Aviation – Page 7 – John Vincent

Just Culture

My thought is that we’ve forgotten the discussion of more than a decade ago. There was a time when the thoughtful reflections on responsibility and accountability were much discussed.

Without focusing on specific examples, there are plenty to choose from, there’s the propensity of our institutions and politicians to reach for “blame” as a first response. When situations go bad the instinctive inclination to hunt out someone to blame. This is an all too prevalent habit.

Naturally, in cases, there’s the strong need to identify who is accountable for bad decisions. Society does not like it when the powerful protect, cocoon themselves and grab for immunity. Certainly, some people and organisations are genuinely blameworthy. However, if we scrutinise and point the finger of blame, it doesn’t help if that finger is pointed at a person’s honest errors. There isn’t a human on this planet who hasn’t made an error.

The finger of blame is easily pointed. Judgment so often falls after an event. The time when more is known, and hindsight comes into play. This tips the balance. It’s so much easier to say: why on Earth did you do that? I would never have done that.

For people to come forward and be fairly heard in an open and fair inquiry or investigation they need to have the confidence that they are not stepping into a public blame-fest. Without trust between those on all sides of it’s less likely that the truth will come out.

“Just Culture” is a concept written into aviation legislation and followed by others. The overriding aim is to learn from mistakes. It’s the surest way of not repeating the same mistakes time and time again. It’s beneficial to have that long-term learning objective. Why suffer the pain of a bad event when the means to avoid it are known and understood?

Now, I’m going back 20-years. I remember being part of an international working group[1] called GAIN. The group compiled guidance about organisational culture. At the time, the group was considering the subject in the context of the air traffic profession. Guidance like the one referenced, emphasise that a Just Culture is not simply a no-blame culture. It’s not, and never has been a way of circumventing accountability.

Determining culpability can be complex. There’s often a test to consider the wilfulness of the participants in a bad event. In other words, did they carelessly, intentionally, maliciously or negligently make decisions that resulted in the bad event? In these cases, the “they” could be an individual or an organisation.

Gross negligence, wilful abuses and destructive acts should be addressed by the enforcement of laws. If we say the criminalisation of honest people involved in bad events has a negative impact. That is not to negate the need for enforcement. Regulators in all sorts of walks of life have a duty to apply enforcement where and when it’s appropriate. Maybe we ought to have applied that to the UK water industry.

My plea here is to first consider the nature of the events in question. Was there an element of genuine honest human error? Is the right balance being struck between the need to learn and the need to ensure accountability?

NOTE: Just Culture is defined in EU law as “A culture in which operational staff or others are not held accountable for actions, acts, omissions or decisions commensurate with their experience and training, but gross negligence, intentional violations and destructive actions are not tolerated” EC 376/2014 Art. 2 Para. 12.

[1] A Roadmap to a Just Culture https://flightsafety.org/files/just_culture.pdf

Turbulence

Turbulence is the result of atmospheric or environmental effects. Afterall, aircraft are craft that fly in the air. This is a hazard that is inherent in flying. Clear air turbulence (CAT) is common. However, extreme examples experienced in commercial aviation are rare. For one, aircraft operators and their crews do their best to avoid known potential atmospheric or environmental upsets, namely bad weather.

En-route turbulence accounts for a substantial number of cabin crew members injuries, and can occur at any time and at any altitude[1]. As far as I know, the UK Civil Aviation Authority (CAA) does not hold detailed data on turbulence injuries occurring on foreign registered aircraft. Numbers of injuries to passengers and flight crew on UK registered aircraft resulting from turbulence are recorded. However, it is not always known whether those injured in turbulence encounters were wearing seat belts.

Nevertheless, I can confidently say that the more passengers that are wearing seat belts during turbulence encounters the less the number of injuries. Deaths in these circumstances are rare. As might be expected fatalities are more likely to results from a combination of multiple causes and factors.

This subject is not immune from airline economics and competition. International flight routes can often be highly competitive. Fought over. So, the route taken, and associated fuel costs, can have an impact on the likelihood of a hazardous weather encounter. In fact, choosing to take routes for the benefit of picking-up specific winds is a common practice.

A high percentage of cases of turbulence events come about by flying too close to active storms[2]. Here there is often visual cues, reports, forecasts and feedback from turbulence encountered by other flights. This all helps crews avoid the worst weather encounters.

With very few exceptions, flight turbulence does not result in fatalities, permanent injure, or structurally damage commercial aircraft. However, turbulence is recognised as both an aviation safety and an economic issue, and it has been steadily increasing. Speculation and some research cites climate change as a reason for this increase. Also, there is the international growth in air traffic and development of new long-range routes.

One thing to say is that until recently, with INTERNET connections now in both in the cockpit and cabin, it could be the case that a passenger could access better real-time weather information than a flight crew. Now, SATCOM connections providing up-to-date weather information are more common on modern civil aircraft types.

There is still more that can be done to reduce crew and passenger injuries during turbulence encounters. There will inevitably happen despite any policy to avoid hazardous weather. The greatest threat to life exists to cabin crew. The cabin is their place of work.

There is potential to develop and employ better airborne detection systems to assist crews. That maybe by enhancing existing weather radar systems. It maybe by new means of turbulence detection using LIDAR, and possibly AI/ML. There is research and innovation that could be done to develop algorithms to better predict turbulence hazards.

Avoidance remains the best strategy.

[1] NASDAC Turbulence Study, August 2004

[2] US CAST briefing in 2004.

Harmonisation

There’s an example in of itself. I’ve used the British English spelling. Perhaps I should have standardised on the American spelling, namely Harmonization. Or does it matter at all given that the definition of the word remains the same, whatever. Oh, I can’t resist the temptation to say; you say Tomato, I say Tomato.

“You say tomato, I say tomato.

You eat potato and I eat potato,

Tomato, tomato, potato, potato,

Let’s call the whole thing off.”

Naturally, in the voice of Fred Astaire[1]. Nice though this is, my subject is not pronunciation.

Aviation is a highly regulated business. It’s been that since its potential for transporting huge numbers of people around the globe was recognised. Safety must be number one. Although, it’s not if you read the first few words of the all-important Chicago convention.

Article 1: Every state has complete and exclusive sovereignty over airspace above its territory.

In the minds of those who signed the convention it was sovereignty that took first place. That didn’t mean abusing the word “sovereignty” as has to often been done. Afterall, the whole basis of the Convention on International Civil Aviation was international cooperation. It still is.

Let’s put that to one side for a moment. One of the challenges of international aviation has been the different rules and regulations in place in each country. There’s a level of harmony in the standards of the International Civil Aviation Organization (ICAO). But ICAO is not a regulator and it’s for each country to interpret agreed standards within their domestic law.

Europe, or at least the European Union (EU) is different in this respect. Since there’s European law and an active European regulator then there’s common rules and regulation set for a regional grouping of countries. So far, Europe is the only region to go this far.

When it comes to aircraft airworthiness this has been a topic of a lot of discussion in the last four decades. In the 1990s, that discussion centred around the idea that a single worldwide code was a desirable achievement. That the time the two major entities engaged in the business of aviation rulemaking, and the maintenance of rules were the FAA (US) and the JAA (Europe).

A single worldwide code could greatly facilitate the movement of aviation produces around the globe. That done to ensure that common safety standards were maintained on every occasion. It proved hard to get to this utopian condition. That said, a great deal was achieved in the harmonisation of existing civil aviation codes. Today, we benefit from that work. I’d say we even take it for granted.

In around 2000, after much study, countries concluded that it was fine to seek some form of equivalence between respective rules rather than having to write done one single set of rules. Mutual recognition has flourished in the form of agreements between countries that has smoothed the path for the aviation industries.

That last major study of the pros and cons of harmonisation is now nearly a generation old. A lot has moved on. For one, in Europe the JAA transition to the EASA.

At the same time the manufacturing countries worked closely together to agree on measures to ensure that there was no great divergence in rules and regulations. Now subjects, like Safety Management Systems (SMS) became codified. However, sovereign countries continued to develop and maintain their own aviation rules and regulations.

International working groups often achieve remarkable commonality and convergence on detailed technical topics. Often because the few people who were deeply embedded in a technical subjects all knew each other and shared information relatively freely.

Discussion as to the viability of a single worldwide code has not completely faded into the past. In fact, there’s some good reason to breath life back into this historic debate. Here’s what’s added to the dynamics of the situation:

Ongoing moves from prescriptive rules to more performance-based rules,
Entirely new products in development, like eVTOL aircraft,
Interdependency, interconnection, and integration all increased since 2000,
Security and safety are becoming inseparable,
Digitisation is changing the ways that we ensure that an aircraft is airworthy.

If you have knowledge of, and thoughts on this subject, I’d be happy to hear from you.

[1] https://youtu.be/LOILZ_D3aRg

Electrics & Mechanics

Yesterday, I wrote on LH2. The potential fuel for electric aircraft of any size. Yes, I’m not just talking about smaller commuter class transport aircraft.

Let me take some anecdotal evidence from the transition that is going on in road transport. Repairer turns up to fix an electric car that will not start. It’s a simple matter given that the car has been standing unused for a long time. The battery had discharged. A quick charge from another battery pack and all is well. Meantime in conversation it’s clear that the repairer hates working on electric cars. I could say, no surprise, they were trained on combustion engines and have been forced to make a transition in technology.

What’s evident here is the apprehension of a person who likely has a mechanical bias towards their work and the necessity to take on fixing powerful electrics. Mechanics, those who love working with moving parts, often have a dislike of electrics and electronics. It’s an engineer’s “feeling” expressed to me casually over the last 40-years.

In fact, it can be the reason that a design or maintenance engineer took the career path that they did. There is a dividing line between mechanical engineers and electrical engineers that is embedded in our institutional, educational, and training systems.

So, there’s two practical human issues to grapple with in a transition:

Propensity of one branch of technically capable people to find mechanical work less fearsome and more satisfying than electrics or electronics, and
Streaming that is embedded in our institutional, educational, and training systems. Qualifications and recognition are often not so multi-disciplinary focused.

I’m not for one single moment making a luddite argument that mechanical engineers[1] and electrical engineers[2] are two tribes that must be kept apart. Far from it. What’s more important is to recognise that transitions are hard.

New electric aircraft are going to demand technical people with a multiplicity of both mechanical and electrical knowledge. The way the engineering world has been divided up in the past doesn’t cut it. Some of our most cherished niches will need to be challenged.

Transitions of this nature always take much longer than is originally anticipated. In a way, that should be such a surprise. It’s a generational change for a community that can be conservative with a small “c”.

This is NOT business as usual. For example, handling powerful 1000-volt electric technology is not for everyone. Removing and replacing cryogenic plumbing is, again, not for everyone. The hazards are clear. The skills needed are clear.

Reorienting the aircraft maintenance engineering world is going to need new plans and programmes. Better start by enthusing people about the change rather than just forcing it.

[1] https://www.imeche.org/

[2] https://www.theiet.org/

Hydrogen in Aviation

The potential for LH2 (liquid hydrogen) is enormous. That’s matched by the logistical and technical difficulties in exploiting this gas’s great potential. It offers energy for a means of propulsion that is nowhere near as environmentally damaging as existing means.

Society already integrates hazardous liquids and gases into everyday life. Each one has been through several iterations. It has been a rollercoaster. Each one has been at the root of disasters, at one time or another.

We use gas for cooking and heating in domestic settings. Periodically explosions demolish buildings. Leaks cannot be ignored. Harm can be done.
We use light and heavy oils widely in transport systems. Periodically intense fires burn vehicles. Care in handling is essential. Harm can be done.

Without having to say it, both above harm the environment. The search for non-CO2 emitting ways of flying is urgent. Here, I’m writing about harm to people. Physical harm. The business of aviation safety.

Often the physical harm is not associated with the design of the systems used but to the maintenance of those systems. Naturally, there was a learning curve. If we look at early versions of those systems, fatal accidents and incidents were far more regular. So, here’s the challenge for aviation. How do we skip the dangers of the early learning phase? How do we embed rigorous maintenance practices from day one? Big questions.

On the first one of these, lots of fine minds are engaged in putting together standards and practices that will address good design. If this works, and it will be tested extensively, the chance opens for introduction to service with a great deal of confidence that the main risks will be managed.

On the second of these, there’s not much happening. You might say there’s an element of chicken and egg. The shape and form of future LH2 systems needs much more work before we can think deeply about how they will be maintained.

I think that’s wrong. It’s old-fashioned thinking. As the industry has often practiced, making the systems first and then devising ways of maintaining them while in-service. That’s yesterday’s reasoning.

Making aviation system maintenance the Cinderella in the LH2 world is to invite failure. This is a situation where advancing the consideration of how the in-service realm could work, day by day, is necessary. It’s advantageous.

Here’s my reasons.

There are generic approaches that can be tested without knowing the detailed design. That can take existing learning from other industries, like chemical and space industries, and consider their application in aviation.
Emerging technologies, like machine learning, coupled with large scale modelling can provide ways of simulating the operational environment before it exists. Thereby rapidly testing maintenance practices in a safe way.
It’s imperative to start early given the mountain that needs to be climbed. This is particularly true when it comes to education and training of engineers, flight crew, airport and logistics staff and even administrators.

Everyone wants to accelerate environmentally sustainable solutions. When they do get to be in-service, they will be there for decades. Thus, an investment, now, in study of maintenance systems will pay dividends in the longer term. Remember, early fatal accidents and incidents can kill otherwise sound projects or at least put them back on the drawing board for a long time.

NOTE 1: I didn’t mention Liquefied Petroleum Gas (LPG). It’s in the mix. Another CO2 contributor. LPG containers have pressure relief valves. LH2 containers will likely have pressure relief valves too. That said, venting LPG is a lot more environmentally damaging than LH2. From a safety perspective they can both create explosive conditions in confined spaces. Maintenance staff may not need to carry a canary in a cage, but they will certainly need to carry gas detectors when working on LH2 powered aircraft. Our noses will not do the job.

NOTE 2: Events on the subject: https://www.iata.org/en/events/all/iata-aviation-energy-forum/

https://events.farnboroughinternational.org/aerospace/sustainable-skies-world-summit-2024

2024 ICAO Symposium on Non-CO₂ Aviation Emissions

Culture

Yet again, Boeing is in the news. The events of recent times, I feel are immensely sad. Now, it is reported that the FAA has opened an investigation into a possible manufacturing quality lapse on the Boeing 787 aircraft[1]. Concern is that inspection records may have been falsified.

A company that once had a massive professional engineering reputation has sunk to a place where expectations are low. It’s not so much that the company is having a Gerald Ratner moment. Unfortunately, the constant stream of bad news indicates something deeper.

It’s interesting to note that Frank Shrontz[2] passed away last Friday at the grand age of 92. He was the CEO and Chairman of Boeing, who led the company during development of the Boeing 737NG and Boeing 777 aircraft. In the 1990s, I worked on both large aircraft types.

A commonly held view is that, after his time and the merger with McDonnell Douglas the culture of the organisation changed. There’s a view that business schools graduates took over and the mighty engineering ethos that Boeing was known for then went into decline. Some of this maybe anecdotal. Afterall, the whole world has changed in the last 30-years. However, it’s undoubtably true that a lot of people lament the passing of an engineering culture that aimed to be the best.

A famous quote comes to mind: “Culture eats strategy for breakfast.” Those sharp 5 words get discussed time and time again. Having been involved in a lot of strategic planning in my time it’s not nice to read. How wonderful intent, and well described policies can be diluted or ignored is often an indicator of decline. It’s that cartoon of two cavemen pushing a cart with a square wheel. One says to the other: “I’ve been so busy. Working my socks off”. Ignored, on the ground is an unused round wheel. If an organisation’s culture is aggressively centred on short-term gain, then many of the opportunities to fix stuff gets blown out of the window.

We keep talking about “performance” as if it’s a magic pill. Performance based rules, performance-based oversight, and a long list of performance indicators. That, in of itself is not a bad thing. Let’s face it we all want to get better at something. The problem lies with performance only being tagged to commercial performance. Or where commercial performance trumps every other value an engineering company affirms.

To make it clear that all the above is not just a one company problem, it’s useful to look at what confidential reporting schemes have to say. UK CHIRP is a long standing one. Many recent CHIRP reports cite management as a predominant issue[3]. Leadership skills are an issue.

[1] https://aviationweek.com/air-transport/some-787-production-test-records-were-falsified-boeing-says

[2] https://www.seattletimes.com/business/boeing-aerospace/frank-shrontz-former-ceo-and-chairman-of-boeing-dies-at-92/

[3] https://chirp.co.uk/newsletter/trust-in-management-and-cultures-is-the-key-to-promoting-confidence-in-safety-reporting/

AAM

This week, I watched an FAAs Advanced Air Mobility (AAM) webinar[1]. The subject was community engagement. AAM could be air taxies but it’s many uses of the new electric aircraft that are becoming a reality. The term eVTOL is used for those aircraft that have the capability of vertical flight. My reflection is that there are several aspects of AAM that need much more attention. Naturally, I’m taking the discussion of what’s going on in the US and thinking about it in relation to the UK.

Land Use Planning

Generally, National Aviation Authorities (NAAs) are consultees when it comes to land use planning. They do not determine planning applications. NAAs may well have set out policies and guidance on the subject but they will not be determining the site of vertiports.

It seems to me that there’s little chance that eVTOL aircraft routes will be established without sufficient community consent. Community engagement has been appropriately recognised as essential. The aspects in play are like those for existing aerodromes. Often for AAM applications proposals are for the use of new locations, hence a concern. Anytime there’s a serious proposal for a new aerodrome the opposition is up and running long before the proposers have got their act together.

The subject is complicated by the mix of public and private ownership of infrastructure. If the intention is to interconnect AAM with other transport services (bus/train/boat/road), then complicated agreements are going to be inevitable. It’s not just about buildings and tarmac but having a trained workforce available is a location dependent issue too.

Business Models

I’m about to sound as if I’m securitising the plans of a contestant on The Apprentice[2]. There are plenty of way of losing money in commercial aviation. It’s been a well-practiced art over the years. Great ideas fall by the wayside after huge amounts of money have been expended. Customers are key. People must want to fly the routes available, time and time again. And like London Black Cabs be prepared to pay the fare. Given the relatively small cabin sizes that are on offer these people are likely to be moderately prosperous groups or individuals.

Regular schedules air services can produce a reliable income. Airport-to-airport connections seem like a good bet. Problem there is the conveyancing of weighty luggage. Busy airspace could be a challenge too. That said, with tens of thousands of people at both ends of a route, no doubt some people will choose a comfortable, speedy direct connection.

There are good possibilities for major event driven transport services. Getting to and from a motor race or horse race event or a concert or festival can be hell when tens of thousands of people are all trying to get to and from a location or venue. The numbers may well stack-up to make eVTOL a premium way of dodging the crowds in an environmentally sound way.

Batteries, Batteries, Batteries

Everything in respect of aircraft performance depends on power density. How much oomph can you get out of a small, light weigh physical space. Recharge and go. Do it, again and again. It’s as simple as that. Not only that but aircraft battery packs must be affordable and available. Whizzy technology that cost a mountain of cash and can only be use for a few hundred cycles is no use at all.

Power distribution infrastructure must be up to the job too. Who will pay for this is up for grabs. There’s a good case for public funding given that there are multiple uses of enhanced electrical supply. Given the monopolistic nature of power generation and distribution this will not be easy or quick.

That’s only three issues that require a great deal of attention. Not the attention of researchers. Not the attention of academics, Not the attention of political policy wonks. Connecting entrepreneurs and public bodies needs practical stimulus. The possibilities are exciting.

[1] https://youtu.be/1sfVuJlPQoY

[2] https://www.independent.co.uk/arts-entertainment/tv/news/the-apprentice-2024-winner-pies-b2531331.html

Highways

The last time I visited the city of Baltimore was in 2012. It was the location of the annual seminar of the International Society of Air Safety Investigators (ISASI)[1]. That was when I was representing the European Aviation Safety Agency (EASA) at such international events.

The relationship between aviation accident investigators and regulators are generally cordial. There’s a great deal of work that requires cooperation and good communication. That’s not to say that the relationships between these two vital parts of national and international aviation safety systems is easy. It’s not. My reflection on that fact is that a degree of constructive tension is inevitable and not always a bad thing.

One way of seeing that relationship is that the primary role of an investigator is to make findings to prevent the repeat of a given accident. For a regulator the primary role is to ensure the complete aviation system runs safely on a day-to-day basis. Both organisations have the public interest at their heart. However, their operational context and perspective are different.

Firstly, my condolence to the families and friends of those who perished because of the Francis Scott Key Bridge accident[2]. The collapse victims and survivors had no way of knowing what was to happen on the night of the accident. I use the word “accident”. This was not an act of God, as some commentators would have it. The safety risks involved in the operation of the port in Baltimore could be anticipated.

In the US there’s an independent federal agency that is tasked with such major investigations. Interestingly, it’s the same one as that investigates aviation accidents and incidents. The National Transportation Safety Board (NTSB) is a multi-modal organisation. That is something we don’t have in the UK. Also, we don’t have a divide between federal and state organisations. Since in the UK we have separate independent national Air, Marine and Rail investigation agencies that cover the country (England, Scotland, Wales, and Northern Ireland).

I will not comment on the accident sequence or causes. It’s the job of an independent investigation to arrive at the technical facts. Recommendations will flow from that investigation.

Where a comment may be in order is that there are many locations across the globe where a vital piece of infrastructure, like a bridge being struck by a large container ship is a possibility. I’d generalise that further. When infrastructure that was designed a built 50 years ago meets modern day operational stress there’s going to be vulnerabilities. Yes, the aviation system is not immune from this fact too. It wasn’t so long ago when I read of PDP-11 computer hardware used for air traffic control (now, historic artifacts[3]). I’m sure there are still Boeing 747s, and alike that need floppy disks to update their hardware.

So, the wider subject is operational legacy systems working with modern systems. This is the interface that requires particular care. The safety risk appetite and exposure in the 1970s/80s was quite different from that which we expect upheld today.

Unfortunately, society is often reluctant to revisit this subject. Additionally, there’s the incentive to go for quick fixes and sweating assets. The example I have in mind the so-called “smart motorways” in the UK[4]. I don’t know how many fatalities can be linked to “smart motorways” but I’m sure, sadly, it’s too many.

POST: In time-off I enjoyed a trip out to Fort McHenry and a walk around the places where The Wire was filmed. The Fort McHenry story is interesting given its role in times of war. The British burnt the White House but the navy didn’t get past Fort McHenry in 1812.

[1] https://www.isasi.org/

[2] https://www.bbc.co.uk/news/av/world-us-canada-68661318

[3] https://www.tnmoc.org/air-traffic-control

[4] https://www.gov.uk/government/speeches/plans-for-new-smart-motorways-cancelled

Safety Culture 2

This may sound at variance with my last blog. I hope it’s not. I hope it’s complementary. What I’m highlighting here has been observed over decades of contact with a wide variety of organisations.

The term safety culture is fused into the pillars of ICAO Annex 19. The essence of building a good safety culture that fosters sound practices and encourages communications, in a non-punitive environment is at the heart of standards and recommended practices. With all those decades behind us the reader might assume that there’s unambiguous and well aligned attitudes and ways of working throughout the aviation industry. That’s not so.

On a spectrum of what could be called hard to soft the manner of application of know best practices can take different forms. By the way, please disassociate those two words with both easy and difficult. That’s not what I mean.

In my interpretation “hard” means like pages of Niccolo Machiavelli’s The Prince[1]. Aggressive, persistent, mandatory, uncompromising and all encompassing.

In my interpretation “soft” means like pages of The Little Book of Calm by Paul Wilson[2]. Harmonious, enlightened, progressive, sympathetic, and understanding.

As with extremes on any scale, going to the ends of that scale are not the best way to operate. I say “best” in terms of getting to ways of working to endure with engagement and effectiveness. I observe much of this depends on how power is disseminated through an organisational structure. Highly hierarchical organisations will approach culture differently from organisations with a relatively flat management system.

It may not be surprising to suggest that aviation Authorities can veer towards the “hard” approach and staff Unions towards the “soft” approach. Even when both are trying to reach the same goal. Where people come from a military background, command and control can be an instinctive reaction. Where people come from an advanced technology company background, collaboration and communication can be an instinctive reaction. In my observation there are advantages in both a hard and soft safety cultural approaches.

One advantage of a hard safety culture is that the time between discovery of a safety problem, taking corrective action and resolving that operational problem can be short. Clearly, that has distinct safety advantages. Certain airlines come to mind.

One advantage of a soft safety culture is that there can be the discovery of safety problems that would otherwise remain hidden. Where collective ownership of the problem is not in question. Again, clearly, that has distinct safety advantages too. Certain manufacturers come to mind.

I guess my message is as per much ancient thinking. All things in moderation. Try to reap the benefits of both ends of the scale. Balance.

[1] https://www.londonreviewbookshop.co.uk/stock/the-prince-niccolo-machiavelli

[2] https://www.waterstones.com/book/the-little-book-of-calm/paul-wilson/9780241257449

Safety Culture

Civil aviation remains an extremely safe means of transport. That said, any form of complacency must be addressed. It’s reassuring to say the past has been great but what passengers are most concerned about is their next flight. To have the confidence, to think it irrational to be afraid of flying, to look forward to the next journey, we must have a safe aviation system everywhere and all the time.

For any widespread system that has complex interactions between people and technology there’s never a moment when it can be taken for granted. We count the numbers, but safety is not purely an absence of accidents and incidents. Numbers counted are always past events. They have no direct causal influence on what happens next. True, there are factors in past accidents and incidents that will pop up again and again, but every flight is a unique event.

One of my colleagues who was a senior captain in a major international airline always remined me of the fact that, for all that has gone before, flight risk begins the moment an aircraft sets off down the runway with the intention getting to a destination. When the wheels lift off the ground there’s no stopping time. Reliant on the diligence, vigilance, and integrity of everyone who made a flight possible, flight risk is then in the hands of the crew.

The above is perhaps why we talk a lot about safety culture. The whole aviation family has a role to play. The care, professionalism, and watchfulness of every person makes a difference.

This can extend from the drafting of a new component for a new design, that a decade down the line. ends up as a part of an aircraft just about to leave the gate. This can go back to a flight instructors’ message that emphasised a key point back in a pilot’s initial training, years ago. This can encompass the extra care a couple of air traffic controllers took as they changed shifts.

Safety culture comes from caring. It’s that heightened awareness of the consequence of actions. Being alert to possibilities. Both the good kind, and the bad.

Safety culture is a matter for both individuals and organisations. One without the other doesn’t work. Placing a vigilant person in an organisation that doesn’t care is much like placing a reckless person in an organisation that does care. Although this is what I’ve written, systemic problems are likely the ones that are most likely to cause negative outcomes. This is where the role of management has the most impact.

Culture exists in context. When the ways people interact are determined by practices, processes, and procedures there’s an obligation on management to ensure they fit the bill. Drivers are often economic. In a commercial operation that’s no surprise. It’s when that driver displaces the safety imperative then safety suffers. There’s been several occurrences of this negative phenomena in the last year.