Saturday, June 25, 2022

Unintended Consequences of Hazard Identification

 Unintended Consequences of Hazard Identification

By OffRoadPilots

An SMS enterprise is required to operate with a process to identifying hazards to aviation safety. Defining hazards to aviation safety is subjective and based on prior experiences, guidance, or fear of failure. When there are none, or very few, hazards in the hazard register, the regulator view this as a nonconforming to a regulatory requirement to identify hazards. A limited hazard register is a red flag to the regulator who then will issue findings to operators. An experienced and high time pilot may view a gravel-runway as a non-hazardous condition, while a low time pilot with, or a pilot without gravel-runway experience rates gravel-runway as a hazardous condition. Both pilots view the same scenario, at the same location, at the same time and with the same meteorological conditions, but experience, guidance and fear of failure leads to two different conclusions. One accepts the condition as hazardous, while the other rejects the conditions as a hazard to aviation safety. However, there are several examples in flying that highly experienced bush-pilots operates with a lower risk level bar than new and inexperienced bush-pilots. 

There is a difference between observing for hazards and actively searching for hazards.

In addition to tangible hazards there are abstract hazards. An example of an abstract hazard is time pressure for on-time departures. Abstract hazard conditions are higher risk levels than tangible hazards, since their outcome cannot be predicted, they cannot be measured, or produce the same outcome each time. A common cause explanation to overlook abstract hazards, such as fatigue or time pressure, is to “get the job done”. When there is a conflict between abstract hazards and tangible hazards, the tangible hazard takes precedence. Red flags are more likely to be attached to personnel who reports abstract hazards than personnel who reports tangible hazards. These types of organizations operate with a systemic fear of failure culture. 


An SMS enterprise is required to operate with a proactive process or system that provides for the capture of information identified as hazards and other data relevant to SMS and develops a hazard register. A hazard register are list items of conditions that could cause occurrences, and it is also a list of hazards derived from past occurrences. Hazards should be assessed and mitigated through safety oversight, training and awareness, and the use of a flight data monitoring system. Performing a proactive assessment within a daily quality control system, and a review of SMS database is necessary to verify the rate of occurrences. An SMS enterprise who indicates that they do not have hazards to report should demonstrate how they have reached this conclusion. 


A hazard register contains two distinct different types of hazards, which are assumed hazards and experienced hazards. These different types of hazards should be separated into different hazard registers to analyze the rate of hazards from occurrences and the rate of assumed hazards occurring. 


A third variant of hazard identification is the planned self-evaluation and actively searching for hazard. Requiring pilots and airport workers to actively search for hazards is a distraction and take away time from their roles and responsibilities leading to unintended consequences. There is a difference between observing for hazards while flying and actively searching for hazards. Most everyone has experienced how a new vehicle changes alertness and observations. When a certain make and color of vehicle is purchased, the same vehicles and colors that were not noticeable before, now attracts attention. These vehicles were still within sight before but were not noticed since they were irrelevant to the operator. There is a universal principle called the Law of Attraction, which says that you attract into your life people, ideas, and resources in harmony with your dominant thoughts. Other ideas and resources become irrelevant and not noticeable. The fact is that humans are living magnets, like iron filings are attracted to a magnet, human nature, or human factors, is to attract the people and professions that are in harmony with your current level of knowledge, wisdom, and experience.

A tangible hazard is comprehended, while an abstract hazard is interpreted.

Awareness is a key element for a successful flight and successful airside maintenance. Human factors is to understanding the effect of why a task is required and the effect of how distraction deviates attention from a priority task. When a flight crew's attention is diverted from the task of flying, the chance of error increases. Over the years there have been dozens of air carrier accidents that occurred when the crew diverted attention from the task at hand and became occupied with items totally unrelated to flying. An example is the Everglade crash in 1972 when three green lights failed to illuminate gear down and locked. The crew conducted a fact-finding task to find a solution. While they were focused on the gear-lights, they did not realize that the airplane was continuing to descend, causing the left engine to strike the ground then the aircraft crashed. The flight crew were actively searching for what hazard had caused the lights not to illuminate. 


When an SMS enterprise expects pilots and airport workers to report hazards, the effect of human factors is to focus on finding a hazard and then focus on the immediate threat. The pilot of a small single engine aircraft taxiing at night may be blinded by the taxi lights of an approaching heavy aircraft, causing the small aircraft to taxi across taxiway islands. Hazards, if they are factual or virtual, have a distractive effect on human behavior. When flight crew and airside workers feel obligated to identify unknown hazards, it is unknown to an SMS enterprise how their attention to hazards distract their attentions from current assigned priority tasks.  


The requirement to actively search for hazards is also a regulatory non-conforming behavior. A regulatory requirement for operations involving taxi, takeoff, landing, and all other flight operations conducted below 10,000 feet MSL is that no flight crewmember may engage in, nor may any pilot in command permit, any activity during a critical phase of flight which could distract any flight crewmember from the performance of his or her duties or which could interfere in any way with the proper conduct of those duties. Activities such as eating meals, engaging in nonessential conversations within the cockpit and nonessential communications between the cabin and cockpit crews, and reading publications not related to the proper conduct of the flight are not required for the safe operation of the aircraft. Actively searching for hazards during critical phase of flight is a violation of the regulatory requirement to maintain a sterile cockpit. Unintended consequences to require active hazard identification is regulatory non-compliance and an induced risk level. 


A review of the effect of non-compliance with the sterile cockpit principle finds that 48% were altitude deviations, 14% were course deviations, 14% were runway transgressions, 14% were general distractions with no specific adverse consequences, 8% involved takeoffs or landings without clearance, and 2% involved near mid-air collisions due to inattention and distractions. 


A key to good Human Factors practice is awareness. It is not enough for pilots and airside workers to know what can affect them, It is also necessary for them to be aware that they are in a position to be affected. As an example, knowing that fatigue affects performance is not useful unless pilots realize that they are fatigued. Realizing fatigue is applicable to all professions, not only pilots. In the old days of long-haul trucking, before automatic transmission, drivers realized that they were fatigued when shifting gears became difficult. In aviation, a pilot realized fatigue by altitude or heading deviations. Automation in aviation has reduced the ability to recognize fatigue, without applying an SMS safety case to operational hours. Regulated flight and duty times does not ensure fatigue compliance since the regulation is not broad enough to cover every aspect of fatigue. When the regulation is incomplete, it is the role and responsibility of an SMS enterprise to add additional layers to identify fatigue. A fear of failure culture marks a red flag to pilots reporting fatigue prior to the end of regulatory flight and duty day, or airside worker reporting fatigue prior to end of their shift.  





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