Safety in the Skies Starts

Safety in the Skies Starts on the Ground

We've all heard the truism that traveling by air is safer than driving. This is true -- although not terribly helpful for anyone who has to do most of their traveling by car, as most of us do. Moreover, it also glosses over an extremely important fact. While it is primarily true that most people are safer in a plane than they are in their cars because they spend so much more time (and so many more miles) in their cars than in an aisle seat, this is only one reason why air travel is in general so fundamentally safe. This latter reason is that air traffic is conducted and controlled by professionals. Unlike the average driver who -- even if licensed -- is likely to be distracted in any number of ways as well as under-trained in a range of useful skills. Aviation is a safe field because far more than any other mode of transportation, it is run by professionals.

This does not mean, of course, that there are not dangers in flying. We're all seen the footage of what can happen when people abandon their natural modes of travel (which tie them to the earth and to a lesser extent to the water) and take to the domain of the birds. Some of the disasters that occur in the skies are put down to nature -- wind shear, ice on the wings, storms that arise from nowhere. But while there are often (indeed usually) natural elements to airplane accidents, aviation safety in some sense always comes down to human error. The pilot, the co-pilot, the navigator, the mechanic, the engineer, the TSA official looking for terrorists -- someone somewhere along the way made a mistake. Sometimes this was the first time that mistake was made -- who would until recently have thought check a passenger's shoes or underwear for bombs? Sometimes the error has been made time and time again -- how many accidents have been caused by pilot distraction or exhaustion?

A well-integrated aviation safety program -- which I will describe in this paper -- is one that both takes into account known dangers, from ice to common pilot errors -- and considers new possible dangers. No human endeavor, of course, can ever be perfect. But when the stakes are as high as they are when someone -- or hundreds of "someones" -- steps onto a plane, the margin of error must be made as thin as possible. An aviation safety plan is best designed by the world's greatest cynic (who assumes that if a human error is possible than a person will make it) who is also the world's greatest pessimist (who assumes that if bad luck can occur, it will). Hoping for the best has no place in designing aviation safety. Planning for the worst and figuring out how to subvert that is.

The Role of Management in Aviation Safety

While everyone has a role to play in establishing and maintaining safety in the airline industry, the most important role is played by management. This may counter-intuitive -- shouldn't it be the pilot who has the greatest responsibility? No -- although, of course, the importance of the pilot cannot be over-emphasized. but, as the new safety director of Sky High Airlines, I would ensure that the company's management understood their leadership role in terms of safety. All safety management systems (or "SMS-es") depend on senior management's allocating enough resources to the practice of safety measures. This is the first stop that must be made by a company to ensure safety. The second -- which is in many ways simply a rewriting of the first one -- is that the top management must not over-rule the expression of safety concerns by others.

One of the key ways in which Sky High has demonstrated its commitment to safety is by hiring a designated safety director. While very small airlines might not need a separate safety director, most commercial airlines do -- even if they are very small. One of the truisms of all forms of business is that if no one has a specific commitment to a task, then it is less likely to get done. If a number of different people are all responsible for different aspects of safety, then this division of labor is all-too-likely to produce both overlaps and gaps in safety measures.

This does not in any way mean that everyone on the staff of an airline company is not also responsible for making things as safe as possible. But there must be one person who is designated as the head of any set of safety procedures and hopefully of the safety procedures. Such an integrated approach is essential to ensure that nothing is overlooked.

The safety director ensures that the management of the company provides whatever sources are needed to run all flight operations, provides training for all the staff so that they are familiar with the latest safety concerns, and also for providing clear lines of communication among all the departments of the company so that knowledge and expertise in one group of workers is shared with everyone else. Along the same lines, information about safety protocols must be expressed in easily understood language: All too often safety instructions are written in either a sort of technical or bureaucratic jargon that makes it difficult for people to read.

Probably the most important task for the management in terms of safety is to provide sufficient resources for safe conditions to be maintained, such as ensuring that pilots are given sufficient rest time. The following commentary from the Airline Pilots Association underscores this problem of airline management cutting safety corners to save money. The article is a response to a PBS documentary:

The Frontline public affairs program, which included excerpts from an interview with ALPA president Capt. John Prater, posed the question "Is the aviation system being stretched beyond its capacity to deliver service that's both cheap and safe?" The one-hour show illustrated many of the challenges facing these airlines, including the extreme cost pressures inherent in fee-for-departure operations that have fueled a race to the bottom in which airlines that seek to invest in safety and training suffer an economic disadvantage in the marketplace.

For years, ALPA has called for enhanced pilot training and mentoring regulations to level the playing field and take safety off the table as an area to cut costs. ALPA worked side by side with the members of Congress to draft legislation aimed at improving pilot certification, training, and flight- and duty-time limits and minimum rest requirements.

Moreover, ALPA's safety structure continues to work closely with the FAA on new regulatory language for pilot training, qualifications, and flight-time and duty-time and minimum rest requirements.

"Pilots should not be disciplined for calling in fatigued or for reporting safety issues," said Prater following the Frontline show. "ALPA pilots know that their union will back them when they put the safety of their passengers and crews first. However, we are seeking commitments from companies to work meaningfully with their pilots to solve these problems before it gets to that point. We hope this Frontline program will encourage more airline managements to work together with ALPA pilots as partners in what must be a tireless commitment to enhancing safety." (http://www.alpa.org / )

The essay above, by an airline pilot, demonstrates how little power or control pilots often have in maintaining safety standards. Of course, pilots are responsible for their own actions, and no pilot has the right to fly if she or he feels exhausted. But the management sets the tone.

While there are a number of ethical, smart, competent people working in the airline industry and trying to keep passengers and staff safe, there are also those who (as is true in other industries) who are simply concerned with profit. And while it is certainly possible to be both safe and profitable, it is not possible to be safe if profit is the only concern. Companies that do as little as possible to meet formal safety requirements are all too likely to make a -- potentially fatal -- mistake all too soon.

A safety director who is backed by a competent management staff, will be able to ensure that the wide range of possible safety problems is addressed in time. This is a n incredibly complicated task, including everything from maintaining the planes to maintaining the airport to ensuring that no one gets food poisoning from the on-board meals. The safety director is responsible not only for the company's staff but for all of the companies and individuals with whom the company contracts -- although this is of course a somewhat diluted responsibility.

Indeed, it is often problems with subcontractors that can prove to be the most vexatious since the safety director of the airline has less control over them. A rather legendary example is a major salmonella outbreak in 1984 that affected British Airlines:

The investigation paralleled a major aircraft disaster in the number of national and international agencies involved and in the variety of disciplines engaged. 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.