Where Birds Don't Fly

Over the years Santa Claus has successfully delivered Christmas gifts all over the world and without major incidents. Every year Rudolph the reindeer takes the lead and ensures kids gets their present. It is an amazing result. Of all places on earth, Santa Clause lives at the North Pole. A deserted place where no one else lives but Santa, his helpers and the reindeers. At the North Pole he gets just the minimum training in roof and chimney approaches, since there are no other homes at that place. Even though not known, he informally assists the Easter Bunny in an attempt to stay airborne-proficient for next Christmas delivery. So far, Santa hasn't had any major incidents. He got stuck in a chimney now and then and the reindeers stumbled as they landed on the rooftops. But the gifts were still delivered before days end, year in and year out.  The deliveries did not always go as planned. However, with the increasingly Cyber competition Santa needed to find a niche to maintain his pos...

SMS is defining parameters in operation. An Enterprise has processes in place for performance parameters that are linked to the organization’s goals and objectives, which again are linked to the safety policy. SMS is the tasks of manage applications within established parameters. Parameters of zero airspeed are no RPM and equalized MP. Add another of oil temperature to improve reliability of statistics. As a simplified example let's look at the parameters of an unsafe landing gear indication, where the corrective action plan of the " unsafe landing gear" checklist is applied. This checklist is a parameter as an integrated part of other performance parameters required during its flight. However, it is different in that it is a non-desired outcome parameter and only addressed in a non-desired state of flight. Assuming that parameter, goal and objective are as follows; Parameter – Unsafe landing gear indication checklist. Goal – Execution of appropriate checklist within endu...

Moneyball is a movie based on a baseball team where players for the team are picked based on their on-base percentage.  By getting players with a higher average of on-base percentages, the team manager executes a plan to build a competitive team at a lower cost and eliminate the subjective and often flawed process of picking high-impact team members. This approach brought a baseball team to the playoffs with only a salary budget of about 33% of the highest salary team.  Statistical Process Control (SPC) and SMS are profit makers when applied to desired operational results. When applying SPC to Aviation Safety, an Enterprise has established measurable parameters.  Identified parameters set the stage for greater profit margin. However, precise application is what makes the difference.  Moneyball in SMS is to know what an Enterprise's values are and what the undesired outcomes are. In the Moneyball movie the value is to win games and the undesired outcome is to play hig...

There is no simplified Quality Assurance of a Safety Management System. What is simplified is to select and accept simplified steps by adding multiple designs; or multiple triangles, without attempting to cover it all with one huge boulder. Planning, organizing, action and control of each step is to simplify the QA of SMS. Without planning, the road leads to nowhere. Without organizing, the pieces don't fit. Without action, nothing is happening. Moreover, without control you don't know if you took the right turn at the fork in the road. The Certificate is the top triangle of Quality Assurance. Everything else are the triangles of QA. When applying building steps of triangles, one can visualize the imbalance if adding or removing triangles. Take away or add one, then other triangles are not connected.   Let's look at an Airport QA of SMS since an airport is where a flight begins and ends. Building the triangles of all activities under the Certificate are QA of Safety Managem...

When a hazard report is received the contributor is issued a confirmation of report received. Following an acknowledgement to contributor, the hazard is either entered in a hazard register for trending and then submitted to appropriate manager for further investigation and analysis, or just entered into the hazard register for trending.   Some hazards are investigated with a timeline for CAPs, while other hazards are closed after entry in the hazard register. After submitting a hazard report, the contributor may receive a confirmation receipt with the following statement:  " Hazard report received, no investigation required". The contributor of this hazard may have gone through a lengthy process and effort to accurately identify, describe and submit this report. A reply of " no investigation required" could imply to the contributor that this hazard was not important to the Enterprise. Next time that same hazard is identified there may be a temptation not to submit....

Over a three-year period, airplanes in one region were on average striking birds at a rate of 92.7 %.   For every 100 landing or take-offs almost 93 of the birds were struck at or near an airport. The other seven birds either were avoided by pilot actions as an abrupt movement or rejected takeoff. The key to manage is to reduce bird activity near airports. Birds is a hazard to aviation safety. The goal is to avoid as many as possible, but travelling at high speed it is not often enough distance available to avoid one or a flock of birds. Often a bird is not observed until after it has been hit. Technology today does not have an effective means of "live time" tracking birds. There are records of migratory bird routes and nesting places. From these historical records, it is possible to assess past bird activity and predict time and location of future activity. Simply said, it is known that the birds travel north in the spring and south in the fall. This knowledge is then applie...

When regulations are performance based they don't prescriptive describe what is required, but communicates what conforms to regulatory compliance. It might be tempting for an enterprise management to believe that actions are not required since regulation doesn't state what prescriptive action to take. If applying this approach the result might not be what conforms to regulatory compliance.  Displacing the threshold 2000ft on a 4500ft runway might be what it takes to conform to regulatory compliance.  Aviation safety has to be managed in a Safety Management System with a Quality Assurance Program where facts are analyzed. Whenever there are temptations to transfer responsibility and accountability from an enterprise to the regulations, that's when it is time to find out what went wrong with the processes.   One regulation may say that airport operators are required to give notice of any known obstructions penetrating the protected Obstacle Limitation Surfaces. This could b...

An owner or family member may be appointed as the Accountable Executive (AE) and never change. Or, in a large organization the AE may be at the mercy of the Board of Directors or the Mayor and be fired for any reason at any time.   An AE is the person in the enterprise who gets to ``draw the line`` . An AE draws  the line of the Safety Policy, Non-Punitive Reporting Policy, Human Resources, Financial Resources and the timeline for reports submitted to AE. At first glance some may find it to be a trivial event that a person who is not involved in the day to day operation is being fired on the spot. However, since the AE is the organizational authority  on drawing the line, an enterprise may end up in a a state of disorder due to absence of nonrecognition of authority.  An AE may not be involved in the daily operation as they decide where to draw the line.  An un-schedule and emotionally driven firing of an AE is different than a planned and organized change. With...

A fix is for the malfunction, while a repair considers malfunction in addition to the malfunction.   An Enterprise without a Plan for the Corrective Action Plans (CAP) is being lost in a Maze of Corrective Options.  The Maze of Corrective Options is a place of traditions and familiar operations, and it is a "safe place" to make decisions. It's a maze because for each decision made there is a fork in the road without a direction sign. CAPs are not just for making changes after surveillance findings of non-regulatory compliance, but also as internal corrections of processes that are giving non-desired outputs. There are generally speaking two types of CAPs. One is an immediate fix and the other is a long term repair. A fix considers the malfunction but not the cause, while a repair considers the problem in addition to the the process which lead to the malfunction.   A fix is compatible to dumping a task on someone, while a repair is a delegation of organizational...

It has been said that Best Practice (BP) is to apply better practices of quality in customer service. In some way that is correct, since operating by meeting minimum regulatory requirement only is not intended to produce satisfactory customer service. On that day when an enterprise was issued an aviation operating certificate, they were regulatory compliant. This was a static mode, where there had been no movements of aircraft or operation of the airport. Maintaining this status quo of regulatory compliance as it was at the issuance of an operation certificate is neither practical nor the intent of the certificate.   Best Practice is to establish customer friendly processes. An enterprise; when operating airplanes or airports must establish processes that is conforming to regulatory compliance. Establishing these operational processes is to go beyond what regulation requires. This is Best Practice; It's to establish processes above and beyond what the regulation requires and to mai...

In some organizations training may be viewed as a redundant task since an employee performs with great results the same tasks day in and day out. Or, some organizations may compare training to a long path of a “never ending story”. However, training is neither redundant nor a long and never ending path; Training is Continuous Improvement and a Circle.  Training is a tower of circles. When a new person is starting in a job the Enterprise has an indoctrination training planned even if one does not exactly know a new employee’s competence level. Based on historical facts, one assumes that a new person is qualified to enter the Circle of Training at the position’s Level of Performance Criteria. Training becomes the circles of a “Circle Cookie Cake” , where each circle represents an organizational competence, performance criteria and training-entry level . The wider circles represent levels where more people are working. At the top, the circle is small with only a few selected indi...

Fall is the migratory bird season and bird activities are causing airport operational challenges. Without an automated real-time bird activity tracking system, airport operators are relying on submitted bird sighting reports for trending.  Birds are on the runway, in the approach/departure, and anywhere else in the vicinity of the airport. If there is a river near by, the birds may follow the river both upstream and downstream. Birds are hazards. There is currently no commonly used technological application for real-time bird activity threats. Airport operators are relying on their own SMS reports submitted by airport staff, pilots or controllers. The bird sighting process may be simplified by counting one bird or a flock of birds as one sighting. An airport somewhere had 58 actual birdstrikes over a 3 year period. 60 % of the birdstrikes occurred in August and September.  During this same 3 year period 60% of the birdstrikes happened on Saturday, Sunday and Monday. From these...

An SMS Enterprise has established policies, objectives and goals. One of the policies is for employees to report hazards, incidents and accidents.  In addition to policies, the Enterprise has an SMS training system in place for requirements of reporting hazards, incidents or accidents. After this training is done, there is a knowledge test distributed and everyone passes. Everyone is now ready to go... or are they? It does not make it a fact that there are no hazards to report if no hazards are reported.   How is it possible to know if all hazard required to be reported are reported? In a “just culture” everyone should feel confidence that reporting hazards are vital to safe operation and that management needs these hazards reported for trending of their hazard register. When hazards have been mitigated it is expected that they do not reoccur. However, if hazards are not reported and mitigated, someone will be exposed to that hazard several times.  At some point this una...

It has been said that size and complexity is not taken into consideration for an Enterprise required to conform to regulatory compliance. Often this implies that regulations are targeted to fit large organizations and does not accommodate smaller Enterprises. Both small and large organizations must conform to regulatory requirements to be regulatory compliant. A small organization should apply less complex systems to meet these requirements than what is expected from a large organization.  On a foggy morning, size and complexity might not be obvious. The issue is not that expectations are the same for both large and small, but rather that the small Operators are adapting processes to identify how a large organization conforms to regulatory compliance. Small Operators do not have manpower to operate in the same manner as large Organizations. An SMS Enterprise has a system in place for the capture of information of hazards, incidents and accidents. In a small organization this may b...

The Root Cause of a Process which does not produce the desired outcome is that the process took the wrong turn at the fork in the road. This fork in the road could be anywhere in the process from the very first step to the last input. If the process does not give the desired outcome, find the fork in the road. A simple distraction of the process is a fork in the road.  When a process is not documented the outcome may vary by subjective inputs. The process of the “pick the card” game has changed over time with various results, and where the outcome did not always produce the correct card each time. Often this happens in organizations, where errors slowly develop and nobody notice and captures these variations. When analyzing the card-game process it is possible to find the link between the cards. As a test of the process, the cards were laid out in one row of Spades, one of Diamonds, one of Hearts and one of Clubs. This established a baseline the Ace as number one the King number ...