Friday, January 5, 2018

Frequent Audits or Enhanced Monitoring

The latest news reports for airlines and passenger jet-aircraft are that 2017 was the safest year on record for commercial air travel with zero fatal accidents. When counting cargo planes and passenger turboprop aircraft, there were both fatalities to passengers and bystanders on the ground. This safety record may be contributed to several factors. Some might say that this is due to the implemented Safety Management System (SMS) in aviation, while other might say that this is due to enforcement of regulatory compliance. What to remember is that there are no self-made safety operators. Safety is a conglomerate of independent, but cooperative systems, processes, procedures and organizational policies.

When an accident happens, it is an over-simplified solution to immediately place blame on the safety management system, in the same manner as it was over-simplified solutions to always blame
A stable system could be effective for years to come.
accidents on pilots. It could be that there was a system failure, and it could be that it was the pilot’s fault. However, without data to justify this root cause, a safety conclusion has been drawn based on bias opinions without facts.

There are inherent risks in aviation. These risks are caused by common cause variations and special cause variations. Simplified, common cause variations could be identified as system failure, while special cause variations are variations due to unpredictable events. An effective Safety Management System is to operate with safety processes at a level above the bar of minimum acceptable level of safety and where anyone who demands process changes comprehends the Air Operator’s safety processes. Without comprehending the SMS there is a danger of over-controlling stable processes, or tampering with the processes. Over-controlling to change a result that is undesirable, or to make good SMS processes better could be due to demands by the regulatory authority, customer’s demand, or the operations itself.  The result of over-controlling could generate a drift into higher probability of special cause variation to occur and generate a higher risk level which could cause a non-scheduled event.

Customer service and regulatory compliance complement each other and do not contradict safety performance. Regulatory requirements form the structure necessary for safety in operations, while customer service drives the safety processes required for regulatory compliance and continuous customer satisfaction improvements. Regulations in themselves are not safety in operations requirements, but requirements for compliance in a static environment. This can be described as the issuance of an operator certificate, which is issued (and must be issued), prior to any flights take place. At the time and location when an aircraft moves under its own power is the beginning of operational safety, or continuous customer satisfaction. The task then becomes to maintain regulatory compliance and in addition, have processes in place to produce the best possible safety outcome. The SMS regulatory requirements are still applicable to static operations and become the accountability of the operators to apply SMS in their systems, policies, processes, procedures and expectations to monitor how their operational processes conform to regulatory requirements while in motion. When it is established that there is compliance with regulatory requirements, then an operator may move into continuous improvements of customer service, or safety, while still maintaining regulatory compliance. The Safety Management System is the NextGen of aviation safety with tools to monitor safety performance.

Occasionally, both customers and regulatory authorities have vested interest in monitoring operations
Viewing from the fence is a process to see the overall picture.
of a service supplier or certificate holder. This can be accomplished by Enhanced Monitoring. When a customer takes on Enhanced Monitoring of their service provider, any findings are submitted to the operator as customer concerns. Should a customer demand changes in operational processes the outcome might be that a stable process could, by drift, produce a special cause variation and an unexpected event.

When the regulatory body takes on findings during Enhanced Monitoring they demand that an operator make changes. The regulator takes the driver’s seat while enhanced monitoring is applied, and an operator does not have the authority to make their own safety decisions. An operator must run all changes via the regulatory authority. This is how it must be, since the duty of the regulatory body is to provide services to the public and to ensure the interest of public safety is maintained. The regulator has an obligation to accept the risk on behalf of the public. The regulatory body has the authority to revoke certificates and must therefore be directly involved in operational management during the time of their Enhanced Monitoring.

Enhanced Monitoring is a series of mini-audits and sampling of processes. The organization or person conducting enhanced monitoring must be onsite to collect real-time data and comprehend safety system processes as they are identified by the operator’s SMS. What Enhanced Monitoring is not: It is not a review of data produced by the operator themselves, since this data in itself is bias (this doesn’t imply that it is wrong or incorrect) and the regulator has not fulfilled their sampling of data or frequent mini-audits requirements to accept the risk on behalf of the public. Enhanced Monitoring only of an operator’s data is nothing else by a task to review intent.

Enhanced Monitoring puts the pieces in a system where they belong.
A true enhanced monitoring is to collect real-time data, produce data into information, gain knowledge from this information and comprehend their SMS by analyzing information. In addition, enhanced monitoring takes on human factors, organizational factors, supervision factors and environmental factors. In short, enhanced monitoring is to sit on the fence to take notes and view the game of operational safety, which does include several common cause variations, and to view with the intent to spot any special cause variations that could cause unscheduled events. It is impossible for any deficiencies in the company's Operational Control System to escape scrutiny during an enhanced monitoring period. An effective enhanced monitoring takes at least three months to complete, depending on size and complexity of the operator. It crucial to safety that any operator, being an airline or airport, conducts ongoing and frequent internal mini-audits of their operations as their own internal enhanced monitoring.