Focus on events in airline safety


Before beginning a description of airline-specific voluntary safety programs, it should be noted that these programs are primarily based on event analysis. Just as in Orville Wright’s day, event analysis is still important; it has been the impetus for the creation of most of the safety programs we are about to discuss, but it will not be the most significant part of the future of Safety Management Systems . Safety Management Systems is not a forensic pass-time. Deeply rooted in quality, Safety Management Systems demands of its practitioners the ability to honestly assess today’s performance, compare that performance to a vision and a plan, and then move forward ever closer to those goals. The most important role of the Safety Management Systems practitioners of the future will not be their analysis of a particular event; rather it will be in uncovering the precursors of such an event; engineering quality into the system, and measuring process indicators to detect when the system is in a state of control that prevents such an occurrence, or when it begins to stray.

That being said, the fact is that the aviation industry, at least the operational side of it, has not yet reached the point in which process measurement and control far outweigh fault or defect detection as a means of determining the state of quality of the system. Just as it took scores of years for the manufacturing sector to understand and embrace quality principles, the same is true for flight operations. Part of this time lag on the flight operations side is due to parochialism. After all, flying is “leading edge” (even that term is borrowed from us). What do we have to learn from widget makers?

Well, quite a lot. If you ask most modern widget maker product design teams what their Quality Function Deployment plan is, they will hand it right over to you. The same is true of their process capability measures—these are estimated even before the first production run. But for us—what is our process capability index for airspeed control from 1,000 AGL to touchdown?

“Don’t know, we fly jets, not make widgets.”

Maybe we should know.

But again, all of the above being said, the fact is that for the present state-ofthe-art in flight operations, fault or defect detection remains, and will remain, an important component of this aspect of our quality management system. In the defense of safety practitioners, the challenge we accept every day is an amazingly complex one, with hugely varying initial conditions, very precise and unforgiving tolerances, and high consequence of failure.

Events matter, we need to know about them, and thus the importance we place on understanding our core event detection systems in Safety Management Systems, which make up the core of the modern safety department. In the U.S., these programs are often referred to as the voluntary safety programs.

Not all of the voluntary safety programs focus on the event. ATOS, AQPs, IEPs, and LOSAs are process-oriented programs, and FOQA can be used in process measurement analyses.

Another important point to make is that as the voluntary programs have emerged from the traditional forensic approaches to safety into the developing philosophy of Safety Management Systems, they have brought along those issues that were so formative at their inception—de-identification and data sharing. We will return to these issues after a brief introduction to the programs.

In the previous chapter, we presented a high-level review of the government’s regulatory approach to aviation safety. Notice the pattern in the evolution of these regulations. From aviation’s beginnings through 1966, with the formation of the NTSB, there was an ever-increasing separation between the entity responsible for promoting and overseeing the operational aspects of aviation, and that entity responsible for analyzing the causes of its failures. This makes intuitive sense. The evolution toward independence was driven by the increasing clarity of the realization that objective evaluation requires independence. This conclusion is as true today as it was in 1966 (witness present-day Federal Aviation Administration advisories concerning the need for independence in the management of Internal Evaluation Programs). And similar to the organizational evolution at the national level, this separation of responsibilities was taking place within corporate borders. Over time, independent safety departments were increasingly the entities responsible for event investigation.


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