllers, maintenance personnel and the like. Such unsafe acts are
likely to have a direct impact on the safety of the system and, because of the
immediacy of their adverse effects, these acts are termed “active failures”.
       Today, such unsafe acts are seen more as consequences than as
principal causes. Although fallibility is an inescapable part of the human
condition, it is now recognised that people working in complex systems make
errors or violate procedures for reasons that generally go beyond the scope of
individual psychology. These reasons are “latent conditions”. Latent
conditions are products of strategic decisions, brought by governments,
regulators, manufacturers, designers, highest company management and low-
level operational managers.




             Figure 1 - “Swiss cheese”1 model of accident causation.


        The main distinction between active failures and latent conditions is
that active failures usually have immediate and relatively short-lived effects
whereas latent conditions can lie dormant for a time doing no particular harm
until they interact with local circumstances to defeat the system’s defences.
More importantly, whereas particular active failures tend to be unique to a
specific event, the same latent conditions – if undiscovered and uncorrected –
can contribute to a number of different accidents. This is the reason why more
safety benefit can be gained by discovering (and correcting) latent conditions,
than wasting time and resources to pinpoint and punish the executors of
active failures. Moreover, for this reason, the latent condition discovered in
one airline is very likely to exist in another airline.


2.3. Discovering latent conditions in air traffic
       The system of air traffic is renown for its high level of safety. The
steady decline in number of accidents lets us content with the system.
However, the complexity of socio-technological system as this leaves no room
for being complacent. Moreover, the dwindling number of accidents leaves us

1
    Swiss Chees model – introduced by J.Reason, 1997.
deprived of information about unsafe latent conditions developing in the fast-
changing system of air traffic.
       If any significant improvement in safety is to be done, methods and
tools for discovery of latent conditions must be developed. The most popular
safety tools, designed particularly to address latent conditions, are various
technical “spies”, confidential reporting systems, confidential questionnaires
and audits.
         While technical “Flight Data Monitoring” tools like Flight Data Recorder
and Quick Access Recorder can get a tremendous amount of data from each
flight, leaving nothing to hide, it is only discovered what happened and not
why. The answer to this, more important, question can only be obtained from
those at the “sharp-end” of the system – operations and maintenance
personnel.
       Confidential questionnaires provide the general overview of safety
culture and interaction between different elements of organisation as
maintenance, ground handling and aircrews. Information obtained is also
useful in introduction and acceptance of fundamental CRM concepts.
      Confidential reporting schemes, grant priceless information on different
aspects of a particular otherwise not reportable incident or near miss. Without
such system, this information would be lost.
Detection of latent conditions:
   -   Unveils system errors before they become a cause of any damage.
   -   Reveal errors in the higher levels of organisation that would otherwise
       remain out of sight.
   -   Provide greater volume of safety data, producing a more realistic
       depiction of risk source and volume.
   -   Enable faster feedback on the yield of safety investments (or
       “savings”).



3. AUDITING AS A SAFETY TOOL


3.1. Inter-airline audits
        One of the most important tools to monitor and evaluate both safety
and efficiency of flight operations is company audit. An audit is independent
system designed to gather relevant objective information about a certain
company or its part, by means of systematic interviews and insight to
company’s documentation. It is evaluation of company (system) status rather
than workforce evaluation or pursuit of blameworthy individual. It is therefore
important to distinguish Authority’s audit and inter-company audit. While
Authority will investigate if all operations are conducted in compliance with
relevant regulations, auditing carrier will seek confirmation that the level of
service, as well as the overall safety of operations matches its own, permitting
it to entrust its passengers to an audited carrier.
        Therefore, the basis of inter-carrier auditing is commercial. Establishing
a code-share agreement does not relief a carrier only selling tickets
(marketing carrier) from the responsibility towards the passenger, which will in
fact travel by another (operating) carrier.


       Simultaneously with upsurge in number of code-share agreements, the
last decade of the last century brought along another trend: the exponential
increase in the number of aeroplanes operated by a third-party operator,
weather on a dry or wet lease2 basis. Furthermore, forming of global alliances
makes it very usual for a carrier to sell a ticket for its flight, which will actually
be operated by another carrier, but with an aeroplane and crew of the third.
The need for a detailed systematic assessment of an associate carrier is now
obvious.


3.2. Safety benefits for the audited airline
       On the other hand, the audited carrier receives a useful opportunity for
(almost) free expert assessment of its system, as well as a valuable
benchmarking. Commonly helpful, deficiencies found on the lower levels of
organisation only now get due attention from the upper levels. This
phenomenon actively increases the efficiency of resource allocation and
promotes investments in safety. Consequently, inter carrier auditing, although
originally started as a legislative confirmation of the required service and risk
control level, has now become a significant safety tool.


3.3. Limitations and deficiencies of inter-airline audits
       Continuous increase of inter-carrier agreements, together with dramatic
expansion of audits’ scope and depth recently revealed overwhelming waste
of resources. Also, audits of different carriers often repeat themselves in
questions and findings. This leads to a noteworthy loss of work-hours of the
most expensive staff – the management.




2
  In the context of JAR-OPS 1, the dry lease is to be differed from the wet lease arrangement
in regards to Air Operator Certification (AOC): dry lease is when the aeroplane is operated
under the AOC of the lessee and wet lease is when the aeroplane is operated under the AOC
of the lessor.
                       Company               Company
                         A                       B



             Company                                 Company
                   C                                    D



                        Company                Company
                             E                     F
      Figure 2 - Airliners inter-auditing leads to waste of resources.



4. IATA OPERATIONAL SAFETY AUDIT (IOSA)


4.1. Goal
       To provide a standardised audit programme based on internationally
recognised standards and a structured system for sharing audits. This will
help to improve operations and reduce the number of audits in the industry.


4.2. Background
       The airline industry is subject to an ever-increasing proliferation of
inspections, reviews and audits that often overlap in intent and content. The
number of airline operational audits that have been conducted over the past
several years has increased significantly, with many airlines subject to
multiple audits and a wide variability of standards often producing uneven
results. It has become evident to industry professionals that a considerable
opportunity exists to standardize, harmonize and rationalize the audit process.
Therefore, IATA took the lead to develop IOSA.


4.3. IATA's Role
       Since 2001, in an intensive effort with the world's leading airlines,
regulatory authorities and other industry entities, IATA has developed IOSA.
The project has been overseen by an IOSA Advisory Group (IAG), which
comprises technical experts from airlines, ICAO and regulatory authorities,
providing a balanced geographical representation from the air transport
industry.
       IATA’s role is to oversee the entire IOSA Programme. Functions
include the ongoing development of the standards, management of the
training and audit organizations, organizer of the IOSA Oversight Cometee
meetings, and keeper of the IOSA Registry.


4.4. Concept
       The IATA Operational Safety Audit (IOSA) Programme is an
internationally recognised and accepted evaluation system designed to
assess the operational management and control systems of an airline. IOSA
uses internationally recognised quality audit principles, and is designed so
that audits are conducted in a standardised and consistent manner.



                         Company             Company
                            A                   B




               Company                              Company
                  C              IOSA                  D




                         Company              Company
                            E                    F

                         Figure 3 - IOSA concept.


       Inherent in the IOSA Programme is a degree of quality, integrity and
security such that mutually interested airlines and regulators can all
comfortably accept IOSA audit reports. As a result, the industry will be in a
position to achieve the benefits of cost-efficiency through a significant
reduction in audit redundancy.


4.5. Audit Reports
       The IOSA Audit Report (IAR) reflects the acceptable closure of all
findings and is the official record of an audit.
                Figure 4 - IOSA Audit reports and database.


       One important benefit of IOSA is achieved through audit sharing. IATA
is the official custodian of all IOSA Audit Reports, facilitating secure and
confidential access to this information by interested and approved parties.


4.6. Industry Benefits
   With the implementation and international acceptance of IOSA, airlines
and regulators will achieve the following benefits:
      The establishment of the first internationally recognised operational
       audit standards
      A reduction of costs and audit resource requirements for airlines and
       regulators
      Continuous updating of standards to reflect regulatory revisions and
       the evolution of best practices within the industry
      A quality audit programme under the continuing stewardship of IATA
      Accredited audit organisations with formally trained and qualified
       auditors
      Accredited training organisations with structured auditor training
       courses
      A structured audit methodology, including standardised checklists
      Elimination of audit redundancy through mutual acceptance of audit
       reports
      Development of auditor training courses for the airline industry


4.7. The downside
      In the very beginnings of IOSA system, many airlines worldwide are
expressing strong scepticism about it. Most of unquestionable deficiencies
can be attributed to the hastily short development time. Although prepared by
the large number of industry’s finest experts, political and legal issues forged
the initial set of requirements to a mare compilation of FAA, JAA and ICAO
regulations with some of the industry’s best practice. Combined together,
these requirements are overwhelming for most carriers, preventing them from
certification and therefore abolishing the possibility of an industry-wide
standard. For that reason it is mandatory for future revisions of IOSA
standards to give in to common practice and loose up on some of the mere
legislative requirements.
       The second shortcoming of the system is its imperative commonality,
which makes it inflexible to carrier’s size or national and organisational
surrounding. “Best practice” requirements are often taken from the major
carriers and are frequently not viable or even oblivious to the small or regional
carriers.
        The third IOSA problem is undeniable influence of the major carriers,
which will too easily be tempted to use the system to put on pressure on the
smaller carriers. High requirements for the certification of audit organisations
will limit the choice of IOSA audit organisations solely to the transformed
quality assurance departments of the major carriers3. Although it has not yet
happened, even suspicions of commercially influenced results will bring major
credibility problem to the yet unproven system.
       In the end, not neglectable is the high price of certification. The logic
behind the pricing policy was estimated 40,000 USD for the auditing airline
and 20,000 USD for the audited one. The unique price tag of 90,000 USD for
IOSA certification therefore seems justified, but these estimates are simply
not true for the smaller airlines. Also, for a smaller airline, this amount of
money is possibly better invested elsewhere in safety enhancement.


5. CONCLUSION
        In the era of global airline alliances, code-share and other commercial
agreements, safety and quality standards are prone to deterioration.
Standards produce control and transparency by making quality measurable
and revealing differences among competitors. However, safety standards and
rules leave a lot of room for interpretation. Effective tool in determination of
safety and quality standards level is audit. The need for uniform audit
standards that will be recognized by airlines through world has led to
development and implementation of IOSA. IOSA programme with quality audit
principles, standardized audit methodology and structured auditor
qualifications standards is enabling airliners and regulators to share and
accept audit results as valid, cost reducing and to avoid audit redundancy.
Potential next step in developing IOSA programme could be expansion of the
concept to cargo operations. While there is still much work to do and to
prevent IOSA programme to become commercially influenced, in the next few
years IOSA may become significant mean of safety assessment of flight
operations.


3
    At the time, the only two certified IOSA audit organisations are United’s and Lufthansa’s.
MEĐUNARODNI SUSTAV AUDITIRANJA LETAČKIH OPERACIJA (IOSA)
U FUNKCIJI SIGURNOSTI


SAŽETAK:
Dosizanjem krajnjih poboljšanja sustava, tradicionalni pristup osiguranja
sigurnosti iscrpio je svoje mogućnosti. Imperativ sigurnosti, te rastući pritisak
smanjenja troškova i povećanja produktivnosti, dovode do razvoja procesnog
pristupa, čime se razvijaju novi alati prikupljanja informacija vezanih za
sigurnost i učinkovitost letačkih operacija. Jedan od najvažnijih alata praćenja
i vrednovanja sigurnosti i učinkovitosti letačkih operacija je auditiranje.
Međusobno auditiranje zrakoplovnih kompanija, započeto kao alat potvrde
razine usluge i kontrole rizika, postaje značajan alat poboljšanja sigurnosti.
Kontinuirano povećanje broja code-share ugovora uz dramatičnu ekspanziju
opsega i dubine samih audita ubrzo dovodi do prekomjernog rasipavanja
resursa. Rješenje ovog problema, uz poboljšanje samog procesa, nalazi se u
globalnoj standardizaciji i unifikaciji sustava auditiranja. Pod okriljem
Međunarodne udruge zrakoplovnih prijevoznika (IATA), razvijen je
Međunarodni sustav auditiranja letačkih operacija (IOSA). Iako još nesavršen,
ovaj sustav bi u slijedećih nekoliko godina mogao postati najznačajnije
sredstvo osiguranja sigurnosti letačkih operacija.


Literature


[1] Reason, J.: Managing the Risks of Organizational Accidents. England,
1997.
[2] Injac, N.: Mala enciklopedija kvalitete, - III dio. Oskar, Zagreb 2001.
[3] Helmreich, R.L.: Building safety on the three cultures of aviation. University
of Texas at Austin Human Factors Research Project: 236 In Proceedings of
the IATA Human Factors Seminar, Bangkok, Thailand, August 12, 1998.
[4] Helmreich, R.L. Wilhelm, J.A., Klinect, J.R., Merritt, A.C.(2001): Culture,
error and Crew Resource Management. University of Texas at Austin Human
Factors Research Project: 254 In. E. Salas, C.A. Bowers, E. Edens, Improving
Teamwork in organizations (pp. 305-331). Hillsdale, NJ:Erlbaum.
[5] Helmreich, R.L.(in press): Culture, threat, and error: Assesssing system
safety in Aviation. University of Texas at Austin Human Factors Research
Project: 257 In Safety in Aviation: The Management Commitment:
Proceedings of a Conference. London: Royal Aeronautical Society.
[6] Air Safety Week (article): Interview with Capt. Jim Anderson, IOSA Project
Manager: Avoiding Perceptions of Mutual Back-Scratching. April 22, 2002.
Internet sources:
http://www.iata.org/iosa/index.htm