Monday, March 9, 2015

Aviation Safety Is About Knowledge And Authority

One upon a time during the pre-CRM years of aviation co-pilots job were only to obey Captains order, sit down and do nothing unless asked. Then CRM – Crew Resource Management came along. CRM opened the door for communication and decisions between pilots in the driver's seats. The co-pilot became enabled to initiate safety concerns to the Captain. Safety had moved forward, and everyone felt safe, secure and good about themselves. 

Then one day a flight attendant spoke up against the Captain about a safety concern. It was snowing heavily and snow was packing on an airplane preparing for takeoff. This interference was a new and unfamiliar for the Captain, since flight attendance were not expected to interfere with the Captains safety decisions. Not only had Captains over years accepted and adjusted to consider advise from the first officer, but now the flight attendant also wanted to become involved in safety. The Captain decided not to take this advise and ordered the concerned cabin crews off the plane. Then, on it's way offshore to 39thousand feet, the plane took off with fewer cabin crew members than planned.    

Precision approach is protected against obstacles with an obstacles free zone authority.
There are two accidents that stands out in history where airplanes lost control after takeoff due to heavy snow. One is the Potomac River accident on January 13, 1982, and the other is the Dryden accident on March 10, 1989. In both instances concerns were raised by a first officer who did not have the authority to speak on the issue. The authority to speak rested with the Captains. In both instances the Captains decided to continue the takeoff with several clues, however not facts, that the outcome could be a severe accident. The snow were clues and not facts since the snow was an indication only, and not an indisputable factor that it would lead to an accident. It was accepted in the industry that airplanes were designed to operate in heavy snowy conditions and therefore design and technology were trusted and lack of operational knowledge minimized facts to clues. 

Knowledge of driving a commercial vehicle  is not the same as authority to drive a commercial vehicle. 
Without knowledge of facts, improvement to aviation safety is simply limited to pre-incident clues. However, if one does not have authority to speak on facts, knowledge becomes irrelevant.  


Monday, March 2, 2015

The Difference Is Accountability

In non-aviation jurisdiction there is a law addressing the issue of honest mistakes being made in working environment. This law states that if the mistake is done by reason of an honest mistake the error cannot be punished with punitive actions. This type of law sets up any organization for failure and with no accountability to job performance. It may be assumed that the non-punitive clause under SMS is the same thing, but that is as far from the fact as it could be. SMS does not function in an environment where failure is accepted, or excused, but has to be embraced in a just culture with job-performance accountability at all levels.

Accountability is to manage time and place.

What is an honest mistake in job-performance anyway? Is there such a thing as a non-honest mistake? What makes a mistake, or a failure honest or dishonest? Describing an event as an honest mistake is an attempt to justify an outcome without accountability and by placing blame on the outcome itself. Applying the honest mistake concept is a common sense approach to avoid discovery of fact and root cause.

In this old picture the quality was not an honest mistake, but root cause discovery which lead to becoming the Master.

A non-punitive policy is the antidote to the honest mistake approach. In a non-punitive environment there is accountability at all levels and the root cause is discovered by at least considering  individual human factors, the environment, supervision and organizational elements. When understanding the root case an enterprise has been given a documented opportunity to change processes for a different outcome. The mistake is no longer an honest mistake, but accountability and accepting an operational process failure.