Unexpected occurrences are undefined systems
Historically aviation accidents are contributed to human, or pilot error and defined as failures. It was pilot error when pilots retracted the landing gear believing that it was the flaps. The root cause was defined as failure to recognize position of the flaps lever. As time went on this failure happened over and over again until it eventually was recognized as design error. The flaps lever designed was changed to look like a wing, and the gear handle to look like a wheel. The outcome of selecting gear up and not flaps were placed into an operational safety management system.
Several years ago an intercontinental flight ran out of fuel due to longer distance travel by thunderstorm diversions and the accident was contributed to pilot error and failure to plan the trip. However, when similar situations continued to happen it was recognized that failure to plan trips were due to pilot-fatigue, or organizational management since pilots worked without sleep for 24-36 hours in one stretch. Regulatory restrictions of flight and duty time were implemented to give pilots an opportunity to be rested before work. The outcome of failure to plan were placed into an operational safety management system with organizational accountability. These two scenarios are examples of a humble beginning of Safety Management System in aviation when systems and established processes came under review and short term fault findings were replaced with long term system changes.
|Interlocked systems work together|
From the point of view of a traveling passenger, families or friends of the traveler, the outcome of the flight is what matters. It becomes a task for the total aviation-system industry to find out where there are breakdowns which could allow for deliberate-systems to infiltrate the safety management system. Just as the flap and gear handle, and flight and duty time restrictions changed the view of root cause analysis, the future holds new and similar challenges from unfamiliar accident-systems that will change how safety is managed.
The outcome of any flight must be viewed from the traveler’s point of view to ensure that inconsolable experiences do not happen within a safety management system.