Wednesday, August 27, 2014

Training, Training, Training and Training

Training is a big chunk of aviation safety and a tool to ensure personnel are qualified to perform their duties. With ongoing training it could look like nobody is never fully trained. If someone is fully qualified and trained, then more training shouldn't be required. Training is therefore often looked at as being required for someone with lack of knowledge, qualifications and failure to perform. It couldn't be farther from the truth than that.

It's a misconception that training only has one function of learning, and that this function is to become qualified. Human culture associates training with learning, where learning begins in preschool, graduates to kindergarten, then elementary, and finally to high school. Each step is required as a level of learning to qualify for the next level. These are building blocks of learning moving from unknown to known. It's to instil knowledge in someone who didn't have that knowledge.

A training environment is the fruit of acquired knowledge, while learning is the bar of acceptance. 

Training has several other functions and cannot only be associated with learning, or lack of knowledge. Functions of training are associated with Human Performance, which again have multiple subsections. Some of these subsections are Human Behavior, Organizational Performance, Human Factors, Medical Performance, Aviation Performance, Optimal Operational Design, Interaction Modeling and more.

When applying the fact that training is associated with Human Performance, ongoing training becomes a tool to capture process deviations from performance parameters. Deviations from performance parameters are not lack of knowledge, but a process deviation to reach a common goal. Most standardized processes are arbitrarily chosen based on bias opinion of the person who established the process in the first place. This doesn't make the process wrong, bad, incorrect or dangerous, it's just the fact that someone established the process based on their experience and personal view of what to them made sense. From these processes, rules are derived to establish the lowest bar acceptable in aviation safety. As an example of a new rule is the Sterile Cockpit rule. This rule was implemented due to one notable accident which caused a crash just short of the runway conducting an instrument approach in dense fog. Training becomes a process to apply standardized procedures, capture deviations and excel in performance above the bar.   

The key to success is not in what was learned, but in the training of applied processes.
Training is not required due to lack of knowledge, but it is required to evaluate performance level against the bar, instil process control, correct process as applicable and assess Human Performance level at or above the bar. Training is to excel to levels that are above the trial and error method level.  


Thursday, August 14, 2014

Holes In The Cheese And Bad Apples Are Causing Accidents

It's neither true that when holes in the cheese lines up accidents happens, nor is it true that bad apples cause accidents. And if the facts were that every major accident is proceed by a few minor accidents and several incidents, there would be no management of safety. Safety would then be managed like a bag of marbles being dropped to spread in random patterns. 

A ridged process runs over variables instead of managing.
The holes in the cheese lines up because of a decision to slice the cheese in a certain way. If the objective was to slice the cheese in a way that the holes would not line up, a thorough analysis and risk assessment prior to slicing would be required. Holes lined  up in the cheese don't cause accidents. It is the outcome of how things are done during day to day of normal operations that are causing these events. When managing safety, daily routines and practices must be analyzed and then proceed to slice the task to manage the holes in the processes.

Bad apples don't cause accidents. Imagine a box of apples, open it and there are one or two bad apples on top. These apples were bad because they were not given proper treatment prior to be placed in the box. A week later, when opening the box again, there are several more bad apples that are discarded, and this goes on until the box is empty. When all bad apples are gone the goal is reached: To have no more bad apples.

People perform their job to the bar of a bad apple to what degree they are allowed to experience proper treatment. By keeping apples at the proper moisture and temperature, they remain good apples. Personnel that are trained property excel in their job to levels well above the bad apple bar. If they are not trained to perform and understand the processes their performance level rapidly decreases to a level of bad apples where they feel accountable to operate. 

When going down the slide for the first time hazards are carefully analyzed. On the next ride they are integrated in the process.
When marbles are dropped they spread in a random pattern. The location where each marble stops are determined by laws of physics; where each marble is in the group at the time of release; how each marble interact at point of impact; and the condition of the surface of impact. If this exact condition could be replicated the marbles would stop at exact same point every time. The reason they are spreading out differently is that the conditions cannot be reproduced. In theory the same result should be achieved, but due to special variables it is impossible to manage to get same result.

Reactions to these unknown and special variables must be applied at the time and location of where each variable occurs.  The key to manage safety is to reduce special variable and take more proactive than reactive measures.

There are no reasons to accept that accidents are inevitable just because a magic number of incidents are reached. Managing safety is to discover and learn about as many as possible of variables and then integrate these variables as a part of normal operation. 


Friday, August 1, 2014

Accidents and Incidents Are Time Converging Events

On a clear blue sky day one airplane left on a westbound trip, while another departed  on a southbound adventure, both bound to be on time for an unknown converging mid-air path. If the data of these two flights had been communicated, applied corrective actions would have separated their paths.

Mathematical equitation are applied every day to avoid conflicts when air traffic controllers (ATC) requests pilots to change speed or heading. These changes were not planned, but due to one or more variations new calculations predicted current paths to be converging in time.

A once perfect project may over time reveal its flaws. 
Unexpected variations, or special variations,  are hidden flaws hidden in layers of safety guards. Accidents happens when flaws are revealed in an unpredictable sequence and causing time crossing paths.

People are the strength of all safety processes with a unique ability above and beyond any automation in resilience, and the understanding of communicated data. Collected data of special variations are accumulate knowledge. This knowledge makes you wiser, not just older. How insignificant the data might seem at the time, it's an asset to improve safety.  

Special variations may be obscured by the view.
Communication is a key factor to manage safety. Tools and technology for effective communication to avoid time converging events may not be available at all locations, or in all types of airspace. The time to "time of no return" becomes relatively short when pilots first  have to establish visual contact.

Special variation management is to discover the unpredictable sequence at which these variations are revealed.