How can we prevent organisational accidents?

Part 4

What goes around comes around[1], so it is said. I think that idiom is often about bad things but can be about good things too. In other words, something done years ago can pop-up and have an impact on the here and now.

Some Microsoft PowerPoint presentations from the 1990s are difficult to read. One that I kept did convert into a readable format. The subject was Safety Management Systems (SMS). In the mid-90s, as a UK CAA Surveyor, I was presenting at a national workshop on design and production issues talking about the need for SMS. Describing what that term meant and how it should be used by approved organisations in the UK.

Airworthiness is about past, present and future. It’s about aircraft, procedures, and people. It’s about design, production, maintenance, repair, and overhaul. It’s a long-lived discipline that has developed over decades and delivered a remarkably good level of aviation safety performance.

What we were looking at 30 years ago was not only the experience of civil aviation but the results of investigation of tragic accidents in other industries. In 1986, the Space Shuttle Challenger was lost. 35 years ago, saw the Zeebrugge car ferry[2] disaster that killed 193 people. In 1988, explosions destroyed the Piper Alpha oil platform in the North Sea. Each accident pointed to the need for stronger safety management. Often the question was asked: how could such fundamental errors have been made? One response was: “Of all God’s creations, corporations seem to have the shortest memories of all”[3].

Lots of good people agreed that civil aviation needed to practice safety management but primarily on a voluntary basis. Not only that but there were numerous interpretations as to the meaning of SMS as applicable to the different disciplines in aviation. So, Air Traffic Services and Aircraft Operations went ahead with their own versions of SMS. Unfortunately, design and production organisations lagged. In the background, some specialists were attempting to distil a generic template for SMS.

It was the year 2005 that shook the tree. Measuring safety performance everyone had become accustomed a story of constantly improving global aviation safety. That year saw a series of major accidents which shook confidence and led to a High-level Safety Conference[4] at ICAO’s Headquarters in Montreal. This HLSC brought together Directors General of Civil Aviation and aviation organisations from most of ICAO’s Member States. Resulting from the HLSC was the Recommendation 2/5 and it was dramatic. It called for a new ICAO Annex on SMS. And so, ICAO Annex 19 was born.

It’s 2022. You might reasonably ask – why is it that we are only now implementing SMS for design and production organisations? Good question.

[1] The results of things that one has done will someday have an effect on the person who started the events.

[2] 6 March 1987, the roll-on, roll-off passenger, and freight ferry capsized 4 minutes after having left harbour.

[3] Safety Management, Strategy and Practice, Roger Pybus, Butterworth-Heinemann 1996.


How can we prevent organisational accidents?

Part 3

Make “challenging” better. Group think can be a source of innumerable problems. It doesn’t necessarily cause unethical organisational behaviours, but it sure does support them when they take hold. One method that can bust a cycle of self-deception is that of peer review. That is the sort of peer review where qualified participants can act independently, use their expertise and comment without prejudice.

I’m going to go back to the early 1990s. I have been fortunate to experience several different ways that aircraft certification and validation can be conducted. The method applied by the UK prior to the gradual harmonisation that took place to form the Joint Aviation Authorities (JAA) was unique.

A multidisciplinary team would visit an aircraft manufacture for a week or more. This was an intense activity of technical investigation. The output was an “orange book” and a series of findings that the aircraft manufacture must address before a national type certificate could be granted.

This process was hard work. It’s advantage was that a complete exploration of an aircraft type could be documented and that an applicant for a type certificate would be left in no doubt what needed to be done next. The first part of the activity was technical familiarisation. Each technical discipline would get a briefing on either the actual aircraft type or what was planned. This was done at the infancy of word processing. Believe it or not, I remember scissors and glue being used to cut and paste text to make-up the explanations and findings.

The purpose of these words is not to describe the use of airworthiness requirements (BCARs and the early JARs) but to describe what happened when the technical team returned home.

Having created an “orange book” with its key findings there was a need to inform colleagues of the who, what, where when and why. The authority’s senior management had to buy-in to the work of the technical team.

There were often a series of genetic findings that would deal with typical additional UK requirements. However, often more contentious was the technical findings that addressed flaws in compliance or design or unique technical features or controversial issues.

Having returned to the office members of the technical team had to justify their findings to their peers. This was done in a formal manner. It could be a daunting process. No stone was left unturned in questioning the investigation that had been done on-site at the aircraft manufacture. It was initiating to do this for the first time. Particularly when standing in front of the grandees who had been doing such work for decades. Some who had written the rules in the first place.

Although this was a tough process, it’s one that benefits a mature organisation a lot. It shakes complacency out of the system. It’s truly to be challenged.

How can we prevent organisational accidents?

Part 2

Make “challenging” better. It’s generally better to have more than one set of eyes on an issue.

The classical challenge is to perform an audit. To take a sample of the work being performed and check that its everything that it’s said to be. This can be done at any stage: design, development, test, production, and in-service. Unfortunately, audits can get bogged down in process, procedures, customs, and practice that get so heavy as to distract from the essences of the task.

There’s a focus on the tangible aspects of work too. How many reports? How many corrective actions? Show me the measurements. Nevertheless, well focused auditing is a powerful tool.

It would be wise not to discount the intangible benefits of an audit. Such activities provide a chance to view the more intangible aspects of work. Here’s a few anecdotes.

Often when being taken for an official guided tour around a design or production facility there time to look beyond what the hosts want you to see. I often found a moment to look at notice boards around a factory, or office and they gave a hint as to the culture in that organisation. Cartoons and jokes of good humour led me to put a “normal” tick in the box. But if they strayed into harsh lampooning of the management or the way of working then there was something to note.

Siting in a manager’s office being briefed as to the timetable for an audit it’s as well to take in the whole scene. All those certificates displayed on the wall. Were they pertinent? Were they there to show off? Or were they showing genuine pride in the achievements of the organisation?

Timetables for an audit are necessary but can be a menace if every second is filled. But an auditor should never be intimidated by a timetable. On occasion, I’ve walked past a pile of records only to turn back and say – and what about this one? Then being told we must hurry on. To which my reaction was to dig in and follow the trail.

It’s true that the environment has changed. Digitisation has made the random selection of a sample more difficult. Digital records lend themselves to more pre-prepared situations.

Mealtimes can be a revelation on organisational culture too. This doesn’t happen anymore, I’m sure. The factory canteen that serves alcohol is truly a thing of the past. However, an auditor being taken out for lunch is still commonplace. It’s possible to get moralistic about such invitations only to miss out on getting a sense of those intangibles that might help understanding.

Additionally, I will warn that there’s the small danger of vexatious challenge. It’s a rarity but obsessions can follow even the most capable of people around. There’s a risk too that focusing on one pet subject can mean gapping great holes are missed. Each subject needs to be taken proportional to its potential impact.