Two NTSB expert share some insights
Both stress need for constant awareness of safety by ALL
Observations applicable to SMS
These three contemporaneous articles by or about an NTSB staffer and the Chairman included inspiring observations about aviation safety. Ms. Leah (Yeager) Read, a Sr. Air Safety Investigator, shares her GA accident investigation experience and Chairman Sumwalt adds some thoughts about the application of SMS to business aviation. Distilled to their essence, both messages assert that aviation safety is a matter of constant consciousness.
In the Board’s informative Safety Compass, Investigator Read summarized her work on GA accidents. The pattern that she found is outlined in these paragraphs:
But there are also times when no one seems to be saying anything much at all about the pilot…until we dig deeper. That’s when we hear things such as, “The pilot never maintained his airplane right.” or “Everybody knew he was going to crash eventually.” There are also times when the investigator will get a call via our communications center that a witness must talk to someone “right away.” The witness then tells us that the pilot had a LONG history of “maverick-like” behavior, was known to “buzz” a friend’s house, or used illegal drugs—as just some examples. In these situations, we will ask the witness if they had talked to the pilot about this behavior or contacted the Federal Aviation Administration (FAA). They sometimes tell us, “I tried to talk to him, but he wouldn’t listen. He was too prideful.” But more often, they tell us that they didn’t say anything to the pilot or FAA. Sometimes, the pilot was a friend whom they didn’t want to embarrass or cause any trouble. Personally, as a fellow pilot, I can understand the concerns.
Later in her essay, she makes the following conclusions:
In the big scheme of things, we need to ask ourselves, who are we really protecting by keeping quiet? As active pilots, mechanics, airport personnel, friends, and family members, you are the eyes and ears to what’s going on out there. You know your airport and the people who use it. You know when your friend or family member seems risky or unsafe. If you identify a hazard, then speak up. Or, file a report with the FAA Hotline. Just remember, we all share the same airspace or may be nearby if their plane crashes. Stay safe and don’t turn a blind eye!
She extends her circle of vision beyond those directly involved in flight to friends and family. Her hope is that all become aware of all indicators of the pilot’s and aircraft’s suitability for flight. Ms. Read urges that all act of their observations to action—talking to the pilot, to those at the airport and even the FAA. The NTSB’s compass is a good symbol of the 3600 perspective which all in every phase of aviation needs to adopt constantly.
The Chairman’s interview with NBAA and the AINsight by Stuart “Kipp” Lau reiterate these themes, applied both to Business Aviation and to all aspects of flying.
Mr. Lau references some well-known management principles in his analysis:
Management and leadership are not synonymous. A manager's job is to plan, organize, and coordinate, while a leader inspires and motivates. Austrian-born American Peter Drucker—credited as the founder of modern management—best described the difference: “Management is doing things right; leadership is doing the right things.” In aviation and other highly regulated hazardous industries, this matters most as it relates to creating a good safety culture. Other academics, ranging from James Reason to Andrew Hopkins, will agree that a manager is more likely to accept status quo, whereas a core characteristic of a mindful leader is to continually challenge and improve systems and culture. The mindset of a leader is one of “chronic unease.” Likewise, really good leaders should be preoccupied with the potential for failure or possibility of a major accident.
In a recent presentation, NTSB chairman Robert Sumwalt’s linked safety culture and leadership by saying, “Safety is not a status you attain, but a never-ending process. It’s not a destination, but a journey. And the journey begins with leadership.”
Sumwalt’s Q&A with NBAA is focused more on the FAA requirement that certificate holders should have Safety Management Systems in place. The pertinent quotes:
People seem to be making this “SMS thing” entirely too difficult. Think of the requirements posed by SMS as those things that a professional flight department should be doing anyway. In many ways, these are the things that many operators are already doing, but they just aren’t calling it SMS. …. So, if safety is important to your flight department, shouldn’t you have a formal way to effectively manage safety? That’s what an SMS does – it provides a structured, business approach to managing safety. … With data collection and analysis, the organization collects and analyzes information from multiple sources so managers can keep their fingers on the pulse of the operation. … The lifeblood of an SMS is using data to keep your finger on the pulse of your operation; the heart of an SMS is a process of continuous improvement; the soul of an SMS is having a strong commitment to safety culture. … Safety culture begins with leadership, but it has to permeate the entire organization. If the leaders aren’t truly committed to it, you won’t get others to buy into it. In other words, people will watch you, and they will do what they think you want, and not necessarily what you say you want. As a leader, what message are you sending? Safety must be a core value that drives everything you do.
The Chairman’s remarks spark some thoughts based on implementing SMS:
- An effective SMS is not implemented by buying a pre-packaged manual and inserting your certificate’s name in the blank spaces. There are best practices, which are useful, but your adoption must be wrapped around your company’s structure, recognize the strengths and weaknesses of your team, be synchronized with where your organization to where it has evolved and adapt to fleet’s age and maintenance regime.
- SMS must involve senior management in its initiation, but more importantly must be reflected in their daily behavior. For example, the Chief Human Resource Officer, walking through a concourse and seeing poor safety habits by the ground staff, MUST stop and express his concerns to the crew leader and the personnel.
- In setting SMS priorities, important decisions must be made in ranking the order of identified risks. All people assigned to the team MUST participate. Just because the specific issue does not touch one of the members’ area of expertise is NO excuse to participate. The point of the 3600 approach is that everyone’s perspective has value and that ownership of each decision contributes to long-term discipline. By skipping Meeting # n, that individual may not fully comprehend the logic of the #n decision when it is applied at Meeting #n+1. Continuity is important.
- Aviation companies devote considerable time of C level executives, officers and internal director to strategic and financial decisions because of their impact. The failure to assign the same level of scrutiny to SAFETY is an absurd misallocation. A major safety failure can imperil the organization’s future.
The cover image is the Eye of Providence, an ancient religious symbol of the eye of God. It is meant to reflect omniscience and divine providence. Though the eye is at the top of the pyramid, it is connected with the structure below. It could serve as a good SMS badge, connoting the importance of safety to all, the involvement of all, the awareness/ consciousness of safety should permeate the organization and the 3600 perspective needed to be successful.
No blind eye and everyone has safety in their vision and consciousness. Thanks Ms. Read and Chairman Sumwalt.
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