Saturday, December 31, 2016

New Year Resolution: Non-Punitive Actions

New year is the time of the year when most of us make promises to ourselves to live a different lifestyle or take on challenges that have been out of reach before. These promises are often made in the spur of the moment and without consequences if not kept. Often, when a new-year resolution is made, it becomes a game to see if anyone can make it last past the first month of the year.

Illegal activity of the SMS.
This year a new-year’s resolution could be to implement a non-punitive policy in the organization. When a safety management system in aviation is required by the regulations a non-punitive policy must be in place to conform to regulatory requirements. This policy is written and implemented, but there are several options to find an “out” when there are issues that goes against operational practices. Unless there is a total commitment to safety in aviation, where information and data is critical to improve safety, the expectations for a non-punitive policy is that it is not applicable to: illegal activity, negligence or willful misconduct. These conditions make fully sense not to include as a “get out of jail free” card to personnel. However, when organizations are unable to pre-qualify and define what actions are included in illegal activity, negligence or willful misconduct, decisions are made in the spur of the moment and after the fact.

Illegal activity must be pre-defined in a job description, or for a job performance evaluation and based of decisions made by the courts. Illegal activity cannot be applied as punishment by a private individual, or an organization, to any person for a job description violation, or lack of job performance. When integrating illegal activity into SMS the management has an obligation to determine if there was an act of illegal activity to any and all incidents or accidents.
Negligence becomes a challenge to defined in a job-description or apply to a job-performance evaluation since this would involve the organization’s effectiveness of training. When an error, mistake, on unplanned event happen to someone the organization has an obligation to determine if the action must be classified as negligence. For a safety management system to identify negligence data must be collected, analyzed and investigated. Within the SMS system there are no regulatory requirement, or standard to assess, or audit a job performance against negligence as this also would jeopardize the just-culture of the SMS system.

Willful misconduct is a human behavior action and the violation is enforceable by a regulation, standard or policy. An organization that includes willful misconduct in their job description, or as a standard for an on-the-job evaluation, have an obligation to assume that every incident, or
Without data, it’s just some person’s opinion.
accident are the result of willful misconduct. When willful misconduct is applied in the SMS investigation processes the organization has developed a culture where job-performance reviews are elevated to a level beyond a functional SMS.

The Safety Management System is a system that can only operate within a just-culture, or a culture where learning is accepted and encouraged. When applying illegal activity, negligence or willful misconduct opportunities for learning are eliminated since these activities are only intended as enforceable policies. When applying these criteria, an organization is moving outside the scope of operational activities and job-performance standards. In addition, these policies are contradictory to a functional Safety Management System and an operational safety culture within a just-culture. Illegal activity, negligence or willful misconduct are the new-year resolutions of aviation safety.


Friday, December 16, 2016

Santa's UAV Deliveries

Santa Claus is manufacturing gifts and presents like never before, with production going exceptionally well. A new toy is the “magic rock” toy, which has the ability to project someone’s thoughts to the rock for viewing. Santa ran into production issues when the supply of rock at the North Pole was running out, but after months and weeks of production Santa finally completed these super-orders and is set for deliveries all over the world.

Santa’s improvement of effectiveness.
This year Santa had improved the SMS, or the Streamlined Mission Service, to include continuous improvement. During the pre-production period Santa did much research of industry standards for deliveries, but since Santa is the only supplier of this specialty delivery service, industry standards were not available. Over the years of deliveries Santa often crashed on roof-tops and damaged the equipment. These crash-variable were not only expenses which reduced profit, but also causing lack of customer service when presents were not delivered on time, or in good working order. In the old days, before technology and fragile freight handling, a crash or two on a roof top did not totally destroy, or damage the gifts and often the snow would cushion the impact. However, with the change in the gift market to almost all electronic gifts, the impact of service had changed. Santa reviewed the Santa Production’s SMS policy annually for applicability to operations, but some changes were not major, or immediate detectable. When reviewing the Safety Policy this year Santa Claus discovered a trend of incident reports and the affect it had on customer service and delivery reliability.

This year Santa had made an improvement to the delivery process by using the UAV, (Universal Autonomous Vessel), or drone. This improved process includes no-landing deliveries and is expected to improve customer service and delivery reliability. As a test-run, Santa loaded up the sleigh with samples and UAV. The size of the UAV fits in the Santa Sleigh by replacing the helpers. Santa completed the test-run and found this new process to be effective above and beyond expectations, but with two hazards. One was that the reindeer would not get rested since the UAV are launched on-the-fly. The other residual hazard was that by doing UAV deliveries, Santa’s long time personal contact with home-owners, home-decorations and getting stuck by climbing down the chimneys was identified as a hazard to customer service with a high probability that customers would be unsatisfied and search for other delivery options.

Santa’s deliveries are tailored to individual homes.
Santa had improved the delivery processes, but was not sure if the success story of this business over of Santa’s deliveries was the gift that people received, or if it was the many centuries visit from Santa that was behind the success. Santa had to implement a safety risk control, since there was a probability that the UAV’s effectiveness could ruin the business. Santa needed to monitor processes and collect data of customer satisfaction. As a safety risk control and data collection, Santa included a mini magic-rock that automatically sends back to Santa a customers’ satisfaction survey of delivery method and the impact that had on the appreciation of the gifts. Santa needed to know if it was his short visit to the families that made Christmas wonderful, or if it was receiving the presents.  Santa’s timeline for evaluation was established and for a review the success of this year’s service package prior to the Elves’ Delivery Review in May of 2017.


Saturday, December 3, 2016

Non-Punitive Reporting of Hazards, Incidents Or Accidents

Variables are the forks in the road and A simple non-punitive reporting policy is the road to success.
A non-punitive policy under an SMS program is a policy for the internal reporting of hazards, incidents or accidents, including the conditions under which immunity from disciplinary action will be granted. The intent of the policy is for organizations to receive data from personnel and then analyse how organizational processes are functioning, or why they are not being as safe as first
A simple non-punitive reporting policy.
assumed. Within an SMS organization, the outcome of processes is not totally dependant on inputs, but also on human factors variables. The concept in process management that outcome is dependant on what is put into the process is based on standard inputs without variation. Within an SMS environment the variables are human factors, where the same input to a process may yield a different outcome with different personnel involved. If the outputs of SMS processes did not vary the variables of human factors, a non-punitive policy would be redundant and ineffective.

Since the beginning of aviation, airports and airlines, have been audited, inspected and assessed for compliance. One year the audit result was found to be in compliance, while the next year the same systems were found not to be in compliance. Often, there were changes to audit and inspection results when an organization hired new personnel to do audits and inspections. This does not imply that one was more correct than the other, but that the variables of human factors made a change in outcome with the same process. In a real world, human factors variations spread out like a dropped bag of marbles.

Human factors variations could be controlled by enforcement. When applying this concept, variations are not managed, or considered, they are only enforced. Some industries are heavily into enforcing technical standards. When enforcing an outcome, the enforcement is of the outcome, or process result itself, and not of the processes which lead up to the result. This is an effective tool for selective non-compliance discovery, but an extreme ineffective and resource demanding tool for an unbiased process compliance discovery. In addition, for fully compliance with this enforcement process, the technical enforcement process itself must also self be enforced, which is a concept causing an indefinite level of layers of enforcement. However, when applying a non-punitive policy of process compliance, the resource demand is drastically reduced, compliance increased and higher profit generated.

Variables are the forks in the road.
Safety Management System in aviation has recognized that human factors exist and that identifying these variables will increase safety margins of processes with the result of a more effective and streamlined organization. With a non-punitive policy in place, the odds of receiving data of critical importance to safety are increasingly in favor of the airports, or airlines. A non-punitive policy does not imply that in times prior to SMS, personnel received punitive punishment for internal reporting of a hazard, an incident or an accident. The non-punitive policy is a defined link within an SMS system for the system be compliance with organizational polices, that it is documented, approved, accountable and applied to operational processes.