Friday, December 25, 2015

When Things Go Wrong As They Sometimes Will

When things go wrong as they sometimes will, everyone scrambles to cover tracks and project blame on someone, or something else. We are not necessary just talking accidents, but also anything from regulatory violations, hazards, or incidents. When tings go wrong we feel embarrassed and inadequate, in addition to worrying about enforcement actions. Things don’t look good for an individual, or an organization when things go wrong.


This is a virtual story about an airport in the middle of nowhere and some busy airlines. At some point there is an incident with lights, but everyone over many years ignored it. Our virtual operators are Somewhere Airport, Across Ocean Flights, Windy Aviation and Elk Regional Airlines. Somewhere Airport is an airport certified for day operations only, with these three airlines offering several daily passengers scheduled flights and on-demand flights.

After a few years, Somewhere Airport installed some home-made runway edge lights which did not meet lighting requirements. But, these lights gave lay out the land for the runway and Somewhere Airport assumed they would be good enough. However, these lights were not good enough for runway visibility, but the airport authority decided that Somewhere Airport could operate at night with these lights as long as they only operated non-regular flights such as on demand flights, medical aviation, helicopter operations, or freight operations.


Over several years Somewhere Airport operated at nights for on-demand operations flown by Across Ocean Flights, Windy Aviation and Elk Regional Airlines. Life was good, and both the airport and airlines were happy. They all knew that the airport was a certified day only airport and that it was listed in the airport directory as not having lights for night operations. But, since the airport authority had no objection to this operation, it went on as if nothing ever happened.

Then one day, a new airport authority moved in and reviewed airport operations. It discovered that the airport had operated in non-compliance with the regulations for several years and immediately closed down all night operations. It was also identified by the airline authority that all airlines had violated regulatory operations by going in at night.


So, who is at fault when non-regulatory operations go on for year after year? Some will say the airport should be blamed, without disclosing ongoing airline operations, while other might say the airlines are to be blamed, because they placed the aircraft and flight operations in a non-compliance situation.

The answer to who is at fault, are those enterprises which did not disclose this known non-compliance and from that finding generated SMS reports, analyzed and investigated the reports, implemented corrective actions to change non-compliance operations to compliance and reported the facts to top management. In this blog of virtual experiences, this non-compliance finding is a system failure of a quality assurance system and audits to properly disclose facts of findings.

Without a Just Culture and accountability to accept facts, an enterprise is setting up for regulatory non-compliance, since a reporting culture cannot exist without accountability.  If decisions are made for a one-time non-accountability clause, or accepting regulatory non-compliance because the issue is to big to fail, that is the day when a Safety Management System has failed beyond a point of recovery. When an SMS system fails, that is when aviation safety is placed in the hands of wing-it and gut-feelings systems and set up for catastrophic failure.


BirdsEye59604

Sunday, December 13, 2015

Santa’s SMS is 95% Safe

Another year since last deliveries and Santa is running in circles to get the job done for gift deliveries this year. The year has been extremely busy and Santa had to hire more helpers than ever before. The reindeer are getting prepared, the sleigh updated with latest navigational gadgets and Santa’s suit is getting improved for chimney-dynamics, sot control and installed with high-tech thermostats.


A few weeks ago Santa reviewed reports from last year’s trip. There were several reports filed, both anonymous and other by Rudolph and Randolph. There were incidents running into an elephant in Nepal, near miss with Himalayan Sasquatch at an undisclosed location, dropping a gift in the wrong kangaroo pocket in Perth, overrunning penguins on Queen Maud’s land, injuring a llama in Peru, getting severely stuck in a chimney in Muskogee and being slammed by a hockey puck on Ellesmere Island. In addition, Santa had several hazard reports from landings, take-offs, approaches and rooftop slide-offs. These incident reports were labelled by SMS Manager Ms. Claus either for further investigation, with Corrective Action Plans (CAPs), or to be entered directly into a hazard register without investigation.

Investigations and CAPs were carried out by Ms. Claus, who had received formal investigation and CAP training from an online provider. This training included regulatory requirements, data collection of facts, analyses of events, interview techniques, process identifications, prioritizing of categories, identify contributing and root causes, propose corrective action plans, execute the corrective action plan, follow-up of results and how to complete an effective report for Santa’s Helpers, Functional Area Managers, Santa Himself, to Accountable Executive Grandma Santa and to the Board of Directors with Rudolph and Randolph as CEOs . Corrective actions from last year’s incidents took on the shape of Santa’s current objective and goals to improve processes for known technology.  

So, Ms. Santa completed all her investigations with CAPs and entered both investigated reports and the not-required investigation reports into the hazard register and prioritized areas for process improvements. 

In Santa’s Safety Management System Policy, it states that Quality Assurance of all systems must be conducted prior to next gift deliveries. The Quality Assurance manager is Great-Grandma Santa, who, with binoculars and magnifying glass, collected data of the regulatory requirements, operational requirements, safety management system and of last year’s quality assurance reports. Regulatory requirements and operational processes were documented. The safety management system tracked operations to review processes for regulatory compliance and for safety operations to be within acceptable limits. This year’s quality assurance audit concluded that Santa had systems in place to continue with gift deliveries, and that the quality assurance audit from last year had included all aspect of operations and the quality assurance program was validated.




With all the regulatory and safety checks done, Santa is ready to head on yet another adventure. Santa is ready to deliver gifts to all in the North, South, East and West with a confidence level of 95% that all safety systems are within the mean of operational standards. 


BirdsEye59604




Wednesday, December 2, 2015

Enforcing Accountability

As the Accountable Executive I am committed to enforce accountability compliance to ensure that everyone is accountable to safety. Your roles and responsibilities are described in the handbook, which was handed out at the beginning of the year. The handbook explicitly states conditions under which lack of accountability is enforceable, e.g. illegal activity, negligence or willful misconduct. In addition, all of you employees signed that you had read and understood everything in the handbook. I will enforce lack of accountability under the authorities of illegal activity, negligence or willful misconduct.

Wouldn't it be great if accountability to safety only would be ensured by the hard hand of enforcement? One would assume that life is good, that there are no hazards, incidents or accidents and everyone show up accountable and happy at work or in school in organizations with these types of leadership.

There are organizations that operate this way and these organizations are frequently enforcing accountability by firing employees. So, how many employees must be fired to ensure 100% accountability? Some organizations firmly believe in policies where accountability is only achieved by enforcement. Schools are enforcing lack of accountability with detention for not completing homework, or enforcing low grades to students when a principle assigns unsuitable study materials.

Safety and accountability is teamwork. Some say that there are no “I” in team, but there is. It’s just that it’s hidden in the “a”.

Accountability exists in a Just Culture, where the first step of accountability is taken by Accountable Executive and then continuing with Accountable Managers and Accountable Employees mirroring management behavior.

Accountability to safety is a tool for imperfect organizations with an unconditional commitment to accountable safety processes. The moment an enterprise demands virtual perfectionism is the day when human factors are discarded and accountability becomes lost.


BirdsEye59604

Monday, November 23, 2015

Best Vocabulary Keeps Aviation Safe

Everyone believe they are the key piece to keep aviation safe. However, it’s the one with the best vocabulary who wins the deal.

For a moment, let’s simplify activities and group into; regulatory, operational and servicing. After major accidents the regulatory response is that there are regulations in place to prevent accidents, operational response that they are fully trained and capable and servicing that technical items were functioning properly. Everyone assigns credit to their own group. With this approach, the one with best vocabulary wins the deal. But, there is no single answer to accident prevention.

When an internal auditor does an audit of compliance of regulatory, operational or servicing data, questions are asked to management and employees. Answer given may vary from elaborating on the issue, to a few short words. If questioning includes people of the incorrect group, who should not be included in the knowledge database, then the results are skewed to non-compliance. When the correct sample is applied to the group, it becomes the one with best vocabulary who wins the deal.

Audits and internal compliance inspections are of job-performance, job-understanding, job-knowledge and process applications. If an internal audit applies the bar of non-regulatory compliance as illegal activities and verbal communication to statement of facts, then the audit becomes invalid as a job-performance and process applications.

Internal audits and compliance inspections requires to be assessed within a standard of parameters. Verbal communication is not standardized, since personnel use different vocabulary to describe same event. Events are remembered differently and ethnical background makes a difference in answers given. An auditor may also lack questioning and communication skills, since they are experts in applying checklist items and are not experts in asking questions. At the end of the day, the auditor, or compliance inspector, determines the outcome. When outcome is based on gut-feelings of answers given, data is obscured by fog and the results are skewed in a bias direction in favor of best vocabulary.  

Samples of standardized questions, or multiple-choice questions, which then are processed with Statistical Process Control (SPC) are non-bias methods to assess processes for regulatory and safety compliance. Timed questions, in groups of 3-5 short questions, specific and targeted are data collection tools.  Online survey tools are great in assisting internal auditors and compliance inspectors with non-bias questions to ensure assessment of job-performance and not of vocabulary performance. 

BirdsEye59604

Wednesday, November 11, 2015

Trial And Error Method In Aviation Safety

Trial and error method in aviation safety as been applied since the first flight on December 17, 1903 and is a frequently used reactive system approach. Trial and error method is when changes are implemented based on the severity of incidents. After a major accident prescriptive measurements are implemented in an attempt to prevent exactly same accident to happen again. In a trial and error system approach the system failure which caused the accident is ignored and corrective change are instead applied to technical or regulatory requirements. In a trial and error system approach the trivial many are corrected, rather than making ground breaking system changes and altering the vital few.

While there is a facade of trustworthiness, it's the unpredictability which make cats superior.
When automation is introduced as a corrective measure to processes, the automation itself is reliable to a point that it defeats it's own purpose and becomes reliable manipulative. Automation is designed to detect within established parameters and is not designed to be resilient with self-induced corrective actions outside established criteria. On the security side automation detects, identify and apply aviation safety to hazards such as water, coffee, shoes, knives or guns. However, automation is not designed to be resilient, unreliable malfunctioning, or to apply the "Colombo Approach".

Border control is a part of national safety and security. While questions are often standard and reliable questions of travellers crossing international border, the spur of the moment and unexpected questions is a system approaches to identify a traveler's behavioral inconsistency. When this "Colombo Approach" is applied the system is unpredictable to manipulate.

My very first blog 2 ½ years ago on this site was the " SMS – a tool beyond the trial and error method". Since that day of my first blog in February of 2013 there have been several major aviation incidents, including a vanished airplane and most recently reports of complete security system failure.  Neither international aviation safety, nor crew and passenger security have caught up reality, but are still playing inside the box with the trivial many, where life is comfortable and feel-good decisions are made. Since my first blog the trial and error method in aviation is still the governing safety system approach.

Automation processes are reliable in turning straw into milk, which make the processes vulnerable to manipulation.
When disasters strike the scapegoat are flight crew, airports or airlines. This trial and error method is a system approach without accountably. When safety and security systems becomes news-worthy, rightfully or not,  these are reliable indicators that real changes in safety management are necessary. Safety Management Systems in aviation is to manage the vital few and not just play with the trivial many.

BirdsEye59604

Wednesday, October 28, 2015

The Purpose Of SMS When Standards Change

The very first step of an effective Safety Management System (SMS) is for management to review and document intent, or documentation of regulatory compliance, the second part is to perform a Quality Assurance (QA) of operational processes to discover degree of processes regulatory compliance, with the following step to perform a QA to discover degree of safe operational processes. The regulatory requirements is the first item on agenda, since without being regulatory compliance, operational criteria do not exists. Before any operational process are established, the enterprise is in a static-state of regulatory compliance.  A hazardous operational condition begins to exists at the split-second of aircraft movement and an airport becomes operational.  Unless managed, this is a hazardous condition which could lead to an incident.

Hazardous conditions exists at the moment an aircraft is operational.
When standards are changed, either in flight operations or airport, it becomes essential to discover how this affect operations. An effective SMS includes a regulatory compliance segment, with the intent to not only capture the changes, but also to assess what effect these changes have on current and future operations. These future effects of changes becomes vital for management to understand. Often, airport master-plans extends beyond 20 year in the future of planned changes to runways, approaches and the capacity of operations. This capacity ranges from volume of passengers, to runway length and precision approach category.

The intent was not to have the town turn into a ghost-town.
Airports are critically dependant on obstacle free approach zones and these obstacles are managed different in different jurisdiction. Some jurisdictions have zoning regulations which restricts the maximum height of obstacles close to the approaches. When a new airport standards are coming into force these zoning regulations, may or may not, protect for future precision approaches to current or future planned runways. Unless the impact is assessed and understood, a fully functional airport could become ghost-airport in the future.   

BirdsEye59604

Sunday, October 18, 2015

Data Respond Only To Objective Assessments

In an SMS world, when an enterprise is assessed for effectiveness without applying Statistical Process Control (SPC), or in other words, when it is the subjective opinion of an assessor that is applied to evaluation of collected data, the assessment has only a subjective impact of the outcome of processes.

Applying assessments with the "gut feelings" tool and not SPC, is ineffective assessment. 
Assessment is the evaluation, or estimation of the nature, or ability of a Safety Management System to function within an organization.  There are two portions to an SMS System; the regulatory portion and the operational portion. Regulatory requirements are not estimations or abilities, but documentation put in place by an enterprise of systems which are showing their intent to conform to regulatory requirements. The operational portion is management of interconnected systems to operationally, in a changing environment, be capable of maintaining regulatory compliance by the intent proclaimed by the enterprise.

A Safety Policy as a regulatory requirement is described to conform to regulatory requirements and when implemented in the organization, the regulatory requirements are met. An assessment of this safety policy could conducted by anyone, and the result, or opinion of the ability of SMS, would change with the assessor's background and experience. Unless factual data and Statistic Process Control (SPC) is applied in assessment for effectiveness , the assessment is subjective and the outcome becomes irrelevant to safety.

A safety policy is not effective just because reports are received, investigated filed and completed. The policy is effective when an SPC analysis shows that the goals of the policy were met, that the objectives were met and the policy itself has an effect on human factors in the organization for a desire to achieve an undisputed safety record.

Data applied in SPC is discovering the variables of a flowing river.
Without applying SPC in assessments, data collected becomes subjective, while data itself respond only to objective assessments.  Subjective assessments do not affect data in the way that a change in processes makes a difference in desired outcome. The change of outcome will simply change because the process was changed by a subjective evaluation, and without regards for an objective desired outcome. When disregarding objective data available and applying a subjective, or "gut feeling" opinions to data,  the changes could have been made without the implementation of a Safety Management System.


BirdsEye59604



Saturday, October 3, 2015

When They Just Come And Talk To You

This month is 15 years ago sine the Singapore Airlines Flight 006 accident happen at Singapore Changi Airport. The airplane lined up and initiated takeoff on parallel runway under construction, and it was barricaded. It was raining, windy, dark and Typhoon was moving in, with gust up to 50 KTS, to the point of almost exceeding aircraft maximum crosswind component. The Captain became the face of the systems which to blame.


In a non SMS World the systems are concealed to show only the face. 
When they just come and talk to you is when there is no Safety Management System in place and airport, air-traffic controllers and pilots are operating in a virtual world of perfect operations. In this virtual world there is no accountability and hazards are not communicated, but ignored. They just come and talk to you where words and sentences of verbal instructions becomes singularized operational standards. Flight 006 was cleared for takeoff on RWY 05L, but ended up on RWY 05R. In the aftermath of this horrific accident the finding concluded with "I told you so".


Construction happens at airports all the times and is more frequent and congested during the summer months. Construction happen on Runways, Taxiways and Aprons with various impact on flight and ground operations, from severe accidents to inconvenience for operations. Construction on aprons may not allow for General Aviation aircraft at uncontrolled aprons to taxi to the normal location for fuelling or deplane passengers. In a non Accountable environment, and in a non Just-Culture environment,  a Blame-Culture exists which is blame someone when an aircraft is guided into a location where the aircraft was not suited to be parked. Blame is most often given by an authority position to a non-authority position.

Placing blame on the tree when leaves are falling is ignorance without accountability to the process.
In an SMS Environment with Accountability and Just-Culture blame is not assigned, but it is an environment where facts are investigated.  Accountability is to do whatever it takes to ensure safety and  a Just-Culture is freedom to express, verbally or written, any ideas or opinions to improve safety. In an SMS Environment they don't  just come and talk to you, they apply facts, they apply weight to the risk, they apply environmental factors, human factors and everything else factors to make changes to processes. In an SMS World, process changes are implemented without blame, but with Accountability. Organizational changes are then implemented at the level of disrespect for Accountability. 

BirdsEye59604

Sunday, September 20, 2015

Data Nucleus

For a moment, look at Data as a Nucleus where Data is the Atom and the Variables are Negative (electron) charges or Positive (proton) charges, creating Data Nucleus. The atom, or data, is constant, while electrons and protons are variables. If the number of protons and electrons are equal, that atom is electrically neutral, and variables in the processes are predictable within standard deviations.
If an atom, or data, has more or fewer electrons than protons, then it has an overall negative or positive charge, respectively. Data is affected by variety of variables, with environmental and human factors as major contributors. Environmental and human factors are reliable unpredictable with only a short time-span when outcome is predictable.
Environmental and human variables shapes data nucleus. 
When conducting a risk assessment based on collected data, and predicting the future based on that data, is like collecting locations of marbles when they are dropped, and then applying assumptions that these marbles will duplicate exact same location every time. The purpose of risk assessments are to predict the future based on past history. This is impossible, since data which are collected are data nucleus, with variable forces at that moment in time. These variable forces do no carry forward with past data collected. Without applying current data nucleus, risk assessments are just opinions of common sense without future reliability.

Incorrect risk-based wildfire management is not management but opinions.
It is widespread knowledge that forests around the world rejuvenate themselves by burning fires. These fires are damaging with an extremely high monetary cost. Wildfires burns not only the forest, but destroy lives, homes, businesses, equipment, recreational structures and everything else that are in their raging path. Precision dispatching of wildfire fighting resources to predicted regions becomes highly important.
These risk-based dispatching decisions, which are based on recorded data from previous years, become assumptions and opinions unless data nucleus is applied to each data collected.

BirdsEye59604

Tuesday, September 1, 2015

Testing Of Safety Management System (SMS)

Introduction of new equipment or processes is done with the expectancy that changes are improvements to increased productivity with a higher rate of return on cash invested. When new airplanes are introduced it is assumed that this will attract more customers and improve service in a competitive world. Airlines with an operational philosophy of high quality customer service have greater chances to attract more repetitious flyers and paint a positive image of the company.

A positive image sets the stage for success.
SMS is a risk-based approach to safety where risks are identified, assessed and placed into existing, or new operational programs. SMS is the management of variables in a Timing Management System (TMS). Timing of variables is a fundamental factor of risk management. It is irrelevant to safety-specific if an airplane is parked on the hanger line due to mechanical failures, but becomes relevant for the purpose of flight. If a crew is waiting for that same airplane to be airworthy, the issue of mechanical failure becomes a variable highly important to safety.

A change-management system must be in place for tabletop exercises and testing how changes affects SMS operational systems. When introducing changes as new equipment or processes, scenarios are configured and played out to establish the risk-factor for risk-factor management. These change-management analysis becomes virtual events of the future, as they are not assessed based on future data collection, but based on past data collection of similar scenarios.

A selective picture of a risk assessment leaves the rest of the story up for assumptions. 
When operational changes or new processes are introduces without a change-management system in n place the testing of SMS is not fully completed. Operational changes involves human factors which are not regular variables, but special, and often unpredictable variations. These human factors cannot be applied to react in the same manner to changes as mechanical factors do. 

Eliminating human factors from the equation when testing SMS, skews a risk assessment in favor of assumptions.

BirdsEye59604

Tuesday, August 25, 2015

Forget About Safety And Think Cash!

For a moment, read this blog and forget about safety and think cash revenue of a successful business. Complete safety are intangible and unreachable goals. Safety goals may be set and aimed for, but in the end there will be other safety goals to reach beyond the newly established goals.

Think about it for a second. How does an organization measure safety? Is it measured as passed records, or as future avoidable accidents? Passed history is not a guarantee for future events and future avoidable accidents do not exist.

Safety is not black and white without changes, but is the range of the color spectrum in a changing world.
Definition of safety is generally accepted as: ” the condition of being protected from or unlikely to cause danger, risk, or injury." How is it then possible to protect someone from danger, risk or injury when the conditions to produce these events are virtual events of future fantasies?  

Cash is what keeps an airline flying and a tool to manage risks. Statistically, a major accident during a longer period of time will happen. However, an accidents are not expected to happen for any specific flight at anytime during that same timeline, and no one have the tools to predict in advance of an accident bound airplane. 

Think cash, and manage risk and safety as cash is managed. Revenue cash is not based on a virtual ballooned cash flow at some time in the future, but is the day to day managed cash flow to sustain a profitable and energetic business. Safety is managed this same way. 

Safety is to keep an eye on the sun and to prepare for changes as it sets behind, or raise above the mountains. 
Safety is not the management of a "ballooned" expensive accident in the future, but by managing processes that are known to produce safety results, and further develop these processes for better safety results. Safety is to manage how things are done day in and day out in an organization. 
The Safety Management System (SMS) and Statistical Process Control (SPC) have become the new tools to discover regular, but unknown operational expenses, by allowing expenses for irregular safety processes to remain undisclosed. SMS is a tool to discover why there is time and cash to do the job twice, but not enough time to do the job right the first time. 

BirdsEye59604

Tuesday, August 11, 2015

Regulatory Compliance Without SMS Is A Selective Picture Of Safety

Technical regulations are static requirements of operations while process regulations are operational safety management. During the Pre-SMS days, when technical regulatory requirements were applied as operational processes, the assumption was that more technical regulations automatically produced a safer operational environment.


Regulatory compliance without SMS is like a bias selection of a still picture.
A car has a breaking system, a steering system, an acceleration system, a power system, a torque system, a display system and several other systems. When it comes off the assembly plant it is regulatory compliant and have met all standards required. A speedometer indicating mph or km/hr, headlights showing white, with correct intensity and alignment, a steering wheel of approved shape and size and operating pedals placed in order as required.
A vehicle operator has a license to operate, has passed both a knowledge test and practical test to drive. The road system, consisting of highways for cross country travel, access roads to local places and streets for city addresses. All aspects conform to regulatory requirements.

An airplane comes off the assembly line in the same manner as a car. The system has put in place runways and airways for travel between points of destinations. An airplane is regulatory compliant with wings, flaps, power units, control-input units, and  pilots who have a pilot license to operate and qualified of aircraft type.

When SMS is Regulatory compliant, that is when operational facts are discovered. 

After major accidents, more technical regulations and standards are put in place to make flying safer. Unless operations have processes in place to manage safety, or risks  (as there are inherent risks in flying), aviation is only safe as long as an airplane conforms to static regulatory compliance on the ground. At the moment it moves, another world of managing safety opens up. Safety does not miraculously comply to safety regulations and standards unless it is managed.

It was not until a Safety Management System came into play in aviation that operations had a tool to manage and make safety happen.

A Safety Management System (SMS) is safety in operation, safety in human factors, environmental factors, organizational factors, supervision factor and it is to make regulatory compliant operating processes. When these processes are in place, the risk in flying is reduced to a level of certainty of processes effectiveness.

BirdsEye59604

Sunday, July 26, 2015

SMS Long Before SMS Was Invented

Lukla Airport in Nepal is said to be the most dangerous airport in the world. The airport is located in the middle of the Himalayas at an elevation 9300 ft, with a 1700 ft runway. The airport is popular because Lukla is the place where most people start the climb to Mount Everest Base Camp. There are daily flights between Lukla and Kathmandu during daylight hours in good weather. Although the flying distance is short, rain commonly occurs in Lukla while the sun is shining brightly in Kathmandu. High winds, cloud cover, and changing visibility often mean many flights can be delayed or the airport closed.

Since SMS can be applied in the middle of the Himalayas, SMS can be unconditionally applied everywhere else. 
Aircraft can use runway 06 only for landings and runway 24 only for takeoffs. There is no prospect of a successful go-around on short final due to the terrain. There is high terrain immediately beyond the northern end of the runway and a steeply angled drop at the southern end of the runway into the valley below. Lukla Airport was constructed in 1964 and long before SMS in aviation was invented.

What makes Lukla Airport the most dangerous airport in the world are the many safety processes of a Safety Management System which has to be applied within a short time of operational management to ensure public safety. These SMS processes are necessary for safe approaches, landings, take-offs and departures.

SMS was implemented for flights into Lukla without questioning if all the processes were required by regulatory requirements.  SMS for Lukla was unconditionally implemented to ensure safety for the public.

SMS is an unconditional one way departure to safety.
When SMS is implemented only as a mandatory regulatory requirement it becomes a safety distraction and not safety processes to ensure operational safety. However, when SMS is unconditionally accepted as processes to manage safety it becomes an operational safety tool.

BirdsEye59604

Thursday, July 16, 2015

There Are No Emergencies, Only Unpreparedness For Events

Emergencies are events with a major surprise, or an event which we don’t believe to have control over. Emergencies are categorized on a scale at the low end of minor emergencies to the high end of extreme emergencies. Everything else in-between are just emergencies. What once was classified as an emergency could be prepared for and no longer become an emergency, or an overwhelming uncontrollable event. Emergencies are manageable to the degree of preparedness and resources allocated.

It is impossible to prepare for all future events, but events which are prepared for will eliminate the surprise of unpreparedness. Even if one cannot prepare for all, one can prepare for selective events.

Emergencies, or non-scheduled events, are as unique as each shade of grey. 
A rule of thumb is the 80-20 rule that states that 80% of outcomes can be attributed to 20% of the causes for a given event. Generally, the 80-20 rule is used to help identify problems and determine which operating factors are most important and should receive the most attention based on an efficient use of resources. Resources should be allocated to addressing the input factors have the most effect on a company's final results. It was an event of the vital few which later demanded that everyone on a passenger ship must have access to lifeboats. 

The 80-20 rule is to manage and allocate resources to either the “vital few” or to the “trivial many”. The trivial many are easy and simple tasks, which contribute very little or none to the cause.  The vital few are difficult and complex tasks with substantial contribution to the cause, and could make the difference between continuous operations or losing it all.  

Preparedness is an opportunity to capture a non-scheduled event. 
Major emergency disasters are unmanageable when resources are allocated based on a low probability score.  However, if allocating resources, training and preparedness to the vital few severe emergencies, these non-scheduled events are no longer unmanageable emergencies, but become management of non-scheduled events. 

BirdsEye59604

Saturday, June 27, 2015

Take SMS With You On The Road

A Safety Management System (SMS) is to take with you on the road, where action to safety is the focus point. SMS is not a tabletop exercise to conform to regulatory requirements, but a hands-on exercise to conform to safe operations.

It might be tempting to leave SMS back at the office with the stack of may other regulatory requirement for any operation. This could be as air operator,  transportation operator or just as simple as a private vehicle operator. What counts for safety is how operations are managed with processes, or how things are done.

Regulatory compliance keeps you floating, while safety management keeps you flying.
History of safety records is not guarantee of a future high safety rating.  Changes in processes are at times minor and almost not noticeable, but accumulative with several minor unnoticeable process changes over time. Without process monitoring there is no way to discover issues which could lead to incidents.  

When the regulatory compliant SMS system is left behind at the office it is not possible to detect operational process changes, or changes in how tings are done, until there is a breakdown in the system. This breakdown could be a simple administrative task, or a major system failure.  What is relevant is how an operator manages process to capture changes in expectations, or process goals. 

When SMS comes with you on the road the system becomes a natural part of day to day activities. SMS becomes the safety culture, the just culture and a culture to foster discovery of process changes, or non-punitive reporting. When decisions are based solely on history the outcome is not managed but assumed. When decision making is based on process review the outcome is managed. 

Safety operations from an office desk is like managing safety through a window.
This is how it goes; If you keep a regulatory compliant SMS on the shelves, it does nothing for safety in operations. You need to take SMS with you on the road to ensure you meet the bar of safety expectations, or safety goals.

BirdsEye59604

Saturday, June 13, 2015

Perimeters vs. Parameters

Perimeters are directives, while Parameters are challenges. Both perimeters and parameters have their operational place in any organization with perimeter being task oriented and parameters are result oriented.

The perimeters are established to stay within confined area. 
Operational perimeters are evaluated to the limits of the perimeters. The issues are for tasks to be performed within the box, without deviation to venture outside the box. As long as all tasks are performed within the perimeters of the box, performance is acceptable.  This limits initiatives and operational decisions to assigned specific tasks. Tasks within the box may be applied in initial learning situations to instil knowledge and behaviour patterns, or to ensure regulatory compliance. This could be explained as when a person first learn to fly an airplane, the pilot-student has to stay within the box of assigned tasks to learn the aircraft's behaviour, and to understand the limits of operational regulatory compliance. As long as all operations are within the limits of the box, or perimeters, life is good.

Operational parameters are job-performance evaluation of results achieved. The limits are not lateral, as with perimeters, but limited to levels of complexity with initiatives and accountability. Parameters are result oriented, where one parameter must be completed before moving onto the next. Operational parameters requires skills, training and knowledgeable personnel. Assigned parameters are effective in  just-culture organizations, where results, or outcome of processes are evaluated.  

The parameters are established for results.
The difference between process parameters and process perimeters, is that process parameters tasks are linked and connected by individual activates,  while process perimeters tasks are individually independent and disconnected. An example of process perimeter could be the assembly line, where one robot has a specific independent task,  while an example of process parameter could be resilience to operational abnormalities.

BirdsEye59604

Wednesday, June 3, 2015

Building A Safety Case

Building a safety case is not just a tabletop exercise, but a conglomerate of several operational hazard analyses of changes that may have safety impact on operations. The outcome of hazard analyses, or operational impact is unknown  until changes considered are entered into the blueprint tool and constructed as a safety case.  When a safety case is built and completed, it becomes a visualization of the future.

Safety case is to buckle up.
An airline may make a safety case for changes to new routes, aircraft or operational bases. Hazard considerations to route changes may include language barriers or regulatory operational standards. Other hazards to change in aircraft may be handling characteristics in manual mode, or display of automation. A new base may need to consider environmental hazards, or local workforce available. Hazards to consider for safety cases could be anything beyond limits of pre-determined assumptions.

Airports may make safety cases for operators, and build safety cases for aircraft movements. Airports as operational surfaces are static in nature, with aircraft movements as one of the variables. These variables could be less than ten movements per day or several hundreds of movements. In addition to variables in aircraft movements, the variables in itself are subject to non-scheduled variables, as aircraft diversion and weather delays. This make airport safety cases more complex in nature than often assumed.

During the summer months there are often construction activities at airports. This could be construction of public facilities or operational taxiways or runways. The upgrades could be simple excavations or major blasting projects where standard operations and obstacles are analyzed. Blasting may be assumed not to have an operational impact since there are no obstacles to evaluate. However, blasting has the potential of a severe malfunction where the emergency measures has to be included in safety cases.

Safety case is venture out with parameters.
Safety cases might not be what they appear to be when analyzing assumptions. Only when analyzing hazard facts can a true safety case be developed.

BirdsEye59604

Sunday, May 17, 2015

Non-Punitive Is Not To Accept Honest Mistakes

Some organizations believe that a non-punitive reporting policy is to accept honest mistakes. This is as far from the fact as it could be. A non-punitive reporting policy is to discover deficiencies within an organization. Any time a non-punitive report addresses an excuse for the process, it reflects a non-accountable safety management.


No matter what is regulatory, safety still rests with the operator.
There are no honest mistakes. Mistakes are due to rush, fatigue, inattentiveness, lack of skill, lack of knowledge, anything else, or just laziness. Mistakes are many things, but one thing they are not; is honest. If mistakes were honest, the operator, or contributor to the mistakes would know in advance that the processes or procedures applied intentionally would cause errors. 

Mistakes reflect on organizational management and not on individual errors. In an organization with none or few mistakes, the leadership have conveyed their message clearly, ensured appropriate training and checking results. In an organization with many or frequent mistakes, excuses are applied to the processes and management do not approach, or accept mistakes with accountability. 

Parking next to an airstrip is not an honest mistake but calculated accountability. 
Recognizing organizations which do not apply the non-punitive accountability is simple. Without accountability, organizational errors are removed from management and transferred to an item, a person, a word, a sentence or simply ignored. Non-accountable organizations or organizations that apply non-punitive reporting as honest mistakes are recognized by their self-defense, and opinion of lack of regulatory requirements. These types of organizations don`t acknowledge that safety is operational.

BirdsEye59604

Thursday, May 7, 2015

Accepting Risks Without Accountability

It is simple to accept the risk without accountability. That's like spending winnings from a lottery, or spending someone else's cash.  These Non-Accountability Risk Assessments often make references to authorities and accepted guidelines. However, they do not take into account unique elements applicable to an individual risk assessment. Risks assessments are as unique and individual as a person.

First thing that comes to mind is to do a risk-assessment
In aviation, risk assessments are done both formally and informally. Pilots must make informal decision based on immediate risks. An unplanned high approach requires an overshoot, or a medical emergency might require an immediate diversion. Airports make risk assessments to power poles, obstructions, wildlife and water lagoons. There are tons of risk assessment documents written about water lagoons and bird attractions. These documents may be developed based on official reports and table top exercises or informal opinions from local personnel. People who are reporting birds might not know one specie from another. Bird experts who are not aviation oriented might believe that a large bird is less hazards, since they should be easier to see. These types of statements are often accepted as facts, and without considerations,  in risk assessments.

Swimming the Kern river needs an accountable risk assessment
When accepting these types of risk factors based on previous and unknown documented assessments, an operator is assigning a Non-Accountability Risk. The strategy becomes that since someone else did this, it must be OK, and it is less work. But, here is the newsflash; Safety = Work.  Just like someone is saying that there is a Santa Claus, someone is saying that Safety does not cost an extra dime. 

A risk assessment is as individual as the person next to you. Applying Safety Management System principles and processes is the only road map to an Accountable Risk-Assessment. 
 
BirdsEye59604