Although the causative organism was rapidly identified (salmonella), and its introduction into the food chain proved to be a key factor, the scale of the outbreak was the result of an interaction of other factors. As with a major aircraft accident, none of the factors alone would have caused the near disaster that occurred. (Burslem, Kelly, & Preston, 1990, p. 40)
This is a very useful reminder that airline disasters can come in many different forms: Salmonella can kill as surely as a crash. And it can be just as disastrous for business.
Hazard Identification and Risk Management
Having established a management structure and accountability system that is focused on safety, the next -- and central -- part of an aviation safety plan is to identify the possible hazards and to reduce as close as is possible to zero the risk of any of these hazards' occurring. Having focused on how important it is to have a management that is very clearly in a leadership position in terms of setting the tone for the company, it is important to shift to a more bottom-up focus when considering how to identify dangers.
This is not -- not to belabor the point, but it is vital -- to say that the management of the company must not always take the lead. Of course it must. But part of the way in which managers take the lead in ensuring safety is to listen to people in all job categories: A brainstorming session that includes pilots, mechanics, and flight attendants is likely to come up with a range of ideas for possible safety improvements that would not be apparent if managers simply consulted each other or only (for example) pilots.
Brainstorming helps create better safety standards in all fields, but it is especially important when potential risks are so high and when people in a company have very different areas of expertise. The following citation explores this idea:
If you're like many safety professionals, you spend your days (and probably nights, too) working on and thinking about ways to make your workplace safer.
Safety awareness means building safety into the way your workers think about things. Without it, workers & #8230; won't make full use of the safety features built into their equipment. And they won't observe simple rules, such as those of good housekeeping, that can prevent accidents. In short, absent safety awareness, workers may think about production, their compensation, or tonight's softball game -- but not safety.
How do you get them to do so? ... Let's start with brainstorming.
Brainstorming is a classic idea generation technique, often used to solve problems. Members of a group are asked to toss out ideas and solutions as quickly as they come to mind, with none shot down or spoken against. The ideas are written as a list. That list is later winnowed down to the best ideas, to be acted upon. (http://safetydailyadvisor.blr.com/archive/2008/05/05/Safety_attitude_awareness_building_methods_tips_techniques_brainstorming.aspx
As safety director of Sky High Airlines, I would certainly include brainstorming sessions on a regular basis to understand where potential problems might be cropping up. Of course, having brainstorming sessions only works if the management -- and that includes the safety director -- listens to the ideas that arise in such sessions. These ideas must be assessed and -- when found to be valid and relevant -- must be conveyed to other members of the staff. The best ideas still need to be operationalized.
In addition to brainstorming sessions, as safety director I would include a number of other ways to assess potential hazards. These would include formalized auditing processes based on established and tested methods of ensuring safety in the aviation industry. For while each company is different and while new problems arise all the time, there are also a number of hazards that have been assessed by other aviation safety experts. In aviation safety, as in all human endeavors, there is no need to reinvent the wheel.
In addition to these two forms of assessing risk, as safety director I would also periodically survey the staff, bring in outside assessors to ensure that the company is not becoming blind to potential hazards simply because the conditions that create them are becoming familiar. I would also -- and this is a key element I believe of any system that is authentically (and not simply putatively) interested in increasing safety -- put into place a confidential reporting system so that anyone could report a safety problem confidentially.
The Danish government recently instituted a mandatory nationwide confidential reporting system that has proven to be highly effective throughout its aviation industry. Here is the official government discussion of the thinking behind such a policy:
As opposed to these systems, the recently introduced system in Denmark is a mandatory, nonpunitive, and yet strictly confidential system. The reporting system is mandatory in the sense that air traffic personnel is obliged to submit reports of events, and it is strictly non-punitive in the sense that they ensured indemnity against prosecution or disciplinary actions for any event they have reported....
It is natural that Air Traffic Controllers and other aviation professionals, like everybody else in society, may not be expected to turn themselves in if they risk punishment; this reluctance to incriminate oneself is no doubt part of human nature. Therefore it is important for the quality of a flight safety reporting system that individuals, within certain well-defined limits, are granted immunity from sanctions. The immunity cannot, and shall not, be complete. It will always be necessary to punish individuals when they have been behaving in a grossly negligent way, and ikewise substance abuse cannot be tolerated.
At the same time, experience from investigation show that gross negligence and substance abuse re extremely rare factors in aviation incidents and accidents.
In order for any reporting system to be useful, particularly where it is expected that individuals are expected to report their own mistakes, it is important that information obtained by self-reporting is not used to prosecute the reporter. (Norbjerg, 2004)
As is noted in this passage, gross negligence will not be excused; however, there has to be some level of confidentiality to ensure that progress can be made in the company's ability to identify, assess, and remedy potential hazards.
Setting up an aviation safety plan is a complex one with a myriad of separate details. I have not looked at the specifics in this paper because there is not the space to do so. An actual airline safety protocol would include everything from ensuring that the upholstery on the seats was fire-proof and that the pilots had the best-designed chairs to sit in. But while such details are essential, of course, what is most important in terms of setting up a safety program is ensuring that the management of the company takes the lead and makes it clear that there will be no tolerance for cutting corners on safety.
Nearly all questions of safety in terms of the airline industry are really questions of resources. We can see this in the crash of Buffalo commuter plane just a little over a year ago. One of the primary reasons for that crash, the National Transportation Safety Board found, was pilot fatigue -- fatigue that rose almost entirely from the co-pilot's being paid far too little.
The co-pilot of a deadly commuter airplane crash near Buffalo, N.Y., earlier this year took a cross-country red-eye flight the night before to get to her $16,000 U.S.-a-year job in Newark, a public hearing into the crash was told Wednesday.
The U.S. National Transportation Safety Board's inquiry in Washington focused its attention on pilot fatigue as a possible contributing factor to the crash of Continental Airlines Flight 3407, which killed all 49 people aboard and one person on the ground.
The night before the crash, she flew overnight as a passenger from Seattle, investigators told the hearing. & #8230; in at times heated exchanges with airline officials during Wednesday's proceedings, board members suggested Shaw's limited salary might have prevented her from living closer to the city where she worked and led her to commute from the Seattle area, where she lived with her parents. (http://www.cbc.ca/world/story/2009/05/13/buffalo-crash-probe051309.html#ixzz0fUOQN5CL)
There will never be a perfectly safe airline flight. But there are many, many, well-established ways of making airline flights unsafe -- including paying pilots pitiable wages. A management structure that encourages transparency, that takes responsibility for providing proper resources -- including proper training and upkeep of equipment -- will minimize those potential hazards. Airline safety is sometimes very much like rocket science. But more often it is a question of commonsense -- and far-from-common commitment.
Airline pilots association, http://www.alpa.org/.
Burslem, C., Kelly, M. & Preston, F. (1990). Food poisoning: A major threat to airline operations. Occupational Medicine 40: 97-100.