Performance Is Exceptional

Performance Is Exceptional

By OffRoadPilots 

Since most of the tasks goes right most of the time, every day performance goes unnoticed and viewed as unexceptional tasks. Airports and airlines fall into a trap to accept repetitious tasks as trivial tasks without considering the successful outcome and these tasks to be less important than complex special tasks assignments. Conventional wisdom is that organizational drift in safety is to drift away from safety in operation to unsafe processes. Drift is neutral and does not affect safety in operations to be improved or reduced. Since drift is neutral, safety improvements or safety reductions are neutral. A concept of an effective safety management system (SMS) is to implement changes for incremental, or continuous safety improvements. Continuous safety improvement is a statement applied to emotions. Such statements are often used in sales and marketing describing a new product or service to be new and improved, which implies that the prior product or service was old and inferior. Safety today does not become old and inferior tomorrow but is fluid and adaptable to external changes.

Continuous safety improvements are the practical drift and the practical compliance gaps. A practical drift is the difference between work imagined and work as actually performed. Work imagined are documented by organizational policies, processes, and procedures. The practical compliance gap is the difference in regulatory compliance in a static environment where nothing moves, and the regulatory non-compliance within a moving environment. When work imagined becomes the compliance standard for safety in operations, it is with an assumption that their systems, processes or procedures are perfect and fail-free. The practical drift system is a common cause variation within the system itself. An airline or airport operator must identify these variations for their SMS to conform to regulatory requirements. Regulatory requirements for the person managing the safety management system are to monitor trends, monitor corrective actions and monitor concerns of the civil aviation industry. Monitoring these tasks is to monitor the outcome, which is different than monitoring for compliance with work imagined.

Continuous, or incremental safety improvements are needed for operations to maintain oversight due to external and common cause variations in processes. A change that is done for the purpose of safety, may or may not be an additional benefit to safety in operations. That the safety card is played, e.g., implemented for safety reasons, is more hazardous to aviation safety than continue operations without changing anything.

Takeoff performance charts for gravel runway are different from performance charts for paved runways. Rolling resistance, sometimes called rolling friction or rolling drag, is the force resisting the motion when a body rolls on a surface. An aircraft rolling on a graveltop surface experiences higher resistance than an aircraft rolling on a blacktop surface. A new type of graveltop runways is the Thin bituminous surface runways classification. Gravel runways have successfully been used for decades in places where it is expensive to make runway pavement or concrete. When operating on gravel runways there are loadbearing restrictions, and there are aircraft performance restrictions. These restrictions are often viewed as a burden and a restriction to operations rather as an additional layer of safety. Gravel runways are located far away from emergency services should an incident occur, and there are airports where public emergency services do not exist. Operating with gravel runways restrictions is to adjust operations to geolocations, since hazards are identified locally. Aircraft weight restriction due to gravel operations is viewed as a trivial task restricting affecting business revenue, rather than for the exceptional performance task it is. Classification of thin bituminous surface runways is a change in classification only, from a gravel runway to a paved runway. With this change, aircraft maximum gross weight is allowed by the regulator to be applied to their takeoff and landing performance. Simplified, there is no changes or construction made to the gravel runway, so the runway remains the same as what it was prior to reclassification. After reclassification, an airline is considered “safe” for takeoff with the stroke of a pen only. The classification criteria itself acknowledges this flaw in performance requirements.

The thin bituminous surface runways are a broad class of surface treatments, which have a variety of performance characteristics. Newly built thin bituminous surface runways require sufficient curing time to provide a competent and durable operational surface. A class 3 pavements may be considered to meet the definition of a thin bituminous surface runway. Since a runway may be considered, is in itself an acknowledgement that there is no data available in support of compliance with all the requirements. In other words, and since the runway may, there are no gravel runways that actually meets the most stringent standard requirement for reclassification as defined. In addition, there performance data for the actual groundroll is not required to assess the validity of the reclassification.

Airport operators designates their most critical aircraft by aircraft group number, which is a numeric value of characteristics of the critical aircraft for which the aerodrome is supporting. The aircraft group number is determined by the critical aircraft wingspan or tail height. An aircraft group number is based on a paved runway surface, with a limited maximum gross weight capability. An airport operator may select an aircraft group number based on aircraft wingspan and tail height, but the standard is lacking a method to verify how an airport operator select an aircraft size based on runway surface performance, or aircraft landing and takeoff performance. The root cause hazard with reclassification to the thin bituminous surface runways is the opportunity for regional compliance by airport operators who wish to maintain gravel operations to reclassify their runway for airlines to operate out of their airport. The one airport operator who remain a gravel runway operator has the highest risk to loose business due to their takeoff and landing restrictions. In addition, they are unable to provide friction characteristics of a runway surface for a runway serving turbojet aircraft, and there are still many unanswered questions. On the other side, the person who was the driving force behind reclassification to thin bituminous surface runways, received a recognized award for the work. When exceptional performance of current processes remains unrecognizable, and risk levels are established by emotions, checkbox syndrome, or by social media likes, any changes to processes becomes its own worst enemy.

Work well done often goes unrecognized as an important work task since everything is operating normally, processes are ignored and discarded as every day normal tasks. Drift is often recognized as drift into unsafe conditions, but unrecognized drift into improved safety in operations is just as much a hazard to aviation safety as drifting into hazardous operating conditions. Hazards are predictable, while incidents and accidents are unpredictable.

For an incident to occur there are three conditions that must meet at the fork-in- the-road. The first condition is that an aircraft, vehicle, or person is performing a task beyond the limits of their capabilities. E.g. an aircraft requiring 3,000 feet takeoff distance is taking off from a 2,000 foot runway. The second condition to be met is recognition of past practices without recognizing special cause variations. E.g.an aircraft normally departs empty and fly to a longer runway for passengers and freight to be loaded but does not recognize the effect of partial loaded aircraft. The third condition is operational drift to complete a task within a defined timeframe. E.g. daily departure performance records are exceptional, but it is not recognized as exceptional since it occurs daily, and drift is occurring to recover lost time for on-time task completion. Capability limits may be skewed based on established operational requirements, just as the thin bituminous surface runway scenario that justified the change as safety improvement in operations, while the root cause of change is to move operational limitations. Past practices may be skewed by an induced level of urgency to complete, and drift to improvement goes unrecognized when emotions or external forces are applied to decisions.

When performance is exceptional, such as operating out of a gravel runway with performance restrictions, drift into improved runway surface condition is just as much a hazard as drift into acceptable practices.

OffRoadPilots

More is Less and Less is More

 More is Less and Less is More

By OffRoadPilots

An accountable executive (AE) once said that they operate their safety management system (SMS) and airport operations by a principle that more is less and less is more. When operating by this principle, their regulatory compliance was in essence non-existing, and the regulator demanded the surrender of their airport certificate. The airport operator presented a corrective action plan to abolish the principle that less is more, and the regulator accepted their corrective action plan. Their airport certificate was secured, but an enormous task was ahead to establish regulatory compliance with all SMS and airport regulations. After the airport certificate was secured and compliance level established, the airport operator abandoned their quality control system and reverted back to their previously less is more principle.

A regulatory requirement is for the AE to be responsible for operations or activities authorized under the certificate and accountable on behalf of the certificate holder for meeting the requirements of the regulations. Traditionally, the airport manager (APM) was the certificate holder and would also remain the certificate holder after implementing the safety management system. As the certificate holder, the APM is the airport authority, the decision maker, and an AE is accountable to the APM to maintain compliance with the regulations. Compliance with all regulations and standards are comprehensive tasks, with compliance established with a line-item audit. When operating by the less is more principle, airport operators take it upon themselves to exclude regulations they have decided not to be applicable to their operations. Airport operators do not take into account that there is none, or minimal, scaling of the regulations to suite size and complexity of airport operations. The scaling is a regulatory requirement applicable to scale the processes as opposed to decline compliance with the regulatory part.

When applying the less is more principle, they are applied laterally to any systems without considerations to the issue at stake or expected outcome. Statements such as, “remember that less is more” are commonly used when undefined expectations are a part of the outcome, or minor tasks are removed from regulatory requirements, or lack of process comprehension, or when non- compliant tasks are excluded from the equation. There are times when the less is more principle is true, but the less-is-more system, is not a system to integrate into a safety management system.

The less-is-more system absolutely has its place within many systems, and advertising is one of them. Imagine for a minute that you are driving down the highway and you see a sign that says something like “Our breakfast menu has pancakes, toast, eggs, farmer’s gravy, bacon, sausage, eggs, and coset between $10-15 per adult person.” By the time you get to pancakes, you have passed the sign and wondering what it said. In a less-is-more system, the sign would say “Hungry? Next exit” With this sign the business gets more visitors who are hungry and generate more revenue. In addition, since there are fewer words, the sign cost less to make. The less-is-more system is a trigger to the imagination to fill in the blanks, and the blanks give positive, or happy feelings of what the imaginary outcome is. Online advertising has also changed to the less-is-more system by shortening their advertisements to five seconds to hit their target points and for the imagination to fill in the rest. Whenever there is a void, it will be filled with something. Other examples of less-is-more is it lower an item price below regular price to sell more units, it is to offer 25-cents video machines to attract more plays, it is to show less of the neighbourhood when advertising a home to attract more customers, it is to pay less for internet with slower connection and spend more time to upload and download, it is to spend less money on personal improvements to assert more internal control of personnel, it is to spend less money on training for a more uniform and conforming environment, or possible most important reason to operate with a less-is-more system is to play ignorance after occurrences. 

An AE once said that it is difficult to work with hazards that are unknown. The less-is-more system absolutely serves a purpose for an AE operate with a less productive safety management system and to some extent the regulator accepts the ignorance play. Just a few weeks ago, an airline gave this excuse for an aircraft that took off with contaminated surfaces saying that the pilots did not follow safety rules and the regulator accepted without further investigation. In 1956 two airlines were operating in a less-is-more environment causing a midair collision. Most people would not chose the less-is-more system when selecting medical treatment, but it is accepted in aviation safety. Ignorance is bliss, or if you do not know about something, you do not worry about it.

The less-is-more system is a destructive system for a safety management system for both airport and airline operations. The role of an accountable executive is to maintain compliance with records keeping. The regulatory requirements for records keeping are to maintain a record system, that do not comprise the integrity of the records system, measures are taken to ensure that the records contained in the recording systems are protected against inadvertent loss or destruction and against tampering, and a copy of the records contained in the recording systems can be printed on paper and provided to the regulatory on notice given. It would take some imagination to make less-is-more out of these requirements, but if works when processes are combined to cover multiple requirements. This is only possible with a daily quality control system, and a user friendly software that comply with all requirements. When a quality control process is established and determined to conform to regulatory requirements, there is minimal work needed in daily operations. Without a proven daily quality control system an airport or airline operator must complete the same tasks daily and start from the bottom every day to ensure compliance. E.g., using paper format records without continuance to the next day or the historical records.

The regulatory requirement foranAEistobe responsible for operations or activities authorized under the certificate and accountable on behalf of the certificate holder for meeting the requirements of the regulations. This is an enormous task and it make sense that an AE sets performance goals to minimalize these tasks as much as possible. Exempting operations from the regulations is not the way to go. A small to medium airport operator may only receive a turbojet aircraft a few times a month and decide on their own that compliance with obligations is not justified since this is how “we always did it.” This is the less-is-more system in that complying with fewer regulations provide more options, or opinions to how airport operations should run. With this approach the safety-card is played, and any tasks or actions are justified by the word “safety.” When the word safety is applied, there is very little opposition to the tasks, and especially if airside personnel remain untrained and without knowledge of oversite requirements. Keeping workers in the dark is a prerequisite when operating with the less-is-more system. Only after a complete line-item audit is completed of the operations, the daily quality control system is in place, and processes assigned to regulatory requirements, the less-is-more system could be applied by monitoring drift and operations daily, and make adjustments as required when personnel are drifting from design operations. However, the AE who decided to change over to the less-is-more system, also excluded the audit requirement from compliance system.

The more is less and less is more system is incompatible with operation of an airport or aircraft, and the safety management system. The litmus test of systems compatible with airport and airline operations is in their daily quality control system.

OffRoadPilots

How to Capture Unknown Hazards

How to Capture Unknown Hazards

By OffRoadPilots 

There is a difference between an unknown hazard and a hidden hazard. Unknown hazards are unknown, but they are not hidden. An unknown hazard is a hazard without a hazard classification, it is a hazard defined by likelihood where times between intervals are imaginary, theoretical, virtual, or fictional.

Unknown hazards are incomprehensible to common sense but are still real hazards. An unknown hazard is in the open and in plain view but is not recognized as a hazard for the purpose of an immediate task to be performed. Unknown hazards also need to be assigned a scope and sequence to learn their whereabouts. A person may be exposed to unknown hazards without knowing it. Exposure to an unknown hazard is a higher risk to aviation safety than exposure to known and hidden hazards since they are unknown and cannot be mitigated.

Hidden hazards are known, but they are hidden and may become visible, or active, if triggered by human factors, organizational factors, supervision factors, or environmental factors. A hidden hazard is removed away from operations in a 3D environment and measured in time (speed), space (location), and compass (direction). Hazards also becomes hidden by remote management environment since the immediate threat to aviation safety does not affect a remote location. A hidden hazard may be hidden for one person, but still be active to another.

A widely accepted method to learn about hidden hazards is to ask personnel to search and identify them in their workplace. One person may identify a condition as a hazard, while another person do not see the same condition as a hazard.

Hazards identified by personnel are often based on emotions, past experiences, based on public opinions, or based on expectations. There are as may reasons to identify a condition as a hazard as there are workers. Mandating a search of hidden hazards is in itself a hazard, since a worker’s attention will be moved from their job activity to searching for hazards. Requesting voluntary hazard reporting as any hazards affects job performance is different, since the workers at that time are focusing on their job tasks rather than identification of what is hidden. After hazards are identified, the role of an SMS Enterprise is to analyze each hazard received, assign a classification, and enter into a hazard register. Identifying a hidden hazard is not the same as identifying an unknown hazard, since hidden hazards are known, but the condition for those hazards do not exist at this time. A prime example of a hidden hazard is when weather conditions are conducive to ice or frost formation on aircraft surfaces, although there is no observable precipitation or fog while an aircraft is on the ground.

Unknown hazards go unattended until there is an incident, accident, or published by a social media post. An unknown hazard is also a special cause variation to aircraft operations since exposure and likelihood has not been accounted for. However, the hazard may be a common cause variation within the process itself. Ice and snow accumulation is known to be a hazard to aviation safety, but at the time of conducting task at hand the hazard is unknown to flight crew until exposed by an incident, unstable flight or published on social media. When this happens, airlines are quick to place blame on pilots, who were just doing their job as expected. A prime example is when an air operator suspends pilots pending investigation into a failure to follow de-icing procedures. In this particular true story, there were no de-icing policy or process established by the air operator to operate out of this airport during icing conditions. 

An aircraft does not carry its own ground deicing equipment and fluids and agreements with airports and contractors are required to deice prior to departure. Without a contract agreement between the airport and airline to deice prior to departures when temperatures are below freezing, pilots complied with management expectations to operate without deicing the aircraft. The aircraft departed without issues, but the hazard became known when posted on social media.

Capturing unknown hazards is an analysis task as opposed to an observation task. Asking workers to actively search for hazards is an observation task. Several hazards can be identified by this method, but the process in itself is reactive since a mitigation plan, or control action is pending on the hazard first being identified. A safety management system (SMS) is simple in concept which is to find the hazards and do something about it. Also, identifying unknown hazards is a regulatory requirement. An SMS enterprise is required to operate with a process for identifying hazards to aviation safety and for evaluating and managing the associated risks. A requirement to identify hazards is for an SMS enterprise to find a hazard, name a hazard, assign a classification to the hazard, and record the hazard in the hazard register. When all this is done, they need a process for setting goals for the improvement of aviation safety and for measuring the attainment of those goals. Capturing unknown hazards is an invaluable tool for goalsetting.

The four items to analyze and capture unknown hazards are within human factors, organizational factors, supervision factors and environmental factors. When searching for unknown hazards, these are the starting points and work backwards from there until hazards are identified. Applying the process inspection flowchart is the same system as the process to capture unknown hazards.

HUMAN FACTORS

An SMS enterprise has an obligation pursuant to the regulations to assign duties on the movement area and any other area set aside for the safe operation of aircraft, including obstacle limitation surfaces, at the airport, which are described in the airport operations manual, only to workers who have successfully completed a safety-related initial training course on human and organizational factors. A human factors training course includes identification of unknown hazards by recognizing that human factors is different than human error. Human factors are behaviors triggered by the five senses. Human error is to complete a task knowing that the task is completed by a non-standard process. This does not imply that that human error is a direct hazard to task at hand, but that unwritten processes are used to “get the job done”. When unwritten processes, or shortcuts are used, the foundation for operational safety analysis are based on unknown criteria, undocumented hazards, or unknown hazards. A shortcut to “get the job done” may actually be the preferred process, but it needs to be documented and unknown hazards identified within the process.

Human factors are vision, hearing, smell, taste, and touch. The SHELL model is the foundation of human factors interactions as the five senses observe and interprets the components in the SHELL model.

• S=Software includes regulations, standards, policies, job descriptions and expectations.

• H=Hardware includes electronic devices, documents, tools, and airfield.

• E=Environment includes designed environment, user friendly environment,

  design and layout, accessibility, and tasks-flow.

• Social Environment includes distancing, experiences, culture, language

• Climate Environment includes geo location, weather, and temperature.

• L=Liveware is yourself and Liveware is other workers within your environment

  Within these areas there are unknown hazards to search for and how they affect operations. An example could be that a regulatory requirement induces stress and shortcuts, or that regulatory compliance increases a level of risk. Tenerife airport disaster is a prime example of how requirements and compliance were contributing factors to the incident. In addition, there are several additional components that could be added to search for unknown hazards within the SHELL model.

ORGANIZATIONAL FACTORS

Organizational factors are factors are strategy solutions, acceptable cultures, technology, regulatory compliance factors and systems information flow within the organizational structure. When an organization, the CEO, President or Accountable Executive of an organization makes a statement to the fact that an incident was caused by non- compliance with a process, is an acknowledgement that their policies, processes and procedures within the organization is perfect and without flaws. There are multitude of organizations that are perfect and without flaws and they operate very successfully. Just recently a large global carrier experienced an unsuccessful event, which they did not have a policy, process or procedure in place to mitigate the hazard. The event was beyond what management expected and the hazard was unknown until it became one of the most disastrous events they experienced. Within an organizational structure data is collected, then turned into information, information is turned into knowledge and knowledge is turned into comprehension. The triennial line-item audit is a tool to identify unknown organizational hazards. An example is an audit line-item 34- 0403 and the debriefing after an emergency response tabletop or full-scale exercise. 

The organization placed the reason for the finding on the auditor who identify the non-compliance. When combining organizational observations, such as operating with icy runway, clearway across a highway, airport vehicle without radio communication on the runway, haying contractor with uncontrolled access to movement areas, construction operations with open trenches, and more, are examples of widespread unknown hazards within organizational factors. An accountable executive, or the regulator, would be unaware of this unless they monitor their daily quality control system. Without comprehension, and training to meet an acceptable comprehension level, unknown hazards will remain unknown.

SUPERVISION FACTORS

Generally speaking, there are four types of supervision. However, in aviation an additional supervision level is introduces. Some of these levels are air traffic services (ATS), air traffic controllers (ATC), flight planning, weather services, control towers, airport ground control, runway, taxiway and apron lights, runway status lights, approach lights, airside markings, markers, and signs. Any of these items are supervisory tasks communicated by other means than words.

Autocratic or Authoritarian supervision:

Under this type, the supervisor wields absolute power and wants complete obedience from subordinates. The supervisor wants everything to be done strictly according to his instructions and never likes any intervention from subordinates. This type of supervision is resorted to tackle indiscipline subordinates.

Laissez-faire or free-rein supervision:
• This is also known as independent supervision. Under this type of supervision, maximum freedom is allowed to the subordinates. The supervisor does not interfere in the work of the subordinates. In other words, full freedom is given to workers to do their jobs. Subordinates are encouraged to solve their problems themselves.

Democratic supervision:
• Under this type, supervisor acts according to the mutual consent and discussion or in other words he consults subordinates in the process of decision making. This is also known as participative or consultative supervision. Subordinates are encouraged to give suggestions, take initiative, and exercise free judgment. This results in job satisfaction and improved morale of employees.

Bureaucratic supervision:
• Under this type certain working rules and regulations are laid down by the supervisor and all the subordinates are required to follow these rules and regulations very strictly. A serious note of the violation of these rules and regulations is taken by the supervisor. This brings about stability and uniformity in the organisation. But in actual practice it has been observed that there are delays and inefficiency in work due to bureaucratic supervision.

The task for an SMS enterprise is to conduct system analyses to find unknown hazards as they apply to operations. An unknown hazard may remain unknown to a

ground crew or aircraft mechanics, but is crucial that the hazard has been found and identified to the flight crew. An example of an unknown hazard is the non- punitive SMS policy, which is only appliable within the jurisdiction where the certificate holder is.

ENVIRONMENTAL FACTORS

Environmental factors are about the surroundings and its affect on accountable executive, managers, workers, personnel, aircraft, cockpit, passenger cabin, aircraft operations, airport operations, or anything else that becomes a part of operations. Environmental factors are more than just the weather, or environment itself, it is also about how work tasks are laid out to function effectively. Environmental factors are about tool boxes and marked tools, it is about checklist and userfriendly flow, and it is about the organizational culture the everyone works within. Airport operators are changing slower to comply with the safety management system environmental factors than airlines are. Airport like to do what they “always” didand not make any changes. In the pre-SMS era, an airport operator could place all blame on the pilot after an accident, as long as the airport had NOTAM’d an issue. This changed with the new airport standards and the safety management system.

Today, the role of an airport operator is to assist flight crew to maintain compliance with their responsibility to ensure that the aerodrome is suitable for the intended operation. Airport operators are still NOTAM 100% ice on runways and expect the flight crew to decide course of action. What airport operators are doing, is preventing medevac or air ambulance from using the airport since most flight crew would not use an icy runway. Environmental factors are also factors withing the regulatory frameworks, which establishes the basis for an environment. Regulations are not minimum safety requirements, but compliance factors to remain as a certificate holder. An example of an unknown hazard within an environmental environment is fear of failure. 

It is critical for an SMS enterprise to accept that not all hazards can be mitigated to an acceptable risk level without cease operations. One such hazard is the probability that a flight crew could establishes an aircraft on an unplanned course any time during a flight but does not justify ceasing operations.

OffRoadPilots