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.