Updated: Jan 6, 2021
In December the US Congress Commerce Committee issued a investigation report concerning to Aviation Safety oversight.
The investigation was started in the aftermath of the two tragic fatal accidents with the B737-MAX and the subsequent fallout in the public domain.
IMHO this report is a must read for every person in a leadership position in Aviation.
There will be very few in the industry that can not relate to the generic contents the report.
In short; several well reputable and established aerospace organisations are raked over the coals in this blistering report.
It exposes a phenomenon that literally has been brewing in the Aviation Industry for decades. I'll come back to that later.
A quoted sentence from one of the conclusions in the report:
"Unfortunately, much of what has been detailed in this report has been well known and reported on for decades. Despite this awareness, the FAA has failed to correct course and solidify an effective safety culture."
Report downloadable below:
This identifies an element in Aviation that is not limited to the FAA but applicable to the entire Aviation Industry; Safety Culture.
The fact that US Congress investigates the practices of the FAA and publishes a public report does not necessarily imply that the situation is much different elsewhere in the world.
The high profile tragic 737 MAX accidents are well documented and the main contributing factors to these accidents were a complex combination of design safety review, certification, maintenance training and awareness and pilot training and awareness.
Decades ago, Aviation Accident Investigations were limited to identifying the most significant flaw in a chain of events and stop right there. "Pilot error" was a very popular conclusion back then... But any human can make errors and accidents with the same errors continued to happen.
Insights evolved and "human factors" are now taken into consideration and expanded to maintenance personnel, and focus on elements like fatigue, mental state (such as depression) substance abuse and personal circumstances (financial, relationships personality incompatibility in crews), etc. which can contribute to misjudgement, distraction and bad decisions.
Now back to the phenomenon "organisation culture". There are many definitions of organisational culture. Below is the Britannica definition:
"Organisational culture, conventionally defined as the ensemble of beliefs, assumptions, values, norms, artifacts, symbols, actions, and language patterns shared by all members of an organization. In this view, culture is thought to be an acquired body of knowledge whose interpretation and understanding provide the identity of the organization and a sense of shared identity among its members."
What has this to do with safety?
Below is the definition of safety culture from FAA Order 8000.72 Appendix A.
This FAA Order is the FAA Integrated Oversight Philosophy Document which provides inspectors with audit policies and guidance.
"The shared values, actions, and behaviors that demonstrate a commitment to
safety over competing goals and demands."
Safety Culture is addressed in the very first section of the document.
FAA order 8000.72 downloadable below
The above definition is the most condensed and practical. It is specifies "safety over competing goals and demands"
Competing goals and demands is what probably every Aviation professional can relate to and what played a major role in events leading up to the MAX accidents.
Competing goals and demands can be:
Getting an aircraft ready for flight on time
Undercutting budgets to please management
Reducing manpower and look productive
Abiding by customer demands in terms of budget, readiness, resources
Pleasing management by not reporting or addressing systemic failures in organisations
Pleasing management by reducing lead times.
Reducing costs to avoid running financial losses
Certainly in the current existential crisis in commercial Aviation, there are many heavyweight "competing goals" that can win over safety culture, and independent Safety Oversight is perhaps more important than ever.
In light of the heavy criticism FAA received, it begs the question; "what can a regulator do?"
How is the span of authority and control of a regulator?
A regulator can regulate and penalise illegal activity but not penalise individuals with a bad attitude, but who have not done anything wrong, let alone change the safety culture in an organisation. Yet the safety culture in an organisation drives the likelyhood of an organisation to take unacceptable safety risks. Consequently, absence or minimal oversight can turn out to be fatal.
Safety culture needs to be changed from within organisations and the industry community is responsible for that. Culture rolls downhill; from the top down. Leadership drives safety culture.
Many can relate to rewarding of people going the extra mile to achieve a goal; be it an on-time release of an aircraft or bringing a product to market or staying under budget on a certain activity (regardless of safety implications). In many cases this pertains to fixing systemic flaws in an organisation.
On the other hand whistleblowers can be perceived as being difficult and uncooperative and are sometimes retaliated against (see Congressional report). These people often address systemic flaws in an organisation.
When leadership rewards individuals fixing systemic flaws but ignores or retaliate against those who address flaws, one should ask the question how that improves or degrades safety culture. This may even happen unintentionally or unknowingly and leaders should be mindful of that.
Leading by example and taking the consequences is the only way forward.
This is a subject recognised by regulators and handled in different ways; a former lecturer from UK CAA once said; "A regulator can't rescue an uncommitted operator. At some point you have to draw a line and walk away."
This holds a lot of truth but is not always feasible or successful.
ICAO came up in te past with the concept of Safety Management Systems (SMS) in their Annex 19, which is an attempt to formalise safety risk assessment and mitigation of all safety critical activities, This started with flight operations and soon will have to be implemented to Maintenance, Continuing Airworthiness Management, Design and Airport operations
Below FAA Advisory circular AC 120-92B which contains guidance material for the development of an SMS.
EASA has issued Notice of Proposed Rulemaking NPA 2019-05 (below) with proposed regulatory language amendments to implement a Safety Management System (SMS) into Maintenance and Design Organisations. It does not provide guidance in terms of philosphy and concept. In that respect, the above AC120-92B is more informative.
Quite a few years back, a study was conducted by the Safety Management System and Safety Culture Working Group of the European Strategic Safety Initialive. Downloadable below...
In other words; there is a lot going on in te regulatory world to mitigate adverse safety cultures and willingly or unwillingly accepting unacceptable safety risks. The devil is in the detail however and it takes critical thinking to accurately compose a realistic risk inventory and mitigation strategy. If the initiative degrades to administrative box ticking by uncommitted parties, the same dilemmas as before will arise.
Below is a video by Scott Perdue. Scott is a very experienced pilot and safety consultant with decades of flying experience with both airlines as well as a USAF fighter pilot He also has an FAA A&P license. He reviews accidents and provides compelling and valuable lessons for Airmen and in this case also for regulators and leadership.
The linked video pertains to a fatal accident with a B-17 vintage bomber used for "Living History Flight Experience" flights. This video is posted with Scott's permission.
In the first part of the video, he addresses the oversight culture over the operator which operated under Part 91 under the provisions of Living History Flight Experience (LHFE) program. His conclusions speak for itself. Watch and learn!
Please let us know if we missed something. Any feedback is appreciated.