Processes as Profit Generators or Destructive Applications?

Bush pilots are regularly operating single and multi engine airplanes into remote areas and places where the birds don’t fly. These airplanes are operated on wheels, skis or floats and on unprepared airstrips, gravel bars, mountain meadows, rivers or lakes, both summer and winter. 

When a bush pilot prepare for a flight, a Risk Assessment is done, but may not documented. A bush pilot knows that even if the flight goes to a place where they have been several times before, this flight may encounter other challenges than previous flights. Each flight is a new flight and risks must be assessed continuously as the flight progresses. 

A process is like an old airplane, it must be maintained to be operational safe. 

Then a bush pilot may go where “the birds don’t fly”

An operator may have flown for 30 years of more without any accidents, but possible a few incidents. Processes have been established and applied, and they work well. Over years customers were satisfied with service and come back and even recommend the operator to friends and family. 

With the introduction of Safety Management System (SMS) a new intersection on was made on the road to safety. Some operators were looking forward and found the road-signs when they arrived at the fork in the road, while others were looking back, admiring the past and missed the signs of directions and continued down this old road. On this old road there were not places to stop and maintain the system. If a system is not maintained and no matter how well the system had performed in the past there will be a time when it becomes beyond repair. 

Someone sitting on the fence might be in a better position to review and trace the merits of a process. 

Then, who decide what process works and should be acceptable?  Is it an operator who has flown in bush country, high mountains, off lakes and rivers for 30 years without an accident? Or is it the operator who was looking forward, followed the signs and changed their processes? It could be both or none of the above. What decides if the process works and is acceptable is the process itself. 

The process must on its own merits conform to regulatory requirements. These merits may be established by reviewing and tracing the process backwards from end to beginning.  A process needs a trigger to be activated which could be human, organizational or environmental factors. The process management are human operational inputs that must conform to regulatory requirements. 

After the process has been executed and come to a completion, that’s when it is possible to assess and determine if the process conformed to regulatory requirements and if the output was regulatory compliant.  After that, make a risk projection based on the processes fail to pass ratio. The objective is to keep as many as possible of the organizational processes regulatory compliant.   

When making a bond-fire the choice of location, effectiveness and fuel inputs are based on risk-assessment. What choices of inputs are given to organizational processes?

When a process is applied to what it was intended for, it is a fire producing energy and revenue. Should the same process be applied for other than intended for, it becomes a fire of destruction.  

Birdseye59604

What's a SIGMA Anyway?

"It's Too Complex for me to Understand!!"............. Quote from I.M.Awiner, SMS Manager..L.A.Y.Z. airways.

Every Safety Management System requires the company to “monitor” processes to assure that they are in control. Most companies accomplish this through the Audit process required by a Quality Assurance System. The question arises: 

HOW OFTEN DO WE DO AUDITS?

Once a month, once every 6 months, or once a year. What about the times “in-between” the audits? This is where Statistical Process Control, SPC, comes in. The entire SPC system is based on a “normal” distribution of data. We have discussed what is “normal” in other articles in this blog. Through the use of statistics, we have the ability to “Quantify” the “Variation” from what is considered “Average" in any process. This variation is encompassed in statistical boundaries called “Control Limits.” These control limits are measured in Standard Deviations which are commonly refered to as  “SIGMAs.”

This is an illustration of the Bell Shape Normal Distribution Curve
with Superimposed Standard Deviations or Sigmas. 

For those who are mathematically inclined, the Standard Deviation, or Sigma, is a distance that can be calculated. Using the average or mean of the data, we can simply plug that information into a formula that calculates the Standard Deviation or Sigma. In the case of percent defective, the Standard Deviation or Sigma is represented by the formula: 

The Formulas for Calculating the Upper and Lower Control Limits
to a Percent Defective Control Chart. Formulas found in the SMS Memory Jogger II.

Let's take a look at the Process of measuring the output of a process usisng Statistical Process Control and the Control Chart tool.

All of the Metrics, or Data, must fall within an area, 3 times one sigma up from the mean and 3 times one sigma down from the mean giving us an “In-Control” area that is 6 sigmas big. Thus the term 6 sigma Quality Control. It is important to remember that these control limits simply tell us if the process is “Normal" or "In Control." The Control Chart does NOT tell us if we are producing a good output. 

By simply recording metrics from any process, then putting that data into a distribution and then calculate control limits. We can tell is the process is normal or not. If the process is normal and none of the data points stay within the control limits, we then have the power to predict what that process will do in the near future....we can plan!

This is the Six Sigma Symbol commonly used.

 Think about the Control your company would have if we could monitor processes using the 6 Sigma method. Your probably saying now, holy crap, I can’t do math, I will never be able to do this. Rest assured that most companies do not have statistician that could implement this system. There are simple computer programs that will do this for you and these programs are surprisingly affordable. I like “SPC for Excel” which available on the web. For under $100, you can have the control power of 6 sigma. I am sure if you Goggle other SPC program, you will find others that are affordable. 

As far as SMS and 6 sigma....If your company is using control charts properly, your Safety Management Quality Assurance System will be acting on variation rather than incidents or accidents. A truly pro-active system.........your thoughts.

(NOTE: Additional information on SPC and Control Charts is found in the SMS Memory Jogger II authored by myself and Sol. You can get your copy at dtitraining.com )

SMS and Small Operators - Like Driftwood

Small, medium or large – any air operator has to conform to regulatory requirements, no matter what size and complexity they are. A small operator may be a one person operation or having 2-3 employees where everyone is involved in the day to day operation. Planning to ensure regulatory conformance becomes an after hours job for the owner, and often goes into the late night hours. 

Unless a system is maintained, no matter how well the system has
performed in the past there will be a time it becomes beyond repair

Certified Airports of any size and complexity are required to operate with a Quality Assurance Program,QAP, and Safety Management System,SMS. Airlines are required to operate in a just culture with an SMS, but airtaxi operators are not regulatory required to implement SMS today. However, airtaxi operators are still required to conform to regulatory requirements, and without a documented system in place it becomes a convoluted task to ensure all requirements are complied with. It is just as simple for an airtaxi operator to implement SMS as it is to re-invent the wheel and apply another non-documented system to ensure regulatory compliance.  A non-documented system to ensure regulatory compliance could be as ineffective as driftwood washed ashore and waiting for the next flood to arrive.  

As a concept the Safety Management System is simple that one must plan, do, check and act.  However, it may become a complex task to identify how to implement processes to conform to regulatory requirements. The six components of an SMS plan are Safety Management Plan, Document Management, Safety Oversight, Training, Quality Assurance and Emergency Preparedness.  How to implement these components could be written on a six page document, or in a 60 page document for a complex organization. 

Safety Management Plan is to have an idea how to operate safe, write this on a document and call it a Safety Policy. It is to accept that when an incident happen, the organization will find out why it happen and make changes to avoid it next time. Some operators call this the non-punitive policy. If the person who had an incident gets fired, hiring a new person could quadruple the work load. The organization has to advertise for new person, interview new person, paperwork for new person and then train the new person, just so this person can repeat the same mistake. 

Some say that training is too expensive and affects the
bottom line. Then, how many employees mst they hire to find one
who is already trained?

 The other five components of an SMS could also be simplified and implemented. In a day to day operation, an airtaxi operator has most of these items are already covered, but possible not documented, filed or placed in an organized “to do list”.

Document Management is to know what documents are required and where to find them. It is also to have a process in place to know what the regulatory requirements are. 

Safety Oversight is to document hazards, incidents, accidents, investigate analyze and make changes to give higher quality of customer service.  

Training is to document training requirements, set date when training is due, use of checklist what to include and do the training as required by regulations. 

Quality Assurance is simplified to check if the organization has established processes to be regulatory compliant and that all processes conform to the regulatory requirements.  

Emergency Preparedness is to have a plan should an emergency occur. 

Enter it all on an electronic checklist and you are ready to go. When the requirement comes for implementation of SMS, several of the requirements are already documented and the organization has learned to understand a safety management system. SMS is simple in concept where human factors, organizational factors and environmental factors are triggers to success. 

Birdseye59604

"State of Transport" Highlights From the WAMEA Symposium

“State of Transport” Highlights From the WAMEA Airworthiness Symposium

I had the privilege of speaking at the Western Aircraft Engineers Association Airworthiness Symposium in Calgary Alberta this past week. Many AME’s who were in classes at the time of my address, asked me to post some of the highlights of what I shared with the group. Here are some of the more salient points I discussed:

• It is no secret that Transport Canada has had to endure a draconian budget cuts this year and the next fiscal year. What are some of the consequences? First to go, in a budget cut, is training. Many inspectors are having to forgo essential training that would keep up the level of expertise at least par with the aviation industry. A collateral consequence of this lack of training dollars, is a major hit to worker morale. 

• Another result of budget cuts is in the way Transport Canada performs it’s surveillance activity on enterprises. Surveillance will concentrate on “System’s Approach” to Assessments. Since SMS requires an enterprise to have a “Self Healing” system. Assessments, PVIs and PIs focus on control of processes. Enterprises that can prove “Control” of risks and processes will require less oversight.  Here is a draft map of the Systems Level Surveillance. 

• The Surveillance Procedure that Transport Canada uses, SUR001, is being revised to version 5. This new version should be rolled out by the end of April. The new version will have more detailed requirements for the issuance of certificate actions. Also due to budget, TCCA surveillance has gone to a “5 year plan” where ALL enterprises will be visited within 5 years. TCCA will use a company risk assessment tool that will yield and Alphanumeric code for your company that will be entered into a special Risk Matrix. The result of this matrix will dictate your risk level and consequently your surveillance interval cycle. 

• SMS is coming to 704,703 enterprises! A big driver for SMS in the smaller carriers is the Air Transport Association of Canada, ATAC. ATAC has petitioned Transport Canada to implement SMS for 704/703 enterprises by April of 2014. It is important for your company to begin the transition to an SMS now.

• For 704/703 enterprises, the story of the golfer is pertinent here. “There was a golfer who was preparing to drive the ball off the tee. He put the tee down next to a large ant hill. He took his first swing and completely missed the ball and hit the ant hill. Ant went flying all over the grass. He squares up again and takes his second swing. Again he misses the ball and hits the ant hill again. The remaining ants look at each other and say,”If we are going to survive, we better get on the Ball!!!”

• Last I was permitted to give a 5 minute commercial for our SMS Memory Jogger which featured an excellent case study on establishing Goals and Objectives based on the companies Safety Risk Profile. It also has a tremendous tool called the “7 step Risk Management Plan” that companies have actually extracted and put on their letterhead. This plan, when followed, meets all the requirements of Hazard/Incident 
• reporting from Awareness through Risk, Root Cause Analysis to closure and follow-up. 


I plan on expanding on the System Approach to Surveillance in some future blogs. Any question or comments, please feel free to email me @dtitraining.juno.com. If you have any thoughts here...............well......feel free to comment. 


• . Note: the SMS Memory Jogger II is available at dtitraining.com.  

SMS System Failure – The Old Barn That Didn’t Make It.

SMS system failure – the old barn that didn’t make it.

One must know what triggers a failure to restore a system. 

When an aviation operator identifies an SMS systematic failure, the opportunity becomes wide open to mitigate for zero tolerance to compromise aviation safety. SMS is a concept, and without the triggers of human, organizational or environmental factors the system of SMS cannot produce failures. However, policies and processes set by the operator, or lack of processes, may cause activation of unwanted results, or systematic failures. The challenge for the operator becomes to establish the correct processes for guidance when coming to the fork in the road. If a process is based on facts for the road making a left, the same process may not be effective if the road instead takes a right at the fork. 

The recognition of SMS systematically failures may not be sudden and obvious, but rather increments of insignificant changes. Who in the organization has the authority to decide what is not important enough to report? 

The barn was at some time serving as a place conforming to expectations of use. Over time it began to insignificantly deteriorate until it became a system failure and could not conform to expectations or regulatory requirements. The cause of deterioration could have been due to regular usage, organizational practices or environmental circumstances. Whatever it was, these insignificant changes were not identified by the organization with the result that the barn became a complete failure. 

If an aviation operator does not have established processes in place to capture insignificant deteriorating changes to the organization, there is a high probability that these systematic changes will cause a failure of the Safety Management System.  Since SMS is a concept and therefore can not fail on its own, the triggers of failures are activation by human, organizational or environmental factors. 

Should an SMS systematically fail, it may become an impossible task to restore the system within a reasonable time frame. An SMS failure could affect the Aviation Certificate and lead to loss of profit or total loss of financial support. 

Depending on what turn the operator takes at the next fork in the road, an aviation operator with may jeopardize the certificate if insignificant hazards and incidents are not assessed and mitigated with established processes. 

Farnorthaviation

Your Thoughts.......

SMS is the Scapegoat!

SMS is the Scapegoat!

Since SMS was first introduced, it has been under fire as a terrible program that allows airlines and companies to “regulate themselves.” There is nothing further from the truth. The following is a recent article sent to me by a friend in Canada. The article comes from the Torstar News Service and relates to an incident that occurred with a Canadian carrier “Sunwing Airlines.”

OTTAWA—Ottawa’s push to let Canada’s airlines police the safety of their own operations is facing fresh questions after a federal watchdog criticized Sunwing Airlines for failing to report a potentially dangerous inflight incident.

In a new report, the Transportation Safety Board of Canada says Sunwing Airlines failed to report an inflight malfunction to safety authorities and was slow to learn the lessons of the March 2011 incident.

Sunwing Flight 531 was departing from Toronto en route to Cozumel, Mexico, with seven crew and 189 passengers on board when the pilots got erroneous airspeed indications during their takeoff roll. The problems continued during the climb as the stall warning sounded, suggesting the Boeing 737-800 jet was close to losing flying speed, and the instruments wrongly told the crew to put the aircraft into a shallow dive.

The crew ignored the erroneous warnings and maintained their climb before returning to Pearson airport for a safe landing.

Sunwing Boeing 737-800

It is clear that this was an emergency situation and potentially could have been a disaster. The pilot appears to have acted to assure the plane could return to the airport in a safe manner. 

At the heart of the investigation is Transport Canada’s safety management system, which puts more responsibility on individual airlines to track and assess risks and identify hazards within their own operations.

Except in this case, Sunwing Airlines didn’t see the incident as serious enough to warrant investigation by the airline’s own safety personnel and failed to report the incident as required to the safety board, the report says.

That led to a “missed opportunity to identify hazards and reduce risk.”

Yet the safety board’s probe of the incident, launched after air traffic controllers filed their own report, turned up several issues of concern.

The Heart of the Investigation is Transport Canada’s SMS?? What!  The incident took place in 2011. This was infancy of the SMS implementation and companies like Sunwing were in the “Phase in” period which means that the program was not fully implemented. Now, I must admit that Sunwing was very wrong in not investigating this incident internally. But, you can not blame Transport Canada’s SMS for this incident. I would like to know how many other incidents of this kind were reported under the old Audit system. 

While Boeing has warned airlines that airspeed failures are happening more often than expected, that information was not passed along by Sunwing to its own pilots.

And the safety board notes there is little guidance given to pilots on dealing with unreliable airspeed indications during a critical phase of flight — takeoff and initial climb — leaving them in the dark about the potential consequences.

The very problem raised here is common among non-SMS companies. SMS requires documentation “Control” which would dictate procedures for the distribution, maintenance and communication of notices, bulletins, forms, documents...etc within the company. Again this is a failure on behalf of Sunwing, who had not fully implemented their SMS yet. 

In this case, the weather was good, allowing pilots to guide the jet by using outside references. But the report cautions that the problem could have been more much serious if bad weather had forced the pilots to rely on the confusing cues presented by their flight instruments.

“Continued use of erroneous guidance in adverse weather could compromise flight safety,” the report said.

And the safety board says the multitude of problems encountered on this particular flight were not documented in the aircraft paperwork and “were not addressed.”

“The aircraft was returned to service without resolution of these defects and, as a result, airworthiness of the aircraft was not assured,” the report said.

Sunwing Airlines’ president Mark Williams agrees with the findings that the safety board should have been notified and that the airline’s safety management system should have flagged the incident for review.

But he says at the time, the safety management system concept was in its infancy, both within his airline and the industry as a whole.

“We’ve made lots of changes since that time because SMS is a system of continual improvement,” Williams said in an interview.

“A safety management system is something that is never finished. It’s a cycle of continual improvement. We’re always looking and fine-tuning it, looking at other people’s systems to try and continually make it better,” he said.

However, he takes issue with the safety board suggestion that the problems on the aircraft weren’t fixed before it was returned to service.

“The parts were immediately replaced on the aircraft before it went flying again,” he said.

It’s not the first time officials have raised concerns with the move toward safety management systems. In 2008, the auditor general warned that Transport Canada’s move to let the aviation industry police its own safety was done with no assessment of the risks involved.

In my opinion, this article has an apparent bias against SMS. The Aviation industry really does NOT police itself. All SMS companies are subject to Regulatory Assessments at any time. The actual assessment processes is more revealing to the company’s Safety Management than the old audit system. To blame SMS for this incident is a reach. It is a fact that SMS does not guarantee 100% accident free travel. But, if implemented properly, the company will have control of all of it’s processes and be able to determine when processes are going out of control BEFORE the incidents occur. A company merely having an SMS does not mean they are safe. The company must DO what they say they do in controlling their processes. SMS does work in improving safety and also profitability in all companies that implement and maintain it properly. Has SMS affected the accident rates among Canadian Aircarriers? Here are the words from Director General Civil Aviation, Martin J. Eley, at the Air Lines Pilots Association International 58th Annual Air Safety Forum. Aug 8, 2012. 

Martin J. Eley Director General Civial Aviation

“Last year, Canada saw the total number of accidents decline to the lowest recorded figure in modern aviation history.

This is despite the significant increases in air traffic. In fact, in the last few years, Canada has averaged more than 40 fewer air transportation accidents a year when compared to the previous ten year average.

These stats belong to all of those in the aviation community committed to making safety tomorrow even better than it is today.

With the number of accidents trending downward and air traffic trending upward, this means our traditional barometer of aviation safety – the accident rate – is also looking quite good.

Since 2000, we have seen a considerable decline in this rate. In 2000, Canada’s air transportation accident rate was nearly eight accidents per 100,000 hours flown; in 2011, this rate fell to fewer than six accidents per 100,000 hours flown. That’s a 25% drop.

The actual number is 5.3%, which is also the lowest it’s ever been.”

Your thoughts......

Accountable Executive – Straight flush or just an Ace as the highest card?

An Accountable Executive (AE) is betting it all on the organization.  The AE is betting on human factors in a just culture with zero tolerance to compromise aviation safety.  The objective of the game is to find the cards for a straight flush, where the Ace is the highest card. 

An Accountable Executive is not an AE of a Safety Management System, but an AE of the Aviation Certificate. A certificate issued to serve the public in an environment where risks are managed to a tolerable level. Quality Assurance (QA) and zero tolerance to compromise aviation safety must not be left up to the rolling dice. 

Accountability is to provide the best possible customer service and ensure that the organization has “what it takes” to do “what it takes”.  There is no secret that some organizations will rather blame on an outside and often fictional force than accept accountability.  When an organization look at other individuals to be accountable the senior management does not understand the old saying: “if you truly want to find out why employees are irresponsible, then stop for a second and look in the mirror”. It is true that employees, management and executives will mirror their superiors or mentors for approval. 

Customers understand that there are risks in aviation, but they do not accept anything less than zero tolerance to compromise aviation safety. 

farnorthaviation

An aircraft in flight is in its right element and doing what it was designed to do. A pilot has been trained to feel in the right element when flying the airplane. Passengers on a commercial flight or spectators at an air show expect the pilot to perform with confident and accountability. Anywhere in aviation the public who are served expects accountability. Customer service is to provide customers with what they need.  In aviation, an operator is applying accountability to fill that need. 

 At the end of the day, an Aviation Operator, that being an Airline or Airport Operator has to make a choice if the Accountable Executive will be a person who is just an Ace as the highest card, or if that person is a team player and look for the other cards to be the Ace of a straight flush, where the Ace is above the King. 

‘farnorthaviation”

What are your thougths ........?

A Controversial Issue: Regulators MUST STOP Approving Manuals

A Controversial Issue

Sol and I have taught in our classes ALL 950 Transport Canada Inspectors..... Twice! We facilitated Transport Canada’s Quality Assurance portion of the Safety Management System,SMS, program and Facilitated their own internal Surveillance Procedures Training Course,SPT, required for their delegation.  We have worked with over 200 Aviation certificate holders in Canada and in the United States and the same problem always slaps us in the face when it comes to implementing SMS. Approved Manuals and Documents.

With the advent of Safety Management Systems, the way regulators oversee the aviation industry has changed. Traditionally regulators performed compliance audits to see if the company is meeting or not meeting regulatory requirements. Each contravention of a regulation was met with a finding that required the company to determine the Root Cause of the deficiency then propose Corrective Actions to eliminate or mitigate the event.  Under SMS, the regulator is performing a “Systems Approach” to self oversight. SMS requires the company to have policy and procedures that ARE FOLLOWED by personnel in order to control those processes governed by the procedures. Then use the Quality Assurance audit to make sure that the processes and procedure are being followed. 

Under SMS, The regulator is “Assessing” whether the company’s system is controlling itself. In the old audit system, the regulatory inspectors might as well be on the companies payroll. The regulatory inspectors are performing the Quality Assurance for the company. Under SMS the company is responsible to perform it’s own Quality Assurance and oversight. It is up to the company’s system to determine if they are performing within the parameters of the regulations. The regulator is merely assessing the “System” to see if it is effective in catching, correcting and improving processes for a safer, and may I add, a more efficient operation. 

As I discussed in previous blogs, the backbone of “Controlling” a system is having and Following standard operating procedures, SOPs. Once we have our procedures written or mapped, we perform the process operation and then monitor and analyze the processes for improvement. We follow the standard Plan, Do, Check, Act cycle for continuos improvement.

Plan, Do, Check, Act Diagram from the SMS Memory Jogger available at dtitraining.com

The requirement for Manual Approval goes back to many years in the aviation business. Manual approval works on the theory that It is impossible for regulatory Inspectors to be constantly monitoring aviation company operations. So, it was believed that having a company manual with policy and procedures that would be followed by company personnel would assure control in-between regulatory audits. I must say that under the audit system, with limited regulatory manpower, that this is the best that could be done. 

OK, let me not mince words here. That “Manual” submitted by the company will have the greatest processes for regulatory compliance and safety. I have seen some of the BEST manuals written by consultants and experts in the industry. These manuals were either written for or simply purchased by the aviation company.  These “pristine” manuals would then be submitted to the regulators for approval.  Of course these well written manuals will be blessed and the regulator will go forth with it’s approval! Ahh now the company is free it fly. Then that “Approved” manual will find it’s place on the appropriate shelf and begin it’s job of collecting dust. 

You must agree that the only time these manuals are even looked at is when you hear that the regulator is going to conduct an audit.

Now, who is going to touch an “Approved Manual?” Of course nobody, it’s APPROVED! The problem is that a company operating under the requirements of a Safety Management System should be monitoring and Improving it’s processes on a continuos basis. This would require analysis of procedures and processes. This analysis would then prompt changes that would affect the manuals. If the manual is an Approved Manual, then changes must be sent the regulator for approval also. Let’s face it, most people can grow old and die before the regulator get’s back to them. The regulator is the “Bermuda Triangle” of requested changes. 

Transport Canada has just recently allowed companies to separate their policy and procedures. I applaud Transport Canada in this effort as they are actually overriding some old regulations to accommodate SMS. They allow certificate holder to include procedures by reference in their Policy manuals. We encourage our clients to separate Procedure from Policy. The reason, policy is not likely to change and therefore not needed to submit for approval as often as procedures. 

All of this confusion can be eliminated if the regulators would simply stop approving manuals and simply accept them at the time of assessment of the system. This will allow the SMS concept of Continuos Improvement to work as intended. Another benefit of not Approving manuals is the reduction of “Parallel Finding.” Parallel findings are findings against the regulator. Mostly contraventions of regulations found in “Approved Manuals.” OK, it’s hard to believe but some inspectors actually miss some of the contraventions of the regulation in the manuals during their review for approval. Not approving manuals would also free up regulatory inspectors to perform other duties instead of reading through manuals. As just mentioned most inspectors are not really thorough in reviewing manuals which lead to a high number of parallel findings. 

If a company truly believes and uses the Safety Management System the way intended, then the Approval of Manuals is really a function of the company Quality Assurance process and free’s up the regulator to conduct more Assessments. Let’s take a serious look at this question; Does an Approved Manual make the company safer? It is obvious that in order to be safer, the company’s processes must be in “Control” which means they must actually do what is in their manuals. By monitoring the outputs of the processes and procedures and then acting upon the results to improve the processes, then there is your proof that the manual is meeting the associated regulations. If the company is seriously working their SMS, then an Approved Manual makes no difference and allows for greater flexibility in continuous improvement changes. 

So, to the regulators........Stop Approving Manuals!...........your thoughts. 

HAZARDS-Just as Surprising as Rolling the DIce!

There is often a possibility for hazards to be categorized in two different fantasy worlds.  One world  is where it is possible to total eliminate a hazard by conducting a risk assessment. The other world is  when the fantasy run wild and the hazard becomes the only possible option. Hazards must be managed in a Quality Assurance System and compared to facts. If not, one could manage hazards by rolling the dice. 

The lifeline of a healthy Safety Management System (SMS)  is to collect, analyze and action reports of hazards, incidents and accidents. Without reports the SMS does not ensure control of risk management and an organizational zero tolerance to compromise aviation safety.  SMS is to get answers to questions not asked.

A hazard is a latent condition, but when armed and activated it becomes an incident. Human factors, organizational factors and environmental factors are the triggers to arm and activate.  When understanding what arms and triggers a hazard, the hazard becomes manageable. 

Hazards my be managed by applying knowledge, location or  time When human triggers an armed hazard and apply a subjective standard to mitigation, it becomes a scenario for hazard escalation. Therefore, hazard management requires human understanding, defined mitigation processes and learned procedures. 

Aviation safety begins and ends at an aerodrome. At any phase between takeoff, landing and taxiing on the airport, there are identified or unidentified armed hazards which could be activated and triggered by human, organizational or environmental factors.  

Human has the ability to adapt to hazards and set subjective standards of hazard mitigation. People of the  tropical and arctic regions have learned to adapt and mitigate hazards. People in cities have learned to adapt and people of the remote wilderness have learned to adapt.  Both  Aviation Operators and Pilots also have the ability to adapt to hazards.  When human adapts, subjective standards are implemented in hazard management. A subjective standard in hazard mitigation is a scenario for hazard escalation. 

When an airplane is operating on a field filled with spectators, everyone is most likely assessing and subjectively managing the associated risk.  Some are close to the airplane and others stay farther away.  The  education level and knowledge of aviation hazards also affects how the hazard is mitigated. Common  sense in hazard mitigation  does not cut it.

During an airplane’s takeoff roll all known and unknown hazards for the duration of that flight are being armed.  When an armed hazard is triggered during the flight and move to the next hierarchy level which is an incident, it becomes the tasks for one or two pilots to analyze and apply correct corrective.  Pilots must therefore have knowledge of what effect the hazard has on flight operations, they must mitigate the hazard’s distance to the fork in the road and they need to mitigate the hazard’s time to escalation. 

Measured by distance, the fork in the road is the distance to point of no return, and measured by time, the fork in the road is the time to point of no return.  When the point of no return is reached, the pilots must mitigate the new hazard before arriving at another point of no return. One cannot bring back past time or distance.  In an effective hazard management operation, a pilot or pilots in a multiple crew environment must have situational awareness and know when the point of no return is near. 

farnorthaviation Hazards – just as surprising as rolling the dice