Safety ... First???

 

All those with a more or less directly relation with the aviation industry are clear that their main goal is Safety, or at least that's the illusion that authorities and operators want to give to the general public. But sometimes decisions made by Aviation authorities to ensure that everyone is safe in the air leave much to be desired from this safety point.

 

Case # 01 - Boeing 787

Everyone is by now more or less aware of what happened with the "Dreamliner" by Boeing.

Long story short for those who do not have information. About two months ago international authorities, following the example of the Japanese authority, ordered the immediate detention and suspension of flight permits of the 50 Boeing 787 aircraft into service. This decision was taken after successive incidents during the operation of the aircraft, the most critical being a fire aboard an aircraft from JAL (Japan Airlines) at the Boston airport while the plane was ready to leave on a flight, and less than a week later, the emergency landing and subsequent evacuation due to smoke on board and failure of an aircraft electrical system of an ANA (All Nippon Airlines) aircraft.

Both situations were caused by the same component: the aircraft's lithium batteries. And this is where we ask: how is it possible that in the super rigorous certification process a passenger aircraft, no one had been able to determine the true level of risk of these components, or the possibility that they might be the source of fire, smoke or toxic fumes in flight? The answer is simple: complacency by the authority.

And I say complacency because during the investigation of these incidents have arisen comments and evidence that the certification process has a lot to be blamed, because it haven't been done in the most appropriate way. Supervision of this key components have relied excessively on the manufacturer's control processes and I don't see an adequate level of supervision, since in this case the batteries and charging systems have never been tested together but individually.

This clearly would not be a big problem if all or most components were manufactured dictly by Boeing, but this is not the case and these components came from multiple vendors around the world. It is illogical to think that, despite being the components individually certified, it will not be possible to fail when installed together.

And well, that's what happened. Apparently the system was not prepared or tested enough to be sure it do not generate risks during the operation, and the result of that lack of supervision is being paid today by operators who have to deal with the financial loss of having the aircraft grounded, flights canceled and pending expansion processes.

The good news is that a few days ago the FAA (Federal Aviation Administration) initially approved the contingency plan from Boeing to modify the battery system of the aircraft. This will authorize them to install these patches on two aircraft and begin test flights, which will be monitored "very closely" by the FAA to certify the safety of modified and ensure that there is not any possibility fire on board as a result of its operation, and eventually remove the restriction and return the fleet to operation.

 

Case # 02 - knives, bats and other desserts

A few days ago the TSA (Transportation Security Administration), an agency created in the U.S. to prevent attacks using civil aircraft on American soil like those of 9/11, reported that as of April would be reauthorized as part of hand luggage dangerous items such as small knives, baseball bats, sky poles, etc., assuming that these do not represent a greater risk to flight crews of comercial aircraft as these are protected by reinforced doors in the cockpit .

Pardon?, So what about cabin crews that have no protection against unexpected attacks by passengers, or is it that they do not count?

Now flight attendants not only will have to take care of the verbal and physical abuse of drunk or angry passengers, but also from the possibility that one of them in a fit of "air rage" do not stabs or hit them with a bat. Of course, as always, in situations like this airlines can restrict these elements in their cabins, as they may be more restrictive than the norm, but this process would be very cumbersome and expensive.Don't know what logic might be behind this new rule, because I do not understand, but the justification of "improving the transport of passengers and provide more easily checks at points of control" is not enough for me. Moreover, it seems that this "initiative" only serves to "facilitate" the work of the TSA agents, but has no technical justification for its implementation; since it is not taking into account the safety of flight attendants who are the first, and last, line of defense against acts of unlawful interference, sabotage or problematic situations with disruptive passengers in flight.

 

These are the news for this week, hopefully Boeing will solve the 787 problems fast and we will soon have the "Dreamliner" returned to service, but as always keeping an adequate level of safety, primary and supreme end of all our operations.

 

Safe flights!!!

 

How to reduce Human Error and Increase Safety

Thanks to all for your comments, they help me to make this blog better every day.

I have seen lately that there are really great ideas to reduce human error in the aviation industry, but sometimes lack of leadership or interest from the Top Management create a wave of latent conditions that sooner or later will end in a mayor incident or accident.

For me, the are three big items to be considered that will help to increase safety levels inside any operation:

1. TRAINING: Training is the most important defense against human error. You can manage the most complex task or system with proper training. I Feel like the industry and regulators have forgotten that effective and continius training is the key to a safe operation.

But training is not only for the operative personel (pilots, flight dispatchers, mechanics, ATC controllers), Top Management should also be trained in matters such as Human Factors and SMS, so they can interact with the operative personnel and get a better picture about the importance of their decisions in daily operations.

With training we are also able to increase experience and problem solving skills, and those skills will help the human operator to take action, think and take effective decisions if problems affect the operation.

When humans are properly trained and have the required skills to manage technology, the safety of a system is increased and the possibility of mismanaging errors and undesired states is reduced.

2. TECHNOLOGY: Technology is so important nowadays that no one can live withou it. We have technology involved in almost everything, but technology needs to be a tool for the human, not a threat.

When humans have the proper knowledge to use that technology everything goes well, because the he/she is in the capacity of using that technology to reduce workload; having more time to monitor the progress of the flight and increasing the situational awareness levels.

But when technology is not understand, or humans have insufficient training to manage that technology, it will probably have catastrophic results. Just take a look at AF447, those guys were completely lost when the auto pilot disengaged due to unreliable speed, and have no idea of what to do with that particular situation. Humans need to manage technology, but they can't let technology manage them. If technology fails during a flight we can't loose and airplane full of people because of it, we need to take control and fly that aircraft to safe.

In order to use technology as a tool to increase safety, humans need to be properly trained and acquire the required skills to understand that technology and be able to manage it.

3. SAFETY CULTURE: And finally to complete our task we need the proper environment to let humans feed and grow safety inside the system. This can only be done if the required tools are installed and humans have faith and confidence in the safety system.

But to archive this goals we need that Top Management understands and backs changes (and investment) in how safety is managed inside the organization. We also need them to understand that error is a normal component of aircraft operations, and blaming and punishing people won't help to reduce error incidence. That's what we call safety culture.

A strong and reliable safety report system does a lot to help us in this task, but we also need some proactive tools like FDA to acquire data from normal operations. We also need hi skilled personnel in the safety department to analyze and convert that data in safety recommendations, and once again we need Top Management to get involved in this process, and give resources to comply with those safety recommendations.

When Top Management of an organization understands safety as a priority, not as a problem, the system will have the required tools and personnel to create a proactive safety system dedicated to recommend changes to avoid risks.

Those are my five cents, and I will talk deeper about this three concepts in later posts. What is important now is that we all need to help the aviation industry to increase safety, and we also need regulators to understand that the safest way to operate is not always the one big airlines and aircraft manufacturers want, because sometimes they are only aimed to reduce costs.

 

Creating a Just Culture

One of the main pillars of safety are safety reports of errors and hazards from operational staff. Without these reports the system can not move towards the goal of becoming predictive, and without that predictivity SMS efficiency is not optimal. Clearly, each operator must design a safe and efficient reporting system, maintaining the confidentiality of those reporting mistakes and above all to ensure non-punitive treatment of these events, but often the reliability of the system is compromised by stories of the past, or by inadequate communication of progress in the implementation of this new organizational culture.

So how do you create a reporting system with these features in an industry where the blame culture has ruled for years? So much depends on the implementation of a Just Culture within the organization and how senior executives take the treatment of these events. During the early stages of the SMS implementation they should be very clear of what is the commitment of the CEO and Manager of Safety against errors, and the best way to demonstrate this is through a document with clear positions on these two important policies: confidentiality and non-punitivity.

Another important item in the implementation of Just Culture within the organization is the responsibility to be assumed by senior management. Senior managers, especially those in the operational area, should be apostles of this Just Culture and must demonstrate their active role and fully support the changes required for this organizational change. To accomplish this they have to be real examples, because if the operational staff sees that the management is really committed and they show it on a day to day basis, this example will enable a rapid transition to the new cultural state.

Communication is also very important in this transition to cultural change. Because it is not just enough to create a safe and reliable reporting system, bearing information from the operational staff to senior management. It is also necessary to create channels of communication that allow information to flow from the management level to operational staff, and this goal can be achieved by creating a system of regular newsletters to keep everyone informed of progress and changes in safety policies within the organization.

Finally, to achieve effectiveness in this cultural change these policies should be integrated in the training program of Human Factors. Courses and workshops like CRM, SMS, CFIT and Accident Prevention are valuable moments in which to exchange information and experiences. We must also keep in mind that instruction can articulate standardized behavior changes in the operational staff, so this valuable tool should also integrate the SMS implementation process.

Achieving implementation of Just Culture is not an easy task, but it should be a priority in the implementation of all SMS. Only archiving proper implementation and cultural change our operational staff will be ready to report at all times, our system reliability will be improved and the data could be analyzed and processed. Only then our predictive and allow a drastic reduction of incidents and accidents within the organization.

Happy Flights!

Multicultural Aviation

 

One of the biggest concerns in today's global aviation is, undoubtedly, the presence of multiculturalism on our flights. More and more opportunities are opened in faraway places, and as result, we find pilots and crews of all nationalities as part of major international airlines. A clear example are the airlines from the Middle East, where we found a variety often surprising.

 

The point is then how we can do to achieve these multiple cultures coexist without causing a threat to our operations. There have been few events where a crew has been involved in an accident or incident due to cultural differences, and this is because we often assume that in aviation we just need to follow our SOPs to understand each other.

 

Psychology tells us that the way we conduct our processes of perception, information processing and decision making are influenced by our cultural baggage. We may assume then that under certain circumstances this cultural base can play a role against safety because of the mental constructs of each individual, assumptions or conventions that are not shared by the other members of the crew.

 

This is where the Human Factors training should shine in every organization, allowing a balanced and uniform transition for each new member to the culture of the operator. This process can be done through CRM courses or workshops, but also could be enhanced with induction programs or processes that allow the candidate seamless adaptation to the mode of operation of the airline.

 

Once this initial stage is archieved, it should be complemented with an IOE instruction oriented to multiculturalism, which besides playing relevant flight technical aspects, should be aimed at the cultural integration of the candidate. Instructors should then be able to observe attitudes or behaviors that may lead to differences with other members of the crew, or that without creating a potential conflict, could jeopardize flight safety.

 

To achieve this seamless integration of cultures is then necessary to design a plan of action that will not only focus on proper integration to the line, but also take the time to establish guidelines and procedures for the coexistence of different cultures without affecting the operational safety level.

Happy Flights!

 

 

La Aviación Multicultural

Una de las mas grandes preocupaciones en la aviación globalizada de hoy es, sin duda, la multiculturalidad presente en nuestros vuelos. Cada vez se abren mas oportunidades en lugares lejanos y encontramos pilotos y tripulantes de todas las nacionalidades formando parte de grandes aerolíneas internacionales. Un claro ejemplo de ello son las aerolíneas del Medio Oriente, en donde encontramos una variedad muchas veces sorprendente.

 

El punto es entonces como hacer para que estas multiples culturas logren convivir sin causar una amenaza a nuestras operaciones. No han sido pocos los eventos en los cuales una tripulación se ha visto envuelta en un accidente o incidente debido a diferencias culturales, y esto se debe a que muchas veces suponemos que en aviación basta con seguir los SOPs para poder entendernos.

 

La psicología nos explica que la forma en que realizamos nuestros procesos de percepción, procesamiento de información y toma de deciciones estan influenciados por nuestra carga cultural. Es posible suponer entonces que bajo ciertas circunstancias esa base cultural pueda jugar un papel en contra de la seguridad, debido a las construcciones mentales propias de cada individuo, o a suposiciones o convenciones que no son compartidas por los demas miembros de la tripulación.

Es aqui donde el entrenamiento en Factores Humanos debe brillar en toda organización, permitiendo una transición equilibrada y uniforme de cada nuevo miembro a la cultura del operador. Este proceso puede hacerse por medio de cursos o talleres CRM, pero podria ser reforzado también con programas o procesos de inducción que permitan la adaptación sin problemas del candidato a la forma de operar de la aerolínea.

 

Una vez completada esta etapa inicial se debe complementar con una instrucción IOE orientada a la multiculturalidad, la cual ademas de tocar los aspectos tecnicos de vuelo pertinentes, debería de estar orientada a la integración cultural del candidato. Los instructores deben entonces tener la capacidad de observar actitudes o comportamientos que puedan generar diferencias con los demas miembros de la tripulación, o que sin crear un posible conflicto, pueda poner en riesgo la seguridad del vuelo.

Para lograr una integración total de culturas es entonces necesario diseñar un plan de acción que permita no solo una adecuada integracion a la línea, sino que cada organización debería tomarse el tiempo de crear lineamientos y procedimientos que permitan la convivencia de las diferentes culturas sin afectar el nivel de seguridad operacional.

¡Felices vuelos!

 

 

Fatigue... The silent enemy

Much emphasis has been doing in recent times on fatigue and its impact on safety, however I can say, unequivocally, that efforts to improve this latent condition in our operations has not been sufficient.

ICAO is finalizing details of its FMRs (Fatigue Risk Management System) whose implementation will be held by the signatory states, but I think the biggest responsibility for managing fatigue lies in each of us, operating personnel, and we must be aware of the real danger that this silent enemy is.

Before going further, let's remember what is fatigue, "Fatigue is a condition characterized by a growing discomfort with reduced capacity to work, reduced efficiency in meeting targets, loss of ability to respond to stimuli, and usually this accompanied by the sensation of tiredness and exhaustion. "

If we dig a little more on this definition we can conclude that fatigue directly affects our level of consciousness, and this reduction may mean that this person must be unable to maintain the level of surveillance necessary for air operations.

A moderate fatigue can mean a lower level of consciousness to Grade IV, in which the individual entered the stage of dreaming and, as a result of this, would be affected by an attenuation of the perceptual process. In this case some of the observed behaviors are: numbness, maladaptive attitudes, poor coordination and disorientation. Additionally alpha brain waves, which allow surveillance, will slow down and will be replaced by beta waves, that are present during sleep.

This condition can lead to a mismatch between the individual and their environment, and may generate a loss of situational awareness that could lead to an accident or incident, and therein lies the importance of effectively managing fatigue and mitigate the effects this may have on our operations.

The first step is usually given by regulations of each state, which should be the first line of defense against this danger. Secondly there must be crew scheduling policies adapted to the operational realities of each operator, and finally, on third place effective management of fatigue by the operational staff (pilots, cabin crew, mechanics, flight dispatchers, air traffic controllers) which must comply with statutory rest periods and improve their personal habits to afford adequate time and quality rest.

By changing our operational culture and paying attention to those conditions that could be causing increased workload, loss of rest quality, and significant changes in our circadian cycles, we can keep this silent enemy away from our operations and reduce the level of its threat.

Happy Flights!

PS: Here a publication of the FAA about this danger http://www.faa.gov/pilots/safety/pilotsafetybrochures/media/Fatigue_Aviation.pdf

Managing the Practical Drift

A week ago I was in San Jose, Costa Rica enjoying a SMS course with fellow instructors from my airline. During the sessions we had the opportunity to present a module from ICAO's SMS course, and, as always, season it with some spices of our own.

During this four intense days, we discussed all the basic principles of SMS, and one that really got my attention was the practical drift. And that attention came because of late events that, in my honest opinion, show us that sometimes our operational performance is really away from the planned baseline performance.

Psychology can easily explain this because, as humans,  our behavior is dynamic and subject to changes, specially when our relations with other humans or the environment is not always the best. In that scenario, we start blaming everything on others, and became "the perfect victim".

This point is important, because when someone became affected by the environment his behavior changes in a negative way and his performance drifts from optimal, opening doors for threats, errors and mismanaged situations. This creates a bigger drift and, sooner or later, I will be involved in an incident or accident.

This is halfway point between the SHELL model and James Reason's "swiss cheese" model, and that interaction of me as human vs other human, environment, technology or regulation/procedures can trigger a latent condition as result of an error or unsafe action.

SMS states that in order to navigate the drift in a safe manner, the system needs to became predictive, but to reach that goal we have to be compromised with safety and help the system to grow. To archive that you have to be in charge of your emotional and mental status, because any situation that affects your performance and deviates the operation from optimal must be immediately managed, and then needs to be reported, specially when an error is identified as result of that particular situation.

This is my opinion in how we can help the system to became predictive, allowing it to collect data and create a realistic and strong database that will help analysts in the creative process of managing future situations through the implementation of strong defenses.

And is no secret that only through a strong voluntary report system and the help of a efficient data collection process we will be able to avoid drifting too far.

Safe flights!