Forward-Looking Accountability

 Forward-Looking Accountability

By OffRoadPilots

Coincident with the safety management system (SMS) regulations, organizations are required to appoint an accountable executive (AE). The accountable executive is a single, identifiable person within each organization who will discharge the certificate holder’s responsibilities, and in particular, lead in cultural change within a just-culture. It is imperative that the correct person be identified as the accountable executive, and that the individual understands and accepts the roles and responsibilities associated with that position. This is not intended to be a position title without accountability, and on the other hand, it is not a position to accept liability. Simplified, the position as an accountable executive is a position where the appointed person is responsible for airline or airport operations and accountable on behalf of the certificate holder (CH) for meeting the requirements of these regulations.

The AE is responsible to the regulator to operate with processes that conforms to regulatory requirement, standards, and the overarching SMS policy. Regulations requiring the appointment of an accountable executive are separate from those requiring an SMS, i.e., an AE is also required for operators that are not controlled by the SMS regulations.

When incidents occur in business, there is often a call to find those who are responsible and hold them accountable for their actions. In too many cases, accountability translates into disciplinary action against the frontline workers directly tied to the incident (such as verbal and written warnings, suspension, and even termination. If a frontline worker is engaged in at-risk behavior that resulted in an incident, punitive actions are not the preferred process. Incidents are rarely just the result of one person’s decision-making process.

A system that seems unjust or unfair leads to the erosion of trust and respect between frontline workers and management. Without trust, excellence in safety is unattainable.

In addition to undermining trust, there are other reasons to be cautious with the use of punitive actions, discipline, and blame. Research shows that negative consequences have detrimental side effects that often outweigh any positive benefit. Some side effects include fear, lower morale, limited engagement, and suppressed reporting of incidents and near misses.

Most importantly, discipline often does not result in safety improvement. Several years ago, a pilot violated a regulation and was placed on leave without pay for two weeks. The safety manager proposed a corrective action plan to investigate the organization, and to learn if there were gaps in any processes, such as crew resource management, flight training, process training or certification. Management rejected the proposal, and within three months the pilot’s behavior was a contributing factor to a fatal King Air crash. Discipline and other negative consequences do not belong in safety. This does not imply a reduced accountability but is a shift from backwards-looking accountability to forward- looking accountability. Backward-looking accountability is about finding blame, finding the individual who made the mistake, and delivering punishment. Forward-looking accountability acknowledges the mistake and any harm it caused but, more importantly, it identifies changes that need to be made, and assigns responsibility for making those changes. The accountability is focused around making changes, changing organizational systems, modifying management practices, addressing hazards, and building safe habit. Forward-looking accountability is a prerequisite to build a positive safety culture, or just-culture.

Conventional wisdom is that an accountable executive is responsible for human and financial resources only. However, there are two requirements for an accountable executive. The first is a knowledge requirement and the second is a condition requirement. The knowledge requirement is that an accountable executive fully comprehend all regulatory requirements with skills required to design, develop, and operate with processes that conforms to regulatory requirements. A certificate holder shall appoint an individual as accountable executive to be responsible for operations or activities authorized under the certificate and accountable on their behalf for meeting the requirements of the regulations. The condition requirement is that the accountable executive exercise full control of financial and human resources that are necessary for the activities and operations authorized under the certificate.

A successful accountable executive is forward-looking and is accountable to both their knowledge requirement to meet the requirements of the regulations, and accountable to their condition requirement to control financial and human resources. Forward-looking accountability is achieved by risk level decisions, priorities, and expected output of processes. If an expected outcome, or expectation is not defined, there is no definite purpose for that process.

Accepting a risk is the responsibility of an accountable executive. Should someone else, e.g. an airport manager, accept the risk for airport operations, the accountable executive does no longer work within a forward-looking accountably system, since the risk was accepted by an unauthorized person.

Forward-looking accountability trickles from the AE to directors, management, and to workers within an SMS enterprise. The accountable executive is the only person responsible on behalf of the certificate holder for compliance with the regulations. All other personnel are accountable for their application of regulatory conforming processes to their area of operations. Regulatory conforming processes are accepted by the AE and distributed to workers for their benefit as guidance to remain within established parameters. Unless conforming processes are distributed to worker, for them to know what is expected, they and the AE, no longer work within a forward-looking accountability system.

Forward-looking accountability is simple in concept, but it takes hard work to implement processes that conforms to regulatory requirements. Simplified, forward-looking accountability is like being safe when driving down a two-lane highway. If someone had told the wagon-train people of 1857 that wagons one day will travel 80MPH in opposite direction on a trail without accidents, they would not believe it. In their mind, a trail was two ruts that were difficult to move away from. Today, vehicles (wagons) are travelling safety at 80MPH on a trail due to forward- looking accountability. Vehicle operators have learned what lights and markings define and they comply with their messages. The road is paved with a yellow line in the middle to separate the opposite wagons (cars). A driver applies the forward- looking accountability principle by complying with the process, to stay on the right side of the line (some countries left side) and is accountable to opposite traffic on the road. After a vehicle is passed, a driver is no longer accountable to that vehicle, but is forward-looking accountable to what lays ahead. A driver is forward-looking accountable to pedestrians, wildlife, or out of control vehicles approaching head- on. Within a forward-looking accountability system, there is not a question if the oncoming driver comply with the rules or not when approaching head-on, the accountability is to initiate an occurrence, or avoidance maneuver, to avoid an accident. If the principle that the regulation does not say to move away was applied, and a driver demanded to exercise their right, an accident is inevitable. Airport and airline operators insist that they do not need to take action since the regulations does not state that they do. Not long ago an airport operated with 100% ice on their runway, since the regulation did not state that they needed to clear the ice.

Forward-looking accountability must be within a just-culture, since it is impossible to predict the future and what, when, where, who, why and how an accident will happen. Within a just-culture there are decisions made, that after the fact may be determined to be a contributing decision to an accident. When working within a forward-looking accountability system, it is crucial to success that the person who made a decision in good fait, but contributing to an accident, is given a thank you by the AE. The outcome of a spontaneous decision due to external interference does not always give a desired output. Some years ago, and within a forward- looking accountability system, a pilot decided to make do a go-around due to cross wind which contributed to a severe crash when the wind suddenly increased from 20KTS to 50KTS, changed direction, and caused the aircraft to stall. The pilot was given a thank you for making the proper decision, which was to initiate a missed approach.

Forward-looking accountability is to take responsibility for reporting, willingness to admit mistakes, and taking responsibility for changes. A forward-looking accountability is a fluid, or an unstable environment since the accountability is to make decisions, as opposed to do what someone else decided for you. This does not imply that policies, processes, or procedures should not be followed, but that resilience and reacting to changes are integrated parts of a forward-looking accountability system. E.g. An aircraft mechanic discover that a tool is missing, but the tool is not needed for current or future jobs. When applying the forward- accountability principle, the mechanic notify supervisor to order the tool. It is said that it is human to error, but at the opposite end of the spectrum, humans are capable of reacting to events, or hazards, to avoid accidents. Forward-looking accountability is different than being proactive, since accountability is strategic planning at the AE position, and proactive is risk analysis at the operations positions.

Accountability that is backward-looking is determined to find a scapegoat, and to blame and shame an individual for messing up. The first stage of accountability is about looking ahead at the fork-in-the-road to find ways to do the work effectively, and the second stage is to accept the accountability.

Forward-looking accountability acknowledges mistakes and the harm resulting from it and lay out the opportunities for making changes to reduce the probability, or risk level of such harm to happen again.

Forward-looking accountability is to design airports to size and complexity of future airliners.

OffRoadPilots

Staying In The Rut

 Staying In The Rut

By OffRoadPilots

Conventional wisdom is that a healthy safety management system (SMS) stays in the rut without deviation from current course. One reason for this belief is that the SMS regulations states airlines and airports must operate with a process for reporting and analyzing hazards, incidents, and accidents, and for taking corrective actions to prevent their recurrence. When this regulation is interpreted that only one reoccurrence is a regulatory violation, the operation, airlines, or airports, must shift gears to operate with an abundance of caution for every flight or airside task. As reoccurrence continues, they must then overcontrol their processes with additional abundance of caution to their processes that already had received several abundances of cautions from their magic wand. Eliminating all hazards, incidents, and accidents is beyond what the magic wand of a safety management system can do.

The regulatory requirement to prevent their recurrence is applied without consideration for the principles of the safety management system, the principles of performance- based regulations, but applied as a prescriptive requirement, as opposed to a performance requirement, and the requirement is incorrectly interpreted as never to occur. Airlines and airport operators are operating under a false assumption that the same hazards, incidents, or accidents are never to occur again. By living under this assumption, they must make new policy statements, develop corrective action plans (CAP), and forbid the root-cause factor that caused the occurrence in the first place, e.g. the principle of sterile flight deck. The principle behind this theory is when a policy is implemented, then there will never again be a recurrence, and for every occurrence a new policy must be implemented. Policy CAPs that forbid behaviors causing occurrences are non- conforming processes to the regulatory requirements of a safety management system. This does not imply that airlines and airports should not implement policies, but that relying on policies, or directives as a function to eliminate behaviors by making new policies are a non-conforming CAPs.

Prevent their recurrence is about the system’s frequency of occurrences and preventing from occurring again is about periodically or repeatedly. The requirement is about human factors, organizational factors, supervision factors, environmental factors, and is not about the outcome or one single event. In a data driver risk matrix, the frequency range is from times between intervals being imaginary, theoretical, virtual, or fictional at the low end in a system, to times between intervals being methodical, planned, and dependable, without defining the operational system or processes involved at the high end in a system.

Another regulatory requirement 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. When operating with a healthy safety management system, goals are measurable, and they are attainable within acceptable timeframes. Without a goal achievement completion time, goals are dreams, or wishes only, and are without tangible results. A goal to be safe is not a measurable goal, and therefore not an attainable goal. Playing the safety card is a tool used to distract from the real issue when a person does not have justification for their reasoning for their demands.

A goal to reduce number of accidents is also not a goal, since accidents must be an integrated part of the system for this goal can be used. At a car race, where they have crash data collected for years and accidents are acceptable, they can improve the track design, vehicle design, and assess the risk ratio for crash excitement to

spectators’ expectations. A car race system is a system where accidents are expected as an entertainment value and as a businesslike approach to safety. A reduction in accidents is therefore a measurable and attainable goal within the timeframe of one race. In aviation, accidents are not entertainment values, accidents are not a businesslike approach to safety, and a reduction in the number of accidents is therefore not a measurable or attainable goal. A measurable and attainable goal for an airport is a daily inspection to what level an airport conforms to airport standards, and for an airline a goal could be to what level they conform to crew duty and rest requirements.

An SMS enterprise cannot have a goal that is not a part of the process, e.g. accidents. A car race event cannot operate with a goal that drivers do not exceeds 51 MPH.

A regulation to prevent their recurrence and another regulation to set attainable goals may at first glance appear not to be compatible, or they appear to be conflicting requirements. It is not about if one regulation is more important than the

other when it appears to be conflicting performance requirements, but it is about how SMS processes are applied to conform to regulatory compliance in both instances. Appearance of conflicting regulatory requirements are when one requirement is to prevent, or for an event to never happen again, and the other requirement is to set an attainable goal for that same event, since a corrective action plans to prevent their recurrence were implemented.

Since regulators are performance based, there are no opposing regulatory requirements. An SMS enterprise must implement processes to conform to each

regulatory requirement by implementing different processes for the requirements. In an advanced and healthy SMS environment, an airport and airline have designed processes where one process conforms to multiple regulatory requirements.

When an SMS enterprise decide to apply performance regulations as prescriptive regulations, a trap to fall into is to stay in the rut. They are not stuck in the rut, but they voluntarily stay in the rut, since that is the safe place to stay. It is human nature to remain within their comfort zone and not to leave the someday island. The someday island is a virtual island, and it is a fantasy island where it is safe to be. The comfort zone is also a reason for procrastination. Getting things done now, or making decisions, are for many an extreme and humongous task. They have learned that when the wrong decision is made, they are being punished, demoted, or even fired. When living in such an environment, it is much better for a person to make no decisions, than making the wrong decision. A wrong decision is not the same as an incorrect decision, but is a decision that the supervisor, manager, or president of an organization did not approve of. Within a healthy SMS environment, they say thank you even when they disagree with a decision, and they say thank you when incorrect decisions are made.

Several years ago, a brand- new worker did a costly error. Feeling upset and disappointed, the worker was certain to be fired, and packed up tools and all belongings ready to walk out the door after being fired. The boss came in and asked why all belongings and tools were paced up. The worker replied that they

were packed up so it would be easier to leave after being fired. The boss replied: I cannot fire you now. In just one day I spent over 100-thousand dollars training you.

This is a true story, and true stories are good. To this day, the worker is acting as a consultant to the boss on billion-dollars projects.

Operating with a safe SMS is to stay in the rut, where there are none, or very few changes. When operating in the rut, on the someday island, each checkbox can safely be checked and show a compliant safety management system. And yes, an SMS is compliant when staying in the rut on someday island since there have not been any changes to the SMS since the SMS was implemented. In a total safe environment there are no changes, all operations are halted, and life is safe and protected from scrutiny.

Staying in the rut is a learned behavior with little or no knowledge of why things are the way they are. An aircraft runup prior to take off is done because someone crash and got scared when an engine quit. Expanding airnavigation radars were done because two airplanes crashed over Grand Canyon in 1956, and the most interesting rut is that the standard railroad gauge (distance between the rails) is 4 feet, 8.5 inches, which is an exceedingly odd number. The reason for the distance between rails is because that's the way they built them in England and English engineers designed the first railroads. The people who built the tramways used the same jigs and tools that they had used for building wagons, which used that same wheel spacing. Roman war chariots formed the initial ruts, which everyone else had to match or run the risk of destroying their wagon wheels. Since the chariots were made for Imperial Rome, they were all alike in the matter of wheel spacing. Therefore, the railroad gauge of 4 feet, 8.5 inches is derived from the original specifications for an Imperial Roman war chariot, which was built to follow the tracks of two horses.

Now, here is the rest of the story. When you see a Space Shuttle sitting on its launch pad, there are two big booster rockets attached to the sides of the main fuel tank, and they are made in another part of the country. The engineers who designed bit fatter, but the SRBs had to be shipped by train from the factory to the launch the SRBs would have preferred to make them a site. The railroad line from the factory happens to run through a tunnel in the mountains, and the SRBs had to fit through that tunnel. The tunnel is slightly wider than the railroad track, and the railroad track, as you now know, is about as wide as two horses. So, a major Space Shuttle design feature, of what is arguably the world's most advanced transportation system, was determined over two thousand years ago by the width of two horses’ tracks. Ancient horses and staying in the rut control almost everything in transportation. Applying processes to performance-based regulations is to move out of the tracks and make new tracks. New tracks are not always comprehended by the accountable executive, and therefore rejected. An accountable executive is not an expert, in most cases, in statistical process control, process analysis, risk analysis, system analysis and audits, but is an expert in financial management to ensure a successful business. The move from prescriptive regulations to performance-based regulations and the safety management system, created challenges and obstacles to overcome. Two major obstacles were to design and apply processes that conform to regulatory compliance, e.g. the output, as opposed to the input, and the other challenge to overcome was to take the first step and move out of the rut.

Staying in the rut with a safety management system is a compliant SMS, but it is an unhealthy SMS with undetected flaws. A healthy SMS has moved out of the rut and is on a path into uncharted territory.

OffRoadPilots