So now you are probably asking, "Okay, how do I get 14 pilot association committees to work with me, the airline safety manager?"
I am so glad that you asked!!!
The key to success here is by working Jointly with the pilot association. What is that? Your airline does not have a pilot association? Hmmm, I wonder if the airline management has done everything possible to discourage a pilot union from forming? If so, they have really done the airline a great disservice. What is that? You say that this same airline management team has only provided the minimum of one person for the entire airline safety program? Wow! That same team has really done the airline a disservice!
In the case about which I previously spoke, our pilot union had 14 committees and well in excess of 100 people doing volunteer safety work on behalf of the union membership. But who also benefited?
Well of course the answer is that the company benefited greatly.
So, how many airlines have the model of a Joint Safety Program?
Not too many.
How many could have an exceptionally effective safety program at very little extra cost by working Jointly with the pilot group?
I would say, just about everyone could.
Saturday, September 24, 2011
Should Safety Managers be good listeners?
Safety managers must be good listeners. It has been my experience that few if any reports from people participating in safety suggestions are actually "trivial."
My experience is actually just the opposite. My experience is that everyone who came to my office to make a report had an important idea to share or an important here-to-fore unreported risk to which to bring our attention.
By listening to the person reporting and taking time to clarify their concern, our safety programs achieved two important goals. First, we found risks that only one person recognized. Funny how in an organization of 300 people, that only one person will see and be willing to report a very valid hazardous risk. Not sure why that is so, but it is. Second, by listening to all who came in to report, and publishing all reports and recognizing the best each week, we developed the excellent reputation of being the "good listener." You would be amazed at the things that really need to be fixed that no one else noticed or bothered to tell anyone about.
So, my suggestion is do not worry about "triviality." In fact the report may be of quite some significance when you later understand its true potential for prevention.
Again that is my experience and I would add, that by doing so, our safety program achieved the goal of reducing losses due to injuries and deaths, property damaged or destroyed to zero. So, I would say that this program worked very well in four very different organizations.
Can Safety Be Done by One Manager? I would add, that Safety is not a job that can be done by one. In fact at my pilot association we had 14 committees that dealt with some portion of the safety pie, yes 14! And we were not the company, we were just the pilot group. Safety is not something that can be done from an asset poor point of view! Safety requires a great deal of attention.
What many airlines have found is that by failing to do the safety job of prevention well, that instead they wind up doing the mishap investigation job. And what a huge waste of time and money that is!!
There has never been a mishap investigation in which I participated, where in the end the conclusion that this mishap was preventable was not reached!
My experience is actually just the opposite. My experience is that everyone who came to my office to make a report had an important idea to share or an important here-to-fore unreported risk to which to bring our attention.
By listening to the person reporting and taking time to clarify their concern, our safety programs achieved two important goals. First, we found risks that only one person recognized. Funny how in an organization of 300 people, that only one person will see and be willing to report a very valid hazardous risk. Not sure why that is so, but it is. Second, by listening to all who came in to report, and publishing all reports and recognizing the best each week, we developed the excellent reputation of being the "good listener." You would be amazed at the things that really need to be fixed that no one else noticed or bothered to tell anyone about.
So, my suggestion is do not worry about "triviality." In fact the report may be of quite some significance when you later understand its true potential for prevention.
Again that is my experience and I would add, that by doing so, our safety program achieved the goal of reducing losses due to injuries and deaths, property damaged or destroyed to zero. So, I would say that this program worked very well in four very different organizations.
Can Safety Be Done by One Manager? I would add, that Safety is not a job that can be done by one. In fact at my pilot association we had 14 committees that dealt with some portion of the safety pie, yes 14! And we were not the company, we were just the pilot group. Safety is not something that can be done from an asset poor point of view! Safety requires a great deal of attention.
What many airlines have found is that by failing to do the safety job of prevention well, that instead they wind up doing the mishap investigation job. And what a huge waste of time and money that is!!
There has never been a mishap investigation in which I participated, where in the end the conclusion that this mishap was preventable was not reached!
Friday, September 2, 2011
It has been said, "You seem to be convinced that a flawed world can be actually made flawless."
My response is this. Human error is part of our nature. However we can make our own flight operations mishap free by remembering Miller's Rule for Safety Management: ALL SAFETY IS LOCAL.
Any one safety manager cannot make a "flawed world ..... flawless." He or she can only affect the operation over which they have control.
I can personally recommend steps to each LOCAL Flight Operations Safety Manager that have worked extremely well to achieve mishap free flight operations.
One person commented, "In a process oriented investigation "human error" cannot be the ultimate root cause. You need to ask yourself, "Why did the humans make the errors?"
My response to this is, "True, but you also need to go further and ask what procedures can be put into the SOP and become part of the training program that will help flight crew members overcome their human errors.
For example, lets say that a very important system characteristic is buried on page 49 of a chapter in the Aircraft Operating Manual. Well, maybe if it is considered to be so important, should it be bold faced, underlined and not buried on page 49? In other words, humans make errors that can easily be corrected. Safety managers need to find ways to help the flight operation correct errors as they are occurring and are reported.
Some have also said, that crew selection and training criteria are often driven by both financial and safety level aspects. FAA and other civilian authorities have criteria set at minimal requirements. But one company may decide to exceed those.
For example, one company may decide to select pilots (1) which have a Commercial Pilots License from a school with a weak syllabus and accept those after a minimal medical and psychological selection process, accepting captains with only 3,000 flight hours. Another company may have require at least a masters degree in technical sciences and demand a very strict medical and psychological selection criteria and accept captains only after 30,000 hrs. The same could and often does apply to training. One set of training requirements are used for a Government operation and another set of training criteria are used for a major airline."
But my response is this. You still have to train flight crew in the company SOP. You still have to check to the SOP and make your operation "procedure oriented" and not technique oriented. This way flight crew are performing procedures and not using their own techniques to operate.
Further, as the operation improves its control, it will develop a need to have more standardization in procedures just so that mixed crews can operate efficiently.
Should the FAA tolerate such a wide variance between airlines? It is the Topic for another day.
My response is this. Human error is part of our nature. However we can make our own flight operations mishap free by remembering Miller's Rule for Safety Management: ALL SAFETY IS LOCAL.
Any one safety manager cannot make a "flawed world ..... flawless." He or she can only affect the operation over which they have control.
I can personally recommend steps to each LOCAL Flight Operations Safety Manager that have worked extremely well to achieve mishap free flight operations.
One person commented, "In a process oriented investigation "human error" cannot be the ultimate root cause. You need to ask yourself, "Why did the humans make the errors?"
My response to this is, "True, but you also need to go further and ask what procedures can be put into the SOP and become part of the training program that will help flight crew members overcome their human errors.
For example, lets say that a very important system characteristic is buried on page 49 of a chapter in the Aircraft Operating Manual. Well, maybe if it is considered to be so important, should it be bold faced, underlined and not buried on page 49? In other words, humans make errors that can easily be corrected. Safety managers need to find ways to help the flight operation correct errors as they are occurring and are reported.
Some have also said, that crew selection and training criteria are often driven by both financial and safety level aspects. FAA and other civilian authorities have criteria set at minimal requirements. But one company may decide to exceed those.
For example, one company may decide to select pilots (1) which have a Commercial Pilots License from a school with a weak syllabus and accept those after a minimal medical and psychological selection process, accepting captains with only 3,000 flight hours. Another company may have require at least a masters degree in technical sciences and demand a very strict medical and psychological selection criteria and accept captains only after 30,000 hrs. The same could and often does apply to training. One set of training requirements are used for a Government operation and another set of training criteria are used for a major airline."
But my response is this. You still have to train flight crew in the company SOP. You still have to check to the SOP and make your operation "procedure oriented" and not technique oriented. This way flight crew are performing procedures and not using their own techniques to operate.
Further, as the operation improves its control, it will develop a need to have more standardization in procedures just so that mixed crews can operate efficiently.
Should the FAA tolerate such a wide variance between airlines? It is the Topic for another day.
Wednesday, August 31, 2011
Forecasting involves learning from previous mishaps
We can forecast by learning from the mishaps of other organizations.
We learn by observing the mistakes that are made. That being said, I would add that we actually have a more superior ability to observe these mistakes as they are made on the line and before they contribute to a mishap.
Did you know for example that Safety Theory tells us that flight crew will make 1000 errors which could lead to 100 reportable events, which could lead to 10 incidents and which could lead to 1 major mishap.
Many people do not believe that or do not understand this very valuable nugget of safety information. This is the key to succeeding in the safety profession and I will tell you this from my own 43 years of experience. You can achieve zero mishaps, you can prevent mishaps at your airline.
Here is how to do it. You must have a reporting system that allows flight crew members to speak about and report their errors and those that they observe. Next the safety person has to investigate these errors, figure out how they impact the operation and take steps to correct the organic reason for the errors. Most often in my experience this involved some adjustment, modification or addition to SOP. But the safety person has to be well versed in flight ops and SOP so that the changes to SOP make sense.
Unfortunately all too many people believe that until an event, incident or mishap occurs, that their operation doesn't "have a problem." However the problems are there because we are human. They will always be there. The key is to incorporate the error reporting process into day to day operations, to talk about them and fix them right then and there.
Allowing human errors to "fester," to unreported and uncorrected is to set the operation up to failure. Can an operation be made error free? Of course not. But at the same time can an operation be made mishap free? Absolutely so, by finding and fixing errors as they occur.
But I believe that as humans we are constantly making errors. A good program that enables us to report and act on these errors as they first occur will enable us to always be one step ahead of the hazards and therefore operate free from mishaps.
We learn by observing the mistakes that are made. That being said, I would add that we actually have a more superior ability to observe these mistakes as they are made on the line and before they contribute to a mishap.
Did you know for example that Safety Theory tells us that flight crew will make 1000 errors which could lead to 100 reportable events, which could lead to 10 incidents and which could lead to 1 major mishap.
Many people do not believe that or do not understand this very valuable nugget of safety information. This is the key to succeeding in the safety profession and I will tell you this from my own 43 years of experience. You can achieve zero mishaps, you can prevent mishaps at your airline.
Here is how to do it. You must have a reporting system that allows flight crew members to speak about and report their errors and those that they observe. Next the safety person has to investigate these errors, figure out how they impact the operation and take steps to correct the organic reason for the errors. Most often in my experience this involved some adjustment, modification or addition to SOP. But the safety person has to be well versed in flight ops and SOP so that the changes to SOP make sense.
Unfortunately all too many people believe that until an event, incident or mishap occurs, that their operation doesn't "have a problem." However the problems are there because we are human. They will always be there. The key is to incorporate the error reporting process into day to day operations, to talk about them and fix them right then and there.
Allowing human errors to "fester," to unreported and uncorrected is to set the operation up to failure. Can an operation be made error free? Of course not. But at the same time can an operation be made mishap free? Absolutely so, by finding and fixing errors as they occur.
But I believe that as humans we are constantly making errors. A good program that enables us to report and act on these errors as they first occur will enable us to always be one step ahead of the hazards and therefore operate free from mishaps.
Wednesday, August 24, 2011
Safety Forecasting for Air France?
Many more mishaps of the same type. They haven't fixed the root causes of the mishaps which they suffered and instead chose to blame everyone else.
Proof? Was it not AF procedure to have a man in a truck do a Foreign Object Damage (FOD) check of the runway prior to the Concorde conducting a take off? If the loss of parts by another airline was a known hazard and the airline had a preventative procedure to counter this threat, why did the mishap acft depart before such a FOD check was made?
Why would AF not advise and train its own pilots about the differences in runway friction between a grooved runway and a non grooved runway such as in Toronto? Why did AF training not equip pilots to go around when landing in a storm?
Why didn't AF take better care of flight crew out over the ocean by sending them the latest weather?
Would I suspect AF to be ready to have another mishap real soon?
Probabilities seem good for that event, in my opinion.
Proof? Was it not AF procedure to have a man in a truck do a Foreign Object Damage (FOD) check of the runway prior to the Concorde conducting a take off? If the loss of parts by another airline was a known hazard and the airline had a preventative procedure to counter this threat, why did the mishap acft depart before such a FOD check was made?
Why would AF not advise and train its own pilots about the differences in runway friction between a grooved runway and a non grooved runway such as in Toronto? Why did AF training not equip pilots to go around when landing in a storm?
Why didn't AF take better care of flight crew out over the ocean by sending them the latest weather?
Would I suspect AF to be ready to have another mishap real soon?
Probabilities seem good for that event, in my opinion.
Saturday, August 20, 2011
How the NTSB, FAA and BEA Add to the Aviation Disaster Tragedy
Safety Mishap Investigations are intended to prevent the same mishap from ever happening again, from ever reoccurring. But what often really does go on during the investigations conducted by NTSB, FAA, BEA, ATSB and other national boards around the world?
Here is my opinion, here is a look into what often goes on in the name of a Safety Investigation:
Rule One: Protect Those in Power, Those with Money and Influence. Prevent those without Power, Money and Influence from gaining control of any part of the "Safety Investigation" by claiming that the "Common Good of the Traveling Public is at Risk!" Then as the board is claiming this as the reason or charter under which the board is operating and all other reasons, charters or claims to be secondary, self serving, sensationalism, self interest or distractions, proceed on protecting the powerful, moneyed and influential, the board conducts a legal based investigation in preparation for going to court. The questions of "What Happened" and "How do we keep this event from ever happening again?" are lost in the rush to "Who was at fault?" and "Who pays?"
Rule Two: Attempt to find persons and parties without Power, Money and Influence and try to legally blame them for a major element of the mishap. Avoid finding the actual cause of the mishap. This way you will not be tasked with the obvious, that is, finding actions to prevent the mishap's recurrence the next day, next flight or next operation. This way nothing needs to be fixed and therefore no one is held accountable for not fixing the hazard sooner. Remember that a cause has to be pretty certain or it is not really a cause; rather it is just a coincidental event. But legally often just coincidental event reasoning is sufficient to assign blame.
Rule Three: Generate "Legal Uncertainty" using the term "Probable Cause" [the greatest oxymoron in this field] so that those with Power, Money and Influence have enough legal smoke screen to hide behind. Remember legally that "reasonable doubt" is enough to protect against guilt in a death case and that the generation of Uncertainty will provide that doubt. Forget all about finding causes as the board should be doing. Come up with all sorts of coincidental events about which the board is not happy and make a big deal about how fixing them is so important. Remember to avoid at all costs finding a cause, unless under Rule Two you can find someone who perished.
Rule Four: Turn all the losses of property over to the lawyers to pay compensation as assigned by courts or separate agreements.
Rule Five: Lawyers have ways of evaluating the worth of each human life lost, through a centuries old calculus of case law, gender, net worth, earning power and other accounting practices. Again, turn the loss of life litigation over to the lawyers to hash out who gets paid and how much, there by avoiding having to deal with the human emotional tragedy of loss of life, lives belonging by the way to the "Traveling Public."
Rule Six: At some very distant point in time down the calendar, maybe at three, five, ten or twenty years, enact some attempts, often outdated by now, at fixing what was wrong in the first place, THE CAUSE(S), that everyone outside the "Parties To The Investigation" and those "Parties To the Investigation" without Power, Money or Influence thought needed to be fixed and demanded such during the investigation. The distancing in time, after the claims litigation is completed allows this process to move forward without incurring new compensation claims. It also allows the human emotional tragedy from having to ever enter into the Mishap Safety Investigation process. Turn that responsibility over to the Grief Counselors who deal with the "inevitability of tragic human loss" in everyday life and this keeps it apart from and unrelated to the investigation for convenience of the boards.
Well, that about sums it up, no?
One question though, why is there no attempt to find out what went wrong quickly so that if the condition exists in other planes, operations, airports, flight crew or other elements of the system, it could be fixed before another tragedy occurs?
Could this be why in commercial aviation we observe the essentially "same disaster" or at least, the same type of disaster reoccurring over and over again? Is the fact that the boards take years to come out with any reports not totally contrary to their basic safety charter and in fact a contributory reason that we take so long to learn the lessons of these mishaps if we ever learn them at all? Isn't this contrary to the reasoning that every living adult tries to learn in their early years to make life successful? Why is there such a great distance in the thinking and reasoning of every living adult and the thinking and reasoning often of the major aviation safety mishap investigation boards?
Shouldn't the purpose of a Safety Investigation be to "find out what went wrong and take action to ensure that this event never happens again?" Isn't that what all of us do in life to keep from making the same mistake twice? Why wouldn't that same reasoning apply when we are talking about "Flying the Traveling Public Around the World in Our Commercial Aviation system?"
Why have we all failed so miserably to make commercial aviation safer? Why have the operators and the safety people and the owners and the regulators failed to make commercial aviation a form of transportation with a mishap rate either at or very near zero? Why do some airlines, why do some airfields, why do some aircraft, why do some flight crew members operate for years mishap free, often for entire careers? Is it just chance as the lawyers would have us believe? Does that even make any logical sense? Have we ever asked an airline, a manufacturer, an airport operator or a flight crew member who has completed a career mishap free for any suggestions? If so, have we ever heeded the same?
Or are we just stuck on Rules One through Six?
Welp, look back at Rules One through Six above and you may find your answer. Are willing to defer power to the powerful and influence to the influential? Do we then will find the mishap rate continuing to hover where it is now or worse yet spike up at times, in places, with aircraft, with people? Will we all continue to spin the wheel and take our chances that the next tragedy will happen to "someone else?"
Maybe, just maybe, we could chart a different course? Could we start to do actual Mishap Safety Investigations? In many cases now what the NTSB, FAA, BEA, ATSB and other national boards do now is to protect the powerful, moneyed and influential, while at the same time fail to achieve their own chartered purpose of Safety.
When will the leadership of national mishap investigation board finally begin to do what they were established to do? Is there any leader who actually knows what they are supposed to be doing?
If so, their voices have yet to be heard.
This of course is my opinion.
Here is my opinion, here is a look into what often goes on in the name of a Safety Investigation:
Rule One: Protect Those in Power, Those with Money and Influence. Prevent those without Power, Money and Influence from gaining control of any part of the "Safety Investigation" by claiming that the "Common Good of the Traveling Public is at Risk!" Then as the board is claiming this as the reason or charter under which the board is operating and all other reasons, charters or claims to be secondary, self serving, sensationalism, self interest or distractions, proceed on protecting the powerful, moneyed and influential, the board conducts a legal based investigation in preparation for going to court. The questions of "What Happened" and "How do we keep this event from ever happening again?" are lost in the rush to "Who was at fault?" and "Who pays?"
Rule Two: Attempt to find persons and parties without Power, Money and Influence and try to legally blame them for a major element of the mishap. Avoid finding the actual cause of the mishap. This way you will not be tasked with the obvious, that is, finding actions to prevent the mishap's recurrence the next day, next flight or next operation. This way nothing needs to be fixed and therefore no one is held accountable for not fixing the hazard sooner. Remember that a cause has to be pretty certain or it is not really a cause; rather it is just a coincidental event. But legally often just coincidental event reasoning is sufficient to assign blame.
Rule Three: Generate "Legal Uncertainty" using the term "Probable Cause" [the greatest oxymoron in this field] so that those with Power, Money and Influence have enough legal smoke screen to hide behind. Remember legally that "reasonable doubt" is enough to protect against guilt in a death case and that the generation of Uncertainty will provide that doubt. Forget all about finding causes as the board should be doing. Come up with all sorts of coincidental events about which the board is not happy and make a big deal about how fixing them is so important. Remember to avoid at all costs finding a cause, unless under Rule Two you can find someone who perished.
Rule Four: Turn all the losses of property over to the lawyers to pay compensation as assigned by courts or separate agreements.
Rule Five: Lawyers have ways of evaluating the worth of each human life lost, through a centuries old calculus of case law, gender, net worth, earning power and other accounting practices. Again, turn the loss of life litigation over to the lawyers to hash out who gets paid and how much, there by avoiding having to deal with the human emotional tragedy of loss of life, lives belonging by the way to the "Traveling Public."
Rule Six: At some very distant point in time down the calendar, maybe at three, five, ten or twenty years, enact some attempts, often outdated by now, at fixing what was wrong in the first place, THE CAUSE(S), that everyone outside the "Parties To The Investigation" and those "Parties To the Investigation" without Power, Money or Influence thought needed to be fixed and demanded such during the investigation. The distancing in time, after the claims litigation is completed allows this process to move forward without incurring new compensation claims. It also allows the human emotional tragedy from having to ever enter into the Mishap Safety Investigation process. Turn that responsibility over to the Grief Counselors who deal with the "inevitability of tragic human loss" in everyday life and this keeps it apart from and unrelated to the investigation for convenience of the boards.
Well, that about sums it up, no?
One question though, why is there no attempt to find out what went wrong quickly so that if the condition exists in other planes, operations, airports, flight crew or other elements of the system, it could be fixed before another tragedy occurs?
Could this be why in commercial aviation we observe the essentially "same disaster" or at least, the same type of disaster reoccurring over and over again? Is the fact that the boards take years to come out with any reports not totally contrary to their basic safety charter and in fact a contributory reason that we take so long to learn the lessons of these mishaps if we ever learn them at all? Isn't this contrary to the reasoning that every living adult tries to learn in their early years to make life successful? Why is there such a great distance in the thinking and reasoning of every living adult and the thinking and reasoning often of the major aviation safety mishap investigation boards?
Shouldn't the purpose of a Safety Investigation be to "find out what went wrong and take action to ensure that this event never happens again?" Isn't that what all of us do in life to keep from making the same mistake twice? Why wouldn't that same reasoning apply when we are talking about "Flying the Traveling Public Around the World in Our Commercial Aviation system?"
Why have we all failed so miserably to make commercial aviation safer? Why have the operators and the safety people and the owners and the regulators failed to make commercial aviation a form of transportation with a mishap rate either at or very near zero? Why do some airlines, why do some airfields, why do some aircraft, why do some flight crew members operate for years mishap free, often for entire careers? Is it just chance as the lawyers would have us believe? Does that even make any logical sense? Have we ever asked an airline, a manufacturer, an airport operator or a flight crew member who has completed a career mishap free for any suggestions? If so, have we ever heeded the same?
Or are we just stuck on Rules One through Six?
Welp, look back at Rules One through Six above and you may find your answer. Are willing to defer power to the powerful and influence to the influential? Do we then will find the mishap rate continuing to hover where it is now or worse yet spike up at times, in places, with aircraft, with people? Will we all continue to spin the wheel and take our chances that the next tragedy will happen to "someone else?"
Maybe, just maybe, we could chart a different course? Could we start to do actual Mishap Safety Investigations? In many cases now what the NTSB, FAA, BEA, ATSB and other national boards do now is to protect the powerful, moneyed and influential, while at the same time fail to achieve their own chartered purpose of Safety.
When will the leadership of national mishap investigation board finally begin to do what they were established to do? Is there any leader who actually knows what they are supposed to be doing?
If so, their voices have yet to be heard.
This of course is my opinion.
Friday, August 19, 2011
Grim Safety Forecast for Air France
The recommendation is contained in the latest BEA accident report investigating the loss of the Air France Flight 447, a document that outlines 10 new safety recommendations, including improved pilot stall-awareness training, the inclusion of cockpit cameras, and adding angle-of-attack readouts in the cockpit.
But it's the inclusion of a call for mandatory data streaming technology that is sure to raise the biggest objections with airlines, who will have to pay for it.
This is a grim future for Air France if these are the BEA's main plan to prevent this event from reoccurring.
I can agree with the angle of attack recommendation. I can agree with the stall awareness training.
But did not having the cameras cause the mishap? Of course not; this is just someone trying to get the camera in the cockpit nnd using thes dead people to do it.
Did not having data streaming from the acft cause the mishap? No, in fact it was not having weather data streaming TO THE AIRCRAFT that was in great part responsible for the mishap.
So, it is my opinion that AF will have a string of these mishaps, more of the same!
But it's the inclusion of a call for mandatory data streaming technology that is sure to raise the biggest objections with airlines, who will have to pay for it.
This is a grim future for Air France if these are the BEA's main plan to prevent this event from reoccurring.
I can agree with the angle of attack recommendation. I can agree with the stall awareness training.
But did not having the cameras cause the mishap? Of course not; this is just someone trying to get the camera in the cockpit nnd using thes dead people to do it.
Did not having data streaming from the acft cause the mishap? No, in fact it was not having weather data streaming TO THE AIRCRAFT that was in great part responsible for the mishap.
So, it is my opinion that AF will have a string of these mishaps, more of the same!
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