I was going upstairs to meet the HR officer of this airline I was about to begin rendering services as Safety Manager. No signs or indications where to find the proper office. No matter what! I found her. It was a huge room with plenty of workstations, laptops and noise all over. We began the conversation and as this was going on, I got a little confused, since she was interviewing me as an employment assessment, but this airline’s CEO had already welcome me to his company, and even set my wage. She also noticed this was going nowhere and hit me mildly with a knife: “I don’t know why I have to make an interview to you guys, when the big boss has already arranged the salary with you!”
As I was making the forms of the WAIS-IV, I was shifted to my first lessons of Human Factors, and I remembered what I read from Professor James Reason’s concept of latent conditions. I learned these were the inevitable “resident pathogens” within the system. It is important we take into account these conditions “arise from decisions made by designers, builders, procedure writers, and top-level management”. What’s the hazard in this case? All such strategic decisions have the potential for introducing pathogens into the system. So, it means nothing, but the organization tears itself down. I mean from within.
But how comes managers, post holders and even CEOs make that kind of decisions to tear their own organization down? As to what I lived in many airlines, AMOs and aerodromes, it is a matter of throwing stones to hit the sun, aiming to the sky without having a real target. What would be the target then? Organizational objectives are key in this scenario. Most of the time, a stone is thrown just to show power. But we need direction, instead of strength!
That means organizations will have a positive culture when they set their hierarchies to achieve their objectives. Last week I was attending a safety roundtable and one of the CEOs told us: “When an order is given in my company, I looked out of the window below me to see if this is accomplished. The next guy does the same, and so on, until the last guy. That’s how we always have someone to blame”. Do you agree with me, guys? Of course, this company is a power-driven one. If the will is not accomplished in this type of organization, someone will be always guilty, and will get the punishment. No organizational approach, just blood to pick up from the battle floor.
I regained consciousness and became surprised as the HR officer began showing to me all the steps of her recruiting procedure using a flowchart. I thought to myself I had already made all these steps in just a few minutes. This written procedure does not align with the actual events I lived before working for this airline. I understood then the HR officer’s frustration, and some questions came to my mind:
- Why do we make so many procedures not to follow them?
- Are all procedures in this company (and others) followed as written?
- Is it unsafe not to follow the procedures?
- Will we have an accident right away by not following a managerial procedure?
Written standards are required in almost every management system. What happens when these documents are not well disseminated and obviously not accomplished? The accident will not happen in that precise time. But a crust is born. A culture of not complying with, because “we do things rationally around here”.
One day not identifying a component could be the case. Another day goes by and jacks did not undergo the incoming parts inspection. Another time the engineer’s toolbox is not controlled. Then, in crescendo unsafety actions could include not reporting the failures in the logbook or even stating them as accomplished when not!
That’s why we have to be very careful to detect such circumstances. Time, money, and efforts must be allocated to know where a hole could appear in the slice. Monitoring activities, disseminating investigation outcomes and recommendations, setting controls, living with the operational people, going deeper to their strengths, looking for what they do right, thinking about direction instead of power, and you will see the difference!
