Safety Uphill Battle

 Safety Uphill Battle

By OffRoadPilots

Conventional wisdom is that safety is to be protected from harm to a person or property, without knowing who the protector is, or how they are protecting a person or property from harm. Safety is a word with indefinite limits in protecting a person or property, and a word that encompasses all virtual events. When the word safety is used in communication its meaning is unlimited, but also restricted by imagination. A person is looking forward to a safe flight, which is to be protected by someone while airborne and deplane without experience harm to their person or to the aircraft. Safety has become a responsibility of someone unknown rather than the person who expects to be safe. Accepting risk is a way of life, and there is an inherent risk in flying, but when it is removed from the equation, safety in aviation becomes an uphill battle.

Safety in aviation, being airlines or airports, is not the absence of accidents or events, but the reliability of their processes, and expected process outputs. A safety management system (SMS) is a businesslike approach to safety. What this entails is that an SMS includes a transaction system, an accounting system and a balance sheet with results. As a businesslike approach to safety an SMS enterprise keeps up a daily quality control system, and closes that system daily. In a business the cash is flowing in, expenses are paid and the leftovers is for anything else. Cash is tangible, while safety is abstract and turns safety into an uphill battle.

When safety in aviation is turned into tangible cash, that is when a safety management system makes sense. It does not make sense to wait for a future accident that would happen without having an SMS, but now it will not happen because of the SMS.

A safety management system is an excellent tool for airlines and airport operators, but they need to know how to use the tool and known what there is to manage. Future accidents cannot be managed, past accidents cannot be managed and abstract, or virtual scenarios established in a risk analysis cannot be managed. Its name is a management system, but we don’t manage risks, we lead personnel, manage equipment and validate operational design for improved performance above the safety risk level bar. Simply said, it takes a leader as the accountable executive to operate with an SMS, it takes a leader who takes an active role in strategic planning, and most important, it takes a leader to accept bad news when performance takes unplanned turns. It is widely expected within the aviation industry, and communicated by the regulator that the safety management systems help companies identify safety risks before they become bigger problems, and that the aviation industry put safety management systems in place as an extra layer of protection to help save lives. Assuming that it is a fact that an SMS save lives, a question to answer should be how this life saving system saves lives, and what its proven track record in life saving is. A regulatory requirement is for an SMS enterprise to operate with a process for setting goals for the improvement of aviation safety and for measuring the attainment of those goals. Since SMS is published by the regulator as “an extra layer of protection to help save lives”, a measurement of the regulatory requirement for “measuring the attainment of those goals” should be measured in how many lives, and specifically what lives were saved. An unspecified goal is not a goal but a wish, and a wish does not have any impact on operations. The moral of the story is that an SMS cannot be a system to save lives since it does not include life-saving processes. A first-aid process is a life-saving process, a surgery is a life- saving process, digging a water well in the desert is a life-saving process, but operating with an SMS is not a life-saving process. The aviation industry has caught on to this misleading definition but are reluctant to oppose the regulators. When the safety-card is played it becomes an uphill battel to work within an SMS system. SMS, as a system in itself is an exceptional system, and the more we learn about SMS, the more intelligent it becomes. However, it was presented and sold to the aviation industry as an excellent system, but when it was delivered it came on the cover of a trash can.

Imagine for a minute that you are at the most beautiful restaurant together with your favorite person. It’s a wonderful atmosphere, the place is spectacular, friendly personnel and everything is a million times better than expected. You are waiting for the meal to be served when you hear the rattling noise of falling trash cans. The next thing you know is that your meal is served on the cover of a trash can. Your meal is also served with a note stating that you must consume this meal to avoid harm. You feel trapped and alone without a place to go and decide to accept the meal, but it is an uphill battle to consume. This is how SMS was presented. It is an excellent system, but it was presented on the cover of a trash can and enforced to be accepted for operators to remain in business.

If the SMS is a system to save lives, another question to answer is if airports and airlines prior to SMS knowingly worked within systems that destroyed lives and properties. When the safety-card is used to promote a cause, airlines and airport operators recognize this as opinions, but they also know that it is not an appropriate response to disagree with safety and obey by default. Opinions are often used to spread ideas, information, or rumor for the purpose of helping or injuring an institution, a cause, or a person. Working within a safety management system is an uphill battle for airlines and airports when they must conform to opinion messages and social media ratings.

It is not long ago that an airliner was cleared for takeoff and reach a takeoff speed of 100 KTS when another major airliner crossed the active runway at a short distance in front of the departing airliner. The tower cancelled takeoff clearance and the departing aircraft aborted their takeoff. A collision was avoided and there were no physical injuries. Both airlines were operating with a safety management system, but that did not prevent an incident. The worst aviation accident is still a pre-SMS accident that happened on March 27, 1977. Since SMS saves lives, the logic is also that an SMS would have prevented this disaster. However, if the departing aircraft had continued its takeoff run after their very first power application for takeoff (which was aborted), the question to answer is if a continued takeoff would have prevented the accident. SMS is not the system that saves lives. People is the system that saves lives.

SMS is an exceptional well-designed system, and when used as intended it is a system where there is trust, learning, accountability, and information sharing. These are the four foundations for an SMS to function in a healthy SMS environment.

One of the most important, but also one of the most overlooked requirements for an SMS enterprise is to monitor the concerns of the civil aviation industry in respect of safety and their perceived effect on the holder the certificate. This requirement is also overlooked by the regulator, who does not inspect for compliance, or how social media concerns affect operations.

There is a fine line to balance between obeying social media demands and assessing the facts before an action is initiated. It is a double edge sward since the aviation industry is dependant on high social media ratings, but also is required to make changes, and possible unpopular changes. Target marketing towards perception is crucial to stay in business and fund the safety management system. When cashflow is reduced, the temptation is to eliminate safety measures, since safety is abstract and does not come with past tangible results. Safety results can only be assessed by process outputs and the number of times things go right. That an airline or airport operates without incidents cannot directly be assigned to their safety management system, since aviation was the safest mode of transportation with very few major accidents prior to SMS implementation. A dilemma in safety is to sell safety to organizational management and the general public since the perception is already that flying is safe. Social media solutions are quick to assign pilot error to accidents, but within an SMS enterprise there is no such thing as pilot error, or human error when things go wrong, but there are human factors considerations in process design.

Safety is an uphill battle to sell and accept when operations already is safe. When an airport operator is focusing their SMS on the role of an accountable executive, (AE), to be responsible on behalf of the certificate holder for compliance with regulations, then they are focusing on maintaining a solid foundation for the SMS. When airport operators divert their focus from the AE to airside operations, their processes become operational control compliance, or assumed compliance, or an omission compliance when things go wrong, as opposed to oversight compliance why things went right the first time. When focusing on airside operations itself and making changes, the inevitable trap is overcontrolling of processes.

Safety is an uphill battle for your SMS enterprise when SMS portrays “life as it should be” and not “life as it is” during airline and airport service delivery operations. No matter what they tell you, there is an I in TEAM. Remove the uphill SMS battle by applying your SMS as the intended support tool that it is. Trust that your policies, processes, and procedures all come with built-in flaws. Trust that acceptable work practices have more values to safety in operations than written procedures, and finally, move away from the I in TEAM.

OffRoadPilots

Decisions

 Decisions

By OffRoadPilots

Operational safety decisions in the aviation industry are based on internal or external pressure, social media ratings, customer opinions, or investors demands. Safety has become a fashionable word in the context of airline and airport operations. Conventional wisdom is that regulations are minimum safety standards and justify reasons for more regulations to improve safety. Regulations are neutral and may not by itself compatible with the safe operation of an airport or aircraft. What makes regulations effective is how it allows for operational processes. It wasn’t until the accountability within a safety management system in aviation became a regulatory requirement that airlines and airports could assess their operational processes to conform to regulatory requirements. The airmail act of 1926 is a prime example how promoting new regulations supported efficient and safe air transportation by applying the latest technology to airnavigation and airport improvements. This new regulation required licensing of pilots, aircraft airworthiness and a national airnavigation system. The airnavigation system used the latest technology for visual navigation and placed lighted towers on mountaintop to identify air routes. Some of these towers are still operational today. Making rules and regulations better improves the health of an organization.

Decisions that are made by authorities and whatever method is applied, or whichever direction it is viewed from, every single decision is made by one person only. Committee, or group decisions are virtual realities, since at the end of the day, it is the person with the best vocabulary who convince the others and makes the decision. When a person wins a vote by improving and impressing others, it is done by their vocabulary and not by promises, and at the end, it was only one person who made that decision. The same is true in aviation, for both airlines and airports, that only one person makes decisions. This person may be a person in authority, such as the CEO, President of a company, business owner, customer, or an investor, or the accountable executive, while the responsibility for regulatory compliance still rests with the accountable executive.

There is a significant difference between a decision and a choice. Decision connects to the place of behavior, performance, and consequence, while a choice connects to the place of desired intention, value, and belief. Simplified, decisions are connected to causes, or expected outcomes, and choices are connected to reasons, or emotions. The difference between a justification and a reason in that a justification is objective and a reason is subjective. An SMS enterprise needs to operate with a system where decisions are made to instill behaviors by objective decisions and unbiased justifications.

Decisions are made to improve the health of an SMS enterprise. It widely accepted that a safety management system is a businesslike approach to safety and applying a businesslike approach has become the first step to a successful SMS. When applying a businesslike approach, an optimization approach to the decision making process to improve its health is also needed. An optimized decisionmaking process within an SMS enterprise is a targeted approach to decisions. In marketing a specific audience is targeted based on their prior behaviors, perceived resources, purchase availability e.g. physical or online, and demographic. Marketing optimization is all about reaching goals. It is the process of making adjustments to marketing efforts based on data collected, and it is to make tune-ups using the marketing tools and tactics spelled out in the decision marketing strategy plan to align results with ambitions, or goals and objectives. In marketing the consumer is targeted by a supplier. In aviation safety, for both airlines and airports, and within a safety management system, an optimized decision making approach is a reversal of the marketing process.

In marketing the objective is to move product or services to a customer. In aviation safety, the objective is to move a customer, or personnel, to the product or service. The product is the process design, e.g. SMS cloudbased as opposed to paperformat, and the service is personnel accepting a cloudbased SMS. When marketing a new system, the task is not to enforce a new system, but to make sure the system userfriendly for personnel to use so that they accept a new system. A prerequisite to introduce a new system is to conduct a system analysis, test the system and communicate the reason for its purpose.

It is a myth that aviation safety operates with perfect safety systems that are without flaws and without malfunctioning system. When things go wrong, many fall into the hindsight bias trap and place blame on the person who was in control of the last link. A root cause analysis is a tool to prepare for decisions. The 5-Why root cause analysis process is an acceptable process within the aviation industry. When using the 5-Why method, the first answer to the Why-question establishes the pathway to the root cause. Root cause analyses are generally associated with accidents but should also be applied to other special cause variations.

When deciding what the answer to very first Why-question is, the answer must be an action item without an explanation or reason. When an answer is given with an opinion, the path to the root cause deviates from a fact-finding path to an opinion path. The first answer to an aircraft crash is often why did the aircraft crash. This question opens up for an answer to go in any direction, with the two primary direction is to go in an opinion-based direction, or a fact-finding direction. An answer that the aircraft crashed because the pilot did not follow procedure is an option-based answer. Scientific data does not conclusive assign deviations from procedures to be a prerequisite for accidents. Back in 1998 an aircraft crashed while the crew were completing their emergency procedure checklist. A decision to make a statement of what did not happen is irrelevant to a solution, since other tasks than checklist tasks were conducted. Time did not just stop while the procedure was not done. When the first answer to the question why the aircraft crashed is based on facts, an answer could be that it crashed because touched down outside of the touchdown area.

A hazard to a decision-making process is to fall into to the trap to assign a solution, or reason for the accidents before all facts are known. There is no rush to assign a solution or root cause to an accident. Assigning an incorrect root cause, such as pilot error, is a higher risk than waiting for facts to come in. After an accident a risk analysis is conducted, which is different from a root cause analysis. The purpose of a risk analysis is for an operator, being airline or airport, to justify a decision of their next action after an accident. The five basic actions are to communicate, or to monitor, or to pause operations (up to 48 hours), or to suspend operations (beyond 48 hours), or to cease operations (until a new system is in place). There are times when it is justified to suspend or cease operations until a root cause has been determined. However, cease, suspend, or pause operations after every accident until a root cause is established is without justification.

An operator with a conventional safety system without a systematic approach to safety, operates with a safety decision making processes defined as common sense. Implying that safety is common sense relegates it to those areas that don’t require much thought or close attention. When safety is treated as common sense, aviation safety is making a mindless act. Common sense changes over time, and it is a learned behaviour. When common sense are applied there are opposing views of how to improve aviation safety, which is an uphill struggle for the safety management system.

Common sense in one region might not be common sense in another region. A safety management system may function well in one region of the world, while it has opposing views in other regions. When exactly the same hazards are identified in different regions, decisions to improve safety may vary from one region to another region when applying the accepted safety management system processes. SMS is a human behavior system and acceptable human behaviors vary across regions. It is impossible to impose, or change, human behaviors to conform to one-world acceptable human behavior. Decision-making processes must therefore be based on data collected to improve safety and not common sense approach.

Humans are resilient with the ability to bounce back or adapt. Safety decisions are often made to force adaptability where management finds it necessary to stay in business. Some of these changes are automation and electronics. Aircraft systems are very different today from what they were just a few years ago. Pilots have become automation monitoring experts rather than pilots, operational managers, and aerodynamics experts. 

Transferring aircraft operational control from pilots to automation does not improve safety in aviation, but moves human-errors into automation as written in this 2013 post:” If automation replaces humans in critical stages of a process, the human-error factor is not eliminated, but transferred into an automation package.” Cabin crew automation may not be as obvious as for pilots, but cabin crews have become social media influencers for their organization to maintain a highest possible rating.

Decisions are necessary to maintain an acceptable level of safety in aviation. Policy, process, procedure, or acceptable work practices decisions do not necessarily improve safety. Decisions might be perceived as safety improvements, which is the purpose of operating a business, and this is not necessarily a hazard for the safe operations of aircraft or airport. Decision-making processes become hazardous to aviation when its outputs are accepted at face value and blue-stamped as an acceptable change without support of a system analysis. Operational risk analyses and decision-making reliability are judgements decisions to be made within a  highly constraint time limit, but are just as much part of a defined decision-making process as decisions made in the office.

OffRoadPilots