The ones that didn't get away
In the past it was believed that by simply following rules or SOP’s everything would be fine. It was the role of the Quality department to monitor that everyone followed the rules. However the rules could not cover all eventualities.
As human beings we will always make mistakes. Our SOP’s will attempt to limit the affects these may have on our performance, however distractions, interruptions, technical issues, fatigue or any combination of other factors will invariably lead to some sort of issues.
The occurrences that you mention are exactly that, OCCURRENCES which further develop into INCIDENTS and eventually ACCIDENTS. Therefore about three years ago ICAO mandated that airlines set up Safety Management Systems to try to pro-actively predict THREATS which might in the future lead to accidents or incidents. These would have to be weeded out. Just like the reason model of holes in Swiss cheese lining up, an attempt would be made to assess and categorize each THREAT and perform a risk assessment on it in or to TRAP, MITIGATE, or AVIOD these issues.
Using the iceberg model it was determined OCCURRENCES amounted to 99.5%, INCIDENTS accounted for 0.49% and, ACCIDENTS 0.01%, based on ASR’s filed by 121/135 operators to the FAA in 2000.
As SMS is a very new concept, many airlines do not fully know how to utilize it yet. What makes an SMS system work is the amount of data available to try and detect dangerous trends. As mentioned above FDM, FOQA, QAR will help identify some trends but may not pick some things up. Another common trend is to have safety audits, but once again it is difficult to cast a wide enough net to pick up real threats. In order to assist with gathering safety information some airlines have setup telephone hotlines, confidential reporting systems or even web forums.
Most important however for this system to work is to have a NON PUNITIVE REPORTING SYSTEM and an OPEN and FAIR company culture. Only when you start to share those experiences where you think you had a close shave can other people start to benefit from your experience as well as finding way to rectify the situation in the future.
If people simply decide to go for a pint and forget about the issue after one such close shave then that is a shame, as useful information that could have helped someone else will get lost. In some cases it may not be fully lost as it works its’ way around the airline on the grapevine with people say “watch out here, as this happened to me…”
If this were the case however that would be a clear indication that the message from the Safety department isn’t getting through or that the company must make a greater effort to create an open working environment, as the company are often the ones who have the correct tools to try and fix issues.