Friday, July 26, 2019

Just Follow The Rules To Avoid Accidents

Just Follow The Rules To Avoid Accidents

By Catalina9

It’s conventional wisdom out there that the only way to avoid accidents is to follow the rules. This includes an assumption that accidents are not affected by other factors than rule-deviations. One justification to make a rule-deviation the root-cause to a finding, pilot-error or failure to comply violation is that the intent of the rule was to improve safety. To ensure that a rule-deviation root cause is fairly applied to human behavior, there is a rule, or procedure made for every action required. If, for some reason there isn’t a rule, a pilot-error root cause cannot be applied. As an example, let’s say there is a wing-strike. The first step in the book is to identify who did it and what rule was not followed. If there is no rule there is no root cause. However, if there is a rule defining a minimum distance between a wingtip and an obstruction, the root cause is assigned as pilot-error root cause.

Knowing the rule does not equal safety in operations. It’s what you do.
Issuing a pilot-error root cause is compatible with the issuance of a highway accident root cause. A road accident could happen with a vehicle travelling below the speed limit, but the rule-deviation root cause would only be applicable if the vehicle was travelling faster than the speed limit. Since there was no rule deviation, there cannot be a root cause applied. Some years ago, a jurisdiction established the speed limit as a speed that is reasonable and prudent for applicable conditions, without a limiting number. This rule applied considerations for a root cause analysis. A rule-based root cause analysis does not apply any considerations since there are only two opposing criteria, which is a rule violation or not a rule violation. In a rule-based root cause analysis there is no justification for not following the rules. In a pilot-error root cause analysis it is irrelevant to the analysis if the person understood, recalled or was aware of the rule. In addition, a rule-based corrective action is reactive without accountability. 

Safety management system is accompanied by a goal achievement plan.
Safety in aviation does not happen by itself. Since the beginning of aviation, safety was common sense while accidents still happened. Safety was learned from experience and incidents. Safety was improved by making changes to avoid specific types incidents and not so much the cause of the accident. If an engine quit after takeoff, the fix was to do an engine runup just prior to departure. This didn’t fix the root cause of an engine failure but established a timeline to assign a pilot-error root cause should the engine fail. During the history of aviation, a pilot, as the last link of an event, would be the root cause of an accident as a failure to complete a task, or estimate a distance between obstruction and wingtip should there be a wing-strike. The root cause was assigned as pilot-error and failure to complete one specific task, failure to comply with a written directive or failure to recognize an approaching conflict. The pilot would be reprimanded or fired as a deterrent for the pilot, or other pilots not to do the same mistake. What took years to realize is that this approach didn’t eliminate accidents. Even with this fact known, a rule-based root cause is still applied in the aviation industry.

Regulations in aviation are required as the tool to structure safety in operations. Without regulations there is no avenue allowed for an effective airline or airport business plan. However, regulations must be performance based to allow for safety. It is incorrectly believed that regulations are a minimum level of safety, while in fact the regulations is a risk acceptance level established by the regulatory authority on behalf of the flying public. A rule-based root cause analysis is effective to the comprehension level of the accident. An accident that is not comprehended is defined as common sense to avoid, meaningless and pilot-error. At a time in aviation history, when it was not understood how aircraft engines could be improved, the corrective action was to make a rule to do a pre-takeoff engine runup. Should there be an engine failure after takeoff pilots could be judged by their pre-takeoff activities.

 process goes wherever the dominos fall and not always to the rule
A rule-based root cause analysis requires an additional element, or reactive action tool than just the rule itself and must be a justification for actions to take against rule-breaking pilots. This justification is defined as illegal activity, negligence or wilful misconduct. With this justification job performance has been criminalized. When criminalizing job performance, corrective actions becomes process output performance reaction, rather than a process input reaction. With this approach it becomes impossible to improve at the pre-process stage, or job performance level of operations since human factors are eliminated from the equation. This does not only include pilots as the last link in the chain of events, but also includes at the input levels of rule makers, policy decision makers, software inputs, including design flaws that were not comprehended, hacking of systems or tampered aircraft automation software. There is always a high possibility, but low probability for illegal activity, negligence or wilful misconduct in any job, but these activities belong in the court system and not in job performance systems. They are not a part of job performance activities and must be eliminated from accident analysis. What must be included are Safety Critical Areas and Safety Critical Functions. Since there is no justification for not complying with a rule, a rule violation is in itself the definition of illegal activity, negligence or wilful misconduct.

Applying a rule-violation as a root cause is common sense and opinion based but is not based on data or facts. A root cause analysis must be based on data collected and becomes a true root cause to the degree of data analyzed. With fewer data points, more assumptions, or opinions must be introduced to the root cause in order to connect the dots.

In a rule violation root cause analysis, there is no need for all components of the 5W+How analysis since the root cause is already established at the pre-analysis level. In a rule-based root cause the Who is the governing factor and excludes the Why and How. In addition, there is no need to analyze Human Factors, Supervision Factors, Organizational Factors or Environmental Factors. A rule-based root cause also excludes objective, goals with the accompanied goal achievement plan. A rule-based root cause it is not compatible with a Safety Management System.


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