Passion For Safety

Passion For Safety

By OffRoadPilots

Safety is in everyone’s interest, but not everyone has a passion for safety.

Generally, safety is defined as the condition of being protected from or unlikely to

cause danger, risk, or injury. Danger is the state of being unprotected from

external or internal forces. Risk is a probability calculation for an event to occur.

Injury is physical or emotional damages. Safety is such a broad definition that it

does not specifically describe future occurrences but is used to eliminate or reduce

opposition to implement reactive events. Air travel has a reputation for being the

safest mode of transportation. That everyone will be safe when travelling is a wish

but is not attainable unless it becomes a goal of how to eliminate danger, risk, or

injury. An aircraft may hit clear air turbulence at 41,000 feet, which then tears

apart any wishes for a safe flight. A passion for safety is not to wish for a safety

outcome, but to accept the forces of nature and work within acceptable unsafe

parameters. Any time motion is involved, such as a moving aircraft, vehicle, or

mountain climbing, there are latent condition waiting to cause danger, risk, injury.

Passion is a strong liking or

desire for or devotion to

some activity, object, or

concept. When one thinks

of passion, usually, it is the

thought of a driving force or

motion that takes over. It is

the one thing that keeps a

person going regardless of

what hurdles lay ahead and

the thing that fuel that

energizes a person when

they are feeling depleted. Passion pushes a person through difficult times when they do not what it takes to become better. Everyone have the ability to create whatever kind of future they want, but secret to living the dream is hidden in passion and what is done because of it. Passion is an emotion to be acted upon.  Without action, passion yields no worthwhile results. When a person has passion for something, they love it even when they dislike it. The difference between successful people and unsuccessful people, is that successful people, because of passion, do what unsuccessful people avoid doing.

A person who is passionate about something, they are excited to do it, even if it is

difficult or does not bring in any revenue or notoriety. When working with a

passion for an issue, time seems to fly by, and it is easy to lose track of time when

tasks are done. Passion is a tool to look forward to every challenge and task,

including going to work, and a person becomes excited when thinking about it.

A person with a passion does not mind putting in the time or effort it takes to

accomplish what it takes to achieve, and they happily will go the extra mile. A

person with a passion goes on until being totally exhausted, and then goes on for

another mile. A person with a passion only sees the horizon without an end and

love the fact that there is no end in sight. 

A person with a passion feels right about what they are doing, they feel fulfilled, and well-being. There is a purpose when working with a passion. A passion has a major definite purpose.

A definite major purpose is something that is personal. No other person can create

it for another person. A major definite purpose can be defined as the one goal that

is most important to a person. It is usually the one goal that will help a person to

achieve more of other goals than anything else to be accomplish.

Albert Einstein quote: “Every person is a genius. But if you judge a fish by its ability

to fly high, it will give its entire life believing that it is an inane”. Working with a

passion is to find the area of expertise a person is talented for, or the personal area

of intelligence. It is not for everyone to become the king of a country, or for

everyone to do sleeping tests as work. Several years ago, a person in his golden

years was stacking fertilizing bags on the production line. Every day he showed up

happy and excited to do his job. It was by many viewed as an unskilled job and

monotonous job. When asked about what the job was, he explained and show in

detail how the process worked. Plastic pebbles were dumped into the processer tobe transformed into plastic, a machine would form it into a tube, and it would go

through a cutter and sealer to finalize the product as a bag. Bags were then folded

by a machine and continued down the roller to the end where a person would

collect several bags and place each bundle on a pallet. Each bundle was stacked

systematically so that all bundles would stay on the pallet and not slide off. He had

worked this process for many, many years. His passion was to be a part of a larger

system, and a system that benefitted humanity. The bags were used to store

synthetic fertilizer.

This plant had produced

synthetic fertilizer since

1903 and was the plant

where a superior synthetic

fertilizer process was

invented. The process was

developed by an industrialist

and scientist, along with his

business partner, and based

on a method used by Henry

Cavendish in 1784. This

process was used to fix

atmospheric nitrogen into nitric acid, one of several chemical processes. The

resultant nitric acid was then used for the production of synthetic fertilizer. At this plant a tall tower as built to extract nitrogen from the air.

When packing the bags on the pallets, the passion was the larger picture, and to be

a part of a global system where synthetic fertilizer was shipped all over the world

to grow food in areas where it was difficult to grow. Packing the bags was just the

first stage in a global system where he could contribute to the process. Without his

expertise and knowledge of how to stack the bags, there would not be bags

available to ship globally. Not only was the person a part of a global process to

grow food in difficult areas, but also became a part of a Nobel Peace Prize winner scientist work to produce a robust crop to grow in places where food previously

would not grow. Working with passion is what a person makes of it.

Passion for safety in aviation is triggered by several reasons. When a young person

witnessed an aircraft towing a glider and at 300 feet the glider pilot pulled the

airbrakes and both aircraft crashed into the lake below. Some years later an

aircraft turned final at the same airport, stalled, and crashed in the river. Several

years later a Helio Courrier crashed when landing on a gravelbar in the middle of

nowhere. All accidents had two things in common, that there were no fatalities,

and the pilots made control inputs that made sense at the time, but in hindsight,

they knew what the outcome would be. None of the pilots were surprised that it

happened. Events like these triggered a young mind to make aviation safety a

passion. Aviation safety was studied, the advent of the SHELL model, the PDCA

model, human factors in aviation, flight training, and airport and aircraft design.

Over years a picture was painted of a comprehensive aviation safety system, but

still was an incomplete aviation safety system. 

The transition of knowledge from study and observations to the regulated safety management system was an easy transition since the SMS introduced processes and data analysis into the equation.

The aviation safety management system (SMS) is the industry standard for safety

in operation. SMS was initially sold as a system to save cash and to prevent future

accidents. SMS was a tool to help companies identify safety risks before they

become bigger problems, which in operations did not happen. Passion for aviation

safety was adapted by operators and their personnel. Over time the SMS did not

deliver what had been promised. Accidents still happened, and pilots continued to

make control inputs they knew in hindsight would create accidents. A prime

example is the Boeing 737-210C combi aircraft that crashed when on approach to

Runway 35T struck a hill about 1 nautical mile east of the runway. The aircraft was

destroyed by impact forces and an ensuing post-crash fire. It was not their SMS

that failed to prevent future accidents, it was the organization that operated within

a system allowing for the flight crew to lineup final approach to a non-runway.

When a system, such as the SMS appears to fail, that is the time when passion for

SMS becomes critical to success. By the way, no matter how many accidents, issues, or occurrences there are for an SMS enterprise, an SMS cannot fail since all

it does is to paint a true picture of the operations itself.

Passion for SMS is beyond a

passion for safety in

aviation. Passion for SMS is

a passion for systems,

processes, acceptable work

practices, data collection,

and process analysis. An

SMS is not at tool designed

to prevent future accidents,

since there are no data

available to determine time

and location of any next

occurrence. An SMS is in itself reactive, including the proactive component of an

SMS, since the future is unknown. The Titanic was unsinkable, and the Tenerife

disaster had two highly qualified captains. The proactive component of an SMS is

when an organization has a proactive process or system that provides for the

capture of hazards. The capture of hazards is a reactive process since these

hazards are visible and already there. Developing a hazard register is a reactive

process since it is a reaction to known hazards. A proactive SMS is a system where

hazards are nonexistent, unimaginable, or unexpected. The hazard of lining up final

approach away from the runway, was not entered into a hazard register, since the

hazard was nonexistent, unimaginable, and unexpected that it could happen. A

proactive SMS is a system where statistical process control (SPC) is applied, and

processes are assessed for common cause variations and special cause variations.

An in-control process is an acceptable process. An out-of-control process requires

a root cause analysis and corrective action plan. When using SPC as a tool to

analyse processes, the issue changes from reacting to hazards, to reacting to

processes. Using the SPC process is based on data only, is an unbiased process,

identify known hazards as common cause variations, and identify unknown hazards

as special cause variations. There are multiple rules to define a special cause variation in an SPC control chart, but a general rule is that any point above the

upper, or lower control limits are special cause variations.

When defining hazards as unknown hazards does not imply that they are not

known to the aviation industry, or that airlines or airports have not experienced

the outcome of any of the unknown hazards. An unknown hazards is applicable to

one specific operator, as opposed to a group of operators, and these hazards are

nonexistent, unimaginable, or unexpected to this specific operator. Hazards

experienced by other operators may be used a reactive process by other operators

and must be relevant to both types of operations. An example is windshear

recovery. Recovery from a windshear on approach is different from types of

aircraft. A windshear recovery by a light twin engine airplane may be different than

a single engine aircraft, a wide body aircraft may be different than a business jet

aircraft. Geolocation may also affect a windshear recovery. Windshear recovery on

the parries, may be different than in the mountains. Using the SPC process and

control charts, it becomes possible for operators to identify their own unknown

hazards, conduct root cause analyses, and implement corrective action plans to

prepare for occurrences.

When building systems with

SPC and using abstract ideas

but not having a physical or

concrete existence, it is

helpful to the process to

have a passion for the

safety management system.

A passion for safety may be

more stressful than helpful,

since there is very little

happening during normal

aircraft or airport

operations. When working with SPC and the safety management system, there is no end in

sight, and the view ahead is an endless horizon. This is a challenge for many, since

everyone feel good when they can see the result of their hard work and a tangible result at the end of the day, but with an SMS there is nothing to show for. It is impossible to distinguish between start and finish.

OffRoadPilots

Organizational Factors

 Organizational Factors

By OffRoadPilots

When identifying contributing factors and root causes, an SMS enterprise considers human factors, supervision factors, organizational factors, and environmental factors. Organizational factors is more than how business structure of an organization, it is about how the organizational structure affect policies, processes, procedures, acceptable work practices, within the organization of the certificate.

Organizational factors are how organizations apply crew resource management to flight crew, maintenance personnel, and airport airside personnel. Crew resource management is commonly known to be used as a tool for pilots to maintain performance levels, but these principles are also suitable for airport airside personnel. Airside personnel must also

uphold a high level of integrity, and acceptable performance levels.

At large international airports, with high aircraft movements, there are time limits for how long runways, taxiways or aprons may be closed for unscheduled maintenance or activities. Crew resource management (CRM) is not to push personnel to complete tasks in an unreasonable fashion, but it is to perform tasks as expected within an assigned timeframe. This timeframe must be applicable to the task itself, and not applied as an assigned computer model for expected time. The time it takes to complete a job must include the time it takes to work within common cause variations. Common cause variations are normal variations to be expected. When driving to work daily, a common cause variation is the volume of traffic. One day it might take 30 minutes, and another day it takes 50 minutes because of traffic. A common cause variation for runway edge light maintenance is the time it takes to travel from one light to the next. This will vary every time. If crew resource management excludes common cause variations, it is not crew resource management, but micromanagement of personnel.

Organizational factors at an airport is an organization, and how this organization within the airport certificate, and the airport operations manual (AOM). Tasks conducted outside of this organization and non-airport tasks and are not required for operations. An example of a task outside of an AOM organization is to perform maintenance on access roads to the airport terminal that are outside of the airport perimeters.

An organizational crew resource management process includes seven components. CRM components are priority management, communication, comprehension, pressure, stress and fatigue, workload management, decision making, and recording and reporting.

Priority management for airside personnel to recognize priorities within their environment and to interpret cues, then discuss and select the appropriate action as appropriate.

Communication for airside personnel to communicate with clear, specific, and unambiguous communication, both verbally and written.

Comprehension for airside personnel is to comprehend the system in a 3D environment measured in time, space, and compass. Time is current and approaching time, space is current and approaching geographical location, and compass is current direction and approaching direction of travel.

Pressure, stress, and fatigue are how to respond to pressure (real or perceived) and the ability to distinguish between pressure and stress. Applying checklists and standard operating procedures are tools for pressure and stress management. The difference between pressure and stress is that stress can be defined as the internal resistive force to upcoming, or unexpected tasks, while pressure can be defined as the amount of perceived, or physical force applied to complete upcoming or unexpected tasks. Communication of progress is a tool for pressure and stress management. Accepting the current status of job performance is a tool for pressure and stress management. An SMS enterprise operating with a conforming safety management system, has developed and implemented a non-punitive reporting policy to reduce pressure, stress and fatigue. Pressure and stress are contributing factors for fatigue, and fatigue is a contributing factor for incidents and accidents.

Workload management is goal setting and time management. The airside rundown system is a workload tool for airside personnel to manage operational tasks. Workloads management is also to prioritize multiple blocks of acceptable work- load tasks. During an emergency at the airport, workload management and prioritizing tasks becomes vital for successful airport operations.

Decision making is a process, and there are 7 steps in a successful decision-making process. A decision is a job performance decision, and a decision based on past airside experience, training received, airport operations flow, airport operations conforming to regulatory requirements or reactions vital to avoid hazards, incidents, or accidents. Airside decision making is not to invent new processes, but to apply current processes. New process suggestions are submitted as hazard reports, or as directive by the accountable executive.

Identify the problem or opportunity. The first step in making the right decision is recognizing the problem or opportunity and deciding to address it.

Decision making process step 2.
Gather information to make a decision based on facts and data.

Decision making process step 3.
Identify alternatives. Once the issue, or hazard is comprehended, it’s time to identify the various solutions.

Decision making process step 4. Weigh the evidence.

Decision making process step 5.
Choose among alternatives. Conduct a risk assessment to comprehend what direct risks, and residual risks are involved. This also includes an on-the-spot informal, or metal risk assessment if a decision was already implemented.

Decision making process step 6.
Take action. Create a corrective action plan for implementation.

Decision making process step 7.
Review, monitor and evaluate the implementation for effectiveness.

An example of a decision-making process is if the driver of an airside vehicle on the ramp observes an aircraft is taxiing on the ramp, towards their position. A decision to be made is to stay or move. In a similar scenario, an airside vehicle driver is in a vehicle on the ramp and observes an aircraft is parked with the engine running. The driver has an urgent task to be completed and the common vehicle route is to drive in front of where the aircraft is parked. A decision to be made is to wait for aircraft to taxi or take an alternate route.

Recording and reporting is to record findings on the daily inspection form, or on an electronic device. Paper forms are still circulating but are slowly disappearing. Report recordings to the safety management system.

Within the organizational environment of airport operators is the daily inspection process. A daily inspection may be performed several times per day. Inspections are pursuant to the schedule in the airport operations manual. The AOM is the organization in which airport operations lives. There are generally three responsibilities positions at an airport. These are the airfield maintainer, who maintains the airport to compliance level with airport standards. The next level is the airport manager, who is responsible for airport operations manual maintenance, process assignments, and monitor daily for airport regulations and standards compliance. The oversight level is the airport general manager, who also is an accountable executive (AE) and responsible on behalf of the certificate holder to maintain compliance with a required regulations.

An airport certificate is its own organization since a certificate is issued to a land- parcel, as opposed to a person. The certificate holder is the person who manages and administers airport certificate tasks and actions. The certificate holder is person who most likely is a member of the airport authority and their organization. A certificate holder may also be a third-party contractor, in which that person has the final authority in airport decisions.

When analyzing the effect of organizational factors, both the certificate organization, (if airside standards conform), and the airport authority organization, (if the airport authority organizational flow supports required activities under the certificate). Simplified, just as an aircraft within its own environment, or organizational flow must maintain compliance with all components and functional requirements, an airport certificate must comply with its own surveyed, determined, recorded, and reported compliance factors within its own environment or organization.

Airport operations is more complex than any other functions in aviation. An airport operator must have comprehensive knowledge of airport operations itself, must have operational knowledge of air navigation services, and must be familiar with all types of aircraft operations. An airport operations manual is the organization that contains all airport operations functions.

The AOM is a document that describes the airport organization, and is a document that describes physical characteristics, or the layout, describes airside operations plans, is approved by the airport operator (AE) and the regulatory, is a legal reference document, describes who is in the administration, the largest aircraft that can use the airport, and hours of operations.

The AOM describes the organizational chart, line of authority and line of reporting. Since the work a contractor does affects the accountable executive’s responsibilities, regulatory compliance and safety performance, a contractor is a like-employee person. The AOM lists documents, manuals and guidance material that must be available for airport operations, audits, and regulatory inspections.

The airport obstacle limitation surfaces (OLS), or maximum heights of structure is controlled by airport zoning regulations and incorporated by reference in the AOM. The AOM describes the airport organization and level of authority, it describes the airport organization and level of authority, describes airport lighting systems, describes runways identified by numbers, taxiway identified by letters, excluding the letter X, and aprons by Roman numerals. An AOM describes markers (elevated above ground) and markings (displayed on the ground surface) and describes airport facilities (may be outside of airport lands) and airside services, and more. It is a prerequisite to assess and define applicable organizational factors within an AOM prior to assessing a root cause how airport authority organizational factors affected the outcome. If the systems within the AOM are not identified, the root cause and corrective action plan may be incorrectly assigned.

Human factors and organizational factors are closely related, with a defined difference. The difference is that human factors is about human reactions to inputs, and organizational factors are the climate, or culture environment imposed on personnel.

Human error is a symptom, not the cause, it is a starting point in root cause analysis, not the conclusion, and it is a symptom of trouble deeper inside an organizational system.

Organizational factors to consider in a root cause analysis are SMS policies, processes, procedures, and acceptable work practices. Organizational climate, structure, chain of command, delegation of authority, communication, accountability, policies, culture, just-culture and more. Assign a weight score between 1 and 4 to each factor and to each one of the 5-Ws + How. The factor with the highest weight score is assigned as the root cause factor and the factor where the CAP needs to be applied. If two weight scores are equal, apply the highest “Why” score as the determining factor.

Just as the square root of a number is defined as the value, which gives the number when it is multiplied by itself, an incident root cause is the value, identified by a number, which is most likely to quadruple in value when the same incident happens one additional time.

When organizational factors are determined to be the highest root cause probability, a corrective action plan must address the current organizational system in both the operational system, and airport or airline authority certificate system.

OffRoadPilots