In my blog “Lessons from the Yak crash that killed the hockey team,” one could infer that the blame for the accident belongs to Yak Service and not the pilots.  Granted, the responsibility for the safety of flight operations belongs to Yak Service, but shifting the blame for the accident to management still focuses on who is at fault, rather than why it happened.

Asking why addresses where the process is broken, not who is at fault.  The emphasis is on the organization’s overall goals, not doling out punitive actions.

Prevention or blame?

Most organizations, like most individuals, have a strong bias for blame. Looking for the causes (why) rather than a single cause (blame) requires a cultural shift for most companies.  If something goes wrong in your organization, and the first question is who, then you have a blame culture.

For example, you go to the drive up window of your favorite fast food restaurant and order a cheeseburger, fries, and a drink.  After leaving the window you reach into the bag to grab a fry and discover there are no fries in your bag.  What’s your first thought?

If you are like most people, your first thought is a variation of, “the (*#*!)  didn’t give me my fries!”  Does blaming the window attendant solve the problem?  Of course not.   The order and delivery process is still broken.

Would punishing the window attendant or requiring remedial training fix the problem?  Maybe for that employee, but what about their replacement?   What affect would this individual solution have when you visit a different restaurant?  If the solution doesn’t address all the scenarios, the process is still broken.

During an evaluation or investigation, organizations that require high reliability examine operational processes to discover what may be broken.  They realize that identifying multiple causes provides greater opportunity for mitigation, which increases the reliability of the organization.

High reliability organizations understand, when something goes wrong, asking why provides more information than asking who.

For more information about safety management systems, visit AirSafetyGroup.com or contact Jeff Whitman.

This article is a continuation of; “I have an SMS, now what do I do with it,” which is located at:

http://proairman.com/i-have-an-sms-now-what-do-i-do-with-it

The fourth question I am addressing is; “What is my daily job?  Do I..”

This question clearly indicates the organizational management lacks the fundamental understanding of the processes of the SMS, or failed to provide the requisite guidance.

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It is important to understand the fundamental SMS processes when designing your safety management system.  Without this understanding, the SMS becomes, at best, an exercise in frustration.

Safety Managers/Officers of organizations with established SMS have asked me the following questions:

1. “What are good performance measures for our SMS?”
2. “What are good organizational controls?”
3. “How can I tell if our SMS is effective?”
4. Recently, “What is my daily job?  Do I …?”

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I ‘ve been a bit busy for the last few months, forgive me for not attending to ProAirman. 

During my absence, I have been privy to, shall we say, spirited discussions, regarding the need and/or value of the Safety Management System (SMS).  There is significant resistance, by some U.S. operators, regarding the implementation of the SMS.
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Progressing To the Next Level of Safety Management

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

In the previous article; “The Shifting Focus of Safety Management,” I made the statement; “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.”
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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.

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IS-BAO – It’s more than an SMS

This article is the sixth in a series to simplify the understanding of the SMS processes. The entire series can be found here.

History of ICAO Annex 6, Part II

Annex 6, Part II, International General Aviation – Aeroplanes, was first introduced in 1968. Since that time, a number of amendments have been made, but the basic structure of this Part remained geared towards a general aviation environment typically operated for recreational purposes, domestically as well as internationally.

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What is the Law – Really

This article is the third in a series to simplify the understanding of the SMS processes. The entire series can be found here.

According to the Convention on International Civil Aviation (also known as Chicago Convention), States that are signatory to the United Nations agree to comply with the Standards and Recommendations (SARPS) of the International Civil Aviation Organization (ICAO).

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The International Business Aviation Council (IBAC) and European Business Aviation Association (EBAA) announced, on August 25, 2009, that the IS-BAO – an International Standard for Business Aircraft Operations – has been granted official European recognition as an industry standard for business aircraft operations.

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Why You Need a Safety Management System

This article is the second in a series to simplify the understanding of the SMS processes. The entire series can be found here.

Why do you need a Safety Management System (SMS)? In the spirit of simplicity, if you operate a turbine-powered airplane, it’s the law.

This statement is not completely accurate, but it is very close.

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