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The organic approach

A culture of safety in aviation is always evolving and it must be managed properly or there won’t be a solid Safety Management System (SMS).

July 7, 2014  By Brian Dunn

The engine that drives a safe operating culture is trust: you can’t punish human error because you want to learn from it and prevent it from happening again.

A culture of safety in aviation is always evolving and it must be managed properly or there won’t be a solid Safety Management System (SMS). That’s the message from David Campbell, vice-president of Safety Security and Environment at American Airlines. And the process is often more important than the culture itself.

Campbell made the comments during a spirited presentation at the recent Safety in Aviation North America conference in Montreal organized by Flightglobal and Flight International. Campbell was one of the key speakers at a session entitled Safety Management Systems at work: Have integration and implementation gone (according) to plan?

Doug Diehl, Director of Safety, Frontier Airlines, echoed Campbell’s comments and asked, “What does it take to change the safety culture and how many people does it take to portray a negative culture in an organization with 10,000 employees? When the U.S. Federal Aviation Administration (FAA) asked Frontier what it was doing to mitigate the problems of overruns at Jackson Hole Airport in Wyoming, the airline turned its attention to backend operations, chief pilot processes and ramp operations. “A lot of incidents result in complete process change. The key is how to collect and use data sources,” said Campbell.

It’s important to get the information to the right people and make sure it’s accurate before arriving at a decision (an informed culture), added Blake Kelly, manager of SMS at Jet Blue airlines. You might have a good safety program, but often the data is rich and the information is poor, he added.


“Competing airlines must share information related to safety in airport approaches,” suggested Michael Anderson, senior director of Safety, Spirit Airlines. He cited the challenging approach to San Jose, Costa Rica, with its surrounding mountains as an example.

global safety  
In order to create a sound global safety culture, pilots from competing airlines must share information in terms of safe airport approaches, says Michael Anderson, senior director of Safety at Spirit Airlines.


There are different reporting cultures within the same airline. Pilot incident reports are different from in-flight incident reports, noted Diehl. One survey of safety issues with onboard personnel was disappointing so maybe the survey should have been worded differently, he offered.

A reporting safety culture should be without consequences to determine what department has the strongest and which one has the weakest culture and how to change it, suggested Kelly. At Jet Blue, flight ops has the strongest reporting culture, while tech ops has the weakest.

The quality of reports had a lot of grey areas at American, but the airline is working with its pilots to improve procedural changes, said Campbell. “We struggled with the maintenance side for years which undermined other programs, but it’s improving.”

Since mistakes happen, a just culture should not be punitive, said Anderson. American has created an atmosphere of responsibility and accountability, but people can’t be blame-free as it would undermine relationships with other employees and the FAA, said Campbell. “We focus on engaging employees, including unionized employees, on how to drive behavioural changes in the company. We focus more on critical behaviour,” he said.

And you can’t hold a person accountable because of different levels of processes, said Kelly. “You can’t punish human error because you want to learn from it and prevent it from happening again. You have to understand what a just culture is all about.” Frontier is working on so many programs in addition to demands from the FAA and senior management; then just culture is added to the mix, which becomes difficult because of powerful unions, said Diehl. “The big challenge is to get a just culture approved, but you’ll never achieve a just culture unless you can apply it to all groups.”

Dealing with potential hazards
Another thought-provoking session during the conference was entitled Identifying risks and hazards to reduce the likelihood of real accidents.

Flexibility and performance measures that reflect constantly changing demands are key to the development of a safe operating culture at today’s airlines.
PHOTO: air canada


Jacques Mignault, senior director safety, quality and security at Air Transat, said his firm uses all available data to determine if they’re at risk in certain areas and brings it to the attention of senior management. “SMS is a never-ending project,” noted Mignault. “We built a team around safety and established what works best within the culture of the airline.”

Air Transat uses events that occur within its own organization, not so much to establish what happened as to find out what might happen next. And its flight data monitoring program is a key tool to tap into. “On the proactive side, we perform a safety case exercise,” Mignault said. “We ask, what are the possible risks associated with changes within the organization? We also look at what’s happening in the rest of the industry and see how we measure up. The internal quality insurance program is also an excellent source of information.”

The predictive side is harder to tackle, he noted. The airline performed a detailed trend analysis to determine if the corrective measures put in place in the past are still relevant today. In terms of fatigue issues, they should be acted upon ahead of time.

“We have the safest aviation system in the world,” said Goran Mrkoci, program manager, safety at CSSI. Founded in 1990, CSSI provides technical services in air traffic management. “On the operational side it all comes down to reporting,” Mrkoci said. “If risks are deemed too high, what kind of mitigation is required?”

ExpressJet Airlines has an internal reporting system where calls are made anonymously, said Sherry Brooks, manager, internal evaluation programs. “The challenge is to analyze what we have and what is happening down the line. We’re very conscience of the need to create follow up reports as it goes a long way to building trust.”

Mignault maintains a key aspect of developing a sound safety culture is developing a strong trust factor, one where employees feel confident to report a problem or a hazard. “You can’t expect every time someone reports something will result in a change of procedures,” he said. “But it can provide feedback so people don’t stop filing reports. Otherwise people would lose confidence in the system. Communications must be tailored to the groups you’re dealing with. Pilots are different from maintenance. In terms of risk management, the challenge in risk assessment is to assess the severity.” The sharing of data is very important to promote safety within the aviation industry, added Mrkoci.

Today’s business environment is constantly changing with increased pressure on capacity, safety, security, the environment, regulations and competition, noted Morten Ydalus, managing director at Vision Monitor Aviation. To continue to operate safely will require flexibility and performance measures to reflect constantly changing demands on the system. “We need to shift from a reactive to predictive approach on safety and we need to develop a new safety culture,” he said. “We can’t just drive by looking in the rear-view mirror.”

As a minimum, an SMS should identify safety hazards, provide for continuous monitoring and regular assessment of the safety performance and strive for a continuous improvement of the overall performance of the SMS. “Obtaining a global picture of your organization’s data is a necessity,” Ydalus said. “Use operational insight to develop foresight and know what you know or don’t know.”

To improve safety, we have to go beyond compliance, be predictive, improve change capability, manage risk to as low as reasonably possible and be transparent, suggested Ydalus.

Focusing on human factors
In terms of human factors, by far the majority of the most recent accidents have occurred with fully operational aircraft, according to Captain Jim Gorman, retired vice-president, managing director, flight training and standards, US Airways, NetJets and FedEx Express.

Air Transat  
Air Transat is using flight data monitoring to help create a safer, more risk-averse operation.
Photo: Air Transat


“The accidents that have had aircraft malfunctions have oftentimes been misidentified or handled incorrectly by the crews,” he said in a presentation entitled Engaging with human factors as a possible risk to ensure a proactive plan. “I don’t believe this is the crew’s fault as much as it is ours for not providing the proper tools for success. We still struggle with identifying and correcting human behaviours with our crews and it inherently lies with not training our trainers adequately.”

Gorman likened basic airmanship, technical proficiency and human factors to a three-legged stool where all three legs work together to make a pilot stronger. “Does there need to be a more technical and practitioner-focused agenda?” he asked. “What happens when we let one of the legs get shorter? How do we strengthen the legs to ensure a strong base?

Gorman maintains that institutionalizing human factors into our operations is one way to ensure compliance. “This also allows our training and standards personnel to train and evaluate to a standard instead of just touching on the ideas,” he said. “Pilots will do what you ask them to if it is in the book and it makes sense. You must be careful not to make it too rote (a memorization technique based on repetition) as people tend to mimic and not comprehend their actions and statements.”

Finding a strategy that takes real human performance into account includes active pilot monitoring, eliminating areas of distraction and adding standards that can be observed, he added. “Using human factors in a positive way to drive and improve safety includes a two-minute debriefing, mentoring, taking ownership (for actions) and showing the wins, not just the losses.”

Making it all work
As the varying perspectives from several industry leaders points out, creating a solid SMS and proactive safety culture is not without it’s challenges, but sharing perspectives, keeping an open mind and providing continuous monitoring and regular assessment of the safety performance can go a long way in making it happen.


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