The air was cut by the frozen mist in my mind when I left home, and could kiss my kid. I drove safely to the office with all the planning I made late the night before. My safety round was the first activity to be done like some years ago, which resulted in pure benefits to this AMO I worked for. Suddenly, the hangar becomes like a fighting ring, wherein everybody was trying to land as much punches as possible to defeat the deadlines. It was an environment crowded by people looking for stands, ladders, and jacks or killing the silence with the pneumatic hammers. Not plenty of space for all these activities. Not enough of many things, and resourceful engineers. During the last part of my safety round I find a very good friend. He is an engineer. We talk about life and things to improve.
Glory days come to my mind and I found myself at the QMS course I attended when I was a Safety Inspector at the CAA of my country. It will always be a lesson each and every day to me. What’s spinning round and round my head? The fundamentals to maintain an organization effective and safe operational. I’m the new guy here, and unfortunately I have to accept all of these are not working in this company, where terms like organization, planning, role assignment and information dissemination are an undone homework all the time. Or maybe it is done, but not properly, not completely or without a risk-based approach.
My friend and I continue with the talking, which shifted to safety now. That’s when my eyes aim at the tail boom of a helicopter undergoing an overhaul. The travel is slow and focused and I find a pretty much big dent and scratches within an already worked area. I asked my friend if he knows something about it. It didn’t happen early this morning. The tail boom was just fine at that time, he replied to me. I cut his speech like a frog eating a fly, and asked how could this happen. I really don’t know, he said. I began an investigation. Results were productive. The engineer told me he had to make an inspection. So he moved the ladder and hit the tail boom. It’s not that big, sir he told me. Why didn’t you speak up? My question was looking for a heading for my investigation. You know, the task must be done, because my colleague is waiting to continue with the other part of the work. Then, these questions came to my head:
- How effective is the safety report procedure here?
- Do we have any written documentation showing this procedure is working?
- How comes the organization has all the required documentation and still someone decides not to tell anything?
- How was this engineer hired? Is there any recruiting and selection process? How proactive is this process?
- Is this just a matter of follow/not follow procedures? Do we have to go further?
- Are there any briefings being done?
- Did the training procedure fail in this case?
- Was there enough space for the inspection to be done?
I was collecting the information, which matched exactly with something I read on ICAO’s 9683 document, paragraph 2.4.3, stating: “Latent failures become evident when triggered by active failures, technical problems or adverse system conditions, breaking through system defenses. Latent failures are present in the system well before an accident and are most likely bred by decision-makers, regulators and other people far removed in time and space from the event.”
Errors and Procedure Violations are fully individual? Are they part of a culture? I always think the system did not have the proper defenses at hand. Are we talking here about lower performance than required and set? I agree in this instance with Mellahi & Wilkinson, when they say that “an organization fails when its ability to compete deteriorates as a consequence of actual or anticipated performance below a critical threshold that threatens its viability.” Hard work and operational safety-based approach must be the objectives. Information is failing? Obviously yes! The same applies for safety promotion and accountability. Operational staff must really know what we expect from them. We need to be sure we trust them. As much trust we give them to make the operations is really operation-based safety. They need to understand all of these. It is not a matter of repeating other companies’ stories and experiences. Safety managers have to fit the proper strategy to achieve success. Copy-and-paste management will not position you as successful as other guys. Attitudes, knowledge, culture of the company must be understood pretty well. Otherwise, all the punches will land properly to make a hole in your defenses at the right spot and at the right time claiming for an organizational accident.
