Frequent Audits or Enhanced Monitoring

 Frequent Audits or Enhanced Monitoring 

Important Safety concept from CatalinaNJB

The latest news reports for airlines and passenger jet-aircraft are that 2017 was the safest year on record for commercial air travel with zero fatal accidents. When counting cargo planes and passenger turboprop aircraft, there were both fatalities to passengers and bystanders on the ground. This safety record may be contributed to several factors. Some might say that this is due to the implemented Safety Management System (SMS) in aviation, while other might say that this is due to enforcement of regulatory compliance. What to remember is that there are no self-made safety operators. Safety is a conglomerate of independent, but cooperative systems, processes, procedures and organizational policies. 

When an accident happens, it is an over-simplified solution to immediately place blame on the safety management system, in the same manner as it was over-simplified solutions to always blame accidents 

 A stable system could be effective for years to come 

on pilots. It could be that there was a system failure, and it could be that it was the pilot’s fault. However, without data to justify this root cause, a safety conclusion has been drawn based on bias opinions without facts. 

There are inherent risks in aviation. 

These risks are caused by common cause variations and special cause variations. Simplified, common cause variations could be identified as system failure, while special cause variations are variations due to unpredictable events. An effective Safety Management System is to operate with safety processes at a level above the bar of minimum acceptable level of safety and where anyone who demands process changes comprehends the Air Operator’s safety processes. Without comprehending the SMS there is a danger of over-controlling stable processes, or tampering with the processes. Over-controlling to change a result that is undesirable, or to make good SMS processes better could be due to demands by the regulatory authority, customer’s demand, or the operations itself. The result of over-controlling could generate a drift into higher probability of special cause variation to occur and generate a higher risk level which could cause a non-scheduled event. 

Customer service and regulatory compliance complement each other and do not contradict safety performance. Regulatory requirements form the structure necessary for safety in operations, while customer service drives the safety processes required for regulatory compliance and continuous customer satisfaction improvements. Regulations in themselves are not safety in operations requirements, but requirements for compliance in a static environment. This can be described as the issuance of an operator certificate, which is issued (and must be issued), prior to any flights take place. At the time and location when an aircraft moves under its own power is the beginning of operational safety, or continuous customer satisfaction. 

The task then becomes to maintain regulatory compliance and in addition, have processes in place to produce the best possible safety outcome. The SMS regulatory requirements are still applicable to static operations and become the accountability of the operators to apply SMS in their systems, policies, processes, procedures and expectations to monitor how their operational processes conform to regulatory requirements while in motion. When it is established that there is compliance with regulatory requirements, then an operator may move into continuous improvements of customer service, or safety, while still maintaining regulatory compliance. The Safety Management System is the NextGen of aviation safety with tools to monitor safety performance. 

Occasionally, both customers and regulatory authorities have vested interest in monitoring operations of a service supplier or certificate holder. 

Viewing from the fence is a process to see the overall picture. 

This can be accomplished by Enhanced Monitoring. When a customer takes on Enhanced Monitoring of their service provider, any findings are submitted to the operator as customer concerns. Should a customer demand changes in operational processes the outcome might be that a stable process could, by drift, produce a special cause variation and an unexpected event.

When the regulatory body takes on findings during Enhanced Monitoring they demand that an operator make changes. The regulator takes the driver’s seat while enhanced monitoring is applied, and an operator does not have the authority to make their own safety decisions. An operator must run all changes via the regulatory authority. This is how it must be, since the duty of the regulatory body is to provide services to the public and to ensure the interest of public safety is maintained. The regulator has an obligation to accept the risk on behalf of the public. The regulatory body has the authority to revoke certificates and must therefore be directly involved in operational management during the time of their Enhanced Monitoring. 

Enhanced Monitoring is a series of mini-audits and sampling of processes. The organization or person conducting enhanced monitoring must be onsite to collect real-time data and comprehend safety system processes as they are identified by the operator’s SMS. What Enhanced Monitoring is not: It is not a review of data produced by the operator themselves, since this data in itself is bias (this doesn’t imply that it is wrong or incorrect) and the regulator has not fulfilled their sampling of data or frequent mini-audits requirements to accept the risk on behalf of the public. Enhanced Monitoring only of an operator’s data is nothing else by a task to review intent. 

Enhanced Monitoring puts the pieces in a system where they belong 

A true enhanced monitoring is to collect real-time data, produce data into information, gain knowledge from this information and comprehend their SMS by analyzing information. In addition, enhanced monitoring takes on human factors, organizational factors, supervision factors and environmental factors. In short, enhanced monitoring is to sit on the fence to take notes and view the game of operational safety, which does include several common cause variations, and to view with the intent to spot any special cause variations that could cause unscheduled events. It is impossible for any deficiencies in the company's Operational Control System to escape scrutiny during an enhanced monitoring period. An effective enhanced monitoring takes at least three months to complete, depending on size and complexity of the operator. It crucial to safety that any operator, being an airline or airport, conducts ongoing and frequent internal mini-audits of their operations as their own internal enhanced monitoring. 

CatalinaNJB 

Santa’s Run 2017

Santa’s Run 2017

Merry Christmas from CatalinaNJB

Santa is getting ready for another journey of delivering gifts all over the world. Over the many years that Santa has delivered, he has experienced incidents and mishaps, but never had a serious accident that would stop him from providing excellence in customer service. Some years ago, Santa implemented the Streamlined Mission Service (SMS) in an attempt to reduce the mishaps and incidents. Most of these mishaps happened on rooftops as the reindeers came in for landing hitting a chimney or had a rooftop excursion. Over the years the gifts had become more sensitive to these incidents compared to the old-days when gifts were more robust, and an incident didn’t do any damages. The SMS was sold to Santa with a promise that when fully implemented he would have fewer incidents than he ever had before.

Since Santa had only managed safety on-the-fly, he had concern about the new way of SMS, but he reluctantly implemented it and was looking forward to many seasons with fewer incidents, which didn’t happen. When reviewing the previous years, Santa had more incidents per landing than ever before. He was disappointed; SMS had not followed through with the promise of fewer incidents. He was determined to put the SMS on the Elves-Shelf and totally dismiss SMS forever. So, instead of preparing for a safer journey this time, he sat down with a good book about the history of flight.

Even with an SMS in place there were unforeseen variables.

Well, Santa had flown his reindeer long time before any person invented the airplane. Except that nobody seen Santa and his reindeers flying, they just seen the tracks after he had left the gifts.  As he was reading something caught his eyes: Safety Management System was not new to aviation, but started in 1903 with the first flight. Back then, SMS was all reactive and safety was not improved until after an accident had happened. For the first 100 years or so, SMS in aviation was reactive processes and applied to Technical Systems only. With the implementation of SMS, Aviation Safety became proactive and was applied to the Human Factors System. Interesting thought Santa and said to himself that this almost makes sense. He was determined to learn more about what SMS actually is, and if it could be a useful tool to improve his gift-delivery customer service safety record.

As he continued reading the book, he realized that by stepping back from the operations itself and enter into a parallel virtual world, he could review operations from the sideline. He sat down on the fence and just observed his operations during the many previous decades of deliveries. 

Hour after hour he sat and observed previous missions and discovered that he had been operating with a Streamlined Mission Service (SMS) ever since he started the operations. Over the years improvements were made to the operations for safer transportation and higher quality of customer service. One major improvement was when the lead reindeer, Rudolph, received the red nose. The red nose became a requirement after a near-miss with another flying reindeer and should help for collision avoidance with other flying creatures. When they see the red-nose they would be able to tell by that red-nose that Santa was coming their way. The only reason for the red colored light was that this was the only colored light-bulb Santa could find in his film and picture development room.  But it worked. He discovered that since that time there were fewer incidents per approaches and departures than ever before. Santa had discovered the true SMS, which is that SMS is not the magic wand to prevent incidents, but two separate systems to be applied as safety tools.

After a long day of deliveries, Santa and the reindeers took the flight home    

One system is as a parallel system to the operations with a purpose to observe the quality of operations and collect data and the second is as a system for continuous improvement to the reindeers’ Hoof Factors (HF) system. By improving the quality of the hooves, the reindeers could focus better on the quality of landing surfaces and landing spots than have to worry on the damages to their low-resistance hooves upon landing and during critical phases of flight. By applying he HF system, Santa was able to change the reindeers’ safety-culture, which had been to force more hoof-weight onto the other reindeers in the group. With the SMS each reindeer was accepting their individual accountability to distribute the landing-force evenly to all hooves.

After learning more about SMS, Santa changes his opinion about SMS and realized that it is not how many incidents that can be avoided, but how each mission is a mission to continuously improve safety.

By this discovery Santa was prepared for another year of world-wide gift delivery. In addition to improve safety, he discovered that improving safety actually had improved his customer service by more on-time deliveries and fewer hours in the shop to repair the HF system. 

When Santa calculated the return of customer service satisfaction, he applied the formula of the continuous improvement factor and apply this factor in other areas of the operations.

Santa hurried back to Mrs. Santa and the Elves and presented his discoveries. They were all excited and supporting Santa in that it’s not the utopia of perfect deliveries that counts, but how every year becomes an operational safety improvement. Also, Santa understood that the SMS sales-gimmick of magically having fewer incidents was not intended to be wrong information, but just that the elves who sold him on SMS did not have any practical SMS experience.

CATALINANJB