Unintended Consequences of Hazard Identification

 Unintended Consequences of Hazard Identification

By OffRoadPilots

An SMS enterprise is required to operate with a process to identifying hazards to aviation safety. Defining hazards to aviation safety is subjective and based on prior experiences, guidance, or fear of failure. When there are none, or very few, hazards in the hazard register, the regulator view this as a nonconforming to a regulatory requirement to identify hazards. A limited hazard register is a red flag to the regulator who then will issue findings to operators. An experienced and high time pilot may view a gravel-runway as a non-hazardous condition, while a low time pilot with, or a pilot without gravel-runway experience rates gravel-runway as a hazardous condition. Both pilots view the same scenario, at the same location, at the same time and with the same meteorological conditions, but experience, guidance and fear of failure leads to two different conclusions. One accepts the condition as hazardous, while the other rejects the conditions as a hazard to aviation safety. However, there are several examples in flying that highly experienced bush-pilots operates with a lower risk level bar than new and inexperienced bush-pilots. 

There is a difference between observing for hazards and actively searching for hazards.

In addition to tangible hazards there are abstract hazards. An example of an abstract hazard is time pressure for on-time departures. Abstract hazard conditions are higher risk levels than tangible hazards, since their outcome cannot be predicted, they cannot be measured, or produce the same outcome each time. A common cause explanation to overlook abstract hazards, such as fatigue or time pressure, is to “get the job done”. When there is a conflict between abstract hazards and tangible hazards, the tangible hazard takes precedence. Red flags are more likely to be attached to personnel who reports abstract hazards than personnel who reports tangible hazards. These types of organizations operate with a systemic fear of failure culture. 

 

An SMS enterprise is required to operate with a proactive process or system that provides for the capture of information identified as hazards and other data relevant to SMS and develops a hazard register. A hazard register are list items of conditions that could cause occurrences, and it is also a list of hazards derived from past occurrences. Hazards should be assessed and mitigated through safety oversight, training and awareness, and the use of a flight data monitoring system. Performing a proactive assessment within a daily quality control system, and a review of SMS database is necessary to verify the rate of occurrences. An SMS enterprise who indicates that they do not have hazards to report should demonstrate how they have reached this conclusion. 

 

A hazard register contains two distinct different types of hazards, which are assumed hazards and experienced hazards. These different types of hazards should be separated into different hazard registers to analyze the rate of hazards from occurrences and the rate of assumed hazards occurring. 

 

A third variant of hazard identification is the planned self-evaluation and actively searching for hazard. Requiring pilots and airport workers to actively search for hazards is a distraction and take away time from their roles and responsibilities leading to unintended consequences. There is a difference between observing for hazards while flying and actively searching for hazards. Most everyone has experienced how a new vehicle changes alertness and observations. When a certain make and color of vehicle is purchased, the same vehicles and colors that were not noticeable before, now attracts attention. These vehicles were still within sight before but were not noticed since they were irrelevant to the operator. There is a universal principle called the Law of Attraction, which says that you attract into your life people, ideas, and resources in harmony with your dominant thoughts. Other ideas and resources become irrelevant and not noticeable. The fact is that humans are living magnets, like iron filings are attracted to a magnet, human nature, or human factors, is to attract the people and professions that are in harmony with your current level of knowledge, wisdom, and experience.

A tangible hazard is comprehended, while an abstract hazard is interpreted.

Awareness is a key element for a successful flight and successful airside maintenance. Human factors is to understanding the effect of why a task is required and the effect of how distraction deviates attention from a priority task. When a flight crew's attention is diverted from the task of flying, the chance of error increases. Over the years there have been dozens of air carrier accidents that occurred when the crew diverted attention from the task at hand and became occupied with items totally unrelated to flying. An example is the Everglade crash in 1972 when three green lights failed to illuminate gear down and locked. The crew conducted a fact-finding task to find a solution. While they were focused on the gear-lights, they did not realize that the airplane was continuing to descend, causing the left engine to strike the ground then the aircraft crashed. The flight crew were actively searching for what hazard had caused the lights not to illuminate. 

 

When an SMS enterprise expects pilots and airport workers to report hazards, the effect of human factors is to focus on finding a hazard and then focus on the immediate threat. The pilot of a small single engine aircraft taxiing at night may be blinded by the taxi lights of an approaching heavy aircraft, causing the small aircraft to taxi across taxiway islands. Hazards, if they are factual or virtual, have a distractive effect on human behavior. When flight crew and airside workers feel obligated to identify unknown hazards, it is unknown to an SMS enterprise how their attention to hazards distract their attentions from current assigned priority tasks.  

 

The requirement to actively search for hazards is also a regulatory non-conforming behavior. A regulatory requirement for operations involving taxi, takeoff, landing, and all other flight operations conducted below 10,000 feet MSL is that no flight crewmember may engage in, nor may any pilot in command permit, any activity during a critical phase of flight which could distract any flight crewmember from the performance of his or her duties or which could interfere in any way with the proper conduct of those duties. Activities such as eating meals, engaging in nonessential conversations within the cockpit and nonessential communications between the cabin and cockpit crews, and reading publications not related to the proper conduct of the flight are not required for the safe operation of the aircraft. Actively searching for hazards during critical phase of flight is a violation of the regulatory requirement to maintain a sterile cockpit. Unintended consequences to require active hazard identification is regulatory non-compliance and an induced risk level. 

 

A review of the effect of non-compliance with the sterile cockpit principle finds that 48% were altitude deviations, 14% were course deviations, 14% were runway transgressions, 14% were general distractions with no specific adverse consequences, 8% involved takeoffs or landings without clearance, and 2% involved near mid-air collisions due to inattention and distractions. 

 

A key to good Human Factors practice is awareness. It is not enough for pilots and airside workers to know what can affect them, It is also necessary for them to be aware that they are in a position to be affected. As an example, knowing that fatigue affects performance is not useful unless pilots realize that they are fatigued. Realizing fatigue is applicable to all professions, not only pilots. In the old days of long-haul trucking, before automatic transmission, drivers realized that they were fatigued when shifting gears became difficult. In aviation, a pilot realized fatigue by altitude or heading deviations. Automation in aviation has reduced the ability to recognize fatigue, without applying an SMS safety case to operational hours. Regulated flight and duty times does not ensure fatigue compliance since the regulation is not broad enough to cover every aspect of fatigue. When the regulation is incomplete, it is the role and responsibility of an SMS enterprise to add additional layers to identify fatigue. A fear of failure culture marks a red flag to pilots reporting fatigue prior to the end of regulatory flight and duty day, or airside worker reporting fatigue prior to end of their shift.  

 

 

 

OffRoadPilots

The Successful AE

The Successful AE

By OffRoadPilots

A successful Accountable Executive (AE) is a person who fully comprehend their Safety Management System (SMS). The successful AE is result oriented and focuses on leadership motivation. The AE set clear goals and provide personnel with their empowerment and tools needed to achieve success. The successful AE is a motivational leader inspiring personnel with directions to work toward goals, and successfully complete one goal at a time. A goal without directions is not a goal but a wish, or a dream. Just as a successful CEO is surrounded by highly qualified personnel to guide them with business transactions, a successful AE accepts the confidential adviser as their go-to person to maintain processes that conform to regulatory requirements.    

During phase one, the SMS knowledge was limited, and no questions were asked.

A safety management system is an evolving system through three phases. A successful AE is in the third phase of their SMS evolution. Evey SMS enterprise go through the same three phases before the accountable executive becomes a successful SMS leader. Achieving success in the third phase is not the completion of an SMS system but it is the beginning of comprehensive application of the safety management system. Canada was the first ICAO state to regulate the safety management system and there was a struggle for operators throughout the four implementation phases. The expectation that an AE was only responsible for their financial and human resources was the wrong turn at the fork-in-the-road and the root cause for the ongoing SMS struggle. Throughout the four implementation phases the regulator misled operators by acting as consultants and they were extremely generously with opinion-based SMS guidance to both airport and airline operators. 

 

The first phase of SMS extends from the implementation phase to the first audit. During the first SMS phase the AE complies with implementation directions and outcome expectations without hesitation, or concerns. The initial phase-in process of the SMS was a learning process with an objective to establish a successful SMS. Every person in the organization at this stage were learning about their roles and responsibilities and were applying tasks without justifications, or reasons for the task. The general guidance at that time was that an SMS was a tool to reduce incidents and accidents. Those safety visions were quicky shattered as there were no evidence that SMS had reduced the number, or severity of incidents, or improved safety at all. Airlines without a fatal incident for over 30 years, experienced their first fatal accident as an SMS enterprise. 

 

The AE, as well as other personnel began to question the purpose and effectiveness of their SMS. Their SMS manuals included safety policies, reporting systems, hazard identification systems, investigation systems, root cause analyses, safety data systems, corrective action processes, monitoring the concerns of the civil aviation industry, and determining the adequacy of training, but without any significant effect on the outcome. Operators began to question why the global aviation Industry, being airlines or airports, needed a safety management system (SMS) today, when they were safe yesterday without an SMS. Without any guidance material of how to reach these goals, airport and airline developed their own systems, with different processes, to reach the same expected outcome. It became more complicated a successful AE, when the regulator took the position that the solution to conform to regulatory compliance was to implement electronic data collection tools, with checkboxes for result completion. The SMS had deviated from its purpose and turned onto a path where completing checkboxes for individual results became the primary task, as opposed to the task to analyse processes for regulatory compliance. This became evident in a survey published in the JDA Journal, April 13, 2017, where the vast majority of oversight inspectors view themselves as having better knowledge of airline and airport operations than the operator themselves, and that they are better qualified than operators to fix safety problems before they become accidents or incidents.  

There is a process for everything.

The second phase of a successful AE is the reactive phase of a safety management system. In the reactive phase, there is no daily quality control, errors and findings are accepted as a normal part of the processes, daily performance tasks are not assigned links to regulatory compliance and the accountable executive is struggling to maintain regulatory oversight and compliance in their operations. The reactive process in phase two was different than the reactive process during the initial SMS phase-in processes. An SMS enterprise may establish a proactive process by including a daily inspection at airports, or a pre-flight inspection for airlines, but during this second phase of SMS, established proactive processes became inactive and transformed into reactive processes. While it is true that these processes discovered findings and trigger repairs, they did not extend beyond the repair itself to become an integrated part of a daily quality control system and system corrections. When FOD was found on the runway, it was removed, or when a damage was found to an airplane, the airplane was grounded, and the damage repaired. These repairs were the initial part of a reactive process, but without a link to an action item beyond the repair itself, they were only reactive processes, and events repeated themselves. An action item is different than a root cause analysis, in that the link to a regulatory component becomes the proactive element of the process. In phase two of a successful AE, they relied on the opinion of external auditors, and the AE’s goal was to become a platinum-members of the auditor’s safety-club. The scenario of an AE in phase two plays out in the global airline industry today where there is a shortage of flight crew and more tickets sold to passengers than airlines capacity. 

 

During the second phase of SMS, it is also common is to assume compliance by reaction, or by performing regulated operational tasks, while non-regulated operational tasks were excluded. With non-regulated tasks excluded, an SMS enterprise became in non-compliances with the SMS regulations. A successful AE in phase two excluded specific tasks that were not included as regulatory tasks to be performed. What the AE was missing, was that the time for an operator to define and design operational tasks is when the tasks are not included in the regulations as regulatory tasks. The AE also assumed during phase two that completing regulatory operational processes automatically conform to regulatory requirements. This assumption was false and was not followed up with data to support their opinion. Some accountable executives carried this believe to the extreme, where their certificates were threatened. It was not until the certificate was threatened that the successful AE realized that the only way forward is to implement a daily quality control and a regulatory oversight plan.  

 

When the successful AE entered into the third phase of SMS, they accepted their accountability that they have several more tasks and responsibilities to comply with than only human and financial resources. At this time the successful AE understood that their roles and responsibilities were much more than just human and financial recourses. In addition, their responsibilities were to scale and adapt their SMS to size, nature and complexity of the operations, activities, hazards, risks associated with the operations and daily quality control for their triennial audits. In the third phase of a successful accountable executive, operational processes were linked to regulatory requirements, and one task was linked to several regulations or standards as a tool to scale and adapt to size and complexity. Airport operations is a relatively small-scale operation in aviation compared to airlines. However, airports provide essential services to the aviation industry for successful flights and customer satisfaction. An airport AE must have comprehensive knowledge of airport operations, they must have general knowledge of airline operations and be familiar with air navigation services. A successful AE has accepted that operational tasks for airports or airlines are many and is more than a full-time job. There are several standards they must ensure compliance with, in addition to many regulatory requirements. Scaling the operations and SMS down to size and complexity is not to exclude unimportant regulations, but to assign multiple regulatory requirements to one single operational task. A critical task for the successful AE is to conform to SMS regulations by ongoing research and development. 

A successful AE knows the path through the SMS maze.

The first task for a successful AE in the third phase is to review and amend their current safety management system manual. When their initial manuals were built, SMS knowledge was limited and data available how to apply processes to human behaviors were inadequate. Quality control and quality assurance had been applied to material strength and material fatigue for decades and the same approach was now applied to the SMS. Over time both airports and airlines found that using this same approach was not complete or effective. Their initial SMS manuals were correctly designed and approved by the regulator based on what was known at that time. Over time SMS evolved to include several unknown factors and changes to SMS became inevitable. The successful AE understands that SMS process applied to mechanical breakdown, material fatigue or occurrences are different than processes required when the human factors system breaks down. The hazard pyramid becomes inverted in a human factor system, since there is a learning factors involved, which is not available to mechanical breakdown, material fatigue or occurrence likelihood. For each vivid event a person is exposed to, that person learns to avoid incidents and near-misses. Exposure to vivid events is crucial to safety in aviation and any pilot who grew up in a protected environment with little or no exposures to vivid events, has lost the value of these experiences. 

 

Roles and responsibilities for a successful AE is oversight, while roles and responsibilities for the person managing the SMS is operations. The successful AE has comprehensive knowledge of each statement in their safety policy to deliberate and speak on the policy in a complete matter. A successful AE has established a comprehensive goal setting program that includes a process to complete one goal by applying the 14-days goal setting process. A successful AE has researched and developed processes to identify hazards. These are not only limited to hazards discovered by the AE or other personnel, but researched hazards, hazards from targeted inspections and hazards identified by in the regular data collection processes. Hazard identification is ongoing and monitored. A successful AE is responsible for oversight of training and that the person managing the SMS is completing training on schedule and on-demand as required. Training is both formal and informal and is ongoing and a part of a daily self-development process. Most importantly, a successful AE is able to deliberate on why operations are safe most of the time. 

 

A successful AE applies a proven statistical control process to analyze how processes conform to regulatory requirement. An SMS manual contains all safety management system processes and a process for personnel to be aware of their responsibilities. In phase one and two, the SMS manual was often handed over to personnel and they were expected to do self-study and learn on their own. In phase three of a successful AE, the AE has established a system where daily on-the-job tasks are targeted for personnel to maintain awareness of their responsibilities. A successful AE operate with a quality assurance program, which includes a daily quality control system as a prerequisite and process for their triennial audits. 

 

A major change for a successful AE is to include in both airport and airline operations any additional requirements for the safety management system. This includes unregulated tasks. As an example, a pilot is required to ensure that an aerodrome is suitable for the intended operation. An aerodrome operator is responsible for compliance with their published services. During the pre-SMS era, an aerodrome operator could publish a runway surface condition NOTAM without any further responsibility. With the global reporting format requirement and SMS regulation, an aerodrome operator at a certified airport, must ensure that the airport maintain compliance with airport standards for each arrival and departure. It is no longer acceptable to publish a NOTAM only. In addition to the NOTAM, the aerodrome operator must do something to ensure compliance, which is achieved by a simple risk analysis or a risk assessment for comprehensive tasks.  

 

An airport operator is required to complete an Aircraft Movement Surface Condition Report during their published hours of operations and at least every 8 hours, or when there are operational changes. A change in wind direction would trigger a new report, since a new runway is now active. Monitoring the weather is a responsibility of the successful AE, while the person managing the SMS implement project the plans assigned by the AE. A daily quality control system includes several tasks to be completed hourly, daily, weekly, monthly annually or on-demand as required. 

 

An addition change for the AE in their third phase of the SMS, is to develop internal Operations Plans as their long-term corrective action plans, and to monitor the concerns of the civil aviation industry in respect of safety and their perceived effect on the holder of the airport certificate. The requirement list for a successful AE could continue for several pages with line-item tasks to conform to regulatory requirements.  

 

There is no magic wand out there to make anyone a successful accountable executive for an airport or airline. Electronic data collection tools and cloudbased SMS are great and necessary tools, but they are not the solutions to become a successful AE. 

 

 

OffRoadPilots