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