When Special Cause Variation Becomes Common Cause Variation
A safety management system (SMS) operates in a risk management environment where associated hazards are assessed, classified, and accepted or rejected by the accountable executive (AE). There are several inherent risks in aviation, triggered by special cause variations or common cause variations.
Inherent risks triggered by common cause variations and are systems required for processes to work as intended, and they are beyond management and control of airport or airline operators.
Adverse weather conditions such as thunderstorms, turbulence, fog, and strong winds can pose significant risks to flight safety.
Despite rigorous maintenance checks, mechanical failures or malfunctions in aircraft systems can occur, leading to potential safety issues.
Collisions between aircraft and birds or other wildlife can pose a threat to aviation safety, potentially damaging the aircraft and compromising its ability to fly.
Incidents where an aircraft, vehicle, or person enters the protected area of an active runway can lead to collisions or runway accidents.
Miscommunications in air traffic control instructions can result in conflicts between aircraft and compromise safety.
Insufficient fuel, fuel contamination, or other fuel-related problems can lead to engine failure and emergency situations.
Fatigue among pilots can impair judgment, reaction times, and overall performance, increasing the risk of accidents.
Issues with navigation equipment or errors in navigation can result in aircraft deviating from intended flight paths.
In-flight medical emergencies can occur, affecting both passengers and crew members and requiring prompt and appropriate response.
The Swiss Cheese Model is a metaphor used in risk management and safety analysis to illustrate how multiple layers of defense, each with its own weaknesses, can still collectively prevent errors or failures.
The model visualizes defense layers as slices of Swiss cheese, where each slice represents a barrier or safeguard against a potential error. The principle is founded on that no single slice is perfect, and each may have holes or weaknesses. When these holes align across multiple layers, they create a pathway for an error to pass through all the defenses, leading to a failure or adverse event.
The key idea is that by having multiple layers of defense with different strengths and weaknesses, the overall system becomes more robust and resilient. The Swiss Cheese Model highlights the importance of addressing vulnerabilities at various levels to enhance the overall safety and reliability of a system.
The holes in the Swiss cheese are formed during the cheese-making process and is the results of external elements and active hazards are introduced used in the process as common cause variations.
The holes in Swiss cheese, also known as eyes, are formed during the cheese-making process. As the cheese ferments, carbon dioxide gas is produced by the bacteria, and these gas bubbles create the characteristic holes in the cheese. At first glance it appears that holes in the Swiss cheese are randomly formed. The process is somewhat controlled but not precisely structured, leading to a unique pattern of holes in each batch of Swiss cheese.
The size and distribution of the holes depend on factors like the type of bacteria used, the temperature, and the duration of fermentation. The Swiss cheese model used as a metaphor to explain what, when, where, why, who and how accidents occur have one thing in common with occurrences, that they also are somewhat controlled but not precisely structured.
The reason the holes line up in a Swiss cheese is related to how the cheese is processed, it is related to the point of view of the observer, and it is related to how the cheese is sliced. These three principles also apply to pre-accident events of occurrences and how special cause variations are be floating within the process to a convergent point where they line up with other special cause variations, or common cause variations.
A common cause variation for air navigation without using navaids is that upper winds move an aircraft away from the desired track. Pilots make estimated corrections for this by selecting a heading into the wind that is left or right or desired track to remain as close as practical to the planned track. By random chance there is an inconceivable likelihood that two aircraft will be at the same intersecting location at the same time.
With the introduction of global positioning system (GPS) air navigation became precision navigation. GPS is a special cause variation since GPS is not required for an air navigation process output. Some years ago, two aircraft were navigating by visual flight rules (VFR) using GPS, both aircraft were on a precision course near St. Brieux and collided midair. The likelihood for two aircraft navigating VFR would be at the same time (speed), space (location), and compass (direction) is inconceivable, and times between intervals are imaginary, theoretical, virtual, or fictional.
Special cause variations become common cause variations when there is drift in processes by acceptable work practices, overcontrolling, or decisions made by the accountable executive.
DRIFT
Process drift refers to the gradual and unnoticed changes that occur in a system or process over time. It can lead to deviations from the intended or expected performance of the system. Process drift affect airport and airlines safety management system, and it is crucial to monitor and manage drift for processes to remain on a path without deviations and continues to meet its objectives.
Pilots are required to follow specific checklists before, during, and after flights. Process drift may occur if pilots start skipping certain checklist items or perform them in a different order over time, leading to oversights and increased risks.
Effective communication is crucial in aviation. Process drift can occur if air traffic controllers or flight crews deviate from established communication protocols. For instance, using non-standard phraseology or not adhering to the correct radio frequency can compromise communication and lead to misunderstandings.
Maintenance crews follow strict procedures when inspecting and repairing aircraft. Process drift in this context may involve technicians deviating from the recommended maintenance practices, potentially leading to undetected issues or improperly repaired components.
Crew Resource Management (CRM) is a set of training and communication skills designed to enhance teamwork within the cockpit. Process drift in CRM may manifest as a gradual breakdown in effective communication and coordination among flight crew members, impacting decision-making and increasing the likelihood of errors.
Pilots rely on accurate and timely weather briefings to make informed decisions about flight routes and conditions. Process drift may occur if flight crews start neglecting thorough weather briefings, leading to unexpected weather-related challenges during the flight.
To mitigate process drift in aviation safety, industry stakeholders, including regulatory bodies, airports, airlines, and training organizations, emphasize the importance of regular training, audits, and adherence to standardized operating procedures. Continuous monitoring and feedback systems are essential to identify and correct any deviations from established processes, ensuring a consistent and high level of safety within the aviation industry. Correcting deviations may include a correction to the process, or it may include a correction of human factors, organizational factors, supervision factors, or environmental factors. However, process drift is neither bad nor good but is neutral. What is learned from drift may be implemented in the process to achieve an acceptable performance outcome, or it may be discarded as a process hazard.
Acceptable work practices in aviation safety are crucial to ensure the well-being of passengers, crew, and the overall safety of air travel. These practices encompass a wide range of activities and procedures that adhere to industry standards and regulations.
Pilots and aircrew must adhere to aviation regulations set by aviation authorities. This includes following guidelines on flight hours, rest periods, and crew qualifications.
Aircraft maintenance personnel must strictly adhere to scheduled maintenance procedures and inspections outlined by the manufacturer and regulatory bodies. This ensures that the aircraft is in optimal condition and reduces the risk of mechanical failures.
Flight crews and ground personnel must undergo regular training on emergency response procedures. This includes handling situations like engine failures, fire emergencies, or medical incidents on board. Training ensures a quick and coordinated response to unexpected events.
Clear and concise communication is vital in aviation. Pilots and air traffic controllers must follow established communication protocols to avoid misunderstandings and ensure safe coordination during takeoff, landing, and in-flight.
Pilots must consider weather conditions when planning flights. Acceptable practices include obtaining up-to-date weather information, assessing its impact on the flight, and making informed decisions, such as diverting to an alternate airport if weather conditions deteriorate.
Aviation professionals engage in ongoing training and education to stay updated on the latest safety practices, technological advancements, and regulatory changes. This ensures that they are well-equipped to handle evolving challenges in the aviation industry.
Accurate record-keeping is essential for tracking maintenance activities, inspections, and operational details. Proper documentation helps authorities monitor compliance with safety regulations and provides a historical record for analysis and improvement.
By adhering to these acceptable work practices, the aviation industry strives to maintain a high level of safety and mitigate potential risks associated with air travel.
OVERCONTROLLING
In aviation safety, overcontrolling processes refer to situations where excessive regulations, strict procedures, or micromanagement may inadvertently hinder overall safety rather than enhance it. While regulations and procedures are crucial for maintaining regulatory compliance, an overly restrictive or bureaucratic approach can lead to unintended consequences.
Overemphasis on extensive documentation and paperwork can divert valuable resources away from actual safety measures. Pilots and maintenance crews may spend more time on administrative tasks than on addressing immediate safety concerns.
Excessive oversight and micromanagement from regulatory bodies or management can create a culture of fear and discourage open communication. This may lead to underreporting of safety concerns by frontline personnel, as they may fear punitive actions.
Overly prescriptive training programs that focus solely on compliance rather than cultivating critical thinking skills can result in pilots and other aviation professionals being ill-equipped to handle unexpected situations.
A bureaucratic approval process for implementing safety improvements may cause delays in the adoption of new technologies or procedures that could enhance safety. This delay could expose the aviation industry to unnecessary risks.
Balancing a robust safety framework with operational flexibility is crucial to ensuring that overcontrolling processes do not compromise aviation safety. Striking the right balance allows for adherence to essential safety standards while enabling quick and effective responses to dynamic and unforeseen challenges in the aviation environment.
DECISIONMAKING PROCESS
In aviation safety, decision-making processes play a critical role in ensuring the well-being of passengers, crew, and the aircraft. There are established frameworks and protocols that guide decision-making at various levels within the aviation industry.
Pilots use ADM to assess the situation, identify potential risks, and make informed decisions. For example, if a pilot encounters unexpected weather conditions, they may decide to divert to an alternate airport.
Crew Resource Management (CRM) This involves effective communication and collaboration among the flight crew. An example is when the crew identifies a discrepancy in instrument readings, they collaborate to troubleshoot and decide on appropriate corrective actions.
Air Traffic Control (ATC) Decision Making are routing and sequencing. ATC makes decisions on aircraft routing and sequencing to ensure safe and efficient air traffic flow. If there's congestion at an airport, ATC might reroute incoming flights or adjust departure schedules.
ATC may alter flight paths or ground operations in response to adverse weather conditions. For instance, during a thunderstorm, ATC might implement holding patterns or ground stops to avoid hazardous conditions.
Maintenance crews may have to decide whether to defer certain non-critical repairs to avoid delaying a flight. They consider factors such as the aircraft's overall safety and operational requirements.
When faced with a malfunction in a critical system, maintenance personnel need to decide whether the aircraft is airworthy or if it requires grounding for repairs.
Regulatory Decision Making are compliance decisions. Aviation authorities make decisions related to regulatory compliance. For example, the decision to update regulations governing flight crew duty hours in response to new data, information, knowledge and comprehension of systems.
Regulatory bodies may issue airworthiness directives requiring operators to perform specific maintenance actions or modifications based on safety concerns or identified issues.
Pilots, air traffic controllers and airport operators may have to make sound emergency decisions during in-flight emergencies or at an airport due to special cause variations. These decisions aim to ensure the safety of the aircraft and its occupants.
In all these cases, the decision-making processes involve assessing available data, information, knowledge, and comprehension when considering safety implications, and selecting the most appropriate course of action. Training, experience, and adherence to established protocols are crucial elements in the effective decision-making processes within the aviation industry.
CRITICAL THINKING
Critical thinking in aviation is crucial for ensuring safety, efficiency, and effective decision-making in a complex and dynamic environment. Aviation professionals, including pilots, air traffic controllers, and maintenance personnel, rely on critical thinking skills to assess situations, identify potential risks, and make informed decisions.
A pilot encounters unexpected weather changes during a flight. Critical thinking involves assessing the current weather conditions, understanding the potential impact on the flight path, and making decisions to ensure the safety of the passengers and crew.
An aircraft experiences a technical issue mid-flight. Critical thinking skills are employed by the flight crew to diagnose the problem, consider available solutions, and implement the appropriate corrective actions to maintain the safety of the flight.
A pilot is planning a flight through mountainous terrain. Critical thinking involves evaluating the potential risks associated with the route, considering factors like weather, altitude, and terrain clearance, and implementing strategies to mitigate those risks.
Effective communication is vital in aviation. Critical thinking is necessary for pilots and air traffic controllers to understand and convey information accurately. For instance, a pilot reporting a fuel emergency needs to communicate the severity of the situation clearly.
Aviation professionals encounter new technologies, procedures, and regulations. Critical thinking is required to adapt to changes, learn from experiences, and apply knowledge to evolving situations, contributing to ongoing safety improvements.
Critical thinking in aviation involves the ability to analyze, synthesize, and evaluate information to make well-informed decisions. It is a cornerstone of aviation safety, helping professionals navigate complex and high-stakes situations to ensure the well-being of passengers and the overall safety of air travel.
When SMS enterprises deviate from processes, special cause variations could be classified as common cause variations and assessed as a critical part of the process for the process to function. Drift is the root cause of accepting special cause variations into a process, with several sub-classification layers of. Just as the Swiss cheese model to some extent controls the locations of and size of the holes in the Swiss cheese, an SMS enterprise, both airport operators and airlines control their acceptable drift. That drift goes untouchable may not have any impact on operations or the outcome. Unintended, and unnoticeable drift does not equal a hazardous condition, but the issue is when SMS operators conducts analyses of their systems and processed, they are based on incorrect data leading operators down an unknown path. Special cause variations, such as accepting ice on the runway as common cause variation, or special cause variation, such as accepting dry snow accumulation on the wings as common cause variation, may in the future, and have in the past caused major airports and airlines occurrences.
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