Regulation as Hierarchical Control
To illustrate the dynamics of control at this level, I want to revisit the example we looked at in Chapter 8 of the crew of a DHC8-Q400, dealing with a propeller overspeed (SHK, 2007). When seeking certification of an aircraft type, the manufacturer, as part of the approval process, has to provide an aeroplane flight manual (AFM) that covers operational instructions, performance data, the minimum equipment list and checklists for normal and abnormal/emergency conditions. When the aircraft is delivered to the operator, it comes w'ith an aircraft operations manual and the quick reference handbook (QRH), both comprising subsets of the information in the AFM. The operator is required to produce its owm operations manual (OM) for issue to
FIGURE 10.1 Document control.
pilots. The authority’s flight operations inspector has oversight of the OM. These relationships are illustrated in Figure 10.1
The AFM is approved by the airworthiness branch of the authority issuing the release to service. The QRH is not approved because it is deemed to be derived from the AFM. The QRH is viewed as a version of the information in the AFM, produced for the benefit of the operator. Any changes to the QRH are negotiated between the operator and the manufacturer and, so, are outside of any oversight process.
As a result of the fragmented approach to document control described above, there were differences between the Q400 AFM and QRH. In the event of overspeed, the Q400 AFM describes the items on the checklist as ‘actions’, whereas they are ‘memory items’ in the QRH. This simple change has implications for how a crew would enact the items on the checklist. In communication terms, it changed the force of the statements. Ironically, as we have seen, it would have no effect on the outcome in this case, but it illustrates how meaning can change without that being the intention of the original authors of the documents.
The propeller-overspeed checklist also contains the statement ‘IF unable to control propeller RPM’. The Swedish accident investigators asked the manufacturer to clarify what that statement meant. The response was:
The AFM/AOM does not define controllable/uncontrollable with respect to the propeller rpm. Pilot aircraft knowledge and training is assumed to provide the necessary basic knowledge of what constitutes normal and abnormal propeller operation.
The investigation discussed the fact that several other operators had encountered problems with the propeller-overspeed checklist. Some crews had dealt with the event in the way the checklist intended while others had used the checklist only partially or even not at all. Several operators pointed out the lack of clarity. The view of the manufacturer, as reported to the investigators, was:
We disagree that the procedures are not satisfactory.
This example reveals much about the gaps in regulatory control as much as the control process itself. Control is anchored in certain key points, such as the aircraft design and the AFM, but considerable latitude exists in the process as a whole. Belcher (2002), in an examination of maritime collision regulations, COLREGS, found that some collisions directly resulted from efforts to avoid accidents by actively trying to follow the rules. Unfortunately, as Belcher points out, regulations have ‘lacunae’ that need to be filled by practice. It is in these spaces that things go wrong. In the example above, the exact meaning of a statement in a checklist is left to the individual pilot to interpret and act upon. The intent of the initial steps in the checklist, discussed in Chapter 8, and their correct application was clearly understood differently by different airlines. These are examples of Belcher’s ‘lacunae’. In this example, the manner in which control is exerted is through the approval of source documents and the oversight of the translation of documents into local procedures. Divisions of responsibility (airworthiness and flight operations in this case) and delegation (development of the QRH) allow opportunities for control to be weakened. The response of the manufacturer to the accident investigation report also shows how the process of control can be disputed and it is better thought of as a negotiated relationship.
Aviation authorities rely on various forms of communication, some of which have the force of mandatory requirements while others are simply for advice and guidance. For communication to fulfil its function as a control, the content of that communication must be available to those affected by it; it must be understood, capable of being complied with and, finally, enacted at the operational level. Formal communication is only effective to the extent that it is complied with or can be enforced. If we reflect on the Pelee island crash discussed in Chapter 2, Canadian Aviation Regulations prohibit a pilot taking off with ice on the wings of an aircraft, a response to a previous fatal accident (Minister of Supply and Services, 1992). This constraint is fully understood by Canadian pilots, and Georgian Express conducted winter operations training during which this message would have been reinforced. The pilot of the Pelee island aircraft had attended the course. His performance on the day was not influenced by the regulation. In another context, because of the incidence of injuries to personnel at UK airports, the Health and Safety Executive (HSE) issued guidance material in 2000 on the management of aircraft turnarounds. The impact of the guidance material was evaluated (HSE, 2006), and the subsequent report commented that 37.5% of respondents to a questionnaire were not aware of the guidance material while a further 12.5% were aware of the document but had not read it. Fully half of the intended audience had not been affected by the advice. Communication through approved documents is a fundamental aspect of regulatory oversight but, as we have just seen, is not infallible. Regulation, in any context, needs to strike a balance between constraint and facilitation. The manner in which this path is navigated goes to the heart of the problem of oversight. In the next section, I want to explore risk at the level of the regulator.
