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