The Shifting Focus of Safety Management

This article is the second in a series of articles that takes a closer look at the aviation safety management system. The entire series can be found here.

Historically, aviation safety management has been based of regulatory compliance.  There is no argument that regulatory compliance is an important part of safety management, although it is impossible to provide rules for every operational situation.

In order to progress to the next level of safety management, a performance based approach is required to assess the actual performance of activities against organizational controls.  I will cover this in greater detail in a future article.

The Evolving Safety Strategy

Follow the rules and safety is assured.
In the early days, aviation was a loosely regulated activity characterized by underdeveloped technology.  There was a lack of proper oversight and insufficient understanding of the hazards underlying aviation operations.  Accident rates were notably higher than what we experience today.

As aviation developed, ca. 1950 – 1970, accident investigations focused on outcomes to determine what happened and who was involved.  If technical breakdowns could not be assigned the cause, the investigation backtracked looking for points in the chain of events where the people directly involved did not perform as expected.  In absence of a technology breakdown, blame was assigned, remedial activities performed and/or new rules were created.

Be a better person and safety is assured.
As the modern aviation industry began to evolve, ca. 1970 – 1990, safety was improved through both airborne and ground-based technological advancements.  The focus of safety improvement moved to human factors.  Training programs introduced crew resource management (CRM), line-oriented flight training (LOFT), automation management, and other human performance factors.

Although different from the era of; “follow the rules,” aviation safety continued to focus on the individual.  The link between the human and the operational environment, why the accident occurred, was not being addressed.

Improve the system and achieve an acceptable level of safety
Today, aviation professionals function within a defined operational context that encompasses organizational, human, and technical factors.  To understand where a breach in safety occurs it is imperative to look at the operational context as a system and go beyond the technical and human failures.

The Goal of the Modern Safety Strategy

The modern approach to safety management moves away from the human factors (who did it) and address the organization factors (why it happened).

A properly designed safety management system analyzes organizational process in an attempt to identify the root cause of active failures, which are typically associated with errors or violations of front-line personnel.  In a purist sense; a person that follows rules and procedures to accomplish a task, but fails to meet the goal of the task, commits an error. On the other hand, a person who willingly deviates from rules and procedures while accomplishing a task commits a violation.

Latent conditions, which are the result of policies created at the organizational level by senior or front-line managers, may remain dormant for a long time.  Individually, these latent conditions are usually not considered harmful, since they are not perceived as being failures in the first place.  They linger in the system, waiting to unleash their potentially catastrophic consequence.

Poorly designed policies, or policies not changed when the situation warrants, often inspire operational workarounds.  Too often, poor policy leads to deviations from approved procedures in order to accomplish practical and immediately measurable operational goals.  These workarounds; referred to as “normalization of deviation,” are often supported by front-line managers and are determined to be causal factors in an accident/incident investigation.

Ref: ICAO Doc 9859 (2009)