Tuesday, April 30, 2013

There is no money or time to do all the paperwork!

Businesses of any size and complexity may see a Safety Management System (SMS) to be costly, too much paperwork and that it takes too much time to administer. This may apply to trucking operators, air operators, construction operators and other businesses.   It is correct that SMS requires human and financial resources, it takes paper files to document and it could easily be more work than what the organization is capable of. 

In a small trucking company the owner is also running the truck, is the manager, bookkeeper, mechanic and takes on other tasks required to operate. At times there isn’t enough time in the world to keep up with all these responsibilities, and let alone to take on another comprehensive SMS tasks.  

This time-constraint approach to justify operating without a safety management system or take short-cuts is a rush to judgement. Operators may assume that others “don’t know what it is like to operate a trucking company” and what it takes each and every day. All this is correct, and others may not know how multiple daily tasks are delegated between one person, or between multiple employees. However, the “blame the time” approach does not promote a healthy business.  

How is then possible for operators to become successful when they are not capable of taking on a new task of safety management? 

The key to success is to look for what makes the organization successful, then prioritize and work on these successful tasks. Regulatory compliance, safety oversight and customer service are ingredients for success. By focusing on these simple principles there is enough time to manage prioritized tasks. 

In a few simple steps, let’s follow a process where a trucking operator did not have processes for safety or regulatory conformance. The outcome is based on a true story. 

When hading out with this rig, legal capacity 80,000 lbs, the daily inspections were skipped, loads were regulary heavy over weight, brakes were not adjusted and driver log-book had no entries. Due to highway DOT control stations, the owner chose to travel back-roads to avoid scales, travel farther distances and constantly be on the lookout for DOT enforcement vehicles. These processes worked for a period of time. However, one day due to material fatigue of being constantly overloaded and travelled on less supportive roads, the tractor-frame caved in. That day the freight didn’t make it to the customer and the operator didn’t get paid for services. In addition, since the incident happened on an interstate overpass just a few miles north of a DOT enforcement station, it didn’t take long for highway enforcement to show up. 

A successful business will remove obstacles, apply appropriate processes and move forward. 

Processes applied by this operator did neither conform to regulatory compliance nor to customer service expectations. The issue is not if there is enough time to implement a safety system, but if the operators are willing to change processes to meet customer’s needs and expectations, and establish processes conforming to regulatory compliance. 

As technology progresses, regulation changes and customers demand better service, businesses must change processes to meet these needs. This applies to any business, not just transportation operators. Several years ago some of the car manufactures did not change processes to meet the current needs and encountered financial difficulties. 

Over time processes becomes obsolete and operators must be able to adapt to these changes.

There will be times when processes become obsolete and must be traded for other up-to-date process. The key to success is to apply processes to ensure regulatory compliance, safety oversight and meet customer’s needs.  


Wednesday, April 24, 2013

School, SMS and Just-Culture

School, SMS and Just-Culture

A school division adapts 29 commitments to guide teacher’s actions, influence decisions and support in moving closer to a desired future of an inspired community of learners. The adaptation of these commitments sounds positive, great and excellent.

One of the commitments states: “Ensuring the physical and emotional safety of all members of our educational communities“.

One day a teacher makes a comment that a student born in a different country should not be proud of their family heritage, but adapt to be proud of the country where they live now. Some students feel an emotional embarrassment for being proud of whom they are. Another teacher makes a comment that one must be punished to be loved and parents who punish are caring parents. The question is forwarded to school division of how these teachings ensure students emotional safety. A school principal response is “Do you actually expect us to live by these commitments this in class?” A response from a school division executive is that this is a local school issue and should not be addressed to school division’s leaders. 

In both instances teachers plays it downs to students misunderstanding, and the principal refuses to receive concerns and comments on the issues.  However, some teachers apply “exit-slips”, to capture feedback of what students believe is being communicated during class and to track what they learn.   

How does this fit in with a Safety Management System (SMS)?

This fits in with what management style students learn at a young age. A school division applies fine words of commitments which are placed on a board for students to read. There is no support at the level of school leaders, or a system of accountability in place to collect data, analyze trends and determine if these commitments were achieved. There is no room for continuous improvement in the school division. How is it then possible for a school division to submit true reports? 

Without a just- culture, accountability and learning, 
the trail leads to somewhere unknown. 
It will become natural for students to continue on this path as they enter into the workforce. In a school system, the responsibilities are removed from school division’s authorities and lack of progress is placed on students who are the lowest level in a hierarchy. There is no just-culture where leaders have free reins to place blame to whoever they pick and chose in the organization. 

SMS is a just-culture of accountability throughout the organization, where members are given responsibilities, and accountability is compatible with learning.   


Your Thoughts......

Friday, April 19, 2013

"Out of Control" Indication in Texas Plant Explosion

"Out of Control" Indication in Texas Plant Explosion


I have mentioned many times, there is always a trail of things going out of control before an accident. As we begin to study what happened in West Texas, we begin to have indications of possible violations of Safety requirements at the plant. As indicated by the article I cited from the Chicago Times.
Fertilizer Plant Explosion in West Texas

“It remains unclear what safety measures, if any, were required of the company or whether West Fertilizer failed to comply. But on Wednesday night, the company's fertilizer complex in West, Texas - population, 2,600 - exploded with such force that 60 to 80 homes were flattened, the school and nursing home took heavy damage and at least 14 people were killed, authorities said.”

2011 filing by the EPA revealed that there was a possible serious health issue with anhydrous ammonia release. Now the substance is not flammable but extremely toxic.

In a separate filing earlier this year to the Texas Department of State Health Services, West Fertilizer disclosed that, as of the end of 2012, the company was also storing more volatile chemical compounds at the same address, including 270 tons of ammonium nitrate.”

Ammonium nitrate is extremely explosive. In addition, there was a history of safety violations.

Investigators stand amid the aftermath of a massive explosion at a fertilizer plant in the town of West, near Waco, Texas

"The privately held fertilizer plant, which has been in operation since 1962, has been cited for safety violations by regulators in the past. Records show the EPA fined West in 2006 for $2,300 for failing to update its risk management plan, a blueprint required to ensure safe operations.”

The company also failed to have a employee training program and did NOT have   “ formal written maintenance program in place.”  . It is disturbing that the EPA did not fine the plant for that violation.  It is so important to have Procedures for everything. 

“In December 2006, it received a 10-year permit from Texas regulators that allowed for the operation of two 12,000-gallon (45,425-liter) storage tanks for anhydrous ammonia. The permit required West Fertilizer to carry out daily visual, auditory and olfactory inspections. It was not clear whether the firm required, or obtained, additional permits for operations involving more volatile compounds.”

Daily inspections...the article indicated that compliance was unclear. If the company truly had a safety program, these required inspection would have been documented and audited to make sure the inspection were carried out. 

In 1985, the company, formerly known as West Chemical & Fertilizer, was cited five times by the federal Occupational Safety & Health Administration. Two of the violations were characterized as "serious," with one related to the storage and handling of anhydrous ammonia, federal records show. There were no records of OSHA fines in more recent years.”
Arial View of Devestation after Blast

So, we have at least three regulatory agencies overseeing the safety requirements of the plant. Texas Dept of Health, EPA, and OSHA. I also found it interesting that the article goes on to state, “A Common Way to Operate.” 

“Thousands of sites across rural America store potentially explosive materials and blend fertilizer for farmers, similar to West Fertilizer. In EPA reports, about 10,000 facilities say they store anhydrous ammonia.

Nitrogen-rich fertilizers help promote crop growth and are used by farms across the country.

Anhydrous ammonia is only flammable at temperatures exceeding 1,500 degrees F (816 C) and would not be expected to trigger such a massive blast, according to an expert.”

Keep in mind that in this plant there was not only anhydrous ammonia but also ammonia nitrate. The article end with these statements.

“Despite the fiery TV images and death toll from the blast, some in the fertilizer industry are not expecting calls for new restrictions on where and how such facilities can operate.

An estimated 6,500 farm retail stores in the United States blend, store or sell fertilizers to farmers, said Daren Coppock, chief executive of the Agricultural Retailers Association. The West Fertilizer plant is far from the only one near homes, he said.”

OK so some in the fertilizer industry are not expecting call for new restrictions on where or how such facilities can operate. What about the oversight of the safety requirements already in place. If the company had a Safety Management System in may NOT have prevented this accident. But, we certainly would have seen actions on the critical safety trail of control issues in the past. 

your thoughts.....

Tuesday, April 16, 2013

Have You Been "SMS'd"?

Have you been SMS’d?

Simplified, there are three questions to ask when an SMS hazard report is received to validate the report.  

1. Does the hazard report include the description of a latent condition which if left unattended could develop into an incident? If the answer is “yes”, it’s a hazard. 
2. Does the hazard report include that the hazard has caused an unexpected event or interruption of a process? If the answer is “yes”, it is not a hazard, but an incident and to be actioned accordingly.  
3. Does the hazard report direct attention to an individual having lack of sound judgment or technical skills? If the answer is “yes”, it is not a hazard, but an organizational issue and to be actioned accordingly.  

Hazard reports may be submitted anonymous since it is a condition which has not interrupted a process. A hazard is to be analyzed, categorized and placed in a hazard register for follow-up action. 

When a hazard report is pointing out an individual, that person becomes the sole responsibly of the outcome. When reviewing a hazard report pointing blame on an individual, it’s time for the SMS manager to move back to the fork in the road and read the signs. One of the signs should show the road to analyze hazard reports. 

If one continues down the wrong path in analyzing reports, it could be a long walk back to find the sings
When a person be SMS’d, or being named in a hazard report, it could be that hazard identification has not been addressed on the management level and communicated throughout the organization. Hazard reports are not intended to replace, or be used a tool in an assessment of individual competency. However, it may indicate shortcomings in organizational training or evaluation of training. 

When using a hazard report to get someone SMS’d, it becomes just as ineffective as attempting to use a tractor as an airplane. It’s not the correct tool, it does not improve aviation safety and the desired result is not reached. Even if one puts a competent person into this equation, the outcome does not improve safety since the design of a tractor is not to become airborne. A process may work great and all the pieces in the puzzle fits, but the design inputs are incorrect when placing blame on a person and they are SMS’d. 

Your thoughts......


Thursday, April 11, 2013

Human Factors, Changes and Eating!

Recently, I have several articles on Food. I think maybe because I am on a Diet. I came across a blog that ties eating and Safety and I thought it was interesting. There are some actual practical ways Human Factors can affect Safety. The science of the size of people and their ‘fit’ with their environment (anthropometry) is key to our design of many ‘Systems’. It has long been a key part of ergonomics (human factors). However, it doesn’t often make the news. This week the UK media has been highlighting a recent concern from the offshore oil industry relating to an increase in weight of offshore workers. I believe this is important in several way. First for the reasons I list below but, also for the many Helicopter and Transport industries that support the Oil rigs. 
Average weight of Off Shore Oil Rig workers on the rise. 
It appears that the average weight of offshore workers in the UK sector has risen in the 25 years since the last systematic survey; and not by a trivial amount. In 1985 the average weight of a male worker was 76 kilo, and in 2010 it was 90 kilos.

This impacts many things that are critical to safety, effectiveness and wellbeing in the industry, including design of 

helicopter seating and number of passengers, lifeboat design, safety equipment such as survival suits, accommodation, shared areas, control rooms, equipment access, and the list is almost endless. From a human factors engineering (HFE) perspective, it reminds us that nothing stays the same and we need to be careful with our data tables. In Quality Assurance terms, “Metrics.” Metrics must be continually updated in order to assure the pertinence of the data to the system. 
Human Factors Metrics is important to maintain

This isn’t an abstract issue. Weight can have a very real consequence if we allow our data to become out of date. The fatal crash of Air Midwest Flight 5481 in 2003 was caused in part by passenger weight data that was over 65 years out of date. When the FAA in the US went back to first principles and measured the 21st century reality, it came up with similar conclusions to the oil platform worker study; their data was out of date and wildly different from reality.

The obvious question to ask is why is this happening? The FAA work shows us that there has been a long term change since 1935 in the general population, but the North Sea data shows a similar change in only the last 25. I suspect that as well as a long term trend to more obesity and higher average weights, there are other factors at play here. Not least the change in demographic of the offshore workforce. Many people currently working in the industry are now in their 50s, having started in their 20s, with all the attendant changes to physiology that that involves. That could be a part of the picture.

The Fat content of foods has increased
some 40% in the last 20 years

I also wonder whether the increased standards of catering on offshore platforms might also be playing a part? We always tout that Continuous Improvement is necessary. However, we need to Risk Assess some of those improvements. Can an improvement to a process or procedure lead to another risk else where? Interesting concept.

Your thoughts....

Monday, April 8, 2013

The Face of a Safety Policy and SMS

The face of a Safety Policy and SMS
A Safety Management System (SMS) is not just paper documents written to sit on the shelf, but a down to earth system on how to manage safety. It is a system showing an outward safety face. An aviation operator must be able to identify and communicate how they conform to regulatory compliance and safe operation. SMS is the new way in safety by proactive management of causes and eliminate as many as possible of symptoms requiring reactive measures. The success of SMS may be by what face is picked. 
A rock-face SMS it is a rigid non-flexible system unable to conform to regulatory compliance. 
A rock-face SMS is a rigid and non-flexible system unable to conform to regulatory compliance. No matter how organizational factors, human factors or environmental factors change, the face of a rock does not change. It will stay its course comes hell or high water. A rock-face SMS simply becomes what it is, and only a severe blast may change the outlook, and may not have the ability to manage changes for safe operation.     

Face of a goat SMS and is a system where safety is actioned by instinct, inspired by the moment and risks are promoted. 
The face of a goat SMS is a system where an organization is living by the moment and action by instincts becomes their safety policy. This SMS will push the limits when climbing the latter to success and follow others on the ledge of a high cliff. An organization managing by instincts does not offer planning or risk-assessments, and only reacts when guided onto the bridge of danger. It could become an unmanageable task to make financial projections to management when safety is inspired by the moment. 

An SMS with a human face has capability to analyze, comprehend, design and inspire. 
A human face SMS is a system where an organization applies the; plan, do, check and act management method. This type of SMS has capability to document operations, communicate safety, analyze risks and design organizational systems. A human based SMS consider human, organizational and environmental factors. It is an organization where training programs are developed to improve technical skills and where causes are identified to eliminate symptoms. By putting a human face on an SMS, customer services are given opportunities to prosper, personnel feel good in a just culture, financial projections are managed and safe operation confirm to regulatory requirements.   

An effective SMS forms, shapes and develop programs for regulatory compliance and safe operation.

A large organization may communicate operational and regulatory compliance through several functional areas. In a small organization communication of regulatory compliance and management of safe operation on a daily basis may be communicated by one person who wears different hats of functional areas. When systems for regulatory compliance and safe operations have been identified operators have discovered their tools to be communicated and what face to put on SMS


Your thoughts......

Monday, April 1, 2013

Rebuttal to: Danger Overhead Part 1: Transport Canada

Danger Overhead Part 1: Transport Canada cuts may endanger small air operators

Safety of commercial flights called into question

There were three separate Canadian Publication that posted articles related to Safety Management Systems, SMS, Today!. It almost looks like a frontal assault on SMS! The main theme of each article is pretty much the same. SMS can not work for small carriers and that Transport Canada is not doing it's job to properly regualate them. All these articles trot out tradgic accidents from the past to set the public mood. These accidents were tragic and cost lives, but, we must truly investigate what the root causes are for each one. 

These accidents are tragic and something needs to be done to prevent and/or mitigate them. The article goes on to suggest that the Transport Canada’s move to Safety Management Systems, SMS, may have contributed to the small operator’s safety issues. It is important to note that ALL the small operation accidents happened NOT under SMS. SMS is not required for small operators at this time. It will be in the future. SMS is tailored to the size of a company.

So the idea that small operators can’t implement SMS because their are not Air Canada or Westjet is irrelevant. SMS can be easily implemented by small operators, with the right training, and is not as hard to implement and maintain as most claim. In fact, the article provides more of an incentive for Transport Canada to mandate SMS to small operators. Statistics show that it does increase Safety to the Public and allow these operators to gain better control of their operations. Yes, Transport Canada is facing resource issues but, their surveillance program, under the Staff Instruction SUR001, does an excellent job of revealing Safety issues in any operator with powerful sampling techniques. 

Transport Canada’s Surveillance program uses a “Systems Approach” to oversight. The concept in a nutshell is this. The enterprise management is responsible to make sure all their operations are under “Control.” What is Control? The company has and is following standard operating procedures, auditing those processes to make sure people are following procedures, performing internal corrective actions on hazards, and continuously monitoring and improving it’s system processes. 

Yes, Transport Canada made some mistakes in it's implementation of SMS for the 705 Carriers. We must remember that no other country in the World has mandated SMS for thier carriers, so Transport Canada was plowing the new ground here. I believe that have first hand experience in what works and what doesn't work better than any other regulator. 

You can not condemn Safety Management Systems if it not tried! Statistics don’t lie, SMS, when implemented properly will make a company safer. Will it prevent an accident? No, but the system will identify when things are going “Out of Control” BEFORE and accident. I my career dealing with the US Military, NASA, Transport Canada...every accident has a trail of something going out of control before the accident. SMS can catch the hole before making through the entire “Swiss Cheese.” 

Illustration of the "Swiss Cheese" model that shows an alignment of the holes that cause and accident. If a company that has SMS will have controls on all their Processes. This will seal each hole in the processes that lead to an accident. 

As the article suggests; “Gord Marshall thinks Transport Canada will have to abandon altogether its hopes for eventually having SMS at air taxis and smaller commuter operators and restore — even boost — traditional front-line inspections.” Is a mistake and going backwards!

NOTE: Sol and I are the Facilitators to all Transport Canada Inspectors for their Surveillance Procedure Training Program as well as the consultants to Transport Canada's Quality Assurance component of the Safety Management System. We also have consulted to over 200 private aviation enterprises, much of which are small operators. 

your thoughts...............

Communication – an Airport Safety Tool

Communication – an Airport Safety Tool.

Airport traffic varies form a handful flights a day to supporting million of passengers per year. Some operators have to manage conglomerates of light, medium and heavy airplanes, in addition to ground vehicle and pedestrian traffic. At times the weather may cause additional safety considerations and risk management challenges. Airplanes are operating on a schedule and expected to be on time comes hell or high water. The airport operator needs to have processes in place to safely manage all possible combinations of events. 

Communications tools have improved since the first flight of 1903
Communication is an effective tool in airport safety management. The airport operator may communicate worse case scenario from closing the airport, to normal operations without unexpected events.  There are several avenues of communication available, from printed NOTAM to direct communication to pilots. The method of communication is governed by the urgency of notification. 
For airport operators to communicate, they must first collect data. It is not effective to communicate expired data.  Data collected must be up to date and as recent as possible and available to departing or arriving aircraft at a time when they are able to apply the information in their planning.

Communication is a tool to manage 
safety and update airport information
Effective communication is not about the airport operator’s schedule or work environment, it is about safe aircraft operation and safety for the flying public. 
Airport safety begins at the outer edge on approach. An airport operator has complete control of obstructions and activities on airport property, but they may not have any jurisdiction to control landuse outside airport property. It is possible that a tall structure, being tower or crane could be erected adjacent to an airport, and be in the way for an airplane on approach. 

An airport operator must therefore have processes in place to collect data of obstructions in the vicinity of the airport and communicate obstructions as soon as possible to alert pilots. Should an airport operator have regulatory authority to restrict building heights outside airport property, the structure, being crane, building, tower or trees may be enforced to be removed. 

Data collection and communication becomes a vital lifeline for safe operation of an airport. Data must be as current as possible and communicated by urgency. Data collection and communication processes are improving and becoming more effective with introduction of new technology. 


Line-Item Audits

  Line-Item Audits By OffRoadPilots A irports and airlines are required to conduct a triennial audit of the entire quality assurance program...