Monday, May 18, 2020

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






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