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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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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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

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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A Review of What We Have Learned

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

I would like to begin this article series with a synopsis of the seven-part article series; “Understanding the SMS.” Following this synopsis, future articles will discuss the SMS components and implementation in greater detail.

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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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I previously reported the FAA’s proposal for Safety Management Systems [Docket No. FAA–2009–0671; Notice No. 09–06].

http://proairman.com/faa-proposes-safety-management-systems/

On December 9 there were 169 comments posted on the FAA web site.

An Industry Sponsored Alternative for SMS Compliance

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

The previous article addressed the current dilemma for operators of States without guidance for safety management system (SMS) implementation.  For those who operate across International boundaries red flags ought to be flying high.

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SMS Across International Boundaries

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

Putting together what we have learned in the first three articles in this series we know that:

• ICAO requires that signatory States implement the requirement for an SMS for certain operators;
• States that are signatory to the United Nations agree to:
  1. Operate in compliance with the regulatory requirements of the State in which the operation takes place, or in compliance with the regulatory requirements of the State of aircraft registration, whichever is most restrictive;
  2. Comply with the ICAO SARPS; and
  3. File differences for the SARPS in which the State will not be in compliance.
• Commercial operators are already required to have an SMS; and
• By November 2010 private operators will be required to have an SMS.

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