The hydraulic hammers complain hard in the hangar invaded by aircraft, technicians, administrators and the last students who arrive quickly to the classroom for their Maintenance Human Factors Course.
Watching the crackling of the steps to reach the main rotor reminds me that I must deliver this course early today. Then, I shall continue with the planning of a scheduled audit and in the afternoon finishing with the measurement of the safety indicators of this month.
We had already started the Maintenance Human Factors course. My students were taking notes of the famous Donald Engen’s statement “… we have spent more than fifty years in the equipment that is now very reliable. It is time for us to take care of people”, and then one of the company’s officials appears with a terrified smile. He knocked on the door with a look that demanded forgiveness without conditions. I gave access to him. We chat and he tells me: What a shame, Sergio! But we have to postpone the course. We are late for the execution of several job cards.
The wax falls again and again to repeat the same litany and I returned to an inspection booth when I was still very young. I arrived to devour all possible experiences, as I learned from my old man and find a partner in shirt sleeves. He was precise and sober when he was stamping and signing the job cards without stopping. Aren’t you supposed to check before stamping and signing? The question was more naïf than proper, because he replied to me… Well, Sergio, what plane has fallen down due to the ink of a pen?
I behold my own surprise at this irrational and terrific murder and see the cockpit on a summer night. I had to carry out my safety round. I was accompanied by the team leader. They had to execute a 400 hour check within schedule: five hours. Everything had to work perfectly. They were prepared for that without a doubt. It was almost 2 a.m. on any given Thursday, and one of our teammates enters into the cockpit, pulls a circuit breaker, greets us and hurries out to continue his checks. Then I told the team leader what about the danger warning card when a circuit breaker is pulled? He didn’t attach it! I looked at my friend and his eyes were not startled and alert at this time. He replied to me, indeed, he didn’t attach the card!
While a Safety Management System (SMS) is made up of a sound structure, by virtue of which their components and elements constitute a block whose purpose lies on defending organizations against accidents, we must recognize the key importance of the Second Component of the SMS Structure: Risk Management. Due to this process, organizations are able to know what hazards they are dealing with, what are the relevant consequences and to what extent an accident or incident is likely to occur and what would be the severity of these events, all of which constitute “fateful” information, so that organizations know what weapons to take to battle, how to use them, and when to defend itself against the vigor of the enemies (the hazards).
I return to my office and on the way I evaluate what these three events have in common. The misfortune was the same in all cases. The procedures were not enough in all cases. The analysis of personal and subjective risk without taking into account the worst foreseeable condition was present in all cases. So it would be worth asking the following questions:
- Are these events the origin of an accident?
- Are we talking about hazards or negative management consequences of an aeronautical organization?
- Are we talking about safety culture in this story?
- How much safety conviction do employees of these three different organizations have and at different times?
- When will an accident occur with this type of practice?
The answers upset me like Tony Tyler’s statement “an accident is already too much!”.
So, should we be designing more procedures? Should we be telling operational employees how to do their job? Should we be distrusting their experience, effort and pride?
Let’s make them convinced that safety is part of the operation. It will not work otherwise. When front-line personnel gives an operational approach to the procedure, including safety aspects, we will eliminate the latent conditions and their catastrophic awakening, as ICAO notes that “latent failures are present in the system long before an accident, and fed them probably by those responsible for making the decisions, for establishing regulations and other people far removed from the event both in time and space”. Otherwise, we will be condemned to march to the hall of the Nordic fallen, the Valhalla, chosen by Odin.
