Friday, April 19, 2019

Hazard Identification Does Not Reduce Accidents

Hazard Identification Does Not Reduce Accidents
By Catalina9

In the 1930’s a triangle, or a pyramid, which shows the relationships between unreported occurrences, reported incidents and accidents was introduced as the Heinrich law. The law had at that time developed facts of interrelationships between the reporting structure in an organization and incidents and accidents. Minor accidents were ignored, or not reported, since it was common sense to move on with the job and get the job done. In short, the law states that in a workplace, for every accident that causes a major injury, there are 29 accidents that cause minor injuries and 300 accidents that cause no injuries.

Heinrich Triangle

When SMS was implemented in the aviation industry the Heinrich concept was embedded into this new and unknown aviation Safety Management System as fact and became the foundation for reducing or even eliminating accidents. Just recently there was an accident at the “world’s most dangerous airport”, Lukla, Nepal. When reviewing reports of this accident and having viewed several previous operations at this airport, there is no evidence that this was event number 330 and therefore an inevitable accident. The Heinrich law was applicable to the comprehension of accidents at its own time but is not applicable to the ratio of near misses in a Safety Management System. If anyone is the contributor to a successful and effective SMS, it’s Napoleon Hill. Just as he identified the reasons of people’s failure to achieve happiness, these same principles can be applied to identify the reasons of airports and airlines failure to enjoy SMS.

It has become the tradition to sort hazards in a hazard registry. In this registry, hazards are sorted by identified hazards and the highest number of hazards wins the competition. These hazards are then moved out of the registry and into the SMS system to be analyzed and actioned to reduce the number of identified hazards. The reason for reducing the numbers of these same hazards is to satisfy the Heinrich pyramid and feel comfortable that action was taken to avoid accidents. Every time the numbers of hazards are reduced, airlines and airports believe that they have taken appropriate steps to ensure that they don’t reach event number 330, which is a major accident.

Hazards are subjectively identified and a definition of an emotion at the time of experiencing the hazard. What might be a hazard to one person, might not be a hazard to another person. The next day the roles are reversed, and the other person owns the hazard. Since hazard reports are emotionally triggered, they are not reliable as data to analyze the health of operational safety. When applying the Heinrich pyramid to emotionally collected data, the pyramid theory falls apart and does not hold water. It is an emotional description of the hazard, or airport, when Lukla Nepal Airport is named the world’s most dangerous airport.

Emotions is a requirement for performance excellence.

When hazards are pre-defined within the Safety Management System, the emotional and biased component are removed from the equation. A bird is a hazard to aviation, both airports and airlines. Pilots are encouraged to report bird activities, but reporting could be forgotten unless the bird caused a vivid experience and the flight crew had to do an avoidance maneuver. Airports could report bird activities, but the same concept applies to airport personnel. Unless there is a vivid experience, in that they witness the airplane make a steep bank to avoid, the birds are often not reported. Since there are no records of how often bird activities are not reported, the principles of the Heinrich pyramid fall apart. Again, the hazard reporting of birds often comes with an attached emotional component. One system to improve the reporting of bird hazards and remove the emotional component, is that operators, being airport or airlines, actively conduct scheduled bird sighting hazard reporting.

There are several logics of bird activities. To mention a few: The migratory bird seasons, runway color, bug activities, landuse in vicinity of an airport, waterways and landfills. These elements are elements which attract bird activities, but there is no logic to state as fact that an increase in bird sighting reports will eventually cause an accident. Some might have the opinion that the Hudson River landing was inevitable and evidence that the Heinrich theory is valid. Computer generated scenarios might also confirm the validity of the Heinrich principle. However, a birdstrike is random and not based on logic. Computer scenarios do not produce reports of random events, since the next strike is known to the computer software, by the frequency timeline within the software.

Emotions applied to risk assessments turns SMS into a roller coaster.

The aviation industry has come to recognize that the Heinrich Pyramid is not a tool to be applied within a Safety Management System. SKYbrary is a recognized aviation safety medium post the following: "Heinrich's law is based on probability and assumes that the number of accidents is inversely proportional to the severity of those accidents. It leads to the conclusion that minimising the number of minor incidents will lead to a reduction in major accidents, which is not necessarily the case."   

The hazard registry in current format has become an obsolete tool to manage aviation safety. Bird examples are used in this post, but the theory that hazard identification of any hazard will reduce accidents is only an opinion without data attached. The task within an SMS to reduce the highest number of hazards is an administrative task and a simple task. It’s a task to work with the trivial many rather than the vital few. The day when opinions were applied to hazard analyses, was the day when SMS took the wrong turn at the fork in the road.

It is the action and analysis applied to a hazard that makes a difference to safety, but only when hazards are analyzed in a pre-defined action-based risk analysis. With this approach, the principles of the Heinrich theory become inverted applicable. For each vivid event one person is exposed to, that person learns to avoid 29 incidents and 300 near-misses. Human factors play a significant role in that the higher number of incidents one person experiences, there is a greater probability that this person will plan ahead to avoid accidents. A pilot who grew up in a protected environment with little or no exposures to vivid events, is not a safety-qualified pilot to operate an aircraft.      


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