tag:blogger.com,1999:blog-36645374171511065362024-03-19T01:48:17.159-07:00SMS QA Control ManagementTo POST: send it to dtitraining@juno.com I will Post, I promise. You can comment here at will!SMS/QA Control Managementhttp://www.blogger.com/profile/09611789820282926862noreply@blogger.comBlogger357125tag:blogger.com,1999:blog-3664537417151106536.post-50119797017051160222024-03-16T05:02:00.000-07:002024-03-16T05:02:22.229-07:00Supervision Factors<p> <span style="font-family: Calibri; font-size: 14pt;">Supervision Factors</span></p><p><span style="font-family: Calibri;"><span style="font-size: x-small;">By OffRoadPilots</span></span></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri;"><b><span style="font-size: x-large;"><i>W</i></span></b><span style="font-size: medium;">hen identifying contributing factors and root causes, an SMS enterprise considers human factors, supervision factors, organizational factors, and environmental factors. Every person is working under supervision, knowing it or not. A CEO of a corporation is supervised, and a AE of an SMS enterprise is supervised. Everyone is supervised in one way or another, and everybody got to serve somebody. Types of supervision also depends on what is being supervised. Different types of supervision are required for education than for operational control, fundamental task supervision is different than auxiliary task supervision, academic task supervision is different than practical application task supervision, and process compliance supervision is different than process output supervision. Every task comes with a supervision factor which depends on what task is supervised.</span></span></p><p><span style="font-family: Calibri;"></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj5U_IZCLlHHoV9m5KS_CJKykc1DSxWNVdDZ75h5Q8yrjcGl0lnFO2axcewrVELdbZZaOd7XSWWM8kpE_Nc9909AVze_T7NGTm1JNlJeaYAlNHATdtkF58OKfTjZ3ZZFTisxpXEXt0pxitb5zHcupQXZLw-I0mhsoWYyIWNuN1vQGmDchMYIRZE1iXa1k6v/s382/Screenshot%202024-03-16%20at%207.54.23%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="179" data-original-width="382" height="188" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj5U_IZCLlHHoV9m5KS_CJKykc1DSxWNVdDZ75h5Q8yrjcGl0lnFO2axcewrVELdbZZaOd7XSWWM8kpE_Nc9909AVze_T7NGTm1JNlJeaYAlNHATdtkF58OKfTjZ3ZZFTisxpXEXt0pxitb5zHcupQXZLw-I0mhsoWYyIWNuN1vQGmDchMYIRZE1iXa1k6v/w400-h188/Screenshot%202024-03-16%20at%207.54.23%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>M</b>icromanagement is considered a form of supervision, it is used by many and is in their opinion an excellent method and the preferred method of supervision. However, micromanagement is not </span><span style="font-family: Calibri; font-size: 14pt;">supervision but management. Micromanagement is where managers feel the need to control aspects of their employee's work and decision-making to an extreme degree, more than is necessary or healthy for a usual working relationship. There is a difference between management and supervision. In general terms, management is how businesses organize and direct workflow, operations, and personnel to meet company goals. The primary goal of management is to create an environment that lets employees work efficiently and productively, and they use supervision as a process tool for oversight to remain on target for their goal. Micromanagement is not suitable for an SMS enterprise, since it does not promote trust, learning, accountability, or information sharing. Within a micromanagement </span><span style="font-family: Calibri; font-size: 14pt;">system there is only one way, process, or method, which is decided by the manager. In a micromanagement system, a manager has previously demanded that a root cause analysis of an independent third-party operator to justify penalties and punitive actions.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiS-5G5Gz7to-sNDvMHuxRT-cgCDu1Puu06F-LaTwn491rt9u2IaTxoNaBk5s0MUnNJnHmqWG3DYao2xbPCgArLQQgf4MFLExolQJFo2L4omScvMB0PJbJgSLS27oG2j7BktB9VeBaOEvtS8fXKTP5-bo31xWByQbHRHGgdURM9nV-uzWLfSc-v-wZy3bA5/s372/Screenshot%202024-03-16%20at%207.55.27%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="279" data-original-width="372" height="300" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiS-5G5Gz7to-sNDvMHuxRT-cgCDu1Puu06F-LaTwn491rt9u2IaTxoNaBk5s0MUnNJnHmqWG3DYao2xbPCgArLQQgf4MFLExolQJFo2L4omScvMB0PJbJgSLS27oG2j7BktB9VeBaOEvtS8fXKTP5-bo31xWByQbHRHGgdURM9nV-uzWLfSc-v-wZy3bA5/w400-h300/Screenshot%202024-03-16%20at%207.55.27%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he different levels of supervision are direct supervision, which supervisor gives specific instructions on all assignments. Work is reviewed for completeness and accuracy, or personnel performs tasks which provide inherent checks built into the nature of the work. Reviewing work is different </span><span style="font-family: Calibri; font-size: 14pt;">from micromanaging work. General supervision is when the supervisor provides continuing or individual assignments by indicating generally what is to be done, limitations, quality and quantity expected, deadlines and priorities. Additional, specific instructions are given for new, difficult, or unusual assignments. Personnel uses initiative in carrying out recurring assignments. The supervisor assures that the work is technically accurate and in compliance with instructions or established procedures. Intermittent supervision is when a supervisor makes assignments by defining objectives, priorities, and deadlines, and assists personnel with unusual situations that do not have clear objectives. Intermittent supervision is when personnel plans and carries out successive steps and resolves problems and deviations in accordance with instructions, policies, and accepted practices. The supervisor reviews the work for technical adequacy and conformance with practice and policy. Administrative supervision is when a supervisor sets the overall objectives and resources available. Both supervisor and personnel, in consultation, develop deadlines, projects, and work to be done. Personnel plans and carries out the assignment, resolves most of the conflicts, coordinates work with others and </span><span style="font-family: Calibri; font-size: 14pt;">interprets policy on own initiative. Personnel keeps the supervisor informed of progress, potentially controversial matters, or far-reaching implications. General direction is when assignments are made in terms of broad practice, precedents, policies, and goals. Work may be reviewed for fulfillment of program objectives and conformance with departmental policy and practice. Long-Range administrative direction is when personnel generally proceed independently in accordance with general plans, policies, and purposes of the department. Results of work are considered technically authoritative and are normally accepted without significant change. Any of these levels of supervision are compatible with an aviation safety management system.</span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhgiIqPQ4T6iQXAM6xzVZJU9CRs5N9cb_Dwdng0IXCxMUCF9V3vFmXoknTO70C2nxe82VvI6fU0V5EPXIwNu1fHeohJwD_aZpFCU8IGE_vcp4AJT-dNSmKWFulAInglBFzKwhqxGgVmx1UU9eYWgtAz5fkKJ-dKJHdahjcXK-x-yi0_AEsspVBkS0wZrV4F/s376/Screenshot%202024-03-16%20at%207.56.28%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="300" data-original-width="376" height="319" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhgiIqPQ4T6iQXAM6xzVZJU9CRs5N9cb_Dwdng0IXCxMUCF9V3vFmXoknTO70C2nxe82VvI6fU0V5EPXIwNu1fHeohJwD_aZpFCU8IGE_vcp4AJT-dNSmKWFulAInglBFzKwhqxGgVmx1UU9eYWgtAz5fkKJ-dKJHdahjcXK-x-yi0_AEsspVBkS0wZrV4F/w400-h319/Screenshot%202024-03-16%20at%207.56.28%20AM.png" width="400" /></a></div><div class="page" title="Page 3"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>E</b>ach level of supervision is linked to a type of supervision. Types of supervision is determined by the way in which work is assigned, when it is reviewed, how it is reviewed, and what guidelines, prototypes and protocols are available.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>C</b>lose supervision is when personnel are assigned duties according to specific procedures. Work is checked </span><span style="font-family: Calibri; font-size: 14pt;">frequently, and in addition there may be formal training. Regular supervision is when personnel perform a variety of routine duties within established policies and </span><span style="font-family: Calibri; font-size: 14pt;">procedures or by referral to the supervisor’s guidelines. </span><span style="font-family: Calibri; font-size: 14pt;">General supervision is when personnel develop procedures for performance of variety of duties or performs complex duties within established policy guidelines. Direction supervision is when personnel establish procedures for attaining specific goals and objectives in a broad area of work. Only the final results of work done are typically reviewed. Personnel typically develops procedures within the limits of established policy guidelines. General direction is when personnel receive guidance in terms of broad </span><span style="font-family: Calibri; font-size: 14pt;">goals and overall objectives and is responsible for establishing the methods to attain them. Generally, personnel are in charge of an area of work, and typically formulates policy for this area but does not necessarily have final authority for approving policy. Any one of these types of supervision are compatible with an aviation safety management system. In a simple format, types of supervision are structural, participative, servant-leader, freedom-thinking, and transformational leadership.</span></p><div class="page" title="Page 4"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>W</b>hen supervision factors are applied to a root cause analysis, it is critical for a successful outcome that it is applied appropriately to the analysis. Conventional wisdom is that any errors within root cause factors are human errors. However, human error is a subfactor of human factors.</span></p></div></div></div></div></div></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgamBBUYTde2FqGuMim0ealwcHC2OrGodq239YoggGtcb22B8MqlaLEw7L8vnRLmz_OeZMk-3_reprk-zMQM1nUknzsf4jT35ATSJPXGt1x19oqSZX4814_x5MxcPkRKFs8OCD7_fNwQTO7GNxlo5DAbg5U0-Tq1tHDGrMORzRpHKpW8OLLoAsHiG0fdWPy/s376/Screenshot%202024-03-16%20at%207.57.35%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="280" data-original-width="376" height="297" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgamBBUYTde2FqGuMim0ealwcHC2OrGodq239YoggGtcb22B8MqlaLEw7L8vnRLmz_OeZMk-3_reprk-zMQM1nUknzsf4jT35ATSJPXGt1x19oqSZX4814_x5MxcPkRKFs8OCD7_fNwQTO7GNxlo5DAbg5U0-Tq1tHDGrMORzRpHKpW8OLLoAsHiG0fdWPy/w400-h297/Screenshot%202024-03-16%20at%207.57.35%20AM.png" width="400" /></a></div><div class="page" title="Page 4"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he first step in analyzing supervision factors is to conduct a root cause analysis and assign one of the four factors to the root cause. Both the fishbone, and the 5-why root cause analyses are acceptable tools. The fishbone provides both visual and text links in the root cause process, while the 5-why is a text </span><span style="font-family: Calibri; font-size: 14pt;">and matrix analysis. </span><span style="font-family: Calibri; font-size: 14pt;">When applying the 5-why method, a matrix of 5 options and 5 considerations should be used. One reason for a 25-point matrix is to reduce the probability for subjective answers. After answering the first few questions subjectively, there is only one way to continue, which is to look at each answer objectively. Another reason for the 25-point matrix is that the first answer to the first question leads to a predetermined root cause. If the question is why an airplane crashed, a </span><span style="font-family: Calibri; font-size: 14pt;">subjective answer could be that the pilot lost control. As the questions goes down the pilot lost control avenue, the outcome is focusing on the pilot only. An objective answer to the same question could be facts of events, such as a wing suddenly banked 60 degrees upon landing. An objective answer leads down the avenue of fact findings of events, as opposed to the avenue of pilot actions. When there is a matrix of 25 answers, there is a higher probability to capture the correct root cause, and it forces a person to think.</span></p><div class="page" title="Page 5"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he root cause analysis is not the end, but the beginning of corrective action plans (CAP). Establish the root cause based on the most likely probability in the 25-point matrix. One or multiple column may be combined to assign the most probable root cause. A root cause cap must be linked to an objective, or establish a new objective, and linked to a safety policy goal.</span></p></div></div></div></div></div></div></div></div></div></div></div></div><p><span style="font-family: Calibri;"></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgW4r3EgX3787Xq-2fjY72ADulx6dlxqA8q1T0Sqe3EDeSVE4w-14yML7oZElTRkOkKgTUo8V8lrbjtidQybFN_r-J2JVgFhdwsSR0ZFI3xWdqKa6qTqnbJMD-jgsMDdpY8Mwy0L2j2bpbJFyQ3-9cFZQwy7lFMsJOpM8cvBEBuuAqWcxl6Y7OhCoFU3qHx/s359/Screenshot%202024-03-16%20at%207.59.06%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="151" data-original-width="359" height="169" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgW4r3EgX3787Xq-2fjY72ADulx6dlxqA8q1T0Sqe3EDeSVE4w-14yML7oZElTRkOkKgTUo8V8lrbjtidQybFN_r-J2JVgFhdwsSR0ZFI3xWdqKa6qTqnbJMD-jgsMDdpY8Mwy0L2j2bpbJFyQ3-9cFZQwy7lFMsJOpM8cvBEBuuAqWcxl6Y7OhCoFU3qHx/w400-h169/Screenshot%202024-03-16%20at%207.59.06%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 6"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>G</b>eneral types are structural, participative, servant-leader, freedom-thinking, and transformational leadership.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b>ssign a weight score between 1 and 4 to each factor and to each one of the 5-Ws + How. The factor with the highest weight score is assigned as the root cause factor and the factor where the CAP needs to be applied. If two weight scores are equal, apply the highest </span><span style="font-family: Calibri; font-size: 14pt;">“</span><span style="font-family: Calibri; font-size: 14pt;">Why</span><span style="font-family: Calibri; font-size: 14pt;">” </span><span style="font-family: Calibri; font-size: 14pt;">score as the determining factor.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>W</b>hen supervision factors are determined to be the highest root cause probability, a corrective action plan must address the current supervision system, which can be extremely difficult to accept by an SMS enterprise. Acceptance and accountability are the only tools available to improve regulatory compliance and safety in operations little by little.</span></p><p><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">OffRoadPilots</span></p></div></div></div><p><span style="font-family: Calibri;"><span style="font-size: medium;"><br /></span></span></p></div></div></div>SMS/QA Control Managementhttp://www.blogger.com/profile/09611789820282926862noreply@blogger.com0tag:blogger.com,1999:blog-3664537417151106536.post-46164324139091572162024-03-02T04:17:00.000-08:002024-03-02T04:17:07.382-08:00Environmental Factors<p><span style="font-family: Calibri; font-size: 14pt;">Environmental Factors</span></p><p>By OffRoadPilots </p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri;"><span style="font-size: x-large;"><i><b>W</b></i></span></span><span style="font-family: Calibri; font-size: 14pt;">hen identifying contributing factors and root cause, an SMS enterprise considers human factors, supervision factors, organizational factors, and environmental factors. These factors support their safety management system (SMS) policy on which the safety management system (SMS) is based, goalsetting system, process to identify hazards, training system, reporting system, communication system, quality assurance system, audit system, and they support their tasks for airlines and airports to operate with a comprehensive and compliant safety management system.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj3Yd27nQhIbpLz6Z6tTKW3TY06UXRKJmME_EPbOcRzgOpPGbN9-QwDDjr_xtRmFIxM18GeD8dYZEAW-gftakHh5FTJgUcOZflu5bRaqGDTHpdDbazGkp47HUjZ5WPPVFnXCvqMzreI6RGG5blLZftACuRrNNXBoD0H_Rcg_3oGjKlF-5pJaHbKpJ1H9M9k/s385/Screenshot%202024-03-02%20at%206.50.41%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="266" data-original-width="385" height="276" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj3Yd27nQhIbpLz6Z6tTKW3TY06UXRKJmME_EPbOcRzgOpPGbN9-QwDDjr_xtRmFIxM18GeD8dYZEAW-gftakHh5FTJgUcOZflu5bRaqGDTHpdDbazGkp47HUjZ5WPPVFnXCvqMzreI6RGG5blLZftACuRrNNXBoD0H_Rcg_3oGjKlF-5pJaHbKpJ1H9M9k/w400-h276/Screenshot%202024-03-02%20at%206.50.41%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>E</b>nvironmental factors are comprehensive factors affecting SMS, since there are several subcategories included. Environmental factors encompass geographical location, climate, ecological, illumination, terrain, natural accelerated events, operational environment, </span><span style="font-family: Calibri; font-size: 14pt;">workplace, design, equipment, communication, and more. Within each subcategory there are multiple secondary categories, and complementary categories. Environmental factors can be scaled down to detail-reliability in processes. When details are defined, a process may be simplified for the end user.</span></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>G</b>eographical locations are located within the four categories of airmasses. These airmasses are artic, tropical, polar, and equatorial. Arctic air masses form in the Arctic region and are very cold. Tropical air masses form in low-latitude areas and are moderately warm. Polar airmasses take shape in high-latitude regions and are cold. Equatorial air masses develop near the Equator and are warm. Secondary categories of the geo location subcategory are regional and local phenomena.</span></p><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>R</b>egional and local phenomena include uninhabited areas located within any of the four airmasses.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he climate subcategory is the long-term pattern of weather in a region. Weather changes from hour-to-hour, day-to-day, month-to-month or even year-to-year. Regional weather patterns tracked for at least 30 years, are considered its climate.</span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjCRRsI2RI2vCWD9BmZy-ArAR96H1FVRSfKZ_mi3i428IVIYoBM9sQZX1ePyuSPM8fcFFgJg3Idk5DV_vQ66lq6G3lla0dti-dpqvsCrvpoURsdjwsFU3qua1KNrgsNd_m0nTj9NXq8xCKqyvaBSQw4rxMo60QmEVP4ZWDCtk_amqdysQiqbMIE-Pi8Xrkt/s369/Screenshot%202024-03-02%20at%207.05.37%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="270" data-original-width="369" height="293" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjCRRsI2RI2vCWD9BmZy-ArAR96H1FVRSfKZ_mi3i428IVIYoBM9sQZX1ePyuSPM8fcFFgJg3Idk5DV_vQ66lq6G3lla0dti-dpqvsCrvpoURsdjwsFU3qua1KNrgsNd_m0nTj9NXq8xCKqyvaBSQw4rxMo60QmEVP4ZWDCtk_amqdysQiqbMIE-Pi8Xrkt/w400-h293/Screenshot%202024-03-02%20at%207.05.37%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he ecological subcategory is how landscape patterns are precisely described patterns into ecosystem units based on similar climate, landscape, vegetation, and soil conditions. This provides for a common ecological language and framework to classify ecosystem units and support land and resource </span><span style="font-family: Calibri; font-size: 14pt;">management. </span><span style="font-family: Calibri; font-size: 14pt;">Illumination, sunlight, and darkness are subcategories of environmental factors. Illumination may be hangar lighting, and type of lighting. Some types of lights may cause colors to blend, while other types are bright and causing shadows. Sunlight, or lack of sunlight, including grey zones, are factors affecting aircraft operations, and maintenance and flight crew performance.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>errain is another environmental factor. Terrain ranges from the shorelines at the three coasts, tundra and the arctic, the level prairies, to rolling hills, the foothills and to the rugged and rocky mountains.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>S</b>ome of the natural accelerated events are earthquakes, blizzards, floods, avalanches, mudslides, volcanic activity, thunderstorms, and more. Some subfactors may also overlap into other factors.</span></p><div class="page" title="Page 3"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he operational environment is a subfactor of the environment. An operational environment is different than the workplace, it is about the workspace. An operational environment is allocating operational workspace in 3D, and measured in time (speed), space (location), and compass (direction). A workspace is flight crew chairs design, the time for a pilot to reach an item to complete a task, the location in the cockpit of the item, and its direction from </span><span style="font-family: Calibri; font-size: 14pt;">the pilot’s chair. In the old </span><span style="font-family: Calibri; font-size: 14pt;">PBY-</span><span style="font-family: Calibri; font-size: 14pt;">5A (Canso), the two generator’s circuit breakers are placed on the bulkhead behind the captain. Should the “</span><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">left</span><span style="font-family: Calibri; font-size: 14pt;">” generator fail, it becomes the “</span><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">right</span><span style="font-family: Calibri; font-size: 14pt;">” </span><span style="font-family: Calibri; font-size: 14pt;">generator for the pilots when pulling the breaker.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he workplace environment is the place where there is interaction between </span><span style="font-family: Calibri; font-size: 14pt;">workers. It’s a </span><span style="font-family: Calibri; font-size: 14pt;">location where you turn up for work, it is an office space</span><span style="font-family: Calibri; font-size: 14pt;">, pilot’s </span><span style="font-family: Calibri; font-size: 14pt;">room, maintenance hangar or locations where you meet co-workers, discuss work, brainstorm, conduct meetings, and get work done.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b> design environment is the process of addressing surrounding environmental parameters when devising plans, programs, policies, buildings, or products. It seeks to create spaces that will enhance the natural, social, cultural, and physical environment of particular areas.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he communication environment is about tools used to communicate. The old way to call loudly across the room has changed and improved by using electronic communication means. Information technology department is communication environment tool to communicate effectively within the organization, and to maintain communication records.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>E</b>quipment is a subfactor of the environment and includes machines and equipment, people and manpower, materials, and measurement. The equipment itself could be an aircraft, a vehicle, a towing tug, maintenance tools, computers, manual calculator tools, and more.</span></p><div class="page" title="Page 4"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>E</b>nvironmental factors are the outsider of the other three factors. Human factors, organizational factors and supervision factors are all in their own special way linked to human behavior.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhaupSW4bCYmroVMG3IjRCqnVzjwQcE0iSVsmEFOo3QkT4GopaFe_w29zoAgWasUdC_cG2qucAnOuAsZVS1HT8pc30r65Z4FCoh2w4Vnh6FtivmvDeE5oQQgKI-iccUM_9m6M1AntiXbP4C29fEaVHeZk5ZvuPbnnOZAeodl16K4sUqzR8WJodGSNXo4Z4D/s182/Screenshot%202024-03-02%20at%207.08.50%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="153" data-original-width="182" height="336" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhaupSW4bCYmroVMG3IjRCqnVzjwQcE0iSVsmEFOo3QkT4GopaFe_w29zoAgWasUdC_cG2qucAnOuAsZVS1HT8pc30r65Z4FCoh2w4Vnh6FtivmvDeE5oQQgKI-iccUM_9m6M1AntiXbP4C29fEaVHeZk5ZvuPbnnOZAeodl16K4sUqzR8WJodGSNXo4Z4D/w400-h336/Screenshot%202024-03-02%20at%207.08.50%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 4"><div class="layoutArea"><div class="column"><div class="page" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;" title="Page 4"><div class="layoutArea"><div class="column"><p><br /></p></div></div> </div><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he climate affects areas of both airline operations and maintenance, and airport operations. The aviation is operating daily between the South and the North Poles. Airport and runways may be ice or snow runways, dessert sand, rivers, lakes or just a narrow mountain trail. Maintenance is performed in suitable hangars, or outside in rain, snow, wind, and in </span><span style="font-family: Calibri; font-size: 14pt;">places with extreme cold or extreme hot. In many areas there are still places with no or limited communication availability, except for using satellite telephone. An aircraft without the 406ELT is difficult to locate in any weather conditions. Bush pilots all over the globe have experienced accidents and destruction of airplanes. Over the years airplanes have crashed in the middle of nowhere in 40 below temperatures and 40 above, and some pilots survived, while other did not. The climate affects survival probabilities and rescue time. Climate may also cause illusions, such as mirages. Several years ago, a large aircraft crashed when the runway lights were </span><span style="font-family: Calibri; font-size: 14pt;">“</span><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">lifted up</span><span style="font-family: Calibri; font-size: 14pt;">” </span><span style="font-family: Calibri; font-size: 14pt;">by an inversion and the airport viewed as being closer than what it actually was. Operators, pilots, and maintenance crew working in these extreme climate areas deserve a medal of honor for overcoming challenges and providing excellent services to people who live here.</span></p><div class="page" title="Page 4"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he ecological factor is affecting the aviation more and more every year. Over millions of years the climate has changed from ice ages to hot climate. Currently ecological factors are assigned the root case for the current climate. Regulations </span><span style="font-family: Calibri; font-size: 14pt;">are changed to support these opinions and operators must maintain compliance for continued operations. Natural resources are assigned contributor factors to the climate, and that current use is deteriorating the ecological environment. Airports may not be able to build, or extend their runways to service increasingly larger aircraft, or to improve fuelling areas for time consuming refuelling. Ecological factors are a limiting factors for the future of aviation.</span></p></div></div></div><div class="page" title="Page 5"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>I</b>llumination, sunlight, and darkness are factors affecting flight and maintenance operations. Aircraft need landing lights, airports need runway edge lights, and maintenance hangars need floodlights. Type of lighting source affects operational performance and compliance. In a maintenance hangar where the floodlights are of the old type, colors in the yellow spectrum blends in with their surroundings, and other parts transform to the grey color spectrum. Bright floodlights to resemble brightness of sunlight is needed for maintenance to perform their obligations. Strong illumination from landing lights is required for a pilot to view an extended length of the runway beyond the aircraft. Runway edge lights are required to define the limits of usable runway areas, and their intensity may vary depending on weather conditions.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>errain is another environmental factor affecting airports, airlines, and maintenance activities. It might not be immediate obvious that terrain affects maintenance activities since most maintenance is performed inside a hangar. However, terrain affects the decision of where to build a hangar, and the loadbearing capacity for taxiway or taxiroute to the facility. For outside maintenance terrain is a crucial factor to work in a stable environment. A helicopter may be in need of maintenance on a mountain range, or somewhere in the boreal forest. Terrain affects airports and airport design. There are airports that do not meet the obstacle clearance limitations and therefore unable to be certified airports. Airlines my required travel several additional miles for approach procedures compliance, burn additional fuel and add time to the flight crew</span><span style="font-family: Calibri; font-size: 14pt;">’</span><span style="font-family: Calibri; font-size: 14pt;">s duty day.</span></p></div></div></div><div class="page" title="Page 6"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b>ccelerated events affects airports and airlines both seasonally and regionally and are contained within a relatively limited area. Volcanic ash from one single volcano outbreak, may be the only event that affects aircraft operations globally. Snowstorms, hurricane, or tornadoes may be spread over a large area, but are relatively regionally limited to for the safe operations of an airport or aircraft.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he operational environment is an environment where personnel feel good about working. It is the place where a person is located, a place that is home-away-from- home, and it is the place a person enjoys coming every day. An operational environment is about performance and how processes are designed to be userfriendly and reliable repetitious.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he workplace environment is different than the operational environment, in that it is designed by the six-sigma principle. The six-sigma is a set of methodologies and tools used to improve business processes by reducing defects and errors, minimizing variation, and increasing quality and efficiency. The goal of Six Sigma is to achieve a level of quality that is nearly perfect, by being tailored to human behaviors. A structured approach is to define, measure, measure, analyze, and improve applying the principles in their SMS safety risk management.</span></p></div></div></div></div></div></div><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiro1iGgH0DNSV5KoN6IDh1Q6jITxdfkAsTyjXliZ9Qz8rpCqRzKcPI1206HV4gnSJJNBuKh3cH3SWf_mh5-GeX58VCyH8uHy5BSEuR4AN-0F1WJmfzmlUNS9wLN3IqWcTfxymh5sUFhr3bN6l-yrC8YJCfz2CQjm1zpl8xewLY7S3bLZgZQ0LwGdd2PqaO/s181/Screenshot%202024-03-02%20at%207.12.26%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="142" data-original-width="181" height="314" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiro1iGgH0DNSV5KoN6IDh1Q6jITxdfkAsTyjXliZ9Qz8rpCqRzKcPI1206HV4gnSJJNBuKh3cH3SWf_mh5-GeX58VCyH8uHy5BSEuR4AN-0F1WJmfzmlUNS9wLN3IqWcTfxymh5sUFhr3bN6l-yrC8YJCfz2CQjm1zpl8xewLY7S3bLZgZQ0LwGdd2PqaO/w400-h314/Screenshot%202024-03-02%20at%207.12.26%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 6"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b> design environment is a fluid environment where persons are tailored to individual and specific needs. An example is the popularity of a standing work-desks. A design environment is not to adapt to personal opinions and request daily, but to assess their inquiries as it relates to their work environment. Several years ago, a pilot </span><span style="font-family: Calibri; font-size: 14pt;">was not allowed to fly bush planes with clogs, since this caused a hazard to for the footwear to be stuck between the pedals and the pilot</span><span style="font-family: Calibri; font-size: 14pt;">’</span><span style="font-family: Calibri; font-size: 14pt;">s ability to quickly escape a sinking floatplane. A design environment needs justification for design, and there are no requirements for everyone to wear the same shoes.</span></p><div class="page" title="Page 7"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>I</b>n the communication environment practical communication tools are used. In the infant years of airport control towers, clearances were given by light signals. As technology continued to change, radio communications become the standard method. As technology is changing rapidly other means of communication were implemented and are continuing with new technologies. Changes in technology requires training sessions to be familiar with new communication and supervised use until personnel easily can use these tools. One example is the online SiteDocs cloudbased SMS program. It takes information sessions to become familiar, and as it is used, it becomes a second nature.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he equipment environment is a broad definition of what to include. Anything that are equipment or tools are included. There is also an interaction between the equipment environment and other environment. These are not defined lines written in rocks between the different environments, but they are rugged, fluid, and flexible. Rugged and fluid lines may be a distraction to personnel, and it becomes the responsibility of management to conduct regular information sessions about the organization and its operation.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>E</b>nvironmental factors are simple to apply within a safety management system when processes are linked to regulatory requirements.</span></p><p><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">OffRoadPilots</span></p></div></div></div></div></div></div><p><span style="font-family: Calibri; font-size: 14pt;"><br /></span></p></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div><p><span style="font-family: Calibri; font-size: 14pt;"><br /></span></p></div></div></div>SMS/QA Control Managementhttp://www.blogger.com/profile/09611789820282926862noreply@blogger.com0tag:blogger.com,1999:blog-3664537417151106536.post-55819995285218154972024-02-17T02:49:00.000-08:002024-02-17T02:49:31.671-08:00Human Factors<p><span style="font-family: Calibri; font-size: 14pt;">Human Factors</span></p><p><span style="font-size: x-small;">By OffRoadPilots </span></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri;"><b><i><span style="font-size: x-large;">H</span></i></b><span style="font-size: medium;">uman factors and human errors are two separate things but are often used interchangeable in conversations and in the aviation industry. Human errors are attached to a person who could be linked to an occurrence. In addition, the severity of the outcome is a predetermining factor how important it is to assign human error as the root cause after an accident.</span></span></p><p><span style="font-family: Calibri; font-size: 14pt;">Human error root cause analysis has widespread support from the aviation industry. However, with the implementation of the Safety Management System (SMS) regulations, accountability came into play, and it became impossible to justify human error as the root cause.</span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgYFN3gMTCL4JYBBbI__W3NFhdgavGspbMg3T3yr6dZXLjJAg_wonaGLoQKd7tydKrs6Giv8BrLt-V6NGDoluFd8QVj86BYLtNiWZdF4TyIp7UzaUB_nplGPv0SuItvlse0kHpXNsEqWuElU8pdi5lIgZ5-rZWNBev8bqmNb9A32Qg5P6yAVLDEDrAMDQAM/s374/Screenshot%202024-02-17%20at%205.39.54%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="299" data-original-width="374" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgYFN3gMTCL4JYBBbI__W3NFhdgavGspbMg3T3yr6dZXLjJAg_wonaGLoQKd7tydKrs6Giv8BrLt-V6NGDoluFd8QVj86BYLtNiWZdF4TyIp7UzaUB_nplGPv0SuItvlse0kHpXNsEqWuElU8pdi5lIgZ5-rZWNBev8bqmNb9A32Qg5P6yAVLDEDrAMDQAM/w400-h320/Screenshot%202024-02-17%20at%205.39.54%20AM.png" width="400" /></a></div><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b> healthy SMS looks at the organization and its systems, and the fact that a person overlooked, or missed an item is no longer a root cause, such as a pilot missing a checklist item. Checklists are required and are used for any flight, but there is no evidence a missed checklist item was the root cause of any accidents. At the other </span><span style="font-family: Calibri; font-size: 14pt;">end of the spectrum, completing the gear-down checklist item was a contributing factor to a fatal accident in 1972. A descent went undetected when the flight crew became focused on a checklist item.</span></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">Human error is a symptom of trouble deeper inside a system or an organization. On the other hand, human error is also a symptom of a successful organization. There are organizations where human errors are integrated with the system and </span><span style="font-family: Calibri; font-size: 14pt;">need to be there for the organization to exist and prosper. It is the system itself that is set up for human errors.</span></p><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>C</b>onventional wisdom is that human error is a” bad” thing when using emotions to </span><span style="font-family: Calibri; font-size: 14pt;">describe an event. Human error is a sub-category of human factors. Simplified, human factors are how a person react when one or more of the five senses, vision, hearing, smell, taste, and touch are triggered. Human factors are also how external forces, or events, e.g., fatigue, weather, illumination and more, affect performance.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiORbIZsffFAytCDwHAGAKBF7duBwo8DhoeQMBvLLoHrmS7GTfBsOg7Xk5j3_MTtG4235b3f_xgFB6dBcunExz-Var3goghpU9oZ2oIA9ueoCYFu_T86OO3T2JdpGkrIe2MRWo6unXwEGBHkCnAK_Zj0COM3_9u-8OWk7Dhg9FOmRqwYF-8NJ-IvSDI1ubW/s385/Screenshot%202024-02-17%20at%205.42.35%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="207" data-original-width="385" height="215" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiORbIZsffFAytCDwHAGAKBF7duBwo8DhoeQMBvLLoHrmS7GTfBsOg7Xk5j3_MTtG4235b3f_xgFB6dBcunExz-Var3goghpU9oZ2oIA9ueoCYFu_T86OO3T2JdpGkrIe2MRWo6unXwEGBHkCnAK_Zj0COM3_9u-8OWk7Dhg9FOmRqwYF-8NJ-IvSDI1ubW/w400-h215/Screenshot%202024-02-17%20at%205.42.35%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">In an organization where there are overwhelming events of human errors, the organization operates within a system that is prone to these errors. An example is Daytona 500, or Reno Air Races, where the </span><span style="font-family: Calibri; font-size: 14pt;">systems (race to win) are setting each driver and pilot up for human error, or a crash. Both the Daytona 500 and Reno Air Race organizers have requirements and systems in place to reduce harm to drivers, pilots, or spectators, but these systems are designed for human errors. Imagine how successful Daytona 500 would be if the speed was limited to 50MPH, or if the Reno Air Race required airplanes to fly between gates separated a mile apart.</span></p></div></div></div><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>C</b>ivil aviation industry systems are not set up as systems where human errors are desirable, but occurrences still happens because aviation operational systems allow for it. Civil aviation systems are not as obvious as the racing-systems to promote human errors, but they both happens because of human and organizational factors, and to get the job done before closing time.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he aviation industry struggles with the human error concept. This struggle affects their organizational environment, and a trap to fall into is to make pilot, or human </span><span style="font-family: Calibri; font-size: 14pt;">errors the root cause. However, the safety management system requires operators to look inward into the organizational systems to repair or replace one or more systems. If a process is stable and undesirable, but not broke, the process should not be fixed. The old saying that </span><span style="font-family: Calibri; font-size: 14pt;">“</span><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">if it ain</span><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">’</span><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">t broke don</span><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">’</span><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">t fix it</span><span style="font-family: Calibri; font-size: 14pt;">” </span><span style="font-family: Calibri; font-size: 14pt;">holds true in aviation safety. A stable, or desirable process may from time to tome turn out faulty items and mistakes. Reacting to these mistakes is tampering with the process contributing to an increase in future errors. Tampering with a stable process moves the process closer to a point to become a contributing factor to accidents.</span></p></div></div></div><div class="page" title="Page 3"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>S</b>everal years ago, a pilot and three passengers went on a mountain flight with a PA-28-140. The aircraft was full of fuel and above max gross weight at takeoff. As often, when there are no other adverse conditions, the flight departed safely, and slowly climbed into the valley towards the taller mountains.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>W</b>hile the winds were relatively calm at the airport, on this day the winds were extremely strong in the mountains. One pilot had earlier that day refused to take the scenic flight because of the mountain winds, but another pilot accepted.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he pilot banked and turned for the passengers to see the beauty of the mountains. Before the pilot could react, the aircraft stalled and crashed. A close friend found them later the next day in a highly remote area.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgamAFwZnlQ2P_MwNhhDYeIG3AdJIJwT9WmZNPoHK_DsZ7wGmwEUnEPz9Sw5h1LAxwMkWf4ZH3Zahgx0OtKYllA4hjEHXyvLSSpQrDST_qZQSpGTAKJ64kiBr8is_4sNd9P20Y1e5VUeo3_rXrxV7ZDCHH0brUl9huen5MfUiUlABVChNs1rFixiyERgj_k/s378/Screenshot%202024-02-17%20at%205.44.57%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="167" data-original-width="378" height="176" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgamAFwZnlQ2P_MwNhhDYeIG3AdJIJwT9WmZNPoHK_DsZ7wGmwEUnEPz9Sw5h1LAxwMkWf4ZH3Zahgx0OtKYllA4hjEHXyvLSSpQrDST_qZQSpGTAKJ64kiBr8is_4sNd9P20Y1e5VUeo3_rXrxV7ZDCHH0brUl9huen5MfUiUlABVChNs1rFixiyERgj_k/w400-h176/Screenshot%202024-02-17%20at%205.44.57%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 3"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">Human and organizational factors are often linked together in the text but are two separate factors. Human factors are how human reacts to inputs, while organizational factors </span><span style="font-family: Calibri; font-size: 14pt;">are the result, or output, of these reactions. The term organizational factors encompass all elements that influence the way that an organization, and everybody within it, behave. Some of these elements are formal management systems, assurance processes, working practices, whether or not formally </span><span style="font-family: Calibri; font-size: 14pt;">documented, risk awareness, how the organization learns from experience, organizational safety culture and more.</span></p><div class="page" title="Page 4"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b> safety policy is directed at human factors. Safety for an airport or airline is to maintain the confidence of the travelling public and safety of the aviation industry is vital to success. Through the introduction of a safety management system, an airport is committing to provide a systemic, explicit, and comprehensive process for managing airside safety risks. By embracing this safety management system, airports establish safety as an integral part of an airport culture where they recognize that safety is paramount.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>H</b>uman factors is a scientific study that evaluates and comprehend human interactions and human behaviors in relation to other human and elements of a workplace system. The human factors five senses reactive or proactive affect human behavior and performance. These senses are vision, hearing, smell, taste, and touch.</span></p></div></div></div></div></div></div><p><span style="font-family: Calibri; font-size: 14pt;"><br /></span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh7Bknxzx0atvvxCdvq8CWU1GaBLtI1G8WU8-q8QVjW8z2RYimEkyULSGO4Sq6cyRYMzmlMenlnZXMQamj9Z6h14Xzsbg1I84_AiyGFpkE_ls0jid2Yj8hdI8qfgU4azdtp8dkRZobSv6lt8V1_HwaRdzlkpUkFBQDVwhkpT1AWsLLchJItA3ue4MBtb10p/s377/Screenshot%202024-02-17%20at%205.46.50%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="285" data-original-width="377" height="303" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh7Bknxzx0atvvxCdvq8CWU1GaBLtI1G8WU8-q8QVjW8z2RYimEkyULSGO4Sq6cyRYMzmlMenlnZXMQamj9Z6h14Xzsbg1I84_AiyGFpkE_ls0jid2Yj8hdI8qfgU4azdtp8dkRZobSv6lt8V1_HwaRdzlkpUkFBQDVwhkpT1AWsLLchJItA3ue4MBtb10p/w400-h303/Screenshot%202024-02-17%20at%205.46.50%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 4"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he SHELL model is a model of human factors interactions and includes the software(S), hardware(H), environment(E), liveware, other(L), liveware, self(L).</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>S</b>oftware are regulations, standards, policies, job descriptions, expectations, and other intangible items.</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>H</b>ardware are the physical and tangible items housing intangible items. Hardware are electronic devices, documents, tools, airfield, and other tangible items. The environment has multiple sub-categories. A sub-category of the environment is the designed environment. A design environment is user friendly environment, </span><span style="font-family: Calibri; font-size: 14pt;">design and layout, accessibility, tasks-flow, and more. The social environment is about distancing, both physical contact between persons and distancing between equipment and objects, experiences, culture, language and more.</span></p><div class="page" title="Page 5"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he climate is another sub-category of the environment. Climate environment includes geo location, weather, temperature, and more. Amy these human factors has an affect human behavior in one way or another.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>W</b>hen one or more of the human senses are targeted by inputs, or when interactions between the elements of the SHELL model are incompatible, the effect on human reaction, or process output, are commonly known as human errors, or pilot errors.</span></p><p><span style="font-family: Calibri; font-size: 14pt;">Human errors are not errors, but reactions to the operational SHELL model system, and human senses are reactions they are exposed to by the system itself.</span></p><p><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">OffRoadPilots</span></p></div></div></div></div></div></div><p><span style="font-family: Calibri; font-size: 14pt;"><br /></span></p></div></div></div></div></div></div></div></div></div></div></div></div><p></p></div></div></div>SMS/QA Control Managementhttp://www.blogger.com/profile/09611789820282926862noreply@blogger.com0tag:blogger.com,1999:blog-3664537417151106536.post-91411865302146208722024-02-03T02:26:00.000-08:002024-02-03T02:26:01.401-08:00Regulatory Conforming Processes<p> <span style="font-family: Calibri; font-size: 14pt;">Regulatory Conforming Processes</span></p><p><span style="font-family: Calibri;"><span style="font-size: x-small;">By OffRoadPilots</span></span></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri;"><b><span style="font-size: x-large;"><i>R</i></span></b><span style="font-size: medium;">egulatory conforming processes are processes producing outputs that conform to regulatory requirements. There are three fundamental tasks required when building regulatory performing processes. The first task is the research for input task, the second task is the process design and development task, and the third is the regulatory identification and assignment task. A process must be linked to one regulatory requirement. In a healthy SMS environment, a process is linked to several regulations, or several standards, and to the SMS policy.</span></span></p><p><span style="font-family: Calibri;"></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgKmRBjcrF9XdH4-J2vRBLYwA2I4n4mxaOtvvpGYe5zqGCd_efOtcqWzpmy1nlkNx1McsGn3Na_UwX5hwjTpvEPDxPJIO9GfEdVUOcOSwjBvh5rGj8vJ0PV671Q7cqZCU56gORoAnfbGBzHznFv5oXKuOz2Awc9ZXtLc9eMAM2MtQsDQeGdMDWlm7LpGXBM/s379/Screenshot%202024-02-03%20at%205.20.08%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="315" data-original-width="379" height="333" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgKmRBjcrF9XdH4-J2vRBLYwA2I4n4mxaOtvvpGYe5zqGCd_efOtcqWzpmy1nlkNx1McsGn3Na_UwX5hwjTpvEPDxPJIO9GfEdVUOcOSwjBvh5rGj8vJ0PV671Q7cqZCU56gORoAnfbGBzHznFv5oXKuOz2Awc9ZXtLc9eMAM2MtQsDQeGdMDWlm7LpGXBM/w400-h333/Screenshot%202024-02-03%20at%205.20.08%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he research for input task is a comprehensive research of regulatory requirements for airport or airline operations. In addition to airport or airline regulations, multiple other federal or local regulations may be applicable, such as environment regulation, transportation of the public regulations, and other regulations. However, when </span><span style="font-family: Calibri; font-size: 14pt;">researching regulatory requirements for the purpose of building a conforming process, only airport or airline operations regulations are researched for inputs. These are the regulations that an airport or airline operating certificate is tied to and dependant on for its existence. Performance-based regulations are based on a 95% confidence level.</span></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>R</b>egulatory research also includes a comprehensive research of standard requirements for airport or airline operations. Standards are also performance- based in the same way as the regulations are. Airport standards has been adapted for use in an operational concept to reflect and support the operational reality of </span><span style="font-family: Calibri; font-size: 14pt;">aircraft capabilities and performance specifications. An airport standard establishes a level of service for an airline and its fleet. Rapidly changing technologies in aircraft performance and avionics have a very real potential to impact future aerodrome operations. An increase in the size of critical aircraft or the provision of lower landing, departure or taxi limits will require the aerodrome operator to re-assess the aerodrome facilities and operational procedures to ensure they provide the required standards.</span></p></div></div></div></div></div></div><p><span style="font-family: Calibri;"></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjMtgJF5c3_6xIsix6Fnp7OKd6o4CJbiNidBmmjqHpM2dCyQumxUMpauD9pQuK7kptiOU2ZIfOckW1eQbaqiYCD0aJADcwFaAJdGcxjkVXDiCUIJahNvp54vyZB6WwAJIDJHQIRgVzEF43erpnpA2ckP0rI8ft9XH_6heMUMlGmK6ze4H4OInPrEJXLIc1d/s385/Screenshot%202024-02-03%20at%205.21.35%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="149" data-original-width="385" height="155" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjMtgJF5c3_6xIsix6Fnp7OKd6o4CJbiNidBmmjqHpM2dCyQumxUMpauD9pQuK7kptiOU2ZIfOckW1eQbaqiYCD0aJADcwFaAJdGcxjkVXDiCUIJahNvp54vyZB6WwAJIDJHQIRgVzEF43erpnpA2ckP0rI8ft9XH_6heMUMlGmK6ze4H4OInPrEJXLIc1d/w400-h155/Screenshot%202024-02-03%20at%205.21.35%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b>ccuracy requirements for aeronautical data are based upon a 95% confidence level and in that respect, three types of positional data are identified. </span><span style="font-family: Calibri; font-size: 14pt;">Positional data are surveyed points e.g. runway threshold, calculated points, e.g. mathematical calculations from the known surveyed points of thresholds for determination of the aerodrome reference point, and declared points, e.g. flight information region boundary points. The confidence level is in the method, or process itself, and is not in a particular confidence interval. If the sampling method was repeated many times, 95% of the intervals constructed would capture the true population mean. As the sample size increases, the range of interval values will narrow, meaning that a larger sample size, or an increased number of data collected, the mean of the sample will generate a much more accurate result if compared with a smaller sample, or fewer tasks completed.</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>here is a misconception among operators that a 95% confidence level is the same as airports or airlines being 95% safe. Conventional wisdom is that the application of numerical safety levels, such as airline ratings are indications of what level the public are protected from harm when an airline has achieved the maximum 7 of 7 in their rating. An airline rating level takes several other parameters into account, such as staff friendliness, service availability and more to provide a complete travel experience safety level. In the same way as airline ratings apply several parameters in their assessment, airline and airports do the same in their operational </span><span style="font-family: Calibri; font-size: 14pt;">assessment oversight. There are therefore no contradictions between a 95% confidence level and a 100% safety rating level, or rated 7/7.</span></p><div class="page" title="Page 3"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b> 95% confidence level is that established safety performance indicators (SPI) and safety performance targets (SPT) will fall within their expectations 95 of 100 times. An airline may establish a confidence level of 95% that their pilots will touch down within the first 1/3 of the runway. For the same airline to establish a 100% confidence level, the airline needs to operate with an expectation that their pilots will touch down anywhere on the full length of the runway 100 of 100 times. A targeted 95% confidence level is therefore safer in operations than a targeted 100% confidence level, which does not provide enough stopping distance for a pilot who used up all of the runway before landing.</span></p></div></div></div></div></div></div><p><span style="font-family: Calibri;"></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiwIkh600MFrkrp10RLMdKI4_xx4UBbJvTjVGAMoPxJOQND3uOQI-MHvQ67NPMioXU2uZlvwanIy8hiRNycnH5g6DwP9kzON2FZKaSK5h5siG38D6R1ck2vAQvL7NWTmgDP11E5qRNyGyV6aHLSPBwpI7d4lnMoF0-6r_F7xR163KLZflgWPSSOvtjKmet9/s384/Screenshot%202024-02-03%20at%205.23.13%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="219" data-original-width="384" height="229" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiwIkh600MFrkrp10RLMdKI4_xx4UBbJvTjVGAMoPxJOQND3uOQI-MHvQ67NPMioXU2uZlvwanIy8hiRNycnH5g6DwP9kzON2FZKaSK5h5siG38D6R1ck2vAQvL7NWTmgDP11E5qRNyGyV6aHLSPBwpI7d4lnMoF0-6r_F7xR163KLZflgWPSSOvtjKmet9/w400-h229/Screenshot%202024-02-03%20at%205.23.13%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 3"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he next step is the process design and development task. When designing processes, the objective is to produce an operational sound outcome. At this stage in the design process, regulations, standards, and the SMS policy are </span><span style="font-family: Calibri; font-size: 14pt;">considered, but they are not applied to the process design. The reason for considering regulations but not applying regulations, is that an easy trap to fall into is to build a regulatory process. In a regulatory process an airliner captain must fly the regulations when they need to fly the process. E.g. if a regulation, or flight operational quality assurance expectation requires a pilot not to bank an aircraft beyond 25 degrees angle, the wind could push the aircraft into an undesired position, as opposed to flying the process when a pilot would increase the bank angle to maintain aircraft control. A goal when building processes, is for processes be practical to use, and with a task-flow that make sense to users.</span></p><div class="page" title="Page 4"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>R</b>egulations are objective and impartial to a process, while safety is subjective and biased. Regulatory compliance is the priority, while safety is paramount. Maintaining continued regulatory compliance is the foundation and building blocks for the existence of an airport or airline certificate. When safety is paramount, it becomes the highest-ranking order of a system, and regulatory priority is the only tool to maintain safety as the highest-ranking order. Just as an accountable executive is the highest-ranking order of a safety management system, regulatory compliance is the operational priority to maintain that order.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b>n airport has an obligation to operate with a runway environment that maintains continuous regulatory compliance. This is achieved in multiple ways when each activity or task is linked to a regulatory requirement. One task several airports have adapted, is the daily inspection task. This is not a regulated task, but by using the process daily, they are engaged in activities, or processes, that conforms to regulatory compliance. The key to success is to comprehend what regulatory requirements each activity is linked to.</span></p></div></div></div></div></div></div><p><span style="font-family: Calibri;"></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj33vWoUtQxlvMgk7hvhWWXuRcWv5z_KCPY9jU9YWq7ufovNR0kTfKbJuAgVhwdo_iRHpwZioHiTD7vXGkXdODwqkWbjbUB4Vmx4bR49ZTU0skqN1sOLfGc3ICPOdN2egCuUhSFSOMv_g69-7dpGi3NTo2KNyfYH4JDgGobH4paKfVPuggGaZ7jXNP_vHEl/s390/Screenshot%202024-02-03%20at%205.24.30%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="285" data-original-width="390" height="293" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj33vWoUtQxlvMgk7hvhWWXuRcWv5z_KCPY9jU9YWq7ufovNR0kTfKbJuAgVhwdo_iRHpwZioHiTD7vXGkXdODwqkWbjbUB4Vmx4bR49ZTU0skqN1sOLfGc3ICPOdN2egCuUhSFSOMv_g69-7dpGi3NTo2KNyfYH4JDgGobH4paKfVPuggGaZ7jXNP_vHEl/w400-h293/Screenshot%202024-02-03%20at%205.24.30%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 4"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he last step is the regulatory identification and assignment task, which is to conduct a process analysis to verify what tasks within the process are lined to a regulation. A process compliance analysis is conducted backwards, starting from the end result and output, and </span><span style="font-family: Calibri; font-size: 14pt;">move backwards until the beginning. Any broken link in the process must be closed for compliance.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><br /></span></p></div></div></div><div class="page" title="Page 5"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b>fter all broken links are closed, the next step is to analyze the process forward and apply compliance to each step in the process. There will also be steps that are not linked to aviation regulations, such as checking the vehicle before operating airside. Compliance requirements are linked to tasks performed while conducting the inspection. One task may be linked to multiple regulations, and one regulation may be linked to multiple tasks. Comprehensive knowledge of the regulations is required to perform these tasks. The accountable executive is the person who is responsible for compliance with all regulations and is also the person who is the final authority for assigning regulations to tasks.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>W</b>hen regulatory conforming processes are built, implemented, and communicated to workers, compliance becomes simple. Airport or airline workers does not need to change how they work, or how things are done, but are simply completing their processes as expected. Over time as data becomes available, the only task left is to enter data into a statistical process control system for control charts to be produced and analyzed.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he beauty of operating with regulatory linked processes, is that all information is available to airport and airline operators when safety performance is analyzed, and when the regulator conducts inspections.</span></p><p><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">OffRoadPilots</span></p></div></div></div></div></div></div>SMS/QA Control Managementhttp://www.blogger.com/profile/09611789820282926862noreply@blogger.com0tag:blogger.com,1999:blog-3664537417151106536.post-36108971370138017992024-01-20T08:37:00.000-08:002024-01-20T08:37:39.515-08:00Forward-Looking Accountability<p> <span style="font-family: Calibri; font-size: 14pt;">Forward-Looking Accountability</span></p><p><span style="font-family: Calibri;"><span style="font-size: x-small;">By OffRoadPilots</span></span></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri;"><b><span style="font-size: x-large;"><i>C</i></span></b><span style="font-size: medium;">oincident 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 </span></span><span style="font-family: Calibri; font-size: 14pt;">certificate holder’s respon</span><span style="font-family: Calibri; font-size: 14pt;">sibilities, 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.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEimbkEMGuqDWy-Rt_X3YDjhtSQrqqQKFMH9hdI9C4u2pFrqnIYcolo-OXDeyDFsvPIxPiBVm53-FbdmIE_BNyVYnkwVXwpWhkQNo3jZEaIfknSDIfewFxLlWXIQRBEp6mmJSFg8BubZg5GnI_tMcauZPZkEPHGXvuGMPnsmX75jy-IYAsOEi880N-r14qc1/s370/Screenshot%202024-01-20%20at%2011.29.10%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="312" data-original-width="370" height="338" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEimbkEMGuqDWy-Rt_X3YDjhtSQrqqQKFMH9hdI9C4u2pFrqnIYcolo-OXDeyDFsvPIxPiBVm53-FbdmIE_BNyVYnkwVXwpWhkQNo3jZEaIfknSDIfewFxLlWXIQRBEp6mmJSFg8BubZg5GnI_tMcauZPZkEPHGXvuGMPnsmX75jy-IYAsOEi880N-r14qc1/w400-h338/Screenshot%202024-01-20%20at%2011.29.10%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he 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 </span><span style="font-family: Calibri; font-size: 14pt;">regulations.</span></p></div></div></div><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">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 </span><span style="font-family: Calibri; font-size: 14pt;">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</span><span style="font-family: Calibri; font-size: 14pt;">’</span><span style="font-family: Calibri; font-size: 14pt;">s decision-making process.</span></p><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b> 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.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhIl5lzMdBtqLOSmbX4NC77-dUk1RtZrTuhRR2a2IxMGIbQNA1yi5bTZQDRQjtQJK5C8BuHmyHiSBoxu6idFfkfLbKN4-U0lC8jg_BZxNtqliTyAqVBizvebkcMDTG4IbMGhuSNJcF4tdGVFUx5-K5gzVEZ0oAWsCP5wG6KPTduZEAL8jTo6jJ4lek4LF-9/s376/Screenshot%202024-01-20%20at%2011.31.19%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="335" data-original-width="376" height="356" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhIl5lzMdBtqLOSmbX4NC77-dUk1RtZrTuhRR2a2IxMGIbQNA1yi5bTZQDRQjtQJK5C8BuHmyHiSBoxu6idFfkfLbKN4-U0lC8jg_BZxNtqliTyAqVBizvebkcMDTG4IbMGhuSNJcF4tdGVFUx5-K5gzVEZ0oAWsCP5wG6KPTduZEAL8jTo6jJ4lek4LF-9/w400-h356/Screenshot%202024-01-20%20at%2011.31.19%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>I</b>n 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.</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>M</b>ost 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</span><span style="font-family: Calibri; font-size: 14pt;">’</span><span style="font-family: Calibri; font-size: 14pt;">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. </span><span style="font-family: Calibri; font-size: 14pt;">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.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhJY-e8MYnGbSMvx0jyXv6S36G6RZOkKjQpiS_dbsgi9vX5efsnW0L7L6ZHICMZzWAn61tuH01gTct8OVIQGS3dIz202gwnRglHDbvX6g0dWxFRd20hPsQjMzAV5RFyfTlcVUDhecbccfQtralHZ7El7icTwGR32etJlwIPamG24RpyIvBH8_WZRa94g65P/s369/Screenshot%202024-01-20%20at%2011.32.31%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="296" data-original-width="369" height="321" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhJY-e8MYnGbSMvx0jyXv6S36G6RZOkKjQpiS_dbsgi9vX5efsnW0L7L6ZHICMZzWAn61tuH01gTct8OVIQGS3dIz202gwnRglHDbvX6g0dWxFRd20hPsQjMzAV5RFyfTlcVUDhecbccfQtralHZ7El7icTwGR32etJlwIPamG24RpyIvBH8_WZRa94g65P/w400-h321/Screenshot%202024-01-20%20at%2011.32.31%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 3"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">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 </span><span style="font-family: Calibri; font-size: 14pt;">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.</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b> successful accountable executive is forward-looking and is accountable to both their knowledge requirement to meet the requirements of the regulations, and </span><span style="font-family: Calibri; font-size: 14pt;">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.</span></p><div class="page" title="Page 4"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">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.</span></p><p><span style="font-family: Calibri; font-size: 14pt;">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.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>F</b>orward-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, </span><span style="font-family: Calibri; font-size: 14pt;">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.</span></p><p><span style="font-family: Calibri; font-size: medium;"><br /></span><span style="font-family: Calibri; font-size: 14pt;"></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiiH3cIMGuCZ5ItWjLFI9Lp3JcinZqz0mj-ungAv6S-vxNVQ0QuYj7cSggy86CQEp4ZwlpUHw9UnvROoeJQWpQlZVBjKhAfSnkfC8G0MRtLuOOlAjjhbyZmiq-0eMTpFOa7f1k3Qptgj0lTyeCS1C9N6mtpHtBHj70t-5-ixsXqY5sY-eTENQRjbRzwTV9L/s376/Screenshot%202024-01-20%20at%2011.34.00%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="241" data-original-width="376" height="256" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiiH3cIMGuCZ5ItWjLFI9Lp3JcinZqz0mj-ungAv6S-vxNVQ0QuYj7cSggy86CQEp4ZwlpUHw9UnvROoeJQWpQlZVBjKhAfSnkfC8G0MRtLuOOlAjjhbyZmiq-0eMTpFOa7f1k3Qptgj0lTyeCS1C9N6mtpHtBHj70t-5-ixsXqY5sY-eTENQRjbRzwTV9L/w400-h256/Screenshot%202024-01-20%20at%2011.34.00%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 5"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">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 </span><span style="font-family: Calibri; font-size: 14pt;">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.</span></p><div class="page" title="Page 6"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>F</b>orward-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.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b>ccountability 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.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>F</b>orward-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.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>F</b>orward-looking accountability is to design airports to size and complexity of future airliners.</span></p><p><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">OffRoadPilots</span></p></div></div></div></div></div></div></div></div></div></div></div></div><p><span style="font-family: Calibri; font-size: 14pt;"><br /></span></p></div></div></div><p><span style="font-family: Calibri; font-size: 14pt;"><br /></span></p></div></div></div></div></div></div></div></div></div>SMS/QA Control Managementhttp://www.blogger.com/profile/09611789820282926862noreply@blogger.com0tag:blogger.com,1999:blog-3664537417151106536.post-71683881050826672872024-01-06T16:28:00.000-08:002024-01-06T16:28:40.463-08:00Staying In The Rut<p> <span style="font-family: Calibri; font-size: 14pt;">Staying In The Rut</span></p><p><span style="font-family: Calibri; font-size: x-small;">By OffRoadPilots</span></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri;"><b><span style="font-size: x-large;"><i>C</i></span></b><span style="font-size: medium;">onventional 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.</span></span></p><div class="separator" style="clear: both; font-size: 14pt; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiIqQ9sS-7vT8IwLFb9YGEKG8n-VG4DUJrW74SDqYRxtuwr7LQwdL6mdZODdJAPONMYRxdYJfrxna_FqH58t7faJ2wD6aR4tYEpFcMidXkdbRxMX1Z3hj48Z1mYO4HQ8p02b9tK0cONlJDBDQRFzjzqiixTNB5CMsGtiZkDVdOUvtMSgTbJ5ug3gF7iwzWO/s382/Screenshot%202024-01-06%20at%206.12.54%20PM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="382" data-original-width="377" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiIqQ9sS-7vT8IwLFb9YGEKG8n-VG4DUJrW74SDqYRxtuwr7LQwdL6mdZODdJAPONMYRxdYJfrxna_FqH58t7faJ2wD6aR4tYEpFcMidXkdbRxMX1Z3hj48Z1mYO4HQ8p02b9tK0cONlJDBDQRFzjzqiixTNB5CMsGtiZkDVdOUvtMSgTbJ5ug3gF7iwzWO/w395-h400/Screenshot%202024-01-06%20at%206.12.54%20PM.png" width="395" /></a></div><p></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he 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 </span><span style="font-family: Calibri; font-size: 14pt;">assumption that the same hazards, incidents, or accidents are never to occur again. By living under this assumption, they must make new policy statements, </span><span style="font-family: Calibri; font-size: 14pt;">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.</span></p></div></div><div class="layoutArea"><div class="column"><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">Prevent their recurrence is about the </span><span style="font-family: Calibri; font-size: 14pt;">system’s </span><span style="font-family: Calibri; font-size: 14pt;">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.</span></p><p><span style="font-family: Calibri; font-size: 14pt;">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.</span></p><p><span style="font-family: Calibri; font-size: 14pt;">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</span></p></div></div></div><div class="page" title="Page 3"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">spectators’ expectations</span><span style="font-family: Calibri; font-size: 14pt;">. 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.</span></p><p><span style="font-family: Calibri; font-size: 14pt;">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.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg6qbmuKBJvbS7LercOMZzjexvma2SPX1nz0mgFUy1Gs8HyJviMh1YzTv46FSkXIf30j37IhaXpGXM1evjOklWqbXTc5wWbr57Ca987npDi4TmpJY9HPKIUAp45sdP_qEwev7IB5luzSVNhTOQ8LWQfJUJfDc-8sNMsblofgiM2JXe1KKeaJO-85lh338Nd/s381/Screenshot%202024-01-06%20at%206.14.07%20PM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="229" data-original-width="381" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg6qbmuKBJvbS7LercOMZzjexvma2SPX1nz0mgFUy1Gs8HyJviMh1YzTv46FSkXIf30j37IhaXpGXM1evjOklWqbXTc5wWbr57Ca987npDi4TmpJY9HPKIUAp45sdP_qEwev7IB5luzSVNhTOQ8LWQfJUJfDc-8sNMsblofgiM2JXe1KKeaJO-85lh338Nd/w400-h240/Screenshot%202024-01-06%20at%206.14.07%20PM.png" width="400" /></a></div><p></p><div class="page" title="Page 3"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">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</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">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.</span></p><p><span style="font-family: Calibri; font-size: 14pt;">Since regulators are performance based, there are no opposing regulatory requirements. An SMS enterprise must implement processes to conform to each</span></p></div></div></div><div class="page" title="Page 4"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">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.</span></p><p><span style="font-family: Calibri; font-size: 14pt;">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.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj9oBq4DNd3QzOrUVm8kojPitzJhu_TIOXx02B7TauJGsr5KxIi3QZpV5v6dcI0Rg4RV4McRwOiVYNCHx0-LrVrFMOvNGpR84NgV6jAsZEoQi4Q6-cX_aKylY9kg-v_PjKPx5j6RqNajeJzI-rhMahW_pbjo9y5ykZ2ebOlx4fPOZ9ErKMvsnBIrVLMmudF/s380/Screenshot%202024-01-06%20at%206.15.17%20PM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="284" data-original-width="380" height="299" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj9oBq4DNd3QzOrUVm8kojPitzJhu_TIOXx02B7TauJGsr5KxIi3QZpV5v6dcI0Rg4RV4McRwOiVYNCHx0-LrVrFMOvNGpR84NgV6jAsZEoQi4Q6-cX_aKylY9kg-v_PjKPx5j6RqNajeJzI-rhMahW_pbjo9y5ykZ2ebOlx4fPOZ9ErKMvsnBIrVLMmudF/w400-h299/Screenshot%202024-01-06%20at%206.15.17%20PM.png" width="400" /></a></div><p></p><div class="page" title="Page 4"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">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</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">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.</span></p></div></div></div><div class="page" title="Page 5"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">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.</span></p><p><span style="font-family: Calibri; font-size: 14pt;">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.</span></p><p><span style="font-family: Calibri; font-size: 14pt;">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 </span><span style="font-family: Calibri; font-size: 14pt;">standard railroad gauge (distance between the rails) is 4 </span><span style="font-family: Calibri; font-size: 14pt;">feet, 8.5 inches, which is an exceedingly odd number. </span><span style="font-family: Calibri; font-size: 14pt;">The reason for the distance between rails is because that's the way they built them </span><span style="font-family: Calibri; font-size: 14pt;">in England and English engineers designed the first railroads. The people who built </span><span style="font-family: Calibri; font-size: 14pt;">the tramways used the same jigs and tools that they had used for building wagons, </span><span style="font-family: Calibri; font-size: 14pt;">which used that same wheel spacing. Roman war chariots formed the initial ruts, </span><span style="font-family: Calibri; font-size: 14pt;">which everyone else had to match or run the risk of destroying their wagon </span><span style="font-family: Calibri; font-size: 14pt;">wheels. Since the chariots were made for Imperial Rome, they were all alike in the </span><span style="font-family: Calibri; font-size: 14pt;">matter of wheel spacing. Therefore, the railroad gauge of 4 feet, 8.5 inches is </span><span style="font-family: Calibri; font-size: 14pt;">derived from the original specifications for an Imperial Roman war chariot, which </span><span style="font-family: Calibri; font-size: 14pt;">was built to follow the tracks of two horses.</span></p></div></div><div class="section"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjjXGNxCJLhSkQr9I9_YIcSLhWLUxQMmj6262sye6Qya1ny5BDKA0qKt1qep6WSvqeSUvQPr1CbLxgnNXkJHX7vdbRA4H7fgOBH2-GQfrTlWONyt3_ke2qB3MZ0auw0uYvkkQ-9cDWK-GfdmCqBrcjFUlI3Z_5FXV09Cm_8vyzLXYsmQ6ji68_V1oU4awkW/s382/Screenshot%202024-01-06%20at%206.16.37%20PM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="266" data-original-width="382" height="279" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjjXGNxCJLhSkQr9I9_YIcSLhWLUxQMmj6262sye6Qya1ny5BDKA0qKt1qep6WSvqeSUvQPr1CbLxgnNXkJHX7vdbRA4H7fgOBH2-GQfrTlWONyt3_ke2qB3MZ0auw0uYvkkQ-9cDWK-GfdmCqBrcjFUlI3Z_5FXV09Cm_8vyzLXYsmQ6ji68_V1oU4awkW/w400-h279/Screenshot%202024-01-06%20at%206.16.37%20PM.png" width="400" /></a></div><p></p><div class="page" title="Page 6"><div class="section"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">Now, here is the rest of the </span><span style="font-family: Calibri; font-size: 14pt;">story. When you see a Space </span><span style="font-family: Calibri; font-size: 14pt;">Shuttle sitting on its launch </span><span style="font-family: Calibri; font-size: 14pt;">pad, there are two big </span><span style="font-family: Calibri; font-size: 14pt;">booster rockets attached to </span><span style="font-family: Calibri; font-size: 14pt;">the sides of the main fuel </span><span style="font-family: Calibri; font-size: 14pt;">tank, and they are made in </span><span style="font-family: Calibri; font-size: 14pt;">another part of the country. </span><span style="font-family: Calibri; font-size: 14pt;">The engineers who designed </span><span style="font-family: Calibri; font-size: 14pt;">bit fatter, but the SRBs had to be shipped by train from the factory to the launch </span><span style="font-family: Calibri; font-size: 14pt;">the SRBs would have </span><span style="font-family: Calibri; font-size: 14pt;">preferred to make them a </span><span style="font-family: Calibri; font-size: 14pt;">site. The railroad line from the factory happens to run through a tunnel in the </span><span style="font-family: Calibri; font-size: 14pt;">mountains, and the SRBs had to fit through that tunnel. The tunnel is slightly wider </span><span style="font-family: Calibri; font-size: 14pt;">than the railroad track, and the railroad track, as you now know, is about as wide </span><span style="font-family: Calibri; font-size: 14pt;">as two horses. So, a major Space Shuttle design feature, of what is arguably the </span><span style="font-family: Calibri; font-size: 14pt;">world's most advanced transportation system, was determined over two thousand </span><span style="font-family: Calibri; font-size: 14pt;">years ago by the width of two </span><span style="font-family: Calibri; font-size: 14pt;">horses’ tracks</span><span style="font-family: Calibri; font-size: 14pt;">. Ancient horses and staying in the rut </span><span style="font-family: Calibri; font-size: 14pt;">control almost everything in transportation. </span><span style="font-family: Calibri; font-size: 14pt;">Applying processes to performance-based regulations is to move out of the tracks </span><span style="font-family: Calibri; font-size: 14pt;">and make new tracks. New tracks are not always comprehended by the </span><span style="font-family: Calibri; font-size: 14pt;">accountable executive, and therefore rejected. An accountable executive is not an </span><span style="font-family: Calibri; font-size: 14pt;">expert, in most cases, in statistical process control, process analysis, risk analysis, </span><span style="font-family: Calibri; font-size: 14pt;">system analysis and audits, but is an expert in financial management to ensure a </span><span style="font-family: Calibri; font-size: 14pt;">successful business. The move from prescriptive regulations to performance-based </span><span style="font-family: Calibri; font-size: 14pt;">regulations and the safety management system, created challenges and obstacles </span><span style="font-family: Calibri; font-size: 14pt;">to overcome. Two major obstacles were to design and apply processes that </span><span style="font-family: Calibri; font-size: 14pt;">conform to regulatory compliance, e.g. the output, as opposed to the input, and </span><span style="font-family: Calibri; font-size: 14pt;">the other challenge to overcome was to take the first step and move out of the rut.</span></p></div></div></div></div><div class="page" title="Page 7"><div class="section"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">Staying in the rut with a safety management system is a compliant SMS, but it is an </span><span style="font-family: Calibri; font-size: 14pt;">unhealthy SMS with undetected flaws. A healthy SMS has moved out of the rut and </span><span style="font-family: Calibri; font-size: 14pt;">is on a path into uncharted territory.</span></p></div></div></div><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">OffRoadPilots</span></p></div></div></div></div></div></div></div><p><span style="font-family: Calibri; font-size: 14pt;"><br /></span></p></div></div></div><p><span style="font-family: Calibri; font-size: 14pt;"><br /></span></p><p><span style="font-family: Calibri; font-size: 14pt;"><br /></span></p></div></div></div><p><span style="font-family: Calibri; font-size: 14pt;"><br /></span></p></div></div></div></div></div></div>SMS/QA Control Managementhttp://www.blogger.com/profile/09611789820282926862noreply@blogger.com0tag:blogger.com,1999:blog-3664537417151106536.post-11956831248643178272023-12-10T04:43:00.000-08:002023-12-10T04:43:35.569-08:00Santa’s System Analysis<div class="page" title="Page 1"><div class="layoutArea"><div class="column"><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">Santa’s System Analysis</span></p><p><span style="font-family: Calibri;"><span style="font-size: x-small;">By OffRoadPilots</span></span></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri;"><span style="font-size: x-large;"><i>S</i></span></span><span style="font-family: Calibri; font-size: 14pt;">ince Santa implemented the Streamlined Mission Service (SMS) 10 years ago, his</span><span style="font-family: Calibri; font-size: 14pt;">SMS system has evolved into a business of its own, and a business system </span><span style="font-family: Calibri; font-size: 14pt;">within the Streamlined Mission Service system. Santa runs his operations as a non- profit organization. This is not a charity organization, but a not-for-profit enterprise, with Santa who is the AE, Mrs. Santa who is HR Director, the Elf Superintendent, the Elf Director of Reindeer Operations, and the Elf Director of Airfield Management as the Board of Directors. The purpose of Santa</span><span style="font-family: Calibri; font-size: 14pt;">’</span><span style="font-family: Calibri; font-size: 14pt;">s operation is to deliver, without profit, gifts to billions of people once a year during a 24-hour period. The task in itself is simple, since delivery methods remains the same for centuries. However, task to deliver within a 24-hour period has become more strenuous</span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgxSdUGUXI7CZxiEAuaal1cPpdFCjsxm-BJmjDnu7sj0yhqDbIybKusu1JoMzEbyV5bAy-68mFUKEMjHibQatS3n2nyIcutElEh6ruhbNVAj8agcTzMrv2OdRP3NEkP3SBfCKI6PqNY4tji8Juor4A9TpVda6hBd1FhWICHDYNvKf4hlEqbtWfBLpK9nWPM/s372/Screenshot%202023-12-10%20at%207.35.55%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="289" data-original-width="372" height="311" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgxSdUGUXI7CZxiEAuaal1cPpdFCjsxm-BJmjDnu7sj0yhqDbIybKusu1JoMzEbyV5bAy-68mFUKEMjHibQatS3n2nyIcutElEh6ruhbNVAj8agcTzMrv2OdRP3NEkP3SBfCKI6PqNY4tji8Juor4A9TpVda6hBd1FhWICHDYNvKf4hlEqbtWfBLpK9nWPM/w400-h311/Screenshot%202023-12-10%20at%207.35.55%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he first time Santa delivered gifts was in the year 872, when he helped a king of the Arctic to convince farmers, laborers, ship builders, accountants, lawyers, and risk management officers to join the king as one nation. Santa used his gifted talent as a used-sleigh salesman to give out gifts to everyone </span><span style="font-family: Calibri; font-size: 14pt;">who agreed. Since this gift-giving process went so smooth, and the reindeers loved it, Santa decided to give gifts to all the nations on the day of the Arctic mid-winter fest when the sun is returning to the region again, the earth is coming back to life, and continuous darkness must give way to daylight. Santa did not plan much for this, since travel and giving gifts were common sense tasks. He gathered up all the nine reindeers he had in the safety corral, where they were protected from </span><span style="font-family: Calibri; font-size: 14pt;">hazards. These nine reindeers were carefully selected from the prime of the best </span><span style="font-family: Calibri; font-size: 14pt;">reindeer-stock in the mountains. The reindeers were used as helpers for the 2-day build-up of the mid-winter fest and the return of the sun, and the 7-day cleanup after the fest. This was not a rowdy and wild fest, but the cleanup needed to take 7-days as a part of a tradition only.</span></p><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b>t the next winter-fest in 873, Santa departed with gifts that him and Mrs. Santa had prepared. The nine reindeers were happy to go and was looking forward to seeing other parts of the flat-shaped earth. Santa and the reindeers had been up in the air before, and when climbing to 3,000 feet above ground, they could easily see the end of the world. Santa didn</span><span style="font-family: Calibri; font-size: 14pt;">’</span><span style="font-family: Calibri; font-size: 14pt;">t think this would take much time or presents and departed on a full moon morning and bright stars. These were the modern times, and there was nothing that was not known to be bright and intelligent people at this time. On the first takeoff one of the reindeers failed and stumbled after a famous wolf crossed the runway, and the reindeer got one of the runway edge lights stuck in his nose. The nose turned red, Santa named the reindeer Rudolph, after the famous wolf, and put Rudolph at the front for safety, since the nose was red.</span></p></div></div></div></div></div></div><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>S</b>anta travelled from home to home and landed on the rooftops. They didn</span><span style="font-family: Calibri; font-size: 14pt;">’</span><span style="font-family: Calibri; font-size: 14pt;">t have chimneys back then, but there was a hole at the gable end for smoke to escape from the living areas. This was a convention place to drop the gifts, and if Santa had to, he could use a rope to slide down into their living room.</span></p><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>E</b>very delivery went well, until Santa ran out of gifts. Santa had travelled for hundreds of miles but did not make it to the earth</span><span style="font-family: Calibri; font-size: 14pt;">’</span><span style="font-family: Calibri; font-size: 14pt;">s end yet. There were still yard lights as far as the eye could see. Santa was disappointed but had to turn around before the reindeers ran out of energy. Safety back at Santa</span><span style="font-family: Calibri; font-size: 14pt;">’</span><span style="font-family: Calibri; font-size: 14pt;">s yard, he sat down and wondered what went wrong since he couldn</span><span style="font-family: Calibri; font-size: 14pt;">’</span><span style="font-family: Calibri; font-size: 14pt;">t deliver to every single home.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>O</b>ver the next few months Santa analyzed the system to learn what went wrong. He researched famous scholars about the flat earth and reindeer energy consumption. After reading and learning more about the earth, Santa came to realize that the earth is round like the sun and the moon. Also, Santa found out </span><span style="font-family: Calibri; font-size: 14pt;">that the reindeer need solid food on their travel and cannot make the full trip by using power from the windturbine installed under the sleigh to supply water when they stop on the rooftops. Santa completed his system analysis for the next trip. The system analysis included the reindeer feeding system, the power generating system, and the earth-shape system. The reindeer feeding system was made automated and powered by the power generator to supply solid and liquid food to the reindeer. The windturbine was placed on top of the sleigh since it was damaged by rooftop landings when installed below. The power generator system added two backup windturbines to ensure power supplies for the whole trip. While Santa had problems defining, or changing the earth</span><span style="font-family: Calibri; font-size: 14pt;">’</span><span style="font-family: Calibri; font-size: 14pt;">s shape, he discovered that he could draw a map of the earth on a round rock and use the rock as his GPS (Grand Path System).</span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjQACffdU2bVwZ_tgiue0DGrPzHByybKKjNhyphenhyphenrZr2NMRrQZT3YETZU9ApmKi_YZNCGrrfhP1VXM4Byvsy9nWhNUGP3-Z2CFMqExdWynA1qwhQmnjQm_iohLVhk6SZcNCU1bx5v9kGPdwnM8hVb1fATAOSSN2-AiQuOCDZ83Sx4S3C1dIxvUpCub2dcHmUEp/s370/Screenshot%202023-12-10%20at%207.38.24%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="278" data-original-width="370" height="300" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjQACffdU2bVwZ_tgiue0DGrPzHByybKKjNhyphenhyphenrZr2NMRrQZT3YETZU9ApmKi_YZNCGrrfhP1VXM4Byvsy9nWhNUGP3-Z2CFMqExdWynA1qwhQmnjQm_iohLVhk6SZcNCU1bx5v9kGPdwnM8hVb1fATAOSSN2-AiQuOCDZ83Sx4S3C1dIxvUpCub2dcHmUEp/w400-h300/Screenshot%202023-12-10%20at%207.38.24%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 3"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">New inventions had come on the market since last year, and now, in the year 874, everything that was needed to be known about global travel was known. Santa had no worries since the experts had given him expert</span><span style="font-family: Calibri; font-size: 14pt;">’</span><span style="font-family: Calibri; font-size: 14pt;">s advice for every possible scenario and ensured his safety. After several hours of travel Santa was surprised that the sun </span><span style="font-family: Calibri; font-size: 14pt;">did not set. Where he came from the sun did not rise all day, but here it was just the opposite. The sun did not set during the night. This reminded Santa of home and how the summer night are long and bright. Santa used an old wheel with six spokes to calculate his travel distance. Santa called his device every 6 balcony (E6B), since he needed to recalculate his route after six rooftop landings. To his surprise, he now was at the bottom of the round rock. Santa continued his deliveries, and he did not look back. The reindeer followed the direction from Rudolph, and the red nose pointed in a straight-ahead direction. After several</span><span style="font-family: Calibri; font-size: 14pt;">more hours, Santa began to recognize places on the ground, and soon he found his landing airstrip. Santa was surprised to learn that he could make it home without turning around. When he told this to the experts, they expelled him from the toy factory since this could not be true. The earth was flat, and anyone who went of the edge never came back. Santa was more eager now than ever to continue his journey and deliver toys to everyone. Just a few days later Santa and Mrs. Santa started their own toyshop with help from all the elves in the area. Their future looked promising.</span></p><div class="page" title="Page 4"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>B</b>y now Santa realized that another system analysis needed to be done, since more systems were added, and he was planning for additional changes for the next toy delivery season. This time Santa included his own experts to do a system analysis. Mrs. Santa as the Director of Financial and Human Resources has roles and responsibilities to ensure that their processes from material to finish product were stable and userfriendly, and the system analysis expert for theses areas. Santa as the Accountable Elf (AE) has responsibility for human factors, organizational factors, supervision factors and environmental factors. In the system analysis Santa used the SHELL model, which stands for self-awareness, health-awareness, encroaching-awareness, limbo-awareness, and lane-awareness. sub-factors of environmental factors are designed environment, user friendly environment, design and layout, accessibility, tasks-flow, social environment, distancing, experiences, culture, language, climate, geo location, weather, temperature, methods, machines, manpower, materials, and measurements. S</span><span style="font-family: Calibri; font-size: 14pt;">anta’s areas of </span><span style="font-family: Calibri; font-size: 14pt;">expertise are applied in a system analysis of these mentioned factors. The Elf Superintendent brought her skills and expertise to the system analysis for Airfield maintenance, construction, and movements. The Elf Director of Reindeer Operations was responsible for all areas of operations, and to bring her expertise skills to the table for the system analysis. The Elf Director of Airfield Management brought his skills to the system analysis for safety, processes, and operation plans management to the system analysis. Santa was satisfied that this year, in year 875 and the year of major constructions, production and delivery of toys around the world would be a success. As the preparation continued, Santa was ready at the mid-winter fest to head out on his delivery adventure. This time he headed south </span><span style="font-family: Calibri; font-size: 14pt;">until the sun did not set, and then northbound until the sun did not rise. By repeating this 24 times, he covered every single home and person all over the globe in a 24-hour period, and all children around the world was as happy as ever.</span></p><div class="page" title="Page 5"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>S</b>anta, with approval by Mrs. Santa, made continuous improvements to production and deliveries, and continued support to the reindeer with helpful navigation aids, food delivery, and Santa also included a rest period for two of the reindeer at a time. With the annual new and improved processes, two of the reindeer were able to take a rest period without affecting the delivery process.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><br /><b>A</b>s homes were improved, the chimney became an obstacle. Santa noticed one year, in 1346, that some homes had build chimneys. At first Santa did not know but learned the hard way when the reindeer crashed into one. After the first incident Santa started to track every home with a chimney and documented this in the Chimney Tracking program. Since Santa had helped out the king in 872, he continued to report to the new kings of the Arctic. In 1537 a king who spoke a different language took over, and at first it was difficult for Santa to understand. Mrs. Santa developed a communication process in addition to the text and spoken word, to include colors and images. This was very helpful, and over time Santa also learned the new language.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiAFXnOuKt7KRHPXI8pwOZXeixUszFV7xr66BZAKt1NowAPGTtvb1Hq_8M-zfyVvudVjb7b_sI4K3oR24d9v8Rmc4OHr9F07QbB_7qKoMPHShQT1LbnNj9HOTdiwrX49pdrcfy6L9eSrywecAHLu6WQEXVL_4qmttCqsixZjvlKJ-4HkFq3qG5MpyY7oLiW/s375/Screenshot%202023-12-10%20at%207.39.44%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="235" data-original-width="375" height="251" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiAFXnOuKt7KRHPXI8pwOZXeixUszFV7xr66BZAKt1NowAPGTtvb1Hq_8M-zfyVvudVjb7b_sI4K3oR24d9v8Rmc4OHr9F07QbB_7qKoMPHShQT1LbnNj9HOTdiwrX49pdrcfy6L9eSrywecAHLu6WQEXVL_4qmttCqsixZjvlKJ-4HkFq3qG5MpyY7oLiW/w400-h251/Screenshot%202023-12-10%20at%207.39.44%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 5"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">Over the years there were ongoing improvements. Just as the chimney improvement, these improvements became a hazard for Santa and his deliveries. One year, one of the homeowners had placed a large evergreen tree inside their house. When Santa</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">dropped down the chimney and rolled into the living room, he rolled over the tree, and it fell over. All decorations broke, and everyone, including the children, woke </span><span style="font-family: Calibri; font-size: 14pt;">up and ran to rescue. Santa made note of this and learned from his experience. Santa also notified the reindeers that there were trees inside some of these homes, which could cause more chimney smoke when branches and wood from the trees were burned on the fire. Santa tracked and documented every home with a tree and recorded it in the Tree Tracking system. Santa realized that system analyses also were useful in predicting hazards and avoid incidents when travelling. In 1814 Santa reported to a new king, who spoke his old language. Santa modified the written text in his messages so that elves and homeowners could understand the message. Santa documented and defined the text in the Write and Talk Tracking system.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgB53e3NFK0Olv8sg5yHPFbEl3hmFQOVtwjq163wOszRDNI5q7SQwRpzQII4HbiSCQhy5mVE7VALEFvc4eF6OXbjioK9m-RK68udf9pzpQoLAPgiYYTH12Xaestzn0XeRROjYSbnQlOF7wdoHRjL8cmiK4iZih5oYdotEE3ZLqcr0JCm5b55Wv2xVzQUVAx/s406/Screenshot%202023-12-10%20at%207.41.09%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="268" data-original-width="406" height="264" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgB53e3NFK0Olv8sg5yHPFbEl3hmFQOVtwjq163wOszRDNI5q7SQwRpzQII4HbiSCQhy5mVE7VALEFvc4eF6OXbjioK9m-RK68udf9pzpQoLAPgiYYTH12Xaestzn0XeRROjYSbnQlOF7wdoHRjL8cmiK4iZih5oYdotEE3ZLqcr0JCm5b55Wv2xVzQUVAx/w400-h264/Screenshot%202023-12-10%20at%207.41.09%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 6"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">Over the years Santa conducted several system analyses. A new invention on December 17, 1903, caught Santa by a surprise when another object, and Santa was not sure what it was, approach him in the air when travelling to a different district for</span></p><p><span style="font-family: Calibri; font-size: 14pt;">deliveries. Even if Santa was not sure of what the object was, him and Mrs. Santa conducted a system analysis of the event and implemented it in the safety manual for the annual toy-run. Santa did not mention this to anyone else, or to the king, since he had concerns that it could create to punitive actions to damage Santa</span><span style="font-family: Calibri; font-size: 14pt;">’</span><span style="font-family: Calibri; font-size: 14pt;">s reputation.</span></p><div class="page" title="Page 6"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>O</b>ne day, a scientist invented an ultra-resilient strain of wheat that would grow food in places where food did not grow before. This also helped out Santa with feeding the reindeer while on the road, since he did not need to do as many detours to fill up the food supplies in the sleigh. In addition, since more food became available, Santa could carry a lighter weight of food, which made the job</span></p></div></div><img alt="page6image1895808" height="198.400000" src="blob:https://www.blogger.com/9418564c-f2c1-4fdf-9713-0b9cc6c1f982" width="311.770000" /></div><div class="page" title="Page 7"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">easier for the reindeer. This worked out so well for Santa that Mrs. Santa awarded the scientist in 1970 the highest medal of honor since the new ultra-resilient strain of wheat helped to make peace between people. Santa, Mrs. Santa, and the elves were all happy to meet the scientist, visit with him and give him a hug and thank you for his hard work over many years.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>O</b>ver centuries, decades and years, there were many challenges to overcome for Santa, and over time he made improvements to increase production, and improve delivery processes to ensure timely deliveries within a 24-hour period. For any changes that were made, minor or major, Santa and Mrs. Santa conducted their system analyses to be prepared for the known and unknown hazards awaiting Santa on his journey.</span></p><p><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">OffRoadPilots</span></p></div></div></div></div></div></div><p><span style="font-family: Calibri; font-size: 14pt;"><br /></span></p></div></div></div><p><span style="font-family: Calibri; font-size: 14pt;"><br /></span></p></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div>SMS/QA Control Managementhttp://www.blogger.com/profile/09611789820282926862noreply@blogger.com0tag:blogger.com,1999:blog-3664537417151106536.post-59741189597816511772023-11-25T06:44:00.000-08:002023-11-25T06:44:03.515-08:00What A Healthy SMS Looks Like<p> <span style="font-family: Calibri; font-size: 14pt;">What A Healthy SMS Looks Like</span></p><p><span style="font-family: Calibri;"><span style="font-size: x-small;">By OffRoadPilots</span></span></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri;"><b><span style="font-size: x-large;"><i>A</i></span></b><span style="font-size: medium;">fter several years of operating with a safety management system (SMS), an SMS enterprise should be operating with zero regulatory findings. The accountable executive (AE) should have full control over the path their SMS has taken in the past and established a vision in their SMS policy of what to expect in the future. The are three regulatory compliance principles for a successful safety management system. The accountable executive is responsible for compliance with all regulations, the certificate holder (CH) is responsible for the quality assurance program (QAP), the person managing the safety management system (SMS manager) is responsible for monitoring concerns that the aviation industry has about your airport. A healthy SMS includes a risk management officer (RMO) position. Risk management is what makes a safety management system a healthy SMS within a fluid environment and ever-changing priorities.</span></span></p><p><span style="font-family: Calibri;"></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEij2gcsJlcqQR_jKpjgL764eLylXFApLPxyxzON5DF9LcpALXp2zforsQFvRg5S0Bcm6mzGWbZ_Cf-9utK9vpfUxbunV72sBuRF5A5zVxH7w_-CKH6PwKTU0f9u7wqqYBRyDZOy46OE_XjuGsNCefmRklyYbNBLG6NFG54q0Wv0QivRIdIAZ_L8qVcGsP-J/s385/Screenshot%202023-11-25%20at%209.34.17%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="251" data-original-width="385" height="261" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEij2gcsJlcqQR_jKpjgL764eLylXFApLPxyxzON5DF9LcpALXp2zforsQFvRg5S0Bcm6mzGWbZ_Cf-9utK9vpfUxbunV72sBuRF5A5zVxH7w_-CKH6PwKTU0f9u7wqqYBRyDZOy46OE_XjuGsNCefmRklyYbNBLG6NFG54q0Wv0QivRIdIAZ_L8qVcGsP-J/w400-h261/Screenshot%202023-11-25%20at%209.34.17%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">The duties of a risk management officer are often assigned to an SMS manager when the CH appoints a person to managing their SMS. The person managing the safety management system shall identify hazards and carry out risk management </span><span style="font-family: Calibri; font-size: 14pt;">analyses of those hazards. Other duties assigned to an SMS manager are to maintain a reporting system, investigate, analyze and identify the cause or probable cause of all hazards, incidents and accidents, maintain a safety data system, by either electronic or other means, to monitor and analyze trends in hazards, incidents and accidents, monitor and evaluate the results of corrective actions with respect to hazards, incidents and accidents, monitor the concerns of the civil aviation industry in respect of safety and their perceived effect on the your airport, and determine the adequacy of the training required. These </span><span style="font-family: Calibri; font-size: 14pt;">responsibilities which are assigned by the regulations to an SMS manager are extremely labor intensive, research intensive, data collection intensive and comprehension intensive. There are not enough hours in a 24-hour day for one person to comply with these requirements in addition to carry out daily risk management analyses.</span></p></div></div></div><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>I</b>f anyone for a minute thought that risk management analyses are not a daily and ongoing tasks, an SMS is not only rolling downhill, but it is also rolling down a path to operational failure. SMS itself cannot fail since all it does is to paint a true picture of a failed operation, but operations can fail by ignoring SMS drift and trends. Just as investments professionals must assess the risk daily, an airline and airport operator must also assess their risks daily.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjNjvqEsgOOH_3NYqqppdI-mDPYGNo0_s49JbHTNSfcustxUF9XqyySkUZ3-mv0ugdUZu9TNuArGz78ChGlN4H4BBq2VT4QoAGrb4ECTWiCXEeH-8RLVy36lZpIp_jZgy6WQ6IeMZh2Tw4tpcaO2PmaoTAgHimXq1MycSAz-E37VGJwMmU5yZHezE7Cn1hw/s379/Screenshot%202023-11-25%20at%209.35.50%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="224" data-original-width="379" height="236" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjNjvqEsgOOH_3NYqqppdI-mDPYGNo0_s49JbHTNSfcustxUF9XqyySkUZ3-mv0ugdUZu9TNuArGz78ChGlN4H4BBq2VT4QoAGrb4ECTWiCXEeH-8RLVy36lZpIp_jZgy6WQ6IeMZh2Tw4tpcaO2PmaoTAgHimXq1MycSAz-E37VGJwMmU5yZHezE7Cn1hw/w400-h236/Screenshot%202023-11-25%20at%209.35.50%20AM.png" width="400" /></a></div><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">Conventional wisdom is that airlines and airports only need to assess the risks for accidents that already have happened. This is also a misconception, but it does not imply that it is wrong or incorrect. When SMS first was introduced, there were little to no information or </span><span style="font-family: Calibri; font-size: 14pt;">literature available of what an aviation safety management system actually is. Airlines and airports required to implement SMS continued the path they were on, which was to react reactively to incidents and accidents. SMS was not fully understood at that time. Common phrase was that safety is common sense, knowing that common sense had produced accidents since the beginning of time on December 17, 1903.</span></p></div></div></div></div></div></div><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">Some time ago, I received a practice SMS report, and this is what the report said:</span></p><p><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">“On 17 DEC 1903 two unlicensed pilots, Orville and Wilbur Wright, made 4 </span><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">unauthorized flights in an unregistered aircraft. They departed and arrived without</span></p></div></div></div><div class="page" title="Page 3"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">communicating with air traffic control or utilizing local CTAF. Their airplane, which had not received its annual inspection by a licensed Aircraft Mechanic, was damaged during their last flight. They failed to report the incident to the TC and TSB, neither of which had been invented yet. Corrective Action: Recommend TC to be invented immediately, and Wilbur and Orville Wright's pilot certificates to be </span><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">issued then revoked.”</span></p></div></div><div class="section"><div class="layoutArea"><div class="column"><p style="text-align: left;"><span style="color: #050505; font-family: Calibri; font-size: 14pt;"><b>I</b>n the Safety oversight component, the reactive reporting process was the first</span></p></div></div><div class="layoutArea"><div class="column"><p style="text-align: left;"><span style="color: #050505; font-family: Calibri; font-size: 14pt;">operational task for airlines and airports. This task was fully understood, since</span></p></div></div><div class="layoutArea"><div class="column"><p style="text-align: left;"><span style="color: #050505; font-family: Calibri; font-size: 14pt;">reactive reporting with corrective actions was how safety was managed prior to a</span></p></div></div><div class="layoutArea"><div class="column"><p style="text-align: left;"><span style="color: #050505; font-family: Calibri; font-size: 14pt;">regulated implemented SMS. There were several other options available on how to</span></p></div></div><div class="layoutArea"><div class="column"><p style="text-align: left;"><span style="color: #050505; font-family: Calibri; font-size: 14pt;">initiate the regulated SMS process, and the consensus was to begin with the</span></p></div></div><div class="layoutArea"><div class="column"><p style="text-align: left;"><span style="color: #050505; font-family: Calibri; font-size: 14pt;">reactive reporting process.</span></p></div></div></div><div class="section"><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;"><b>W</b>hen operating with a reactive process system, an incident or accident must first</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">happen before it is reported and analyzed by applying statistic process control</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">(SPC). The first step to report an accident was familiar to operators, but the</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">challenge came when the analytical process took place. In the pre-SMS days, the</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">broken piece was fixed, forgotten about, and nobody conducted process analysis.</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">Special cause variation for root cause analysis was unknown, and most operators</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">could not identify the difference between common cause variations and special</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">cause variations. SMS was implemented with several other new definitions and</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">tasks in the reactive system, which immediately caused confrontations. Since the</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">SMS regulations are performance based, the golden rule is that if the regulation</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">does not specifically state what needs to be done, that is the exact reason why an</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">airline or airport operator must do what it takes to meet the intent of the</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">regulations. A common phrase with the SMS implementation was that </span><span style="color: #050505; font-family: Calibri; font-size: 14pt; font-style: italic;">“the</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt; font-style: italic;">regulations does not say that.”</span></p></div></div></div><div class="section"><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">The next step of the safety oversight element was to phase-in the proactive</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">process. There was still a confusion among airlines and airport operators, including</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">the Regulator, of what defined an SMS process. Since the phase-in was a proactive</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">task, the consensus became to identify hazards and do something about that</span></p></div></div></div></div><div class="page" title="Page 4"><div class="section"><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">hazard before it became a bigger problem or would lead to an incident. Operators</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">dangled carrots, or bribes, for employees to report hazards. Whoever reported the</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">most hazard in a month would receive a gift. Gifts, or bribes, when initiating a</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">process to learn the process itself is acceptable, but within a fully operational SMS,</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">bribes, or carrots do not paint a true picture of the health of an SMS.</span></p></div></div></div><div class="section"><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">The Heinrich Pyramid, or the Heinrich Law, was used as justification to action to</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">prevent minor hazards immediately, since they would, unquestionable, lead to</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">accidents. Heinrich's law is based on probability and assumes that the number of</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">accidents is inversely proportional to the severity of those accidents. It leads to the</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">conclusion that minimizing the number of minor incidents will lead to a reduction</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">in major accidents, which is not necessarily the case. In a workplace, for every</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">accident that causes a major injury, there are 29 accidents that cause minor</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">injuries and 300 accidents that cause no injuries. Hinrich Law is applicable to an</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">overcontrolled environment with common cause variations only, and where</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">special cause variations are excluded. Eventually, several airline and airport</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">operators put the Heinrich Law aside and referenced this principle as guidance and</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">instruction material only, rather than a law written in stone.</span></p></div></div></div><div class="section"><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">After the reactive and proactive process systems were phased-in, the next step in</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">the SMS was to implement investigation and analysis. The first constraint for this</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">phase-in period was to determine what to investigate and a consensus made sense</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">to investigate accidents and incidents. After all, this is what TSB did, so operators</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">assumed they were expected to do the same. Accidents and incident investigated</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">by operators were not limited to the severity of the outcome, but anything that</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">failed were placed in the investigation hat. Upon completion of an investigation an</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">operations bulletin was issued for personnel to read and accept, and after just a</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">few months, the paper clipboard was overloaded with bulletins. An airport would</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">conduct a root cause analysis and investigate a burnt-out runway edge light, and</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">airline would do the same for a burnt-out aircraft taxi light. During the phase-in</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">period SMS personnel had limited training to comprehend the safety management</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">system. Investigations and analysis of incidents that were done at that time were</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">not the wrong thing to do, since it was common sense based on their current</span></p></div></div></div></div><div class="page" title="Page 5"><div class="section"><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">knowledge. Investigating the outcome itself was the incorrect thing to do. The</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">difference between doing the wrong thing and the incorrect thing, is that doing the</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">wrong thing is to do a task against better knowledge, and doing the incorrect thing</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">is the lack of knowledge of what needs to be done. As the SMS learning level</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">progressed, it became clear that the investigation was not to investigate the</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">outcome, but to investigate the hazard and how a hazard was carried forward in</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">the operational process.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgPVas5EIxbS0sss_P9hbESfcH6HObk2CRncTguMu0GOjiR-KglpzlX_JKzQfGKl6Y2ZxGPxNko4QDHAUpg8LbmS3XBPUhw_fWsdudu1-x3E3ZRp23TwATsi_nFphY3FLcDcQhtRapnusxN3f3yr_HQOJmJYfTcMnN7adOJA_oVXdkZF_ffqvlQ3_y2ByUw/s378/Screenshot%202023-11-25%20at%209.37.11%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="289" data-original-width="378" height="306" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgPVas5EIxbS0sss_P9hbESfcH6HObk2CRncTguMu0GOjiR-KglpzlX_JKzQfGKl6Y2ZxGPxNko4QDHAUpg8LbmS3XBPUhw_fWsdudu1-x3E3ZRp23TwATsi_nFphY3FLcDcQhtRapnusxN3f3yr_HQOJmJYfTcMnN7adOJA_oVXdkZF_ffqvlQ3_y2ByUw/w400-h306/Screenshot%202023-11-25%20at%209.37.11%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 5"><div class="section"><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">The final step in the 4-year</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">phase-in period was to</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">implement the quality</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">assurance program and</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">assess the effectiveness of</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">SMS. The struggle with this</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">phase-in period was to</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">determine what makes an</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">effective SMS. Conventional</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">wisdom was that operating</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">with zero accidents or</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">incidents was the prime key-</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">performance indicator, and the SMS performance level was assessed to the</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">number of incidents during an established time period. This is still an ongoing</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">assessment process used to establish an effective SMS. Effectiveness is analyzed in</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">graph-charts and run-charts, where a downwards trends are good, and upward</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">trends are bad. Applying this process provides some useful information, but the</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">analysis is based on opinions and emotions. When opinions and emotions are the</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">foundation for analyses, the trap to fall into is overcontrolling of processes. When</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">there is overcontrolling of processes, the ops-bulletin clipboard gets filled up faster</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">than the paper can be printed. An invaluable tool to operate with a paper-format</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">SMS is that process overcontrol can easily be identified by viewing the number of</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">paper files. When operating with a flawed system, e.g. flying an airplane without</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">required maintenance, by random chance that flight will be successful and safe. If</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">a pilot on a precision approach misread the approach chart minimums, e.g. a </span><span style="color: #050505; font-family: Calibri; font-size: 14pt;">flawed training system, and lands in zero-zero, the odds by random chance is that</span></p><div class="page" title="Page 6"><div class="section"><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">the flight will be successful. The moral of the story is that lack of accidents is not a</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">key performance indicator (KPI) of how effective an SMS is.</span></p></div></div></div><div class="section"><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">The most critical task and difficult task in assessing the effectiveness of a safety</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">management system is to rate, or classify processes to different risk levels, safety</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">critical areas and safety critical functions within these areas. From a non-analytical</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">point of view, all processes in flying must be assessed as high-risk levels since there</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">are always possibilities for an element to cause an accident. Operating with</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">possibilities is an emotional assessment of effectiveness. There is no evidence that</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">missing one or all items on a landing checklist will cause an accident. The</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">effectiveness of a safety management system cannot be determined without</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">applying statistical process control since it must be assessed by probabilities, as</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">opposed to possibilities.</span></p></div></div></div><div class="section"><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;"><b>T</b>he quality assurance program is a component of the safety management system</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">and is therefore an integrated part of an SMS in the same manner as the safety</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">polity, processes for setting goals, measuring the attainment of goals, hazard</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">identification, training, reporting system, process manual, communication to</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">personnel, periodic review of the SMS and review for cause are integrated</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">components of the SMS.</span></p></div></div></div><div class="section"><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;"><b>A</b> regulatory requirement of a safety management system is to conduct an audit of</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">the entire quality assurance program carried out every three years. During the 4</span><span style="color: #050505; font-family: Calibri; font-size: 9pt; vertical-align: 5pt;">th</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">year phase-in period, the struggle with this requirement was to identify what the</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">quality assurance program actually was and what it should look like. Since the</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">quality assurance program is a component of the SMS system, it must be treated</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">the same way as a safety policy, goalsetting processes, or reporting processes.</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">Since none of these components include specific text on what an airline or airport</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">must include to meet the performance requirement, an airline or airport must</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">design their own quality assurance program tailored specifically to their</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">operations. One vital component, and prerequisite of a healthy quality assurance</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">program is an operational daily quality control system. This system is not included</span></p></div></div></div></div><div class="page" title="Page 7"><div class="section"><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">in the text of the regulations but is a component of the overarching quality</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">assurance system. With the daily quality control program implemented, and just as</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">any small or large grocery store counts the cash at the end of the day, an SMS</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">enterprise must count their daily quality control processes daily. When the quality</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">control system is counted, an audit of the quality assurance program is possible,</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">and the checkboxes may be downgraded to be incidental to the daily quality</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">control.</span></p></div></div></div></div><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjPpI0NASi3KaFAUoXLy3Ttp1PQxSTrjZu3npkXJbboKcXaiiqJiTIR-qfI5wd5vOG-65tlvuBXyqvkP_VzjiuM4gaxHBn5SF3k4j0tNKZY_0iXU22awWnapiPLYaRVnVQKlH5r2_z-ZkayvnJwN7fV8CzdBFqgcqK0tWZx1UIHmjU7pZuKtWh_MB_rf4zA/s380/Screenshot%202023-11-25%20at%209.38.36%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="289" data-original-width="380" height="304" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjPpI0NASi3KaFAUoXLy3Ttp1PQxSTrjZu3npkXJbboKcXaiiqJiTIR-qfI5wd5vOG-65tlvuBXyqvkP_VzjiuM4gaxHBn5SF3k4j0tNKZY_0iXU22awWnapiPLYaRVnVQKlH5r2_z-ZkayvnJwN7fV8CzdBFqgcqK0tWZx1UIHmjU7pZuKtWh_MB_rf4zA/w400-h304/Screenshot%202023-11-25%20at%209.38.36%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 7"><div class="section"><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">Over a period of four years,</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">both airlines and airport had</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">been operating with an SMS</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">without knowing or</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">comprehending its definite</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">purpose. This also caused</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">conflicts and struggles</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">within the industry to define</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">the SMS path of how to </span><span style="color: #050505; font-family: Calibri; font-size: 14pt;">apply </span></p><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">this to operations. A </span><span style="color: #050505; font-family: Calibri; font-size: 14pt;">consensus for a solution was </span><span style="color: #050505; font-family: Calibri; font-size: 14pt;">to ensure that all required</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">checkboxes were completed, and the aviation SMS quality assurance program built</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">its platform on this principle. The checkbox syndrome is still the basis of SMS</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">performance and effectiveness and has become so powerful that it was also</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">implemented in the initial pilot training programs. Checkboxes are necessary for a</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">healthy SMS, but when checkboxes become the primary task, the accountable</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">executive takes their SMS down the wrong path. As I learned from a</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">groundbreaking woman in aviation, who also become one of the first female pilots</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">hired by a major airline, that completing all checkboxes have become a more</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">important task than the actual individual flight training.</span></p><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;"><br /></span></p><div class="page" title="Page 7"><div class="section"><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;"><b>O</b>perating with a healthy SMS is a simple task when all the groundwork is</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">completed. A healthy SMS does not interfere or affect roles, responsibilities or</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">assigned tasks that an airline or airport has assigned to a consultant, director of</span></p></div></div></div></div><div class="page" title="Page 8"><div class="section"><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">operations, airside crew, airport manager, SMS manager, airfield maintainers,</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">airside operations personnel, or cloudbased SMS resources systems. A healthy SMS</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">is scaled to the size and complexity of operations by assigning multiple regulatory</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">requirements to one task and operating with a regulatory element of the SMS and</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">an operational element of the SMS separately, but with both integrated in the SMS</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">analysis.</span></p><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;"><br /></span></p></div></div></div><div class="section"><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;"><b>T</b>he single most significant role for a healthy SMS to accept that the accountable</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">executive is the person who is responsible for complying with the regulatory</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">requirement to be responsible for operations, and to be accountable on behalf of</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">the certificate holder for meeting the requirements of the regulations. A healthy</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">SMS looks like an organization where major factors affecting operations are</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">monitored daily. A healthy SMS collects data from multiple different sources, such</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">as web cameras, internal and external reports, and publicly available flight critical</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">observations and predictions. A healthy SMS operates with an Above the Fold</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">system, where factors that the risk management officer has assessed as</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">operational priority risk levels for that day are placed above the fold,</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">communicated to the AE, and monitored by the SMS manager.</span></p><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;">A healthy SMS is when an accountable executive accepts that a healthy SMS is a</span></p></div></div></div><span style="color: #050505; font-family: Calibri; font-size: 14pt;">maturity system.</span></div><div class="page" title="Page 8"><span style="color: #050505; font-family: Calibri; font-size: medium;"><span style="caret-color: rgb(5, 5, 5);"><br /></span></span><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">OffRoadPilots</span></p></div></div></div></div></div></div></div><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;"><br /></span></p></div></div></div></div><p><span style="color: #050505; font-family: Calibri; font-size: 14pt;"><br /></span></p></div></div></div></div></div></div></div>SMS/QA Control Managementhttp://www.blogger.com/profile/09611789820282926862noreply@blogger.com0tag:blogger.com,1999:blog-3664537417151106536.post-20541318641114045822023-11-11T04:57:00.000-08:002023-11-11T04:57:10.567-08:00The Devil Is In The Details<p> <span style="font-family: Calibri; font-size: 14pt;">The Devil Is In The Details</span></p><p><span style="font-family: Calibri;"><span style="font-size: x-small;">By OffRoadPilots</span></span></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri;"><b><i><span style="font-size: x-large;">T</span></i></b><span style="font-size: medium;">he Titanic disaster was caused by a detail in the watertight compartment design flaw that the walls separating the bulkheads extended only a few feet above the water line, so water could pour from one compartment into another, especially if the ship began to list or pitch forward.</span></span></p><p><span style="font-family: Calibri; font-size: 14pt;">The Alexander Kielland disaster was caused by a fatigue crack in one of its six bracings, which connected the collapsed D-leg to the rest of the rig. This was traced to a small 6mm fillet weld which joined a non-load-bearing flange plate to this D-6 bracing.</span></p><p><span style="font-family: Calibri; font-size: medium;"><br /></span><span style="font-family: Calibri; font-size: 14pt;"></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgsxxOtYPtyjVTrLZ2MaO_sJdY6TYiYAAlav-re9LywRc21KZozaifff8YxsHh4rtMvivsDjXkFgTfFvRARCQ815FjqIH1w-FV6SGxtUQC0oMJI1twQsaSTNpQZ8pj_TbTrOa8sDi_Xtd-2ZVyQZO2fa6t_sdl3M6K2ix7hrIMCnsib4RYD65rfjKcvbQHl/s372/Screenshot%202023-11-11%20at%207.51.11%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="277" data-original-width="372" height="297" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgsxxOtYPtyjVTrLZ2MaO_sJdY6TYiYAAlav-re9LywRc21KZozaifff8YxsHh4rtMvivsDjXkFgTfFvRARCQ815FjqIH1w-FV6SGxtUQC0oMJI1twQsaSTNpQZ8pj_TbTrOa8sDi_Xtd-2ZVyQZO2fa6t_sdl3M6K2ix7hrIMCnsib4RYD65rfjKcvbQHl/w400-h297/Screenshot%202023-11-11%20at%207.51.11%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he Sioux City IA air disaster was cause by a catastrophic failure of its tail-mounted engine due to an unnoticed manufacturing defect in the engine's fan disk, which resulted in the loss of many flight controls. </span><span style="font-family: Calibri; font-size: 14pt;">None of these details were identified as issues of any concerns, but they caused </span><span style="font-family: Calibri; font-size: 14pt;">some of the most horrific and catastrophic historical events within their own areas of history. Titanic was built to be unsinkable, a deep-sea diver once said to me that there were terrible working conditions for underwater welders, and it was known ten years prior to the disk failures that these disks had flaws and could fail.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>D</b>etails may be known by management, but are often dismissed, they are brushed aside as being unimportant, or seen as irrelevant to the issue. Details are not only important in operations, but also for regulatory and standard compliance.</span></p><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">both airlines and airports have to maintain compliance with a comprehensive safety management system (SMS). I concept, an SMS is simple but unless details are identified within a system analysis, the system becomes complex and often unmanageable. A manageable SMS is based on daily quality control, established processes and each operational task is linked to multiple compliance requirements. When processes are established, an SMS has been simplified and manageable, with the primary tasks to monitor for deviations from assigned path. The more details paid attention to in an SMS make the SMS simpler and easier to use. When details are known, it is easy to see where the pieces fit into the whole picture, as opposed to fit a large piece into a detailed issue. When SMS is forced, it makes it difficult and complex to apply in operations. A symptom of an SMS that is too complex or unmanageable for operations, is therefore when SMS is overloaded, or overcontrolled, and safety information is a tool to justify its existence.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgoGMmuYVsL3UjTmm2kzWKumovSJeb3sftg9-_wbQSzTimr0RaZMvOyeVrfbs3hnPtHt6uhRUs19N6MpORsbthFb8XjlAoshz7H1eM4XuGwiCCrNE7ISrWidvbgpa1VstQeSpxZxG9TUIV6S0UEkzyKTbIa4sNcWKcFAvcyR325htSGIXLL2Tolo7dyscXD/s415/Screenshot%202023-11-11%20at%207.53.00%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="415" data-original-width="367" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgoGMmuYVsL3UjTmm2kzWKumovSJeb3sftg9-_wbQSzTimr0RaZMvOyeVrfbs3hnPtHt6uhRUs19N6MpORsbthFb8XjlAoshz7H1eM4XuGwiCCrNE7ISrWidvbgpa1VstQeSpxZxG9TUIV6S0UEkzyKTbIa4sNcWKcFAvcyR325htSGIXLL2Tolo7dyscXD/w354-h400/Screenshot%202023-11-11%20at%207.53.00%20AM.png" width="354" /></a></div><p></p><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>P</b>aying attention to details is a regulatory requirement for a certificate holder to adapt their safety management system to the size, nature and complexity of the operations, activities, hazards, and risks associated with the operations. Adapting to size and complexity requires detailed knowledge of their operations. When an operator only has a high- level knowledge and overview of their systems does not allow for a</span></p><p><span style="font-family: Calibri; font-size: 14pt;">certificate holder to apply operational targeted processes that suits their size of operations. A certificate holder is required to appoint an accountable executive </span><span style="font-family: Calibri; font-size: 14pt;">(AE) to be responsible for operations or activities authorized under the certificate and accountable on their behalf of the certificate holder for meeting the requirements of the regulations. This requirement does not imply that an AE only need to be familiar, or only have partial knowledge of the regulations, but is a requirement for the AE to have detailed knowledge of regulations to detect deviations from established paths and non-conforming processes. Conventional wisdom is that an AE only need to be responsible for financial and human resources, which is a job description of their position, while the knowledge of regulations is the requirements for accepting the role. SMS is a businesslike approach to safety, and no business owners, corporate directors or airport authority would hire an accountant or lawyer who have limited knowledge of regulatory requirements and their areas of responsibilities. However, they continue to hire accountable executives who do not have the knowledge base to fulfil their obligations to the regulations.</span></p><div class="page" title="Page 3"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>O</b>bligations of an airport operator is to review each issue of each aeronautical information publication on receipt and, immediately after a review, notify the Regulator of any inaccurate information. Detailed knowledge of how to obtain a copy of the aeropub is required, detailed knowledge of how often a new revision is issued, and what date it is published is required. They need detailed knowledge of what information pertains to their operations, what action to take in addition to reporting any errors to the Regulator, and how their internal SMS process capture these requirements. An operator must design, develop, and submit to the Regulator an operations plan for airside construction, and operate with airside operations plans for maintenance and repairs. Operations plans must include details of operations for processes to conform to regulatory requirements.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he person managing the safety management system, or SMS manager is required to monitor the concerns of the civil aviation industry in respect of safety and their perceived effect on the certificate holder and determine the adequacy of the training for personnel. In-depth and detailed knowledge of their own operations are required for an SMS manager to monitor the aviation industry in respect to safety and how they view different independent operators. An airport operator </span><span style="font-family: Calibri; font-size: 14pt;">who frequently closes their runways due to maintenance and repairs, may be viewed as unsafe since this particular airport does not have project plans in place for airside management and for runways to remain open for business. An airport operator may choose to close a runway between 2AM and 4AM for daily maintenance and inspection, which is different that publish NOTAMS for unexpected maintenance requirements during hours of operations. An SMS manager is required to determine requirement of training, and without the details of expected outcome of the training this function cannot be performed.</span></p></div></div></div><div class="page" title="Page 4"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>C</b>omprehension of details in operations, the text of regulations, and the intent of performance-based regulations are required for an operator to design processes that conform to regulatory requirements.</span></p></div></div></div></div></div></div><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgDxpqjfMCiMVrFW8AMzoq-aveicKb0cbu5eW_98mwsGlYfdvsPBQx4MTTcj0VLu98B_ae5V3iml9UikRg3q_x-N-mrOp9VYlvwZz9YgrfWw2fIKs4Bh9qRNKam_n_LaKn15mPD-sED0gtE2v24EF8_1YAPEn4ZjgKbi_izMqUTs3PH75aGJyHxmfsvX3v4/s370/Screenshot%202023-11-11%20at%207.54.40%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="288" data-original-width="370" height="311" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgDxpqjfMCiMVrFW8AMzoq-aveicKb0cbu5eW_98mwsGlYfdvsPBQx4MTTcj0VLu98B_ae5V3iml9UikRg3q_x-N-mrOp9VYlvwZz9YgrfWw2fIKs4Bh9qRNKam_n_LaKn15mPD-sED0gtE2v24EF8_1YAPEn4ZjgKbi_izMqUTs3PH75aGJyHxmfsvX3v4/w400-h311/Screenshot%202023-11-11%20at%207.54.40%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 4"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>G</b>enerally speaking, a regulation is applicable to any airline or airport, unless there are special provisions for size and complexity. One such regulation is the airport winter maintenance regulations, where the regulation is applicable to airports serving turbojet aircraft, and the other part appliable to airport serving </span><span style="font-family: Calibri; font-size: 14pt;">propeller aircraft and on-demand operations only. Winter operations for airports serving propeller aircraft is to consult a representative sample of the air operators that use the airport about the intended level of winter maintenance and the remove sand from movement areas when it is no longer needed. Additional requirements for airports serving turbojet aircraft are that they have a winter operations plan, snow removal priority areas, pre-threshold maximum snow accumulation, use of ice control and chemicals, friction measurement and movement area inspection reports. The detail of this regulatory requirement is not </span><span style="font-family: Calibri; font-size: 14pt;">in this regulation itself, but in the requirement for an airport certificate. An applicant for an airport certificate must maintain verification records that they can operate with a safety management system and is requirement for non-certified aerodrome operations prior to the issuance of an airport certificate. When a certified airport operator elects to operate as an airport serving propeller aircraft only, they voluntarily give up their SMS records for operations serving turbojet aircraft. Should an airline operator wish to operate turbojet aircraft out of this airport, they must delay their operations until the airport can verify their capability to operate with an SMS supporting turbojet aircraft. The detail of this requirement is to connect the link between two regulations to conduct a system analysis of future operational restrictions. With the implementation of the safety management system, any operational regulations must be linked to the SMS regulations. This is a detail that an AE must be aware of and able to distinguish between multiple regulations and how they are linked to same SMS regulation.</span></p><div class="page" title="Page 5"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b>n airport is required to maintain a runway strip, or an area beyond the side of the pavement of a runway, and beyond both threshold, that are without aeronautical obstructions. This includes natural obstructions and other encroachments such are riverbanks. One airport decided, without consultation, to fill in a riverbend to widen their runway strip.</span></p></div></div></div></div></div></div><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhJubUUfFyEP0Seqsj1Ibq1Js143qcocyLOEh0DJl5xUzXSvs3-XyQOTqbPRGTjAMYiq18STj5ZdQmX4-u1-DL-rGej_ycuBjxwLohf2gJLFbnkvsSNbOJfuXgNy2B6Wmtg3LsDD-MY-14AOpdkNKEWmerw5KhfaXYqyrkmI3K0jQb-lpmKVzX_FRC6s43S/s366/Screenshot%202023-11-11%20at%207.55.42%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="287" data-original-width="366" height="314" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhJubUUfFyEP0Seqsj1Ibq1Js143qcocyLOEh0DJl5xUzXSvs3-XyQOTqbPRGTjAMYiq18STj5ZdQmX4-u1-DL-rGej_ycuBjxwLohf2gJLFbnkvsSNbOJfuXgNy2B6Wmtg3LsDD-MY-14AOpdkNKEWmerw5KhfaXYqyrkmI3K0jQb-lpmKVzX_FRC6s43S/w400-h314/Screenshot%202023-11-11%20at%207.55.42%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 5"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b>fter the construction application was submitted, the community responded with opposition to this initiative. The airport boundary needed to be expanded by filling in the river and bird wetlands. In practice, this means that birds, wildlife, and plants are forced to leave their habitats. In the application, </span><span style="font-family: Calibri; font-size: 14pt;">the airport manager wrote the following: </span><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">"Regarding natural diversity: The airport does not have the professional expertise to assess any special impacts on natural diversity. Our experience from operating the airports over several years is that there is very limited animal and bird life in that area. We assume that this is due to the presence of the lake on the opposite side of the runway, which has a bustling wildlife and bird activities, and which therefore seems to be more attractive. Nor has any extensive movement of wildlife or birds been observed between this lake and the riverbend, which is probably due to the activity on the runway. In addition, </span><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">the airport has limited data entries in their bird and wildlife register.” </span><span style="font-family: Calibri; font-size: 14pt;">The airport manager states in their application that they do not have the professional expertise to assess impact on bird and wildlife, and due to airport operations, bird and wildlife activities are scared away and therefore does not exist as a justification to stop the construction project. This application is in non-compliance with an SMS to conduct system analysis of projects and comprehend all details included. An accountable executive needs to be able to comprehend the details and impact on the community by reading their own submission. There is also a regulatory requirement for airport extensions to consult with their neighbors, stakeholder, and other interested parties.</span></p></div></div></div><div class="page" title="Page 6"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>W</b>hen the Regulator conducts an inspection, and since the regulations are performance based, they will inspect what is not written in the text of the regulations. An inspection includes the regulations itself, how it is linked to other regulations, and how an SMS enterprise maintain a path to monitor processes. An AE needs to have knowledge to link for an airport to publish NOTAM (Notice To Air Men, and the new definition is Notice To Air Missions), and for the captain of an aircraft to be able to assess an airport for suitability. The intent of an airport operator, and a certificate requirement, is for an operator to operate an aerodrome as an airport. This requirement implies that the airport meet certification standards 24/7. A published NOTAM does not change that requirement but is a tool for an airport operator to fix or repair an unexpected issue within a short timeframe.</span></p></div></div></div><div class="page" title="Page 7"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he devil is in these details and other safety or regulatory details. For all practical purposes, what this mean is that an SMS enterprise does not have any justifiable cause to operate outside of the intent of the regulations, or exempting themselves from standards, or their own policies as they please, and most important, it is a responsibility for an accountable executive to know what this entail to ensure ongoing compliance.</span></p><p><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">OffRoadPilots</span></p></div></div></div></div></div></div></div></div></div></div></div></div>SMS/QA Control Managementhttp://www.blogger.com/profile/09611789820282926862noreply@blogger.com0tag:blogger.com,1999:blog-3664537417151106536.post-24967532850036838972023-10-28T12:58:00.003-07:002023-10-28T12:58:30.205-07:00SMS Reviews<p><span style="font-family: Calibri; font-size: 14pt;">SMS Reviews</span></p><p>By OffRoadPilots</p><p><span style="font-family: Calibri;"><span style="font-size: x-large;"><i>A </i></span></span><span style="font-family: Calibri; font-size: 14pt;">role for an accountable executive (AE) are to review their safety management system (SMS) and determine their SMS deviation from its planned course and path. A fully functional SMS cannot fail since it paints a true picture of operations, and any deviations from the path come from operational drift. An SMS enterprise operate with processes for conducting reviews or audits of their safety management system at regular intervals, and reviews or audits for cause or on- demand, of the safety management system when there are planned deviations from their current SMS. In addition to reviews and audits of deviations, an SMS enterprise operates with processes for reviewing the safety management system to determine its effectiveness. The first step to determine an SMS effectiveness is to determine what an effective SMS looks like.</span> </p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgB7zyoGd5XTY26LI2jNyRdsFLgEaxC8eL4Iu6nG4rAkgvlx3vlhgAeOe_Hblz2udk1RWH4moZ6XI9OAKXTOdSZ0a0Vc0UxJsq0dO1FRGUyLjNzt5dN7N98DjhR_EEAVu6N4CLApMWlYNpgU2FeAV3CCJR84ZWlWzbyo5DQ1j__AqO_ZCw7hWal7ZuFCvq5/s371/Screenshot%202023-10-28%20at%203.53.51%20PM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="216" data-original-width="371" height="233" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgB7zyoGd5XTY26LI2jNyRdsFLgEaxC8eL4Iu6nG4rAkgvlx3vlhgAeOe_Hblz2udk1RWH4moZ6XI9OAKXTOdSZ0a0Vc0UxJsq0dO1FRGUyLjNzt5dN7N98DjhR_EEAVu6N4CLApMWlYNpgU2FeAV3CCJR84ZWlWzbyo5DQ1j__AqO_ZCw7hWal7ZuFCvq5/w400-h233/Screenshot%202023-10-28%20at%203.53.51%20PM.png" width="400" /></a></div><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>here are several views of what an effective safety management system should look like, and one effective SMS may be different for one organization to another. Effectiveness also changes with new tools, new inventions, or changes in expectations. A simple </span><span style="font-family: Calibri; font-size: 14pt;">example are the changes from a paperformat SMS to electronic SMS and to a live cloudbased and automated SMS. The foundation of an effective safety management system is that the system conforms to regulatory requirements. Regulatory requirements are the foundation for an effective SMS, the foundation for airline or airport operations, and the foundation for issuance of their operating certificates. There are twelve factors of building blocks forming the platform for an effective SMS. A factor is circumstance, fact, or influence that contributes to a result or outcome of the SMS. When one of the blocks drift away, or deviate from its path, there is a change in the effectiveness of an SMS. The twelve building </span><span style="font-family: Calibri; font-size: 14pt;">blocks are human factors, organizational factors, supervision factors, environmental factors, trust factors, learning factors, accountability factors, information sharing factors, data factors, information factors, knowledge factors and comprehension factors. When combined in one system, these blocks of interacting systems form the foundation for SMS effectiveness to be built.</span></p><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b></b></span></p><div class="separator" style="clear: both; text-align: center;"><b><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjL28pIKEW_lvp4IVsdK92iaGfWamXEbu9Dhyphenhyphen8UxiEkdsVi3kvP8JeDAe4qC03Mn8nNPYL8126xmd8mJ0OR8pxwriQZQeNiEvIf72m7xQd4JiQ7rBIh0JM72QFLjvcUM-hzO8_bwghU3pRhukFpKVu3_c3lHBMlJrBRSBENTstmUTJWGzzpDMlgya1FVkxq/s367/Screenshot%202023-10-28%20at%203.55.00%20PM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="299" data-original-width="367" height="326" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjL28pIKEW_lvp4IVsdK92iaGfWamXEbu9Dhyphenhyphen8UxiEkdsVi3kvP8JeDAe4qC03Mn8nNPYL8126xmd8mJ0OR8pxwriQZQeNiEvIf72m7xQd4JiQ7rBIh0JM72QFLjvcUM-hzO8_bwghU3pRhukFpKVu3_c3lHBMlJrBRSBENTstmUTJWGzzpDMlgya1FVkxq/w400-h326/Screenshot%202023-10-28%20at%203.55.00%20PM.png" width="400" /></a></b></div><b>C</b>onventional wisdom is that after a goal is established, the next steps in the processes are to wait for the goals to be reached. Goals are not reached by doing nothing but are only reached by hard work. Operating with a safety management system is hard work and it is without a guarantee that this hard work will payoff, or that future accidents are eliminated. SMS is hard work by applying a daily quality control system and monitor processes for drift within its path and deviates outside of its path. Operating with an effective SMS, or a high-performing SMS is also hard work and requires strategic operating processes.<p></p><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">Several items are tools to operate with an effective SMS. A formalized safety policies is the first step to a successful SMS. Effective and regular communication about safety is another sign of a successful SMS. Having safety policies that are frequently communicated and accessible to everyone is important. An accountable </span><span style="font-family: Calibri; font-size: 14pt;">executive is the base of support for behavior-based safety and accountability. It is crucial for an effective SMS that habits around safety are established. An SMS enterprise must focus on behavior-based safety, which is a safety methodology that focuses on improving safety through habit creation.</span></p><div class="page" title="Page 3"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>U</b>nsafe behavior, or deviation from processes, are naturally habitual for workers, and they are often unaware of their own unsafe behaviors. Oftentimes, an activity has been done the wrong way for so long that workers do not consider an incorrect behavior in many cases. SMS organizations can create acceptable behavior by forming positive habits while breaking old ones. According to behavioral expert James Clear, it takes 66 days on average to develop a new habit. That means that time must be dedicated to continuous improvement in order to achieve results. The three main triggers to change habits are reminder (the trigger that initiates the behavior), routine (the behavior itself, or action taken), and reward (the benefit gained from doing the behavior). An SMS enterprise with an outstanding safety records has developed a systematic method to measure what is going on throughout their entire operation. It enables them to quickly and easily understand why something went wrong when it does.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he ability to identify high-risk situations quickly and precisely should be on every SMS </span><span style="font-family: Calibri; font-size: 14pt;">manager’s and AE’s </span><span style="font-family: Calibri; font-size: 14pt;">checklist for safety performance. Leading indicators can provide insight for an SMS enterprise to predict what could happen and take action to avoid accidents or incidents from occurring. SMS enterprise with low injury rates equip their workers for success and they do so through more than just processes and safety management programs. They leverage cutting-edge tools and systems to keep workers prepared and ready to handle whatever they need to. The most impactful safety management system is one that links worker with easy access the information they need and report an issue. SMS enterprises needs SMS managers who recognize the importance of continuous learning and schedule regular learning activities. Learning should be easy, practical and be tailored to expected job performance. Workers that may become leaders also needs to be prepared with tasks, tools, and support to take on leader roles when they are ready. Learning activities for managers, supervisors and workers should instill knowledge of proper practices, develop awareness of how to manage hazards to reduce risks, and gain specialized skills when their specific roles require unique preparations. The foundation of learning is for personnel to know where their comfort zone is, that they must step outside of their comfort zone, and have the tools, skills, and support required to move forward beyond their comfort zone.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg5-9lKX3Ou16u2y60OfmbsWLfut4SjEDP_pkahxzZEoB3hmifBG4FRTdvqCfL8i0p3p94qyq7cXc32Xeyh8prmkaKl1-jj6qX12DFqb3zXIHd5AL_DmC97TSr6Y7Q3nh4pmXJDAYN_bJdYQqhf5WsHZiAYMBuAVgjq5PFzylCnhxxjYWDFMozXEUBFiE6a/s537/Screenshot%202023-10-28%20at%203.56.36%20PM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="537" data-original-width="390" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg5-9lKX3Ou16u2y60OfmbsWLfut4SjEDP_pkahxzZEoB3hmifBG4FRTdvqCfL8i0p3p94qyq7cXc32Xeyh8prmkaKl1-jj6qX12DFqb3zXIHd5AL_DmC97TSr6Y7Q3nh4pmXJDAYN_bJdYQqhf5WsHZiAYMBuAVgjq5PFzylCnhxxjYWDFMozXEUBFiE6a/w290-h400/Screenshot%202023-10-28%20at%203.56.36%20PM.png" width="290" /></a></div><p></p><div class="page" title="Page 4"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">Empowering personnel through the safety management system yields tremendous outcomes for an SMS enterprise. Often, the challenge with a safety management system is when focus is on preventing injuries by highlighting how bad things can get and scaring workers straight. Scaring people and information overload does very little to motivate workers to perform better. This results in a fear- based culture rather than one based on success, thus reducing the morale. A successful safety management system consistently promotes proper safety through continuous </span><span style="font-family: Calibri; font-size: 14pt;">education, consistent reinforcement, and ongoing improvements.</span></p><div class="page" title="Page 4"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">It is natural to want to get the job finished on schedule, or even ahead of time, but with a </span><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">“get it done quick</span><span style="font-family: Calibri; font-size: 14pt;">” attitude </span><span style="font-family: Calibri; font-size: 14pt;">is the focus, there is an increased risk for incidents to happen. Personnel may take shortcuts </span><span style="font-family: Calibri; font-size: 14pt;">to “get the job done” and </span><span style="font-family: Calibri; font-size: 14pt;">deviate from a specified path. Shortcuts may not be a wrong process to complete the job, but a shortcut is a deviation from a planned process with an acceptable track record. A shortcut is overcontrolling a process and over time, overcontrolling processes may cause other or additional hazards that are unknown and unaccounted for. An accident impacts productivity more than anything in a </span><img src="blob:https://www.blogger.com/1aac6cad-1f23-49f1-9463-ceb4766c4c2e" /></p><div class="page" title="Page 7"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he review of a safety management system is ongoing in the daily quality control system. When it is time for a complete review for effectiveness, all data is already surveyed, determined, collected, recorded, classified, and reported in the safety management system. The final step in assessing the effectiveness of an SMS is to allocate goals to sensitivity levels.</span></p><p><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">OffRoadPilots</span></p></div></div></div></div></div></div></div></div></div><p><span style="font-family: Calibri; font-size: 14pt;"><br /></span></p></div></div></div></div></div></div></div></div></div></div></div></div><p><br /></p>SMS/QA Control Managementhttp://www.blogger.com/profile/09611789820282926862noreply@blogger.com0tag:blogger.com,1999:blog-3664537417151106536.post-88459455722858167182023-10-14T13:21:00.005-07:002023-10-14T13:21:59.303-07:00SMS Owners<p> SMS Owners</p><p><span style="font-size: x-small;">By OffRoadPilots</span></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri;"><span style="font-size: x-large;"><i><b>T</b></i></span></span><span style="font-family: Calibri; font-size: 14pt;">wo owners of a safety management system (SMS) are flight operations and airport operations. In their own area of operations, they are the hazard owners and hands-on process control managers. With the implementation of SMS operational safety was moved </span><span style="font-family: Calibri; font-size: 14pt;">away from the safety manager’s office and </span><span style="font-family: Calibri; font-size: 14pt;">to areas of operations where they belong. In addition to social media opinions, there are still aviation managers who believe that a safety manger</span><span style="font-family: Calibri; font-size: 14pt;">’s role is to keep everyone </span><span style="font-family: Calibri; font-size: 14pt;">safe, it is their role to establish acceptable risk levels, and that it their role to overrule operations mangers and airport mangers if a safety manager decided a decision to be unsafe.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhOPOHEizWvjbv11DtNaE2jRO0MhfxN3GL5xFQOmMV_HE8Ckhn5sCGVj6s0zv4V9VdnozUakBicYEwnX9VfOEnGmJjaPZZ9KpwPS3Kmi8LVJ4-No94pANUmunlTwLoZZURRBquKPex8_uTfuP4VQJkBKE7cU-iVerx1fFoE1AThgACqgwvolIxpU4VGSZ5d/s384/Screenshot%202023-10-14%20at%204.14.47%20PM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="285" data-original-width="384" height="297" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhOPOHEizWvjbv11DtNaE2jRO0MhfxN3GL5xFQOmMV_HE8Ckhn5sCGVj6s0zv4V9VdnozUakBicYEwnX9VfOEnGmJjaPZZ9KpwPS3Kmi8LVJ4-No94pANUmunlTwLoZZURRBquKPex8_uTfuP4VQJkBKE7cU-iVerx1fFoE1AThgACqgwvolIxpU4VGSZ5d/w400-h297/Screenshot%202023-10-14%20at%204.14.47%20PM.png" width="400" /></a></div><p></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b> safety management system is about processes and daily work practices. The final authority for risk acceptance is the accountable executive (AE). It is important to know that an SMS is not the magic wand that prevents future accidents from happening but is a tool to lay out the path for success. The first </span><span style="font-family: Calibri; font-size: 14pt;">task on this path is to develop work practices with an output that conforms to regulatory requirements. One daily task may combine compliance with several compliance requirements. Another task is to develop work practices that conforms to safety in operations. Safety in operations is more than preventing accidents, it is also reliability of operational tasks. This could be reliability of the daily inspection at an airport, reliability of developing aside operations plans, or reliability to communicate non-standard airside work practices and decisions in a timely manner to the SMS manager and AE. A healthy SMS is not about prohibition and restraints but is about communication and accountability.</span></p><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>aking ownership at work is to take initiative and responsibility for success or failure of SMS enterprise. SMS teams needs players willing to step up and take ownership of mistakes or challenges, as opposed to wanting to blame others for any issues. In practice, taking ownership within an SMS system means being proactive, solution-oriented, accountable, and committed to continuous improvement. Anyone who takes on ownership at work are prepared and ready to take on whatever challenges come their way. They have strong problem-solving skills and anticipate problems to prevent them before they happen, rather than waiting for things to go wrong and scrambling to fix them. They are also looking for ways to improve things. They're the ones who come up with new ideas and find creative solutions to complex problems. Workers who take ownership also take responsibility for their own actions. They own their mistakes and take responsibility for their successes. SMS team members don't shy away from accountability, they embrace it. Ownership is key to having a high-performing team. When a worker buys into the SMS, and its vision and they feel that they have a stake in its success, they are more likely to be engaged in their work.</span></p></div></div></div></div></div></div><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgMByMFaaY46ls3aElqNdZuK9CdCRsSD3LyavVF9M5GP6tRcdaeqCw3mOLudAwLdC_wDZDvqYRUj0R0NkfKatvwEL_1ck5RRfSSLnrhF-r5jVfH5RyCXNRTDEH7eP__wl89dwrIi-xh_DFlH-uBS-YCdrp-IS5IXvL3ANlPjymbKlYeTt2_pR8fBSvXJ5gH/s379/Screenshot%202023-10-14%20at%204.16.03%20PM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="231" data-original-width="379" height="244" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgMByMFaaY46ls3aElqNdZuK9CdCRsSD3LyavVF9M5GP6tRcdaeqCw3mOLudAwLdC_wDZDvqYRUj0R0NkfKatvwEL_1ck5RRfSSLnrhF-r5jVfH5RyCXNRTDEH7eP__wl89dwrIi-xh_DFlH-uBS-YCdrp-IS5IXvL3ANlPjymbKlYeTt2_pR8fBSvXJ5gH/w400-h244/Screenshot%202023-10-14%20at%204.16.03%20PM.png" width="400" /></a></div><p></p><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">There is a difference between a worker taking initiatives and a worker accepting a risk or developing risk controls outside of their area of responsibility. Accepting or rejecting a risk is the role of an accountable executive. A </span><span style="font-family: Calibri; font-size: 14pt;">worker’s </span><span style="font-family: Calibri; font-size: 14pt;">initiative is not to </span><span style="font-family: Calibri; font-size: 14pt;">make changes that affects operations, but to take initiatives to communicate suggestion, hazards or options with managers and the accountable executive when issues arise. It is also to make initiatives and take actions when there is an apparent threat to personnel, equipment, or structures. Such action could be to initiate a missed approach without being instructed by ATC.</span></p><div class="page" title="Page 3"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>U</b>nknowingly to the flight crew their airliner on final approach was lined up on the taxiway with several sequenced aircraft for departure. The flight crew observed lights, that they thought were aircraft on the runway. They made an inquiry to the tower who informed them that the runway was clear. Within an SMS world, a pilot is allowed to conduct a missed approach even if they are wrong in their assessment of an apparent danger. An airside ground vehicle with a clearance to cross a runway, may decline the clearance if there is something they have concerns about, even if their concern was not an actual issue. Taking initiatives within an SMS enterprise is to take initiative without consideration for punitive actions, or to take initiative for actions that later was shown not to be necessary.</span></p></div></div></div></div></div></div><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEggzRpHHuFZKc6V0qU9M54LMWc70R8PPytEX7aGKQSuqkEPDo3aMeSv8JwvPBUx3bTigeZ1iGXDExcMn5Q399jGkeVwdiG753a1fUJuErAACgi5JxwP_FT1N1tq-Iafds0n3cnzjyf81zunlErOZTXNcLrhhNVkc3p6KLgLFyLBcFhRfHgT_MDqnhGjNbGj/s379/Screenshot%202023-10-14%20at%204.17.14%20PM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="224" data-original-width="379" height="236" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEggzRpHHuFZKc6V0qU9M54LMWc70R8PPytEX7aGKQSuqkEPDo3aMeSv8JwvPBUx3bTigeZ1iGXDExcMn5Q399jGkeVwdiG753a1fUJuErAACgi5JxwP_FT1N1tq-Iafds0n3cnzjyf81zunlErOZTXNcLrhhNVkc3p6KLgLFyLBcFhRfHgT_MDqnhGjNbGj/w400-h236/Screenshot%202023-10-14%20at%204.17.14%20PM.png" width="400" /></a></div><p></p><div class="page" title="Page 3"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he safety management system was sold as the solution for airlines and airports to identify risks before they become bigger problems, and that the regulations was required as an extra layer of protection to help save lives. When the safety card is played, i.e. that </span><span style="font-family: Calibri; font-size: 14pt;">the regulation will </span><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">“save lives”, </span><span style="font-family: Calibri; font-size: 14pt;">is a red flag since their safety statement is without merit for an effective safety management system. It sounds good that SMS will save lives, but accidents have still happened after SMS was implemented. SMS was, and still is, sold as </span><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">“saving lives” </span><span style="font-family: Calibri; font-size: 14pt;">tool. If this statement is true that an SMS actually saves lives, it is not the fault of an SMS operator when there are occurrences.</span></p><div class="page" title="Page 3"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>I</b>n 2011 an SMS enterprise crashed an airliner. In this instance their SMS did not prevent the accident from happening. The aircraft was cleared to descend out of controlled airspace for an approach. The crew initiated the pre-descent checklist and the FO contacted the terminal controller and provided an ETA, with their </span><span style="font-family: Calibri; font-size: 14pt;">intentions to conduct a Runway 35 approach. The crew then contacted tower controller, who advised them of the altimeter setting, winds, and instructed them to report 10 nm final for Runway 35. The crew asked tower controller for a runway condition report and was advised that the runway was a little wet and that no aircraft had used it during the morning. The crew initiated the in-range checklist, they configured the aircraft for approach and landing, and initiated the landing checklist. At 10 NM final for Runway 35 the captain called for the gear to be lowered and for flaps 15. At this point in the approach, the crew had a lengthy discussion about aircraft navigation. The aircraft flew a controlled flight into terrain about 1 NM east of the runway.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi9bi8-vtb0SoGFSQSX-4hanyjLL6r22m0YWr2Hi5y6iw9wTmqc1Llk1Q_gBooMi6emZRO-CowuKrrAnuabxjK4MsbsyqZX8FiT5R6q7_RCuE3lcgLcZjtwf_wsslpKljbMyzGUR_ozSafXWILNDRk1S16NTE4yGsYrs3FImAxOJL4pR_i1ONws8xY4T1Qh/s361/Screenshot%202023-10-14%20at%204.18.39%20PM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="275" data-original-width="361" height="305" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi9bi8-vtb0SoGFSQSX-4hanyjLL6r22m0YWr2Hi5y6iw9wTmqc1Llk1Q_gBooMi6emZRO-CowuKrrAnuabxjK4MsbsyqZX8FiT5R6q7_RCuE3lcgLcZjtwf_wsslpKljbMyzGUR_ozSafXWILNDRk1S16NTE4yGsYrs3FImAxOJL4pR_i1ONws8xY4T1Qh/w400-h305/Screenshot%202023-10-14%20at%204.18.39%20PM.png" width="400" /></a></div><p></p><div class="page" title="Page 4"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b>nother incident that an SMS was unable to prevent, was a taxiway overfly at a busy airport. An aircraft was cleared to land on runway 28R but instead lined up with parallel taxiway. Four air carrier airplanes (a Boeing 787, an Airbus A340, another Boeing 787, and a Boeing 737) were on the taxiway sequenced for takeoff. On </span><span style="font-family: Calibri; font-size: 14pt;">approach the flight crew contacted ATC with a concern that there were aircraft lights on RWY 28R, and ATC informed them that the runway was clear. The flight crew of one of the sequenced aircraft then informed ATC that the approaching aircraft was </span><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">“on the taxiway”. </span><span style="font-family: Calibri; font-size: 14pt;">The tower controller instructed the incident flight crew to go-around. The approaching airplane descended to an altitude of 100 ft above ground level and overflew the first airplane on the taxiway continued its descent to 60 ft overflying the second airplane on the taxiway before starting to climb.</span></p></div></div></div><div class="page" title="Page 5"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he flight crewmembers had recent experience flying into this airport at night and were likely expecting the airport to be in its usual configuration, but on the night of the incident, parallel runway 28L was scheduled to be closed. The captain later stated that, as the airplane approached the airport, he thought that he saw runway lights for runway 28L and thus believed that runway 28R was runway 28L and that taxiway C was runway 28R. The captain asked the first officer to contact the controller to confirm that the runway was clear, at which time the first officer looked up. By that point, the airplane was lined up with taxiway C, but the first officer presumed that the airplane was aligned with runway 28R due, in part, to his expectation that the captain would align the airplane with the intended landing runway. Neither flight crewmember recognized that the airplane was not aligned with the intended landing runway until the airplane was over the airport surface, at which time the flight crew initiated a low-altitude go-around.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>B</b>oth incident airlines were operating with a regulatory conforming safety management system, but their SMS were unable to prevent the incidents. There are several reasons, or justifications, for these occurrences, but one fundamental SMS principle lost in the equation, was for the rightful owner to take ownership of their SMS and do something about it. In the second example, both ATC and one of the sequenced flight crew took ownership and prevented a disastrous outcome. SMS ownership is what made a difference, and SMS ownership is what prevented a major accident. SMS in itself did not prevent any of these occurrences, but taking ownership of progressing events would have made a different outcome.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b> successful SMS is built on a foundation that personnel accept their roles as hazard owners. An SMS that does not identify its rightful hazard owners is an ineffective tool. A captain is the final authority and decisionmaker of a flight and this principle must not change. Everyone else need to accept that the captain is the final authority, and that other flight crew members have other ownership roles.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b>n accountable executive is the owner of regulatory compliance and safety in operations. However, an AE is not the owner of an SMS manager, and when they reject a recommendation from an SMS manger, the AE must take ownership and </span><span style="font-family: Calibri; font-size: 14pt;">develop their own action to implement in their safety management system. Just as a CEO of a corporation may reject a recommendation made by an accountant or lawyer, a CEO, or AE may also reject a recommendation by an SMS manger and design their own action plan. Ownership is different than authority. Authority is to make decisions on behalf of someone else, while ownership is applied to a floating task for a person to pick up. Ownership is not an action that someone else need to do but is an action that I need to do at this moment.</span></p></div></div></div><div class="page" title="Page 6"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b>n accountable executive is the owner of all hazards, director of flight operations is the owner of all flight hazards, director of maintenance is the owner of all maintenance hazards. In addition to these SMS owners, each person within these departments are the owners of hazards as they are applicable to their job performance expectations.</span></p><p><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">OffRoadPilots</span></p></div></div></div></div></div></div></div></div></div><p><span style="font-family: Calibri; font-size: 14pt;"><br /></span></p></div></div></div>SMS/QA Control Managementhttp://www.blogger.com/profile/09611789820282926862noreply@blogger.com0tag:blogger.com,1999:blog-3664537417151106536.post-19964002240593807882023-09-30T08:33:00.002-07:002023-09-30T08:33:34.005-07:00SMS Performance Evaluation<p> <span style="font-family: Calibri; font-size: 14pt;">SMS Performance Evaluation</span></p><p><span style="font-family: Calibri; font-size: x-small;">By OffRoadPilots</span></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri;"><b><i><span style="font-size: x-large;">W</span></i></b><span style="font-size: medium;">hen competing in the Daytona 500, the key performance indicators are not how many errors each driver made during the race to lose, but how many laps they did better than the others to win</span></span><span style="font-family: Calibri; font-size: 14pt;">. Each driver’s </span><span style="font-family: Calibri; font-size: 14pt;">performance was compared to the other drivers in the race and the winner is the driver who performs better than everyone else. A safety management system (SMS) is in concept not any different than a Daytona 500. It is a race to perform at the highest level for operators to win their internal race to operate without regulatory findings. A regulatory compliant safety management system does not guarantee an accident-free environment, but both airport and airline operator must first adhere regulatory compliance to achieve success. There are no sound reasons to operate with regulatory non- conformances.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiWJXqK_3kIotKugULpMAmFcXrxc7aCz-AfcURtU8U2EekYbAuIshDRPhDBzcIbBc7KVZDzv2XO2po0pTWLVf6USdItkRrPpUQhZVLgm8zIuWEYDvuWPob03DbUasR4Rkg_TCLg0ekGCyCoMxJI_tLdZeC-r6U56BXOAOtvbFvJg51tREOCs4VIKPv2L8Ue/s372/Screenshot%202023-09-30%20at%2011.28.31%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="313" data-original-width="372" height="336" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiWJXqK_3kIotKugULpMAmFcXrxc7aCz-AfcURtU8U2EekYbAuIshDRPhDBzcIbBc7KVZDzv2XO2po0pTWLVf6USdItkRrPpUQhZVLgm8zIuWEYDvuWPob03DbUasR4Rkg_TCLg0ekGCyCoMxJI_tLdZeC-r6U56BXOAOtvbFvJg51tREOCs4VIKPv2L8Ue/w400-h336/Screenshot%202023-09-30%20at%2011.28.31%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">SMS performance assessment is a regulatory requirement, but it is not as obvious to pick a winner in an SMS as it is in the Daytona 500. After all drivers have crossed the finish line is when the winner is awarded a gold medal. It is an incomprehensible task to establish the finish line in an SMS when there are expectations to operate in a </span><span style="font-family: Calibri; font-size: 14pt;">hazard-free environment without occurrences. A high performing SMS does not ensure that accidents never happen again, but it is to be prepared when they happen. Just as a Daytona 500 winner needs to be prepared when things go wrong, maintain control, and stay ahead of in the game, an SMS enterprise must have control measures in place as needed for their own operations.</span></p><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">The first part of a goalsetting process is for the improvement of aviation safety. Improving aviation safety is a regulatory requirement, but the regulation does not define what it means to improve safety. Since the regulations are performance based, and when the regulation does not state requirements, or definitions, it is up to each airport and airline operator to define what improving aviation safety is. If aviation safety is new and improved today implies that it was old and inferior yesterday, which is not necessarily true. Aviation may have been safe yesterday, but without process patterns to follow, it was undocumented why it was safe until SMS regulations came along. The old </span><span style="font-family: Calibri; font-size: 14pt;">quote that “</span><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">if it ain’t broke, don’t fix it</span><span style="font-family: Calibri; font-size: 14pt;">” is not </span><span style="font-family: Calibri; font-size: 14pt;">what improving safety is. Improving safety are minor, almost unnoticeable changes, within the patterns, in human factors, organizational factors, supervision factors or environmental factors.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b>n SMS enterprise is required to have a process for setting goals for the improvement of aviation safety and for measuring the attainment of those goals. After they have crossed the finish line is when it is possible to evaluate and analyze their performance of how they reached that goal. One trap to watch out for when setting goals is to make an attainable goal timeline so far into the future that it becomes irrelevant to the goal what an airport or airline do today. An attainable goal for an airport operator for the improvement of aviation safety could be to conduct an obstacle survey every five years of obstacles in any of the approaches. This goal is correctly assigned a five-year irrevocable timeline which is closing the timeframe gap for the goal. With this five-year timeline goal, an airport operator, which is a task normally assigned to an airport manager (APM), may set a target date for the next survey in five years and file the goal on the shelf.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>W</b>hen a goal is out of reach, it is also out of mind until it is triggered by a notification. This is absolutely the correct method to use for an obstacle survey, and this was how airports operated prior to SMS. However, what is forgotten in the equation is that the person managing the safety management system (SMS manager) is required to implement a reporting system to ensure the timely collection of information related to hazards, incidents and accidents that may adversely affect safety. It is crucial for the performance of a safety management </span><span style="font-family: Calibri; font-size: 14pt;">system that there is an open communication line between the APM and SMS manager. An SMS manager must also define what information may adversely affects safety. Unknown obstacles in the approach may adversely affect safety, since the obstacle may cause an avoidance action by an airliner on final approach. An SMS manager may define in their safety management system manual that the </span><span style="font-family: Calibri; font-size: 14pt;">definition of “</span><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">adversely affect safety</span><span style="font-family: Calibri; font-size: 14pt;">” is when a pilot is required to </span><span style="font-family: Calibri; font-size: medium;">make an immediate avoidance actions. When an SMS manager has assigned definitions, and these definitions are accepted by the Accountable Executive (AE), an APM has a tool to assign daily quality control tasks for meeting the requirement of a five-year survey timeline. The first goal a daily communication line between APM and SMS manager, and the second part of the goal is for airside personnel to daily observe for new obstacles in the approach. A five-year survey goal timeline becomes manageable when an airport operator applies their daily quality control system.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg0mK7SN6nmPVAhFDKAtu6QGrwaGU0htW_8IdA3ol-emMWyBzsnFY41wvpTlov6GW1diAt-jGobIorBxRf1ggfldRAyDWUc6jsD8n-gX6DOAo1Ga7pyvAS1skNSb3xjsLnnBfo0QMTf2qeVB8QqhTGj8Prnwpu7QQnqXqjAsnl-ZO_TswGHfCywrSekjohR/s381/Screenshot%202023-09-30%20at%2011.30.00%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="300" data-original-width="381" height="315" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg0mK7SN6nmPVAhFDKAtu6QGrwaGU0htW_8IdA3ol-emMWyBzsnFY41wvpTlov6GW1diAt-jGobIorBxRf1ggfldRAyDWUc6jsD8n-gX6DOAo1Ga7pyvAS1skNSb3xjsLnnBfo0QMTf2qeVB8QqhTGj8Prnwpu7QQnqXqjAsnl-ZO_TswGHfCywrSekjohR/w400-h315/Screenshot%202023-09-30%20at%2011.30.00%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 3"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">Airport standards accuracy requirements for aeronautical data are based upon a 95% confidence level with three types of positional data identified. Position data are identified as surveyed points (e.g. runway threshold), calculated points (e.g. mathematical calculations from the known surveyed </span><span style="font-family: Calibri; font-size: 14pt;">points of thresholds for determination of the aerodrome reference point), and declared points (e.g. flight information region boundary points). Compliance with airport standards is a condition for the issuance and maintaining an airport certificate.</span></p><div class="page" title="Page 3"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">Linked to the accuracy requirements are the Integrity classification of aeronautical data. Classification based upon the potential risk resulting from the use of</span></p></div></div><img alt="page3image41960880" height="198.400000" src="blob:https://www.blogger.com/31c2bafd-473c-46c8-9d81-c598efa348dd" width="297.600000" /> <img alt="page3image59155984" height="29.150000" src="blob:https://www.blogger.com/e04d3466-cbe2-4e1e-a3db-a6b87e814658" width="297.600000" /><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 8pt; font-style: italic;">95% confidence level that all data points are acceptable.</span></p></div></div></div><div class="page" title="Page 4"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">corrupted, or incorrect data. Aeronautical data is classified as routine data where there is a very low probability when using corrupted routine data that the continued safe flight and landing of an aircraft would be severely at risk with the potential for catastrophe.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>E</b>ssential data is when there is a low probability when using corrupted essential data that the continued safe flight and landing of an aircraft would be severely at risk with the potential for catastrophe.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>Cr</b>itical data is when there is a high probability when using corrupted critical data that the continued safe flight and landing of an aircraft would be severely at risk with the potential for catastrophe.</span></p></div></div></div></div></div></div><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjlXw-WHlTT08p1hIdPvqrFDxEJ_EfPPDDYEPWzLcTFS5hq3Q6id-YQ5GXPOgi9ljrqpd_TflLk265RTFmdurgJleaAQUZb8epj4nIVl3OAqc36__AGT7R-1obgbvJPvYpuEM5B4Y-bRlX4PttRnEPIZbzCfuDpA17gPjovaBQ30nOAaNesUZOyNMXVJSvQ/s394/Screenshot%202023-09-30%20at%2011.31.16%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="290" data-original-width="394" height="295" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjlXw-WHlTT08p1hIdPvqrFDxEJ_EfPPDDYEPWzLcTFS5hq3Q6id-YQ5GXPOgi9ljrqpd_TflLk265RTFmdurgJleaAQUZb8epj4nIVl3OAqc36__AGT7R-1obgbvJPvYpuEM5B4Y-bRlX4PttRnEPIZbzCfuDpA17gPjovaBQ30nOAaNesUZOyNMXVJSvQ/w400-h295/Screenshot%202023-09-30%20at%2011.31.16%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 4"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b>nother task for an airport manager is to assign classification in accordance with airport standards to aeronautical data. When all data points have been classified, an airport operator may set attainable goals for compliance. Most of these points are assumed to be permanent unless there is a major airport </span><span style="font-family: Calibri; font-size: 14pt;">project planned. When surveyed points are assumed to a permanent location, a long-term goal is beyond the timespan in a position as the APM or SMS manager. An attainable goal for a permanent surveyed, measured or calculated aeronautical point comes with challenges. An attainable goal is therefore a reversal process and it is to comply with a requirement to review each issue of each aeronautical information publication and notify the regulatory of any inaccurate information. An attainable goal is then established on a 56-day cycle for review of published information, and compare this information to surveyed data points.</span></p></div></div></div><div class="page" title="Page 5"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b>n SMS manager is required to implement a safety data system, by either electronic or other means, to monitor and analyze trends in hazards, incidents and accidents, monitor and evaluate the results of corrective actions, and monitor the concerns of the civil aviation industry in respect of safety and their perceived effect on their operations. All these requirements are goal oriented, and it is up to an airport operator to decide on what monitoring tool to use, and what monitoring processes to use.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b> system is a set of components that works together in harmony. A system is reliable and performing its assigned purpose within a pattern. A requirement of a safety data system is not necessary that it is automated, but that it is linked to a performance expectation flow chart. Processes are impossible to design without expectations. A safety data system must show performance in data collection, data storage, data retrieval and data analysis. Without operating with a data storage system, each new data collected become its own new system. If an airport has operated with an acceptable quality control system over the past few years, and one day decide to change over to a different system, all previous collected data becomes invalid unless data, including data from inspections, audits and corrective actions are transferred into the new safety data system. A performance goal for a safety data system is not how may reports it received, but how adaptable it is to changes and to carry forward previously collected and analyzed data.</span></p></div></div></div></div></div></div></div></div></div><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj517bVKeUULbTbWxwr68Nr4URGDtsYi1_-zMnlkBVumvMW6vINJZZbIOGDcKAwxAi9PGAqHT807B0Z6vL0i1Qp5djTMPORccsIco0dnVzatpKfHvk-HfOORYsAMUG7kztsgXi1kIPEM2K9HxQygJoDHHcNOhecA8ET5F5yi_bJ8sQOwAx4OUq4uTBdeYIt/s376/Screenshot%202023-09-30%20at%2011.32.26%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="329" data-original-width="376" height="350" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj517bVKeUULbTbWxwr68Nr4URGDtsYi1_-zMnlkBVumvMW6vINJZZbIOGDcKAwxAi9PGAqHT807B0Z6vL0i1Qp5djTMPORccsIco0dnVzatpKfHvk-HfOORYsAMUG7kztsgXi1kIPEM2K9HxQygJoDHHcNOhecA8ET5F5yi_bJ8sQOwAx4OUq4uTBdeYIt/w400-h350/Screenshot%202023-09-30%20at%2011.32.26%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 6"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">Performance evaluation of a safety management system is an evaluation of how components work together in harmony to produce a conclusion as an output. A system concludes by its deviation in time (hours- minutes-seconds), space (geographical location), and compass (direction) from an established goal. A Daytona 500 driver enters the race to </span><span style="font-family: Calibri; font-size: 14pt;">win, and to be on target, but at the end of the race there is only one winner, and all other drives crossed the finish line successfully, but deviated from their goal. Deviation from goals is not a failure of a safety management system, but a success of a system without corrupt processes. A process in a race, being the Daytona 500, a 100-meter track and field, or a speedskating race could be overcontrolled, manipulated and corrupted by an expectation that everyone should cross the finish line at the same time. A corrupt SMS system is identified in statistical process control (SPC) control charts.</span></p></div></div></div><div class="page" title="Page 6"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>P</b>erformance evaluation of an SMS is to evaluate deviations from goals in time, space, and compass, and apply adjustment to human factors, organizational factors, supervision factors, or environmental factors. A Daytona 500 driver who finished second in the race today, may have to make an adjustment to the engine oil to perform with a winning team tomorrow.</span></p><p><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">OffRoadPilots</span></p></div></div></div></div></div></div>SMS/QA Control Managementhttp://www.blogger.com/profile/09611789820282926862noreply@blogger.com0tag:blogger.com,1999:blog-3664537417151106536.post-2801782335694755222023-09-16T07:29:00.000-07:002023-09-16T07:29:23.538-07:00Overcontrolling Or Adjusting<p> <span style="font-family: Calibri; font-size: 14pt;">Overcontrolling Or Adjusting</span></p><p><span style="font-family: Calibri;"><span style="font-size: x-small;">By OffRoadPilots</span></span></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri;"><b><i><span style="font-size: x-large;">O</span></i></b><span style="font-size: medium;">vercontrolling of a stable process for a result that is undesirable, or for a result that is extra good, the output that follows will be worse than if the process had been left alone. Overcontrolling or tampering with a process is to make immediate modifications to a process in good faith with the intent for the process to produce a desired result. Adjusting a process is to adjust a process for drift, or identified work practices that are moved away from the pattern designed. An adjustment to a process is to move the process back on track and to adjust for drift. Overcontrolling and adjusting processes are two different operational tasks. Overcontrolling makes the result worst, while adjusting maintains a process on a predetermined path.</span></span></p><p><span style="font-family: Calibri;"></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh8vOd_SioR1q9GB6_LKYNwyUDZ8alF2p-by-7X4tq8TTdpVXKh4C_-47gQGBPOF1xvqheVXIGysW4gosrS2Q1JYqysHxE2TOBmc-oKjypZgCVst553sdLpUaQPO78OYWKK6muMx1Y414pPgiaVM9BM33BxL6kNY7zemvJendMqygMJ4_E8q1AvZ7yQdjZA/s374/Screenshot%202023-09-16%20at%2010.19.32%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="316" data-original-width="374" height="338" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh8vOd_SioR1q9GB6_LKYNwyUDZ8alF2p-by-7X4tq8TTdpVXKh4C_-47gQGBPOF1xvqheVXIGysW4gosrS2Q1JYqysHxE2TOBmc-oKjypZgCVst553sdLpUaQPO78OYWKK6muMx1Y414pPgiaVM9BM33BxL6kNY7zemvJendMqygMJ4_E8q1AvZ7yQdjZA/w400-h338/Screenshot%202023-09-16%20at%2010.19.32%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>C</b>ontrol options are required to operate with a safety management system. These control options are designed, formalized, documented, and applied to all areas of operations for airports and airlines. Control options are used to maintain processes on track for a desired outcome. For airports and airlines to apply control options of processes, they </span><span style="font-family: Calibri; font-size: 14pt;">must operate with a daily quality control system. Simplified, this is a system where each task is tagged to one or more regulatory requirements, a task is tagged to the SMS safety policy, and a task is tagged to one expected outcome. A task within a daily quality control system may be tagged to multiple regulatory requirements, an outcome will complete those requirements, but there is still only one expected outcome of the task.</span></p></div></div></div><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>For</b> airport operators, a daily inspection task is expected to complete a daily inspection daily, or at shorter intervals as defined in their controlled manual. A daily inspection task, depending on tasks assigned to the daily inspection pattern, conforms to the accountable executive requirement for meeting the requirements of the regulations, the task conforms to the SMS requirement to maintain a quality assurance program, it conforms to the obligations of operator, and it conforms to the requirement for an SMS manager to identify hazards and carry out risk management analyses of those hazards, and to determine the adequacy of the training required for airside workers. For airlines, a pre-flight inspection is required prior to each flight and, depending on the size and complexity of the aircraft and airline operations, this inspection may be done by the flight crew, or other assigned personnel. A pre-flight inspection conforms to the accountable executive requirement for meeting the requirements of the regulations, the task conforms to flight operations requirements, and aircraft equipment requirements.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b>s a daily inspection, or pre-flight inspection progresses, each task assigned in the pattern is entered into a monitoring system. Upon completion, these two tasks must be analyzed in a statistic process control (SPC) system and viewed in control charts for process reliability and if a process is in-control, or out-of-control. The first level of SPC analysis is to analyze if the processes itself is in-control, as opposed to any findings documented during the process. A trap for both airports and airlines, is to immediately jump to target findings before it is known if their processes are in-control or out-of-control. Data collected from an out-of-control processes, and a processes with special cause variations, are unreliable data to be applied in a decisionmaking process.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b> control chart is a chart with data point plotted above or below an average, and plotted within six zones, or 6-sigma. Zones C-B-A are above the calculated average, and 3-sigma are below the average. Zone C is the zone closest to the average, zone B is the middle zone, and zone A is the zone farthest from the average, where a point beyond its most outer limit is an out-of-control point. A control chart removes emotions from the analysis and without bias displays a process to be in- control, or out-of-control. There are several different control chart and different </span><span style="font-family: Calibri; font-size: 14pt;">statistical analyses of processes available. One control chart displays out-of-control tests when 7 points in a row are trending up or down, or 2 points in zone A or beyond, or 4 points in zone B or beyond, or zone C when 8 points in a row on one side of average, or with 8 points in a row, but no points in zone C, or 15 points in a row within zone C, or 14 points in a row altering up/down. Out-of-control processes are caused by special cause variations, or variations that are not necessary to be a part of the process for the process to function. A common cause variation is required for the process to function, such as how long it takes to complete a daily inspection or a pre-flight inspection.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjyyJWcPQirVbLui6s7llrQ0WuE1M8yAZ6ZnWd1xGi8c5WfM2yIT5QWuX_uG7Z9CCilscm9doH2lNIUIXy4d3XvMbMl3wIVX2p4Wr6sDWrNSjIzxAelzEkDVca36HI3yS6rgM-T1lzc9sg5k4nYhwsdhuNhW7MflXAdm86nMYhsq9km7yDp4qEUVY-3wnad/s398/Screenshot%202023-09-16%20at%2010.21.46%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="298" data-original-width="398" height="300" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjyyJWcPQirVbLui6s7llrQ0WuE1M8yAZ6ZnWd1xGi8c5WfM2yIT5QWuX_uG7Z9CCilscm9doH2lNIUIXy4d3XvMbMl3wIVX2p4Wr6sDWrNSjIzxAelzEkDVca36HI3yS6rgM-T1lzc9sg5k4nYhwsdhuNhW7MflXAdm86nMYhsq9km7yDp4qEUVY-3wnad/w400-h300/Screenshot%202023-09-16%20at%2010.21.46%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 3"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">The rules of seven tests are often used as an initial test for SMS enterprises to learn a simple method for interpreting control charts. As above, the rule of seven test is when there are seven points in a row above the average, or seven points in a row below the average, or seven points in a row trending up, or seven points </span><span style="font-family: Calibri; font-size: 14pt;">in a row trending down. The other simple test to apply as a beginner when using control charts for an airport or airline operator, is when there are two points in zone A or beyond.</span></p><div class="page" title="Page 3"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b>n out-of-control process and special cause variation requires a root cause analysis. A root cause analysis within an SMS enterprise includes consideration of human factors, organizational factors, supervision factors, and environmental factors. There are two paths for a root cause analysis within an SMS world, and one is for regulatory noncompliance, and the other is for operational variations. Regulatory compliance is a prerequisite for both airline and airport operations. Without regulatory compliance, both airline and airport operations are operating </span><span style="font-family: Calibri; font-size: 14pt;">outside of their authority given to them by their certificates. Regulatory noncompliance affects the whole operations, and not just affect the items that were noncompliant. Regulatory compliance is based on a static environment, without any movements. E.g. an operations certificate is issued prior to the fist flight or the first day of airport operations.</span></p></div></div></div><div class="page" title="Page 4"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>W</b>hen an SMS enterprise is in noncompliance one day, and the noncompliance continues, a control chart will show another data point in zone A or beyond the next day. When a control chart displays an out-of-control process for regulatory compliance, a root cause analysis must be conducted as soon as the noncompliance is identified. A regulatory non-compliance is compatible to a system breakdown in manufacturing, where one breakdown has a fundamental impact on their processes. On the other path leading to operational noncompliance, a root cause analysis is applied to trends, or applied to a risk level severity. A daily inspection at an airport that normally takes 20-30 minutes to complete, may one day take over an hour due to a flat tire. The next day there is another flat tire and now there are two data points in zone A or beyond defining the special cause variation. Normally, this would generate a root cause analysis, but since all tires on the vehicle were changed to new tires, the issue was resolved, and there is no need for a root cause analysis of the special cause variation identified in the daily inspection.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>O</b>n the other hand, if the tires keep blowing daily, then a root cause analysis of the daily inspection is required, and include considerations of human factors, organizational factors, supervision factors and environmental factors. When a special cause variation is identified with a severe outcome, then a root cause is required. E.g. an aircraft slides off the runway due to icy spots. A root cause analysis is required to identify the cause of icy spots, and a cause for not reporting or NOTAM the ice. In short, a root cause analysis is required when there is an event with an unacceptable risk level but is not needed when the event remains within an acceptable risk level until a trend is established.</span></p></div></div></div><div class="page" title="Page 5"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri;"></span></p><div class="separator" style="clear: both; font-size: 14pt; font-weight: bold; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgQZmbAsN4omXbSEaNLaksx4gQGqu2faXekbKuKQm8kbfaXBX4zX99BaEgJu4BpcoJK6mUgXVOCT5l3J93nEogug6FF8mRvmEXYDRUhlv8UO7RfbIeqAD9eZu_aIDBHNoEgyf2i0AbNMoOGiaDbDlUJilU52rGoX-6JqeOijyCGVQPZoVjuxD6v2LL9KIAn/s513/Screenshot%202023-09-16%20at%2010.23.25%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="513" data-original-width="369" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgQZmbAsN4omXbSEaNLaksx4gQGqu2faXekbKuKQm8kbfaXBX4zX99BaEgJu4BpcoJK6mUgXVOCT5l3J93nEogug6FF8mRvmEXYDRUhlv8UO7RfbIeqAD9eZu_aIDBHNoEgyf2i0AbNMoOGiaDbDlUJilU52rGoX-6JqeOijyCGVQPZoVjuxD6v2LL9KIAn/w288-h400/Screenshot%202023-09-16%20at%2010.23.25%20AM.png" width="288" /></a></div><br /><span style="font-size: medium;">B</span><span style="font-size: medium;">oth overcontrolling and adjusting are linked to human factors, organizational factors, supervision factors and environmental factors. Overcontrolling in one area affects outcomes in the other areas. On the same note, adjusting in one of the areas for a process to remain within its assigned pattern, has an affect the other areas. </span><p></p><p><span style="font-family: Calibri; font-size: 14pt;">A controlling function is an accomplishment of measures that further makes progress towards the organizational goals and brings to light the drift and directs corrective action. A trap in process control is overcontrolling by feathering processes and to manipulate an outcome for any justified reasons. Overcontrolling is done in good faith to reach a goal, or to produce a perfect outcome. Perfectionism is a fundamental flaw in process management and is a hazard when causing overcontrolling. A crucial function of control is to be used as a tool for workers to </span><span style="font-family: Calibri; font-size: 14pt;">know in advance what is expected of their job performance. Controlling is a motivational tool and helping workers to reach their performance potential. Overcontrolling has an opposite effect and is a motivational obstacle for performance improvements and causing a deteriorating working environment. There is overcontrolling in a process when there is interruption by management, or </span><span style="font-family: Calibri; font-size: 14pt;">others for a worker to make immediate and unauthorized changes to their job task.</span></p><div class="page" title="Page 6"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>An</b> air carrier normally departed without passengers and freight due to a short runway and flew to a longer runway 10 miles away. One day, the operations manager interrupted the process by overcontrolling and loaded more fuel, freight and passengers than the process pattern allowed for. The aircraft crashed on departure due to overload for what the runway environment could support. The intent of overcontrolling was to catch up to lost time and provide a better service to their customers.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b>djusting a process is to analyze drift and make correction to remain on track. In the aircraft crash scenario above, an operations manger may have detected a drift if the pilot had taken it upon themselves to accept the risk and deviate from the normal process. An option for the operations manager would be to adjust the drift and move the process back on track to depart empty. However, when overcontrolling becomes a part of the daily routine and process patterns are ignored, then workers become hesitant to follow an acceptable process without receiving pre-approval from an authority.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>W</b>hen a process is overcontrolled it might produce an acceptable outcome the first time, but as changes to the process are made, each change makes the point of origin in the process move farther and farther away from the original point of origin established by the pattern. One day, one passenger may be boarding for take off at the shorter strip, the next day two passenger, the third day three passengers and so on. They do not keep boarding passengers until an aircraft crash, but they are satisfied that their process is safe and acceptable. What is missing is that the process is so far removed from the pattern that when there is an undetected change, such as higher temperature, wind direction, or a change in runway surface conditions, an accepted overcontrolled process fails, and the aircraft crash.</span></p></div></div></div><div class="page" title="Page 7"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b> root cause analysis of an overcontrolled process includes consideration of human factors, organizational factors, supervision factors, and environmental factors. Human factors are the five senses of vision, hearing, smell, taste, and touch, and how they affect a reactive or proactive action. Human factors are not the same as human errors but is a description of a cause to justify overcontrolling a process. E.g. The accident happened because a pilot failed to follow the checklist. The five senses affect human behavior. Overcontrolling of human factors could be to ignore reactions to any of the five senses.</span></p></div></div></div></div></div></div></div></div></div><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg1vhdtHMIXWsI5iiZzf5MJ0yTOJ4qR4Xi0cmz-3aLiyLH6Rukt4DWCes9A_BgCybH-g137-M0HY29ojh5JhlpCOn6y5D-qMQDrjOyHRL0omMncnJkZimmjyyBuKXFMwyU4eQi9ToiGCMWotuIEiFed7SQxO9SPpvZDDyfMD5UmD-FjGYR0WCK2xiuv0qQR/s403/Screenshot%202023-09-16%20at%2010.25.45%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="307" data-original-width="403" height="305" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg1vhdtHMIXWsI5iiZzf5MJ0yTOJ4qR4Xi0cmz-3aLiyLH6Rukt4DWCes9A_BgCybH-g137-M0HY29ojh5JhlpCOn6y5D-qMQDrjOyHRL0omMncnJkZimmjyyBuKXFMwyU4eQi9ToiGCMWotuIEiFed7SQxO9SPpvZDDyfMD5UmD-FjGYR0WCK2xiuv0qQR/w400-h305/Screenshot%202023-09-16%20at%2010.25.45%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 7"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">Organizational factors are the organization where a pattern is engaged. Organizational factors are the flight crew organization and their operations manual, or the airside operations organization and their airport operations manual. An organizational factor must be assigned to the patterns where their tasks </span><span style="font-family: Calibri; font-size: 14pt;">belong. When organizational factors are assigned to top management, they are removed by several levels from where tasks are performed to be effective in operations. Overcontrolling of organizational factors could be to demand timely performance as opposed to pattern performance.</span></p><div class="page" title="Page 7"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">Supervision factors are the effect supervision has on operations. Supervision could by lines of authority and organizational charts, but also by self-supervision of checklists and acceptable work practices. Supervision is a function of accountability. Overcontrolling of supervision factors could be a self-induced expectation for a pilot to complete all tasks items of an approach and landing checklist without considering other factors, such as the most important task at hand at the moment, or to terminate the checklist and initiate a missed approach.</span></p></div></div><span style="font-family: Calibri; font-size: 14pt;"><b>O</b>vercontrolling this process could also be when an operations mangers assigns faults to a person due to a missed approach.</span></div><div class="page" title="Page 8"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">Three environmental factors are the</span></p><ul><li style="font-family: SymbolMT; font-size: 14pt;"><p><span style="font-family: Calibri; font-size: 14pt;">Designed Environment</span></p><p><span style="font-family: CourierNewPSMT; font-size: 14pt;">o </span><span style="font-family: Calibri; font-size: 14pt;">User Friendly Environment, Design and Layout, Accessibility, Tasks- flow</span></p></li><li style="font-family: SymbolMT; font-size: 14pt;"><p><span style="font-family: Calibri; font-size: 14pt;">Social Environment<br /></span><span style="font-family: CourierNewPSMT; font-size: 14pt;">o </span><span style="font-family: Calibri; font-size: 14pt;">Distancing, Experiences, Culture, Language</span></p><p><span style="font-size: 14pt;">• </span><span style="font-family: Calibri; font-size: 14pt;">Climate<br /></span><span style="font-family: CourierNewPSMT; font-size: 14pt;">o </span><span style="font-family: Calibri; font-size: 14pt;">Geo Location, Weather, Temperature</span></p><p><span style="font-family: Calibri; font-size: 14pt;">Overcontrolling environmental factors could be when a person in authority, such as an accountable executive, expects a worker to perform tasks flawlessly within these environments without first having received training.</span></p><p><span style="font-family: Calibri; font-size: 14pt;">Overcontrolling moves a process farther away from its original track, and is opinion based, while adjusting maintain a process on track based on data with a proven end results.</span></p><p><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">OffRoadPilots</span></p></li></ul></div></div></div></div></div></div><p><span style="font-family: Calibri; font-size: 14pt;"><br /></span></p></div></div></div></div></div></div>SMS/QA Control Managementhttp://www.blogger.com/profile/09611789820282926862noreply@blogger.com0tag:blogger.com,1999:blog-3664537417151106536.post-36802478157068406452023-09-02T03:37:00.000-07:002023-09-02T03:37:17.268-07:00SMS Patterns<p> <span style="font-family: Calibri; font-size: 14pt;">SMS Patterns</span></p><p><span style="font-family: Calibri;"><span style="font-size: x-small;">By OffRoadPilots</span></span></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri;"><span style="font-size: x-large;"><b><i>U</i></b></span></span><span style="font-family: Calibri; font-size: 14pt;">nless patterns are implemented, regulatory compliance and safety in operations are achieved by random chance only and is not the result of a safety management system (SMS) and its processes.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhVid4u_QfOvuRouGicH3prizxu8Xf6MEb2XIMGC_Nse5NpchhJYrYeAisSSZbqb4C3OuzWpomYo4lAjPDcKEBBDxE6MJjhWyzK4atq6uxZXUX493t8thVwwpWbUZCtRfs6-lQlJx0gpzExNKhqNgF-Dr9kfN0S-l4u7z8fUaI1Onb8OlH4xRR6_F-sAR8E/s411/Screenshot%202023-09-02%20at%206.24.19%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="197" data-original-width="411" height="191" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhVid4u_QfOvuRouGicH3prizxu8Xf6MEb2XIMGC_Nse5NpchhJYrYeAisSSZbqb4C3OuzWpomYo4lAjPDcKEBBDxE6MJjhWyzK4atq6uxZXUX493t8thVwwpWbUZCtRfs6-lQlJx0gpzExNKhqNgF-Dr9kfN0S-l4u7z8fUaI1Onb8OlH4xRR6_F-sAR8E/w400-h191/Screenshot%202023-09-02%20at%206.24.19%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he purpose of an SMS is to identify patterns and build these patterns. Patterns is what makes SMS unique. Incidents are trends in operational patterns, but their root causes may vary from event to event. The </span><span style="font-family: Calibri; font-size: 14pt;">root causes of Cali air disaster on December 20, 1995, and Andes air disaster October 13, 1972, had different root causes, but both airliners flew a controlled flight into mountainous terrain. Often, but not always, a common denominator of a root cause is lack of situational awareness, or the flight crew failed to complete one task. Since both flight crews assumed they were tracking on their desired track, and on their way to their destinations, in their mind they had situational awareness.</span></p></div></div></div><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>W</b>hen a root cause is determined to be the loss of situational awareness, solving the problem is a simple solution by storing situational awareness is a place where it cannot be lost. Situational awareness needs to be trained for to a point where a pilot knows which way is up, down, left or right. This can only be achieved by </span><span style="font-family: Calibri; font-size: 14pt;">training, and when stored in a pilot’s mind, i</span><span style="font-family: Calibri; font-size: 14pt;">t cannot be lost. Just as a deep-sea diver needs to know which way is up, a pilot needs to know what lays ahead. A pilot needs to know their pattern by heart and use other tools to verify their actions. When flight 447 crashed on June 1, 2009, the flight crew attempted to leave a pattern without a tool to get out.</span></p></div></div></div><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">SMS patterns are the foundation of a safety management system. Trends and patterns are two distinct and different tools, each one tells their own important story of an SMS enterprise, and both are crucial tools for a successful SMS. A pattern has rules of which objects belong to the pattern and which objects do not belong to the pattern. Patterns are stable and reliable, and tasks have repetitiously been completed to their expected outcomes. Trends that are moving up, down, or sideways in number values, and when a value is above or below control limits, there is an unstable processes in the pattern.</span></p><p><b style="font-family: Calibri; font-size: 14pt;">C</b><span style="font-family: Calibri; font-size: medium;">onventional wisdom is that a trend is when there are two of the same occurrences. When applying two occurrences as a trend, there could be a runway incursion one year, and another incursion three years later, which now makes runway incursion a trend for this operator. The four seasons, spring, summer, fall, and winter are patterns, but the air temperatures during seasons are trends. Aircraft automation are patterns, while operational functionality and reliability of automation are trends. When applying two events as the threshold for trends, overcontrolling of processes is the result. An overcontrolled process is unstable and cannot be stabilized by continued overcontrolling. Overcontrolling a process makes the result worst than a process in control containing errors. The only option is to ship the error or damaged goods and provide the same level service with that process. A process needs to be monitored adjusted for drift from assigned patterns, which is a different task than over-controlling and making process changes for a different output.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj_zgOTwTnj2YvihcadpEv9azafcgyl4HYxpKWjvJTpAbwWgDv0p8nXhd0xk0BAil9_DNnMZ46KnonXQYLCMvvJdGeyVOnoOYf7Mnf0Xg6oKiyZN5Ox03U45es_3LEMZ0gf-YXsM78QBpr318HCXowtfo-qCMJmUr5inJJ_XrgiJ9niiXCEfxTO7Ipce1Id/s414/Screenshot%202023-09-02%20at%206.28.45%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="245" data-original-width="414" height="236" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj_zgOTwTnj2YvihcadpEv9azafcgyl4HYxpKWjvJTpAbwWgDv0p8nXhd0xk0BAil9_DNnMZ46KnonXQYLCMvvJdGeyVOnoOYf7Mnf0Xg6oKiyZN5Ox03U45es_3LEMZ0gf-YXsM78QBpr318HCXowtfo-qCMJmUr5inJJ_XrgiJ9niiXCEfxTO7Ipce1Id/w400-h236/Screenshot%202023-09-02%20at%206.28.45%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 3"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>C</b>onstructing the base, or cornerstone, of a safety management system that is built on trends provides a weak support base for an SMS. That there are zero incidents does not imply that an SMS is effective. Trends, even stable processes, includes variables in its foundation </span><span style="font-family: Calibri; font-size: 14pt;">and is unreliable for a system to be based on. A system needs to be built on patterns with a base constructed of repeatability, consistency, and accountability. Repeatability is its function for the same task to be repeated over and over again by any trained worker and producing the same outcome. Consistency is a system where ongoing tasks to performed at dependable intervals. Accountability is when repeatability and consistency are unaffected by common cause variations, or variations that are built into any systems for the system to function as intended, and for accountability to be applied as a long-term master planning tool.</span></p><div class="page" title="Page 3"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>D</b>aily inspections and daily quality control are two patterns in airport operations, and they are building blocks for completing patterns. These patterns are laid out to paint a true picture of airport accountability and its expected outcome. Common cause variations do not affect accountability, since there is a built-in variables in the time it takes an airport operator complete their daily inspection. A daily inspection could vary between 20-30 minutes at a medium size airport. An inspection does not complete at 23 minutes every day. Another common cause variation is the time of day when an airport operator has completed their quality control task and communicate this to airside personnel. </span><span style="font-family: Calibri; font-size: 14pt;">An airport’s daily </span><span style="font-family: Calibri; font-size: 14pt;">quality control task may be completed between 4AM and 7AM but does not complete exactly at 4:35 AM every day. These variations are common cause variations built into processes, but are not flaws, or findings in patterns.</span></p></div></div></div><div class="page" title="Page 4"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b> supreme example of how critical patterns are to produce a desired result is cross-stitching. Cross-stitching patterns are designed and built before any operational tasks takes place. Cross-stitching comes with design patters which includes a final display of what an image or text will look like upon completion. Cross-stitching a wolf that comes in all different shades of grey is one of the most strenuous patterns to complete. A wolf pattern comes with explanations, directions, and process to follow to complete the pattern and by scaling down the process to one stitch at a time the pattern leads workers to a light at the end of the tunnel. A cross stich pattern may include thousands of stitches before the pattern is completed. The pattern is the foundation and is what a cross-stitching person has built their service and production upon. Their one goal is to complete the pattern. After a pattern is built, or the foundation for the cross-stitching output is finalized, that is when roles, responsibilities, expectations kick in, and tasks are assigned to individuals. As their work progresses and patterns are completed is the time to analyze a pattern for compliance with repeatability, consistency, and accountability.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgeT-7_xtA0BbFPujW_KUOefian_6Ce5nkHL0Pw02YhySyvs0i94V5XGDj2lFuBfjuDc_8bglh-xTjVXpU3lLJEhA76hbFJDXuZe9obH7lM0PkmJpiuSR2-yrZ-2YoMr5QywWkzFInK5AJwOF4w1lRX7xMzw1qaaGUMQBOGVnh9jvbb__ZQ9fVWxj1B5Fhv/s409/Screenshot%202023-09-02%20at%206.31.24%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="306" data-original-width="409" height="299" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgeT-7_xtA0BbFPujW_KUOefian_6Ce5nkHL0Pw02YhySyvs0i94V5XGDj2lFuBfjuDc_8bglh-xTjVXpU3lLJEhA76hbFJDXuZe9obH7lM0PkmJpiuSR2-yrZ-2YoMr5QywWkzFInK5AJwOF4w1lRX7xMzw1qaaGUMQBOGVnh9jvbb__ZQ9fVWxj1B5Fhv/w400-h299/Screenshot%202023-09-02%20at%206.31.24%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 4"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b>n SMS enterprise lives by the same pattern concept as a cross-stitching person does. Airlines and airports have several patterns they need to complete at regular intervals, and it is not just one grey-wolf pattern. They have mountain-patterns, they have field-patterns, they have city-patterns, or anything else you can think of to be completed. When </span><span style="font-family: Calibri; font-size: 14pt;">all patterns are designed and built, they can start building operational policies for each pattern. When policies are established, they can build processes, procedures, and acceptable work practices to move their design patterns out of the office and </span><span style="font-family: Calibri; font-size: 14pt;">over to operations to be completed. When operations, at airlines or airports, have completed one pattern, that pattern is stored in records and a new pattern with the same image, or task, is to be produced over again by operations the next day. Just as a cross-stitching person hang their image on the wall, give it away as a gift or sell it, and then they do the same pattern over again with the same image. A pattern for an airplane to depart does not being at their taxi but begins several hours before departure for the flight crew to be rested and fit for flying.</span></p><div class="page" title="Page 5"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>O</b>ne pattern often used by airport operators is to wait for the regulator to complete their inspection and assign them findings. When findings are identified, an airport operator develops and implement corrections, but then wait again for the next oversight inspection show up and issue more finings. This is a true story and true stories are good.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b> regulator replied to an email that their responsibility is to inspect for regulatory compliance, and that they accepts that an active runway is compliant when it is 100% ice covered. Their email states about an icy runway that </span><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">“there is no issue </span><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">from a regulatory perspective</span><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">...” </span><span style="font-family: Calibri; font-size: 14pt;">The regulator accepts a pattern for an airport operator to operate with icy runways, as long as there is a pattern for the operator to publish a runway surface condition report when icy. What the regulator omitted was that the person managing the safety management system is required to identify hazards and carry out risk management analyses of those hazards. If an SMS manager recommend the hazard, and their accountable executive (AE) accepted the hazard, then an airport operator has been authorized to operate with an icy runway and must publish their NOTAM. However, it is not incumbent on airside workers, or an airport manger to accept that risk and publish a NOTAM without an </span><span style="font-family: Calibri; font-size: 14pt;">SMS Manager’s </span><span style="font-family: Calibri; font-size: 14pt;">recommendation and an AE</span><span style="font-family: Calibri; font-size: 14pt;">’</span><span style="font-family: Calibri; font-size: 14pt;">s acceptance of the hazard.</span></p><div class="page" title="Page 5"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he regulator also omitted the regulatory requirement for an SMS manger to maintain a reporting system to ensure the timely collection of information related to hazards, incidents and accidents that may adversely affect safety. They omitted a regulatory requirement for an SMS manager to monitor the concerns of the civil </span><span style="font-family: Calibri; font-size: 14pt;">aviation industry in respect of safety and their perceived effect on the certificate holder. After an intercontinental 8-hour flight an airline and its flight crew expect that their runway is </span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjuWxJlxm738klKCQ9T06p8nxn0r-7kNtiizyMk26OHIsy4RdFQqHdj2fHBSkPZjDwJ8r-DxtrPJcvREjhx2Szi3Aai0Zjn6il48c8FNl-poOT7a_p2lfW-6U5i96U_Z_F0CE7LWAIxTEDllRIwW0QTy47QFjAI0s4xZfKjh_bOenROkE_iPgJbT8AX-0qX/s476/Screenshot%202023-09-02%20at%206.33.55%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="476" data-original-width="420" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjuWxJlxm738klKCQ9T06p8nxn0r-7kNtiizyMk26OHIsy4RdFQqHdj2fHBSkPZjDwJ8r-DxtrPJcvREjhx2Szi3Aai0Zjn6il48c8FNl-poOT7a_p2lfW-6U5i96U_Z_F0CE7LWAIxTEDllRIwW0QTy47QFjAI0s4xZfKjh_bOenROkE_iPgJbT8AX-0qX/w353-h400/Screenshot%202023-09-02%20at%206.33.55%20AM.png" width="353" /></a></div><br />suitable for their operations, and that it is not covered with ice. Finally, the regulator also omitted in their reply that the required safety policy for an airport operator may commit to do what it takes for their airport environment and runway conditions to be compatible for the safe operations of an aircraft. SMS changed everything in airport and airline operations, but it didn<span style="font-family: Calibri; font-size: 14pt;">’</span><span style="font-family: Calibri; font-size: 14pt;">t change anything for the regulator.</span><p></p></div></div></div></div></div></div></div></div></div><div class="page" title="Page 6"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>W</b>ith the implementation of the SMS, patterns became crucial for both regulatory compliance and safety in operations for airlines and airports, while trends are still the crucial component for regulatory compliance only. </span><span style="font-family: Calibri; font-size: 14pt;">The regulator’s own guidance </span><span style="font-family: Calibri; font-size: 14pt;">material states that </span><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">“</span><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">Runway conditions which may permit the safe take off and landing of one aircraft may not be suitable for another aircraft</span><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">...,” </span><span style="font-family: Calibri; font-size: 14pt;">and they left out that since the runway no longer is suitable for certain </span><span style="font-family: Calibri; font-size: 14pt;">types of aircraft, an airport operator should change their Aircraft Group Number (AGN) to aircraft suitable for icy runway operation. This will put the level of service decision in the hands of the airport operator since it is ultimately their business decision. This certification level of service assists the flight crew to determine the suitability of the aerodrome for the intended operation.</span></p><div class="page" title="Page 7"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b> pattern established by the regulator is that they are only conducting oversight of regulatory compliance and not of safety in operations, which was always the case, and their role did not change with the implementation of the safety management system. What changed with the SMS, was that airlines and airport operators are now required to build their operational patterns for safety in operations and regulatory compliance.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>D</b>esigning, building, and moving patters into operations is the foundation that a successful safety management system is built on. Patterns is the tool for operators to remain focused on tasks at hand, monitor and adjust drift, and to prevent overcontrolling of processes to adjust an outcome. Patterns is a tool established for repeatability, consistency, and accountability.</span></p><p><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">OffRoadPilots</span></p></div></div></div></div></div></div></div></div></div></div></div></div><p><span style="font-family: Calibri; font-size: 14pt;"><br /></span></p></div></div></div></div></div></div>SMS/QA Control Managementhttp://www.blogger.com/profile/09611789820282926862noreply@blogger.com0tag:blogger.com,1999:blog-3664537417151106536.post-15794949311160923362023-08-19T05:28:00.001-07:002023-08-19T05:28:59.308-07:00Roles Of An SMS Manager<p> <span style="font-family: Calibri; font-size: 14pt;">Roles Of An SMS Manager</span></p><p><span style="font-family: Calibri;"><span style="font-size: x-small;">By OffRoadPilots</span></span></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri;"><b><span style="font-size: x-large;"><i>A</i></span></b><span style="font-size: medium;"> safety management system (SMS) is required for an applicant for an air operator certificate or an applicant for an airport certificate. An applicant is any person or entity applying for one of the certificates. A certificate is issued to the applicant, who becomes the certificate holder and the operator upon receiving the certificate. An applicant may choose to assign the role as an operator and certificate holder (CH) to any person or entity. An operator in respect of an airport is the certificate holder of the appropriate aviation document that is in force.</span></span></p><p><span style="font-family: Calibri;"></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiHTteDyc-e83YnZtelKaFSr2q5dhFBRlSZxINkn6GnDlP8pOT5e9WRRuKMuqED9Ti0ljiS9nx80OdhOAfbO2D-Erhhl54q2i3gY5fg7l1ZPvUkbEMw5eLCkiWni0zezhiSJCBzIb4O0BgFwz25WaJssJ11W5t1hV3hsJAmiPYyHBSA_nMYy10LIhxgb_Ai/s377/Screenshot%202023-08-19%20at%208.21.21%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="377" data-original-width="362" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiHTteDyc-e83YnZtelKaFSr2q5dhFBRlSZxINkn6GnDlP8pOT5e9WRRuKMuqED9Ti0ljiS9nx80OdhOAfbO2D-Erhhl54q2i3gY5fg7l1ZPvUkbEMw5eLCkiWni0zezhiSJCBzIb4O0BgFwz25WaJssJ11W5t1hV3hsJAmiPYyHBSA_nMYy10LIhxgb_Ai/w384-h400/Screenshot%202023-08-19%20at%208.21.21%20AM.png" width="384" /></a></div><p></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">The appointment of an accountable executive (AE) and having an operational SMS in place is required for an applicant of an aviation document to establish their compliance record prior to issuing the certificate. An airport certificate is issued to an applicant authorizing the applicant to operate an aerodrome as an airport if the proposed airport operations manual is approved by the regulator, and the airport standards are met. An airport certificate is </span><span style="font-family: Calibri; font-size: 14pt;">an operations certificate issued to the airport land parcel, and an airport manager (APM) is required to manage operational tasks, since the parcel itself in not capable of these tasks. This coordination between a certificate and certificate holder is unique since other aviation documents has a person attached to operations. There is no aviation document, certificate, or license required to hold a position as an airport manager. However, the airport manager position becomes a </span><span style="font-family: Calibri; font-size: 14pt;">regulated position when the APM is the certificate holder, with regulatory responsibilities to appoint the AE to be responsible on behalf of the certificate holder, with regulatory responsibilities to maintain a safety management system, and regulatory responsibility to appoint a person to manage the safety management system. In an organizational hierarchy, the accountable executive, the SMS manager, and the airport manager, reports directly and independently to the certificate holder. At airports where the airport manager maintains the role of a certificate holder, there could be a conflict of interest between the APM as certificate holder and the APM in the non-regulated airport operations position.</span></p><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he role of an accountable executive is operational oversight of the SMS and its daily quality control systems, to be responsible for operations, and accountable on behalf of the certificate holder for meeting the requirements of the regulations. The AE reports to the certificate holder. The role of the person managing the safety management system is operational control of the SMS, and to be responsibilities for processes to remain in conformity with regulatory requirements. The SMS manager reports to the certificate holder. The role of the certificate holder is to facilitate for their systems to operate with support from the safety management system.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he quality assurance program is a component of a safety management system, with a responsibility of the certificate holder to maintain the program. At several airports, the person holding their certificate is the airport manager and is therefore the person responsible for the program. A program is a set of related measures or activities with a particular long-term aim. A quality assurance program includes a process for periodic audits of activities authorized under a certificate and audits for cause of those activities. For cause audits are audits conducted for various compelling reasons. An airport manager, as the certificate holder, must establish the audit process, e.g. audit checklists, and the frequency of audits, not to exceed beyond three years from their firs audit. There is no regulated position as a quality assurance manager, and the certificate holder may therefore assign audit duties to any preferred person or organization, except these duties must be fulfilled by persons who are not responsible for carrying out those tasks or activities which are </span><span style="font-family: Calibri; font-size: 14pt;">being audited. A prerequisite for a quality assurance program is an SMS enterprise</span><span style="font-family: Calibri; font-size: 14pt;">’</span><span style="font-family: Calibri; font-size: 14pt;">s daily quality control program. Without a quality control program an audit under the quality assurance program must fail all audit line-items, since compliance are at random as opposed to compliance due to oversight and management.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi1E3OtNU-cWfou8fIsRSvRjxHgilrQEFqsF_lOLMwq1mDVHJCOffBzz12J1gVVVjfP1qLS9d0lW7NanFit5LUbvwKgM76C-xIqYQjCNuV-D5FP8PlorAkSbPWcDtbKzldBQzs7SGyQeMlZMvroJLWrEsznhitzRyHYcZyqBMMl7bfLAZRGVNXOOth-4TFm/s328/Screenshot%202023-08-19%20at%208.22.46%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="253" data-original-width="328" height="309" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi1E3OtNU-cWfou8fIsRSvRjxHgilrQEFqsF_lOLMwq1mDVHJCOffBzz12J1gVVVjfP1qLS9d0lW7NanFit5LUbvwKgM76C-xIqYQjCNuV-D5FP8PlorAkSbPWcDtbKzldBQzs7SGyQeMlZMvroJLWrEsznhitzRyHYcZyqBMMl7bfLAZRGVNXOOth-4TFm/w400-h309/Screenshot%202023-08-19%20at%208.22.46%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 3"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he difference is that QA is process oriented and QC is product or service oriented. Testing for quality does not assuring quality, it is process control that assures desired outcomes. Quality assurance oversight is to establish processes to identify patterns caused by processes and maintain control of those processes.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><br /></span></p><p><span style="font-family: Calibri; font-size: 14pt;"><br /></span></p><div class="page" title="Page 3"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">A quality assurance program includes a followup inspection of corrective action plans (CAP), and current controls implemented. The implementation of corrective actions are changes inserted into processes, or design and develop new processes to establish a regulatory compliant outcome. Regulatory compliance is a static mode of operations, and actual compliance is unknown until the process is put in place by workers. These processes must include a control measure to establish if they actually function and produces the expected outcome of the CAP.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he roles of a person managing the safety management system includes responsibilities to the certificate holder, accountable executive, and the quality assurance program. Their first responsibility is to the accountable executive since the AE is the person responsible for operations and accountable on behalf of the certificate holder for meeting the requirements of the regulations. Their second responsibility is to the certificate holder, since the CH must ensure that the person </span><span style="font-family: Calibri; font-size: 14pt;">managing the safety management system performs their duties required by the safety management system. Their third responsibility is to the quality assurance program since the program requires daily quality control processes to perform its audit functions. When these three lines of responsibility are opened up, the person managing the safety management system may design and develop their duties to fulfill their responsibilities.</span></p></div></div></div><div class="page" title="Page 4"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>here are several regulated responsibilities for an SMS manager, but their most important and crucial responsibility to a safety management system is not defined in the regulations. Their responsibility to an SMS is to find, assign and document patterns within each system of human factors, organizational factors, supervision factors and environmental factors.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjsYIRC3x7MN3JBxms0xfungC5xzqNC2vJpOjFcgDQmaJeNQWGA0Nc4vSsaWYViZAXnxgwi3IBRr2riLbJUrmVeUcAkPVWiS5e4YbJo8FGdJw7nVOElHxrLOoZXDJZ3oYaqjGutuMVyPKEf5vWcy3mZE0Abfy0sP63iSA1ReL_G2Va-9ajjqJXh4lCdsREP/s326/Screenshot%202023-08-19%20at%208.24.50%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="254" data-original-width="326" height="311" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjsYIRC3x7MN3JBxms0xfungC5xzqNC2vJpOjFcgDQmaJeNQWGA0Nc4vSsaWYViZAXnxgwi3IBRr2riLbJUrmVeUcAkPVWiS5e4YbJo8FGdJw7nVOElHxrLOoZXDJZ3oYaqjGutuMVyPKEf5vWcy3mZE0Abfy0sP63iSA1ReL_G2Va-9ajjqJXh4lCdsREP/w400-h311/Screenshot%202023-08-19%20at%208.24.50%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 4"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>S</b>ome of the responsibilities for the person managing the safety management system is to implement a reporting system to ensure the timely collection of information related to hazards, incidents and accidents that may adversely affect safety. An accident or incident have already adversely affected aviation safety and a </span><span style="font-family: Calibri; font-size: 14pt;">reporting system must include these two items. Hazards are defined differently from person to person since hazards are opinions and an event has not occurred. References to future possible events are based on comprehension of systems and opinions of interpretations. An SMS should include an unrestricted hazard submission clause. Timely delivery of these reports is also an opinion and how an SMS enterprise communicate internally. Today, and with access to electronic data bases, a simple cloudbased SMS program that meets the regulatory requirements is SiteDocs and accessible for review by emailing <b><u>offroadpilots@gmail.com.</u></b></span></p></div></div></div><div class="page" title="Page 5"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b>n SMS manager must identify hazards and carry out risk management analyses of those hazards. Processes for identifying hazards may take different shape and turns, but the most commonly used process is for workers to report what they interpret as a hazard. Each regulatory non-compliance is a hazard, and hazards are therefore identified in line-item audits. Without a line-item audit of regulatory requirements, the audit may be a biased review of an SMS enterprise. Hazard identification process may also be from publicly available aviation hazards, incidents and accidents data, and applied as applicable as hazard for an SMS enterprise. Whan carrying out risk management analysis it is crucial that the SMS manager identify the scope and authority of the hazard. A hazard may be detrimental to aviation safety, but changes must be within the authority of an SMS manger and solutions may be different than making changes to a hazardous environment.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he role of an SMS manager is to investigate, analyze and identify the cause or probable cause of all hazards, incidents and accidents. Identifying a cause of all hazards is an enormous task. Identifying probable cause is simple since these are opinion statements without support in data or facts. When identifying a probable cause, only one event or hazard is needed to establish the cause. When identifying a cause, or root cause of a hazard, a system analysis is required to ensure that all supporting statements and justifications are referenced with data and facts.</span></p></div></div></div></div></div></div><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgjZHdPfDNt0B-I88F21IwLOF1dHofWlhEWoJY8fAIGukTugyV-cFho6f1-t6zSyHFLiohnP5EhGUJyp4Dg-iayYiABztjy-BvotEpNApaBkST6azsWc6PKNAsm2kwbiPsdQGFe5AQFkdWMIWJ4nTU0PYt09HiJKN8x5o3rE954cjZ08GacNJHr5YrDNZV-/s347/Screenshot%202023-08-19%20at%208.26.35%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="259" data-original-width="347" height="299" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgjZHdPfDNt0B-I88F21IwLOF1dHofWlhEWoJY8fAIGukTugyV-cFho6f1-t6zSyHFLiohnP5EhGUJyp4Dg-iayYiABztjy-BvotEpNApaBkST6azsWc6PKNAsm2kwbiPsdQGFe5AQFkdWMIWJ4nTU0PYt09HiJKN8x5o3rE954cjZ08GacNJHr5YrDNZV-/w400-h299/Screenshot%202023-08-19%20at%208.26.35%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 6"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">Monitoring trends, or patterns is the responsibility of an SMS manager. Since regulations were written in the onset of common access to electronic devices, paper trending was acceptable. However, paper trending of patterns is very labor intensive and the use of electronic SMS cloud based </span><span style="font-family: Calibri; font-size: 14pt;">programs should be the preferred process. Data must be statistically analyzed in a statistical process control program to avoid the trap of overcontrolling processes.</span></p><div class="page" title="Page 6"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b> safety management system is a businesslike approach to safety and is an excellent to for marketing of your airline or airport. A responsibility of an SMS manager is to monitor the concerns of the civil aviation industry in respect of safety and their perceived effect on the holder of the certificate. Prospects, clients or customers are highly sensitive to perceived safety levels of your organization. Social media places an important role on perceived risks, or safety levels by rating your organization with approval stars. Unless the full screen, normally 5 stars, is filled, a prospect moves on to the next service or goods supplier. In addition to ratings, your SMS enterprise must be placed Above the Fold, as it is in the Daily Rundown System, for prospects to learn about your existence.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>here are several other regulated responsibilities of an SMS manger, and everything an SMS manger does must link to the AE as competent to maintain regulatory compliance, it must link to the CH to facilitate for regulatory compliance, and it must link to the QA manager with a daily quality control system.</span></p></div></div></div></div></div></div><p><span style="font-family: Calibri; font-size: 14pt;">OffRoadPilots</span></p></div></div></div><p><span style="font-family: Calibri; font-size: 14pt;"><br /></span></p></div></div></div></div></div></div><p><span style="font-family: Calibri;"><span style="font-size: medium;"><br /></span></span></p></div></div></div>SMS/QA Control Managementhttp://www.blogger.com/profile/09611789820282926862noreply@blogger.com0tag:blogger.com,1999:blog-3664537417151106536.post-88269086820273843062023-08-05T08:44:00.004-07:002023-08-05T08:44:47.655-07:00Overcontrolling Processes<p><span style="font-family: Calibri; font-size: 14pt;">Overcontrolling Processes</span></p><p><span style="font-size: x-small;">By OffRoadPilots</span> </p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri;"><span style="font-size: x-large;"><i><b>C</b></i></span></span><span style="font-family: Calibri; font-size: 14pt;">onventional wisdom is that flying must be perfect with procedures detailed to the minute. With the global position system (GPS) airnavigation has become more precise and accurate for aircraft to maintain their tracks. Dead reckoning was the processes used when no navaids were available, or navaids were placed at a distance greater than aircraft reception. Dead reckoning is to determine without the aid of celestial navigation, electronic navigation, or GPS, the position of an aircraft from the desired track to be flown and the distance made from a known starting point. Operating by instrument flight rules (IFR) in uncontrolled airspace using the dead reckoning process created random events of aircraft and aircraft intercepting positions, and near misses.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgm7hqp5UZQTI8nc-qWDrlnaYWYKXx4Wp1mwfKbDVf-vZWC2ZW18odGCL0P08DKrih86QEaXZyxEscnoQQmAF7LYwIZ7zT43tCWBQJv5PeMb63DBZS32Pl8kLaUHKJpbwT1w4LbrxyD1nsdLwZ6I_-K8GnA0smF15GXzSa_b_5unc08_H3iV1ag2_yWMR0N/s374/Screenshot%202023-08-05%20at%2011.36.45%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="238" data-original-width="374" height="255" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgm7hqp5UZQTI8nc-qWDrlnaYWYKXx4Wp1mwfKbDVf-vZWC2ZW18odGCL0P08DKrih86QEaXZyxEscnoQQmAF7LYwIZ7zT43tCWBQJv5PeMb63DBZS32Pl8kLaUHKJpbwT1w4LbrxyD1nsdLwZ6I_-K8GnA0smF15GXzSa_b_5unc08_H3iV1ag2_yWMR0N/w400-h255/Screenshot%202023-08-05%20at%2011.36.45%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>W</b>ith GPS and its precise course track, aircraft are now flying at predetermined intercepting positions allowing for predictable near miss positions. These positions are often unknown to pilots, since aircraft track while in uncontrolled airspace is only internally </span><span style="font-family: Calibri; font-size: 14pt;">known to that specific flight crew, while other aircraft may be randomly tracking on a collision course with an unknown flight paths to both flight crew. GPS navigation is overcontrolling of the navigation process and other control options must be applied, such as air traffic control (ATC), satellite tracking of aircraft, or other control measures. Implementation of GPS was a corrective action to navigational drift with good intentions for ATC to control aircraft separation. The difference between corrective action and control is that a corrective action is a one-time reaction to correct a segment of a process and designed after an undesired event occurs in an organization, e.g. GPS, while control is ongoing and </span><span style="font-family: Calibri; font-size: 14pt;">performed continuously to influence or direct behavior, or to influence course of events, e.g. ATC.</span></p><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b>s with any system, it is impossible for a safety management system (SMS) to predict time (speed), space (location), and compass (direction) of an future midair collision. However, with overcontrolling of processes, but one or more control options are excluded from that process, the process itself becomes a higher risk level than what it was prior to overcontrolling. Back in 2012 a midair collision occurred in the middle of nowhere. Both aircraft were on a predetermined track directly to their destination airport. A few minutes takeoff delay by one aircraft would have prevented the collision with current flight conditions that day since their intersecting track would not have intersected at either aircraft time of arrival at that location. GPS tracks predetermined their intersecting positions. Both tracks were overcontrolling a common cause variations by overcontrolling natural drift and heading corrections due to winds.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiVVzqeNQpQliMdlzlpIZhpiun8At-Tn-gxgIZw45cgTvCGPzONRMg9F4wcDv64begGYbdHI_MJLnFVIeGGksG9WRSMTB-1NgYoIW8EgQTFhxfFa7qYB7UaZ7cfwy8N1RlRRSesr3KU-cFqcx5Lf5vLfkQscVB8992l3Hqb5AmGva9HL-j7v1ScmBtcM7K3/s368/Screenshot%202023-08-05%20at%2011.38.23%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="277" data-original-width="368" height="301" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiVVzqeNQpQliMdlzlpIZhpiun8At-Tn-gxgIZw45cgTvCGPzONRMg9F4wcDv64begGYbdHI_MJLnFVIeGGksG9WRSMTB-1NgYoIW8EgQTFhxfFa7qYB7UaZ7cfwy8N1RlRRSesr3KU-cFqcx5Lf5vLfkQscVB8992l3Hqb5AmGva9HL-j7v1ScmBtcM7K3/w400-h301/Screenshot%202023-08-05%20at%2011.38.23%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>W</b>hat was missing here, was ATC with their control option to manage the overcontrolled GPS track. Without GPS precision tracking, common cause variations would have drifted either aircraft off track to intersect at a different location. With only one degree of compass error and assuming no wind corrections, one aircraft </span><span style="font-family: Calibri; font-size: 14pt;">would have been 5 NM off track, and the other 2 NM off track. By a random draw and at their known time of departure, the odds, or probability for each aircraft to match each of these conditions, their time within 2.3 seconds, location within 1/8 SM, and track within 1/128 degree to be within approximately 50 feet of each other are inconceivable, and times between intervals are imaginary, theoretical, </span><span style="font-family: Calibri; font-size: 14pt;">virtual, or fictional. By random chance these aircraft would not been involved in a midair collision, but with an overcontrolled process, and elimination of one control item, the accident happened. For anyone who has flown aircraft for a few years, it is known that the highest risk of midair was when an aircraft was crossing a ground-based navigation fix. Today, with GPS direct tracks, any GPS geopoint is a ground-based navigation fix.</span></p><div class="page" title="Page 3"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">Human behavior is to overcontrol processes for a perfect result output. A simple example is marketing of new products stating that this product is new and improved, which implies that the prior product was old and inferior. The old and inferior product may have produces satisfactory outputs, but human factors demands overcontrolling and new and improved products. A safety management system is in the same risk category that improvements is necessary to improve </span><span style="font-family: Calibri; font-size: 14pt;">safety in aviation. The old saying still holds true within an SMS, “if it ain’t broke, don’t fix it”. There is a very fine line to balance between improving a process and </span><span style="font-family: Calibri; font-size: 14pt;">overcontrolling the same process, or implementing a fix to a process that was not broke.</span></p><p><span style="font-family: Calibri; font-size: 14pt;">Overcontrolling of processes is an easy trap to fall into for a certificate holder since there are SMS systems and limitations constraints. Every system comes with constraints and limitations, and within an SMS enterprise it is crucial that the person managing their SMS comprehend these constraints and limitations, and consider how overcontrolling affect policies, operational processes, procedures, acceptable work practices and safety cases or system analyses.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>P</b>rocess control is the ability to monitor and adjust a process to give a desired output. It is used in the safety management system to maintain performance expectations and continued safety improvements. An example of process control is to control the temperature in a room by using a heater or cooler and a thermostat as a control tool with display to verify desired temperature. The assumption when using this process control is that goods, vegetables or produce placed in the room will also maintain the same temperature internally as what the room temperature </span><span style="font-family: Calibri; font-size: 14pt;">is. When a refrigerator temperature is set to 37° F, it is assumed that everything else placed in that refrigerator also will maintain 37° F.</span></p></div></div></div><div class="page" title="Page 4"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>O</b>ne of the most difficult task for the person managing a safety management system is to classify hazards by safety critical areas and their safety critical function. A departure is a safety critical area, with several safety critical functions are attached. One of these safety critical functions is rotation where several parameters must have been met for a pilot to initiate the rotation. Some of these parameters are engine performance, aircraft performance and airfield suitability, e.g. runway condition and length. A published suitable runway may not be suitable for take of at the time when an aircraft reaches rotation speed. Rotation is a higher risk level than a clearance from ATC to line up and wait on the runway. Each of these two examples are safety critical areas with attached safety critical function as their classification identification, but one of these classifications is a hazard with a higher risk level. It is this risk level that is a challenge for the SMS manager to assign differently to each safety critical function. Overcontrolling of processes occurs when all safety critical functions and associated classification identification are assigned the same risk level.</span></p></div></div></div></div></div></div><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgFE8In8umlwGJ-F1HZRDLrKrTQs8Z5cFu5edvoXfEKfOjhBkB2pz2QyGqnoGrJ6NdNPi2xZTGTeV7YA4w3hLuB5UUYwJB6S10cejbz6attS1XYpqWAYQXerOLsrop0DlEP8qKF4vp2lYa34sxp1Chbd0P3y3KZn0UpL7edZiBXHK8r_OQdbfdQXvYyA5v-/s375/Screenshot%202023-08-05%20at%2011.39.56%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="290" data-original-width="375" height="309" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgFE8In8umlwGJ-F1HZRDLrKrTQs8Z5cFu5edvoXfEKfOjhBkB2pz2QyGqnoGrJ6NdNPi2xZTGTeV7YA4w3hLuB5UUYwJB6S10cejbz6attS1XYpqWAYQXerOLsrop0DlEP8qKF4vp2lYa34sxp1Chbd0P3y3KZn0UpL7edZiBXHK8r_OQdbfdQXvYyA5v-/w400-h309/Screenshot%202023-08-05%20at%2011.39.56%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 4"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>O</b>vercontrolling of processes occurs when an occurrence is assigned a possibility to occur, as opposed to a probability level. There are possibilities for events to occur anytime daily, while the probability for events to happen is scaled from 0 to 1. A probability level of zero is justified as inconceivable, and times between intervals </span><span style="font-family: Calibri; font-size: 14pt;">are imaginary, theoretical, virtual, or fictional. A probability level of 1 is justified as systematically, and times between intervals are methodical, planned, and </span><span style="font-family: Calibri; font-size: 14pt;">dependable, without defining the operational system or processes involved. There is a possibility that an aircraft will experience an engine failure on every departure, but the probability of an engine failure for one departure is highly unlikely. A departure may be assigned a probability level of 0.3 with a justification of remotely, and times between intervals are separated by breaks, or spaced greater than normal operations could foresee. For a probability level to be effective and reliable, it is assigned specifically to the current task at hand and is not assigned to multiple future tasks. An example is that a probability level is assigned to the current departure at a specific airport but is not assigned to other departures at that same airport until an aircraft is released for movement.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhjoGQC0G8jl_t8nM8x_2fdtrnKjfBdbuMej3f_VXaSfFX8xh9zb8OJ-XDGbMWQXDVs4boGDJ1TShYGtihU-SVOz1VhyqZcKeamKlFKgYzSi1v4tjK5LxXXKLdPpKxK33nFSoPJc1miftUeMjfgltpc_e59Epp7x-XGLmIaatExfXjRevJxxOcBcRXdV0VD/s409/Screenshot%202023-08-05%20at%2011.41.27%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="279" data-original-width="409" height="272" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhjoGQC0G8jl_t8nM8x_2fdtrnKjfBdbuMej3f_VXaSfFX8xh9zb8OJ-XDGbMWQXDVs4boGDJ1TShYGtihU-SVOz1VhyqZcKeamKlFKgYzSi1v4tjK5LxXXKLdPpKxK33nFSoPJc1miftUeMjfgltpc_e59Epp7x-XGLmIaatExfXjRevJxxOcBcRXdV0VD/w400-h272/Screenshot%202023-08-05%20at%2011.41.27%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 5"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b>n airport operator may assign a safety critical area with a safety critical function to winter operations. Different runways may be assigned a different hazard classification identification, and each runway may be assigned a different risk level. Variables affecting runways are the obvious ice and snow in the winter, but </span><span style="font-family: Calibri; font-size: 14pt;">also arrival and departure obstacles and current wind direction and velocity. Wind gusts may not always be detected by weather stations in time to be published and notify pilots on approach or departure. </span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b>n example of an aircraft crash due to this phenomena is that the crosswind 20KTS with gust to 25KTS, but instantly and without warning a crosswind gust went to 48KTS. One runway may also have a different runway condition code than another runway at the same airport. A runway condition code is reported by runway thirds, and each 1/3 may be assigned a different code with an associated risk level. </span><span style="font-family: Calibri; font-size: 14pt;">In the aviation industry and applied that a trend equals two events. When two events become a trend, overcontrolling of processes becomes a trap for certificate holders. A second trap for a certificate holder is to incorrectly identify common cause variations as special cause variations or incorrectly identify special cause variations as common cause variations. When a common cause variation is identified as a special cause variation with a root cause analysis is initiated, the root cause will be incorrect since the identified variation is required for the process to function as intended. When assigning a corrective action plan to an incorrect root cause, with the additional control action, a process becomes unstable since the certificate holder now is forcing a required element out of the process. While this is a special cause event for airport operations to experience a wind gust to gust from 25KTS to 48KTS without warnings and without visible thunderstorms, it is outside of the scope for an airport to conduct a root cause analysis since they do not have control over the environment, or the weather system reporting process. Overcontrolling the process could lead to other hazards if the airport frequently is closed due to possibilities of unexpected events.</span></p><div class="page" title="Page 6"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">Over a period of twelve months an airport experienced one runway incursion with an airport vehicle. When a vehicle is obstructing an aircraft for landing or takeoff, is a special cause variation and a root cause analysis is needed. After the root cause is identified a corrective action plan is implemented, and control options are added to operations. One event over twelve months is not a trend, or a pattern. A corrective action could be to install a moving map in the vehicle for the driver to view aircraft movements on the field. It may not be possible to for a driver to see an aircraft if a vehicle is 1-2 miles away. Overcontrolling this process would be to develop a minute by minute procedure for tasks to be completed prior to proceeding to the next segment for a vehicle operator when approaching a runway, which could include hundreds of specific items before entering a runway.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b>ny of these tasks on their own may be tasks that make sense, but when combined into an overcontrolling process these tasks combined by the number of tasks and the purpose of each task. Overcontrolling a process takes the focus away from the process output itself and move the focus to task compliance. The process output is for the driver to proceed when it has been established that there is not a conflict </span><span style="font-family: Calibri; font-size: 14pt;">between an aircraft and vehicle. One vehicle and aircraft incursion over a twelve- month period at an airport with 1 million movements is not a trend and becomes acceptable within a safety management system statistical process control (SPC) analysis. What makes this so very difficult to accept by an airport operator, is that an accepted incursion within an SPC process is incorrectly interpreted as an acceptance of the incursion itself.</span></p></div></div></div><div class="page" title="Page 7"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>O</b>vercontrolling processes is a result of an airport or airline operating a safety management system without a statistical process control system. Without an SPC an operator is missing out at the process level and applies their control to the procedure level, or acceptable work practices level. Overcontrolling a process is to assign unnecessary tasks for a defined expected outcome.</span></p><p><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">OffRoadPilots</span></p></div></div></div></div></div></div><p><span style="font-family: Calibri; font-size: 14pt;"><br /></span></p></div></div></div><p><span style="font-family: Calibri; font-size: 14pt;"><br /></span></p></div></div></div></div></div></div><p><span style="font-family: Calibri; font-size: 14pt;"><br /></span></p></div></div></div>SMS/QA Control Managementhttp://www.blogger.com/profile/09611789820282926862noreply@blogger.com0tag:blogger.com,1999:blog-3664537417151106536.post-23675826296878611522023-07-22T11:38:00.004-07:002023-07-22T11:38:40.678-07:00Justification Of Processes<div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">Justification Of Processes</span></p><p><span style="font-family: Calibri;"><span style="font-size: x-small;">By OffRoadPilots</span></span></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri;"><b><span style="font-size: x-large;"><i>O</i></span></b><span style="font-size: medium;">n March 10, 1988, an aircraft crashed shortly after takeoff during winter condition operations. Air Ontario Flight 1363 was a scheduled Air Ontario passenger flight which crashed near Dryden, Ontario, on 10 March 1989 shortly after takeoff from Dryden Regional Airport. The aircraft was a Fokker F28-1000 Fellowship twin jet. It crashed after only 49 seconds because it was not able to attain sufficient altitude to clear the trees beyond the end of the runway, due to ice and snow on the wings.</span></span></p><p><span style="font-family: Calibri;"></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhfK0YQ2IEa45q3fwm6nuSf56VAa-s-FzWSAZhUjhqSEHgFIgg8OC_NXxohaNQZTHgA3CGujXOsivNA1ZCJ-V-zbJfrZOTCuR6ffMzGtJi-LOMl2mRB9kUYR_uz9MJq8u04QxEOcBtU0IN7Y4aB82UpjaNQGsWkcXy3a3luVLJaoGHOP9j2k5mHJUBmsVLW/s393/Screenshot%202023-07-22%20at%202.30.13%20PM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="323" data-original-width="393" height="329" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhfK0YQ2IEa45q3fwm6nuSf56VAa-s-FzWSAZhUjhqSEHgFIgg8OC_NXxohaNQZTHgA3CGujXOsivNA1ZCJ-V-zbJfrZOTCuR6ffMzGtJi-LOMl2mRB9kUYR_uz9MJq8u04QxEOcBtU0IN7Y4aB82UpjaNQGsWkcXy3a3luVLJaoGHOP9j2k5mHJUBmsVLW/w400-h329/Screenshot%202023-07-22%20at%202.30.13%20PM.png" width="400" /></a></div><p></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b>t that time there were no regulated safety management system (SMS) in place and the accident generated several safety improvements and operational changes to aviation. A question to ask is if the same accident could happen today with an implemented and operational SMS. SMS is not </span><span style="font-family: Calibri; font-size: 14pt;">a system that is dependent on a specific person in charge but is reliant on processes. If processes are incomplete, then the same type of accident could happen again today with an SMS. Prior to SMS became the regulatory requirement for safety in operations, safety was absolutely dependant on individuals and their opinions. Conventional wisdom within the aviation industry is if the individual in charge of the crashed Dryden airline had not left their position, the accident would have been avoided. This is of course speculations, and speculations does not have a place for the safe operations of an aircraft or airport.</span></p></div></div></div><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>W</b>inter, snow, ice, and runway contamination seem so far away when it is in the middle of summer and hot weather. The Drayden accident happened in the month of March, which is towards the end of winter many places in the Northern Hemisphere. The pilots had flown many snowy days during their last few months of work. When they came to work that day, they expected to complete their runs on time and rest for their next duty day. There was nothing unusual about this trip until the flight crew departed with snow on their aircraft. Just a few years later Air Florida crashed into the 14th Street Bridge over the Potomac River. The aviation industry had not learned their lessons from the Dryden accident.</span><span style="font-family: Calibri; font-size: 14pt;">trap for airlines and airports with an SMS is to expect that they need to be perfect and extreme proficient in their operations and have zero accidents goals </span><span style="font-family: Calibri; font-size: 14pt;">and to stay safe. This leads to tampering with processes, or over controlling of processes by adjusting the aiming point after occurrences. When a stable process is adjusted to correct a result that is undesirable, or for a result that is extra good, the output that follows will be worse than if he had left the process alone. When a process is centered on target and is in state of statistical control, any adjustments to the process only increase variation.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiLILLE1X5efhPwnUf21JDvjsYzwMSBZDGoiQzwS9CdyKWxOxKetiEFwVyf3fLBQOOZQ-IscNzR0dqS6Uxb3fcHpd_Mv-_ygqNcghcBEYEyg--RGNcyUN5fYd6ISl2w8CF-6MbsvW9U_55GaRAqZuwOKz4i6fB-dgM4vNASiyP-NJfjuCcP1MLX-Vg19qxm/s357/Screenshot%202023-07-22%20at%202.33.35%20PM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="314" data-original-width="357" height="351" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiLILLE1X5efhPwnUf21JDvjsYzwMSBZDGoiQzwS9CdyKWxOxKetiEFwVyf3fLBQOOZQ-IscNzR0dqS6Uxb3fcHpd_Mv-_ygqNcghcBEYEyg--RGNcyUN5fYd6ISl2w8CF-6MbsvW9U_55GaRAqZuwOKz4i6fB-dgM4vNASiyP-NJfjuCcP1MLX-Vg19qxm/w400-h351/Screenshot%202023-07-22%20at%202.33.35%20PM.png" width="400" /></a></div><p></p><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>here is a heavy load of responsibility on the accountable executive (AE) after an accident, but when accidents are of the magnitude of Dryden or Potomac River accidents, their responsibilities just quadrupled. Recovery from accidents is not just to say or post the right words, it is to build back trust with the regulator, aviation industry and the flying public. One of the </span><span style="font-family: Calibri; font-size: 14pt;">responsibilities of an AE is to ensure that the person managing the safety management system performs the duties. An SMS manager is responsible for monitoring the concerns of the civil aviation industry in respect of safety and their </span><span style="font-family: Calibri; font-size: 14pt;">perceived effect on the certificate holder, being airline or airport. After a sever accidents social media ratings for an airline or airport operator involved may plummet within hours.</span></p><div class="page" title="Page 3"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he fact that a captain of an aircraft is the final decisionmaker for safety in operations, there are additional responsibilities for airport operators with an approved safety management system to perform their role to ensure that their airport is suitable. Before taking off from, landing at or otherwise operating an aircraft at an aerodrome, the pilot-in-command of the aircraft must be satisfied that the aerodrome is suitable for the intended operation. Available airport information for pilots is recorded in an airport operations manual (AOM). An AOM contains information about paved and dry movement area surfaces and includes references to airside operations plans when there are deviations from AOM recordings. Where there are deviations, an airport operator is required to publish a NOTAM. A winter operations plan must include procedures for publishing a NOTAM in the event of winter conditions exists that are hazardous to aircraft operations or affect the use of movement areas and facilities. An airport has multiple options when publishing a NOTAM. They could publish that the runway is ice covered, that it is covered with slush, that snow clearing is in progress, or that the runway is closed. An airport operator may close the runway that is covered with slush, ice or snow since their obligations as an operator is to inspect the airport for hazards to aviation safety, and when slush, ice or snow are identified, there are hazards to aviation safety. A justification for maintaining such runways active may be to move aircraft to avoid congestion. It is also a role for an SMS manager to determine the adequacy of training required for airside personnel. Since an airport operator is required to inspect </span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgsYgZ3kqMO3SRbqftmkn3jgPbORNpNEsGMaC-nNoqevZBU5Iz9DdDDvDyIgSn-vGKKX_TAQ-6VJGQCY9wgp4BxYWz3_eDf7QCymp6tV93nQG_A8HfSCl4k3oaYRRQJQ0Dp5wo9kiTj8lnIlsamjJ-7akc4gDNLm2uDNNIYfg2FG7ltgQ0GQsqPpCBAt84n/s371/Screenshot%202023-07-22%20at%202.36.04%20PM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><br /></a></div><br />for hazards, they are also required to train airside personnel to learn what hazards they are looking for, and how airside personnel justify their decision that slush, ice, or snow-covered runways are hazardous to aviation safety. Decisions made by an airport operator is a required tool for an airline captain to determine if the airport is suitable for their type of aircraft operations. An airport operator who does not comply with notification about hazardous operations environment is a concern to the aviation industry and requires an SMS manager to implement corrective action plans.<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgsYgZ3kqMO3SRbqftmkn3jgPbORNpNEsGMaC-nNoqevZBU5Iz9DdDDvDyIgSn-vGKKX_TAQ-6VJGQCY9wgp4BxYWz3_eDf7QCymp6tV93nQG_A8HfSCl4k3oaYRRQJQ0Dp5wo9kiTj8lnIlsamjJ-7akc4gDNLm2uDNNIYfg2FG7ltgQ0GQsqPpCBAt84n/s371/Screenshot%202023-07-22%20at%202.36.04%20PM.png" imageanchor="1" style="font-family: Calibri; font-size: 18.666666px; margin-left: 1em; margin-right: 1em; text-align: center;"><img border="0" data-original-height="228" data-original-width="371" height="246" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgsYgZ3kqMO3SRbqftmkn3jgPbORNpNEsGMaC-nNoqevZBU5Iz9DdDDvDyIgSn-vGKKX_TAQ-6VJGQCY9wgp4BxYWz3_eDf7QCymp6tV93nQG_A8HfSCl4k3oaYRRQJQ0Dp5wo9kiTj8lnIlsamjJ-7akc4gDNLm2uDNNIYfg2FG7ltgQ0GQsqPpCBAt84n/w400-h246/Screenshot%202023-07-22%20at%202.36.04%20PM.png" width="400" /></a></div><p><span style="font-family: Calibri; font-size: 14pt;">Everything changed with implementation of a regulatory required SMS. Rule of thumb in the old safety world was that if it was not stated in the regulation as a requirement, the task was not required to be done. With an SMS the rule of thumb is that since a </span><span style="font-family: Calibri; font-size: 14pt;">task is not stated in the regulatory text is the very same reason why an airport operator or airline must do what it takes to ensure safety. Regulations are just not broad enough to cover each acceptable work practice, procedure, process, policy, or standard. In ICAO states, flight crew are still charged with criminal intent after accidents. A non-punitive reporting policy is not necessarily accepted by the local authorities. On a clear and calm day November 1, 2022, a helicopter crashed and fatally injured all passengers shortly after takeoff. The helicopter pilot was charged criminally, and later the operator was also charged since the helicopter pilot acted on behalf of the operator. The Accident Investigation Board stated that no technical faults had been found that could explain the accident. Without technical fault the only other available justification was to lay criminal charges against pilot and operator since public perception was that someone needed be held accountable. A non-punitive safety policy is far away from a get-out-of-jail free card, but places additional responsibilities on operators and crews to do the right thing when operational tasks are excluded from the text in the regulations.</span></p><div class="page" title="Page 4"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>aking off an airplane with snow or ice on the wings is one of the very first thing a new pilot learn, but for some reasons this basic knowledge is forgotten. Several years ago, a Cessna 185 pilot took off with dry snow on the tail surfaces, the tail stalled, and the aircraft pitched up violently to about a 45 degrees angle. The pilot was able to recover and continue the flight, but justification for takeoff by a several years veteran as a bush pilot was based on other priorities than safety in aviation.</span><span style="font-family: Calibri; font-size: 8pt; font-style: italic;">.</span></p></div></div></div><div class="page" title="Page 5"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b>ir Ontario justified their takeoff and expected the flight to be normal, and the same for Air Florida and the helicopter. However, all captains had clues presented to them before starting their takeoff run, or prior to rotation, but in their ongoing mental risk analysis they all independently justified their takeoff.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b>n SMS manager plays a critical role in aviation safety by their roles to identify hazards and carry out risk management analyses of those hazards. These hazards include hazards other than hazard or incident reported to the SMS system but are hazards already known to the aviation industry. Since an SMS manager cannot be onboard an aircraft 100% of the times, at 100% of their locations, and analyse 100% of their risks, an operator must establish a link between the SMS manager</span><span style="font-family: Calibri; font-size: 14pt;">’s </span><span style="font-family: Calibri; font-size: 14pt;">risk management analyses and their operations. This organizational link is the Director of Operations or Director of Maintenance. Communication of risk analyses results with associated decision-making process are performed by flight following or dispatch, or by maintenance supervisors. For private and smaller operators, such as a helicopter pilot or a small bush plane operator, this link remains with one person, who is the captain of the aircraft.</span></p></div></div></div></div></div></div></div></div></div><p><span style="font-family: Calibri; font-size: 14pt;"><i>OffRoadPilots</i></span></p></div></div></div></div></div></div></div></div></div>SMS/QA Control Managementhttp://www.blogger.com/profile/09611789820282926862noreply@blogger.com0tag:blogger.com,1999:blog-3664537417151106536.post-20241203274802549162023-07-08T06:00:00.005-07:002023-07-08T06:00:36.975-07:00Could SMS Have Prevented March 27th Disaster?<p> <span style="font-family: Calibri; font-size: 14pt;">Could SMS Have Prevented March 27</span><span style="font-family: Calibri; font-size: 9pt; vertical-align: 5pt;">th </span><span style="font-family: Calibri; font-size: 14pt;">Disaster?</span></p><p><span style="font-family: Calibri;"><span style="font-size: x-small;">By OffRoadPilots</span></span></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri;"><b><span style="font-size: x-large;"><i>I</i></span></b><span style="font-size: medium;">f the safety management system (SMS) of today could have prevented the March 27, 1977, worst aviation accident in history when two B-747 at the Los Rodeos Airport on Santa Cruz de Tenerife is a question without answers. There are no answers since SMS is forward-looking and accidents cannot be predicted until the last few seconds when it is evitable that an accident will occur. At the time of the accident, it was assumed that aviation was operating with safe and fail-free systems, except for pilot errors as the bad apples in the box. Pilot error had become industry acceptable root cause to any accidents. It is unknown when pilot error became the popular root cause solutions, but accident reports since the late </span></span><span style="font-family: Calibri; font-size: 14pt;">60’s and early 70’s support this </span><span style="font-family: Calibri; font-size: 14pt;">as a solution. However, after the June 30, 1956, Grand Canyon disaster, the probable cause of the mid-air collision was not allocated to pilot error, but that the pilots did not see each other in time to avoid the collision due to other multiple factors. Human factors are not the same as human error. Human errors or other negatives are not useful for intervention to improve safety but are symptoms of much deeper cause within systems.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjHIr0ZF1PQmXEFbf-HaXWrokY5Latkh2VfbboAUycSuhSdGYiJEl-Loeja4EKUK21v339S0gPLnDKD95wsSxiSCmQqfOY64lS1qyg7FKVeEF53Wcl8NW-1wC38mBz2pByBrlgltwZjkGU7d9ixdRTvDD5fRNL4URjjiT05gZR92OGYg7chVLEmx4H89D9E/s379/Screenshot%202023-07-08%20at%208.54.42%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="316" data-original-width="379" height="334" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjHIr0ZF1PQmXEFbf-HaXWrokY5Latkh2VfbboAUycSuhSdGYiJEl-Loeja4EKUK21v339S0gPLnDKD95wsSxiSCmQqfOY64lS1qyg7FKVeEF53Wcl8NW-1wC38mBz2pByBrlgltwZjkGU7d9ixdRTvDD5fRNL4URjjiT05gZR92OGYg7chVLEmx4H89D9E/w400-h334/Screenshot%202023-07-08%20at%208.54.42%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>B</b>efore we answer the question if an SMS could have saved both aircraft, </span><span style="font-family: Calibri; font-size: 14pt;">let’s look at what SMS is.</span><span style="font-family: Calibri; font-size: 14pt;">SMS is a system that introduces an evolutionary and is a structured process that obligates organizations to manage safety with the same level of priority that other core business processes are managed. SMS is a structured means of </span><span style="font-family: Calibri; font-size: 14pt;">safety risk management decision making, it is a means of demonstrating safety management capability before system failures occur, it is increased confidence in </span><span style="font-family: Calibri; font-size: 14pt;">risk controls though structured safety assurance processes, it is an effective interface for knowledge sharing internally and between external organizations, and it is a safety promotion framework to support a sound safety culture an promote business strategies. An effective safety management system is a support system to the business itself just as serval other systems are required to conform to regulatory compliance, to recognize competitors, to maintain business relations and to evaluate processes for effectiveness to meet defined goals.</span></p></div></div></div><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he four factors of the 1977 disaster that stands out in the accident report are human factors, such as communication and observations, it is organizational factors, such as authority and decision-making, it is supervision factors, such as air traffic services, lights and signage, and environmental factors, such as weather and airport design. These factors combined played their roles in designing, planning and execution of the disaster. At the time when the decision was made to divert all aircraft to Los Rodeos the accident process was put in place.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he first aircraft to taxi was backtracking runway 12 for departure runway 30 and instructed to exit the runway at the 1</span><span style="font-family: Calibri; font-size: 9pt; vertical-align: 5pt;">st </span><span style="font-family: Calibri; font-size: 14pt;">taxiway to hold at runway 30 but was later cleared to taxi to button runway 30 for takeoff. The second aircraft was also cleared to backtrack runway 12 but to clear the runway at the 3</span><span style="font-family: Calibri; font-size: 9pt; vertical-align: 5pt;">rd </span><span style="font-family: Calibri; font-size: 14pt;">taxiway. After they were lined up on runway 30 the first aircraft received their departure clearance. The second aircraft was still backtracking runway 12 looking for the third taxiway exit when the first aircraft departed runway 30 and an accident was evadible to occur. At the time of accident runway visibility varied between 300 meters to 1500 meters (1000 ft </span><span style="font-family: Calibri; font-size: 14pt;">– </span><span style="font-family: Calibri; font-size: 14pt;">5000 ft).</span></p><p><span style="font-family: Calibri; font-size: 14pt;">The first task to operate with an SMS is to appoint an accountable executive (AE) to be responsible for operations or activities authorized under the certificate and accountable on behalf of the certificate holder for meeting the requirements of the regulations. An SMS policy includes safety objectives, commitment to fulfill safety objectives, a safety reporting policy of safety hazards or issues, and defines unacceptable behavior. A safety policy must also be documented and communicated throughout the organization. What the safety policy does is to </span><span style="font-family: Calibri; font-size: 14pt;">establish the base and foundation to build an SMS, and to plant the seed that safety is paramount. Human factors, organizational factors, supervision factors and environmental factors must be linked to the safety policy to instill process awareness and accountability in all personnel. With a mature SMS it is expected that personnel have learned to consider special operations, such as the combination of hazards with overcrowded airports, low visibility, and more aircraft on the movement area than the airport was designed to support. An SMS in 1977 would include tools to affecting the outcome since the accountable executive appointed by their name takes pride in their roles to be responsible for safety. In addition, and between the airport operator, ATS and the two airlines, there was a tool available to recognize that their SMS includes processes to recognize that a combination of an overcrowded ramp and low visibility is special operations and therefore normal operations processes are invalidated.</span></p></div></div></div><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiqGsLWJ0o4gfOXkJX3hyla0_TnAZaG4uV3RAN8wypRZgXFf6xg2DAccTESTRrplBAZVqtn336Ds7EmLPzW6D6rRqoUarVw3gJHhEPO17GEuZzFUNpQG7mevtzX9kWoQPJi6kh448RM2UdmgjfZtfRxMdn0xD7bIxytuZwjcPd0Rx2PCex_7z4wHTQNIkB1/s380/Screenshot%202023-07-08%20at%208.56.22%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="282" data-original-width="380" height="296" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiqGsLWJ0o4gfOXkJX3hyla0_TnAZaG4uV3RAN8wypRZgXFf6xg2DAccTESTRrplBAZVqtn336Ds7EmLPzW6D6rRqoUarVw3gJHhEPO17GEuZzFUNpQG7mevtzX9kWoQPJi6kh448RM2UdmgjfZtfRxMdn0xD7bIxytuZwjcPd0Rx2PCex_7z4wHTQNIkB1/w400-h296/Screenshot%202023-07-08%20at%208.56.22%20AM.png" width="400" /></a></div><div class="page" title="Page 3"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b> regulatory requirement of an SMS is to adapt to is the size, nature and complexity of the operations, activities, hazards and risks associated with the operations of the certificate holder. Since there were an abnormal level of heavy aircraft and abnormal number of aircraft that day, an SMS applicable to normal operations would </span><span style="font-family: Calibri; font-size: 14pt;">be scaled to much smaller operations. If an SMS had been in place on that day, the airport operator or ATS would have had a tool to recognize that their SMS was not designed, or capable of managing the increased traffic volume. Human factors would be affected by communication and observations, organizational factors by authority and decision-making processes, supervision factors by ATS overload compared to normal operations, and environmental factors by weather and airport design. An SMS designed to size, and complexity is essential in a </span><span style="font-family: Calibri; font-size: 14pt;">decision making process to establish a limit when the system becomes overloaded. Just as an electric cable is designed for a limited voltage, an SMS is designed for a limited load factor.</span></p><div class="page" title="Page 4"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b> quality assurance program is a requirement to be included in an SMS. A prerequisite to maintain a quality assurance program is operational quality control. If a quality assurance program had been in place at that time, it would have included a daily quality control system where processes are linked to regulatory requirement and safety expectations. In a business transaction cash is counted daily and the same principle applies to a safety management system. Process compliance with regulatory requirement, safety policy and process outcome must be accounted for daily to recognize drift, limitations and volume. An SMS that day would have included tools to capture the fact that runway capacity was overloaded that day.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b> safety management system is required to assign duties on the movement area and any other area set aside for the safe operation of aircraft, including obstacle limitation surfaces, at the airport, only to personnel who have successfully completed a safety-related initial training course on human and organizational factors. Airside personnel that day would have been equipped with SMS tools to recognize the overload on human and organizational factors with the increased volume and aircraft size.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b>n SMS is required to include a policy for the internal reporting of hazards, incidents and accidents, including the conditions under which immunity from disciplinary action will be granted. If an SMS had been in place that day, the flight crew of any aircraft, not just the two involved in the accident, would have been equipped with a tool to recognize hazards and filed hazard reports by telephone or fax. A report is an SMS tool to trigger a reaction to an overloaded airport operations that day.</span></p><p><span style="font-family: Calibri; font-size: 14pt;">The accountable executive is the person accountable on behalf of the certificate holder to meet the requirements of the regulations, and compliance with their SMS policy. This position is not a position for the person to be held accountable, or responsible for past incidents, but for the person to maintain oversight and </span><span style="font-family: Calibri; font-size: 14pt;">communicate with workers and the regulator on issues and compliances. An SMS is required to include procedures for making progress reports to the accountable executive at intervals determined by the accountable executive and other reports as needed in urgent cases. A report to the AE of low visibility operations, volume and aircraft size is an SMS tool to trigger urgent issues and when reported immediately it is an SMS tool for the AE for action and communication with their flight crew and airport operator.</span></p></div></div></div><div class="page" title="Page 5"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b> quality assurance program is required to be included in the SMS is a function of the SMS to establish policies, processes, and procedures. These processes and procedures are then applied in an operational quality assurance program to perform specific required task. One of the tasks is to perform regular audits. For airports, audits are preformed by checklists of all activities controlled by the airport operations manual. An SMS on March 27</span><span style="font-family: Calibri; font-size: 9pt; vertical-align: 5pt;">th </span><span style="font-family: Calibri; font-size: 14pt;">would have included a tool to recognize the excess volume and workload and a trigger for the airport operator to review their activities controlled by the airport operations manual.</span></p></div></div></div></div></div></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgdlw9f2KuWfOp2C5hXMpq_qAWStRPAK-cmqGJOmbLc0G2JQNafuro92akEDbeJ3e3NLMvajTMWMDij1U8qZ5z_r5FtPCv5s6BgfwdWGDqz4Yi8qP9tEV7YVbXT6KQgxcoOZM4XYlLwPRYa8daowyAtuqNy09oBU58JsFPMXufqw4dRIevBBAHPKNR6856k/s376/Screenshot%202023-07-08%20at%208.59.12%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="286" data-original-width="376" height="304" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgdlw9f2KuWfOp2C5hXMpq_qAWStRPAK-cmqGJOmbLc0G2JQNafuro92akEDbeJ3e3NLMvajTMWMDij1U8qZ5z_r5FtPCv5s6BgfwdWGDqz4Yi8qP9tEV7YVbXT6KQgxcoOZM4XYlLwPRYa8daowyAtuqNy09oBU58JsFPMXufqw4dRIevBBAHPKNR6856k/w400-h304/Screenshot%202023-07-08%20at%208.59.12%20AM.png" width="400" /></a></div><div class="page" title="Page 5"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he person managing the SMS, which could be the position of an SMS Manager, Safety Officer, or Director of Safety, is required to determine the adequacy of the training required in their safety management system. This training includes indoctrination training, initial training, upgrade</span></p><p><span style="font-family: Calibri; font-size: 14pt;">training and annual refresher training. Flight crew or airside personnel received this training would have a tool to recognize hazardous condition and reported it via their SMS process.</span></p><div class="page" title="Page 6"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he person managing the SMS is also required to monitor the concerns of the civil aviation industry in respect of safety and their perceived effect on the certificate holder, or SMS enterprise. Dispatch for any of the airlines were monitoring diversions and weather conditions with their tools available at that time, and their SMS training would have triggered a report of this abnormal condition to their SMS system, and someone would be required to make a decision if any actions were required, and if these hazards combined were incompatible with the safe operation of an airport or aircraft.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>W</b>ithin an SMS the hazards of March 27</span><span style="font-family: Calibri; font-size: 9pt; vertical-align: 5pt;">th </span><span style="font-family: Calibri; font-size: 14pt;">need to be analyzed without knowing, or considering the outcome, but be analyzed as an event in the future based on information available at that time. SMS is unable to establish if an incident will occur or not in the future, and it is therefore impossible to determine if an SMS would have prevented the March 27</span><span style="font-family: Calibri; font-size: 9pt; vertical-align: 5pt;">th </span><span style="font-family: Calibri; font-size: 14pt;">accident. On January 13</span><span style="font-family: Calibri; font-size: 9pt; vertical-align: 5pt;">th</span><span style="font-family: Calibri; font-size: 14pt;">, 2022 there was a similar incident at JFK airport, except there were no low clouds or fog. The tower could see an aircraft crossing directly in front of a departing aircraft and their takeoff was aborted. On this day, both airlines involved were operating with an SMS, but an SMS did not prevent the incident, and an SMS by itself could not have prevented the Los Rodeos accident without applying tools in the SMS toolbox.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>H</b>owever, on March 27</span><span style="font-family: Calibri; font-size: 9pt; vertical-align: 5pt;">th </span><span style="font-family: Calibri; font-size: 14pt;">an SMS would have made available several triggers for flight crews, ATS and the airport operator to pause operations and assess their next step and special cause variations that existed that day. A pause would at a minimum have generated a decision-making process for either the airlines, ATS or the airport operator.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b>n SMS exposes the </span><span style="font-family: Calibri; font-size: 14pt;">“</span><span style="font-family: Calibri; font-size: 14pt;">holes in the Swiss cheese</span><span style="font-family: Calibri; font-size: 14pt;">”</span><span style="font-family: Calibri; font-size: 14pt;">. When the cheese is sliced it exposes the holes within the cheese which comes available to assessed within the context of a system analyses and within observed special operating conditions. Without an SMS there were no triggers, or a person assigned to slice the Swiss cheese on that day, and that is what was missing.</span></p><p><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">OffRoadPilots</span></p></div></div></div></div></div></div><span style="font-family: Calibri; font-size: 14pt;"><br /></span><p></p></div></div></div>SMS/QA Control Managementhttp://www.blogger.com/profile/09611789820282926862noreply@blogger.com0tag:blogger.com,1999:blog-3664537417151106536.post-28687664181024386892023-06-25T05:13:00.000-07:002023-06-25T05:13:15.846-07:00Safety Uphill Battle<p> <span style="font-family: Calibri; font-size: 14pt;">Safety Uphill Battle</span></p><p><span style="font-family: Calibri;"><span style="font-size: x-small;">By OffRoadPilots</span></span></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri;"><b><i><span style="font-size: x-large;">C</span></i></b><span style="font-size: medium;">onventional 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.</span></span></p><p><span style="font-family: Calibri;"></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj90tvMY-dg9dLEOy06IV363lx8YiiWn-egG7YPiPgX-44mNdhc4Ziu02y3X9pD00WAcOFLQRKf2T6fNZ-vT1Md--C9BzUoYu77-oDRGkwKMNQTblkVidB9vnY3JFsuM6xUoZ5pYrOHC3akzTnOhpdymJCIO7ur0iz_4V3QUKGvtoPGEH2gIM9rRFxdLLIv/s377/Screenshot%202023-06-25%20at%208.04.22%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="286" data-original-width="377" height="304" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj90tvMY-dg9dLEOy06IV363lx8YiiWn-egG7YPiPgX-44mNdhc4Ziu02y3X9pD00WAcOFLQRKf2T6fNZ-vT1Md--C9BzUoYu77-oDRGkwKMNQTblkVidB9vnY3JFsuM6xUoZ5pYrOHC3akzTnOhpdymJCIO7ur0iz_4V3QUKGvtoPGEH2gIM9rRFxdLLIv/w400-h304/Screenshot%202023-06-25%20at%208.04.22%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>S</b>afety 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 </span><span style="font-family: Calibri; font-size: 14pt;">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.</span></p></div></div></div><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>W</b>hen 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.</span></p></div></div></div><p><span style="font-family: Calibri;"></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhuE6Bp7nv2CgTMFRexqujlqdU8meQtvJV8LxIKXMnWILbWKhuReeZe7_-4UtVPsIz0LFcEHYjLlGuL5u3_yQBDVrpk78lBXPDMKjXgPMnIQUDbCZ_o6dLChc3Ut5PIxhju2IJZYbMbtMCcgVa8ZzrdhLyA3AE_khy0iLOrnW3JY3NDyd9bT8iLX50SsBuc/s466/Screenshot%202023-06-25%20at%208.07.55%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="466" data-original-width="265" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhuE6Bp7nv2CgTMFRexqujlqdU8meQtvJV8LxIKXMnWILbWKhuReeZe7_-4UtVPsIz0LFcEHYjLlGuL5u3_yQBDVrpk78lBXPDMKjXgPMnIQUDbCZ_o6dLChc3Ut5PIxhju2IJZYbMbtMCcgVa8ZzrdhLyA3AE_khy0iLOrnW3JY3NDyd9bT8iLX50SsBuc/w228-h400/Screenshot%202023-06-25%20at%208.07.55%20AM.png" width="228" /></a></div><p></p><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b> 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 w</span><span style="font-family: Calibri; font-size: 14pt;">e don’t manage </span><span style="font-family: Calibri; font-size: 14pt;">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. </span><span style="font-family: Calibri; font-size: 14pt;">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 </span><span style="font-family: Calibri; font-size: 14pt;">the attainment of those goals. Since SMS is published by the regulator as </span><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">“an extra layer of protection to help save lives”, </span><span style="font-family: Calibri; font-size: 14pt;">a measurement of the regulatory </span><span style="font-family: Calibri; font-size: 14pt;">requirement for “</span><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">measuring the attainment of those goals” </span><span style="font-family: Calibri; font-size: 14pt;">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.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi3SiOmEI3gdRWzF-9xsBjyjCZwiQOxwOAZkMvPd8PaQ1auqSZLVubnJvQ5mBe11oZ1h4e8k_0sITx-0JyKkBXeTAHthC63ZIT4WszGMwUyQukj01--a6ApRNzO2R8s1rTi6ZmMRdazUyr1ojp6Tg63Dhv0_CzI_BtI1GdoJzkPWO-y3hpxdPEacOp0u0cN/s378/Screenshot%202023-06-25%20at%208.09.53%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="317" data-original-width="378" height="335" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi3SiOmEI3gdRWzF-9xsBjyjCZwiQOxwOAZkMvPd8PaQ1auqSZLVubnJvQ5mBe11oZ1h4e8k_0sITx-0JyKkBXeTAHthC63ZIT4WszGMwUyQukj01--a6ApRNzO2R8s1rTi6ZmMRdazUyr1ojp6Tg63Dhv0_CzI_BtI1GdoJzkPWO-y3hpxdPEacOp0u0cN/w400-h335/Screenshot%202023-06-25%20at%208.09.53%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 3"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">Imagine for a minute that you are at the most beautiful restaurant together with your favorite person. </span><span style="font-family: Calibri; font-size: 14pt;">It’s a wonderful </span><span style="font-family: Calibri; font-size: 14pt;">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 </span><span style="font-family: Calibri; font-size: 14pt;">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 </span><span style="font-family: Calibri; font-size: 14pt;">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.</span></p></div></div></div><div class="page" title="Page 4"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>I</b>f 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.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>I</b>t 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.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>SMS</b> 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.</span></p></div></div></div><div class="page" title="Page 5"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>O</b>ne 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.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiCL4v5of_m1EWojsTu1IAskBRnBTDBQm81c4cl4wNQhbsEwfyByM7d4b8oAOwkoib7vEO82f6YokcqaHHAn9t4Kyee9H_tlIN21gy_4EhLbTCIekAZoIMNE15FuGpqFos-A9FSB1vP_iwgGHy7rHjlAbzzGQskz-HFYLX99ygGEuAgh96E0Afq_exhNHfh/s367/Screenshot%202023-06-25%20at%208.11.23%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="285" data-original-width="367" height="311" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiCL4v5of_m1EWojsTu1IAskBRnBTDBQm81c4cl4wNQhbsEwfyByM7d4b8oAOwkoib7vEO82f6YokcqaHHAn9t4Kyee9H_tlIN21gy_4EhLbTCIekAZoIMNE15FuGpqFos-A9FSB1vP_iwgGHy7rHjlAbzzGQskz-HFYLX99ygGEuAgh96E0Afq_exhNHfh/w400-h311/Screenshot%202023-06-25%20at%208.11.23%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 5"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">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 </span><span style="font-family: Calibri; font-size: 14pt;">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.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>S</b>afety 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, </span><span style="font-family: Calibri; font-size: 14pt;">(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.</span></p></div></div></div><div class="page" title="Page 6"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>S</b>afety is an uphill battle for your SMS enterprise when </span><span style="font-family: Calibri; font-size: 14pt;">SMS portrays “life as it should be” </span><span style="font-family: Calibri; font-size: 14pt;">and not </span><span style="font-family: Calibri; font-size: 14pt;">“life as it is” during </span><span style="font-family: Calibri; font-size: 14pt;">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.</span></p><p><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">OffRoadPilots</span></p></div></div></div><p><span style="font-family: Calibri; font-size: 14pt;"><br /></span></p></div></div></div><p><span style="font-family: Calibri; font-size: 14pt;"><br /></span></p></div></div></div><p><span style="font-family: Calibri;"><span style="font-size: medium;"><br /></span></span></p><p><span style="font-family: Calibri;"><span style="font-size: medium;"><br /></span></span></p><p><span style="font-family: Calibri;"><span style="font-size: medium;"><br /></span></span></p><p><span style="font-family: Calibri;"><span style="font-size: medium;"><br /></span></span></p></div></div></div>SMS/QA Control Managementhttp://www.blogger.com/profile/09611789820282926862noreply@blogger.com0tag:blogger.com,1999:blog-3664537417151106536.post-17032381301969311502023-06-10T05:35:00.001-07:002023-06-10T05:35:28.825-07:00Decisions<p> <span style="font-family: Calibri; font-size: 14pt;">Decisions</span></p><p><span style="font-family: Calibri;"><span style="font-size: x-small;">By OffRoadPilots</span></span></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri;"><b><i><span style="font-size: x-large;">O</span></i></b><span style="font-size: medium;">perational 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 </span></span><span style="font-family: Calibri; font-size: 14pt;">wasn’t until the accountability within a safety management system in aviation </span><span style="font-family: Calibri; font-size: 14pt;">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.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgfsAmqzaXvRwSGOXdnDK37ByDj0tH0BmQu7rA8BKEtnj6LTezoxlW8WvLa0eyXI7fjtzBvV-5vvfX9F_dvHBva3bAlK19Kf_l7nvvV5PATryrJ3-eTV_3iipFDou8C95buf4LfPkJiLwClRGIKUFdfe1NM-ZhaWndhtocM01921MhPmuQdycaNTgNgkw/s385/Screen%20Shot%202023-06-10%20at%208.28.44%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="316" data-original-width="385" height="329" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgfsAmqzaXvRwSGOXdnDK37ByDj0tH0BmQu7rA8BKEtnj6LTezoxlW8WvLa0eyXI7fjtzBvV-5vvfX9F_dvHBva3bAlK19Kf_l7nvvV5PATryrJ3-eTV_3iipFDou8C95buf4LfPkJiLwClRGIKUFdfe1NM-ZhaWndhtocM01921MhPmuQdycaNTgNgkw/w400-h329/Screen%20Shot%202023-06-10%20at%208.28.44%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>D</b>ecisions 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 </span><span style="font-family: Calibri; font-size: 14pt;">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.</span></p></div></div></div><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">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.</span></p></div></div></div><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjLsUt4jZctoFJr_LaIrfHW62vcUiGQB8E-MKqr9Ju9vDMDKl93P9-IS3PwosjowwmU2buDM_dDgU2vEgak5A83BqKlVf1Pmgos3JioAyTNQKJitJodWAij9DQBEy3MoBpWMNCMMgG5CtSGme-0onEqbmRXcifgBrxthfp0tqHSwPBBKjBM0b4Ibhapvw/s389/Screen%20Shot%202023-06-10%20at%208.29.59%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="266" data-original-width="389" height="274" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjLsUt4jZctoFJr_LaIrfHW62vcUiGQB8E-MKqr9Ju9vDMDKl93P9-IS3PwosjowwmU2buDM_dDgU2vEgak5A83BqKlVf1Pmgos3JioAyTNQKJitJodWAij9DQBEy3MoBpWMNCMMgG5CtSGme-0onEqbmRXcifgBrxthfp0tqHSwPBBKjBM0b4Ibhapvw/w400-h274/Screen%20Shot%202023-06-10%20at%208.29.59%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>D</b>ecisions 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 </span><span style="font-family: Calibri; font-size: 14pt;">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 </span><span style="font-family: Calibri; font-size: 14pt;">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.</span></p><div class="page" title="Page 3"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>I</b>n 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.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>I</b>t 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.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>W</b>hen 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 </span><span style="font-family: Calibri; font-size: 14pt;">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.</span></p></div></div></div><div class="page" title="Page 4"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b> 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.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b>n 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 </span><span style="font-family: Calibri; font-size: 14pt;">that don’t </span><span style="font-family: Calibri; font-size: 14pt;">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.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>C</b>ommon 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-</span><span style="font-family: Calibri; font-size: 14pt;">world acceptable human behavior. Decision-making processes must therefore be based on data collected to improve safety and not common sense approach.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiF-3UsGwmj014TxNxIHlFdUQOcsmBBpnekqlHIodjp-KueWzjZrmueVlyoxaiMbvRjdAcJGAwVwcT1NdIUsu0W2w6Q8NGunnLqOEFj37Tm2_Z6c1rLaY4RW6bUQQn8hIaieluCBvCBW3YSiqUtd11PITKWSOmNpekO_vEFPJmGOb0Lf756TwM28YyjQA/s385/Screen%20Shot%202023-06-10%20at%208.32.23%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="314" data-original-width="385" height="326" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiF-3UsGwmj014TxNxIHlFdUQOcsmBBpnekqlHIodjp-KueWzjZrmueVlyoxaiMbvRjdAcJGAwVwcT1NdIUsu0W2w6Q8NGunnLqOEFj37Tm2_Z6c1rLaY4RW6bUQQn8hIaieluCBvCBW3YSiqUtd11PITKWSOmNpekO_vEFPJmGOb0Lf756TwM28YyjQA/w400-h326/Screen%20Shot%202023-06-10%20at%208.32.23%20AM.png" width="400" /></a></div><div class="page" title="Page 5"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">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 </span><span style="font-family: Calibri; font-size: 14pt;">monitoring experts rather than pilots, operational managers, and aerodynamics experts. </span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>ransferring 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</span><span style="font-family: Calibri; font-size: 14pt;">:” </span><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">If automation replaces humans in critical stages of a process, the human-error factor is not eliminated, but transferred into an automation package.</span><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">” </span><span style="font-family: Calibri; font-size: 14pt;">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.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>D</b>ecisions 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 </span><span style="font-family: Calibri; font-size: 8pt; font-style: italic;"> </span><span style="font-family: Calibri; font-size: 14pt;">highly constraint time limit, but are just as much part of a defined decision-making process as decisions made in the office.</span></p></div></div></div><div class="page" title="Page 6"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">OffRoadPilots</span></p></div></div></div><span style="font-family: Calibri; font-size: 14pt;"><br /></span><p></p></div></div></div></div></div></div><p><span style="font-family: Calibri; font-size: 14pt;"><br /></span></p></div></div></div>SMS/QA Control Managementhttp://www.blogger.com/profile/09611789820282926862noreply@blogger.com0tag:blogger.com,1999:blog-3664537417151106536.post-18636815260958347832023-05-27T07:07:00.001-07:002023-05-27T07:07:49.187-07:00SMS Most Wanted<p><span style="font-family: Calibri; font-size: 14pt;">SMS Most Wanted</span></p><p><span style="font-size: x-small;">By OffRoadPilots</span> </p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri;"><b><i><span style="font-size: x-large;">A</span></i></b><span style="font-size: medium;"> safety management system includes a list of the ten most wanted fugitive hazards and they are on the run. The most wanted hazards are identifiable hazards, but airports or airlines are unable to locate the whereabouts of their solutions. Hazards are locally different in the operational environment of airport or aircraft operation based on locations, destinations or flight conditions and require an operating environment specific safety risk management system applied.</span></span></p><div class="separator" style="clear: both; text-align: center;"><span style="font-size: medium;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhRl5VDLYQGWC62HR_Sw4Cgpgs-QnqW3LItBnuWeJeaVD_jlFSCD7ISxyM2WW16pGUUt4sWZp-xlVAYeQaASeSxZEfaGq6I0ISrNUlmguhAScVIMK_602S_aa-CHLdnRC72ozewbz_sszXzMdikdORJRJ3iDdZCHW9lEyesfBEDftFW9wAs45WkhPE3oA/s434/Screen%20Shot%202023-05-27%20at%209.55.54%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="434" data-original-width="314" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhRl5VDLYQGWC62HR_Sw4Cgpgs-QnqW3LItBnuWeJeaVD_jlFSCD7ISxyM2WW16pGUUt4sWZp-xlVAYeQaASeSxZEfaGq6I0ISrNUlmguhAScVIMK_602S_aa-CHLdnRC72ozewbz_sszXzMdikdORJRJ3iDdZCHW9lEyesfBEDftFW9wAs45WkhPE3oA/w290-h400/Screen%20Shot%202023-05-27%20at%209.55.54%20AM.png" width="290" /></a></span></div><p></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>C</b>onventional wisdom is that hazard is a condition, when left unattended becomes a risk that foreseeable could cause harm to personnel or contribute to an incident or accident. The person managing a safety management system (SMS) has an obligation to identify hazards and carry out risk management analyses of those hazards. When the whereabout of hazards are unknown there are no requirements to carry out risk management. Make sense. The person managing the SMS is also responsible for implement a reporting system to ensure the timely collection of information </span><span style="font-family: Calibri; font-size: 14pt;">related to hazards, incidents and accidents that may adversely affect safety. This responsibility does not include collection of all hazards, but only hazards that may adversely affect safety. If a condition is an actual hazard to aviation safety is either determined by emotions or data. When emotions are the determining factor, most activities relating to aviation are hazardous. When data is applied as the determining factor, only past occurrences are applied to hazard identification. Both these hazard identification systems come with one built-in flaw, which is that they </span><span style="font-family: Calibri; font-size: 14pt;">are a accepted hazards because someone reported it, or because of past results. What is missing is the identification, or the whereabout of the hazard itself.</span></p></div></div></div><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>hat an aircraft did not slide off a runway when landing on a 100% ice covered runway did not eliminate ice on runway as a hazard because it went unreported or the aircraft arrived without an occurrence, but it became one of the most wanted hazards within the decisionmaking process used by an airport operator and aircraft operator. When an airport operator is using a safety data system to monitor and analyze trends in hazards, incidents and accidents, the value of their trend analysis, or return on their investment, is shaped by their decisionmaking process.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he ten SMS most wanted hazards are identified within an SMS </span><span style="font-family: Calibri; font-size: 14pt;">Enterprise’s</span></p><ol><li style="font-family: Calibri; font-size: 14pt;"><p><span style="font-size: 14pt;">Decisionmaking process;</span></p></li><li style="font-family: Calibri; font-size: 14pt;"><p><span style="font-size: 14pt;">Hazard classification process;</span></p></li><li style="font-family: Calibri; font-size: 14pt;"><p><span style="font-size: 14pt;">Risk level process;</span></p></li><li style="font-family: Calibri; font-size: 14pt;"><p><span style="font-size: 14pt;">Root cause process;</span></p></li><li style="font-family: Calibri; font-size: 14pt;"><p><span style="font-size: 14pt;">Differences identification process;</span></p></li><li style="font-family: Calibri; font-size: 14pt;"><p><span style="font-size: 14pt;">Humanfactorsprocess;</span></p></li><li style="font-family: Calibri; font-size: 14pt;"><p><span style="font-size: 14pt;">Organizationalfactorsprocess;</span></p></li><li style="font-family: Calibri; font-size: 14pt;"><p><span style="font-size: 14pt;">Supervision factors process;</span></p></li><li style="font-family: Calibri; font-size: 14pt;"><p><span style="font-size: 14pt;">Environmentalfactorsprocess;and</span></p></li></ol><p><span style="font-family: Calibri; font-size: 14pt;">10.System analysis.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b> decisionmaking process is a learned process and highly customized to any specific tasks. A pilot may be responsible for the safety of a flight, but for large airlines the decisionmaking process rests with dispatch and management. A decisionmaking process to release an aircraft for departure is a learned process and must fall within approved parameters. Decisionmaking processes for airlines with operational dispatch may not necessarily be a decisionmaking process but are performed based on internal compliance processes to conform to regulatory requirements.</span></p></div></div></div><div class="page" title="Page 3"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b>n on-demand and smaller air operator, operating aircraft under 12,500 lbs was using a similar method as their decisionmaking process. Since their routes were pre-established between the same airport and in the same sequence, they applied a standard time enroute and fuel consumption for each flight and applied the same fuel weight for VFR and IFR conditions based on the most critical condition of flight. Without a regulated dispatch, this process was unacceptable. When a decisionmaking process becomes a product of compliance, as opposed to safety limits and parameters, one of the ten most wanted hazards are disguised within the process itself.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he hazard classification process is a process to establish safety critical areas and unacceptable behaviors while performing airside tasks at an airport or operating an aircraft. A safety critical area is an area of airport or airline operations which for the purpose of safety or immediate threat to aviation or personnel should be fail- free. Conditions affecting safety critical areas and establishing unacceptable safety risk levels are unacceptable behaviors for continued operations. Hazard classification are the safety critical area and the safety critical function. A safety critical function is the activity or task performed within the safety critical area. An aircraft is taking off from a paved runway is a safety critical area. As the aircraft rotate and transitions into a 3D environment is a safety critical function of that area. Rotation becomes the function to focus on for both airlines and airport operators. Since both airlines and airports operates with declared distances and point of rotation becomes the critical point of action for airlines, and the clearway the critical point for airport operators.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he purpose of a differences identification process is to identify hazards locally. A process where one-fit-all process does not support a safety management system. An airlines may depart one airport within a set of hazards parameters, while these parameters may be invalid at their next departure point. Airport operators may assess a risk differently for each runway end with the same hazard classification. The most wanted hazard within differences are operational assumptions.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgRvdW9c0o8LGZVd5gRxdwlE_Gebb5OOnsj20j_ioQtpxzwkh7t-bSQGd9o599wTRjqsdS9UmuISl4uSajwTeLWYJAkyVNEiDNT1XlLT2XVSQI7QGDYwtPLLakhcn4OXYIOwefqQxs2FDqTsWp8knQLyipSnX5nXcgYYiSrUKI3sRaDQX1wBUXEPVG8sA/s379/Screen%20Shot%202023-05-27%20at%209.59.04%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="275" data-original-width="379" height="290" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgRvdW9c0o8LGZVd5gRxdwlE_Gebb5OOnsj20j_ioQtpxzwkh7t-bSQGd9o599wTRjqsdS9UmuISl4uSajwTeLWYJAkyVNEiDNT1XlLT2XVSQI7QGDYwtPLLakhcn4OXYIOwefqQxs2FDqTsWp8knQLyipSnX5nXcgYYiSrUKI3sRaDQX1wBUXEPVG8sA/w400-h290/Screen%20Shot%202023-05-27%20at%209.59.04%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 4"><div class="section"><div class="section" style="background-color: white;"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he risk level process is to analyse probability of occurrence (likelihood that a defined hazard will affect the outcome), severity (caused by the occurrence) and exposure of an identified hazard (level of exposure while performing a task). An aircraft is exposed </span><span style="font-family: Calibri; font-size: 14pt;">to the same hazards through the entire flight, but one hazard may be more severe during a defined phase of </span><span style="font-family: Calibri; font-size: 14pt;">flight. An engine failure may cause a more severe outcome if it happens on takeoff than if it happens in cruise flight. The most wanted hazard is hidden in the justification of likelihood that hazard will affect an operational task. When likelihood is the perfect number probability, but so complex to calculate that it is unrealistic to use it, the hazard lay within the likelihood itself. When calculating the likelihood of an occurrence with a </span><span style="color: #333333; font-family: Calibri; font-size: 14pt;">statistically probability of 10</span><span style="color: #333333; font-family: Calibri; font-size: 9pt; vertical-align: 5pt;">-7</span><span style="color: #333333; font-family: Calibri; font-size: 14pt;">-10</span><span style="color: #333333; font-family: Calibri; font-size: 9pt; vertical-align: 5pt;">-9 </span><span style="color: #333333; font-family: Calibri; font-size: 14pt;">that it will occur includes an analysis of indefinite factors within the affected systems with a probability to activate a hazard. Such an analysis would include the probability that an engine attachment bolt would share off during takeoff due to incorrect installment process. Without justification documented by mathematical calculations the likelihood selection is invalid and a hazard in itself. It has been said that an aircraft is exposed to an engine failure at every takeoff. The hazard of an engine failure exists, but until the engine fails the flight crew is not exposed to an engine failure. The Titanic was not exposed to an iceberg until the iceberg approach its path. Airport operators are also affected by the hidden hazards within </span><span style="color: #333333; font-family: Calibri; font-size: 14pt;">their risk level process. T</span><span style="color: #333333; font-family: Calibri; font-size: 14pt;">he most wanted hidden hazard in the airport operator’s </span><span style="color: #333333; font-family: Calibri; font-size: 14pt;">risk level process is to apply the number of times things went wrong in their calculation as opposed to the reasons why things went right. When it is known why things go right, then drift and changes are based on a platform to be analysed.</span></p></div></div></div><div class="section" style="background-color: white;"><div class="layoutArea"><div class="column"><p><span style="color: #333333; font-family: Calibri; font-size: 14pt;"><b>T</b>he purpose of a root cause process is to establish an area, or factor, within operations to target corrective actions. Targeted corrective action plans are more successful in generating expected changes than randomly applied corrections to randomly selected areas. A root cause is allocated to human factors, organizational factors, supervision factors, or environmental factors. </span></p></div></div></div></div></div><div class="page" title="Page 5"><table style="background-color: white; border-collapse: collapse;"><tbody><tr><td style="border-bottom-color: rgb(0, 0, 0); border-left-color: rgb(0, 0, 0); border-right-color: rgb(0, 0, 0); border-style: solid; border-width: 0pt 0pt 0.006pt;"><div class="layoutArea"><div class="column"><p><span style="color: #333333; font-family: Calibri; font-size: 14pt;"><b>T</b>he first step in a root cause analysis is to determine if it is withing scope, control and authority of the SMS enterprise. The litmus test is if the Accountable Executive can freely apply human and financial resources to implement a corrective action plan. An AE at an airport has this authority to apply human and financial resources to airside operations, but does not have this same authority over a construction contractor doing work at the airport. An airline may use towing vendors to move their aircraft, but it is not within the airline</span><span style="color: #333333; font-family: Calibri; font-size: 14pt;">’</span><span style="color: #333333; font-family: Calibri; font-size: 14pt;">s scope and control to determine the root cause within the towing contractor</span><span style="color: #333333; font-family: Calibri; font-size: 14pt;">’</span><span style="color: #333333; font-family: Calibri; font-size: medium;">s operations system. Two commonly used root cause analysis processes are the 5-WHY process and the fish-bone process. The 5-WHY process is most effective if <span style="caret-color: rgb(51, 51, 51);">analyzed</span> within a 5x5 matrix.</span></p></div></div></td></tr><tr><td style="border-left-color: rgb(0, 0, 0); border-right-color: rgb(0, 0, 0); border-style: solid; border-top-color: rgb(0, 0, 0); border-width: 0.006pt 0pt 0pt;"><div class="layoutArea"><div class="column"><p><span style="color: #333333; font-family: Calibri; font-size: 14pt;"><br /></span></p><p><span style="color: #333333; font-family: Calibri; font-size: 14pt;"><b>W</b>hen there is only one path to the answer in the 5-WHY process, the first question determines the root cause outcome if the WHY is asked five times, or 100 times. Within a 5x5 matrix there are five first-questions asked, and each question is different. When applying the fish- bone process, there are unlimited brain-storming opportunities. When a root cause is applied outside scope and control, limited reasonable questions are answered, and unless opportunities for a hazard to be activated are exhausted, the most wanted hazard in a root cause analysis is on the run within overcontrolled processes.</span></p></div></div></td></tr></tbody></table><div class="layoutArea"><div class="column"><p><span style="color: #333333; font-family: Calibri; font-size: 14pt;"><b>T</b>he most wanted hazards within Human Factors, Organizational Factors, Supervision Factors, and Environmental Factors are found within the answers to the WHAT-WHEN-WHRE-WHY-WHO (position) and HOW questions.</span></p><p><span style="font-family: Calibri; font-size: 14pt;">HUMAN FACTORS are human reaction triggered by eyesight, hearing, taste, touch, or smell. It is human behavior, personal attitude with respect to situation, person or thing, values, beliefs or a just culture environment. Human factors are character and emotions, and other factors affecting the decision-making process and output.</span></p><p><span style="font-family: Calibri; font-size: 14pt;">ORGANIZATIONAL FACTORS is the organizational environment a person works within and as it relates to interactions defined in the SHELL model.</span></p><p><span style="font-family: Calibri; font-size: 14pt;">SUPERVISION FACTORS are direct supervision, remote supervision, or self- supervision. General types of supervision and leaders are structural, participative, servant-leader, freedom-thinking, and transformational leader.</span></p></div></div></div><div class="page" title="Page 6"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">ENVIRONMENTAL FACTORS are operational environment, topographical environment, climate environment, geo-environment, level of just-culture environment, or workstation environment.</span></p><p><span style="font-family: Calibri; font-size: 14pt;">WHAT<br />HUMAN FACTORS - Human behavior, performance, and reaction to event ORGANIZATIONAL FACTORS - A framework to outline authority, accountability, roles, responsibilities, and communication processes.<br />SUPERVISION FACTORS - Function of leading, coordinating, and directing the work of others to accomplish the objective.<br />ENVIRONMENTAL FACTORS - Design and performance environment of design applicability for job performance and encouraging engagement or disengagement in task-result oriented activities.</span></p><p><span style="font-family: Calibri; font-size: 14pt;">WHEN<br />HUMAN FACTORS - Aviation safety process and decision making. ORGANIZATIONAL FACTORS - Design of process and application of process in the operational environment.<br />SUPERVISION FACTORS - Daily, within the regular working hours of personnel, with result-oriented applications.<br />ENVIRONMENTAL FACTORS - Daily, within working hours in Operations, Maintenance, Flight Following or as assigned location.</span></p><p><span style="font-family: Calibri; font-size: 14pt;">WHERE<br />HUMAN FACTORS - Operations and within operational management personnel. ORGANIZATIONAL FACTORS - Management policies and operational processes. SUPERVISION FACTORS - Organizational management in a hierarchy of organizational.<br />ENVIRONMENTAL FACTORS - Operations, Maintenance, Flight Following or as assigned.</span></p></div></div></div><div class="page" title="Page 7"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">WHY<br />HUMAN FACTORS - Human factors knowledge is used to optimize the fit between people and the system in which they work to improve safety and performance. ORGANIZATIONAL FACTORS - Establish an organizational culture for operational processes and expectations for level of safety in operations.<br />SUPERVISION FACTORS - Establishing authority, accountability, roles, and decision authority within the operational processes.<br />ENVIRONMENTAL FACTORS - Establishing and maintaining an environment where personnel have access to design tools and encouragement of performance engagement.</span></p><p><span style="font-family: Calibri; font-size: 14pt;">WHO [position]<br />HUMAN FACTORS - Anyone with operational or SMS roles and responsibilities in operations, maintenance or flight following or other personnel when designing operational processes.<br />ORGANIZATIONAL FACTORS - Established, maintained, communicated, and assessed by all Directors and managers reporting to the Safety Management System are responsible for activities on behalf of the Accountable Executive. SUPERVISION FACTORS - The Accountable Executive is responsible for operations and activities on behalf of the certificate holder. All Directors and managers reporting to the Safety Management System are responsible for activities on behalf of the Accountable Executive.<br />ENVIRONMENTAL FACTORS - Applicable to all personnel, where the Accountable Executive leads with a Safety Policy and objectives and goals safe operation.</span></p><p><span style="font-family: Calibri; font-size: 14pt;">HOW<br />HUMAN FACTORS - Application of processes and tasks for both reactive management and proactive management.<br />ORGANIZATIONAL FACTORS - The delivery of structured processes within the organization.<br />SUPERVISION FACTORS - Processes within the basic types of supervision. General types of supervision and leader are: Structural, Participative, Servant-Leader, Freedom-Thinking and Transformational Leader.</span></p></div></div></div><div class="page" title="Page 8"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">ENVIRONMENTAL FACTORS - Safety operational systems designed for timely delivery within the SHELL model, designed to achieve user friendliness, and for personnel to stay informed during process application.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhPu2jpjJpc2xaB_YyCA9W3wq6DmYPNd2jFrqA-VK9wjbhNhOUaMba5Z0tsnWglNb7D7Dhj7QZgulz47T10MYzXR3I2ZiGVmh42zhIxBfqdC-ibjoGvoI6K2M-udgd7hkYcoVqUqgm8Vk79aAGYJkQ8OG6DcwUv2DIWDg1Cr4wlyDXyi3UE38n86kbmxQ/s377/Screen%20Shot%202023-05-27%20at%2010.04.43%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="273" data-original-width="377" height="290" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhPu2jpjJpc2xaB_YyCA9W3wq6DmYPNd2jFrqA-VK9wjbhNhOUaMba5Z0tsnWglNb7D7Dhj7QZgulz47T10MYzXR3I2ZiGVmh42zhIxBfqdC-ibjoGvoI6K2M-udgd7hkYcoVqUqgm8Vk79aAGYJkQ8OG6DcwUv2DIWDg1Cr4wlyDXyi3UE38n86kbmxQ/w400-h290/Screen%20Shot%202023-05-27%20at%2010.04.43%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 8"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b> System Analysis is a comprehensive analysis of systems, their sub- subsystems, departments and divisions and on- demand processes. System analysis processes are processes to identify hazards within the context of the system analysis. A system analysis is applied to </span><span style="font-family: Calibri; font-size: 14pt;">analyses when considering implementation of new systems, revision of existing systems, or design and development of operational procedures, or identification of hazards, ineffective risk controls through the safety assurance processes, or change management. In addition to a system analysis is of the entire safety management system, a system analysis includes operations or activities authorized under the certificate, and analysis of vendor</span><span style="font-family: Calibri; font-size: 14pt;">’</span><span style="font-family: Calibri; font-size: 14pt;">s who are performing tasks affecting how the aviation industry perceive the certificate holder and accountable executive performance. A system analysis is applicable to vendors and third-party contractors limited to their tasks of operations. In the unlikely event of an incident, a vendor or third-party contractor may conduct their internal root cause analysis and submit to the airline or airport operator. The inclusion of a system analysis of vendors and third-party contractors operational process does not affect the scope, control and authority of an airline or airport root cause analysis.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he most wanted hazard within a system analysis are hazards beyond scope, control and authority of a certificate holder and their accountable executive.</span></p><p><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">OffRoadPilots</span></p></div></div></div><p><span style="font-family: Calibri; font-size: 14pt;"><br /></span></p></div></div></div><p><span style="font-family: Calibri; font-size: 14pt;"><br /></span></p></div></div></div><p><span style="font-family: Calibri;"><span style="font-size: medium;"><br /></span></span></p></div></div></div>SMS/QA Control Managementhttp://www.blogger.com/profile/09611789820282926862noreply@blogger.com0tag:blogger.com,1999:blog-3664537417151106536.post-15349528180408684222023-05-13T03:29:00.000-07:002023-05-13T03:29:50.031-07:00Elevated Runway Edge Lights By Inversion<p> <span style="font-family: Calibri; font-size: 14pt;">Elevated Runway Edge Lights By Inversion</span></p><p><span style="font-family: Calibri;"><span style="font-size: x-small;">By OffRoadPilots</span></span></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri;"><b><span style="font-size: x-large;"><i>W</i></span></b><span style="font-size: medium;">hen operating in the arctic, subarctic, mountainous areas, or sparsely settled areas, airlines and airports needs a safety management system (SMS) that includes optical illusion by inversion, optical illusion by sun angle, and optical illusion known as the black-hole effect. An optical illusion is real and the same as a mirage. A mirage is a real optical phenomenon that can be captured on camera since light rays are actually refracted form the false image. A mirage occurs when there is a temperature inversion. An inversion is when air at higher altitudes is warmer than the air below. When the air below the line of sight is colder than the air above it and when passing through the temperature inversion, the light rays are bent down, and so the image appears above the true object. Mirages tend to be stable, as cold air has no tendency to move up and warm air has no tendency to move down. Mirages make objects below the horizon, or outside of a normal line of sight, visible at the horizon. A sun angle optical illusion is when color of rocks in mountain combined with sun angle make a large mountain range impossible to see.</span></span></p><p><span style="font-family: Calibri;"></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgwa7IoxTA8yG2oEP2WrRrCnIsbUiGqomTwp61bP_EmhAmquF7Ifuicnl8F78rqqDyeHX2Se4nrvY_QkNS8vrqfLYlpgtLhUDvOQBZEwJbh11eojphnJ19U7-eyu-P3Qdks7_FFflrjKaVx07L6dvQwRvnb-ZmahwZ2ZbWUJR4hnOOw5cToVvSelxvglw/s380/Screen%20Shot%202023-05-13%20at%206.18.45%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="199" data-original-width="380" height="210" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgwa7IoxTA8yG2oEP2WrRrCnIsbUiGqomTwp61bP_EmhAmquF7Ifuicnl8F78rqqDyeHX2Se4nrvY_QkNS8vrqfLYlpgtLhUDvOQBZEwJbh11eojphnJ19U7-eyu-P3Qdks7_FFflrjKaVx07L6dvQwRvnb-ZmahwZ2ZbWUJR4hnOOw5cToVvSelxvglw/w400-h210/Screen%20Shot%202023-05-13%20at%206.18.45%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he black hole illusion is a nighttime illusion that occurring when only the runway is visible to pilots without surrounding ground lights. With this illusion there is a tendency, or a trap, for pilots to estimate an incorrect required </span><span style="font-family: Calibri; font-size: 14pt;">descent angle and causing the approach to be lower than required for the runway. Another illusion caused by the black hole conditions on dark nights with no moon or starlight, or without a visible horizon, triggers pilots to believe that are on approach slope since they have a steady view of the runway in their windshield, causing them to fly a longer and shallower approaches than needed to clear obstacles. Unless a pilot has up to date knowledge and is intimately familiar with</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhQvOneRSX_6Xhd1XjdjP2XnQgMNzQJoZrEJZP4XoFzvhrQ7E09Y0XNTZwmvEy0LodAP4h0Prz9OK8KFyxOtVjWYiwlzk_25HeAtB71DwF-yBTZc2MdIWhfre6ey9M77bgkKtP9OuRjHnlUWm3FOIo3qcr9w591e8FHrrCOTO8SStTsHRaqpJD6G6S-0A/s377/Screen%20Shot%202023-05-13%20at%206.20.26%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="210" data-original-width="377" height="223" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhQvOneRSX_6Xhd1XjdjP2XnQgMNzQJoZrEJZP4XoFzvhrQ7E09Y0XNTZwmvEy0LodAP4h0Prz9OK8KFyxOtVjWYiwlzk_25HeAtB71DwF-yBTZc2MdIWhfre6ey9M77bgkKtP9OuRjHnlUWm3FOIo3qcr9w591e8FHrrCOTO8SStTsHRaqpJD6G6S-0A/w400-h223/Screen%20Shot%202023-05-13%20at%206.20.26%20AM.png" width="400" /></a></div><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: medium;">the airfield, thorough pre- approach study and preparation is required to mitigate the black hole hazard. Today, there are online tools and maps available for pilots to become familiar with approaches and departures at most aerodromes and certified airports.</span></p><p><span style="font-family: Calibri; font-size: medium;"><br /></span></p><p><span style="font-family: Calibri; font-size: medium;"><br /></span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiG1-fnliipaQ1MWk1WoxYoIOysKR_Rv8PsbR8D5N8mfgVxN2X52DcqcjCdLFMgPoUtPj9JrL5az2o-D8Wg1ioN7fst4bm8J5gZvDSJ_xmD1K7HPpCqUjGfkN-FzC9lTLR0CItfHLXYFs0Bi5sI5baumCfREmILeUl9svxIypAPjHjEk9egYILet4itUQ/s381/Screen%20Shot%202023-05-13%20at%206.22.36%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="291" data-original-width="381" height="305" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiG1-fnliipaQ1MWk1WoxYoIOysKR_Rv8PsbR8D5N8mfgVxN2X52DcqcjCdLFMgPoUtPj9JrL5az2o-D8Wg1ioN7fst4bm8J5gZvDSJ_xmD1K7HPpCqUjGfkN-FzC9lTLR0CItfHLXYFs0Bi5sI5baumCfREmILeUl9svxIypAPjHjEk9egYILet4itUQ/w400-h305/Screen%20Shot%202023-05-13%20at%206.22.36%20AM.png" width="400" /></a></div><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: medium;">The same black hole illusion occurs during takeoff when the acceleration g-force is applied to the pilot and their cllimbout angle appears as a steeper than normal. On a dark night, without moonlight or starlight, and without a view of the horizon due to the black hole illusion, a tendency is to reduce aircraft pitch and departure </span><span style="font-family: Calibri; font-size: 14pt;">angle may be lower than required to clear obstacles or could even be a negative angle. A contributing factor to a King Air accident in 2007 after a missed approach was caused by the illusion of a climb, when the aircraft was descending.</span></p><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>I</b>t is a regulatory requirement for an airport operator to identify in their airport emergency plan potential emergencies within a critical rescue and fire-fighting access area that extends 1000 m beyond the ends of a runway and 150 m at 90° outwards from the centreline of the runway, including any part of that area </span><span style="font-family: Calibri; font-size: 14pt;">outside the airport boundaries. It is also a regulatory requirement for an airport operator to identify emergencies that can reasonably be expected to occur at the airport or in its vicinity and that could be a threat to the safety of persons or to the operation of the airport. Optical illusions are real and therefore reasonable to be expected to occur for arrivals and departures. The question to answer is how far away from the airport, beyond the 1000 m distance and 150 m from centerline mark an airport operator assess to be reasonable to initiate an emergency response. In 2017 an aircraft crashed and came to a rest beyond a point 150 m from the extended centerline. Since the airport was operating with a safety management system it was reasonable expect that they would initiate their emergency response plan at that time.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEguOq196ykheLoAxNRhvfH1iAg-8vQFIN9jieudF0hVdx7g6IgSzzs2mRHtS0kgLRTyWZrKS6u2QpMn3CJa0nLa1AuDwGJWUf-xIl9ze21fDjKHTThvjLVVuDyVyDq8v6vRHLf_gErez8lPvIMlKgUtxVOYe2_WGVPsAEyxZ7Mjas-ZrPCy8Ri2ux7unA/s380/Screen%20Shot%202023-05-13%20at%206.26.12%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="336" data-original-width="380" height="354" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEguOq196ykheLoAxNRhvfH1iAg-8vQFIN9jieudF0hVdx7g6IgSzzs2mRHtS0kgLRTyWZrKS6u2QpMn3CJa0nLa1AuDwGJWUf-xIl9ze21fDjKHTThvjLVVuDyVyDq8v6vRHLf_gErez8lPvIMlKgUtxVOYe2_WGVPsAEyxZ7Mjas-ZrPCy8Ri2ux7unA/w400-h354/Screen%20Shot%202023-05-13%20at%206.26.12%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 3"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">It is also reasonable to expect that airports identify their outer identification surface as their outer limits of primary responsibility and with a responsibility to assist upon request beyond that distance. In 2011 an airplane crashed about 3000 m from an airport and 280 m from the extended centerline, and the airport responded to the accident. In another accident in 2011 </span><span style="font-family: Calibri; font-size: 14pt;">an aircraft crashed 1500 m from the centerline and the airport activated their response. A safety management system must be tailored specifically to each airport and that airport emergency plan definitions of distance in its vicinity will vary. Since the regulations are not broad enough to cover every detail of airline or airport operations, their SMS must include a practical application of their plan to address hazards and operational tasks. A rule of thumb for an effective SMS is if </span><span style="font-family: Calibri; font-size: 14pt;">the regulations does not require it, this now becomes the very same reason why it is incumbent on airlines or airports to do it.</span></p><div class="page" title="Page 4"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">There are several non-certified aerodromes and remote airports operating without vertical or lateral guidance to their runways. At night, a lighted object, e.g. tower, may appear to be just a few miles ahead of an aircraft in cruise flight, while the actual distance could be 100 miles. When pilots are relying on visual clues as their vertical and lateral guidance, there are times when their aircraft has drifted away from an extended centerline or is low or high on approach. In 1993 a twin engine aircraft approach to an airport at night had the runway in sight at 1200 feet, with a flight visibility near minima. On final approach the crew descended blow a virtual glidepath and aircraft crashed in a hilly and snowy terrain located 5 km short of runway 26. Other examples are major carries approaching low on approach to international airports or lined up on the taxiway for landing. Optical illusions could happen at any airport, but there is a higher probability that an aircraft will be low, high, or drifted away from centerline on approach to airports without vertical and lateral guidance systems.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiTmVsxcXNxtzqLAjKpgkqXVzbVruZnNJBpNoxvozR8NlBSVRY4Dz5f6Pdj5ma8BckPflDhxeV2vFOpjSFH2cT7_5PJXH6X6bLs8a85d_t7lUt-JIiQrjJOqcW-nK5sJlLzTlgLDs-mvkqN_SncOfelVRsmK598bysxwHQdztZUEmnUbg23IiNIf8km7Q/s382/Screen%20Shot%202023-05-13%20at%206.27.22%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="312" data-original-width="382" height="326" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiTmVsxcXNxtzqLAjKpgkqXVzbVruZnNJBpNoxvozR8NlBSVRY4Dz5f6Pdj5ma8BckPflDhxeV2vFOpjSFH2cT7_5PJXH6X6bLs8a85d_t7lUt-JIiQrjJOqcW-nK5sJlLzTlgLDs-mvkqN_SncOfelVRsmK598bysxwHQdztZUEmnUbg23IiNIf8km7Q/w400-h326/Screen%20Shot%202023-05-13%20at%206.27.22%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 4"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">A guidance approach system installed an several airports is the Precision Approach Path Indicator (PAPI), which is a vertical guidance system for aircraft on final approach. Flying the glidepath of a PAPI keeps aircraft within the obstacle protected surface as long as the airport operator is applying their safety management system </span><span style="font-family: Calibri; font-size: 14pt;">processes to monitor for unknown, or new obstacles. An optical illusion created by </span><span style="font-family: Calibri; font-size: 14pt;">a PAPI system is when there is frost on the PAPI lenses, and their lights are deflected.</span></p><div class="page" title="Page 5"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b> rule of thumb when flying approaches without PAPI installed is to be 1000 feet above the runway at 3 NM and to maintain runway edge lights visible in a fixed view. The illusion without guidance is that an aircraft is too high when the actual altitude may be below the safe approach angle. In Canada, airports standards are only applicable to airports serving scheduled service for the transport of passengers. An aerodrome serving large airlines, with hundreds of passengers onboard, is not required to comply with the Canadian Aviation Regulations standards compliance. This is a flaw in the regulatory system when the method of how tickets are purchased determines monitoring of safety at destination or departure airports. If the same principle was to be applied to highway travel, speed limits would only be applicable to national bus carriers with paying passengers.</span></p><p><span style="font-family: Calibri; font-size: 14pt;">Requirements for a certified airport to install PAPI is that they conduct a risk assessment within their SMS to establish the need for a PAPI. One airport determined by their risk assessment that a PAPI was not to be required since there were no data supporting low, high, or off-centre approaches to their airport. When such data is not collected, risk analyses become simple, but do not paint a true picture of their operations. The absence of incidents is not an indication of a healthy safety management system, or a healthy operational environment. Most times things go right because human factors come with built-in resilience, or the ability to correct errors, or bounce back after an occurrence. An occurrence is not just that an aircraft crash, but also when an approach is flown below the slope of a standard approach path. When occurrences go unreported it makes it a simple to fill in the SMS compliance checkboxes, but optical illusions are occurrences to be reported.</span></p><p><span style="font-family: Calibri; font-size: 14pt;">On a dark October night an aircraft was on approach to an airport in the Arctic. That night it was a temperature inversion causing an illusion that runway edge lights were raised well above ground level. When runway lights were elevated, they could be seen from a farther distance and appear to be closer. This night the </span><span style="font-family: Calibri; font-size: 14pt;">runway lights were raised by optical illusion to a heigh where they could be seen above a mountain range that normally would obscure the lights at this distance. Since the lights were visible, the position of the aircraft was determined to be inside the mountain range and safe of obstructions. However, within a few minutes the airplane crashed, since the viewed runway edge lights was an illusion, and they were still on the backside of the mountain.</span></p></div></div></div><div class="page" title="Page 6"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>I</b>n addition to natural made optical illusions, there is a man-made optical illusion that, at night, when an aircraft is parked on the runway in the same direction as an approaching aircraft, makes the park runway aircraft invisible.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>O</b>ptical illusions are real. Only by knowing of their existence, learning about the nature of this phenomena, and verifying position by aircraft instruments can it be determined that they are illusions. When flying on visual clues illusions are real, aircraft may be invisible and runway edge lights may be elevated several feet above their actual ground level location.</span></p><p><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">OffRoadPilots</span></p></div></div></div></div></div></div></div></div></div></div></div></div><p><span style="font-family: Calibri; font-size: 14pt;"><br /></span></p></div></div></div></div></div></div><span style="font-family: Calibri; font-size: medium;"><br /></span><p></p></div></div></div><span style="font-family: Calibri; font-size: 14pt;"><br /></span><p></p></div></div></div><p><span style="font-family: Calibri;"><span style="font-size: medium;"><br /></span></span></p></div></div></div>SMS/QA Control Managementhttp://www.blogger.com/profile/09611789820282926862noreply@blogger.com2tag:blogger.com,1999:blog-3664537417151106536.post-86773214255394674282023-04-29T04:10:00.000-07:002023-04-29T04:10:54.424-07:00Performance Is Exceptional<p><span style="font-family: Calibri; font-size: 14pt;">Performance Is Exceptional</span></p><p><span style="font-size: x-small;">By OffRoadPilots </span></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri;"><b><span style="font-size: x-large;"><i>S</i></span></b><span style="font-size: medium;">ince most of the tasks goes right most of the time, every day performance goes unnoticed and viewed as unexceptional tasks. Airports and airlines fall into a trap to accept repetitious tasks as trivial tasks without considering the successful outcome and these tasks to be less important than complex special tasks assignments. Conventional wisdom is that organizational drift in safety is to drift away from safety in operation to unsafe processes. Drift is neutral and does not affect safety in operations to be improved or reduced. Since drift is neutral, safety improvements or safety reductions are neutral. A concept of an effective safety management system (SMS) is to implement changes for incremental, or continuous safety improvements. Continuous safety improvement is a statement applied to emotions. Such statements are often used in sales and marketing describing a new product or service to be new and improved, which implies that the prior product or service was old and inferior. Safety today does not become old and inferior tomorrow but is fluid and adaptable to external changes.</span></span></p><p><span style="font-family: Calibri;"></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgJe0H-mj8EkX5gFnuKv4GZdTA_4F5mrrcZbn4eH3y0E6ZqblyAek3ukH6q97TQ55m_5wyV4OgdzuiZ2IOe4qqK9fvIP0fm8jqrvM5HhZSbDePBB8KieTaCpdB7hKp2bZiPsh7vHUh5_Jrs9dLO0twxSgQHMIZZDHRyrq1tt5A9abLhm_fQcY3YPAq15A/s387/Screen%20Shot%202023-04-29%20at%207.05.27%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="282" data-original-width="387" height="291" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgJe0H-mj8EkX5gFnuKv4GZdTA_4F5mrrcZbn4eH3y0E6ZqblyAek3ukH6q97TQ55m_5wyV4OgdzuiZ2IOe4qqK9fvIP0fm8jqrvM5HhZSbDePBB8KieTaCpdB7hKp2bZiPsh7vHUh5_Jrs9dLO0twxSgQHMIZZDHRyrq1tt5A9abLhm_fQcY3YPAq15A/w400-h291/Screen%20Shot%202023-04-29%20at%207.05.27%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>C</b>ontinuous safety improvements are the practical drift and the practical compliance gaps. A practical drift is the difference between work imagined and work as actually performed. Work imagined are documented by organizational policies, processes, and procedures. The practical compliance </span><span style="font-family: Calibri; font-size: 14pt;">gap is the difference in regulatory compliance in a static environment where nothing moves, and the regulatory non-compliance within a moving environment. When work imagined becomes the compliance standard for safety in operations, it is with an assumption that their systems, processes or procedures are perfect and </span><span style="font-family: Calibri; font-size: 14pt;">fail-free. The practical drift system is a common cause variation within the system itself. An airline or airport operator must identify these variations for their SMS to conform to regulatory requirements. Regulatory requirements for the person managing the safety management system are to monitor trends, monitor corrective actions and monitor concerns of the civil aviation industry. Monitoring these tasks is to monitor the outcome, which is different than monitoring for compliance with work imagined.</span></p><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">Continuous, or incremental safety improvements are needed for operations to maintain oversight due to external and common cause variations in processes. A change that is done for the purpose of safety, may or may not be an additional benefit to safety in operations. That the safety card is played, e.g., implemented for safety reasons, is more hazardous to aviation safety than continue operations without changing anything.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjsr7kMqD6qX05aztDRUyzXO4VsWCVeHbY6FRxq5uZ1AoNOoNEtVTUgdAv7jxz00mnxmdjMyGrwaTWdMjm53tx1BfAQ1gZ-eYeKAxTDMcdq_GfwSWd-AMmC_2-UK8nQrlJ2-DZ5FEHiRTl2z8w6c7cKZrwRAzwgmHIBfUlly4TxjdAmcWXfrYS9-KJitw/s367/Screen%20Shot%202023-04-29%20at%207.06.48%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="201" data-original-width="367" height="219" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjsr7kMqD6qX05aztDRUyzXO4VsWCVeHbY6FRxq5uZ1AoNOoNEtVTUgdAv7jxz00mnxmdjMyGrwaTWdMjm53tx1BfAQ1gZ-eYeKAxTDMcdq_GfwSWd-AMmC_2-UK8nQrlJ2-DZ5FEHiRTl2z8w6c7cKZrwRAzwgmHIBfUlly4TxjdAmcWXfrYS9-KJitw/w400-h219/Screen%20Shot%202023-04-29%20at%207.06.48%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>akeoff performance charts for gravel runway are different from performance charts for paved runways. Rolling resistance, sometimes called rolling friction or rolling drag, is the force resisting the motion when a body rolls on a </span><span style="font-family: Calibri; font-size: 14pt;">surface. An aircraft rolling on a graveltop surface experiences higher resistance than an aircraft rolling on a blacktop surface. A new type of graveltop runways is the Thin bituminous surface runways classification. Gravel runways have successfully been used for decades in places where it is expensive to make runway pavement or concrete. When operating on gravel runways there are loadbearing restrictions, and there are aircraft performance restrictions. These restrictions are often viewed as a burden and a restriction to operations rather as an additional layer of safety. Gravel runways are located far away from emergency services should an incident occur, and there are airports where public emergency services </span><span style="font-family: Calibri; font-size: 14pt;">do not exist. Operating with gravel runways restrictions is to adjust operations to geolocations, since hazards are identified locally. Aircraft weight restriction due to gravel operations is viewed as a trivial task restricting affecting business revenue, rather than for the exceptional performance task it is. Classification of thin bituminous surface runways is a change in classification only, from a gravel runway to a paved runway. With this change, aircraft maximum gross weight is allowed by the regulator to be applied to their takeoff and landing performance. Simplified, there is no changes or construction made to the gravel runway, so the runway remains the same as what it was prior to reclassification. After reclassification, an </span><span style="font-family: Calibri; font-size: 14pt;">airline is considered “safe” for takeoff with the stroke of a pen only. </span><span style="font-family: Calibri; font-size: 14pt;">The classification criteria itself acknowledges this flaw in performance requirements.</span></p><div class="page" title="Page 3"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he thin bituminous surface runways are a broad class of surface treatments, which have a variety of performance characteristics. Newly built thin bituminous surface runways require sufficient curing time to provide a competent and durable operational surface. A class 3 pavements may be considered to meet the definition of a thin bituminous surface runway. Since a runway may be considered, is in itself an acknowledgement that there is no data available in support of compliance with all the requirements. In other words, and since the runway may, there are no gravel runways that actually meets the most stringent standard requirement for reclassification as defined. In addition, there performance data for the actual groundroll is not required to assess the validity of the reclassification.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b>irport operators designates their most critical aircraft by aircraft group number, which is a numeric value of characteristics of the critical aircraft for which the aerodrome is supporting. The aircraft group number is determined by the critical aircraft wingspan or tail height. An aircraft group number is based on a paved runway surface, with a limited maximum gross weight capability. An airport operator may select an aircraft group number based on aircraft wingspan and tail height, but the standard is lacking a method to verify how an airport operator select an aircraft size based on runway surface performance, or aircraft landing and takeoff performance. The root cause hazard with reclassification to the thin bituminous surface runways is the opportunity for regional compliance by airport </span><span style="font-family: Calibri; font-size: 14pt;">operators who wish to maintain gravel operations to reclassify their runway for airlines to operate out of their airport. The one airport operator who remain a gravel runway operator has the highest risk to loose business due to their takeoff and landing restrictions. In addition, they are unable to provide friction characteristics of a runway surface for a runway serving turbojet aircraft, and there are still many unanswered questions. On the other side, the person who was the driving force behind reclassification to thin bituminous surface runways, received a recognized award for the work. When exceptional performance of current processes remains unrecognizable, and risk levels are established by emotions, checkbox syndrome, or by social media likes, any changes to processes becomes its own worst enemy.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhV-3We1bD_3JfXx2Va3cC79cU8Zm3l20c5DNK9fCZLuuPVcnbLdJVJKOiBEVwsGS33Nvi4Z3KMMbnP2Zor0h99N9bV6RaKd1ZfhynEyA7tT53lEcKAPoCOPhbiWFOZ8f5LBeTHmHWXbdLhxlv6Xw3wka95RBsH76jqVFkwnomA_3OkFAfv-iZ6KB3aNQ/s378/Screen%20Shot%202023-04-29%20at%207.08.24%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="289" data-original-width="378" height="306" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhV-3We1bD_3JfXx2Va3cC79cU8Zm3l20c5DNK9fCZLuuPVcnbLdJVJKOiBEVwsGS33Nvi4Z3KMMbnP2Zor0h99N9bV6RaKd1ZfhynEyA7tT53lEcKAPoCOPhbiWFOZ8f5LBeTHmHWXbdLhxlv6Xw3wka95RBsH76jqVFkwnomA_3OkFAfv-iZ6KB3aNQ/w400-h306/Screen%20Shot%202023-04-29%20at%207.08.24%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 4"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>W</b>ork well done often goes unrecognized as an important work task since everything is operating normally, processes are ignored and discarded as every day normal tasks. Drift is often recognized as drift into unsafe conditions, but unrecognized drift into improved safety in operations is just as much a </span><span style="font-family: Calibri; font-size: 14pt;">hazard to aviation safety as drifting into hazardous operating conditions. Hazards are predictable, while incidents and accidents are unpredictable.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>F</b>or an incident to occur there are three conditions that must meet at the fork-in- the-road. The first condition is that an aircraft, vehicle, or person is performing a task beyond the limits of their capabilities. E.g. an aircraft requiring 3,000 feet takeoff distance is taking off from a 2,000 foot runway. The second condition to be met is recognition of past practices without recognizing special cause variations. E.g.an aircraft normally departs empty and fly to a longer runway for passengers </span><span style="font-family: Calibri; font-size: 14pt;">and freight to be loaded but does not recognize the effect of partial loaded aircraft. The third condition is operational drift to complete a task within a defined timeframe. E.g. daily departure performance records are exceptional, but it is not recognized as exceptional since it occurs daily, and drift is occurring to recover lost time for on-time task completion. Capability limits may be skewed based on established operational requirements, just as the thin bituminous surface runway scenario that justified the change as safety improvement in operations, while the root cause of change is to move operational limitations. Past practices may be skewed by an induced level of urgency to complete, and drift to improvement goes unrecognized when emotions or external forces are applied to decisions.</span></p><div class="page" title="Page 5"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>W</b>hen performance is exceptional, such as operating out of a gravel runway with performance restrictions, drift into improved runway surface condition is just as much a hazard as drift into acceptable practices.</span></p><p><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">OffRoadPilots</span></p></div></div></div></div></div></div><p><span style="font-family: Calibri; font-size: 14pt;"><br /></span></p></div></div></div></div></div></div><p><span style="font-family: Calibri; font-size: 14pt;"><br /></span></p></div></div></div></div></div></div><p><span style="font-family: Calibri;"><span style="font-size: medium;"><br /></span></span></p><p><span style="font-family: Calibri;"><span style="font-size: medium;"><br /></span></span></p></div></div></div>SMS/QA Control Managementhttp://www.blogger.com/profile/09611789820282926862noreply@blogger.com0tag:blogger.com,1999:blog-3664537417151106536.post-45493824527083012302023-04-16T04:52:00.000-07:002023-04-16T04:52:14.551-07:00More is Less and Less is More<p> <span style="font-family: Calibri; font-size: 14pt;">More is Less and Less is More</span></p><p><span style="font-family: Calibri;"><span style="font-size: x-small;">By OffRoadPilots</span></span></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri;"><b><span style="font-size: x-large;">A</span></b><span style="font-size: medium;">n accountable executive (AE) once said that they operate their safety management system (SMS) and airport operations by a principle that more is less and less is more. When operating by this principle, their regulatory compliance was in essence non-existing, and the regulator demanded the surrender of their airport certificate. The airport operator presented a corrective action plan to abolish the principle that less is more, and the regulator accepted their corrective action plan. Their airport certificate was secured, but an enormous task was ahead to establish regulatory compliance with all SMS and airport regulations. After the airport certificate was secured and compliance level established, the airport operator abandoned their quality control system and reverted back to their previously less is more principle.</span></span></p><p><span style="font-family: Calibri;"></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgmmpGTak0FycSV9hUMVCkDlKWr2tQnaiX-wsgotLBabDDbgxIN3v_oGSGS-m33xC271uUMgJZFR0c8n36jLpfCqKC2OIxXX5xqG01S1vV8hluRzfjdpPHdlI3ClLR989HcB3VWiTSfbI_dea1M8vuOSL-X9VJ_DwO70YIFD6oeTDJJ0mUXV0hsAnhYcA/s434/Screen%20Shot%202023-04-16%20at%207.46.41%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="434" data-original-width="384" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgmmpGTak0FycSV9hUMVCkDlKWr2tQnaiX-wsgotLBabDDbgxIN3v_oGSGS-m33xC271uUMgJZFR0c8n36jLpfCqKC2OIxXX5xqG01S1vV8hluRzfjdpPHdlI3ClLR989HcB3VWiTSfbI_dea1M8vuOSL-X9VJ_DwO70YIFD6oeTDJJ0mUXV0hsAnhYcA/w354-h400/Screen%20Shot%202023-04-16%20at%207.46.41%20AM.png" width="354" /></a></div><p></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b> regulatory requirement is for the AE to be responsible for operations or activities authorized under the certificate and accountable on behalf of the certificate holder for meeting the requirements of the regulations. Traditionally, the airport manager (APM) was the certificate holder and would also remain the certificate holder after implementing the safety management system. As the certificate holder, the APM is the airport authority, the </span><span style="font-family: Calibri; font-size: 14pt;">decision maker, and an AE is accountable to the APM to maintain compliance with the regulations. Compliance with all regulations and standards are comprehensive </span><span style="font-family: Calibri; font-size: 14pt;">tasks, with compliance established with a line-item audit. <b>W</b>hen operating by the less is more principle, airport operators take it upon themselves to exclude regulations they have decided not to be applicable to their operations. Airport operators do not take into account that there is none, or minimal, scaling of the regulations to suite size and complexity of airport operations. The scaling is a regulatory requirement applicable to scale the processes as opposed to decline compliance with the regulatory part.</span></p><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>W</b>hen applying the less is more principle, they are applied laterally to any systems without considerations to the issue at stake or expected outcome. Statements </span><span style="font-family: Calibri; font-size: 14pt;">such as, “remember that less is more” are commonly </span><span style="font-family: Calibri; font-size: 14pt;">used when undefined expectations are a part of the outcome, or minor tasks are removed from regulatory requirements, or lack of process comprehension, or when non- compliant tasks are excluded from the equation. There are times when the less is more principle is true, but the less-is-more system, is not a system to integrate into a safety management system.</span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he less-is-more system absolutely has its place within many systems, and advertising is one of them. Imagine for a minute that you are driving down the highway and you see a sign that says something like </span><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">“</span><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">Our breakfast menu has pancakes, toast, eggs, farmer</span><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">’</span><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">s gravy, bacon, sausage, eggs, and coset between $10-15 per adult person.</span><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">” </span><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">By </span><span style="font-family: Calibri; font-size: 14pt;">the time you get to pancakes, you have passed the sign and wondering what it said. In a less-is-more system, the sign would say </span><span style="font-family: Calibri; font-size: 14pt;">“</span><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">Hungry? Next exit</span><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">” </span><span style="font-family: Calibri; font-size: 14pt;">With this sign the business gets more visitors who are hungry and generate more revenue. In addition, since there are fewer words, the sign cost less to make. The less-is-more system is a trigger to the imagination to fill in the blanks, and the blanks give positive, or happy feelings of what the imaginary outcome is. Online advertising has also changed to the less-is-more system by shortening their advertisements to five seconds to hit their target points and for the imagination to fill in the rest. Whenever there is a void, it will be filled with something. Other examples of less-is-more is it lower an item price below regular price to sell more units, it is to offer 25-cents video machines to attract more plays, it is to show less of the neighbourhood when advertising a home to attract more </span><span style="font-family: Calibri; font-size: 14pt;">customers, it is to pay less for internet with slower connection and spend more time to upload and download, it is to spend less money on personal improvements to assert more internal control of personnel, it is to spend less money on training for a more uniform and conforming environment, or possible most important reason to operate with a less-is-more system is to play ignorance after occurrences. </span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b>n AE once said that it is difficult to work with hazards that are unknown. The less-is-more system absolutely serves a purpose for an AE operate with a less productive safety management system and to some extent the regulator accepts the ignorance play. Just a few weeks ago, an airline gave this excuse for an aircraft that took off with contaminated surfaces saying that the pilots did not follow safety rules and the regulator accepted without further investigation. In 1956 two airlines were operating in a less-is-more environment causing a midair collision. Most people would not chose the less-is-more system when selecting medical treatment, but it is accepted in aviation safety. Ignorance is bliss, or if you do not know about something, you do not worry about it.</span></p></div></div></div></div></div></div><p><span style="font-family: Calibri;"></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiToadI0C0idhaL75x_e8Ql-VvnCLxr0GOxF76zwocv5gcLSe7uzt2-lx8TRe2WpFnHhw9B26esKkk4fTnlhrPKZXxJUgeFLyWZOBBqS0DlGDC8YUyTIQ-5sn2G-Ci6fTrziZYYINIHhOWtlvEPAKQvWVzvJAIdRV8ggfDosKzVkNh44MiiEMPN1eD6EQ/s382/Screen%20Shot%202023-04-16%20at%207.48.36%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="261" data-original-width="382" height="274" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiToadI0C0idhaL75x_e8Ql-VvnCLxr0GOxF76zwocv5gcLSe7uzt2-lx8TRe2WpFnHhw9B26esKkk4fTnlhrPKZXxJUgeFLyWZOBBqS0DlGDC8YUyTIQ-5sn2G-Ci6fTrziZYYINIHhOWtlvEPAKQvWVzvJAIdRV8ggfDosKzVkNh44MiiEMPN1eD6EQ/w400-h274/Screen%20Shot%202023-04-16%20at%207.48.36%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 3"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he less-is-more system is a destructive system for a safety management system for both airport and airline operations. The role of an accountable executive is to maintain compliance with records keeping. The regulatory requirements for records keeping are to maintain a record system, </span><span style="font-family: Calibri; font-size: 14pt;">that do not comprise the integrity of the records system, measures are taken to ensure that the records contained in the recording systems are protected against inadvertent loss or destruction and against tampering, and a copy of the records contained in the recording systems can be printed on paper and provided to the regulatory on notice given. It would take some imagination to make less-is-more out of these requirements, but if works when processes are combined to cover </span><span style="font-family: Calibri; font-size: 14pt;">multiple requirements. This is only possible with a daily quality control system, and a user friendly software that comply with all requirements. When a quality control process is established and determined to conform to regulatory requirements, there is minimal work needed in daily operations. Without a proven daily quality control system an airport or airline operator must complete the same tasks daily and start from the bottom every day to ensure compliance. E.g., using paper format records without continuance to the next day or the historical records.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiVigQvVuboBvwr62yib-I2SQ-oUwhlGgOt4qzYZYcPl1I2AO2f_5wEL8gECjpGwi1K6zj8QWdSdpRfs0i-EZpBIBEwQm7SsuOC-zkshfRQ6A71QJwLIJ3m-BPqdMedb4KbPZWCAuclxNhEFjUR5p7Ak35iuTcYvrFUfU-K6kb_b9zX6-KDsyBQxr2rDw/s376/Screen%20Shot%202023-04-16%20at%207.50.13%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="282" data-original-width="376" height="300" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiVigQvVuboBvwr62yib-I2SQ-oUwhlGgOt4qzYZYcPl1I2AO2f_5wEL8gECjpGwi1K6zj8QWdSdpRfs0i-EZpBIBEwQm7SsuOC-zkshfRQ6A71QJwLIJ3m-BPqdMedb4KbPZWCAuclxNhEFjUR5p7Ak35iuTcYvrFUfU-K6kb_b9zX6-KDsyBQxr2rDw/w400-h300/Screen%20Shot%202023-04-16%20at%207.50.13%20AM.png" width="400" /></a></div><div class="page" title="Page 4"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he regulatory requirement foranAEistobe responsible for operations or activities authorized under the certificate and accountable on behalf of the certificate holder for meeting the requirements of the regulations. This is an enormous task and it make sense that an AE sets performance goals to </span><span style="font-family: Calibri; font-size: 14pt;">minimalize these tasks as much as possible. Exempting operations from the regulations is not the way to go. A small to medium airport operator may only receive a turbojet aircraft a few times a month and decide on their own that compliance with obligations is not justified since this is how </span><span style="font-family: Calibri; font-size: 14pt;">“</span><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">we always did it</span><span style="font-family: Calibri; font-size: 14pt;">.</span><span style="font-family: Calibri; font-size: 14pt;">” </span><span style="font-family: Calibri; font-size: 14pt;">This is the less-is-more system in that complying with fewer regulations provide more options, or opinions to how airport operations should run. With this approach the safety-card is played, and any tasks or actions are justified by the word </span><span style="font-family: Calibri; font-size: 14pt;">“</span><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">safety</span><span style="font-family: Calibri; font-size: 14pt;">.</span><span style="font-family: Calibri; font-size: 14pt;">” </span><span style="font-family: Calibri; font-size: 14pt;">When the word safety is applied, there is very little opposition to the tasks, and especially if airside personnel remain untrained and without knowledge of oversite requirements. Keeping workers in the dark is a prerequisite when operating with the less-is-more system. Only after a complete line-item audit is completed of the operations, the daily quality control system is in place, and processes assigned to regulatory requirements, the less-is-more system could be applied by monitoring </span><span style="font-family: Calibri; font-size: 14pt;">drift and operations daily, and make adjustments as required when personnel are drifting from design operations. However, the AE who decided to change over to the less-is-more system, also excluded the audit requirement from compliance system.</span></p><div class="page" title="Page 5"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he more is less and less is more system is incompatible with operation of an airport or aircraft, and the safety management system. The litmus test of systems compatible with airport and airline operations is in their daily quality control system.</span></p><p><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">OffRoadPilots</span></p></div></div></div></div></div></div><span style="font-family: Calibri; font-size: 14pt;"><br /></span><p></p><p><span style="font-family: Calibri; font-size: 14pt;"><br /></span></p></div></div></div><p><span style="font-family: Calibri;"><span style="font-size: medium;"><br /></span></span></p></div></div></div>SMS/QA Control Managementhttp://www.blogger.com/profile/09611789820282926862noreply@blogger.com0tag:blogger.com,1999:blog-3664537417151106536.post-51120557887101468702023-04-02T04:06:00.000-07:002023-04-02T04:06:00.975-07:00How to Capture Unknown Hazards<p><span style="font-family: Calibri; font-size: 14pt;">How to Capture Unknown Hazards</span></p><p><span style="font-size: x-small;">By OffRoadPilots </span></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri;"><span style="font-size: x-large;"><i><b>T</b></i></span></span><span style="font-family: Calibri; font-size: 14pt;">here is a difference between an unknown hazard and a hidden hazard. Unknown hazards are unknown, but they are not hidden. An unknown hazard is a hazard without a hazard classification, it is a hazard defined by likelihood where times between intervals are imaginary, theoretical, virtual, or fictional.</span></p><p><span style="font-family: Calibri; font-size: 14pt;">Unknown hazards are incomprehensible to common sense but are still real hazards. An unknown hazard is in the open and in plain view but is not recognized as a hazard for the purpose of an immediate task to be performed. Unknown hazards also need to be assigned a scope and sequence to learn their whereabouts. A person may be exposed to unknown hazards without knowing it. Exposure to an unknown hazard is a higher risk to aviation safety than exposure to known and hidden hazards since they are unknown and cannot be mitigated.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjqv_RlQf0dkLEvB-YpG6h8otF1b7AO7AU7r2DzfRF6ishKa1g5C9EqnAT05fMbaOztJFVWT9-sm67FdMbtdqBdplSVgTNgx18aaPzHo2lknnK3A37yiYA0PFS1lx5hD3SA0slPLSdg1URg2nq0XYnVFWlnu82OzW3GCSun1VzX3_GkgFoJrdtqHova_Q/s372/Screen%20Shot%202023-04-02%20at%206.50.11%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="231" data-original-width="372" height="249" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjqv_RlQf0dkLEvB-YpG6h8otF1b7AO7AU7r2DzfRF6ishKa1g5C9EqnAT05fMbaOztJFVWT9-sm67FdMbtdqBdplSVgTNgx18aaPzHo2lknnK3A37yiYA0PFS1lx5hD3SA0slPLSdg1URg2nq0XYnVFWlnu82OzW3GCSun1VzX3_GkgFoJrdtqHova_Q/w400-h249/Screen%20Shot%202023-04-02%20at%206.50.11%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>H</b>idden hazards are known, but they are hidden and may become visible, or active, if triggered by human factors, organizational factors, supervision factors, or environmental factors. A hidden hazard is removed away from operations in a 3D environment and </span><span style="font-family: Calibri; font-size: 14pt;">measured in time (speed), space (location), and compass (direction). Hazards also becomes hidden by remote management environment since the immediate threat to aviation safety does not affect a remote location. A hidden hazard may be hidden for one person, but still be active to another.</span></p><div class="page" title="Page 1"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b> widely accepted method to learn about hidden hazards is to ask personnel to search and identify them in their workplace. One person may identify a condition as a hazard, while another person do not see the same condition as a hazard</span><span style="font-family: Calibri; font-size: 8pt; font-style: italic;">.</span></p></div></div></div><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>H</b>azards identified by personnel are often based on emotions, past experiences, based on public opinions, or based on expectations. There are as may reasons to identify a condition as a hazard as there are workers. Mandating a search of hidden hazards is in itself a hazard, since </span><span style="font-family: Calibri; font-size: 14pt;">a worker’s </span><span style="font-family: Calibri; font-size: 14pt;">attention will be moved from their job activity to searching for hazards. Requesting voluntary hazard reporting as any hazards affects job performance is different, since the workers at that time are focusing on their job tasks rather than identification of what is hidden. After hazards are identified, the role of an SMS Enterprise is to analyze each hazard received, assign a classification, and enter into a hazard register. Identifying a hidden hazard is not the same as identifying an unknown hazard, since hidden hazards are known, but the condition for those hazards do not exist at this time. A prime example of a hidden hazard is when weather conditions are conducive to ice or frost formation on aircraft surfaces, although there is no observable precipitation or fog while an aircraft is on the ground.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiSttQE3Bms0lktl7BkX16vacRHxJI1NuFGjEvRU1xKi49EjTD8C5JhF6O4i-x9RTvulzLoDI2PE5sr0LJWQBuLNan2Haf8zuWOa6U0cg6A9RptTw7Mmx2P6lyrpeSA2_EykopiotRK0kd4tJ_SRaqE2BN-pM8vsSjCmgJoHOSJ9Dj-232VE5jdaQm8pA/s370/Screen%20Shot%202023-04-02%20at%206.52.39%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="320" data-original-width="370" height="346" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiSttQE3Bms0lktl7BkX16vacRHxJI1NuFGjEvRU1xKi49EjTD8C5JhF6O4i-x9RTvulzLoDI2PE5sr0LJWQBuLNan2Haf8zuWOa6U0cg6A9RptTw7Mmx2P6lyrpeSA2_EykopiotRK0kd4tJ_SRaqE2BN-pM8vsSjCmgJoHOSJ9Dj-232VE5jdaQm8pA/w400-h346/Screen%20Shot%202023-04-02%20at%206.52.39%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 2"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>U</b>nknown hazards go unattended until there is an incident, accident, or published by a social media post. An unknown hazard is also a special cause variation to aircraft operations since exposure and likelihood has not been accounted for. However, the hazard may be a common cause variation within the process itself. Ice and snow accumulation is </span><span style="font-family: Calibri; font-size: 14pt;">known to be a hazard to aviation safety, but at the time of conducting task at hand the hazard is unknown to flight crew until exposed by an incident, unstable flight or published on social media. When this happens, airlines are quick to place blame on pilots, who were just doing their job as expected. A prime example is when an air operator suspends pilots pending investigation into a failure to follow de-icing </span><span style="font-family: Calibri; font-size: 14pt;">procedures. In this particular true story, there were no de-icing policy or process established by the air operator to operate out of this airport during icing conditions. </span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b>n aircraft does not carry its own ground deicing equipment and fluids and agreements with airports and contractors are required to deice prior to departure. Without a contract agreement between the airport and airline to deice prior to departures when temperatures are below freezing, pilots complied with management expectations to operate without deicing the aircraft. The aircraft departed without issues, but the hazard became known when posted on social media.</span></p><div class="page" title="Page 3"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>C</b>apturing unknown hazards is an analysis task as opposed to an observation task. Asking workers to actively search for hazards is an observation task. Several hazards can be identified by this method, but the process in itself is reactive since a mitigation plan, or control action is pending on the hazard first being identified. A safety management system (SMS) is simple in concept which is to find the hazards and do something about it. Also, identifying unknown hazards is a regulatory requirement. An SMS enterprise is required to operate with a process for identifying hazards to aviation safety and for evaluating and managing the associated risks. A requirement to identify hazards is for an SMS enterprise to find a hazard, name a hazard, assign a classification to the hazard, and record the hazard in the hazard register. When all this is done, they need a process for setting goals for the improvement of aviation safety and for measuring the attainment of those goals. Capturing unknown hazards is an invaluable tool for goalsetting.</span></p><p><span style="font-family: Calibri; font-size: 14pt;">The four items to analyze and capture unknown hazards are within human factors, organizational factors, supervision factors and environmental factors. When searching for unknown hazards, these are the starting points and work backwards from there until hazards are identified. Applying the process inspection flowchart is the same system as the process to capture unknown hazards.</span></p></div></div></div></div></div></div><div class="page" title="Page 3"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>HUMAN FACTORS</b></span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>A</b>n SMS enterprise has an obligation pursuant to the regulations to assign duties on the movement area and any other area set aside for the safe operation of aircraft, </span><span style="font-family: Calibri; font-size: 14pt;">including obstacle limitation surfaces, at the airport, which are described in the airport operations manual, only to workers who have successfully completed a safety-related initial training course on human and organizational factors. A human factors training course includes identification of unknown hazards by recognizing that human factors is different than human error. Human factors are behaviors triggered by the five senses. Human error is to complete a task knowing that the task is completed by a non-standard process. This does not imply that that human error is a direct hazard to task at hand, but that unwritten processes are used to </span><span style="font-family: Calibri; font-size: 14pt;">“get the job done”. When unwritten processes, or shortcuts are used, the </span><span style="font-family: Calibri; font-size: 14pt;">foundation for operational safety analysis are based on unknown criteria, undocumented hazards, or unknown hazards. </span><span style="font-family: Calibri; font-size: 14pt;">A shortcut to “get the job done” </span><span style="font-family: Calibri; font-size: 14pt;">may actually be the preferred process, but it needs to be documented and unknown hazards identified within the process.</span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbFFWR_geGtMpuP1kYMpSvE87splhRKFuv8HklGYTYEmYioeMpm0I_G393Xidv5y0Ft4-3rg6XHeXa6dpu2Kr6wQ6Q9nE_TFiXXDCvJYNf3LHLRnlqaYpJQJD_zI0PrX8fkbxxhwAria5ROoHUM5wDHZvmNLZMnhIQAadafCmj2kUtZTFHifdYQvXLqQ/s383/Screen%20Shot%202023-04-02%20at%206.55.00%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="289" data-original-width="383" height="301" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbFFWR_geGtMpuP1kYMpSvE87splhRKFuv8HklGYTYEmYioeMpm0I_G393Xidv5y0Ft4-3rg6XHeXa6dpu2Kr6wQ6Q9nE_TFiXXDCvJYNf3LHLRnlqaYpJQJD_zI0PrX8fkbxxhwAria5ROoHUM5wDHZvmNLZMnhIQAadafCmj2kUtZTFHifdYQvXLqQ/w400-h301/Screen%20Shot%202023-04-02%20at%206.55.00%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 4"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">Human factors are vision, hearing, smell, taste, and touch. The SHELL model is the foundation of human factors interactions as the five senses observe and interprets the components in the SHELL model.</span></p><div class="page" title="Page 4"><div class="layoutArea"><div class="column"><p><span style="font-family: SymbolMT; font-size: 14pt;">• </span><span style="font-family: Calibri; font-size: 14pt;">S=Software includes regulations, standards, policies, job descriptions and expectations.</span></p><ul><li style="font-family: SymbolMT; font-size: 14pt;"><p><span style="font-family: Calibri; font-size: 14pt;">H=Hardware includes electronic devices, documents, tools, and airfield.</span></p></li><li style="font-family: SymbolMT; font-size: 14pt;"><p><span style="font-family: Calibri; font-size: 14pt;">E=Environment includes designed environment, user friendly environment,</span></p><p><span style="font-family: Calibri; font-size: 14pt;">design and layout, accessibility, and tasks-flow.</span></p></li><li style="font-family: SymbolMT; font-size: 14pt;"><p><span style="font-family: Calibri; font-size: 14pt;">Social Environment includes distancing, experiences, culture, language</span></p></li><li style="font-family: SymbolMT; font-size: 14pt;"><p><span style="font-family: Calibri; font-size: 14pt;">Climate Environment includes geo location, weather, and temperature.</span></p></li><li style="font-family: SymbolMT; font-size: 14pt;"><p><span style="font-family: Calibri; font-size: 14pt;">L=Liveware is yourself and </span><span style="font-family: Calibri; font-size: 14pt;">Liveware is other workers within your environment</span></p><p><span style="font-family: Calibri; font-size: 14pt;">Within these areas there are unknown hazards to search for and how they affect operations. An example could be that a regulatory requirement induces stress and shortcuts, or that regulatory compliance increases a level of risk. Tenerife airport disaster is a prime example of how requirements and compliance were contributing factors to the incident. In addition, there are several additional components that could be added to search for unknown hazards within the SHELL model.</span></p></li></ul></div></div></div><div class="page" title="Page 5"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>ORGANIZATIONAL FACTORS</b></span></p><p><span style="font-family: Calibri; font-size: 14pt;"></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiD9Y65P6_F1bOh5Hhm2VaoMIlOI1mfPJmEWwXyOY7dxXX53xetTBSDiL-xwvU7IkvO6uhjfgyYphL1x0rnlXfED8i8luwK33ewGB0l7OJQEilopYYf2h3dA3_Gimbg6_Q1-wMeeH6D6lX6LsdS3gGGox_9D3_PnQCTaX7VG3d5uV9A5M2MVMwJZ-LY5w/s383/Screen%20Shot%202023-04-02%20at%206.59.12%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="376" data-original-width="383" height="393" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiD9Y65P6_F1bOh5Hhm2VaoMIlOI1mfPJmEWwXyOY7dxXX53xetTBSDiL-xwvU7IkvO6uhjfgyYphL1x0rnlXfED8i8luwK33ewGB0l7OJQEilopYYf2h3dA3_Gimbg6_Q1-wMeeH6D6lX6LsdS3gGGox_9D3_PnQCTaX7VG3d5uV9A5M2MVMwJZ-LY5w/w400-h393/Screen%20Shot%202023-04-02%20at%206.59.12%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 5"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">Organizational factors are factors are strategy solutions, acceptable cultures, technology, regulatory compliance factors and systems information flow within the organizational structure. When an organization, the CEO, President or Accountable Executive of an organization makes a statement to the fact that an incident was caused by non- compliance with a process, is an acknowledgement that </span><span style="font-family: Calibri; font-size: 14pt;">their policies, processes and procedures within the organization is perfect and without flaws. There are multitude of organizations that are perfect and without flaws and they operate very successfully. Just recently a large global carrier experienced an unsuccessful event, which they did not have a policy, process or procedure in place to mitigate the hazard. The event was beyond what management expected and the hazard was unknown until it became one of the </span><span style="font-family: Calibri; font-size: 14pt;">most disastrous events they experienced. Within an organizational structure data is collected, then turned into information, information is turned into knowledge and knowledge is turned into comprehension. The triennial line-item audit is a tool to identify unknown organizational hazards. An example is an audit line-item 34- 0403 and the debriefing after an emergency response tabletop or full-scale exercise. </span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he organization placed the reason for the finding on the auditor who identify the non-compliance. When combining organizational observations, such as operating with icy runway, clearway across a highway, airport vehicle without radio communication on the runway, haying contractor with uncontrolled access to movement areas, construction operations with open trenches, and more, are examples of widespread unknown hazards within organizational factors. An accountable executive, or the regulator, would be unaware of this unless they monitor their daily quality control system. Without comprehension, and training to meet an acceptable comprehension level, unknown hazards will remain unknown.</span></p><div class="page" title="Page 6"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>SUPERVISION FACTORS</b></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhJdbfdmgf4UfTTX76WCmCZ6UOQTAVwXZLDPoToz_ATzt10mLxorbg6Oi9FZkQQHVEXWTd73cS4QwW4OMQxfCERzfD_f51rDSoGlhp3Tmzj662xuWpmpJzECbatlqNG8duh9PX84qIhuQAHjAB9w_XKOjgzd_yVUUuZLgvJTldwBX6s1zZ-mY0DJ2rL7A/s384/Screen%20Shot%202023-04-02%20at%207.01.00%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="282" data-original-width="384" height="294" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhJdbfdmgf4UfTTX76WCmCZ6UOQTAVwXZLDPoToz_ATzt10mLxorbg6Oi9FZkQQHVEXWTd73cS4QwW4OMQxfCERzfD_f51rDSoGlhp3Tmzj662xuWpmpJzECbatlqNG8duh9PX84qIhuQAHjAB9w_XKOjgzd_yVUUuZLgvJTldwBX6s1zZ-mY0DJ2rL7A/w400-h294/Screen%20Shot%202023-04-02%20at%207.01.00%20AM.png" width="400" /></a></div><div class="page" title="Page 6"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>G</b>enerally speaking, there are four types of supervision. However, in aviation an additional supervision level is introduces. Some of these levels are air traffic services (ATS), air traffic controllers (ATC), flight planning, weather services, control towers, airport ground control, runway, taxiway and apron lights, runway status </span><span style="font-family: Calibri; font-size: 14pt;">lights, approach lights, airside markings, markers, and signs. Any of these items are supervisory tasks communicated by other means than words.</span></p></div></div><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">Autocratic or Authoritarian supervision:</span></p><p><span style="font-family: Calibri; font-size: 14pt;">Under this type, the supervisor wields absolute power and wants complete obedience from subordinates. The supervisor wants everything to be done strictly according to his instructions and never likes any intervention from subordinates. This type of supervision is resorted to tackle indiscipline subordinates.</span></p><div class="page" title="Page 7"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">Laissez-faire or free-rein supervision:<br /></span><span style="font-family: SymbolMT; font-size: 14pt;">• </span><span style="font-family: Calibri; font-size: 14pt;">This is also known as independent supervision. Under this type of </span><span style="font-family: Calibri; font-size: 14pt;">supervision, maximum freedom is allowed to the subordinates. The supervisor does not interfere in the work of the subordinates. In other words, full freedom is given to workers to do their jobs. Subordinates are encouraged to solve their problems themselves.</span></p><p><span style="font-family: Calibri; font-size: 14pt;">Democratic supervision:<br /></span><span style="font-family: SymbolMT; font-size: 14pt;">• </span><span style="font-family: Calibri; font-size: 14pt;">Under this type, supervisor acts according to the mutual consent and </span><span style="font-family: Calibri; font-size: 14pt;">discussion or in other words he consults subordinates in the process of decision making. This is also known as participative or consultative supervision. Subordinates are encouraged to give suggestions, take initiative, and exercise free judgment. This results in job satisfaction and improved morale of employees.</span></p><p><span style="font-family: Calibri; font-size: 14pt;">Bureaucratic supervision:<br /></span><span style="font-family: SymbolMT; font-size: 14pt;">• </span><span style="font-family: Calibri; font-size: 14pt;">Under this type certain working rules and regulations are laid down by the </span><span style="font-family: Calibri; font-size: 14pt;">supervisor and all the subordinates are required to follow these rules and regulations very strictly. A serious note of the violation of these rules and regulations is taken by the supervisor. This brings about stability and uniformity in the organisation. But in actual practice it has been observed that there are delays and inefficiency in work due to bureaucratic supervision.</span></p><div class="page" title="Page 7"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>he task for an SMS enterprise is to conduct system analyses to find unknown hazards as they apply to operations. An unknown hazard may remain unknown to a</span></p></div></div></div><div class="page" title="Page 8"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">ground crew or aircraft mechanics, but is crucial that the hazard has been found and identified to the flight crew. An example of an unknown hazard is the non- punitive SMS policy, which is only appliable within the jurisdiction where the certificate holder is.</span></p></div></div></div></div></div></div></div></div></div><div class="page" title="Page 8"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>ENVIRONMENTAL FACTORS</b></span></p><p><span style="font-family: Calibri; font-size: 14pt;"></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiKwVodfVjafGxgnfDBA0H4Qtgku0BTiSZvfDLvj3HhcT3ltJUOwT3p59uhIz2UuF45xuLtYR2AzN9vlNoXbIOQwVTBjGrVbhiC2DMQJ-PgreurCTaI1Xr4LwwHLCM670I_v6ZFPYZrxFMcWTv4aTfqe4vvvxk-T_QLLfougKvz_0JhgU_EIO4b3F1p2w/s382/Screen%20Shot%202023-04-02%20at%207.02.40%20AM.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="295" data-original-width="382" height="309" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiKwVodfVjafGxgnfDBA0H4Qtgku0BTiSZvfDLvj3HhcT3ltJUOwT3p59uhIz2UuF45xuLtYR2AzN9vlNoXbIOQwVTBjGrVbhiC2DMQJ-PgreurCTaI1Xr4LwwHLCM670I_v6ZFPYZrxFMcWTv4aTfqe4vvvxk-T_QLLfougKvz_0JhgU_EIO4b3F1p2w/w400-h309/Screen%20Shot%202023-04-02%20at%207.02.40%20AM.png" width="400" /></a></div><p></p><div class="page" title="Page 8"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;">Environmental factors are about the surroundings and its affect on accountable executive, managers, workers, personnel, aircraft, cockpit, passenger cabin, aircraft operations, airport operations, or anything else that becomes a part of operations. Environmental factors are more than just the weather, or environment itself, it is also </span><span style="font-family: Calibri; font-size: 14pt;">about how work tasks are laid out to function effectively. Environmental factors are about tool boxes and marked tools, it is about checklist and userfriendly flow, and it is about the organizational culture the everyone works within. Airport operators are changing slower to comply with the safety management system environmental factors than airlines are. Airport like to </span><span style="font-family: Calibri; font-size: 14pt;">do what they “always” did</span><span style="font-family: Calibri; font-size: 14pt;">and not make any changes. In the pre-SMS era, an airport operator could place all </span><span style="font-family: Calibri; font-size: 14pt;">blame on the pilot after an accident, as long as the airport had NOTAM’d an issue. </span><span style="font-family: Calibri; font-size: 14pt;">This changed with the new airport standards and the safety management system.</span></p></div></div></div><div class="page" title="Page 8"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt;"><b>T</b>oday, the role of an airport operator is to assist flight crew to maintain compliance with their responsibility to ensure that the aerodrome is suitable for the intended operation. Airport operators are still NOTAM 100% ice on runways and expect the flight crew to decide course of action. What airport operators are doing, is preventing medevac or air ambulance from using the airport since most </span><span style="font-family: Calibri; font-size: 14pt;">flight crew would not use an icy runway. Environmental factors are also factors withing the regulatory frameworks, which establishes the basis for an environment. Regulations are not minimum safety requirements, but compliance factors to remain as a certificate holder. An example of an unknown hazard within an environmental environment is fear of failure. </span></p><p><span style="font-family: Calibri; font-size: 14pt;"><b>I</b>t is critical for an SMS enterprise to accept that not all hazards can be mitigated to an acceptable risk level without cease operations. One such hazard is the probability that a flight crew could establishes an aircraft on an unplanned course any time during a flight but does not justify ceasing operations.</span></p></div></div></div><div class="page" title="Page 9"><div class="layoutArea"><div class="column"><p><span style="font-family: Calibri; font-size: 14pt; font-style: italic;">OffRoadPilots</span></p></div></div></div></div></div></div></div></div></div><p><span style="font-family: Calibri; font-size: 14pt;"><br /></span></p></div></div></div><p><span style="font-family: Calibri; font-size: 14pt;"><b><br /></b></span></p></div></div></div><p><span style="font-family: Calibri; font-size: 14pt;"><br /></span></p><p><span style="font-family: Calibri; font-size: 14pt;"><br /></span></p><p><span style="font-family: Calibri; font-size: 14pt;"><br /></span></p><p><span style="font-family: SymbolMT; font-size: 14pt;"><span> </span></span></p></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div>SMS/QA Control Managementhttp://www.blogger.com/profile/09611789820282926862noreply@blogger.com0