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

Human Factors

Human Factors

By OffRoadPilots 

Human factors and human errors are two separate things but are often used interchangeable in conversations and in the aviation industry. Human errors are attached to a person who could be linked to an occurrence. In addition, the severity of the outcome is a predetermining factor how important it is to assign human error as the root cause after an accident.

Human error root cause analysis has widespread support from the aviation industry. However, with the implementation of the Safety Management System (SMS) regulations, accountability came into play, and it became impossible to justify human error as the root cause.

A healthy SMS looks at the organization and its systems, and the fact that a person overlooked, or missed an item is no longer a root cause, such as a pilot missing a checklist item. Checklists are required and are used for any flight, but there is no evidence a missed checklist item was the root cause of any accidents. At the other end of the spectrum, completing the gear-down checklist item was a contributing factor to a fatal accident in 1972. A descent went undetected when the flight crew became focused on a checklist item.

Human error is a symptom of trouble deeper inside a system or an organization. On the other hand, human error is also a symptom of a successful organization. There are organizations where human errors are integrated with the system and need to be there for the organization to exist and prosper. It is the system itself that is set up for human errors.

Conventional wisdom is that human error is a” bad” thing when using emotions to describe an event. Human error is a sub-category of human factors. Simplified, human factors are how a person react when one or more of the five senses, vision, hearing, smell, taste, and touch are triggered. Human factors are also how external forces, or events, e.g., fatigue, weather, illumination and more, affect performance.

In an organization where there are overwhelming events of human errors, the organization operates within a system that is prone to these errors. An example is Daytona 500, or Reno Air Races, where the systems (race to win) are setting each driver and pilot up for human error, or a crash. Both the Daytona 500 and Reno Air Race organizers have requirements and systems in place to reduce harm to drivers, pilots, or spectators, but these systems are designed for human errors. Imagine how successful Daytona 500 would be if the speed was limited to 50MPH, or if the Reno Air Race required airplanes to fly between gates separated a mile apart.

Civil aviation industry systems are not set up as systems where human errors are desirable, but occurrences still happens because aviation operational systems allow for it. Civil aviation systems are not as obvious as the racing-systems to promote human errors, but they both happens because of human and organizational factors, and to get the job done before closing time.

The aviation industry struggles with the human error concept. This struggle affects their organizational environment, and a trap to fall into is to make pilot, or human errors the root cause. However, the safety management system requires operators to look inward into the organizational systems to repair or replace one or more systems. If a process is stable and undesirable, but not broke, the process should not be fixed. The old saying that “if it ain’t broke don’t fix it” holds true in aviation safety. A stable, or desirable process may from time to tome turn out faulty items and mistakes. Reacting to these mistakes is tampering with the process contributing to an increase in future errors. Tampering with a stable process moves the process closer to a point to become a contributing factor to accidents.

Several years ago, a pilot and three passengers went on a mountain flight with a PA-28-140. The aircraft was full of fuel and above max gross weight at takeoff. As often, when there are no other adverse conditions, the flight departed safely, and slowly climbed into the valley towards the taller mountains.

While the winds were relatively calm at the airport, on this day the winds were extremely strong in the mountains. One pilot had earlier that day refused to take the scenic flight because of the mountain winds, but another pilot accepted.

The pilot banked and turned for the passengers to see the beauty of the mountains. Before the pilot could react, the aircraft stalled and crashed. A close friend found them later the next day in a highly remote area.

Human and organizational factors are often linked together in the text but are two separate factors. Human factors are how human reacts to inputs, while organizational factors are the result, or output, of these reactions. The term organizational factors encompass all elements that influence the way that an organization, and everybody within it, behave. Some of these elements are formal management systems, assurance processes, working practices, whether or not formally documented, risk awareness, how the organization learns from experience, organizational safety culture and more.

A safety policy is directed at human factors. Safety for an airport or airline is to maintain the confidence of the travelling public and safety of the aviation industry is vital to success. Through the introduction of a safety management system, an airport is committing to provide a systemic, explicit, and comprehensive process for managing airside safety risks. By embracing this safety management system, airports establish safety as an integral part of an airport culture where they recognize that safety is paramount.

Human factors is a scientific study that evaluates and comprehend human interactions and human behaviors in relation to other human and elements of a workplace system. The human factors five senses reactive or proactive affect human behavior and performance. These senses are vision, hearing, smell, taste, and touch.

The SHELL model is a model of human factors interactions and includes the software(S), hardware(H), environment(E), liveware, other(L), liveware, self(L).

Software are regulations, standards, policies, job descriptions, expectations, and other intangible items.

Hardware are the physical and tangible items housing intangible items. Hardware are electronic devices, documents, tools, airfield, and other tangible items. The environment has multiple sub-categories. A sub-category of the environment is the designed environment. A design environment is user friendly environment, design and layout, accessibility, tasks-flow, and more. The social environment is about distancing, both physical contact between persons and distancing between equipment and objects, experiences, culture, language and more.

The climate is another sub-category of the environment. Climate environment includes geo location, weather, temperature, and more. Amy these human factors has an affect human behavior in one way or another.

When one or more of the human senses are targeted by inputs, or when interactions between the elements of the SHELL model are incompatible, the effect on human reaction, or process output, are commonly known as human errors, or pilot errors.

Human errors are not errors, but reactions to the operational SHELL model system, and human senses are reactions they are exposed to by the system itself.

OffRoadPilots

Regulatory Conforming Processes

 Regulatory Conforming Processes

By OffRoadPilots

Regulatory conforming processes are processes producing outputs that conform to regulatory requirements. There are three fundamental tasks required when building regulatory performing processes. The first task is the research for input task, the second task is the process design and development task, and the third is the regulatory identification and assignment task. A process must be linked to one regulatory requirement. In a healthy SMS environment, a process is linked to several regulations, or several standards, and to the SMS policy.

The research for input task is a comprehensive research of regulatory requirements for airport or airline operations. In addition to airport or airline regulations, multiple other federal or local regulations may be applicable, such as environment regulation, transportation of the public regulations, and other regulations. However, when researching regulatory requirements for the purpose of building a conforming process, only airport or airline operations regulations are researched for inputs. These are the regulations that an airport or airline operating certificate is tied to and dependant on for its existence. Performance-based regulations are based on a 95% confidence level.

Regulatory research also includes a comprehensive research of standard requirements for airport or airline operations. Standards are also performance- based in the same way as the regulations are. Airport standards has been adapted for use in an operational concept to reflect and support the operational reality of aircraft capabilities and performance specifications. An airport standard establishes a level of service for an airline and its fleet. Rapidly changing technologies in aircraft performance and avionics have a very real potential to impact future aerodrome operations. An increase in the size of critical aircraft or the provision of lower landing, departure or taxi limits will require the aerodrome operator to re-assess the aerodrome facilities and operational procedures to ensure they provide the required standards.

Accuracy requirements for aeronautical data are based upon a 95% confidence level and in that respect, three types of positional data are identified. Positional data are surveyed points e.g. runway threshold, calculated points, e.g. mathematical calculations from the known surveyed points of thresholds for determination of the aerodrome reference point, and declared points, e.g. flight information region boundary points. The confidence level is in the method, or process itself, and is not in a particular confidence interval. If the sampling method was repeated many times, 95% of the intervals constructed would capture the true population mean. As the sample size increases, the range of interval values will narrow, meaning that a larger sample size, or an increased number of data collected, the mean of the sample will generate a much more accurate result if compared with a smaller sample, or fewer tasks completed.

There is a misconception among operators that a 95% confidence level is the same as airports or airlines being 95% safe. Conventional wisdom is that the application of numerical safety levels, such as airline ratings are indications of what level the public are protected from harm when an airline has achieved the maximum 7 of 7 in their rating. An airline rating level takes several other parameters into account, such as staff friendliness, service availability and more to provide a complete travel experience safety level. In the same way as airline ratings apply several parameters in their assessment, airline and airports do the same in their operational assessment oversight. There are therefore no contradictions between a 95% confidence level and a 100% safety rating level, or rated 7/7.

A 95% confidence level is that established safety performance indicators (SPI) and safety performance targets (SPT) will fall within their expectations 95 of 100 times. An airline may establish a confidence level of 95% that their pilots will touch down within the first 1/3 of the runway. For the same airline to establish a 100% confidence level, the airline needs to operate with an expectation that their pilots will touch down anywhere on the full length of the runway 100 of 100 times. A targeted 95% confidence level is therefore safer in operations than a targeted 100% confidence level, which does not provide enough stopping distance for a pilot who used up all of the runway before landing.

The next step is the process design and development task. When designing processes, the objective is to produce an operational sound outcome. At this stage in the design process, regulations, standards, and the SMS policy are considered, but they are not applied to the process design. The reason for considering regulations but not applying regulations, is that an easy trap to fall into is to build a regulatory process. In a regulatory process an airliner captain must fly the regulations when they need to fly the process. E.g. if a regulation, or flight operational quality assurance expectation requires a pilot not to bank an aircraft beyond 25 degrees angle, the wind could push the aircraft into an undesired position, as opposed to flying the process when a pilot would increase the bank angle to maintain aircraft control. A goal when building processes, is for processes be practical to use, and with a task-flow that make sense to users.

Regulations are objective and impartial to a process, while safety is subjective and biased. Regulatory compliance is the priority, while safety is paramount. Maintaining continued regulatory compliance is the foundation and building blocks for the existence of an airport or airline certificate. When safety is paramount, it becomes the highest-ranking order of a system, and regulatory priority is the only tool to maintain safety as the highest-ranking order. Just as an accountable executive is the highest-ranking order of a safety management system, regulatory compliance is the operational priority to maintain that order.

An airport has an obligation to operate with a runway environment that maintains continuous regulatory compliance. This is achieved in multiple ways when each activity or task is linked to a regulatory requirement. One task several airports have adapted, is the daily inspection task. This is not a regulated task, but by using the process daily, they are engaged in activities, or processes, that conforms to regulatory compliance. The key to success is to comprehend what regulatory requirements each activity is linked to.

The last step is the regulatory identification and assignment task, which is to conduct a process analysis to verify what tasks within the process are lined to a regulation. A process compliance analysis is conducted backwards, starting from the end result and output, and move backwards until the beginning. Any broken link in the process must be closed for compliance.

After all broken links are closed, the next step is to analyze the process forward and apply compliance to each step in the process. There will also be steps that are not linked to aviation regulations, such as checking the vehicle before operating airside. Compliance requirements are linked to tasks performed while conducting the inspection. One task may be linked to multiple regulations, and one regulation may be linked to multiple tasks. Comprehensive knowledge of the regulations is required to perform these tasks. The accountable executive is the person who is responsible for compliance with all regulations and is also the person who is the final authority for assigning regulations to tasks.

When regulatory conforming processes are built, implemented, and communicated to workers, compliance becomes simple. Airport or airline workers does not need to change how they work, or how things are done, but are simply completing their processes as expected. Over time as data becomes available, the only task left is to enter data into a statistical process control system for control charts to be produced and analyzed.

The beauty of operating with regulatory linked processes, is that all information is available to airport and airline operators when safety performance is analyzed, and when the regulator conducts inspections.

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Forward-Looking Accountability

 Forward-Looking Accountability

By OffRoadPilots

Coincident with the safety management system (SMS) regulations, organizations are required to appoint an accountable executive (AE). The accountable executive is a single, identifiable person within each organization who will discharge the certificate holder’s responsibilities, and in particular, lead in cultural change within a just-culture. It is imperative that the correct person be identified as the accountable executive, and that the individual understands and accepts the roles and responsibilities associated with that position. This is not intended to be a position title without accountability, and on the other hand, it is not a position to accept liability. Simplified, the position as an accountable executive is a position where the appointed person is responsible for airline or airport operations and accountable on behalf of the certificate holder (CH) for meeting the requirements of these regulations.

The AE is responsible to the regulator to operate with processes that conforms to regulatory requirement, standards, and the overarching SMS policy. Regulations requiring the appointment of an accountable executive are separate from those requiring an SMS, i.e., an AE is also required for operators that are not controlled by the SMS regulations.

When incidents occur in business, there is often a call to find those who are responsible and hold them accountable for their actions. In too many cases, accountability translates into disciplinary action against the frontline workers directly tied to the incident (such as verbal and written warnings, suspension, and even termination. If a frontline worker is engaged in at-risk behavior that resulted in an incident, punitive actions are not the preferred process. Incidents are rarely just the result of one person’s decision-making process.

A system that seems unjust or unfair leads to the erosion of trust and respect between frontline workers and management. Without trust, excellence in safety is unattainable.

In addition to undermining trust, there are other reasons to be cautious with the use of punitive actions, discipline, and blame. Research shows that negative consequences have detrimental side effects that often outweigh any positive benefit. Some side effects include fear, lower morale, limited engagement, and suppressed reporting of incidents and near misses.

Most importantly, discipline often does not result in safety improvement. Several years ago, a pilot violated a regulation and was placed on leave without pay for two weeks. The safety manager proposed a corrective action plan to investigate the organization, and to learn if there were gaps in any processes, such as crew resource management, flight training, process training or certification. Management rejected the proposal, and within three months the pilot’s behavior was a contributing factor to a fatal King Air crash. Discipline and other negative consequences do not belong in safety. This does not imply a reduced accountability but is a shift from backwards-looking accountability to forward- looking accountability. Backward-looking accountability is about finding blame, finding the individual who made the mistake, and delivering punishment. Forward-looking accountability acknowledges the mistake and any harm it caused but, more importantly, it identifies changes that need to be made, and assigns responsibility for making those changes. The accountability is focused around making changes, changing organizational systems, modifying management practices, addressing hazards, and building safe habit. Forward-looking accountability is a prerequisite to build a positive safety culture, or just-culture.

Conventional wisdom is that an accountable executive is responsible for human and financial resources only. However, there are two requirements for an accountable executive. The first is a knowledge requirement and the second is a condition requirement. The knowledge requirement is that an accountable executive fully comprehend all regulatory requirements with skills required to design, develop, and operate with processes that conforms to regulatory requirements. A certificate holder shall appoint an individual as accountable executive to be responsible for operations or activities authorized under the certificate and accountable on their behalf for meeting the requirements of the regulations. The condition requirement is that the accountable executive exercise full control of financial and human resources that are necessary for the activities and operations authorized under the certificate.

A successful accountable executive is forward-looking and is accountable to both their knowledge requirement to meet the requirements of the regulations, and accountable to their condition requirement to control financial and human resources. Forward-looking accountability is achieved by risk level decisions, priorities, and expected output of processes. If an expected outcome, or expectation is not defined, there is no definite purpose for that process.

Accepting a risk is the responsibility of an accountable executive. Should someone else, e.g. an airport manager, accept the risk for airport operations, the accountable executive does no longer work within a forward-looking accountably system, since the risk was accepted by an unauthorized person.

Forward-looking accountability trickles from the AE to directors, management, and to workers within an SMS enterprise. The accountable executive is the only person responsible on behalf of the certificate holder for compliance with the regulations. All other personnel are accountable for their application of regulatory conforming processes to their area of operations. Regulatory conforming processes are accepted by the AE and distributed to workers for their benefit as guidance to remain within established parameters. Unless conforming processes are distributed to worker, for them to know what is expected, they and the AE, no longer work within a forward-looking accountability system.

Forward-looking accountability is simple in concept, but it takes hard work to implement processes that conforms to regulatory requirements. Simplified, forward-looking accountability is like being safe when driving down a two-lane highway. If someone had told the wagon-train people of 1857 that wagons one day will travel 80MPH in opposite direction on a trail without accidents, they would not believe it. In their mind, a trail was two ruts that were difficult to move away from. Today, vehicles (wagons) are travelling safety at 80MPH on a trail due to forward- looking accountability. Vehicle operators have learned what lights and markings define and they comply with their messages. The road is paved with a yellow line in the middle to separate the opposite wagons (cars). A driver applies the forward- looking accountability principle by complying with the process, to stay on the right side of the line (some countries left side) and is accountable to opposite traffic on the road. After a vehicle is passed, a driver is no longer accountable to that vehicle, but is forward-looking accountable to what lays ahead. A driver is forward-looking accountable to pedestrians, wildlife, or out of control vehicles approaching head- on. Within a forward-looking accountability system, there is not a question if the oncoming driver comply with the rules or not when approaching head-on, the accountability is to initiate an occurrence, or avoidance maneuver, to avoid an accident. If the principle that the regulation does not say to move away was applied, and a driver demanded to exercise their right, an accident is inevitable. Airport and airline operators insist that they do not need to take action since the regulations does not state that they do. Not long ago an airport operated with 100% ice on their runway, since the regulation did not state that they needed to clear the ice.

Forward-looking accountability must be within a just-culture, since it is impossible to predict the future and what, when, where, who, why and how an accident will happen. Within a just-culture there are decisions made, that after the fact may be determined to be a contributing decision to an accident. When working within a forward-looking accountability system, it is crucial to success that the person who made a decision in good fait, but contributing to an accident, is given a thank you by the AE. The outcome of a spontaneous decision due to external interference does not always give a desired output. Some years ago, and within a forward- looking accountability system, a pilot decided to make do a go-around due to cross wind which contributed to a severe crash when the wind suddenly increased from 20KTS to 50KTS, changed direction, and caused the aircraft to stall. The pilot was given a thank you for making the proper decision, which was to initiate a missed approach.

Forward-looking accountability is to take responsibility for reporting, willingness to admit mistakes, and taking responsibility for changes. A forward-looking accountability is a fluid, or an unstable environment since the accountability is to make decisions, as opposed to do what someone else decided for you. This does not imply that policies, processes, or procedures should not be followed, but that resilience and reacting to changes are integrated parts of a forward-looking accountability system. E.g. An aircraft mechanic discover that a tool is missing, but the tool is not needed for current or future jobs. When applying the forward- accountability principle, the mechanic notify supervisor to order the tool. It is said that it is human to error, but at the opposite end of the spectrum, humans are capable of reacting to events, or hazards, to avoid accidents. Forward-looking accountability is different than being proactive, since accountability is strategic planning at the AE position, and proactive is risk analysis at the operations positions.

Accountability that is backward-looking is determined to find a scapegoat, and to blame and shame an individual for messing up. The first stage of accountability is about looking ahead at the fork-in-the-road to find ways to do the work effectively, and the second stage is to accept the accountability.

Forward-looking accountability acknowledges mistakes and the harm resulting from it and lay out the opportunities for making changes to reduce the probability, or risk level of such harm to happen again.

Forward-looking accountability is to design airports to size and complexity of future airliners.

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Staying In The Rut

 Staying In The Rut

By OffRoadPilots

Conventional wisdom is that a healthy safety management system (SMS) stays in the rut without deviation from current course. One reason for this belief is that the SMS regulations states airlines and airports must operate with a process for reporting and analyzing hazards, incidents, and accidents, and for taking corrective actions to prevent their recurrence. When this regulation is interpreted that only one reoccurrence is a regulatory violation, the operation, airlines, or airports, must shift gears to operate with an abundance of caution for every flight or airside task. As reoccurrence continues, they must then overcontrol their processes with additional abundance of caution to their processes that already had received several abundances of cautions from their magic wand. Eliminating all hazards, incidents, and accidents is beyond what the magic wand of a safety management system can do.

The regulatory requirement to prevent their recurrence is applied without consideration for the principles of the safety management system, the principles of performance- based regulations, but applied as a prescriptive requirement, as opposed to a performance requirement, and the requirement is incorrectly interpreted as never to occur. Airlines and airport operators are operating under a false assumption that the same hazards, incidents, or accidents are never to occur again. By living under this assumption, they must make new policy statements, develop corrective action plans (CAP), and forbid the root-cause factor that caused the occurrence in the first place, e.g. the principle of sterile flight deck. The principle behind this theory is when a policy is implemented, then there will never again be a recurrence, and for every occurrence a new policy must be implemented. Policy CAPs that forbid behaviors causing occurrences are non- conforming processes to the regulatory requirements of a safety management system. This does not imply that airlines and airports should not implement policies, but that relying on policies, or directives as a function to eliminate behaviors by making new policies are a non-conforming CAPs.

Prevent their recurrence is about the system’s frequency of occurrences and preventing from occurring again is about periodically or repeatedly. The requirement is about human factors, organizational factors, supervision factors, environmental factors, and is not about the outcome or one single event. In a data driver risk matrix, the frequency range is from times between intervals being imaginary, theoretical, virtual, or fictional at the low end in a system, to times between intervals being methodical, planned, and dependable, without defining the operational system or processes involved at the high end in a system.

Another regulatory requirement for an SMS enterprise to operate with a process for setting goals for the improvement of aviation safety and for measuring the attainment of those goals. When operating with a healthy safety management system, goals are measurable, and they are attainable within acceptable timeframes. Without a goal achievement completion time, goals are dreams, or wishes only, and are without tangible results. A goal to be safe is not a measurable goal, and therefore not an attainable goal. Playing the safety card is a tool used to distract from the real issue when a person does not have justification for their reasoning for their demands.

A goal to reduce number of accidents is also not a goal, since accidents must be an integrated part of the system for this goal can be used. At a car race, where they have crash data collected for years and accidents are acceptable, they can improve the track design, vehicle design, and assess the risk ratio for crash excitement to

spectators’ expectations. A car race system is a system where accidents are expected as an entertainment value and as a businesslike approach to safety. A reduction in accidents is therefore a measurable and attainable goal within the timeframe of one race. In aviation, accidents are not entertainment values, accidents are not a businesslike approach to safety, and a reduction in the number of accidents is therefore not a measurable or attainable goal. A measurable and attainable goal for an airport is a daily inspection to what level an airport conforms to airport standards, and for an airline a goal could be to what level they conform to crew duty and rest requirements.

An SMS enterprise cannot have a goal that is not a part of the process, e.g. accidents. A car race event cannot operate with a goal that drivers do not exceeds 51 MPH.

A regulation to prevent their recurrence and another regulation to set attainable goals may at first glance appear not to be compatible, or they appear to be conflicting requirements. It is not about if one regulation is more important than the

other when it appears to be conflicting performance requirements, but it is about how SMS processes are applied to conform to regulatory compliance in both instances. Appearance of conflicting regulatory requirements are when one requirement is to prevent, or for an event to never happen again, and the other requirement is to set an attainable goal for that same event, since a corrective action plans to prevent their recurrence were implemented.

Since regulators are performance based, there are no opposing regulatory requirements. An SMS enterprise must implement processes to conform to each

regulatory requirement by implementing different processes for the requirements. In an advanced and healthy SMS environment, an airport and airline have designed processes where one process conforms to multiple regulatory requirements.

When an SMS enterprise decide to apply performance regulations as prescriptive regulations, a trap to fall into is to stay in the rut. They are not stuck in the rut, but they voluntarily stay in the rut, since that is the safe place to stay. It is human nature to remain within their comfort zone and not to leave the someday island. The someday island is a virtual island, and it is a fantasy island where it is safe to be. The comfort zone is also a reason for procrastination. Getting things done now, or making decisions, are for many an extreme and humongous task. They have learned that when the wrong decision is made, they are being punished, demoted, or even fired. When living in such an environment, it is much better for a person to make no decisions, than making the wrong decision. A wrong decision is not the same as an incorrect decision, but is a decision that the supervisor, manager, or president of an organization did not approve of. Within a healthy SMS environment, they say thank you even when they disagree with a decision, and they say thank you when incorrect decisions are made.

Several years ago, a brand- new worker did a costly error. Feeling upset and disappointed, the worker was certain to be fired, and packed up tools and all belongings ready to walk out the door after being fired. The boss came in and asked why all belongings and tools were paced up. The worker replied that they

were packed up so it would be easier to leave after being fired. The boss replied: I cannot fire you now. In just one day I spent over 100-thousand dollars training you.

This is a true story, and true stories are good. To this day, the worker is acting as a consultant to the boss on billion-dollars projects.

Operating with a safe SMS is to stay in the rut, where there are none, or very few changes. When operating in the rut, on the someday island, each checkbox can safely be checked and show a compliant safety management system. And yes, an SMS is compliant when staying in the rut on someday island since there have not been any changes to the SMS since the SMS was implemented. In a total safe environment there are no changes, all operations are halted, and life is safe and protected from scrutiny.

Staying in the rut is a learned behavior with little or no knowledge of why things are the way they are. An aircraft runup prior to take off is done because someone crash and got scared when an engine quit. Expanding airnavigation radars were done because two airplanes crashed over Grand Canyon in 1956, and the most interesting rut is that the standard railroad gauge (distance between the rails) is 4 feet, 8.5 inches, which is an exceedingly odd number. The reason for the distance between rails is because that's the way they built them in England and English engineers designed the first railroads. The people who built the tramways used the same jigs and tools that they had used for building wagons, which used that same wheel spacing. Roman war chariots formed the initial ruts, which everyone else had to match or run the risk of destroying their wagon wheels. Since the chariots were made for Imperial Rome, they were all alike in the matter of wheel spacing. Therefore, the railroad gauge of 4 feet, 8.5 inches is derived from the original specifications for an Imperial Roman war chariot, which was built to follow the tracks of two horses.

Now, here is the rest of the story. When you see a Space Shuttle sitting on its launch pad, there are two big booster rockets attached to the sides of the main fuel tank, and they are made in another part of the country. The engineers who designed bit fatter, but the SRBs had to be shipped by train from the factory to the launch the SRBs would have preferred to make them a site. The railroad line from the factory happens to run through a tunnel in the mountains, and the SRBs had to fit through that tunnel. The tunnel is slightly wider than the railroad track, and the railroad track, as you now know, is about as wide as two horses. So, a major Space Shuttle design feature, of what is arguably the world's most advanced transportation system, was determined over two thousand years ago by the width of two horses’ tracks. Ancient horses and staying in the rut control almost everything in transportation. Applying processes to performance-based regulations is to move out of the tracks and make new tracks. New tracks are not always comprehended by the accountable executive, and therefore rejected. An accountable executive is not an expert, in most cases, in statistical process control, process analysis, risk analysis, system analysis and audits, but is an expert in financial management to ensure a successful business. The move from prescriptive regulations to performance-based regulations and the safety management system, created challenges and obstacles to overcome. Two major obstacles were to design and apply processes that conform to regulatory compliance, e.g. the output, as opposed to the input, and the other challenge to overcome was to take the first step and move out of the rut.

Staying in the rut with a safety management system is a compliant SMS, but it is an unhealthy SMS with undetected flaws. A healthy SMS has moved out of the rut and is on a path into uncharted territory.

OffRoadPilots

Santa’s System Analysis

Santa’s System Analysis

By OffRoadPilots

Since Santa implemented the Streamlined Mission Service (SMS) 10 years ago, hisSMS system has evolved into a business of its own, and a business system within the Streamlined Mission Service system. Santa runs his operations as a non- profit organization. This is not a charity organization, but a not-for-profit enterprise, with Santa who is the AE, Mrs. Santa who is HR Director, the Elf Superintendent, the Elf Director of Reindeer Operations, and the Elf Director of Airfield Management as the Board of Directors. The purpose of Santa’s operation is to deliver, without profit, gifts to billions of people once a year during a 24-hour period. The task in itself is simple, since delivery methods remains the same for centuries. However, task to deliver within a 24-hour period has become more strenuous

The first time Santa delivered gifts was in the year 872, when he helped a king of the Arctic to convince farmers, laborers, ship builders, accountants, lawyers, and risk management officers to join the king as one nation. Santa used his gifted talent as a used-sleigh salesman to give out gifts to everyone who agreed. Since this gift-giving process went so smooth, and the reindeers loved it, Santa decided to give gifts to all the nations on the day of the Arctic mid-winter fest when the sun is returning to the region again, the earth is coming back to life, and continuous darkness must give way to daylight. Santa did not plan much for this, since travel and giving gifts were common sense tasks. He gathered up all the nine reindeers he had in the safety corral, where they were protected from hazards. These nine reindeers were carefully selected from the prime of the best reindeer-stock in the mountains. The reindeers were used as helpers for the 2-day build-up of the mid-winter fest and the return of the sun, and the 7-day cleanup after the fest. This was not a rowdy and wild fest, but the cleanup needed to take 7-days as a part of a tradition only.

At the next winter-fest in 873, Santa departed with gifts that him and Mrs. Santa had prepared. The nine reindeers were happy to go and was looking forward to seeing other parts of the flat-shaped earth. Santa and the reindeers had been up in the air before, and when climbing to 3,000 feet above ground, they could easily see the end of the world. Santa didn’t think this would take much time or presents and departed on a full moon morning and bright stars. These were the modern times, and there was nothing that was not known to be bright and intelligent people at this time. On the first takeoff one of the reindeers failed and stumbled after a famous wolf crossed the runway, and the reindeer got one of the runway edge lights stuck in his nose. The nose turned red, Santa named the reindeer Rudolph, after the famous wolf, and put Rudolph at the front for safety, since the nose was red.

Santa travelled from home to home and landed on the rooftops. They didn’t have chimneys back then, but there was a hole at the gable end for smoke to escape from the living areas. This was a convention place to drop the gifts, and if Santa had to, he could use a rope to slide down into their living room.

Every delivery went well, until Santa ran out of gifts. Santa had travelled for hundreds of miles but did not make it to the earth’s end yet. There were still yard lights as far as the eye could see. Santa was disappointed but had to turn around before the reindeers ran out of energy. Safety back at Santa’s yard, he sat down and wondered what went wrong since he couldn’t deliver to every single home.

Over the next few months Santa analyzed the system to learn what went wrong. He researched famous scholars about the flat earth and reindeer energy consumption. After reading and learning more about the earth, Santa came to realize that the earth is round like the sun and the moon. Also, Santa found out that the reindeer need solid food on their travel and cannot make the full trip by using power from the windturbine installed under the sleigh to supply water when they stop on the rooftops. Santa completed his system analysis for the next trip. The system analysis included the reindeer feeding system, the power generating system, and the earth-shape system. The reindeer feeding system was made automated and powered by the power generator to supply solid and liquid food to the reindeer. The windturbine was placed on top of the sleigh since it was damaged by rooftop landings when installed below. The power generator system added two backup windturbines to ensure power supplies for the whole trip. While Santa had problems defining, or changing the earth’s shape, he discovered that he could draw a map of the earth on a round rock and use the rock as his GPS (Grand Path System).

New inventions had come on the market since last year, and now, in the year 874, everything that was needed to be known about global travel was known. Santa had no worries since the experts had given him expert’s advice for every possible scenario and ensured his safety. After several hours of travel Santa was surprised that the sun did not set. Where he came from the sun did not rise all day, but here it was just the opposite. The sun did not set during the night. This reminded Santa of home and how the summer night are long and bright. Santa used an old wheel with six spokes to calculate his travel distance. Santa called his device every 6 balcony (E6B), since he needed to recalculate his route after six rooftop landings. To his surprise, he now was at the bottom of the round rock. Santa continued his deliveries, and he did not look back. The reindeer followed the direction from Rudolph, and the red nose pointed in a straight-ahead direction. After severalmore hours, Santa began to recognize places on the ground, and soon he found his landing airstrip. Santa was surprised to learn that he could make it home without turning around. When he told this to the experts, they expelled him from the toy factory since this could not be true. The earth was flat, and anyone who went of the edge never came back. Santa was more eager now than ever to continue his journey and deliver toys to everyone. Just a few days later Santa and Mrs. Santa started their own toyshop with help from all the elves in the area. Their future looked promising.

By now Santa realized that another system analysis needed to be done, since more systems were added, and he was planning for additional changes for the next toy delivery season. This time Santa included his own experts to do a system analysis. Mrs. Santa as the Director of Financial and Human Resources has roles and responsibilities to ensure that their processes from material to finish product were stable and userfriendly, and the system analysis expert for theses areas. Santa as the Accountable Elf (AE) has responsibility for human factors, organizational factors, supervision factors and environmental factors. In the system analysis Santa used the SHELL model, which stands for self-awareness, health-awareness, encroaching-awareness, limbo-awareness, and lane-awareness. sub-factors of environmental factors are designed environment, user friendly environment, design and layout, accessibility, tasks-flow, social environment, distancing, experiences, culture, language, climate, geo location, weather, temperature, methods, machines, manpower, materials, and measurements. Santa’s areas of expertise are applied in a system analysis of these mentioned factors. The Elf Superintendent brought her skills and expertise to the system analysis for Airfield maintenance, construction, and movements. The Elf Director of Reindeer Operations was responsible for all areas of operations, and to bring her expertise skills to the table for the system analysis. The Elf Director of Airfield Management brought his skills to the system analysis for safety, processes, and operation plans management to the system analysis. Santa was satisfied that this year, in year 875 and the year of major constructions, production and delivery of toys around the world would be a success. As the preparation continued, Santa was ready at the mid-winter fest to head out on his delivery adventure. This time he headed south until the sun did not set, and then northbound until the sun did not rise. By repeating this 24 times, he covered every single home and person all over the globe in a 24-hour period, and all children around the world was as happy as ever.

Santa, with approval by Mrs. Santa, made continuous improvements to production and deliveries, and continued support to the reindeer with helpful navigation aids, food delivery, and Santa also included a rest period for two of the reindeer at a time. With the annual new and improved processes, two of the reindeer were able to take a rest period without affecting the delivery process.

As homes were improved, the chimney became an obstacle. Santa noticed one year, in 1346, that some homes had build chimneys. At first Santa did not know but learned the hard way when the reindeer crashed into one. After the first incident Santa started to track every home with a chimney and documented this in the Chimney Tracking program. Since Santa had helped out the king in 872, he continued to report to the new kings of the Arctic. In 1537 a king who spoke a different language took over, and at first it was difficult for Santa to understand. Mrs. Santa developed a communication process in addition to the text and spoken word, to include colors and images. This was very helpful, and over time Santa also learned the new language.

Over the years there were ongoing improvements. Just as the chimney improvement, these improvements became a hazard for Santa and his deliveries. One year, one of the homeowners had placed a large evergreen tree inside their house. When Santa

dropped down the chimney and rolled into the living room, he rolled over the tree, and it fell over. All decorations broke, and everyone, including the children, woke up and ran to rescue. Santa made note of this and learned from his experience. Santa also notified the reindeers that there were trees inside some of these homes, which could cause more chimney smoke when branches and wood from the trees were burned on the fire. Santa tracked and documented every home with a tree and recorded it in the Tree Tracking system. Santa realized that system analyses also were useful in predicting hazards and avoid incidents when travelling. In 1814 Santa reported to a new king, who spoke his old language. Santa modified the written text in his messages so that elves and homeowners could understand the message. Santa documented and defined the text in the Write and Talk Tracking system.

Over the years Santa conducted several system analyses. A new invention on December 17, 1903, caught Santa by a surprise when another object, and Santa was not sure what it was, approach him in the air when travelling to a different district for

deliveries. Even if Santa was not sure of what the object was, him and Mrs. Santa conducted a system analysis of the event and implemented it in the safety manual for the annual toy-run. Santa did not mention this to anyone else, or to the king, since he had concerns that it could create to punitive actions to damage Santa’s reputation.

One day, a scientist invented an ultra-resilient strain of wheat that would grow food in places where food did not grow before. This also helped out Santa with feeding the reindeer while on the road, since he did not need to do as many detours to fill up the food supplies in the sleigh. In addition, since more food became available, Santa could carry a lighter weight of food, which made the job

easier for the reindeer. This worked out so well for Santa that Mrs. Santa awarded the scientist in 1970 the highest medal of honor since the new ultra-resilient strain of wheat helped to make peace between people. Santa, Mrs. Santa, and the elves were all happy to meet the scientist, visit with him and give him a hug and thank you for his hard work over many years.

Over centuries, decades and years, there were many challenges to overcome for Santa, and over time he made improvements to increase production, and improve delivery processes to ensure timely deliveries within a 24-hour period. For any changes that were made, minor or major, Santa and Mrs. Santa conducted their system analyses to be prepared for the known and unknown hazards awaiting Santa on his journey.

OffRoadPilots