Building A Winning SMS Team

Building A Winning SMS Team
By Catalina9

Building a winning Safety Management System (SMS)team is beyond extreme hard work which starts with the Accountable Executive (AE). When the regulator performs SMS assessments of enterprises, the AE is the last person on their list to interview and the questions are simple overarching questions and policy questions. The AE should be interviewed first with the most difficult questions to answer. The SMS Manager is the person who is grilled by the regulator and expected to comprehend the Safety Management System. In addition, pilots and airline ground crews, and airport airside personnel are expected to recall tasks and SMS expectations beyond their operational requirements. By applying this philosophy, the regulator has an approach to SMS assessment to ensure regulatory compliance at the top level but is deterrent to aviation safety. This approach is neither good nor bad, since the regulator’s mandate is regulatory oversight which is different than operational oversight and control. An inspector’s role is to inspect for compliance only. Compliance is defined as the state of meeting regulatory requirements, the state defined as the particular condition that someone or something is in at a specific time. Regulations are independent of safety since they are applicable to a static environment. 

A Winning SMS Team is defined by its strategies

The AE of an airline or airport has a task that may contradict regulatory requirement in that their mandate is to build a Winning SMS Team of processes that conforms to regulatory requirements. If a process conforms to regulatory requirements is not known until after it has been tested. Design of a particular process may be built with a compliance intent, while the outcome of the intent is not known util the operations of the process loop is closed, e.g. from the time an airline leaves the gate for departure until it arrives at the gate at its destination. Within this time-frame, which could be between ½ hour to 15 hours, there are several forces of special cause variations acting on both the airline and airport contributing to non-compliance.

An Accountable Executive takes on a humongous and conglomerate task to proactively mitigate special cause variations. Special cause variations come in a 3D format of time (travel), space (geo-location) and compass (direction). The fall of both airlines and airports after the onset of COVID-19 pandemic is one example of how airlines and airports had ignored building a Winning SMS Team. While it’s true that they could not affect how the virus developed, they had full control over how they applied their operations in servicing their customers. Newspapers are reporting that airlines are back in business with 100% capacity. If there were one lesson airlines would have learned with a Winning SMS Team is that passenger seats need to be spaced similar to how they are spaced in a car. As a preventative tool for the next pandemic airplane seats should be separated 1-meter center to center between passengers. Airports would have learned that they are not in the business of processing, manipulating and storing passengers, but that they are in the business of caring for memories and sentimental values. However, and as always, when there is a conflict between safety and short-thinking cash, safety is the loosing partner.

The regulatory requirement to serve as an Accountable Executive is that the person has control of the financial and human resources that are necessary for the activities and operations authorized under the certificate. Accountability is; without supervision, to comply with regulatory requirements, standards, policies, recommendations, job descriptions, expectations or intent of job performance and for personnel to be actively and independently involved. An Accountable Executive is expected to work with a Winning SMS Team. Conduct a survey within your own enterprise and learn that every single person in your organization, customers, vendors and contractors expect that you operate with a Winning SMS Team.

Objectives and goals are crucial to build a Winning SMS Team. In addition, it is crucial for success that all personnel are actively involved, which includes the Accountable Executive. The accountability, interest and ownership an AE takes in their SMS is gauged by how many hazard reports the AE submits. There are seventeen principles to build a Winning SMS Team and it’s solely on the shoulders of the AE and Confidential Advisor to the AE to design, implement and monitor these principles.

Mastermind Alliance is to work in perfect harmony

The first principle is to design a Definiteness of Purpose. This is the first principle of all achievements. Without this principle an enterprise is a Titanic approaching unknown icebergs, or pandemics.

The second principle is to design a Mastermind Alliance, which is when minds are working in perfect harmony for the attainment of objectives. A successful Accountable Executive is dependent on a Mastermind Alliance towards a common objective and attainable goals. 

The third principle is Applied Faith. Faith is to harness comprehension of the Safety Management System. Comprehension comes from data, which is turned into information and knowledge. With knowledge systems are comprehended for the AE to move forward with Applied Faith. 

The fourth principle is Going the Extra Mile, which is to render more and better service to personnel, vendors and contractors than what they expect. Helping others to solve their problems will help solving your own. Nature is neutral to problems which will find their way around any obstacle to show up in one form or another. 

The fifth principle is a Pleasing Personality, which is the aggregate of all the agreeable, gratifying and likable qualities of any one individual. The attitude you transmit to others will tell you more about yourself the word you say, how well they are written or how you look. If there are problems within your enterprise, take a look in the mirror to find the root cause. 

The sixth principle is Personal Initiative. It is crucial for success of your position as the Accountable Executive that personnel are allowed to take personal initiatives within their roles and involvement in the SMS. Personal initiative is the inner power that starts all actions. Personal initiative is self-motivation. An AE micromanaging their organization find it extremely difficult to work with self-motivated people. 

The seventh principle is a Positive Attitude, which is the means by which the AE can balance their life and relationship to people and circumstances. Everyone is born with initiative and a positive attitude. Negative attitudes are learned and fostered by daily acceptance that all negatives are true. The saying “watch what you wish for” comes true with both a positive and negative attitude. Excellence or Mediocrity is your choice as the AE.   

The eight principle is Enthusiasm, which inspires actions and is the most contagious of all emotions. Enthusiasm is the energy of your SMS. Enthusiasm is not to be smiling and happy all day long, but to have faith in your own capabilities and comprehension of your job performance. A person with enthusiasm transmits confidence to others. 

The ninth principle is Self-Discipline, which is to take control of your own mind. The power of thought is the only thing over which any human being has complete, unquestionable control. Self-discipline is a prerequisite for success.

The tenth principle is Accurate Thinking. Accurate thought involves two fundamentals. First, you, as the Accountable Executive or other organizational personnel, must separate facts from mere information or unverified postings. Second, facts must be separated into two classes: The important and the unimportant. By the habit of doing this is accurate thinking achieved.   

The eleventh principle is Controlled Attention, which is the act of coordinating all the faculties of the mind and directing their combined power to a given end. Keep your mind on the tings you want and off the things you don’t want. 

The twelfth principle is Teamwork, which is the willing cooperation and coordination of effort to achieve a common goal. Teamwork difference from the Mastermind principle in that it’s based on coordination of effort without necessarily embracing the principle of Definiteness of Purpose or the purpose of absolute harmony. 

The thirteenth principle is Adversity and Defeat. Every adversity you meet, as the AE or any other role within the organization, carries with it a seed of equivalent or grater benefit. Every problem has a solution and you have to find it. If you can look at problems as a temporary setback and stepping-stones to success, you will come to believe that the only limitations you have are the ones in your own mind. 

The fourteenth principle is Creative Vision, which is a quality of mind to follow the habit of going the extra mile with the highest aim to do what others say is impossible. 

An Accountable Executive has the power of choice to make a Winning SMS Team.

The fifteenth principle is Maintenance of Sound Health, which is to follow work with play, mental activity with physical activity and seriousness with humor.   

The sixteenth principle is Budgeting Time and Money. A successful SMS budgets and protects time spent on SMS activities in the same manner as cash spent on time. A healthy SMS is not to spend cash every time someone throws out the safety-card. A healthy SMS is budgeting time, cash and return on investment. 

The seventeenth principle is Cosmic Habitforce is the power of choice which is established by thought and behavior patterns. 

The Safety Management System at Your Amazing Airport or Airline has already made a choice between Excellence or Mediocrity. Change is if you must, or move forward with confidence. 

Catalina9

The 14-Day Goal Setting Challenge

The 14-Day Goal Setting Challenge
By Catalina9

The Accountable Executive (AE) at your amazing Airport or Airline has broader powers given to them by the Safety Management System (SMS) Regulations than what is required of them to make sound business decisions as the CEO. However, the AE’s ultimate powers are limited to the operational comprehension levels of  aviation safety inspectors or auditors. Decision powers are not limited in scope, but in options, availability, flexibility and applicability to size and complexity. Operating a successful SMS under these conditions becomes a challenge for the AE to balance the field length with sound business judgments.

A Safety Management System is your goal setting plan.

Conventional wisdom of a process it that what comes out of a process is equal to the quality of inputs. However, within an SMS organization the outcome of processes is strongly depends on special cause variables as inputs, or also defined as human factors, organizational factors, supervision factors or environmental factors. Mitigation of these factors are achieved by goal setting plans and achievement. 

The last blog was about goal setting. Now is the time to put your goals into work by taking on the 14-day goal setting challenge. If you ask what this has to do with SMS you are on the right track since SMS is all about goal setting and goal achievement. Goal setting is also a regulatory and SMS policy requirement. The difference between required goal settings and the 14-goal setting challenge is that this challenge is about you and your Amazing Airport or Airline. All other goals you have are made up by someone else. But why wait for someone to bail you out, when you have more powers within yourself than anyone else for a successful goal achievement plan.

Outputs of a process is a product of multiple inputs.

SMS is hard work, goal setting is extreme hard work, while goal achievement is beyond extreme hard work. The toughest part about goal setting is to do it. The path of least resistance is to leave goal setting alone today and pick it up at a later date. It’s also easier to wait for someone else to take charge, make your goals and move on without commitment. Fear of failure and commitments is of the highest contributing factors to avoid commitment and goal planning. There is an inside fear that if you don’t make it you will be disappointed. Your inside voice is right that you will be very, or beyond extreme disappointed if you don’t make it. On the other hand, if you don’t start the 14-day goal setting challenge, everyone else will be very disappointed. When the purpose of your Amazing Airport or Airline is to serve, there are no other options available but to jump in with both feet and work hard towards your goals.

The 14-day goal setting challenge is just a few simple steps daily for the next 14 days.
Day 1 - Think about your Amazing Airport or Airline as it is now and write down the things that are most important to you in your life for successful operations.
Day 2 - Imagine that you could wave a magic wand and make your Amazing Airport or Airline as perfect in each area of your life for successful operations. Imagine what would it look like.
Day 3 - Using your imaginations from yesterday, write down each goal you would like to achieve for your ideal Amazing Airport or Airline. Make your description clear and detailed in every sense. Use a pencil and paper when writing your goals.
Day 4 - Decide upon your major definite purpose for your Amazing Airport or Airline. Ask yourself what you would do if you could achieve any goal on this list within 24 hours, which one goal would have the greatest positive impact on your life for successful operations.
Day 5 - Set A Deadline and think of a reasonable date for you to achieve
your goal for Your Amazing Airport or Airline. If your goal is includes multiple areas of operations, set sub-deadlines for each building block.
Day 6 - Identify obstacles, interference, restrictions, snags and obstructions you need to overcome to achieve your goal for your Amazing Airport or Airline. Determine how to overcome each one of the snags

The day you are confident that you have all knowledge you have nothing.

Day 7 – Identify knowledge and skills you’ll need that would help. Decide on what one skill, if you developed and did it consistently, in an excellent fashion, would help you the most to achieve your number one goal for your Amazing Airport or Airline. Decide on who is the Confidential Advisor to the Accountable Executive. 

Day 8 - Make a list of everything, including each and every step you will have to do to achieve your goal.

Day 9 - Organize your list into a plan and organize your list into a series of steps

from the beginning all the way through to the completion of your goal. As the Accountable Executive design your own process flowchart for your goal. 

Day 10 - Write your plan down in an agenda and write down each phase of your plan in your agenda all the way through completion of your goal. Plan each day,

week and month in advance.

Day 11 - Determine your support system and make a list of every person that you work with to achieve your goal at your Amazing Airport or Airline. 

Day 12 - Make your goal public. Tell everyone what you want to achieve. As the Accountable Executive communicate your goals to all personnel. 

Day 13 – Practice visualization of your goal for your Amazing Airport or Airline. Create clear, vivid, exciting, emotional pictures of your goals as if they were already a reality.

Day 14 - Do your first task.  The hardest part is starting. On the last day of the challenge, complete the first that you outlined for yourself and get started on the path to success for your Amazing Airport or Airline. 

A goal setting challenge prepares you for the tasks ahead, the obstacles you will face and the stamina you need to withstand any opposition. SMS is hard work and there is always only one person who makes the final decision and that person may as well be you as the Accountable Executive for your Amazing Airport. 

Catalina9

My Zero Incidents Goal

My Zero Incidents Goal 

By Catalina9 

I have a goal of zero incidents at My Amazing Airport or Airline. The regulator has a goal of zero incidents at an airport. An incident triggers a reactive inspection by the regulator, which is an inspection of what occurred in the past and how the airport emergency plan managed the incident. As longs as both the regulator and operator have a common goal of zero incidents life is good. However, if there is a runway excursion by any aircraft operator, the airport is in breach of contract. 

Reaching for the stars is a journey

You may have heard that when you reach for the stars you may not quite get one, but you won't come up with a handful of mud either. Many lives by a philosophy dreaming about unattainable wishes to navigate through disappointments. They avoid setting goals and goal-achievement plans. Taking the path of least resistance is human nature. Reaching for the starts is much more reliable process than setting a goal to read one book a month. If it didn’t happen you always have away out that at least you tried. All wishes are unattainable, while all goals are attainable with attainable timelines. When you set a goal to read one book a month and each book have 150 pages, read 5 pages a day, 2 pages in the morning, 1 at lunch and 2 at night. Goal-achievement timelines makes a difference. 

Taking the path of least resistance is to avoid attainable goal-timelines. Fear of failure is the reason why someone does not explore their full potential. We don’t like to fail, or not reach a personal commitment. We might be good at setting goals and goal-planning for others, but we are often very reserved when it comes to our own goal-achievement plan. Goal setting is a requirement for an effective Safety Management System. While goal setting is a regulatory requirement it’s also a Safety Policy requirement to design a process for setting goals for the improvement of aviation safety and for measuring the attainment of those goals. Setting a goal of zero incidents is the perfect goal and everyone can rest, sit back and relax and just wait for the goal to happen. When there is an incident everyone feels good since at least they tried. 

Goal setting and goal-achievement is a process like any other hard work. Safety Management System (SMS) is hard work with daily failures. In an effective and true SMS everyone fails and often they might also want to give up on safety. Anyone who expects zero incidents at their Amazing Airport or Airline have already given up on the Safety Management System. 

The first step in goal setting is to decide exactly what in every key area of your airport or airline operations. Start off by Idealizing. Imagine that there are no limitations on what you can be, have or do. Imagine that you have all the time and money, all the friends and contacts, all the education and experience that you need to accomplish any goal you set for your Amazing Airport or Airline. Yes, you can also decide on zero incidents. 

The second step is to write your goals down. Goals must be clear, specific, detailed and measurable. You must write out your goals as if you were placing an order for your goal to be manufactured in a factory at a great distance. Make your description clear and detailed in every sense. Make your goal your goal and not someone else’s goal. Yes, you might also write down a goal of zero incidents when you place this order, including details and descriptions. Your right to set a zero-incident goal can never be taken away from you. 

The third step is to set a deadline or timeline for achieving the goal. Your subconscious mind uses deadlines as “forcing systems” to drive you, consciously and unconsciously toward achieving your goal on schedule. If your goal is big enough, set sub-deadlines.  If for some reason you don’t achieve your goal by the deadline, simply set a new deadline. There are no unreasonable goals, only unreasonable deadlines. Yes, you may set a timeline for zero incidents that includes what actions you must take to reach this goal. A goal without action is just a wish. 

Obstacles are not problems but success.

The fourth step is to identify obstacles. Identify the obstacles that you will have to overcome to achieve your goal. The Theory of Constraints is that there is always one limiting factor or constraint that sets the speed at which you achieve your goal. The 80/20 Rule applies to constraints. Fully 80% of the reasons that are holding you back from achieving your goal are inside yourself. They are the lack of a skill, a quality or a body of knowledge. Only 20% of the reasons you are not achieving your goal are on the outside. Start with yourself to achieve the zero-incident goal. 

The fifth step is to identify the knowledge, information and skills you will need to achieve your goal. Especially, identify the skills that you will have to develop to put Your Amazing Airport or Airline among the top 10% of your field. Your weakest key skill is your highest level of goal achievement and your success. You can make more progress by going to work on the one skill that is holding you back more than any other. As yourself the question of what one skill, if you developed and did it in an excellent fashion, would have the greatest positive impact on your goal.  What one skill, if you developed and did it consistently, in an excellent fashion, would help you the most to achieve your most important goal. Whatever the skill, write it down, make a plan and work on it every single day. Write down what skills you require to achieve zero incidents in operations. 

The sixth step is to identify the people whose help and cooperation you will

require to achieve your goal. Make a list of every person in your organization and third-parties that you will have to work with or work around to achieve your goal. Start with the members of your own organization, whose cooperation and

support you will require. List your boss, coworkers and subordinates. Especially, identify the customers whose support you will need to reach your goal.

Once you have identified the key people whose help you will require, ask yourself this question; What’s in it for them. Be a “go-giver” rather than a “go-getter.”

To achieve big goals, you will have to have the help and support of lots of people. One key person at a certain time and place in your life will make all the difference. The most successful people are those who build and maintain the largest networks of other people whom they can help and who can help them in return. Identify the person who is most valuable person to achieve zero incidents. 

The seventh step is to make a list of everything you will have to do to

achieve your goal. Combine the obstacles that you will have to overcome, the knowledge and skills you will have to develop, and the people whose cooperation you will require. List every single step that you can think of that you will have to follow to ultimately achieve your goal. As you think of new items, add them to your list until your list is complete. When you make out a list of all the things you will need to do to achieve your goal, you begin to see that this goal is far more attainable than you thought. “A journey of a thousand miles begins with a single step.” You can build the safest airport or airline in the world by one decision at a time. Decide on your fist step to achieve zero incidents. 

The eight step is to organize your list into a plan. You organize this list by arranging the steps that you have identified by sequence and priority.

Sequence – what do you have to do before you do something else, and in what order.

Priority – what is more important and what is less important

The 80/20 Rule says that 80% of your results will come from 20% of your activities.

The 20/80 Rule says that the first 20% of time that you spend planning your goal and organizing your plan will be worth 80% of the time and effort required to achieve the goal. Planning is very important. Plan your sequence and priority for your zero-incident goal. 

The ninth step is to make a plan. Organize your list into a series of steps

from the beginning all the way through to the completion of goals for Your Amazing Airport or Airline. When you have a goal and a plan and a plan for incremental safety improvements, you increase the likelihood of achieving your goals by 10 times.

Plan each day, week and month in advance.

Plan each month at the beginning of the month.

Plan each week the weekend before.

Plan each day the evening before.

The more careful and detailed you are when you plan your activities, the more you will accomplish in less time. The rule is that each minute spent in planning saves 10 minutes in execution. This means that you get a 1000% return on your investment of time in planning your days, weeks and months in advance. Plan you first item of your zero-incident goal achievement plan. 

The tenth step is to select your number one, most important task for each day.

Set priorities on your list using the 80/20 Rule.

Ask the question if I could only do one thing on this list, which one activity

is most important. Whatever you answer to that question, put a number “1” next

to that activity. Then, ask yourself, if I could only do one other task on this list, which one task would be the most valuable use of my time. Then write a number “2” next to that task. Keep asking this question, what is the most valuable use of my time on this list until you have your seven top tasks, organized by sequence and priority. Concentration are the keys to success. Focus means that you know exactly what it is that you want to accomplish, and concentration requires that you dedicate yourself to doing only those things that move you toward your goal. Select your task for today’s zero-incident goal. 

The eleventh step is to develop the habit of self-discipline. Once you have decided on your most important task, resolve to concentrate single-mindedly on that one task until it is 100% complete. Concentrate 100% on the task to achieve zero-incidents. 

The twelfth step is the visualization on your goals. Create clear, vivid, exciting, emotional pictures of your goals as if they were already a reality. See your goal as though it were already achieved. Imagine yourself enjoying the accomplishment of this goal. In visualizing, take a few moments to create the emotions that would accompany the successful achievement of your goal. 

The thirteenth step is to do a goal-setting exercise. Take a clean sheet of paper and write the word “Goals” at the top of the page along with today’s date. Discipline yourself to write out at least 10 goals that you would like to accomplish in the next 12 months. State your goal of zero-incidents as though it already is a reality, as though you had already accomplished this.

Zero-Incident Goal Meter Your Amazing Airport or Airline

The fourteenth step is to decide upon your major definite purpose. Once you have written out a list of 10 goals, ask yourself a question if I could wave a

magic wand and achieve any goal on this list within 24 hours, which one goal would have the greatest positive impact on my Amazing Airport or Airline. 

Whatever your answer to that question, put a circle around that goal. Then, transfer the goal to the top of a clean sheet of paper. Transfer your zero-incident goal to the top of the page now, if that was still the major definite purpose you picked.

Children learn easily because they accept each achievement as a great success, no matter what they achieve. Learning the letter “A” is an achievement of success and triggering a desire to learn more. Before you know it, they know the whole alphabet. As we grow older, we self-impose a reality where it becomes a failure to achieve something that is looked upon as minor, or what we believe we should already know or be able to task. For this reason, there are Accountable Executives out there, in your Amazing Airport or Airline who believe training and learning is waste of resources.  

Catalina9

SMS Implementation Step-by-Step

Failure To Comply

Failure To Comply

By Catalina9

When the airplane crashed the probable cause was determined to be flight crew’s preoccupation with matters unrelated to cockpit duties. About sixty years later the probable cause in an airplane crash was the pilot’s failure to maintain airspeed and correct pitch attitude. Over a period of 60 year the probable cause was turned upside down, or 180 degrees and had gone from tasks performed to tasks that was not performed. In the 50’s they got the correct probable cause, while today the cause is assigned to an event that didn’t take place. The difference is that it is impossible to fail to comply with a task since one task or another is always performed. In addition, it becomes impossible to develop corrective action plans to a task that did not occur.

Airplane crashes happens because of human behavior and not because of human error, or failure to comply with an arbitrary defined task. There is a reason for the Safety Management System to consider human factors, organizational factors, supervision factors and environmental factors in a root cause analysis. There is a reason for airports to train their airside personnel in human and organizational factors prior to being assigned airside tasks. There is a reason that some airports apply crew resources management training to airside personnel just as an airline apply these principles to their flight crew. The reason is that it is human nature is to take the path of least resistance, which includes preoccupation with trivial tasks.

The Safety Management System is a wonderful process control tool applied to operations. When processes are applied to a certificate it is operational control. When applied to job performance it is monitoring and oversight. A flight crew certificate is managed by operational control, while airport personnel are managed by performance oversight. There is an option for operational control of an airport certificate by implementing the airport zoning regulations.

It is impossible to run an effective Safety Management System without a Statistical Process Control analysis. Without process control any corrective action plans are short-term and the issue will repeat itself over and over again. A downward trend in a bar-chart or a pie-chart is not a guarantee of an in-control process. These are trending charts displaying an upward or downward trend, or the size of each piece in the pie-chart. Definition of these trends are a “good trend” or a “bad trend”, which are emotional definitions and not derived from data. Trends are not good or bad, they are just trends. Simplified, an upward trend of incidents may be “bad trend”, while it could also be a “good trend” if compared to a baseline. If an airline quadrupled their fleet and cycles, while the incidents doubled, it is a “good trend”. The question is not if operations is in a “good” or “bad” state, but if processes are operational acceptable. Either as an airport or airline, an SPC analysis control chart paints you a quality assurance pictures of your operational processes. The question then becomes how to make incremental improvements to lower the upper control limit.

Airlines are promoting themselves as the safest mode of transportation. If this is the case, why does the Global Aviation Industry, being Airlines or Airports, need a Safety Management System (SMS) today, when they were safe yesterday without an SMS? Air travel per flight may have become a safer mode of transportation today than decades ago, but the question to ask is if their operational processes are in-control with a lower upper control limit today than they were decades ago.

SMS processes are analyzed with respect to human factors, organizational factors, supervision factors and environmental factors. A root cause analysis places a weight-factor on all of these factors and the highest factor is the root cause. When investigating an accident for a probable cause one of these factors will stand out as the root cause.

In the examples below an aircraft type was randomly selected for SPC analysis of accidents between 1985 and 2019. This analysis included all global reported accidents and operators. The next step was to select one operator and analyse the processes for that specific operator. The result shows that airline travel processes are not safer today than what it was in 1985.

The first control chart shows operational control that is out-of-control. The upper control limit is 19.5, or that operators of this type of aircraft accepts a process with 19.5 accidents per year.

The control chart below of one selected operator shows an in-control-process. This operator accepts a process with 4.3 accidents per year.

Let’s assume for a moment that aviation safety has improved over the years and that the time frame between 1985 and 2019 is a bit far expanded. The next step is to analyze the same scenarios, but between 2010 and 2019.

The below control chart shows that operational processes have become less safe than in prior years.

When narrowing the time frame to 10 years, the processes produced a result with 22.7 acceptable accidents per year.

In addition, since this is an in-control-process, as opposed to an out-of-control process between 1985-2019, this process systematically accepts 22.7 accident per year.

For the operator, their operational processes produced an improved result, with acceptable processes of 3.4 accidents per year, which is down from 4.3.

When analyzing quality assurance of processes, this specific scenario produced a result that aviation processes are not safer today than what they were in 1985. That aviation is the safest mode of transportation could be an illusion. The beauty of a Safety Management System is that it will capture processes that are out-of-control and in-control processes accepting an unacceptable level of accidents. With an SPC process analysis incremental improvements can be made to human factors, organizational factors, supervision factors and environmental factors. It appears that the aviation industry in the 50’s, identifying flight crew’s preoccupation with matters unrelated to cockpit duties as a probable cause had a better grip on safety processes than they do today.

Catalina9

The Red Car

The Red Car

By Catalina9

Hazard identification is the foundation of a healthy Safety Management System. Events and occurrences are the consequences of hazards and a simple task to identify. In the old days of aviation safety incident and accidents were defined as pilot error. Without any further analysis, pilot error became the standard solution to past occurrences. After a major occurrences new regulation were implemented, technical standards were changed, and new equipment were installed. Still, after decades with new and improved changes, accidents still happened. As an attempt to overshadow the inherent hazards of flying accidents were defined as meaningless and safety defined as common sense. Hazards were trivialized and flying was promoted as the safest mode of transportation. After thousand of hours of accident investigations hazards were brushed aside as an insignificant element of safety since safety was common sense and accidents meaningless.

It’s not always the change, but the process change itself that is opposed.

With the implementation of the Safety Management System (SMS), the aviation industry was required to actively identify hazards, implement a hazard registry and analyze hazards affecting their operations. This approach was new to the industry and rejected with the explanation that hazard identifications was a part of the pilot’s or airport personnel daily task and their duty to avoid. In addition, the lack of hazard reports was a sign of complete safety in an operational environment without any hazards. In their own mind they had become as safe as possible without the need for improvements.

One day, when you bought a new red car, you noticed how many other red cars on the road. Not were the other cars the same colors as your, but they were also the same make and model. It was not until you became aware of your own make and model that you noticed this. How often did you not drive down the same road for several year, but then one day you noticed a new house. In your own mind, the house was brand new. However, after a short review, you realized that it was always there, except you had not noticed it before.

All hazards identification is as distracting as using the smartphone while taxiing

Hazard identification operates with the same principles. Unless they are actively identified, they will not be observed. A hazard is not only the airside vehicle that out of nowhere runs across the taxiway in front of you, but it is also the vehicle that waits for you to taxi or enter the taxiway behind you. Hazards are everywhere, but when the same hazard is observed regularly the tendency is to eliminate this as a hazard since it has become a part of normal operations. Some operators, being airlines or airports, may demand that all hazards are reported. However, the answer to hazard management is not as simple as to report everything. Reporting all hazards in itself could distract a pilot’s attention of priority tasks and be a contributing cause of an incident. For the airside vehicle operator, identifying all hazards could be a contributing factor for a runway incursion. Hazard management is hard work and extremely complex.

Hazards are an inherent risk of aviation for both airlines and airport operators. That a hazard repeat itself regularly and often, does not eliminate it as a hazard, but it becomes a common cause variation of hazard management. For an airline, the constant airside vehicle operations is a hazard to their operations. On the other hand, for an airport operator, the constant taxiing of airplanes is a hazard to their operations. At some point in time, these two hazards are literally on collision course. Even though the primary purpose of an airport is for aircraft operations, does not give an airline the hazard priority. Both airplanes and vehicles are of the same hazard priority, while they are operating under different rules. That an airplane has the right-of-way, while a vehicle is required to yield does not imply that the vehicle is the sole hazard.

Both airlines and airports have access to a statistical process control tool to identify the effectiveness of their hazard reporting culture, or if their hazard reporting system is in control.

In the control chart below the hazard reporting culture is in-control. Statistically, the result conforms to the process, adjusting the upper and lower control limits.

A shown in the chart below, if there were 10 times more hazards reported, the process is still an in-control reporting culture.

There are several data to be extracted from these control chart, but one fundamental observation is that the process conforms to its own environment to maintain an in-control process. I.e. human behavior conforms to expectations or reporting all or reporting none. In an organization where zero hazards are reported, human behavior conforms to that expectation. With a hiring spree and several personnel beginning at the same time, the same process may show an out-of-control process, since these new eyes are observing hazards without biased, or without prior exposure to the hazards.

Without the comprehension of both airline and airport operations, this control chart may cause incorrect mitigation of hazards. Since there are inherent risks involved in aviation, it is the special cause variations of hazards that must be reported. That there are new personnel involved is not an indication of additional hazards, but an indication that operational management did not have in place a hazard reporting system.

A hazard reporting system is when there are defined parameters of what is expected to be reported. For an airline this could be for the flight crew to report wildlife hazards while taxiing straight on Taxiway A, or for the airport operator the task for airside personnel could be to report wildlife hazards on approach to RWY 27 during a specified time. When the parameters are established it becomes possible to capture special cause variations, populate the hazard registry, conduct a root-cause analysis and implement a corrective action plan. Operational hazard management must live by the principle of “The Red Car” and define hazard parameters.  

Catalina9

CAP Complexity

CAP Complexity

By Catalina9

When the CAP is too complex for the regulator to understand they will dump it, reject it and without any attempt to analyze it, trash it. A complex CAP is nothing more than a reflection of publicly available guidance material issued by the regulator. This guidance material comes in the form of an Advisory Circular (AC).

Guidance material is communication

 The purpose of guidance material is to communicate the regulator’s expectation to the aviation industry.  An AC for a root cause method is a document which explains the root cause analysis and corrective action process to address internal audit findings or oversight inspection findings of non-compliance. A root cause AC incorporates ideas from experts in the field of causal analysis.

Each ICAO State may have different objectives, but their common goal is to ensure a level of safety in aviation that the flying public will accept. One goal a regulator publishes is to provide a safe and secure transportation system moves people and goods across the world, without loss of life, injury or damage to property. This is a goal of nice, positive and carefully selected words, but it is also an unattainable goal. In an environment of moving parts, equipment and people, damages are inevitable. A utopia of safety only exists in a regulatory and static environment. When a goal is utopia, safety is status quo where there is no room for incremental safety improvements. Since there are zero process that exists for an operation to ensure no damages, the regulator must exercise their opinions to enforce subjective compliance. If this subjective compliance is not adhered to, they take certificate actions against an aviation document. In a world where no damages are acceptable, the regulator cannot issue one single operations certificate. In a world where no damages are acceptable, it would be foolish by an operator to implement a new process without first the regulator designing and approve the process with their corporate seal. When a corporate seal is attached, the regulator has a tool to micromanage an operator, without operational responsibility. When the regulator applies an inspector’s opinions as regulatory compliance, their view is backwards looking where new systems are incompatible and an obstruction to their opinion.

Internal, or external audit findings can be at a system level or at a process level. System level findings identify both the system and the specific technical regulation that failed, and process level findings identify the process that was not functioning. To develop an effective CAP, an operator and more important, the regulator must understand the nature of the system or process deficiency which led to the finding. A finding must clearly identify which system or process allowed the non-compliance to occur. Without this clarification a corrective action plan cannot be developed.

A system may be without aim or directions for the untrained eye.

A system level finding is a finding of a process without oversight. Some of the system findings may be related to safety management system, quality assurance program, operational control system or a training program. An operational control system is applicable to an aviation document in flight operations. An airport aviation document is the airport certificate, which is issued to the airport parcel itself. An operational control tool for an airport certificate is the airport zoning regulations.

A process level finding is a finding where at least one component of a system generated an undesired outcome. A process level finding is an operational task of any system, except for the oversight system of affected process. Without oversight, or a Daily Rundown Quality Control, a process, or how things are done, are continuing to generate undesirable outcomes.

When a corrective action plan is developed, it is as effective as the operational comprehension level of the person implementing the plan. An Accountable Executive may fully comprehend the CAP, wile an inspector of the regulatory body oversight may not. It is normal for an inspector, who is not involved in the daily operations, to be at a level below comprehension of the plan. This is the exact reason why an Advisory Circular so beautifully directed their regulatory oversight inspectors to only assess the process used to come up with the CAP and not the CAP itself.

There are four levels to comprehension of a system. The first level is data, second level is information, third level is knowledge and the fourth level is comprehension. Data is collected by several means and methods. This data is then formatted and analyzed into sounds, letters or images to provide information, which again is turned into knowledge for a person to absorbed. The absorbed knowledge turns into comprehension of one system and how multiple systems interacts. It is unreasonable and unjust to expect that a regulatory oversight inspector comprehends the operational systems of airlines and airports.   

A short-term corrective action plan is to immediately design and implement the plan. This immediate plan could be as simple as schedule training to be completed within 30 days. A long-term corrective action plan is a change of policy or a process change to design a plan to be implemented within a reasonable timeframe. A long-term winter operations CAP might take a year to be implemented, while a short term could be to clear the snow that day. Without defined timelines the long-term CAP does not exist, no matter how well the plan is written. 

Facts give you directions.

A root cause analysis is fundamental to the design of a corrective action plan. Questions to ask when developing a CAP is to ask the 5-W’s and How; What, when, where, why, who and how.

The What question is to establish the facts. The When question is to establish a timeline. The Where question is to establish a location. The Why question is to populate the events as defined in the What question. The Who question is to define a position within the organization as defined in the Where question. The How question is to answer the events as defined in the Why question. When asked correctly, the How question takes you backwards in the process to the Fork In The Road where a different decision would have lead down a different path. This does not ensure that an incident would not have happened if this path was taken. All it does is to take a different path than the path that lead to an incident.

The 5-Why is a recognized root cause analysis. However, if the Why question is asked incorrectly the root cause statement becomes an incorrect answer. The Why question must be asked how it relates to the How question.

Another element to be analyzed within a root cause analysis are the four causal factors, or factors that affected the root cause statement. Depending on organizational operations and policies, these factors may be expanded to include other and specific operational factors. The four are the Human Factors, Organizational Factors, Supervision Factors and Environmental Factors. When analysed in a root cause analysis each factor is assigned a weight-factor in a matrix of the 5-W’s and How. The factor with the highs weight factor then becomes the determining, and priority factor in the root cause analysis.

When applying this comprehensive approach to the CAP and root cause analysis it should be expected that the process is too complex for someone who are not daily involved in operations. Additional supplementary information of the CAP could be to design a flowchart of how each item in the system affects other items with an expected outcome. This design must be simple and directed to specifics of the Fork In The Road where multiple options are available. When submitting a CAP to the regulatory oversight body, being the regulator or Accountable Executive, it is vital for operational success that reasoning for the CAP is supported by data.  

     

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