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About Signal Charlie
HF & SMS Seminar
by Kent Lewis
“Safety Promotion requires creating an environment where safety objectives can be achieved” (FAA ANPRM 2010)
Promotion of safety systems is one of the most important discussions that will be in a high reliability organization. There is much written on policy and risk management, but philosophies and tools will be most effective if the right message is communicated effectively at the right time, among the people who will use these tools and put philosophy into practice. This chapter could be titled Safety Communication or Safety Information, but “Safety Promotion” adds a positive, collaborative character to the process of sharing information within an organization in order to increase the safety knowledge base.
In order to effectively promote operational safety within an organization, it is essential to create an open environment of knowledge sharing and learning. Assessments of human performance and behavior will be the best indicators of safety health and provide opportunities to develop continuous improvements to a safety management system. Many times a safety program is “promoted” in a one dimensional fashion, information is transmitted from organizations or regulators and there is little or no opportunity for feedback from those tasked with interpreting safety philosophy and turning procedures into practice. This approach to “checking the blocks” is most likely found in a pathological or bureaucratic organization. Performance is measured in an audit fashion and when vagaries in the system appear, a “blame and train” mentality is taken to address past behavior, in hopes of preventing future recurrence. This “promotion” of safety can most often be identified by safety bulletins that exhort increased attention to vigilance, situational awareness and warnings to combat complacency. If any attempt was made to examine the multiple situational factors that lead to divergence from expected system norms, behaviors and expectations, it is usually not shared in communications but rather buried deep in investigation reports. By taking a proactive approach, essential knowledge is shared with the people who will benefit most from the information, and system operators become excited about the collegial aspects of information sharing. Some other indicators of safety health are dedication of resources for safety programs in terms of direct budget control or human resources, provisions for training in safety management systems for everyone in the organization, enabled by education and experience of key safety personnel. This approach is farsighted; adequate resources, training and experience are necessary to properly manage and operate a system safely. One current threat to the system is a failure to capitalize of the strengths afforded organizations in the information age. In order for systems to adopt a proactive or generative approach, information must flow freely throughout the entire system, barriers to communication must be removed and safety information should only be used for the purposes of enhancing safety, not for criminal and civil litigation or punitive purposes. This lingering reluctance by States to address best practices can be overcome if international safety values are defined and adopted. There has been much discussion on the important role that a positive safety culture plays within an organization, and that same culture must be embraced by system regulators and operators. With shared values, a systems approach will flourish. Leaders for this initiative will be found at all levels of the system, and those providing information to the pool of operational safety knowledge are the most valued promoters. Positive indicators of this type of system are open access to information and active involvement in the event reporting process by all personnel.
Recipe for Success: A Four Step Plan.
2. Work Together
Simple enough, right? You probably could stop reading right here, but you’ve invested this much time in the book already, so hang a round for a few more pages. Let’s discuss the first ingredient, communications. Why are communications important? Communications are important because that is how information is transferred. A message is sent and we hope someone not only receives it but also understands the content. Some type of feedback is necessary to ensure that the message is understood, and in aviation we even have controlled vocabulary to acknowledge understanding of a message, “roger” or willingness to comply, “wilco.” If the message is not understood or contains incorrect information, then a path is needed to ensure that correct information is obtained. A good system offers opportunities for people to talk and listen, and good resource managers gather information from all sources to make the best decisions. This is important for safety promotion, because it is important to transmit the right message in a team environment. Shared cultures, shared goals and shared mental models are essential foundations of safety promotion, everyone on the team needs to be pulling in the same direction or it will be difficult to balance system conflicts between production and protection. When these conflicts develop, high functioning teams identify threats and deal with them in a safe, efficient manner because they have shared understanding of organizational philosophies, policies, procedures and practices. When operations begin a drift away from expected norms, team members can communicate to find the most effective solutions to return a system to its normal state. An operational example of this would be dispatchers sharing time critical information about enroute turbulence to a flight crew, so that proactive measures can be taken to change routes or altitudes, and to ensure the safety of cabin crews and passengers. Another example is conducting safety seminars, where information on operational issues, ongoing research and lessons learned can be discussed and action plans crafted to address hazards to operational safety. Modern day communications include platforms such as facebook, twitter, webinars and you tube. The model with these mediums is to share early and to share often in a social networking environment. This social contact enhances learning, the medium is simple and consistent, and relevant, timely lessons can be shared.
It is critical to mention once more that everyone on the team must be involved in this communication and there must be a joint responsibility to promote an open, informed and just culture of knowledge sharing. “The organization should promote safety as a core value” (FAA AC 120-92 2006, App. 1). High functioning teams often define core values as part of their mission and vision statements, one example is the United States Marine Corps, whose core values are “Honor, Courage and Commitment.” The Marine Corps operational doctrine rests solidly on a foundation of a combined arms concept, it is an Air-Land-Sea combat system charged with the mission of seizing and defending advanced naval bases. Operational safety is an important component of this mission, and resources must be protected in order to complete the mission. The number one responsibility for every unit commander was to take care your Marines. If you took care of your Marines, they would take care of the mission. Time and time again there are proven cases in the military where leading causes of loss were not from combat operations, but rather from training or administrative evolutions. After the Persian Gulf War of 1990-91, more Marines were lost the first six months in off duty mishaps than during the seven months of Operations Desert Shield and Desert Storm. There are no missions in peacetime that justify the loss of personnel or property, and even in wartime the right mix of knowledge, training, communication, resources and skill will guarantee a successful outcome. Safety is a core value that should be adopted by high reliability organizations to ensure the same successful outcome.
Organizations must work together, both internally and with external agencies to accomplish organizational goals. Safety must be inherent and embedded with those goals, and placed at the appropriate level to ensure production is also optimized. When production goals increase, safety goals must also increase to maintain a balance. Operational risk decision makers must maintain accountability by ensuring safety stays at the same level or moves to a higher level, adjusting risk controls as warranted. Within a SMS, this can be accomplished by training and dissemination of information (FAA SMS 2007, 8.3):
-Employees must understand the SMS.
-Employees benefit from safety lessons learned.
-Explain WHY particular actions were taken.
-Develop a positive safety culture.
-Promotion is continuous, just like camouflage.
It may be obvious that the author of this section has a military background, and “Everything I need to know about safety I learned in the Marine Corps.” There was a great deal of thought put into developing aviation safety programs that combined education of Aviation Safety Officers (ASO) on reporting, aero structures, human factors, fixed wing and rotary wing aerodynamics, mishap investigation and command programs with a Commander’s leadership course in aviation safety. This was a team concept also, and to borrow the term “gung ho,” which the Marines adopted from the Chinese, teams worked together to safely accomplish the mission. This is the second ingredient in the promotion process. The team forms a cooperative with shared mission, vision and goals and leadership is apparent at every level of the organization. Promotion of safety is not the sole responsibility of a safety manager, but rather it is inherent in everyone’s mission. There is a visible dedication to this value from management, regulators, manufacturers as well as employees and other team members. Communications are blended with command, control and information systems to ensure that proper resources are allocated and a clear, consistent message is delivered. Conflict can develop if safety management is not blended properly with business management, because the primary commitment of SMS is not to create a product but rather to maintaining processes or systems. These processes are founded on leadership principles such as knowledge, justice and “ethical standards of behavior as well as intellectual integrity and sound thinking. Resources are always scarce and there is always competition for them, but the battles over resources are fundamentally contests to assure that these basic processes are properly supported” (Swigger, 2010). This previous statement was taken from a discussion in a Master’s course on governance for academic libraries, as an illustration of the universal nature of team challenges to resource management. “Properly supported” is a case that often gets disputed, but if a team starts out with the same fundamental values and goals, the gaps between production and protection can be identified and sealed. Information transfer is key to the optimization of resource utilization, and most mishaps have roots in failures of an information system. The right information was not identified and provided to the right people at the right time. Certification standards may not have been communicated or properly developed, or runway conditions reported in an ambiguous manner. Crew alerting systems may not have had salient enough cues, or a Quick Reference Handbook may contain outdated information. There are information search and retrieval challenges of great magnitude in high reliability organizations, and those who address these challenges up front as a team and communicate efficiently will ensure the greatest success. Information must be shared so safety critical tasks are properly trained and team members are made aware of hazardous areas of operation. The mission must be well defined and understood, especially with respect to threats to the operation. As mentioned in the risk management section, threats can be mitigated through avoidance or transfer, or through appropriate risk controls. Threats can also be controlled by sharing information and acting on “lessons learned” to continuously improve the system. “Lessons learned” must be incorporated into learning systems that educate personnel in State safety systems, manufacturers, airports and air traffic personnel, as well as educational and awareness programs for operational personnel.
The third ingredient in safety promotion is education. Safety is not necessarily a product, but rather a system that contains tightly coupled processes. Education is necessary to develop understanding of the nature of the system, as well as roles and responsibilities to maintain the system in the desired state. Education programs may take many forms, perhaps the form of a seminar, newsletter or an informational website. Regardless of the form, user needs must be recognized and the appropriate messages must be communicated. There are many excellent examples of education materials addressing operational safety, one is the website SKYbrary (
) a collaboration between Eurocontrol, Flight Safety Foundation, ICAO, UK Flight Safety Committee, European Strategic Safety Initiative and the International Federation of Airworthiness. The US Federal Aviation Administration (
) and Transport Canada (
) both have excellent information available on their websites. Flight Safety Foundation (
) and Aircraft Owners and Pilots Association (
) offer free safety information on their websites. Curt Lewis and Associates also offer a free flight safety information newsletter (
). Traditional sources of information cannot be emphasized enough, as public and academic libraries hold treasure chests full of information, and web technologies lend themselves to development of open access journals that report on the latest research.
Communication and education is about the transfer of information, and emerging web technologies need to be examined to better understand the future roles they play in safety promotion. Web 2.0 technologies offer collaborative platforms where team members can share information in an efficient manner beyond the applications of static websites that are “transmit only.” These technologies “facilitate interactive information sharing, interoperability, user-centered design and collaboration” (Wikipedia Web 2.0 2010). One example is the aerospace safety wikispace Signal Charlie (
). Utilizing this platform, timely information is shared globally. Web 2.0 technologies allow qualitative aspects of promotion to emerge that complement the quantitative nature of audits, aviation safety reporting systems (ASRS), flight operations quality assurance (FOQA) programs and aviation safety action programs (ASAP). New web architecture allows information to emerge from a static state into a dynamic platform that is more representative of and compatible with the latest generations of safety systems. This information conduit is an excellent partner to traditional methods of safety promotion such as bulletin boards, forums, seminars, magazines, and other multimedia materials. One last comment on safety management systems in the information age; it is imperative that library and information systems be developed to capture and preserve corporate knowledge, capitalize on the lessons learned and minimize the weaknesses inherent in safety promotion and communications. Information systems facilitate sharing of information, stimulate thinking and enable development of industry standards and recommended practices. This helps to keep us from “re-learning” lessons the hard way. By sharing information, knowledge is enhanced and the best return on investments in operational safety can be realized.
No systems approach would be complete without a mechanism to evaluate system behavior. This fourth ingredient is essential in developing a SMS. In the simplest form, we want to see if we are doing what we said we were going to do and observing the system to see if we are getting the desired results. If the answer is no to either assessment, then change is needed to ensure that practice matches procedure, and output meets desired goals. One example for this process is the found in the U. S. Navy, where teams from the Naval Safety Center or sister squadrons would conduct a safety audit on a unit to determine its safety health. These audits would be in addition to unit evaluations, or in the civilian world quality assurance and air transportation oversight systems. There are many ways to assess an organization’s performance, and one of those ways must address measuring the effectiveness of the safety management system.
Safety promotion allows us to address issues of mutual concern, such as the challenge of managing human performance in high reliability, tightly coupled systems. In the late 1990s the FAA, NASA and Department of Defense crafted the National Plan for Civil Aviation Human Factors (Signal Charlie 2010). This plan has since been superseded by the work of the Commercial Air Safety Team (CAST) but there were two important goals identified.
1. Reducing error in human-system interactions.
2. Increase efficiency of human-system performance.
A national agenda was developed that focused on research and application of research. It is within the area of research applications where we find comparative attributes of a 21st Century SMS:
1. Create environment for change.
2. Develop HF education and training programs at all levels
3. Equip personnel and facilities with modern tools and techniques of the HF engineering discipline.
4. Develop infrastructure to translate and disseminate human factors products.
With only a small amount of imagination these tasks can be expanded to meet the promotion goals within a SMS. An example of this plan in action can be found by looking at the FAA Safety Team (FAASTeam 2010), where government program managers team with volunteer representatives and industry members to promote aviation safety. Two core components of this initiative are promotion of awareness and education for SMS and human factors, and as a team we will develop tools to continuously improve and promote aviation safety. National programs such as these increase access to information from mishap investigations, incident reporting, trend analysis and safety databases. The NASA ASRS database online is the largest repository of aviation safety information, and uses both qualitative and quantitative methods to assess data and provide information to system agents who can effect change (NASA ASRS 2010). Individuals as well as large organizations can access this data and develop a scalable, comprehensive approach to safety management.
It is important to communicate, work together, continue learning and measure the success of a SMS. Awareness and education is required at all levels of an organization, and those charged with development of a SMS should possess the necessary experience and education to mentor fellow team members and guide a learning system. “Management recognizes that all levels of the organization require training in safety management and that needs vary across the organization” (ICAO Safety Management Manual 2010, 15.9.1). It is necessary for managers to have a deep understanding of safety systems, otherwise there is a risk of a shallow “sticker safety” campaign developing that has no substance or support from top leaders. The message and the medium are important, and must be tailored to the audience. Embry Riddle Aeronautical University, the Transportation Institute and the University of Southern California’s Viterbi School of Engineering are just a few examples of organizations that provide quality education on SMS to industry professionals, and this type of education is essential to manage a safety system.
Restricting the flow of information for fear that learners will be overwhelmed is to be guarded against; instead it is rewarding to see when mutual respect is shared among team members and collegial learning develops as a result. And while the law of least effort applies in many circumstances, access for all to critical safety information should be the goal for a SMS. Promotion of safety is essential communication between team members that must take place in order to ensure safe operation of the system. Education and assessment are also key ingredients. When we couple the power of knowledge with the right attitude, operational safety performance will attain new heights.
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About the author:
Kent Lewis is an Air Transport Pilot currently flying with Delta Air Lines in Atlanta, Georgia. He has international flying experience on the Boeing 777 and currently flies the MD-88. Kent graduated with Honors from the U.S. Navy Postgraduate School’s Aviation Safety Officer course, and was the Director of Safety and Standardization at MCAS Yuma, the largest aviation training facility in the United States and was previously the Safety Department Head at VT-27, the Navy’s busiest aviation training squadron. His safety programs have been recognized as the best in the Navy/Marine Corps and have a zero mishap rate. He currently volunteers as the Director of Safety at the Vintage Flying Museum in Ft Worth, TX and owns the safety website www.signalcharlie.net. Kent also volunteers as a FAA Safety Team Lead Representative for the Ft Worth FSDO, and he was selected as the 2009 National FAASTeam Representative of the Year. He has attended the Air Line Pilots Association Basic Safety School, Safety Two School, Accident Investigation 2 (AI2), Advanced Accident Investigation course (AI3), FAA SMS Standardization course and FAA Root Cause Analysis Training. Kent's focus is Human Factors and System Safety. Current committee work includes ALPA SMS and Human Factors, and FAA Runway Safety Root Cause Analysis Team, as well as teaching the Human Factors module in ALPA's Accident Investigation-2 course. As the ALPA Atlanta Council 44 Safety Chairman, he represents over 3500 of his fellow pilots on aviation safety matters.
Kent is a graduate of the University of Texas at Austin, with a Bachelor of Arts degree in History. He is currently pursuing a Masters in Library Science at Texas Woman's University.
Kent was a flight instructor while in the U.S. Marine Corps, teaching all phases of the fight curriculum to Navy and Marine primary and intermediate students in the T-34C, a fixed wing turboprop trainer. He also flew helicopters and was a Terrain Flight, Search And Rescue and Night Vision Goggle Instructor. In 1998 he was qualified as a Aircrew Coordination Training Facilitator. He gained certification with the FAA to be a Certificated Flight Instructor, Instrument Instructor and Multi-engine Instructor in airplanes.
Kent is a member of the International Society of Air Safety Investigators, American Library Association, Air Line Pilots Association, Aircraft Owners and Pilots Association, Society of Aviation and Flight Educators, Ancient Order of Shellbacks, and the National Association of Flight Instructors.
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