Where Birds Don't Fly

Thinking outside the box and brainstorming is an element of root cause analysis within an SMS system. Two of the most applied tools are the fishbone analysis and the 5-Why’s. When applying brainstorming and outside the box thinking loss of situational awareness concept takes on a different meaning than what conventional wisdom expects, or even beyond what the industry accepts. Time. Loss of situation awareness has a history of being identified as one of the primary factors in accidents attributed to human error. Situational awareness may come in different shapes and forms but is generally speaking identified as perception of the elements in the environment within a volume of time and space, comprehension of operational meaning and projection of operational status in the near future. In other words, situational awareness is the Captain’s comprehension of where the aircraft was, where it is now and where it’s going. In the old way of reactive safety and prior to SMS, this was a simple op...

When the car runs out of gas on a remote backroad, it’s not the vehicle system that failed, but the gas supply system. When a vehicle has a flat tire on a busy highway, it’s not the vehicle system that failed, but the tire system. When an aircraft excurses a runway, it’s not the aircraft system, or airport system that failed, but a sub-system of the aircraft or the airport, or any one of these undesired events could have been caused by the human performance capability system or the level of comprehension of any of these systems. During the history or aviation, the aviation industry became safer without the requirement to conduct safety cases. Building safety cases with the introduction of new aircraft type, change in route structures, additions to the movement area or change in key personnel were a part of ongoing changes and adapting to these changes as they occurred.  A safety case will be your most precious friend of aviation SMS. However, with the introduction of the Safety Man...