Reporting safety events can uncover hazards, reveal mitigations, and save lives. So why aren’t we doing more of it?
“We corrected that right away, so there was no need to report it,” the grizzled maintenance officer declared.
“Congratulations,” I replied with thinly veiled frustration. “Do you think any OTHER operator might encounter this same issue but fail to find and fix it before it led to a costly mishap? Wouldn’t it be GREAT if we could alert them before that happened?”
I occasionally engaged in conversations like this one in my previous role as a safety auditor in a different organization. Exasperating exchanges like these underscore how easily operators could help others avoid the same, preventable mistakes if only they’d share a lot more information with each other.
Our desire to suppress critical safety information is killing us and causing serious reputational damage to the helicopter industry. Why do pride and embarrassment so often prevent us from doing the right thing and helping to prevent costly repeat events? Our flawed expectation of a zero-defect industry has been historically unkind to those who make mistakes, or worse, have had the audacity to admit one while revealing a systemic problem.
Many company leaders lack even the basic curiosity to uncover the root causes of a problem and instead attempt to sweep it—and the employees involved—away. I can still recall the words of one of my former executives when they were informed of a costly operational mishap. “What happened, and whom do I need to fire?”
The opposite of a just culture, the “blame, fire, and forget” culture hasn’t yet been eradicated. Its continued existence supports the claim that senior executives are unaware of 96% of workplace hazards, a figure cited in a 1989 study by manufacturing consultant Sidney Yoshida. These leaders occupy the “iceberg of ignorance,” as Yoshida called it, shutting down voluntary reporting programs and suppressing the discovery and correction of killer norms, near misses, and unsafe acts that influence the next preventable and costly accident or incident.
The practice of routinely sharing valuable safety data isn’t limited to large air carriers or well-financed operators, though we’d do well to model some of their safety practices. Many VTOL operators understand that rock-solid just and reporting cultures serve as the catalysts for other key safety program elements. Open, anonymous reporting programs that obsessively focus on finding and fixing safety issues is a crucial first step in this process.
Self-Assessments and Surveys
A simple self-assessment or survey can help us identify gaps in our safety culture and then create a plan to close those gaps. Below are two helpful resources from SKYbrary, an electronic repository of aviation safety knowledge from various organizations, that can help you plan safety surveys and culture assessments.
- Safety surveys. SKYbrary’s comprehensive explanation of safety surveys includes best practices for conducting them as well as the results you can expect and how to manage them. Visit skybrary.aero/articles/safety-surveys for more information.
- Industry Safety Culture Evaluation Tool and Guidance. This tool helps facilitate self-assessment activities and is available in an editable, downloadable version that enables operators to tailor their own surveys to their organization’s needs. Visit skybrary.aero for more details.
Confronting Hard Realities
Whether you conduct a safety survey or a safety management system (SMS) self-assessment, some of the first questions you’ll likely see in either will focus on your organization’s commitment to safety. The answers to these questions could vary widely between managers and frontline employees. Management may discover some hard truths from the surveys and audits; how they choose to respond will reveal their commitment to safety and the value they place on employee feedback.
Employees, in turn, must demonstrate a personal commitment to safety when management makes it clear that safety is a core value. But what happens if you work for a manager who doesn’t get it?
Perhaps you’ve already considered leaving a bad culture, or maybe you even have one foot out the door. That can be a risky career move. But we can’t ignore the risk that comes with remaining with an operator that doesn’t value your personal safety.
If you find yourself struggling in this area, consider the late Matt Zuccaro’s sage advice: “When you believe safety is being compromised, ‘I cannot safely do that, and so I will not do that’ is the only acceptable response.” If such a response isn’t supported in your organization, the former HAI president and CEO recommended that aviation professionals “get a cardboard box” and be prepared to use it in the event you have to pack up your personal items and go home (see ROTOR, Summer 2018, p. 6).
Has your organization completed the first steps in implementing a sound safety culture, with leaders and staff who actively encourage and participate in the identification and resolution of safety issues?
Maybe you’ve built the foundation to an effective SMS but could use some help getting to the next level. Or perhaps your safety efforts have matured to a point that you’re now ready to serve as a model or mentor to others.
If you’re seeking continuous improvement in any of these areas, here are a few ideas to consider:
- Establish an SMS. There are abundant resources available on establishing and sustaining an effective SMS, including an extensive library from the Vertical Aviation Safety Team (vast.aero).
- Use SMS software and other safety support services. HAI members can access the HAI SMS Program on rotor.org to contact three industry-leading SMS software providers that also provide other safety support services.
- Use the Aviation Safety Reporting System (ASRS), a voluntary, confidential, nonpunitive incident-reporting program established by the FAA and administered by NASA.
- Participate in the Aviation Safety Action Program (ASAP). Go to rotor.org/asap to learn more.
- Share data through the Aviation Safety Information Analysis and Sharing (ASIAS) system. This FAA program has transformed the way valuable data is exchanged between a growing number of US operators. Go to asias.faa.gov to learn more.
- Care enough to share. Tell others your story. Even when recounting the events of a mundane flight or maintenance procedure, there’s almost always something that didn’t go as anticipated and is thus worth sharing to enhance operational efficiency, effectiveness, and safety.
If you’re attending HAI HELI-EXPO 2022 in Dallas, Texas, Mar. 7–10 (exhibits open Mar. 8–10), come join the HAI Safety Working Group for the annual HAI Safety Symposium, Mar. 7, from 8:30 am to 10:30 am. We’ll hear personal stories from one guest speaker who’ll share how she survived an IIMC encounter and from another who lived through two separate crashes into the water. (For a preview of the first speaker’s presentation, see “How I Survived IIMC,” p. 68.) Visit heliexpo.com/safety for more details. Can’t make the symposium? Check back to that web page, where we’ll post a recording of the event shortly after Expo.