Where Birds Don't Fly

A safety management system cannot exist without a just culture since a non-just culture in itself is an opposition to forward looking accountability. Not only does a non-just culture oppose forward looking accountability, but it also opposes the principles of continuous safety improvements. In a traditional safety culture, safety is a mandate established by senior management and demanded that all personnel strictly follow these mandates. Aviation accidents are still classified as a failure to comply with regulations, policies or procedures. The conclusions are often that If only those pilots had complied with regulations, policies and processes there would not be a single aviation accident anymore.  Well, we know that’s not true. In 1956 and the Grand Canyon disaster both Captains of both airlines were following regulations, policies and procedures and they ended up in a mid-air collision. On the other hand, if KLM 4805 had continued their first takeoff roll without a clearance, is the

The Safety Management System (SMS) is a safety tool for an imperfect organization, being an airline or airport, to discover hazards and maintain an acceptable level of safety. Airlines and airports in North America are mostly implementing their SMS for regulatory compliance and not for safety improvements. SMS is simply implemented as a requirement to maintain the operations certificate. As a regulatory demand SMS might be viewed as another bureaucratic burden to satisfy paperwork trails. However, after working with SMS and comprehend the systems, operators may experience changes of opinion and discovered the benefits, including a higher return on investment, by the implementation of SMS.  Any operator, who does not require an SMS for regulatory compliance, would benefit strongly by implementing an SMS program voluntarily and be ready when SMS eventually becomes a regulatory requirement. This timeframe period would build SMS comprehension and readiness for SMS compliance. SMS is a safe

Before a corrective action plan is applied to a special cause variation, it must first be established if the variation itself is a special cause or a common cause variation. On the surface it might look like a simple task to identify a common cause variation since this variation is known to occur each time the process is applied. This could be in a manufacturing process, a service process, a training process, a safety improvement process or in any other processes. That a variation is common in the process does not necessary define that variation as a common cause variation. It could be a special cause variation disguised as a common cause and embedded into the process. It is conventional knowledge that new pilots are less qualified than long-time pilots. While this might be true, by accepting this as a common cause variation, there is no corrective action required for continuous improvements. There are opportunities for an increased return on investments by making minor adjustments to