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1 Y O U R MONTH L Y S O UR C E F OR SA F ET Y IN F OR MAT ION S EPT EMBER V O L U ME XVII ISS U E IX IN THIS EDITION PAGE 1 Defining Trust in Safety Culture PAGE 4 Did You Know? FAA Airworthiness Directives (AD s) PAGE 5 Safety Performance Indicators and Effective Risk Management PAGE 7 Safety Manager s Corner PAGE 8 Quote of the Month On Short Final... Defining Trust in Safety Culture BY: Susan Cadwallader, PRISM Responsibility, trust, communication these are all words that we associate with effective safety cultures and there are hundreds of publications touting the benefits. While most people would agree these descriptions are absolutely true, it is worth taking a look at some reasonable checks and balances between trust, accountability and who should be shouldering risk. This article will delve into what organizations should be thinking about with respect to trust in their safety cultures as they establish processes / procedures and set priorities for tasking. In short, organizations need to continuously work hard to not inadvertently cloak a lack of thoughtful support and a lack of consistent verification under the guise of trust. Lets start by imaging an organization that is rolling out a Flight and/or Ground Risk Assessment Program (FRAT/GRAT). Besides the obvious fact that it initially feels unnatural to assign numbers to daily routine and emerging risks, pilots and technicians might view a FRAT/GRAT as a lack of trust in them on the part of the organization. Worse yet, they may feel they are being micro-managed. But some may look at the FRAT/GRAT with kind of relief, like this is safety net for me and the leadership has my back. While individual personality types play a role here, the message that gets delivered by the leadership can go a long way toward setting the tone. The worst thing that can happen is the Safety Manager alone gets tasked with rolling out the 1

2 FRAT/GRAT and it just feels like another chore to those who fill them out. If the leadership, however, stands up and owns it as something they want to use to be sure you are getting support from them - then it feels quite different. The message of senior leadership wants high risk decisions made at their level is no longer a threat to thrust but rather an affirmation of their support for the pilot or the technician. It encourages ongoing dialogue within the organization whenever there is an elevated FRAT/GRAT and reminds individuals of two things: (1) that they are not on their own and (2) there is consistent accountability at all levels. Tool Control serves as a good example. Some organizations lay the entire responsibility for tool control on the individual technician. If a tool gets misplaced, or left on an aircraft, that technician get disciplined. That may sound fair and just in an organization that touts itself as high performing and having high trust - but did they really set up the technician to succeed? Speaking for me personally, I often cannot remember where I left my coffee cup five minutes ago so the odds of me misplacing a tool are quite high. Misplacing items is in fact a common human attribute so for an organization to foist that entire responsibility on an individual rather than doing the hard work to build effective organizational mitigations is naive. Trust should not mean that an organization places an excessive amount of risk management at the individual level. Another example might be a Read and Initial board. If the organization has things they want to make sure you know, they might implement a Read and Initial board, where you initial on a list of items to signal that you have read them. Is this a demonstration of a lack of trust or is this a clear establishment of priorities? In my normal work day I have dozens of things competing for my attention and it is really not possible to get to all of them. The Read and Initial board for many people is clear priority tasking and the initial list helps keep track of what has and has not been read. Proper organizational support for a Read and Initial board would include notification when something gets posted and provided the time for people to sit down and read through the assignments. I think it is safe to say that many people prefer (and probably enjoy) being trusted and being allowed to do their job with little oversight. We should, however, a high level of awareness that people s natural tendency is toward doing what they want to do and that there are usually too many things competing for a person s attention especially in this age of information overload and distraction. 2

3 Roderick Kramer wrote an article in the Harvard Business Review titled Rethinking Trust. He essentially proposes that there may be a problem with how we trust and that our willingness to trust often gets us in trouble. To survive as individuals (and as organizations), we have to learn to trust wisely and well. That kind of trust called tempered trust doesn t come easily, but it can be developed by diligently asking the right questions. Organizations, can adapt in a similar manner. Many best practices associated with Safety Management Systems (SMS) can help organizations strike a good balance between trust, support, and verification. The longer an organization goes without an incident, the more chance there is for a loss of appreciation of risk. It is well known that the people who are involved in incidents are typically high-performers, otherwise known as Go-to Guys. They are so good at what they do that they are trusted in everything they do and never questioned. They rarely make mistakes but when they do, they are often huge. The deadliest airline crash in history (Tenerife 583 fatalities) was directly caused by the Captain of one of the aircraft who was so revered (and trusted) that he was considered the face of the company. When an individual shoulders that kind of responsibility, they try very hard to live up to it. I have learned to never underestimate what a person will do to get the job done. In summary, it may be comfortable to say that your organization has a high level of trust in its Safety Culture but organizations need to be careful that this does not become an excuse for not using, or ignoring, checks and balances. High performing people like to stay that way and they will take on risk to do so. Constant effort is necessary to find ways to keep the dialogue open, develop/employ thoughtful mitigations for human factors, and keep people feeling not just trusted but also supported and accountable in your Safety Culture. 3

4 Did You Know? FAA Airworthiness Directives (AD s) BY: Susan Cadwallader, PRISM Source: FAA We have seen a lot of Airworthiness Directives (ADs) over the years but have you ever learned how they are created? Here are some basic and interesting facts behind the process: The FAA issues three types of Airworthiness Directives (ADs): 1. Notice of Proposed Rulemaking (NPRM), followed by a Final Rule 2. Final Rule; Request for Comments 3. Emergency AD What is considered the standard AD process? The standard AD process is to issue a Notice of Proposed Rulemaking (NPRM) followed by a Final Rule. After an unsafe condition is discovered, a proposed solution is published as an NPRM, which solicits public comment on the proposed action. After the comment period closes, the final rule is prepared, taking into account all substantive comments received, with the rule perhaps being changed as warranted by the comments. The preamble to the final rule AD will provide response to the substantive comments or state there were no comments received. Here is a link to ADs that are currently Open for Comment. What process can be used if an unsafe condition requires correction quickly? Final Rule; Request for Comments. In certain cases, the critical nature of an unsafe condition may warrant the immediate adoption of a rule without prior notice and solicitation of comments. This is an exception to the standard process. If time by which the terminating action must be accomplished is too short to allow for public comment (that is, less than 60 days), then a finding of impracticability is justified for the terminating action, and it can be issued as an immediately adopted rule. The immediately adopted rule will be published in the Federal Register with a request for comments. The Final Rule AD may be changed later if substantive comments are received. When is an Emergency Airworthiness Directive (AD) issued? An Emergency AD is issued when an unsafe condition exists that requires immediate action by an owner/operator. The intent of an Emergency AD is to rapidly correct an urgent safety of flight situation. For more information, see the Emergency AD page. 4

5 Safety Performance Indicators and Effective Risk Management BY: Steve Witowski, PRISM How a safety management system (SMS) and safety culture influence safety performance indicators (SPIs) Exposure to the concept of safety for individuals involved in aviation typically begins at the earliest stages. If one attempts to discover the definition of safety, they quickly find themselves beginning a journey on the long and winding road. Mistakes lead to accidents, and accidents lead to deaths and damaged equipment; this mantra is well known. Therefore, measuring safety performance often pointed to accident counts and rates, which leaned toward a crisis management approach: when the crisis occurs react and figure out how to stop it from happening again. The rarity of an aviation accident combined with its typically catastrophic results made it a poor SPI. Safety management aims to change that approach significantly: identify performance indicators and measure their occurrences. A performance indicator like taxi confusion tracks as a precursor to runway incursions; runway incursions tracks as a precursor to ground collisions. Identifying weakness trends in both or either of these indicators helps an aviation operation address the problem before a ground collision accident happens. Indicators like these also come with another added advantage: they are clear and easy to understand. They are also measurable, but how easily? More on that question when the effects of safety culture are discussed later in this article. Revisiting the definition of safety, current methods enter the word control into the lexicon. Phrases like risks associated with operations are reduced and controlled to an acceptable level describe the linchpin of safety management practices. That s all fine and good in theory, but how does an operator gain control of these risks in the real world? Aviation operations occur in a highly dynamic, complex system of interactions between dependent entities, creating countless effects on final safety outcomes. To achieve the highest safety posture, an operator must identify indicators that mark the best opportunity to cope with known risks, evaluate exposure to those indicators, and react predictively to that exposure. Not only will this practice reduce risk, it will also identify opportunities for improvement and increased efficiency. ICAO defines a safety performance indicator as a databased safety parameter for monitoring and assessing performance. Indicators often have safety performance targets, defined as the planned or intended objective for safety performance indicators over a given period. Lagging indicators measure events already occurred (typically negative in nature), and may be of high or low severity; for example- the number of ground collisions/ year (high severity), or number of altitude deviations/ year (low severity). Leading indicators measure are both positive and negative, measuring things that have the potential to contribute to a negative or positive future 5

6 outcome. Examples of leading indicators are number of safety reports submitted/year (positive tendency), or number of extended duty days for flight crews and maintenance personnel (negative tendency). Identifying appropriate safety performance indicators is both simple and complex. Simple in the sense that several resources provide examples to select from. Various reporting programs utilize a data dictionary containing abundant choices applicable to any aviation operation. Shopping through that type of list provides standard and accepted industry indicators. Complex in the sense that indicators must monitor identified items that influence risk in your operation, both positively and negatively. The more complicated indicators pertain to organizational conditions and postures, not tracking simple data points like altitude deviations. Avoiding the temptation to exclusively use indicators that track easily is critical. For example, an SPI like employee turnover measurements might reflect relationships to many critical risk areas (proficiency, experience, moral, etc.). This SPI identification effort demands participation from all levels of management, however few or numerous exist. It s just not realistic to think a safety manager is tuned in to every aspect of risk throughout all areas of the entire operation. Safety performance indicators require measurement, not only as a characteristic but also must pass a reasonable test. For example, if a flight operation does not have a flight data monitoring program (often known by the acronym FOQA) to record unstable approaches, reliance falls upon pilots self-reporting. Without a safety culture that promotes and sustains this self-reporting, tracking SPIs like this one is pointless. Although counting unstable approaches is measurable, it is only reasonable when reporting confidence is high. Promoting a positive safety culture requires effective feedback to stakeholders, and accurate performance indicators provide a sensible and quantifiable snapshot. Safety performance indicators must contribute to effective risk management, otherwise they are simply a counting exercise. Understanding the intricacies involved in identifying appropriate indicators and determining their impact is one of the crucial keys to an effective safety management system and will help guide decision making and resource allocation. 6

7 Reporting Program Tracker The PRISM Hazrep Program Tracker has a new name - now the "Reporting Program Tracker (RPT)." This new title more accurately reflects what the tool actually does - allow for reporting of hazards, incidents, suggestions, and other items our customers have built into their templates. It has all of the same functionality and you will find it in the same place in the menu bar: ARMOR > Reporting Program Tracker. You can also find it in the Quick Links and in the Classic Dashboard under its new name. 7

8 Quote of the Month We can only know th at we know nothin g. And th at i s th e high est degre e of human wi sdom. BY: Leo Tolstoy Feeling comfortable is not a bad thing. Its just that something inevitably comes along and shakes things up. Organizations experience the same dynamic. If your organization is feeling comfortable, keep in mind that something is coming Effective organizations frequently challenge their awareness and understanding of what is going on at all levels and what might be coming... On Short Final. 8