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.