[Peetwo]

Real World vs The wizards of Oz aviation safety obfuscation -   

References from AP forum this week:

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 P2 comment - Read the Ben Cook PelAir Part 2 article here: The ditching of Australian aviation governance - Part 2

»» CASA’s procedures and guidance for scoping an audit included several important aspects, but it did not formally include the nature of the operator’s activities, the inherent threats or hazards associated with those activities, and the risk controls that were important for managing those threats or hazards.
»» Consistent with widely agreed safety science principles, CASA’s approach to conducting surveillance of large charter and air ambulance operators had placed significant emphasis on systems-based audits. However, its implementation of this approach resulted in minimal emphasis on evaluating the conduct of line operations (or ‘process in practice’).

Although there are pragmatic difficulties with interviewing line personnel and conducting product surveillance of some types of operations, such methods are necessary to ensure there is a balanced approach to surveillance, particularly until CASA can be confident that operators have mature safety management systems (SMSs) in place. [If CASA surveillance is too shallow how do more senior personnel (chief pilot, standards managers, check and training pilots) know whether their own practices are adequate and
aligned with best practice?]

Ultimately, inadequate regulatory oversight also contributed heavily to a false sense of security within Pel‑Air. How devastating it must have been post accident to have CASA inspectorate staff suddenly find so many systemic issues that had not been picked up during previous CASA surveillance.

Now watch again the '$89 million bucket' video (above). Anyone else get the impression there was no love lost between the former DAS McComic and BC 

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The theme for this week's SBG revolved around the Yin and Yang - or reality vs fantasy; black hats vs white hats - of the Australian aviation safety bureaucracy. This gives me the perfect opportunity to draw attention some excellent articles, tackling the closing of safety loops, from the real world of aviation safety; rather than the self-serving, 'BOLLOCKS' bureaucratic world of aviation safety administration in Sleepy Hollow, Can'tberra:

Irony is wasted on the stupid" | AuntyPru.com : Home of PAIN :

So first from AIN magazine:

AINsight: Rogue Pilots or Just Bad Procedures?
by Stuart “Kipp” Lau[/url]
 - June 22, 2018, 8:55 AM




Procedural noncompliance is a topic that gets a lot of attention. In most recent studies, much of the focus centers on pilots who intentionally deviate from a procedure because they are either too complacent, unprofessional, or worse, just bad apples.

The “fast thinker”—those seeking cognitive ease—might buy into this notion. For them, blaming an incident or accident on a “rogue” pilot is easy. Pilots should just follow the procedures and incidents and accidents won’t occur.

Their solution: remove that individual, issue a bulletin for the rest to “comply,” and the problem will go away, right?

The “slow thinker”—those wrestling with cognitive strain—will question the notion of a “rogue” pilot, understanding that complex issues don’t have one single solution, nor will they simply go away. The solution in this case might begin with identifying the human-factors issues associated with noncompliance and a healthy reflection on the procedures themselves. Line operations safety assessments (LOSA) studies suggest a high prevalence of noncompliance often points to an ineffective or bad procedure.  

At one time, procedural noncompliance was on the NTSB’s “Most Wanted List” and currently is a top safety issue for the NBAA Safety Committee. NBAA identifies procedural noncompliance as a significant contributing factor in aircraft accidents and incidents.

Furthermore, NBAA recommends, “Aviation professionals in all vocational categories must become aware of the extent that noncompliance has proliferated in business aviation, identify the causal factors for noncompliance and develop workable solutions that eliminate these events.”

Universally, it’s recognized that good procedures ensure standard pilot actions. Likewise, pilots adhering to good procedures enhance aviation safety. Thus, there’s typically a bad outcome when pilots intentionally don’t follow procedures. In fact, it’s a very slippery downward slope.

The LOSA Collaborative, founded by Dr. James Klinect, has more than 20,000 observations in its archive. This data shows that, on average, “Flights that have two or more intentional noncompliance errors have two to three times as many mismanaged threats, errors, and undesired aircraft states as compared to flights with zero intentional noncompliance errors.”

Intentional noncompliance by pilots might be more closely related to science than bad behavior. Some human-factors studies suggest that there are a number of issues related to a pilot becoming intentionally noncompliant. Often, these pilots, given a poorly written procedure, simply do not agree with the procedure and might believe their way is better—“an informed workaround.” Others might not fully understand a procedure or the risk associated with not complying. Additional factors such as fatigue can also play a role in intentional noncompliance.

Researchers also point toward three “perceived justifications” of being noncompliant: rewarding the violator (for example, “I get home earlier if I don’t go-around”); knowledge of associated risk (for example, “My risks are justified because I know better…”); or consideration of peer reaction (for example, “My reputation precedes me. I am a good pilot.”). The trick is to break these perceptions.

Organizations also have some culpability when it comes to procedural noncompliance. Operators must understand that there are indeed bad procedures. When it comes to developing and writing good procedures, words and actions matter.

Advisory Circular 120-71B provides some outstanding guidance on the design, development, and implementation of SOPs and checklists. It goes into great detail about the importance of providing flight crews background information on a new procedure or a change in existing procedure. Background helps a crew “buy into” the procedure by providing context and relevance.

According to the AC, implementation of any procedure is most effective when the procedure is appropriate for the situation; the procedure is practical to use; crewmembers understand the reasons for the procedure; pilot flying and pilot monitoring duties are clearly defined; effective training is conducted; adherence to standard is emphasized; and crewmembers understand the risk and hazards of not following the procedures.

For any developer or manual writer, this AC is a must. As an example, the use of ambiguous words—such as should or may—often leads a crew to noncompliance, by simply giving them an option not to comply.

The AC recommends the use of more positive words—such as do and must—since they are easier to read and less likely to be misunderstood.

Procedural noncompliance is a difficult issue to identify within an organization. LOSAs, when compared to the other voluntary safety programs, are one of the most effective tools to identify procedural noncompliance by highlighting areas where it is most prevalent. From those results, an organization can determine if it’s a pilot problem or organizational problem

Pilot, safety expert, consultant, and aviation journalist Stuart “Kipp” Lau writes about flight safety and airmanship for AIN. He can be reached via email.
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Next from World renown Flight Instructor John (& Martha) King, where even Dick gets a mention... :

LET’S QUIT TALKING ABOUT SAFETY



Article appeared in Flying Magazine January 2018 by John King

“There can be no compromise with safety.” “Safety is our number one priority.” You hear these kinds of quotes all the time from well-meaning people—very often people like the Secretary of Transportation or the Administrator of the FAA. The assertions are meant to be comforting, and they are—especially after a crash. They assure the public of the firm resolve by people in power to do better. The problem is they aren’t, and can’t be, true.

You can’t start an engine without compromising safety. If safety were our number one priority, we’d never move an airplane. Clearly going somewhere is in itself a demonstration that moving the airplane ranks ahead of safety. It would always be safer to stay put. These little intellectual dishonesties tend to end discussion and substitute for genuine analysis on the subject.

It can be discomforting to talk openly and honestly about safety. So we often make false assurances and otherwise deceive ourselves. For instance, we usually talk about safety as if it were an absolute. But absolute safety is an impossibility. In reality, safety is relative. Every activity has a greater or lesser degree of risk associated with it. Still, when someone departs on a trip, we usually say, “Have a safe trip” as a polite expression of goodwill. We say this when we know having a genuinely safe trip is literally impossible.

Not only do we find it uncomfortable to admit to ourselves that we can never achieve absolute safety, but we sometimes utterly lie to ourselves in order to not have to face reality about safety. General aviation pilots used to frequently tell themselves, and their passengers, that the drive to the airport was the most dangerous part of the trip. They wanted to believe that flying their piston-engine general aviation airplane was safer than driving. When it became known that the fatality rate per mile in a general aviation airplane was seven times that of driving, they had a very hard time accepting that reality. (On the other hand, for various reasons travel on the airlines is in fact seven times safer than travel on the roads.)

Sometimes our self-deception on the subject of safety just reflects wishful thinking. After a series of commuter airline crashes, the Administrator of the FAA attempted to mandate one level of safety for little airplanes as well as big airplanes. The problem is that it is not possible for a small airplane to be as safe as a Boeing 747. Safety equipment is adds weight. A little airplane can’t carry the weight of the safety provisions of a 747. Plus, safety is expensive. A little airplane can’t afford the cost of safety equipment the way a bigger plane can. But who wants to tell that to someone about to fly in a smaller airplane?

On the other hand, when noted Australian thought-leader and avid pilot (weight-shift trikes, single-engine airplanes, helicopters, and jets) Dick Smith was Chairman of the Australian Civil Aviation Safety Authority, he steered people away from disingenuous talk about safety. He shocked people by talking about “affordable safety.” His point was that when safety becomes too expensive there can be a net reduction in safety. When excessively expensive safety measures are mandated, the cost of flying goes up. At some point people take less-safe surface transportation instead, and fatalities go up.

Another problem with the way we talk about safety has to do with how safety advice is normally given. It often provides very inadequate guidance. Safety advice usually takes a negative approach, stating what you cannot do rather than focusing on positive things you should do. In many cases it is limited to a hodgepodge of rules and sayings. The rules and sayings may all be good, but they are not adequate, because they fail to provide the big picture and structure.

Moreover, safety advice can even generate resistance. It can be preachy—taking on an off-putting air of smugness and superiority. It is not uncommon for advisors to suggest that someone does not exercise proper “judgment” or “aeronautical decision-making.” This comes across as a vague, demeaning criticism, but once again, with very little guidance.

So what is the alternative?

We need to change our vocabulary. In nearly every case, it is more insightful and helpful to talk about risk management. The concept of risk management suggests a proactive habit of identifying risks, assessing them, and exploring mitigation strategies for them. Those words “risk management” provide much-needed guidance about what people should do to get a safer outcome, in a way that the condescending criticisms, and emphasis on “safety,” do not.

One of the problems about the way we sometimes use the word “safety” is that if someone wants something done a certain way, they can often just simply trot out the word “safety,” or for that matter, “security,” and get carte blanche with little analysis. But the words “risk management” require a more thoughtful discussion—including in most cases identification and assessment of the risks and the appropriateness of the mitigation strategies.

When an aviation tragedy occurs, rather than trying to reassure and comfort people by promising things that are not possible, aviation leaders should say, “Our job is to understand the risk management failures that allowed this to happen and see that they do not occur again.”

Much to their credit, the FAA’s Flight Standards Service has embraced “risked-based decision-making” as one of its core values. The idea is that in this business of creating rules about how aviation should be run, they will now think in terms of the risks of an activity. Every safety measure has a trade-off in loss of fun and utility. When risked-based decision-making is a core value, that trade-off will be taken into consideration during rule-making.

The good news is that much of the aviation community is now focused on “risk management” rather than “safety.” First, flight schools are moving towards scenario-based training in order to help pilots learn risk management. The idea is to give a learning pilot the tools to habitually identify, assess, and mitigate risk. Then when that pilot is evaluated during the practical test, the FAA’s new Airman Certification Standards (ACS) require their risk management to be evaluated in every area of operation.

Martha and I have been promoting straight talk about safety for years. We finally figured we must be making progress when an attendee came up to us after a talk and said, “Have a relatively safe trip home.”[/size][/color]

 JK - Choccy frog is in the mail...  


MTF...P2