Michael Graham became the 45th member of the National Transportation Safety Board on Jan. 3, 2020, bringing with him a deep background of military and business aviation operations and safety expertise. Beginning his career as a U.S. naval aviator flying A-7s and F/A-18s, Graham also spent more than two decades with Textron Aviation, most recently as director of flight operations safety, security, and standardization. He has chaired the Air Charter Safety Foundation (ACSF) as well as led the NBAA Safety Committee’s Single Pilot Safety Working Group.
He recently spoke with AIN about his transition to the Safety Board and his thoughts on risk management and safety management systems (SMS).
Q. Could you tell us about your move to the NTSB and how your work at Textron Aviation and ACSF has played into your role there?
A. It seemed like a good opportunity for me, a good next step in my career. It also seemed like a great idea to have somebody on the Safety Board with a background in business aviation and the charter industry. With my background also including military, general aviation, and manufacturing, I’ve done a lot of work in safety management systems over the years. I think that is a strength that I brought to the board, SMS and risk management. SMS is not just for aviation, but it works in all of the modes, whether it’s rail or marine, or trucking fleets.
Q. From the Safety Board perspective, what are you seeing as far as trends with business aviation?
A. I think you'll hear from not just board members, but a lot of our investigators, that we're not seeing any new accidents out there. It's a lot of the same thing over and over again. A lot of operators are not managing their risk and a lot of them don't have SMS. That's why we've been pushing this really hard since 2016. We put it on the [NTSB] Most Wanted list in 2021 with more of a focus on not just 135, but any passenger revenue-carrying operation. There’s a lot of 91 out there—whether it's air tour, skydiving, parachuting, living history flights, or even hot air ballooning. The paying public deserves the same safety and risk management that we’re seeing in the 121 world and the same with 135 operators. We see in these accidents time and time again, that risk management is not there. They're not identifying the hazards and the risk. They may have good policies and procedures in place, but operationally they're not assuring that those policies and procedures are being followed or if there are issues with them. A lot of times there are known risks that aren't being eliminated or mitigated. That's why we call on SMS. It comes from the top, but SMS engages every single employee in that operation.
Q. What are some of the barriers for operators to adopting SMS and risk management?
A. I think there's a misconception that it's going to be very time-consuming. It's going to be a lot of work that's going to be wasted and it’s going to cost a lot. We need to get that perception erased in the industry. In my perspective, it's not costly and difficult. It could be very simple, especially for small operators. There's a lot of concern because we all know that the FAA is probably getting close to a notice of proposed rulemaking on this and I think there's a lot of concern that it's just going be a blanket Part 5 [regulations addressing SMS for Part 121]. Unfortunately, there's not a lot of good information on what scalability looks like [under Part 5], and that's why I have focused on and talked about what SMS for a smaller operator could look like. We’ve not only called for SMS to be required and verified for effectiveness by the FAA, but we've asked for the FAA to give some guidance to the smaller operator on what an SMS would look like. I think it's the fear of the unknown that is scaring a lot of these operators. It’s up to the industry to promote SMS on every level.
Q. What is an example of a simple way where risk management could be implemented?
A. I’ve given an example of the air tour crash in Kauai [Hawaii]. It involved a smaller operator that had a handful of helicopters and I think about 25 employees. It actually had some very good guidance and policies and procedures, especially for the aircrew. But there was no operational control over that. The management never was checking to see whether the pilots were following this. Several of their helicopters had cameras on them to recreate the customer's flight going through the beautiful valleys, and waterfalls. Some [other] operators were using that as kind of a flight data monitoring, and [the accident operator] could have gone back and reviewed some of the videos and evaluated whether they were following the guidance out of the manuals.
Q. How concerned is the Safety Board about operators having but not using their SMS programs?
A. We are very concerned. There have been some business aviation accidents where the operator had an SMS, but how effective was it? I think that that's one of the reasons we made it very specific on our Most Wanted list to not just require SMS but to verify the effectiveness of it. In the 121 world, there were a couple of accidents in 2019 that accounted for four fatalities. And I think in both cases, the operator's SMS was not quite up to speed. Had they had an effective SMS, they might have caught a couple of the issues that led up to these accidents. We see that in business and charter aviation also. An SMS is not a one-and-done. It's not a book on the shelf. It's a living program. It's daily engaging everybody. It's constantly looking for hazards and risks out there and what may be a risk one day and be mitigated the next day. It's a constant, continuous living program.
Q. What are you seeing in terms of buy-in and willingness to use the SMS properly at these operators?
A. There are a lot of operations that have an SMS but they may not be as effective as they should be. You have to have a good, positive safety culture that is nonpunitive. You need a reporting culture where everybody knows that they are the safety officer and if they see something that's not right, they need to report it and get the attention of management. Likewise, leadership and management need to be engaged when they receive reports like that, they need to investigate them, do something about it, and then they need to communicate it back. So, the communication has to be two-way. If it's not, that's not a great culture. There are some really good cultures out there. Unfortunately, in a lot of the accidents we go to, the safety culture is not where it should be. And as a matter of fact, we've done some accidents where they've been very negative. You can never have an effective SMS if you have a toxic safety culture.
Q. What is a message you would like to get across to operators?
A. Especially for those that don't have SMS I always have two questions for them—what are the risks to your operation and how do you know? If you don't have a way, a procedure, or a policy or a program out there that is basically trying to identify the hazards and risks to your operation, then that puts your whole operation at risk.
National Transportation Safety Board (NTSB) member Michael Graham is concerned that perceptions regarding safety management systems (SMS) are deterring small operators from adopting such programs. Graham, a former U.S. naval aviator who chaired the Air Charter Safety Foundation and was director of flight operations safety, security, and standardization, noted that “there's a misconception that [safety management systems] are going to be very time-consuming. It's going to be a lot of work that's going to be wasted and it’s going to cost a lot.
“We need to get that perception erased in the industry, said Graham, who is set to participate on Thursday in a panel on scaling safety management systems for business aviation. "In my perspective, it's not costly and difficult. It could be very simple, especially for small operators.”
Graham noted uncertainties surrounding the FAA’s looming proposed rulemaking that will expand SMS regulations to charter and maintenance organizations. He added that the fear is the FAA will simply apply the existing Part 5 regulations written for Part 121 to other operators.
“Unfortunately, there's not a lot of good information on what scalability looks like [under Part 5], and that's why I have focused on and talked about what SMS for a smaller operator could look like,” he told AIN.
The NTSB’s Most Wanted list includes SMS for all passenger revenue-carrying operations, but the agency also wants the programs to be verified for their effectiveness by the FAA, he noted.
“We've asked for the FAA to give some guidance to the smaller operator on what an SMS would look like. I think it's the fear of the unknown that is scaring a lot of these operators. It’s up to the industry to promote SMS on every level.”
Even with the uncertainty surrounding SMS rulemaking, Graham is a strong believer in their implementation. “You'll hear from not just board members, but a lot of our investigators, that we're not seeing any new accidents out there," he said. "It's a lot of the same thing over and over again. A lot of operators are not managing their risk and a lot of them don't have SMS. That's why we've been pushing this really hard since 2016.”
In many accidents, operators are not identifying hazards and risks, Graham continued. “They may have good policies and procedures in place, but operationally they're not assuring that those policies and procedures are being followed or if there are issues with them. A lot of times, there are known risks that aren't being eliminated or mitigated. That's why we call on SMS. It comes from the top, but SMS engages every single employee in that operation.”
Graham will be part of a panel tomorrow from 9:30 to 10:30 a.m. at the NBAA Safety Education Center. Moderated by NBAA’s Doug Carr, the session will also feature Andrew Karas from the International Business Aviation Council, Bob Rufli from the Air Charter Safety Foundation, and Amanda Ferraro from Aviation Safety Solutions.