Are we facing a safety issue?
CRM is more difficult in a medical setting as sometimes it is hard to define a team. In an operating room there isnt one "captain" but three: the surgeon, the anasthesiologist and the nurse in charge. All are aimed at the successful completion of the surgery and are interdependent, but each has the final say for their own particular role in the surgery. No one person has complete control over the OR. Conflict ensues when the aims of each role diverge.
Possible? Framer.
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I am a pilot, not an economist. But it's clear to me that full deregulation of airlines simply does not work. At least not in the pilots favor. Over the last few years airlines have constantly been cutting costs, often from the personnels pockets.
Its the most bizarre scenario really! If the oil price increases, gas prices increase, and therefore ticket prices should increase proportionally. But instead fierce competition between the airlines drives them to cut salaries instead of increase prices. Surely some sort of dynamic laws will have to be introduced to prevent this. If all the airlines had to increase their prices, then the competition would remain the same. Surely a passenger would pay an extra 1$, but be sure that there is a competent person at the sharp end, who is not a millionaire, but has a decent lifestyle and gets treated well.
If this continues, clever people will turn away from becoming pilots and we will end up with a bunch of nitwits and hillbillies flying buses in the air. Sad really!
Its the most bizarre scenario really! If the oil price increases, gas prices increase, and therefore ticket prices should increase proportionally. But instead fierce competition between the airlines drives them to cut salaries instead of increase prices. Surely some sort of dynamic laws will have to be introduced to prevent this. If all the airlines had to increase their prices, then the competition would remain the same. Surely a passenger would pay an extra 1$, but be sure that there is a competent person at the sharp end, who is not a millionaire, but has a decent lifestyle and gets treated well.
If this continues, clever people will turn away from becoming pilots and we will end up with a bunch of nitwits and hillbillies flying buses in the air. Sad really!
Paxing All Over The World
Regular PAX speaking, although from a flying family and nephew is current RHS on 738. I have read the complete thread and am going to be pessimistic in this post.
The comparisons with the financial world are more than apt. I was working for an American merchant bank in the late 80s (in telecommunications) and saw outsourcing start. I knew it was going to be bad but did not realise quite what a tip-of-the-iceberg it was. However, the financial prang of a year ago did not surprise and there is clearly more bad times to come. That is because not enough people have yet suffered financial crisis. I know that seems harsh to those who have - but if bonus' are being paid so soon, then there is more pain to come.
The comparisons with the medical world are also I apt and I suggest the problem is NOT in the operating theatre but at the bedside. When the consultant is making the diagnosis and deciding on treatment they ARE 'god' (at least in the UK). I have seen and heard many stories of the doctor (or nurse) not being challenged on the basis of common sense and what can be seen from the history chart. One area they have improved is that, before an operation, they now mark your body with a black felt-tip pen. This was because of too many times when the wrong knee/kidney/leg was operated on.
gravity enemy
I think that many bright people will continue to want to be pilots and will do their very best to overcome the new limitations. I also think that they will be killed along with the others.
mercurydancer
Me either but we all know it ain't gonna happen! The money would be siphoned off faster than a 3rd world dictator takes the profits of his country.
DingerX
THANK YOU. one of the single most interesting observations I have seen in years.
It is human nature to repeat ourselves and our history. We often learn that 'new' ideas were well established in civilisations 1000 years ago. We did not learn the lessons of October 1929 and we are paying for it now. We have become complacent about prangs and we are going to have more of them.
Why? Because the only thing that changes human behaviour is money and death. It is the desire for more money that is making the industry less safe and the bell-curve is more advanced than many realise. Once more deaths occur (= less money due to costs and failing bookings) then the industry will have some bright ideas about how to improve it.
There is a well know French expression:
Plus ça change, plus c'est le męme chose
The more things change, the more things remain the same.
The comparisons with the financial world are more than apt. I was working for an American merchant bank in the late 80s (in telecommunications) and saw outsourcing start. I knew it was going to be bad but did not realise quite what a tip-of-the-iceberg it was. However, the financial prang of a year ago did not surprise and there is clearly more bad times to come. That is because not enough people have yet suffered financial crisis. I know that seems harsh to those who have - but if bonus' are being paid so soon, then there is more pain to come.
The comparisons with the medical world are also I apt and I suggest the problem is NOT in the operating theatre but at the bedside. When the consultant is making the diagnosis and deciding on treatment they ARE 'god' (at least in the UK). I have seen and heard many stories of the doctor (or nurse) not being challenged on the basis of common sense and what can be seen from the history chart. One area they have improved is that, before an operation, they now mark your body with a black felt-tip pen. This was because of too many times when the wrong knee/kidney/leg was operated on.
gravity enemy
If this continues, clever people will turn away from becoming pilots and we will end up with a bunch of nitwits and hillbillies flying buses in the air.
mercurydancer
As a matter of essential importance, the raising of air fares for the adequate training of air crew wont meet any objection from the vast majority of passengers. I certainly wouldn't object.
DingerX
Charging for meals may make a few bucks, but even giving out free crackers will calm the folks down and establish the proper power dynamic (provider-client as opposed to servant-patron), which, by the way, will help tremendously in an emergency.
It is human nature to repeat ourselves and our history. We often learn that 'new' ideas were well established in civilisations 1000 years ago. We did not learn the lessons of October 1929 and we are paying for it now. We have become complacent about prangs and we are going to have more of them.
Why? Because the only thing that changes human behaviour is money and death. It is the desire for more money that is making the industry less safe and the bell-curve is more advanced than many realise. Once more deaths occur (= less money due to costs and failing bookings) then the industry will have some bright ideas about how to improve it.
There is a well know French expression:
Plus ça change, plus c'est le męme chose
The more things change, the more things remain the same.
Some Points to Ponder
Safety is gained by knowledge
Knowledge in a highly technical environment is gained by Lessons Learned.
I contend that we aren't completely ignorant, but instead something is standing in the way of Lessons Learned.
I don't put money in the forefront but rather arrogance the kind of stuff like
it can't/won't happen to me because (fill in the blank)
so how do we address this?
Knowledge in a highly technical environment is gained by Lessons Learned.
I contend that we aren't completely ignorant, but instead something is standing in the way of Lessons Learned.
I don't put money in the forefront but rather arrogance the kind of stuff like
it can't/won't happen to me because (fill in the blank)
so how do we address this?
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I guess someone is going to have to explain to me why anyone starts a business. Is it to ensure that the employees are paid handsomely, provided unequalled benefits and a glowing retirement? Or is it to make money for the person owning (and perhaps running) the business? Why would an airline be any different than a hamburger stand? Yes, it true that airlines provide an essential service that the economy has become quite dependent upon … and to that extent, the folks who are responsible for the economy probably need to take heed regarding the perils and successes of the airline business. But, who are those who are those people responsible for the economy? Who controls the economy? Anyone? Is it the government? I’ll ask you, what does a government do that no one else can do and does it better than anyone could, even if someone else wanted to do it? Whose money would a government use as the “front” money to get a business started? Who would reap the profits … assuming there were any profits to reap? If the government doesn’t actually run the business, should the government step in and set limits on people’s salaries in any/every business? How about limits on what a business can charge for a product or service or, perhaps, all products and services? Would all products and services have to meet some level of acceptability? For example, should only 4-star hotels be allowed to rent rooms over night? Who would hand out the “Stars?” The government? Should the government decide where a business is located, or what goods or services they produce or provide? Where does government’s role in the conduct of business start and stop? Should the government decide who works where – or should the government have the authority to tell a business owner who they should hire … how many employees they need … and what each should be paid? Should the government keep very careful track of the cost of raw materials and force companies to increase or decrease the price of goods or services if that business is affected in any way by the raw material price changes? How big would that government have to be to do these things – and what source of funding would be provided for the government to maintain those records and keep tabs on those businesses?
-OR-
Should the government set minimum safety standards, applicable to everyone and keep it’s nose out of the rest your/his/her business?
-OR-
Should the government set minimum safety standards, applicable to everyone and keep it’s nose out of the rest your/his/her business?
lomapaseo;
Organizations which have not had a major accident with which to deal are prone to an unusual arrogance with regard to examining information which is contrary to their collective self-image or "culture".
Curiously, these are the airlines which are most at risk because production-driven managers see their priorities and their behaviours as "successful" and see no reason to change because they have already "learnt".
NASA
Despite clear precursors in their operational data, NASA continued to operate the shuttle with ongoing O-ring anomalies and foam-shedding. Both precursors had signficant and numerous data-points throughout years of operations. Such anomalies were "normalized" into each launch, to the point where serious questions could not be asked of the engineering people without concurrent heavy resistance from a "can-do" mentality.
The key to understanding this is the question always asked by "production-minded" managers, "so if you think we're not safe to operate, where are the accidents to prove your point?" In other words, precursors to accidents are not taken as "real", nor are near misses. The notion of "luck" and "skill" are often invoked in such a mentality.
The Concorde accident was the result of the same kind of thinking. There were many, many data points indicating that shrapnel from tires shredding retread material could and in some cases did, damage the wings and compromise the fuel tanks. A flight out of (I believe) Washington DC actually caught fire when the tank was holed by shrapnel but the fire did not continue.
To cite an example much closer to the homes of most airlines, the Australian Accident Board's report on QANTAS' B-744 overrun at Bangkok stated quite succinctly that the overrun accident was in their flight data in the years leading up to the overrun. Reduced flap settings and idle reverse plus high speeds over the fence and long landings were all in the data but nothing was done to address these issues and so they continued to build data-points. The accident occurred when, as always, several other issues coincided in combination with these factors. The accident was "preventable" (by changing the approach SOPs) but the data cannot tell an airline "which airplane, which day?"
I know another airline in which this very same phenomenon is occurring even as I write but the holes haven't lined up yet; but they will. The data is telling them something, in fact a number of things, that production-minded managers have so far ignored because they have a habit of "explaining away" the outliers and reflecting on and otherwise being satisfied with, an admirable, relatively accident-free history.
Your question may be posed on many levels and thus any tentative response must be understood on these different levels, to be effective and implementable.
First, we must recognize that we are seeing fatal accidents of a different nature today than just twenty years ago, a very short time in this business. Twenty years ago, mid-air collision, CFIT and a few mode-confusion causes were seen. Off the top of my head, we have at least a dozen, possible thirteen major loss-of-control accidents in the last eight or nine years* in which training, competency, skill or situational awareness are a signficant part of the discussion on causes of these accidents.
We may examine a single "event" in the data and pose one response which may resolve that one issue, once, and it may re-occur because it is not "learned from". We may move to a much broader view and discuss how deregulation of the airlines has provided fertile ground for the emergence of serious but thus-far latent systemic safety issues. Such discussions can't resolve individual problems but can point to revisions of a system which preclude the worst of individual events.
It is important to be able to move within these levels but I wonder if most airline CEOs are capable of such thinking these days with production pressures so high? In such cases we must turn to other areas in which to work and otherwise evoke a response that suitably addresses the precursors of an accident without instilling an irrationality to the operation.
We obviously can't "re-regulate" and expect to solve the problem at that very high level of systemic cause. What's next?
Next level "down" might be defined in terms of SMS. If the regulator continues or returns to a level of oversight such that airlines will not or cannot get away with cutting corners by privileging commercial priorities over safety priorities, then SMS will survive as a very effective data-driven safety system just as it was originally conceived.
What is next follows on SMS. Data analysis by competent, experienced individuals including pilots and not just amateur interns who are paid next to nothing, is the least harmful, least expensive and most benign response possible: I think looking at and understanding the data in terms of "precursors" is where the solution and the answer to your question lies. The difficulty is, being shown information that "all is not well" interferes with egos and the self-image of the airline as a completely safe operation, and therefore intereferes with the feedback process which is essential to "learning lessons". How do we address this?
We accomplish this by using the lessons learnt by NASA as a result of the Challenger and Columbia accidents and which are extremely well documented and openly available in just two very good books, "The Challenger Launch Decision" by Diane Vaughan, and "Organization at the Limit" by William Starbuck and Moshe Farjoun.
We first examine the theme of these easy lessons then we examine how such lessons may be tailored to our own operation. Then we take it to the practical level, using materials which reflect our own operations "at the street level", turning theoretical work into practical approaches to daily safety issues. Culture is informed by the data, and the value of data is enhanced and valued within the culture.
The questions asked are the most important. Bill Starbuck's paper, "Fine-tuning the Odds Until Something Breaks" is also well worth reading but many works by for example Sidney Dekker, now address these issues in a much more practical way for those airlines that are serious about knowing and learning.
This is what I meant by "what", not "who" in the discussion above. Where "learning the lesson" fails and arrogance wins, we will always find that what took the organization off the right course was "who", never "what".
If an airline either does not use, look at or respond to their data (or doesn't even do data collection except to tick the box), then there is effectively nothing to be done. Organizations cannot be "forced" to be safe, especially when they can point to their record of "no accidents", or "explanable accidents".
Data analysis works because recognition is the first step to addressing a problem if there is one. Then avoiding denial is the next step followed by defining the problem using experienced people examining the data and addressing the SOP or the procedure then publishing the results in their ops manals.
Of course, as we have discussed here and elsewhere, this assumes an airline is first of all aware of these issues (that it may be 'at risk' even though they dont' want to think so) and that they wish to do something about a problem which is showing up in the data.
One can work "inside", with similar-minded people who also have the power and courage to do the right thing. That happens once in a while and we shouldn't be too idealistic - it works and is sometimes needed.
Short of reasonably-expected intelligent responses or working with those outside the organization but who have the power to enact change, the alternative frankly, is "heroic action" - the kind of direct action that, for example, Greenpeace, Amnesty International and thousands of other groups engage in. Whistle-blowing actions for example are both short-term solutions and far riskier in terms of achieving the originally-conceived goals. In other words, unless an organization is cognizant of all aspects of its operation and not just the commercial, profit-making aspects, sooner or later, in a relatively high-risk operation such as aviation, the outcomes are well understood.
If the airline isn't doing any of this on a daily basis then nothing has been learnt and the answer to your question is, there is nothing to be done except to wait; the airline is on it's way to learning from an accident. Just ask NASA.
* Gulfair 320, Armavia Air 320, TAM 320, Spanair MD83, Turkish B737, Colgan Q400, One-Two-Go MD82, Garuda B737, Comair CRJ, Pinnacle CRJ, Helios B737, Adam Air B737, possibly AF447...
so how do we address this?
Curiously, these are the airlines which are most at risk because production-driven managers see their priorities and their behaviours as "successful" and see no reason to change because they have already "learnt".
NASA
Despite clear precursors in their operational data, NASA continued to operate the shuttle with ongoing O-ring anomalies and foam-shedding. Both precursors had signficant and numerous data-points throughout years of operations. Such anomalies were "normalized" into each launch, to the point where serious questions could not be asked of the engineering people without concurrent heavy resistance from a "can-do" mentality.
The key to understanding this is the question always asked by "production-minded" managers, "so if you think we're not safe to operate, where are the accidents to prove your point?" In other words, precursors to accidents are not taken as "real", nor are near misses. The notion of "luck" and "skill" are often invoked in such a mentality.
The Concorde accident was the result of the same kind of thinking. There were many, many data points indicating that shrapnel from tires shredding retread material could and in some cases did, damage the wings and compromise the fuel tanks. A flight out of (I believe) Washington DC actually caught fire when the tank was holed by shrapnel but the fire did not continue.
To cite an example much closer to the homes of most airlines, the Australian Accident Board's report on QANTAS' B-744 overrun at Bangkok stated quite succinctly that the overrun accident was in their flight data in the years leading up to the overrun. Reduced flap settings and idle reverse plus high speeds over the fence and long landings were all in the data but nothing was done to address these issues and so they continued to build data-points. The accident occurred when, as always, several other issues coincided in combination with these factors. The accident was "preventable" (by changing the approach SOPs) but the data cannot tell an airline "which airplane, which day?"
I know another airline in which this very same phenomenon is occurring even as I write but the holes haven't lined up yet; but they will. The data is telling them something, in fact a number of things, that production-minded managers have so far ignored because they have a habit of "explaining away" the outliers and reflecting on and otherwise being satisfied with, an admirable, relatively accident-free history.
Your question may be posed on many levels and thus any tentative response must be understood on these different levels, to be effective and implementable.
First, we must recognize that we are seeing fatal accidents of a different nature today than just twenty years ago, a very short time in this business. Twenty years ago, mid-air collision, CFIT and a few mode-confusion causes were seen. Off the top of my head, we have at least a dozen, possible thirteen major loss-of-control accidents in the last eight or nine years* in which training, competency, skill or situational awareness are a signficant part of the discussion on causes of these accidents.
We may examine a single "event" in the data and pose one response which may resolve that one issue, once, and it may re-occur because it is not "learned from". We may move to a much broader view and discuss how deregulation of the airlines has provided fertile ground for the emergence of serious but thus-far latent systemic safety issues. Such discussions can't resolve individual problems but can point to revisions of a system which preclude the worst of individual events.
It is important to be able to move within these levels but I wonder if most airline CEOs are capable of such thinking these days with production pressures so high? In such cases we must turn to other areas in which to work and otherwise evoke a response that suitably addresses the precursors of an accident without instilling an irrationality to the operation.
We obviously can't "re-regulate" and expect to solve the problem at that very high level of systemic cause. What's next?
Next level "down" might be defined in terms of SMS. If the regulator continues or returns to a level of oversight such that airlines will not or cannot get away with cutting corners by privileging commercial priorities over safety priorities, then SMS will survive as a very effective data-driven safety system just as it was originally conceived.
What is next follows on SMS. Data analysis by competent, experienced individuals including pilots and not just amateur interns who are paid next to nothing, is the least harmful, least expensive and most benign response possible: I think looking at and understanding the data in terms of "precursors" is where the solution and the answer to your question lies. The difficulty is, being shown information that "all is not well" interferes with egos and the self-image of the airline as a completely safe operation, and therefore intereferes with the feedback process which is essential to "learning lessons". How do we address this?
We accomplish this by using the lessons learnt by NASA as a result of the Challenger and Columbia accidents and which are extremely well documented and openly available in just two very good books, "The Challenger Launch Decision" by Diane Vaughan, and "Organization at the Limit" by William Starbuck and Moshe Farjoun.
We first examine the theme of these easy lessons then we examine how such lessons may be tailored to our own operation. Then we take it to the practical level, using materials which reflect our own operations "at the street level", turning theoretical work into practical approaches to daily safety issues. Culture is informed by the data, and the value of data is enhanced and valued within the culture.
The questions asked are the most important. Bill Starbuck's paper, "Fine-tuning the Odds Until Something Breaks" is also well worth reading but many works by for example Sidney Dekker, now address these issues in a much more practical way for those airlines that are serious about knowing and learning.
This is what I meant by "what", not "who" in the discussion above. Where "learning the lesson" fails and arrogance wins, we will always find that what took the organization off the right course was "who", never "what".
If an airline either does not use, look at or respond to their data (or doesn't even do data collection except to tick the box), then there is effectively nothing to be done. Organizations cannot be "forced" to be safe, especially when they can point to their record of "no accidents", or "explanable accidents".
Data analysis works because recognition is the first step to addressing a problem if there is one. Then avoiding denial is the next step followed by defining the problem using experienced people examining the data and addressing the SOP or the procedure then publishing the results in their ops manals.
Of course, as we have discussed here and elsewhere, this assumes an airline is first of all aware of these issues (that it may be 'at risk' even though they dont' want to think so) and that they wish to do something about a problem which is showing up in the data.
One can work "inside", with similar-minded people who also have the power and courage to do the right thing. That happens once in a while and we shouldn't be too idealistic - it works and is sometimes needed.
Short of reasonably-expected intelligent responses or working with those outside the organization but who have the power to enact change, the alternative frankly, is "heroic action" - the kind of direct action that, for example, Greenpeace, Amnesty International and thousands of other groups engage in. Whistle-blowing actions for example are both short-term solutions and far riskier in terms of achieving the originally-conceived goals. In other words, unless an organization is cognizant of all aspects of its operation and not just the commercial, profit-making aspects, sooner or later, in a relatively high-risk operation such as aviation, the outcomes are well understood.
If the airline isn't doing any of this on a daily basis then nothing has been learnt and the answer to your question is, there is nothing to be done except to wait; the airline is on it's way to learning from an accident. Just ask NASA.
* Gulfair 320, Armavia Air 320, TAM 320, Spanair MD83, Turkish B737, Colgan Q400, One-Two-Go MD82, Garuda B737, Comair CRJ, Pinnacle CRJ, Helios B737, Adam Air B737, possibly AF447...
Last edited by PJ2; 25th Oct 2009 at 21:17.
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Why would an airline be any different than a hamburger stand?
if you are a Mac donald's employee, forgetting the big mac sauce when preparing this hamburger will have very little consequences on the customer.
If you are an airline employee, forgetting to lower the gear may have huge and definitive consequences on the customer.
When you are in the transport industry (Boat, train, airplanes) you are responsible for the body and the saoul of your customers, just because they actually have to come into your vehicle.
Making money whatever it takes doesn' t apply to the transport industry.
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Originally Posted by KAG
If you are a Mac donald's employee, forgetting the big mac sauce when preparing this hamburger will have very little consequences on the customer.
If you are an airline employee, forgetting to lower the gear may have huge and definitive consequences on the customer.
If you are an airline employee, forgetting to lower the gear may have huge and definitive consequences on the customer.
Originally Posted by KAG
Making money whatever it takes doesn' t apply to the transport industry.
Lessons Learned & How to Address
PJ2 above introduces the word precursor and acknowledges the arrogance by management to recognize lessons that need to be learned (sic)
As always the trouble with data is the inability to recognize data in vs actions out.
OK, my first inkling is to not kid yourself that operational data is a solution. It's not even a tool, however it is the ingredients.
The concept of Lessons Learned in safety is to couple the operational data with global experience (not just a single airline, manufacturer, etc.) to agree on what has constituted Precursors or what some may call "regression factors" If you add in the concept of precursers to the data it often infers that the data is OK fo now only due to luck or chance. Conversely when you run out of luck by repeating a similar data chain then you have an accident and big time economic impacts.
The knowledge of precursors (that's what safety professionals are expected to know) coupled together with in-service data within an airline or a manufacturer must be actionable or expect accidents and claims of negligence which can bring an organization to the brink of extinction.
The concept of precursors can only be sustained by safety professionals and certainly not by bean counters. So beware of ignoring a safety professional who has verifiable knowledge of precursors.
Again, the concept of the Lesson Learned is a combination of data and the knowledge of precursers
As always the trouble with data is the inability to recognize data in vs actions out.
OK, my first inkling is to not kid yourself that operational data is a solution. It's not even a tool, however it is the ingredients.
The concept of Lessons Learned in safety is to couple the operational data with global experience (not just a single airline, manufacturer, etc.) to agree on what has constituted Precursors or what some may call "regression factors" If you add in the concept of precursers to the data it often infers that the data is OK fo now only due to luck or chance. Conversely when you run out of luck by repeating a similar data chain then you have an accident and big time economic impacts.
The knowledge of precursors (that's what safety professionals are expected to know) coupled together with in-service data within an airline or a manufacturer must be actionable or expect accidents and claims of negligence which can bring an organization to the brink of extinction.
The concept of precursors can only be sustained by safety professionals and certainly not by bean counters. So beware of ignoring a safety professional who has verifiable knowledge of precursors.
Again, the concept of the Lesson Learned is a combination of data and the knowledge of precursers
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cost of training
1 - Airlines will "cut corners" whenever (and wherever...) they can.
2 - Airlines have a strong "lobby" with the government to keep requirements (via regs) on the limit. If you have a chance to talk to any FAA POI, he (or she) will tell you that most airlines give poor training to their pilots.
3 - Nice training comes sometimes only by pressure from insurance companies. I've got some nice factory training (in helicopters) not because my boss was nice, but because he would have significant reduction on insurance premiums if he would send all his pilots to factory "refreshment" courses every year, to include power-off touchdown autorotations.
4 - Unfortunately, insurance companies only "think" statistics. More airplanes will have to fall off the sky due to lack off pilot training before they put some pressure on the airlines to raise their "standards".
When I fly as a passenger I look for an airline that has new aircraft flown by old pilots. Unfortunately (again) what I see more is young pilots flying old airplanes...
Rob
2 - Airlines have a strong "lobby" with the government to keep requirements (via regs) on the limit. If you have a chance to talk to any FAA POI, he (or she) will tell you that most airlines give poor training to their pilots.
3 - Nice training comes sometimes only by pressure from insurance companies. I've got some nice factory training (in helicopters) not because my boss was nice, but because he would have significant reduction on insurance premiums if he would send all his pilots to factory "refreshment" courses every year, to include power-off touchdown autorotations.
4 - Unfortunately, insurance companies only "think" statistics. More airplanes will have to fall off the sky due to lack off pilot training before they put some pressure on the airlines to raise their "standards".
When I fly as a passenger I look for an airline that has new aircraft flown by old pilots. Unfortunately (again) what I see more is young pilots flying old airplanes...
Rob
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@AirRabbit
Best response to this thread by far... Thank you for taking a logical stance to what seems to me to be an illogical arguement.
Fact is that the majority of our infrastructure was financed by taxpayers money, years ago I must admit (unless you are Italian
).When the automobile industries went tits up, when the banks started collapsing, where agriculture is concerned, where steel comes into play, where the arms industry is at stake, yes even at Boeing and Airbus, the government steps in.
AirRabbit's argument has value IF and only IF you reject all of the financial support in the mentioned and additional examples. In which case the government apparatus starts to become obsolete, i.e. it is no longer governing. What do you present as an alternative, surely not free market. That was the inital trigger of the ongoing downhill slide of the airline business and therewith the definite trigger for pay-for-training, crap salaries and the likes, ultimatly degrading safety to an extent that US Congress is looking into Colgan 3407. By my knowledge the first time ever that politicians cared for an accident in the transport sector.
Kindly awaiting response.
Last edited by postman23; 26th Oct 2009 at 15:02. Reason: typo
postman23;
FWIW, I couldn't agree with your comments more.
But the fact is, here we, rather this industry, are; what do we do?
The FAA has realized, very late in their game, that corporate enterprises cannot be left on their own and trusted to do the right thing. In Canada, the regulator has yet to comprehend that fact and I am franky standing by for a "correction" here which I hope will be adminstrative in nature and not an accident like it took to get both the FAA's and Congress's attention in the US.
The precursors for an accident exist in the data now and are already communicated to those whose responsibility it is to act. An organization thoroughly focussed on the control of costs to the exclusion of all else, is at risk. For change to occur, situational awareness is critical. How that occurs is the question in such an environment. Sites like this help but are not primary agents of change. Regulatory oversight and POI action are required.
FWIW, I couldn't agree with your comments more.
But the fact is, here we, rather this industry, are; what do we do?
The FAA has realized, very late in their game, that corporate enterprises cannot be left on their own and trusted to do the right thing. In Canada, the regulator has yet to comprehend that fact and I am franky standing by for a "correction" here which I hope will be adminstrative in nature and not an accident like it took to get both the FAA's and Congress's attention in the US.
The precursors for an accident exist in the data now and are already communicated to those whose responsibility it is to act. An organization thoroughly focussed on the control of costs to the exclusion of all else, is at risk. For change to occur, situational awareness is critical. How that occurs is the question in such an environment. Sites like this help but are not primary agents of change. Regulatory oversight and POI action are required.
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What to do?
PJ2, a valid question you ask.
The answer is complex if one were to tackle the problem in total.
On an individual basis it is a lot simpler: you draw the line somewhere and do not cross it!
That line may be one of income, aircraft status, health, commercial pressure, you name it. All these lines are laid down carefully in manuals and laws by people who make their living writing legal texts. One of the purposes of these legal aspects is to simplify nailing your behind to the wall if something goes wrong, which means you need to protect yourself while it is an illusion that legislation will protect you. That self protection requires discipline and courage, two factors that easily buckle when peer-pressure and financial concerns exist. In the end though, the choice is ours.
One may not make friends in chosing what is right, but it just might save that behind one day.
PS: the "U" word could provide some basic protection but attempted to stay clear of subtopics, where most people nowadays associate unions with T & Cs alone, instead of including best industry practices in their sales raps.
The answer is complex if one were to tackle the problem in total.
On an individual basis it is a lot simpler: you draw the line somewhere and do not cross it!
That line may be one of income, aircraft status, health, commercial pressure, you name it. All these lines are laid down carefully in manuals and laws by people who make their living writing legal texts. One of the purposes of these legal aspects is to simplify nailing your behind to the wall if something goes wrong, which means you need to protect yourself while it is an illusion that legislation will protect you. That self protection requires discipline and courage, two factors that easily buckle when peer-pressure and financial concerns exist. In the end though, the choice is ours.
One may not make friends in chosing what is right, but it just might save that behind one day.
PS: the "U" word could provide some basic protection but attempted to stay clear of subtopics, where most people nowadays associate unions with T & Cs alone, instead of including best industry practices in their sales raps.
Last edited by postman23; 26th Oct 2009 at 17:05. Reason: added PS
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As we all know these days the terms and conditions are degraded alot in regards to the deep crisis the whole aviation industry is experiencing right now.
But my mind I would think that as soon we are getting over the crisis and things are opening up the salaries will get higher again because the demands for pilots will be higher than the supply.
So is this the normal cyclus that happens every 5-10 years or are we facing a new situation? Are we just too many pilots around? Can we blame the low cost Airlines?
I have put to many $ on the line so it pisses me off that is has to be so hard to get a job with a decent salary
But my mind I would think that as soon we are getting over the crisis and things are opening up the salaries will get higher again because the demands for pilots will be higher than the supply.
So is this the normal cyclus that happens every 5-10 years or are we facing a new situation? Are we just too many pilots around? Can we blame the low cost Airlines?
I have put to many $ on the line so it pisses me off that is has to be so hard to get a job with a decent salary
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cycle
That supposedly normal cycle, I have yet to witness any evidence of that in my time aloft.
What I have seen is a steady and determined deterioration of working conditions on planet Earth. No stopping that, if you ask me. Surely salaries will go up, usually not by as much as they have gone down the years before though. And that is excluding inflation. If you want to become rich you must start up a flight school and keep on drivelling about that cycle that never comes. Don't feel bad about it, they got me
and I am sure there are plenty that will follow us.
What I have seen is a steady and determined deterioration of working conditions on planet Earth. No stopping that, if you ask me. Surely salaries will go up, usually not by as much as they have gone down the years before though. And that is excluding inflation. If you want to become rich you must start up a flight school and keep on drivelling about that cycle that never comes. Don't feel bad about it, they got me
and I am sure there are plenty that will follow us.
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PJ2
"The key to understanding this is the question always asked by "production-minded" managers, "so if you think we're not safe to operate, where are the accidents to prove your point?" In other words, precursors to accidents are not taken as "real", nor are near misses. The notion of "luck" and "skill" are often invoked in such a mentality."
Wise words indeed. I recently encountered exactly that in questioning the design of an intravenous pump which is capable of delivering a lethal amount of moprhine. The problem was so simple, the casing had a hinge mechanism which was insecure. Once the casing was open then it would be very easy for a confused patient to inadvertently depress the driver button and inject a lethal dose. It was reported on an incident reporting mechanism but the "management" adopted exactly that defensive approach. No one has died so whats the problem?
"The key to understanding this is the question always asked by "production-minded" managers, "so if you think we're not safe to operate, where are the accidents to prove your point?" In other words, precursors to accidents are not taken as "real", nor are near misses. The notion of "luck" and "skill" are often invoked in such a mentality."
Wise words indeed. I recently encountered exactly that in questioning the design of an intravenous pump which is capable of delivering a lethal amount of moprhine. The problem was so simple, the casing had a hinge mechanism which was insecure. Once the casing was open then it would be very easy for a confused patient to inadvertently depress the driver button and inject a lethal dose. It was reported on an incident reporting mechanism but the "management" adopted exactly that defensive approach. No one has died so whats the problem?
mercurydancer;
In flight safety work, this approach to risk is known by a number of terms beginning with "tombstone safety". Another term is "blood priority".
For your, and for postman23 and lomapaseo's benefit and hopefully others who have continued to read this thread, I want to reproduce (rather than just link) an article that covers all areas of interests expressed thus far. I think it answers the question, "How do we do that?"; I think it provides some basic notions on how serious flight safety work must be done but too often isn't and I think it provides a positive way forward without a sense of pointing fingers or giving up in the face of daunting odds.
I have colored blue those statements which I think are especially valuable and would apply equally to medicine as to other industries including of course, aviation from whence it came.
PJ2
http://www.fsinfo.org/docs/FSISpecial052603.pdf
Organizational Culture and Safety
The beginning of the organizational culture period of accident investigation and analysis can be traced back to the nuclear accident at Chernobyl in 1986 (Cox & Flin, 1998). On April 26 1986, two explosions blew off the 1000-ton concrete cap sealing the Chernobyl-4 reactor, releasing molten core remains into the vicinity and fission products into the atmosphere.
It was the worst accident in the history of nuclear power generation. It has so far cost over 30 lives, contaminated approximately 400 square miles around the Ukrainian plant and significantly increased the risk of cancer deaths over a wide area of Scandinavia and Western Europe (Read, 1990).
Poor safety culture was identified as a contributing factor in the Chernobyl disaster (Cox & Flin, 1998). Since then safety culture has been discussed in other major accident enquiries and analysis of system failures, such as the King's Cross Underground fire in London and the Piper Alpha oil platform explosion in the North Sea (Cox & Flin, 1998; Pidgeon, 1998).
According to Meshkati (1997), the most dramatic turning point for "safety culture" in the United States came with an aviation accident that killed 14 people -the in-flight structural breakup and crash of Continental Express Flight 2574 near Eagle Lakes, Texas, on September 11, 1991. As a member of the National Transportation Safety Board (NTSB) at that time, Dr. John Lauber suggested that the probable cause of this accident included "The failure of Continental Express management to establish a corporate culture which encouraged and enforced adherence to approved maintenance and quality assurance procedures" (Meshkati, 1997).
As a result of this and other similar aviation accidents, safety culture came to the forefront as the exclusive topic at the U.S. National Summit on Transportation Safety, hosted by the NTSB in 1997. The acknowledgment of the meaning of safety culture in preventing accidents has led to many studies attempting to characterize safety culture in a number of high-risk manufacturing companies. Cox and Flin state, there have been few attempts to examine the various definitions of safety culture that have been proposed in the literature, nor have there been any attempts to culture within organizations.
Furthermore, such terms as "safety climate" are often used in conjunction with safety culture, with little if any differentiation between the concepts (Cox & Flin, 1998). Consequently, while the concept of safety culture continues to attract more attention, "the existing empirical efforts to study safety culture and its relationship to organizational outcomes have remained unsystematic, fragmented and in particular under-specified in theoretical terms" (Pidgeon, 1998).
The first thing to recognize about Safety Culture is that it cannot be quantitatively measured. Instead, it is more appropriate to survey attitudes, and observe employee and management behaviors, and the quality of the work process. The rapid development of new technology has fundamentally changed the nature of work and has increased the complexity of systems within a variety of industries (Hendrick, 1991). Among these complex systems are those commonly known as "high-risk" systems, such as nuclear power plants, chemical processing facilities, and aviation operations that require a tight coupling between both technical and human subsystems. It is critical to have positive workplace attitude – from the president to the newest hire.
Management is the key to a successful safety culture. This positive attitude must flow from the top down. How may times have you heard the expression "flavor of the month" directed at a new organizational program or process? It’s common for corporations to adapt this lack-luster attitude and it is one of the largest mistakes made. Deliberate how safety programs are conventionally presented to would-be participants. A corporate administrator learns about a new safety program and orders the appropriate materials. Some companies go as far as to hire a trainer to teach the new step-by-step procedures to certain personnel. Then these employees demonstrate the new procedures to others while on the job, and thus a new safety program is implemented plant wide.
But to many this is just another set of temporary procedures, which attempt to reduce recordable injuries and make management look good. It is commonly believed that the new program won't really work to reduce injuries, and therefore it won't be long before it will be replaced with another "flavor of the month.” The "flavor-of-the month" attitude occurs when people are not taught the principles or rationale behind a program. They are just trained on how to implement the new process. They are not educated about the research-supported theory and corporate mission statement from which the program originated.
A true safety culture is established when safety is valued consistent with productivity and profitability. Managers and supervisors need to be held accountable for safety in the same manner as production and profitability.
Paul O’Neill, U.S. Secretary of the Treasury, as printed in the Industrial Safety and Hygiene News (ISHN), March 2001, explains: “Many companies still see safety management as a costly legal requirement with no real business benefits, but this is not the case. He explains that all truly great organization must be aligned around values that bind the organization together." “This is how companies withstand competitive pressures and operate consistently on a far_flung global basis.”
He stated that: great organizations have three characteristics:
• Employees are treated with dignity and respect.
• They are encouraged to make contributions that give meaning to their lives.
• Those contributions are recognized.
According to O'Neill: "Safety is a tangible way to show that human beings really matter." He continues to state that: "Leadership uses safety to make human connections across the organization. Stamping out accidents (which at Alcoa O'Neill called "incidents"), and telling employees we can get to zero incidents is a way to show caring about people. This is leadership."
Leadership accepts no excuses, and does not excuse itself, when safety problems arise.
• Simply caring about safety is "not nearly enough, not nearly enough,” He continues to say: "At the end of the day, caring alone is not enough to make sure that an incident never happens again."
• What's needed is for "safety to be as automatic as breathing," "It has to be something unconscious almost."
• This won't happen by leadership simply giving orders. "You need a process in place to get results." A process based on leadership, commitment, understanding, and no excuses.
• "Safety is not a priority at Alcoa, it is a precondition. If a hazard needs to be fixed, it's understood by supervisors and employees that "you do it today. You don't budget for it next year."
He continues by stating: How do you get an organization to believe this? "You always must be constantly thinking about ways of refreshing the organization's thinking about safety."
O'Neill outline five steps he took soon after coming to Alcoa. He called in the safety director to review the company's performance.
O'Neill was told Alcoa's rates were below industry average. "That's good," "But the goal is for no Alcoan to be hurt at work," he told his safety director. No injuries down to first aid cases. "The only legitimate goal is zero." Otherwise, who's going to volunteer to be that one annual case, or whatever?
Getting to zero is a journey of discovery, O'Neill said, and at no point can you stop and say, "We've reached the point of diminishing returns and can't afford to get better."
O'Neill met with employees and gave them his home phone number. "I told them to call me if their managers didn't fix safety problems.
What I was doing was making a point to my managers." O'Neill had 26 business units. Vice presidents call him personally whenever their group experienced a lost workday case. "This constantly engaged them about safety," he said. It forced them to confront themselves: "Why do I have to make this call I hate to make?"
When Alcoa launched an internal computer network, safety information came online first, before marketing, sales or finance, according to O'Neill. Just another way to keep safety in front of employees and managers and reinforce that it is a precondition, he explained.
O'Neill told his financial people, "If you ever try to calculate how much money we save in safety, you're fired." Why? He didn't want employees looking at safety as a "management scheme" to save money.
"Safety needs to be about a human value. Cost savings suggest something else. Safety is not about money; it's about constantly reinforcing its value as a pre-condition."
OSHA strongly believes that an effective safety and health program is the answer and results are the proof. After focusing on its safety and health program, an Atlanta company reported that, from 1994 to 1996, their annual Workers' Compensation claim costs fell from $592,355 to $91,536, a savings of $500,000. After implementing a 100% fall protection program and supervisory accountability for safety, Horizon Steel Erectors, Inc., had a 96% reduction in its accident costs per person per hour, from $4.26 to $0.18 (Mallon, 2001).
To go along with the “flavor of the month syndrome”, a lot of companies cannot release the Blood Priority or otherwise known as the Tombstone Safety Program. Mr. Richard Wood, author of “Aviation Safety Programs,” states that Tombstone Safety refers to the idea that it’s a lot easier to get something corrected if you just had an accident or killed someone - there is literally blood on the accident report.” The result to this is that it is difficult to get something corrected if it has not caused an accident.
This is the, “If it ain’t broke, don’t fix” attitude. This type of attitude is taught, and it comes from the top down. If the corporation has the Tombstone Safety Program, then that’s what the employee’s will do…Tombstone Safety!
Team Building and Safety Culture Building a safety culture is not a safety function, but a project management function. And no one person can do it alone. Kenneth Blanchard, author of the “One Minute Manager Builds High Performing Teams,” states, “Not one of us is as smart as all of us put together.”
Empower the employee’s and getting them involved is exactly Paul O’Neill done at Alcoa. He built a high performing team that was focused on safety culture. To do this one must be totally involved and empower the workforce. However you manage your other projects, you need to build a safety culture in a particular way.
Consider the ATTAM approach: Assess, Train, Teach, Assign, and Monitor.
Assess. Observe people working, and take notes. What are the recurring unsafe acts? Record each unsafe act as it occurs. Once employees notice you in an area, they put on a face of safety and limit your ability to observe. That's the time to ask, "Why are these unsafe acts occurring?" Assess your people to determine who can champion the correcting of attitudes, behavior, and ignorance. Who are the key players? Usually, they are crew leaders, supervisors, and others with authority. Identify the people, and then identify their attitudes and basic safety knowledge.
Train. Once you've selected your safety champions, you must do
more than just tell them, "Now I am making safety part of your performance evaluation." They must learn the causes of injury and alternatives to practicing those causes. You must train everyone that safety is equal to or greater than all other goals, including production. Safety champions are teachers, but they are only as effective as their training and the backing of management allow them to be. Consider purchasing "train the trainer" safety programs.
Teach. Your trained safety champions teach safety to the rest. The simple teaching method has three parts. First, stop when you enter an area. Scan the area, then look, listen, smell, and feel for unsafe conditions. Look for such things as improper tool use. Listen for high ambient noise. Smell for gasoline fumes. Feel for high heat. When you notice an unsafe act, approach the worker, making him or her aware of the unsafe practice. Then you must follow up to ensure that worker corrects it. You also teach by looking for safe acts. For example, if you see an employee- working overhead and wearing a safety belt, let that person know you recognize and appreciate his or her attention to safety.
Assign. Some unsafe acts wouldn't happen if you could correct environmental problems. For this, you must hold individuals responsible. If it's nobody's job, nobody will do it. Make specific work assignments and hold individuals accountable for certain safety objectives. • Assign individuals to inspect equipment and work areas for problems such as poor lighting, missing guards, damaged equipment. • Assign ownership of an individual problem to an individual (who may lead a group in resolving it). • Assign individual safety ownership of specific power distribution equipment, so such activities as breaker testing and transformer inspection actually happen. • Assign someone to audit inspections, safety tours, safety meetings, and other activities.
Monitor. Check your safety culture progress by asking key questions. How are employees responding? How are your teachers carrying out their duties? Do they need more training? What are the recurring types of unsafe behavior? When did you last observe people working? Are safety inspection reports precipitating action? Is it easy to report unsafe conditions or equipment? Are you replacing unsafe equipment? Are you rewarding your employees for safe or unsafe acts?
Everything boils down to two questions: Do your employees know how much you value safe behavior? Are you sure you want them to know?
Safety Culture vs. Tombstone Safety By Gary L. Hanes
44 Flight Safety Information Journal - May 2003 www.FSinfo.org
References
Blanchard, K. (2000). One-Minute Manager Builds High Performing Teams. Retrieved May 7, 2003:
Ken Blanchard Companies
Cox, S.; Flin, R. (1998). Safety culture: Philosopher's Stone or man of straw. Retrieved April 18, 2003:
http://www.aviation.uiuc.edu/new/htm...shamithf02.pdf
Read, P. (1998). Ablaze, The story of the heroes and victims of Chernobyl
Retrieved April 19, 2003: http://www.ceet.niu.edu/faculty/vanmeer/chernob.htm
Meshkati, N. (1997). Chernobyl Accident. Retrieved April 20, 2003: http://www.worldnuclear.
org/info/chernobyl/inf07.htm
Hendrick, W. (1991). Ergonomics in organizational design and management. Retrieved April 20, 2003:
www.ehs.cornell.edu/Geneva/safety_manual.pdf
O’Neill, P. (2001). Safety Exchange of America. Retrieved April 25, 2003:
http://www.emeetingplace.com/Culture...roduction/Part 2.htm
Mallon, J. (2001). Nine Oklahoma Companies Earn 2002 Safety Award. Retrieved April 29, 2003:
http://www.state.ok.us/~okdol/press/pr042202.htm
No one has died so whats the problem?
For your, and for postman23 and lomapaseo's benefit and hopefully others who have continued to read this thread, I want to reproduce (rather than just link) an article that covers all areas of interests expressed thus far. I think it answers the question, "How do we do that?"; I think it provides some basic notions on how serious flight safety work must be done but too often isn't and I think it provides a positive way forward without a sense of pointing fingers or giving up in the face of daunting odds.
I have colored blue those statements which I think are especially valuable and would apply equally to medicine as to other industries including of course, aviation from whence it came.
PJ2
http://www.fsinfo.org/docs/FSISpecial052603.pdf
Organizational Culture and Safety
The beginning of the organizational culture period of accident investigation and analysis can be traced back to the nuclear accident at Chernobyl in 1986 (Cox & Flin, 1998). On April 26 1986, two explosions blew off the 1000-ton concrete cap sealing the Chernobyl-4 reactor, releasing molten core remains into the vicinity and fission products into the atmosphere.
It was the worst accident in the history of nuclear power generation. It has so far cost over 30 lives, contaminated approximately 400 square miles around the Ukrainian plant and significantly increased the risk of cancer deaths over a wide area of Scandinavia and Western Europe (Read, 1990).
Poor safety culture was identified as a contributing factor in the Chernobyl disaster (Cox & Flin, 1998). Since then safety culture has been discussed in other major accident enquiries and analysis of system failures, such as the King's Cross Underground fire in London and the Piper Alpha oil platform explosion in the North Sea (Cox & Flin, 1998; Pidgeon, 1998).
According to Meshkati (1997), the most dramatic turning point for "safety culture" in the United States came with an aviation accident that killed 14 people -the in-flight structural breakup and crash of Continental Express Flight 2574 near Eagle Lakes, Texas, on September 11, 1991. As a member of the National Transportation Safety Board (NTSB) at that time, Dr. John Lauber suggested that the probable cause of this accident included "The failure of Continental Express management to establish a corporate culture which encouraged and enforced adherence to approved maintenance and quality assurance procedures" (Meshkati, 1997).
As a result of this and other similar aviation accidents, safety culture came to the forefront as the exclusive topic at the U.S. National Summit on Transportation Safety, hosted by the NTSB in 1997. The acknowledgment of the meaning of safety culture in preventing accidents has led to many studies attempting to characterize safety culture in a number of high-risk manufacturing companies. Cox and Flin state, there have been few attempts to examine the various definitions of safety culture that have been proposed in the literature, nor have there been any attempts to culture within organizations.
Furthermore, such terms as "safety climate" are often used in conjunction with safety culture, with little if any differentiation between the concepts (Cox & Flin, 1998). Consequently, while the concept of safety culture continues to attract more attention, "the existing empirical efforts to study safety culture and its relationship to organizational outcomes have remained unsystematic, fragmented and in particular under-specified in theoretical terms" (Pidgeon, 1998).
The first thing to recognize about Safety Culture is that it cannot be quantitatively measured. Instead, it is more appropriate to survey attitudes, and observe employee and management behaviors, and the quality of the work process. The rapid development of new technology has fundamentally changed the nature of work and has increased the complexity of systems within a variety of industries (Hendrick, 1991). Among these complex systems are those commonly known as "high-risk" systems, such as nuclear power plants, chemical processing facilities, and aviation operations that require a tight coupling between both technical and human subsystems. It is critical to have positive workplace attitude – from the president to the newest hire.
Management is the key to a successful safety culture. This positive attitude must flow from the top down. How may times have you heard the expression "flavor of the month" directed at a new organizational program or process? It’s common for corporations to adapt this lack-luster attitude and it is one of the largest mistakes made. Deliberate how safety programs are conventionally presented to would-be participants. A corporate administrator learns about a new safety program and orders the appropriate materials. Some companies go as far as to hire a trainer to teach the new step-by-step procedures to certain personnel. Then these employees demonstrate the new procedures to others while on the job, and thus a new safety program is implemented plant wide.
But to many this is just another set of temporary procedures, which attempt to reduce recordable injuries and make management look good. It is commonly believed that the new program won't really work to reduce injuries, and therefore it won't be long before it will be replaced with another "flavor of the month.” The "flavor-of-the month" attitude occurs when people are not taught the principles or rationale behind a program. They are just trained on how to implement the new process. They are not educated about the research-supported theory and corporate mission statement from which the program originated.
A true safety culture is established when safety is valued consistent with productivity and profitability. Managers and supervisors need to be held accountable for safety in the same manner as production and profitability.
Paul O’Neill, U.S. Secretary of the Treasury, as printed in the Industrial Safety and Hygiene News (ISHN), March 2001, explains: “Many companies still see safety management as a costly legal requirement with no real business benefits, but this is not the case. He explains that all truly great organization must be aligned around values that bind the organization together." “This is how companies withstand competitive pressures and operate consistently on a far_flung global basis.”
He stated that: great organizations have three characteristics:
• Employees are treated with dignity and respect.
• They are encouraged to make contributions that give meaning to their lives.
• Those contributions are recognized.
According to O'Neill: "Safety is a tangible way to show that human beings really matter." He continues to state that: "Leadership uses safety to make human connections across the organization. Stamping out accidents (which at Alcoa O'Neill called "incidents"), and telling employees we can get to zero incidents is a way to show caring about people. This is leadership."
Leadership accepts no excuses, and does not excuse itself, when safety problems arise.
• Simply caring about safety is "not nearly enough, not nearly enough,” He continues to say: "At the end of the day, caring alone is not enough to make sure that an incident never happens again."
• What's needed is for "safety to be as automatic as breathing," "It has to be something unconscious almost."
• This won't happen by leadership simply giving orders. "You need a process in place to get results." A process based on leadership, commitment, understanding, and no excuses.
• "Safety is not a priority at Alcoa, it is a precondition. If a hazard needs to be fixed, it's understood by supervisors and employees that "you do it today. You don't budget for it next year."
He continues by stating: How do you get an organization to believe this? "You always must be constantly thinking about ways of refreshing the organization's thinking about safety."
O'Neill outline five steps he took soon after coming to Alcoa. He called in the safety director to review the company's performance.
O'Neill was told Alcoa's rates were below industry average. "That's good," "But the goal is for no Alcoan to be hurt at work," he told his safety director. No injuries down to first aid cases. "The only legitimate goal is zero." Otherwise, who's going to volunteer to be that one annual case, or whatever?
Getting to zero is a journey of discovery, O'Neill said, and at no point can you stop and say, "We've reached the point of diminishing returns and can't afford to get better."
O'Neill met with employees and gave them his home phone number. "I told them to call me if their managers didn't fix safety problems.
What I was doing was making a point to my managers." O'Neill had 26 business units. Vice presidents call him personally whenever their group experienced a lost workday case. "This constantly engaged them about safety," he said. It forced them to confront themselves: "Why do I have to make this call I hate to make?"
When Alcoa launched an internal computer network, safety information came online first, before marketing, sales or finance, according to O'Neill. Just another way to keep safety in front of employees and managers and reinforce that it is a precondition, he explained.
O'Neill told his financial people, "If you ever try to calculate how much money we save in safety, you're fired." Why? He didn't want employees looking at safety as a "management scheme" to save money.
"Safety needs to be about a human value. Cost savings suggest something else. Safety is not about money; it's about constantly reinforcing its value as a pre-condition."
OSHA strongly believes that an effective safety and health program is the answer and results are the proof. After focusing on its safety and health program, an Atlanta company reported that, from 1994 to 1996, their annual Workers' Compensation claim costs fell from $592,355 to $91,536, a savings of $500,000. After implementing a 100% fall protection program and supervisory accountability for safety, Horizon Steel Erectors, Inc., had a 96% reduction in its accident costs per person per hour, from $4.26 to $0.18 (Mallon, 2001).
To go along with the “flavor of the month syndrome”, a lot of companies cannot release the Blood Priority or otherwise known as the Tombstone Safety Program. Mr. Richard Wood, author of “Aviation Safety Programs,” states that Tombstone Safety refers to the idea that it’s a lot easier to get something corrected if you just had an accident or killed someone - there is literally blood on the accident report.” The result to this is that it is difficult to get something corrected if it has not caused an accident.
This is the, “If it ain’t broke, don’t fix” attitude. This type of attitude is taught, and it comes from the top down. If the corporation has the Tombstone Safety Program, then that’s what the employee’s will do…Tombstone Safety!
Team Building and Safety Culture Building a safety culture is not a safety function, but a project management function. And no one person can do it alone. Kenneth Blanchard, author of the “One Minute Manager Builds High Performing Teams,” states, “Not one of us is as smart as all of us put together.”
Empower the employee’s and getting them involved is exactly Paul O’Neill done at Alcoa. He built a high performing team that was focused on safety culture. To do this one must be totally involved and empower the workforce. However you manage your other projects, you need to build a safety culture in a particular way.
Consider the ATTAM approach: Assess, Train, Teach, Assign, and Monitor.
Assess. Observe people working, and take notes. What are the recurring unsafe acts? Record each unsafe act as it occurs. Once employees notice you in an area, they put on a face of safety and limit your ability to observe. That's the time to ask, "Why are these unsafe acts occurring?" Assess your people to determine who can champion the correcting of attitudes, behavior, and ignorance. Who are the key players? Usually, they are crew leaders, supervisors, and others with authority. Identify the people, and then identify their attitudes and basic safety knowledge.
Train. Once you've selected your safety champions, you must do
more than just tell them, "Now I am making safety part of your performance evaluation." They must learn the causes of injury and alternatives to practicing those causes. You must train everyone that safety is equal to or greater than all other goals, including production. Safety champions are teachers, but they are only as effective as their training and the backing of management allow them to be. Consider purchasing "train the trainer" safety programs.
Teach. Your trained safety champions teach safety to the rest. The simple teaching method has three parts. First, stop when you enter an area. Scan the area, then look, listen, smell, and feel for unsafe conditions. Look for such things as improper tool use. Listen for high ambient noise. Smell for gasoline fumes. Feel for high heat. When you notice an unsafe act, approach the worker, making him or her aware of the unsafe practice. Then you must follow up to ensure that worker corrects it. You also teach by looking for safe acts. For example, if you see an employee- working overhead and wearing a safety belt, let that person know you recognize and appreciate his or her attention to safety.
Assign. Some unsafe acts wouldn't happen if you could correct environmental problems. For this, you must hold individuals responsible. If it's nobody's job, nobody will do it. Make specific work assignments and hold individuals accountable for certain safety objectives. • Assign individuals to inspect equipment and work areas for problems such as poor lighting, missing guards, damaged equipment. • Assign ownership of an individual problem to an individual (who may lead a group in resolving it). • Assign individual safety ownership of specific power distribution equipment, so such activities as breaker testing and transformer inspection actually happen. • Assign someone to audit inspections, safety tours, safety meetings, and other activities.
Monitor. Check your safety culture progress by asking key questions. How are employees responding? How are your teachers carrying out their duties? Do they need more training? What are the recurring types of unsafe behavior? When did you last observe people working? Are safety inspection reports precipitating action? Is it easy to report unsafe conditions or equipment? Are you replacing unsafe equipment? Are you rewarding your employees for safe or unsafe acts?
Everything boils down to two questions: Do your employees know how much you value safe behavior? Are you sure you want them to know?
Safety Culture vs. Tombstone Safety By Gary L. Hanes
44 Flight Safety Information Journal - May 2003 www.FSinfo.org
References
Blanchard, K. (2000). One-Minute Manager Builds High Performing Teams. Retrieved May 7, 2003:
Ken Blanchard Companies
Cox, S.; Flin, R. (1998). Safety culture: Philosopher's Stone or man of straw. Retrieved April 18, 2003:
http://www.aviation.uiuc.edu/new/htm...shamithf02.pdf
Read, P. (1998). Ablaze, The story of the heroes and victims of Chernobyl
Retrieved April 19, 2003: http://www.ceet.niu.edu/faculty/vanmeer/chernob.htm
Meshkati, N. (1997). Chernobyl Accident. Retrieved April 20, 2003: http://www.worldnuclear.
org/info/chernobyl/inf07.htm
Hendrick, W. (1991). Ergonomics in organizational design and management. Retrieved April 20, 2003:
www.ehs.cornell.edu/Geneva/safety_manual.pdf
O’Neill, P. (2001). Safety Exchange of America. Retrieved April 25, 2003:
http://www.emeetingplace.com/Culture...roduction/Part 2.htm
Mallon, J. (2001). Nine Oklahoma Companies Earn 2002 Safety Award. Retrieved April 29, 2003:
http://www.state.ok.us/~okdol/press/pr042202.htm
I think that many bright people will continue to want to be pilots and will do their very best to overcome the new limitations. I also think that they will be killed along with the others
There will always be differences of opinion between pilots on whether or not manual flying skills are still vital in highly automated aircraft. But, despite my personal views on the subject, it seems to me the generally accepted procedure where automatics are engaged as soon as practicable after lift off, until the last few second before touch down, has largely contributed to the good safety record of big airliners. This, despite newly graduated barely out of flight school first officers who, by definition, are second in command of a big jet, and who lack real world experience of the art of manually flying especially where an emergency dictates such a skill.
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Originally Posted by postman
@AirRabbit
Quote:
Best response to this thread by far... Thank you for taking a logical stance to what seems to me to be an illogical arguement.
Not so fast Tommojonm.
Fact is that the majority of our infrastructure was financed by taxpayers money, years ago I must admit (unless you are Italian ).
When the automobile industries went tits up, when the banks started collapsing, where agriculture is concerned, where steel comes into play, where the arms industry is at stake, yes even at Boeing and Airbus, the government steps in.
AirRabbit's argument has value IF and only IF you reject all of the financial support in the mentioned and additional examples. In which case the government apparatus starts to become obsolete, i.e. it is no longer governing. What do you present as an alternative, surely not free market. That was the inital trigger of the ongoing downhill slide of the airline business and therewith the definite trigger for pay-for-training, crap salaries and the likes, ultimatly degrading safety to an extent that US Congress is looking into Colgan 3407. By my knowledge the first time ever that politicians cared for an accident in the transport sector.
Kindly awaiting response.
Quote:
Best response to this thread by far... Thank you for taking a logical stance to what seems to me to be an illogical arguement.
Not so fast Tommojonm.
Fact is that the majority of our infrastructure was financed by taxpayers money, years ago I must admit (unless you are Italian ).
When the automobile industries went tits up, when the banks started collapsing, where agriculture is concerned, where steel comes into play, where the arms industry is at stake, yes even at Boeing and Airbus, the government steps in.
AirRabbit's argument has value IF and only IF you reject all of the financial support in the mentioned and additional examples. In which case the government apparatus starts to become obsolete, i.e. it is no longer governing. What do you present as an alternative, surely not free market. That was the inital trigger of the ongoing downhill slide of the airline business and therewith the definite trigger for pay-for-training, crap salaries and the likes, ultimatly degrading safety to an extent that US Congress is looking into Colgan 3407. By my knowledge the first time ever that politicians cared for an accident in the transport sector.
Kindly awaiting response.
A good many Americans forget what the US Declaration of Independence actually says. The rights of all Americans are, what the framers called “unalienable Rights,” limited to “Life, Liberty, and the pursuit of Happiness.” No where in that short list is found the right to be successful in any business.
You make the statement that
When the automobile industries went tits up, when the banks started collapsing, where agriculture is concerned, where steel comes into play, where the arms industry is at stake, yes even at Boeing and Airbus, the government steps in.
Automobile industry – in history, only once did the government provide assistance for an automobile manufacturer – It was Chrysler Corporation and the government made a Load to that corporation – that was paid back, in full, with interest, prior to the note coming due. Recently, the current Administration decided it would step in and provide “stimulus” funds – and, as far as I know, Ford declined any of the money. The jury is still out on what the result will be.
Agriculture – there are some farmers today who are paid NOT to plant, grow, harvest, and sell specific crops. Why? Because lobbyists have convinced the legislature that too many farmers growing the same crop will cause some farmers to go bankrupt because of the decline in the salable price of those crops (more supply = less demand = less money it will draw). As a result, we have some farmers breaking their necks to “till the soil,” while others drink mint juleps on the porch? What’s fair about that?
The banking industry – while everyone says the banking industry fell onto hard times – it wasn’t because of bad management or substandard risk taking on their own. What happened? The government REQUIRED banks to make sub-prime loans to persons who would not normally qualify for that loan. Some – likely a majority– of those loans were interest only loans – requiring the client to pay only on the interest for the first part of the loan. Unfortunately, they were still not able to make the required monthly payment – so whatever what not paid was added as debt to the principle. When the loan reverted to payments including both interest AND principle payments … the borrower still couldn’t make the payments. So it was necessary for the bank to foreclose. Unfortunately, where the bank could normally foreclose, take possession, and sell the home for at least the equity the bank had invested, but not now. Now, the outstanding principle was so high the home was not worth what was due on it. However, banks were given the opportunity to “sell” these “upside-down” loans to the Federally supported Federal National Mortgage Association (“Fannie May”) and the Federal Home Loan Mortgage Corporation (“Freddie Mac”). Note that both of these organizations are chartered by the US Congress – sort of an underhanded way to have the government pay for housing that the home “owner” couldn’t pay for. That is why the banking industry fell on its face. A good share of the loans that were out were secured by less and less valuable real estate holdings … pretty soon, the bubble burst! Guess what … well, you know the story.
Sorry, I know very little about the steel industry nor the arms industry.
My point is that things were going well for most businesses until the government got involved - and they got involved to help those who had less “stuff” – so that they would be able to have more “stuff” – whether or not they were able to afford that “stuff.” Who paid for it? I’ll give you a guess – yep – the tax payers. My concern is whether we, as a country, are going to continue to throw good money down that same rat hole in the attempt to buy “stuff” for those who cannot otherwise afford that “stuff.” The Declaration of Independence says an unalienable Right is the pursuit of happiness – NOT that everyone is guaranteed happiness of their own choosing. That is simply NOT the role of government, it’s probably against the law, and it certainly isn’t provided for in the US Constitution or the Declaration of Independence.
Oh, and I doubt that the US government is officially going out on a limb to help out Airbus – unless it is a reciprocal agreement for aircraft certification (something like … the US accepts French certification of Airbus Aircraft and France accepts US certification of Boeing aircraft). And as you probably are aware, Boeing just recently moved its corporate headquarters from Washington State to Illinois … why – because the tax structure in Illinois was better for Boeing’s concerns. Government enticement is a lot different than government regulation. The US aviation industry, in my non-so-humble opinion, doesn’t need government intervention into the running of airlines – salaries, salary caps, personnel decisions, markets, market shares – unless they can provide an equal distribution of the revenue dollars – and can you imagine the cost to the taxpayer to support such a burgeoning bureaucracy? Only to have the government restrict who can go into that business, have the government tell you what you can fly, where you can fly, how much you can/must pay the crewmembers. Shoot, they can’t even control the price of jet fuel.
No thanks. I’ll take my chances on the free market methodology.