Organizational Factors

 Organizational Factors

By OffRoadPilots

When identifying contributing factors and root causes, an SMS enterprise considers human factors, supervision factors, organizational factors, and environmental factors. Organizational factors is more than how business structure of an organization, it is about how the organizational structure affect policies, processes, procedures, acceptable work practices, within the organization of the certificate.

Organizational factors are how organizations apply crew resource management to flight crew, maintenance personnel, and airport airside personnel. Crew resource management is commonly known to be used as a tool for pilots to maintain performance levels, but these principles are also suitable for airport airside personnel. Airside personnel must also

uphold a high level of integrity, and acceptable performance levels.

At large international airports, with high aircraft movements, there are time limits for how long runways, taxiways or aprons may be closed for unscheduled maintenance or activities. Crew resource management (CRM) is not to push personnel to complete tasks in an unreasonable fashion, but it is to perform tasks as expected within an assigned timeframe. This timeframe must be applicable to the task itself, and not applied as an assigned computer model for expected time. The time it takes to complete a job must include the time it takes to work within common cause variations. Common cause variations are normal variations to be expected. When driving to work daily, a common cause variation is the volume of traffic. One day it might take 30 minutes, and another day it takes 50 minutes because of traffic. A common cause variation for runway edge light maintenance is the time it takes to travel from one light to the next. This will vary every time. If crew resource management excludes common cause variations, it is not crew resource management, but micromanagement of personnel.

Organizational factors at an airport is an organization, and how this organization within the airport certificate, and the airport operations manual (AOM). Tasks conducted outside of this organization and non-airport tasks and are not required for operations. An example of a task outside of an AOM organization is to perform maintenance on access roads to the airport terminal that are outside of the airport perimeters.

An organizational crew resource management process includes seven components. CRM components are priority management, communication, comprehension, pressure, stress and fatigue, workload management, decision making, and recording and reporting.

Priority management for airside personnel to recognize priorities within their environment and to interpret cues, then discuss and select the appropriate action as appropriate.

Communication for airside personnel to communicate with clear, specific, and unambiguous communication, both verbally and written.

Comprehension for airside personnel is to comprehend the system in a 3D environment measured in time, space, and compass. Time is current and approaching time, space is current and approaching geographical location, and compass is current direction and approaching direction of travel.

Pressure, stress, and fatigue are how to respond to pressure (real or perceived) and the ability to distinguish between pressure and stress. Applying checklists and standard operating procedures are tools for pressure and stress management. The difference between pressure and stress is that stress can be defined as the internal resistive force to upcoming, or unexpected tasks, while pressure can be defined as the amount of perceived, or physical force applied to complete upcoming or unexpected tasks. Communication of progress is a tool for pressure and stress management. Accepting the current status of job performance is a tool for pressure and stress management. An SMS enterprise operating with a conforming safety management system, has developed and implemented a non-punitive reporting policy to reduce pressure, stress and fatigue. Pressure and stress are contributing factors for fatigue, and fatigue is a contributing factor for incidents and accidents.

Workload management is goal setting and time management. The airside rundown system is a workload tool for airside personnel to manage operational tasks. Workloads management is also to prioritize multiple blocks of acceptable work- load tasks. During an emergency at the airport, workload management and prioritizing tasks becomes vital for successful airport operations.

Decision making is a process, and there are 7 steps in a successful decision-making process. A decision is a job performance decision, and a decision based on past airside experience, training received, airport operations flow, airport operations conforming to regulatory requirements or reactions vital to avoid hazards, incidents, or accidents. Airside decision making is not to invent new processes, but to apply current processes. New process suggestions are submitted as hazard reports, or as directive by the accountable executive.

Identify the problem or opportunity. The first step in making the right decision is recognizing the problem or opportunity and deciding to address it.

Decision making process step 2.
Gather information to make a decision based on facts and data.

Decision making process step 3.
Identify alternatives. Once the issue, or hazard is comprehended, it’s time to identify the various solutions.

Decision making process step 4. Weigh the evidence.

Decision making process step 5.
Choose among alternatives. Conduct a risk assessment to comprehend what direct risks, and residual risks are involved. This also includes an on-the-spot informal, or metal risk assessment if a decision was already implemented.

Decision making process step 6.
Take action. Create a corrective action plan for implementation.

Decision making process step 7.
Review, monitor and evaluate the implementation for effectiveness.

An example of a decision-making process is if the driver of an airside vehicle on the ramp observes an aircraft is taxiing on the ramp, towards their position. A decision to be made is to stay or move. In a similar scenario, an airside vehicle driver is in a vehicle on the ramp and observes an aircraft is parked with the engine running. The driver has an urgent task to be completed and the common vehicle route is to drive in front of where the aircraft is parked. A decision to be made is to wait for aircraft to taxi or take an alternate route.

Recording and reporting is to record findings on the daily inspection form, or on an electronic device. Paper forms are still circulating but are slowly disappearing. Report recordings to the safety management system.

Within the organizational environment of airport operators is the daily inspection process. A daily inspection may be performed several times per day. Inspections are pursuant to the schedule in the airport operations manual. The AOM is the organization in which airport operations lives. There are generally three responsibilities positions at an airport. These are the airfield maintainer, who maintains the airport to compliance level with airport standards. The next level is the airport manager, who is responsible for airport operations manual maintenance, process assignments, and monitor daily for airport regulations and standards compliance. The oversight level is the airport general manager, who also is an accountable executive (AE) and responsible on behalf of the certificate holder to maintain compliance with a required regulations.

An airport certificate is its own organization since a certificate is issued to a land- parcel, as opposed to a person. The certificate holder is the person who manages and administers airport certificate tasks and actions. The certificate holder is person who most likely is a member of the airport authority and their organization. A certificate holder may also be a third-party contractor, in which that person has the final authority in airport decisions.

When analyzing the effect of organizational factors, both the certificate organization, (if airside standards conform), and the airport authority organization, (if the airport authority organizational flow supports required activities under the certificate). Simplified, just as an aircraft within its own environment, or organizational flow must maintain compliance with all components and functional requirements, an airport certificate must comply with its own surveyed, determined, recorded, and reported compliance factors within its own environment or organization.

Airport operations is more complex than any other functions in aviation. An airport operator must have comprehensive knowledge of airport operations itself, must have operational knowledge of air navigation services, and must be familiar with all types of aircraft operations. An airport operations manual is the organization that contains all airport operations functions.

The AOM is a document that describes the airport organization, and is a document that describes physical characteristics, or the layout, describes airside operations plans, is approved by the airport operator (AE) and the regulatory, is a legal reference document, describes who is in the administration, the largest aircraft that can use the airport, and hours of operations.

The AOM describes the organizational chart, line of authority and line of reporting. Since the work a contractor does affects the accountable executive’s responsibilities, regulatory compliance and safety performance, a contractor is a like-employee person. The AOM lists documents, manuals and guidance material that must be available for airport operations, audits, and regulatory inspections.

The airport obstacle limitation surfaces (OLS), or maximum heights of structure is controlled by airport zoning regulations and incorporated by reference in the AOM. The AOM describes the airport organization and level of authority, it describes the airport organization and level of authority, describes airport lighting systems, describes runways identified by numbers, taxiway identified by letters, excluding the letter X, and aprons by Roman numerals. An AOM describes markers (elevated above ground) and markings (displayed on the ground surface) and describes airport facilities (may be outside of airport lands) and airside services, and more. It is a prerequisite to assess and define applicable organizational factors within an AOM prior to assessing a root cause how airport authority organizational factors affected the outcome. If the systems within the AOM are not identified, the root cause and corrective action plan may be incorrectly assigned.

Human factors and organizational factors are closely related, with a defined difference. The difference is that human factors is about human reactions to inputs, and organizational factors are the climate, or culture environment imposed on personnel.

Human error is a symptom, not the cause, it is a starting point in root cause analysis, not the conclusion, and it is a symptom of trouble deeper inside an organizational system.

Organizational factors to consider in a root cause analysis are SMS policies, processes, procedures, and acceptable work practices. Organizational climate, structure, chain of command, delegation of authority, communication, accountability, policies, culture, just-culture and more. Assign a weight score between 1 and 4 to each factor and to each one of the 5-Ws + How. The factor with the highest weight score is assigned as the root cause factor and the factor where the CAP needs to be applied. If two weight scores are equal, apply the highest “Why” score as the determining factor.

Just as the square root of a number is defined as the value, which gives the number when it is multiplied by itself, an incident root cause is the value, identified by a number, which is most likely to quadruple in value when the same incident happens one additional time.

When organizational factors are determined to be the highest root cause probability, a corrective action plan must address the current organizational system in both the operational system, and airport or airline authority certificate system.

OffRoadPilots

Supervision Factors

 Supervision Factors

By OffRoadPilots

When identifying contributing factors and root causes, an SMS enterprise considers human factors, supervision factors, organizational factors, and environmental factors. Every person is working under supervision, knowing it or not. A CEO of a corporation is supervised, and a AE of an SMS enterprise is supervised. Everyone is supervised in one way or another, and everybody got to serve somebody. Types of supervision also depends on what is being supervised. Different types of supervision are required for education than for operational control, fundamental task supervision is different than auxiliary task supervision, academic task supervision is different than practical application task supervision, and process compliance supervision is different than process output supervision. Every task comes with a supervision factor which depends on what task is supervised.

Micromanagement is considered a form of supervision, it is used by many and is in their opinion an excellent method and the preferred method of supervision. However, micromanagement is not supervision but management. Micromanagement is where managers feel the need to control aspects of their employee's work and decision-making to an extreme degree, more than is necessary or healthy for a usual working relationship. There is a difference between management and supervision. In general terms, management is how businesses organize and direct workflow, operations, and personnel to meet company goals. The primary goal of management is to create an environment that lets employees work efficiently and productively, and they use supervision as a process tool for oversight to remain on target for their goal. Micromanagement is not suitable for an SMS enterprise, since it does not promote trust, learning, accountability, or information sharing. Within a micromanagement system there is only one way, process, or method, which is decided by the manager. In a micromanagement system, a manager has previously demanded that a root cause analysis of an independent third-party operator to justify penalties and punitive actions.

The different levels of supervision are direct supervision, which supervisor gives specific instructions on all assignments. Work is reviewed for completeness and accuracy, or personnel performs tasks which provide inherent checks built into the nature of the work. Reviewing work is different from micromanaging work. General supervision is when the supervisor provides continuing or individual assignments by indicating generally what is to be done, limitations, quality and quantity expected, deadlines and priorities. Additional, specific instructions are given for new, difficult, or unusual assignments. Personnel uses initiative in carrying out recurring assignments. The supervisor assures that the work is technically accurate and in compliance with instructions or established procedures. Intermittent supervision is when a supervisor makes assignments by defining objectives, priorities, and deadlines, and assists personnel with unusual situations that do not have clear objectives. Intermittent supervision is when personnel plans and carries out successive steps and resolves problems and deviations in accordance with instructions, policies, and accepted practices. The supervisor reviews the work for technical adequacy and conformance with practice and policy. Administrative supervision is when a supervisor sets the overall objectives and resources available. Both supervisor and personnel, in consultation, develop deadlines, projects, and work to be done. Personnel plans and carries out the assignment, resolves most of the conflicts, coordinates work with others and interprets policy on own initiative. Personnel keeps the supervisor informed of progress, potentially controversial matters, or far-reaching implications. General direction is when assignments are made in terms of broad practice, precedents, policies, and goals. Work may be reviewed for fulfillment of program objectives and conformance with departmental policy and practice. Long-Range administrative direction is when personnel generally proceed independently in accordance with general plans, policies, and purposes of the department. Results of work are considered technically authoritative and are normally accepted without significant change. Any of these levels of supervision are compatible with an aviation safety management system.

Each level of supervision is linked to a type of supervision. Types of supervision is determined by the way in which work is assigned, when it is reviewed, how it is reviewed, and what guidelines, prototypes and protocols are available.

Close supervision is when personnel are assigned duties according to specific procedures. Work is checked frequently, and in addition there may be formal training. Regular supervision is when personnel perform a variety of routine duties within established policies and procedures or by referral to the supervisor’s guidelines. General supervision is when personnel develop procedures for performance of variety of duties or performs complex duties within established policy guidelines. Direction supervision is when personnel establish procedures for attaining specific goals and objectives in a broad area of work. Only the final results of work done are typically reviewed. Personnel typically develops procedures within the limits of established policy guidelines. General direction is when personnel receive guidance in terms of broad goals and overall objectives and is responsible for establishing the methods to attain them. Generally, personnel are in charge of an area of work, and typically formulates policy for this area but does not necessarily have final authority for approving policy. Any one of these types of supervision are compatible with an aviation safety management system. In a simple format, types of supervision are structural, participative, servant-leader, freedom-thinking, and transformational leadership.

When supervision factors are applied to a root cause analysis, it is critical for a successful outcome that it is applied appropriately to the analysis. Conventional wisdom is that any errors within root cause factors are human errors. However, human error is a subfactor of human factors.

The first step in analyzing supervision factors is to conduct a root cause analysis and assign one of the four factors to the root cause. Both the fishbone, and the 5-why root cause analyses are acceptable tools. The fishbone provides both visual and text links in the root cause process, while the 5-why is a text and matrix analysis. When applying the 5-why method, a matrix of 5 options and 5 considerations should be used. One reason for a 25-point matrix is to reduce the probability for subjective answers. After answering the first few questions subjectively, there is only one way to continue, which is to look at each answer objectively. Another reason for the 25-point matrix is that the first answer to the first question leads to a predetermined root cause. If the question is why an airplane crashed, a subjective answer could be that the pilot lost control. As the questions goes down the pilot lost control avenue, the outcome is focusing on the pilot only. An objective answer to the same question could be facts of events, such as a wing suddenly banked 60 degrees upon landing. An objective answer leads down the avenue of fact findings of events, as opposed to the avenue of pilot actions. When there is a matrix of 25 answers, there is a higher probability to capture the correct root cause, and it forces a person to think.

The root cause analysis is not the end, but the beginning of corrective action plans (CAP). Establish the root cause based on the most likely probability in the 25-point matrix. One or multiple column may be combined to assign the most probable root cause. A root cause cap must be linked to an objective, or establish a new objective, and linked to a safety policy goal.

General types are structural, participative, servant-leader, freedom-thinking, and transformational leadership.

Assign a weight score between 1 and 4 to each factor and to each one of the 5-Ws + How. The factor with the highest weight score is assigned as the root cause factor and the factor where the CAP needs to be applied. If two weight scores are equal, apply the highest “Why” score as the determining factor.

When supervision factors are determined to be the highest root cause probability, a corrective action plan must address the current supervision system, which can be extremely difficult to accept by an SMS enterprise. Acceptance and accountability are the only tools available to improve regulatory compliance and safety in operations little by little.

OffRoadPilots

Environmental Factors

Environmental Factors

By OffRoadPilots 

When identifying contributing factors and root cause, an SMS enterprise considers human factors, supervision factors, organizational factors, and environmental factors. These factors support their safety management system (SMS) policy on which the safety management system (SMS) is based, goalsetting system, process to identify hazards, training system, reporting system, communication system, quality assurance system, audit system, and they support their tasks for airlines and airports to operate with a comprehensive and compliant safety management system.

Environmental factors are comprehensive factors affecting SMS, since there are several subcategories included. Environmental factors encompass geographical location, climate, ecological, illumination, terrain, natural accelerated events, operational environment, workplace, design, equipment, communication, and more. Within each subcategory there are multiple secondary categories, and complementary categories. Environmental factors can be scaled down to detail-reliability in processes. When details are defined, a process may be simplified for the end user.

Geographical locations are located within the four categories of airmasses. These airmasses are artic, tropical, polar, and equatorial. Arctic air masses form in the Arctic region and are very cold. Tropical air masses form in low-latitude areas and are moderately warm. Polar airmasses take shape in high-latitude regions and are cold. Equatorial air masses develop near the Equator and are warm. Secondary categories of the geo location subcategory are regional and local phenomena.

Regional and local phenomena include uninhabited areas located within any of the four airmasses.

The climate subcategory is the long-term pattern of weather in a region. Weather changes from hour-to-hour, day-to-day, month-to-month or even year-to-year. Regional weather patterns tracked for at least 30 years, are considered its climate.

The ecological subcategory is how landscape patterns are precisely described patterns into ecosystem units based on similar climate, landscape, vegetation, and soil conditions. This provides for a common ecological language and framework to classify ecosystem units and support land and resource management. Illumination, sunlight, and darkness are subcategories of environmental factors. Illumination may be hangar lighting, and type of lighting. Some types of lights may cause colors to blend, while other types are bright and causing shadows. Sunlight, or lack of sunlight, including grey zones, are factors affecting aircraft operations, and maintenance and flight crew performance.

Terrain is another environmental factor. Terrain ranges from the shorelines at the three coasts, tundra and the arctic, the level prairies, to rolling hills, the foothills and to the rugged and rocky mountains.

Some of the natural accelerated events are earthquakes, blizzards, floods, avalanches, mudslides, volcanic activity, thunderstorms, and more. Some subfactors may also overlap into other factors.

The operational environment is a subfactor of the environment. An operational environment is different than the workplace, it is about the workspace. An operational environment is allocating operational workspace in 3D, and measured in time (speed), space (location), and compass (direction). A workspace is flight crew chairs design, the time for a pilot to reach an item to complete a task, the location in the cockpit of the item, and its direction from the pilot’s chair. In the old PBY-5A (Canso), the two generator’s circuit breakers are placed on the bulkhead behind the captain. Should the “left” generator fail, it becomes the “right” generator for the pilots when pulling the breaker.

The workplace environment is the place where there is interaction between workers. It’s a location where you turn up for work, it is an office space, pilot’s room, maintenance hangar or locations where you meet co-workers, discuss work, brainstorm, conduct meetings, and get work done.

A design environment is the process of addressing surrounding environmental parameters when devising plans, programs, policies, buildings, or products. It seeks to create spaces that will enhance the natural, social, cultural, and physical environment of particular areas.

The communication environment is about tools used to communicate. The old way to call loudly across the room has changed and improved by using electronic communication means. Information technology department is communication environment tool to communicate effectively within the organization, and to maintain communication records.

Equipment is a subfactor of the environment and includes machines and equipment, people and manpower, materials, and measurement. The equipment itself could be an aircraft, a vehicle, a towing tug, maintenance tools, computers, manual calculator tools, and more.

Environmental factors are the outsider of the other three factors. Human factors, organizational factors and supervision factors are all in their own special way linked to human behavior.

 

The climate affects areas of both airline operations and maintenance, and airport operations. The aviation is operating daily between the South and the North Poles. Airport and runways may be ice or snow runways, dessert sand, rivers, lakes or just a narrow mountain trail. Maintenance is performed in suitable hangars, or outside in rain, snow, wind, and in places with extreme cold or extreme hot. In many areas there are still places with no or limited communication availability, except for using satellite telephone. An aircraft without the 406ELT is difficult to locate in any weather conditions. Bush pilots all over the globe have experienced accidents and destruction of airplanes. Over the years airplanes have crashed in the middle of nowhere in 40 below temperatures and 40 above, and some pilots survived, while other did not. The climate affects survival probabilities and rescue time. Climate may also cause illusions, such as mirages. Several years ago, a large aircraft crashed when the runway lights were “lifted up” by an inversion and the airport viewed as being closer than what it actually was. Operators, pilots, and maintenance crew working in these extreme climate areas deserve a medal of honor for overcoming challenges and providing excellent services to people who live here.

The ecological factor is affecting the aviation more and more every year. Over millions of years the climate has changed from ice ages to hot climate. Currently ecological factors are assigned the root case for the current climate. Regulations are changed to support these opinions and operators must maintain compliance for continued operations. Natural resources are assigned contributor factors to the climate, and that current use is deteriorating the ecological environment. Airports may not be able to build, or extend their runways to service increasingly larger aircraft, or to improve fuelling areas for time consuming refuelling. Ecological factors are a limiting factors for the future of aviation.

Illumination, sunlight, and darkness are factors affecting flight and maintenance operations. Aircraft need landing lights, airports need runway edge lights, and maintenance hangars need floodlights. Type of lighting source affects operational performance and compliance. In a maintenance hangar where the floodlights are of the old type, colors in the yellow spectrum blends in with their surroundings, and other parts transform to the grey color spectrum. Bright floodlights to resemble brightness of sunlight is needed for maintenance to perform their obligations. Strong illumination from landing lights is required for a pilot to view an extended length of the runway beyond the aircraft. Runway edge lights are required to define the limits of usable runway areas, and their intensity may vary depending on weather conditions.

Terrain is another environmental factor affecting airports, airlines, and maintenance activities. It might not be immediate obvious that terrain affects maintenance activities since most maintenance is performed inside a hangar. However, terrain affects the decision of where to build a hangar, and the loadbearing capacity for taxiway or taxiroute to the facility. For outside maintenance terrain is a crucial factor to work in a stable environment. A helicopter may be in need of maintenance on a mountain range, or somewhere in the boreal forest. Terrain affects airports and airport design. There are airports that do not meet the obstacle clearance limitations and therefore unable to be certified airports. Airlines my required travel several additional miles for approach procedures compliance, burn additional fuel and add time to the flight crew’s duty day.

Accelerated events affects airports and airlines both seasonally and regionally and are contained within a relatively limited area. Volcanic ash from one single volcano outbreak, may be the only event that affects aircraft operations globally. Snowstorms, hurricane, or tornadoes may be spread over a large area, but are relatively regionally limited to for the safe operations of an airport or aircraft.

The operational environment is an environment where personnel feel good about working. It is the place where a person is located, a place that is home-away-from- home, and it is the place a person enjoys coming every day. An operational environment is about performance and how processes are designed to be userfriendly and reliable repetitious.

The workplace environment is different than the operational environment, in that it is designed by the six-sigma principle. The six-sigma is a set of methodologies and tools used to improve business processes by reducing defects and errors, minimizing variation, and increasing quality and efficiency. The goal of Six Sigma is to achieve a level of quality that is nearly perfect, by being tailored to human behaviors. A structured approach is to define, measure, measure, analyze, and improve applying the principles in their SMS safety risk management.

A design environment is a fluid environment where persons are tailored to individual and specific needs. An example is the popularity of a standing work-desks. A design environment is not to adapt to personal opinions and request daily, but to assess their inquiries as it relates to their work environment. Several years ago, a pilot was not allowed to fly bush planes with clogs, since this caused a hazard to for the footwear to be stuck between the pedals and the pilot’s ability to quickly escape a sinking floatplane. A design environment needs justification for design, and there are no requirements for everyone to wear the same shoes.

In the communication environment practical communication tools are used. In the infant years of airport control towers, clearances were given by light signals. As technology continued to change, radio communications become the standard method. As technology is changing rapidly other means of communication were implemented and are continuing with new technologies. Changes in technology requires training sessions to be familiar with new communication and supervised use until personnel easily can use these tools. One example is the online SiteDocs cloudbased SMS program. It takes information sessions to become familiar, and as it is used, it becomes a second nature.

The equipment environment is a broad definition of what to include. Anything that are equipment or tools are included. There is also an interaction between the equipment environment and other environment. These are not defined lines written in rocks between the different environments, but they are rugged, fluid, and flexible. Rugged and fluid lines may be a distraction to personnel, and it becomes the responsibility of management to conduct regular information sessions about the organization and its operation.

Environmental factors are simple to apply within a safety management system when processes are linked to regulatory requirements.

OffRoadPilots