Sunday, May 20, 2018

What To Report In SMS

What To Report In SMS

Post by CatalinaNJB

The Safety Management System (SMS) is a safety tool for an imperfect organization, being an airline or airport, to discover hazards and maintain an acceptable level of safety. Airlines and airports in North America are mostly implementing their SMS for regulatory compliance and not for safety improvements. SMS is simply implemented as a requirement to maintain the operations certificate. As a regulatory demand SMS might be viewed as another bureaucratic burden to satisfy paperwork trails. However, after working with SMS and comprehend the systems, operators may experience changes of opinion and discovered the benefits, including a higher return on investment, by the implementation of SMS.  Any operator, who does not require an SMS for regulatory compliance, would benefit strongly by implementing an SMS program voluntarily and be ready when SMS eventually becomes a regulatory requirement. This timeframe period would build SMS comprehension and readiness for SMS compliance. SMS is a safety tool, and a speciality tool required, to coordinate both complex and simple systems and as a tool for cooperation with continuous safety improvements. 

The Safety Bunny is attentive, listens and looks out for hazards.
SMS is a tool in the beginning stage of supporting safety in aviation. Safety does not happen overnight but is a change in operational culture. SMS is a tool to be accepted on an equal platform as an accounting department, human resource department and sales and marketing department in a successful business. In addition, there are several other organizational functions that are required to support the business success. However, SMS is not just another tool, but the single most important tool in promoting business activities. Aviation cannot be promoted without SMS as the core purpose in bringing passengers and freight safely home. 

Hazard reporting in SMS has everything to do with an effective SMS and continuous safety improvements. When SMS is first implemented there is no prior data collected to establish the organizational confidence level of safety. An enterprise without an SMS may believe that they are 100 % safe, while in fact they operate with a zero percent confidence level of safety. Without documented safety processes there is no safety. It’s only the random probability of hitting the jackpot. A common trend when rolling out the SMS is to promote everything to be reported. Everything includes hazard reports and any incident or accident observed or being involved in. Hazards are subjective and individually assessed as a risk based on opinion and experience. Exposure intervals to specific hazard often changes the opinion of the safety risk involved. When rolling out a brand-new SMS all hazards should be reported. It should not be expected that untrained personnel make risk assessment of a hazard and decide if it is reportable or not. There is a reason why a hazard was observed, and it is that a condition caught someone’s attention. It is simply a hazard because it was discovered. There is no magic to discover and report hazards. When assessing the risk factor of a specific hazard it could well be that it is irrelevant to aviation safety, but it doesn’t take away the fact that in the moment someone determined that it was. 

What's important is how changes are managed when the line is washed out.
The first purpose of SMS is to establish a baseline of current operational processes. This baseline is not a safety level baseline, but strictly a baseline of current processes. The next step is to assess current processes to regulatory requirements. If current processes are equal to or exceed an outcome for regulatory compliance, then this baseline is acceptable to proceed to the next step. An enterprise must have processes in place where the outcome of these processes conforms to regulatory compliance before continuing to the next step, which is continuous safety improvements.  The continuous safety improvement step is to draw the line in the sand or establish an objective of where to set the safety bar. When the safety bar is accepted and set by an enterprise the opportunities for improvements are infinite. This bar may vary from one operator to another operator. It is vital for success in safety not to compare safety bar levels between operators, but to compare current result to established goals. When an operator restricts hazard reports, they are restricting the evolution of SMS and safety will maintain status quo. This might be acceptable for an operator who is safety-superior, but not for operators with a goal for continuous safety improvements.     


CatalinaNJB

Monday, May 7, 2018

Special Cause Variations vs Common Cause Variations

Special Cause Variations vs Common Cause Variations

Post by CatalinaNJB

Before a corrective action plan is applied to a special cause variation, it must first be established if the variation itself is a special cause or a common cause variation. On the surface it might look like a simple task to identify a common cause variation since this variation is known to occur each time the process is applied. This could be in a manufacturing process, a service process, a training process, a safety improvement process or in any other processes. That a variation is common in the process does not necessary define that variation as a common cause variation. It could be a special cause variation disguised as a common cause and embedded into the process. It is conventional knowledge that new pilots are less qualified than long-time pilots. While this might be true, by accepting this as a common cause variation, there is no corrective action required for continuous improvements. There are opportunities for an increased return on investments by making minor adjustments to processes, but some operators don’t see the forest for all the trees.

A common cause variation may also be disguised as a special cause variation. By incorrectly assigning a special cause variation as a common cause, a finding could be applied to a common cause variation of that type of process. When a finding incorrectly is applied to a common cause variation it becomes a task in itself to develop a corrective action plan, since this variation is necessary for the process to function effectively. The weather process is a common cause variation. It commonly varies by the day or by the hour. If the weather is defined as a special cause variation, then a corrective action plan must be applied to the weather process.  

SPC of standard operating parameters and operating in a virtual reality.
It might not be obvious to discover when a common cause or special cause variations are incorrectly identified. There might be times when standard parameters are applied to simplify the flight planning process. A standard fuel burn is established and no matter what the weather and winds are that day, the operator does not change time enroute to compensate for a common variation and the variations in weather. Weather variations are common cause variations. When analyzing standard operating parameters in SPC it becomes obvious that something is not right with the process. It’s a straight line! Real life processes do not produce straight lines.

A standard weight may also be applied as a passenger weight. When a standard weight is applied, the actual weight of the airplane will not be correct and fuel burn deviates from standard. Passenger weight variations are also common cause variations. It is common for this weight to change. In a statistical process control, the process may show an out of control process when a common cause variation is applied as special cause variation. Should an airplane run out of fuel due to incorrect passenger weight when applying company accepted standards, the passenger weight might incorrectly be identified as a special cause variation. Applying standard inputs to processes is to operate in a virtual reality. Applying SPC as a tool to identify a virtual reality is a simple task and the control chart will show that there are no variations. When it has been established that a process is a virtual reality process, implementing corrective actions to that process becomes an impossible task, since the process itself is not applicable to any real data. A new process must be implemented.

Special cause variations identified.
Standard weights are still used in calculations as it has been since the first flight. Then, when there is an incident the weight could be assigned as a contributor factor to the incident, while it was known all along that the weight was manufactured.

This Fuel Burn SPC Chart shows that there is an out of control process. However, because of the red point, the process cannot automatically be scrapped, but needs to be investigated. The investigation revealed that another type of aircraft was utilized during the days of red points and it was determined to be a special cause variation. A CAP was implemented to utilize one type of aircraft only for these runs the next 30 days to monitor the process.

Variations are acceptable. Make sense that a different aircraft did not affect safety.
Special cause variations require that corrective action plans are implemented. Defining the special cause variations becomes a safety critical area in operations. Not everything is equally unsafe in flying. There is no need for an incident to occur before special cause variations are identified.  
The next safety question might be to identify if by using another type of aircraft affected safety in operations. Another SPC Chart was developed with the following result that for the process to be in control, it is acceptable to utilize another type of aircraft and still maintain safety in operations.

CatalinaNJB





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