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.

In September 2011, a Yak Service Yak-42, carrying a professional ice hockey team, crashed on takeoff from Yaroslavl-Tunoshna Airport in Russia, killing 44 of the 45 occupants. The world was shocked and saddened by the news. Obviously something had gone terribly wrong. This week, crash investigators made public their findings. The reason: Pilot error.

Surprising?  No.  Preventable?  Yes.   The pilots clearly made errors.  But the sad truth is that the crash was preventable.  How?  To answer that we must dig deeper and go beyond the “who” is to blame and turn our focus to the “why.”  That is how we’ll uncover the underlying problems – the real reasons for the crash – and determining a way to solve them.

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Your SMS does not meet the Standard specified in ICAO Annex 6, Part II.  Well, not by its self anyway. Ok, admittedly overstated, sorry.

My reason for the attention-getting statement is that many operators are under the misconception that the only requirement they need to meet is to implement an SMS.  There are more requirements, but they are being overshadowed by the SMS discussions.

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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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On December 2, 2010, Bermuda announced that foreign aircraft operators subject to the Annex 6 Part 2 requirements, who have not yet achieved compliance, would be granted an extension to April 1, 2011.

In the interim period, aircraft visiting L.F. Wade International Airport (TXKF) may be subjected to random Ramp Inspections whereby evidence of progress towards compliance will be assessed and recorded by the Bermuda Department of Civil Aviation.

More information available at: http://www.dca.gov.bm/Lists/Announcements/Attachments/86/Clarification%20letter.pdf

Bermuda Department of Civil Aviation announced today that on November 18, 2010, all visiting FAR Part 91 and 125 operators will be required to be compliant with ICAO Annex 6 Part 2 Section 3.

Compliance with the SMS requirements will be monitored by random ramp inspections at the L.F. Wade International Airport (TXKF). Operators discovered to be not compliant will be refused entry to Bermuda until they can demonstrate compliance.

In relation to the SMS requirement, the Bermuda Department of Civil Aviation will accept the following as evidence of compliance:

• IS-BAO registration;
• Air Charter Safety Foundation (ACSF) registration;
• ARG/US rating;
• An SMS manual deemed acceptable by the State of Registry; or
• Proof of intent to produce an SMS (e.g. a contract with a vendor (such as Air Safety Group) who is enabling IS-BAO registration).

More information available at:

http://www.dca.gov.bm/Lists/Announcements/Attachments/77/Annex%206%20Pt%202%20compliance%20(3).pdf

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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In a recent post on the NBAA AirMail forum an operator questioned the discovery, during an IS-BAO audit, of the requirement for a flight data recorder (FDR) to be installed on their aircraft. The individual did not provide information, regarding aircraft type or age, so it is not possible to address the FDR requirements specifically for this operator.

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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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