The cellphone line is mute which goes inbound my aviation best friend’s life. He’s a good friend of mine indeed. Two years of working together for a Maintenance Organization meant something. He was the Quality Manager and I was as usually the Safety Manager. I heard the news from a local radio station. I was off my base station to make an audit, and in the middle of such an event I heard the news in a local radio station. Crew names are still unknown, but the line again does not understand what I read some years ago from Tony Tyler: “An accident is too many”.
Some years before when we worked together, I was really impressed with this organization’s operational environment. Or safety culture should I say? ISO 9001:2015, prescribes “the organization shall determine external and internal issues that are relevant to its purpose and its strategic direction and that affect its ability to achieve the intended result(s) of its management quality system.” I’d use such an information for my hazard register, I guess it is smart to say. But what about safety culture? I feel we, humans, work in aeronautical organizations according to the safety culture we build, desire or regret. And is this statement not aligned with the external and internal issues that are relevant to its purpose and its strategic direction and that affect its ability to achieve the intended result(s)? Let me share with you an excerpt from ICAO’s 9859 4th edition: “A safety culture is the natural consequence of having humans in the aviation system. Safety culture has been described as ‘how people behave in relation to safety and risk when no one is watching’. It is an expression of how safety is perceived, valued and prioritized by management and employees in an organization.”
What must aeronautical organizations do about it? I mean with the statement “the natural consequence of having humans in the aviation system”. Once organizations are aware of this root cause, we need to stop working on building, shaping and forming a negative, poor or ineffective natural consequence of having humans in the aviation system, but in a positive, planned and operational one, which means our intervention or management, including directing and controlling through processes such as planning, designing, executing, monitoring and re-making strategies as long as possible to achieve the aforementioned intended results. Are we doing something about it? The IS 9001:2015 above also states “when planning for the quality management system, the organization shall consider the issues referred to in 4.1[1] and the requirements referred to in 4.2[2] and determine the risks and opportunities”.
Back to the culture I was addressing, a phrase from an airline CEO hammers my head. I heard this during an employment interview wherein we were not able to reach an agreement: “If I have to contract an outsourced service or external instructor, my rules and risk management are simple and they don’t fail: I go for the cheapest one!”. I heard this back in 2012 and recently this year some other aviation CEO told me almost the same. What safety culture or what operational context are we building? How about the acceptance CEOs must be granted by the CAA? Are we talking about documented information here? I mean is there any written process for the acceptance of such Top Management officers?
Operational environments or safety culture are a consequence, no doubt about it, but it is clear and wise to say such consequences need to be reduced and controlled once they are recognized as a negative feature or a threat. A monitoring process of latent conditions is my advice, since such latent conditions are insidious or almost negligible at the beginning, but once they built a culture, it will be hard to tear them down. Did you hear the statement culture does not occur overnight?
I must add to this story my friend changed his shift with a partner that morning. The partner, who was also a friend of mine, was killed in that accident. When did this crash begin? Maybe when a statement like “the cheapest one” was thrown through the air.
Thus, let me share some thoughts with you guys to enrich the concepts above:
| Range[3] | Positive (Safety) Operational Environment | Negative (Safety) Operational Environment |
| Man | Sharing information; safety reports sharing & discussion. | Information hidden or forbidden. |
| Method | QMS / SMS established, documented, implemented and maintained. | Management systems remain as bug-in-the-wall documentation. |
| Machine | Facilities, tools, and equipment acquired to reach goals. | Goals are not considered, but operational needs as they arise. |
| Material | Components or consumables acquired to reach goals. | Goals are not considered, but operational needs as they arise. |
| Milieu | Learning, just culture, risk management-based events. | Hierarchies with a heavy specific weight. |
| Measurement | Inspections & audits, KPIs monitoring as established. | Processes not measured. |
Organizations are pretty aware of what they do each and every day as well as the expenses they use and need for the operations. And they will be expensive, ineffective though, and insufficient if such organizations will not be using management system fundamentals, which will turn organizations into disciplined, defined and operational profitable commercial and safe entities.
[1] IS 9001:2015, clause 4.1 states “the organization shall determine external and internal issues that are relevant to its purpose and its strategic direction and that affect its ability to achieve the intended result(s) of its management quality system.”
[2] IS 9001:2015, clause 4.2 title is “Understanding the needs and expectations of interested parties.”
[3] 6Ms concepts from the Ishikawa Method were used by the author of this article.
