Photo above: Mark Bennett
Always do your safety homework: risk management doesn’t take a sabbatical.
It’s time we rotorheads stop lamenting or seem surprised when things go bad. Instead, we need greater focus on making positive change for our industry. And yes, each of us plays a role in the outcome.
The fatal accident rate in the helicopter industry still isn’t improving like it should be. In its cumulative FY 2022 rotorcraft accident summary, October 2021–May 2022, the FAA reported 71 accidents and 15 fatal accidents, with 26 fatalities, in the United States. The FY 2022 estimated fatality rate through May was 1.35 per 100,000 hours—way too high!
In December 2021, the industry experienced four fatal accidents with a loss of seven lives. According to the FAA data, the number of fatal accidents was the highest for any December since FY 2005, and the seven fatalities were the second highest recorded for a December in the past 10 fiscal years.
These statistics are alarming and should motivate you to take stock of your own processes and the processes in your organization. We need to stop making excuses and always do our safety homework. Risk management doesn’t take a sabbatical.
The 7 Ps
When I was young, I distinctly recall my father—who spent a career in the US Navy—often using an old military adage at home. Perhaps you’ve heard it: “Prior Proper Planning Prevents Piss-Poor Performance.” The saying originated in the British Army and can be recognized nowadays in several variations.
I was fortunate to be reminded of this expression in my own military profession by instructors who constantly reinforced its importance (and not always with a sympathetic delivery). No matter what version of the adage you might be familiar with, it speaks to the need for preparation in producing positive outcomes.
Consistent, successful performance of aviation activities doesn’t happen because the work is easy or good luck is with you. Successful performance results from constantly doing your homework. As Todd Conklin, a senior advisor at the US Department of Energy’s Los Alamos National Laboratory, says, “Safety isn’t the absence of accidents. For us, safety is really the presence of defenses. We have to move away from reacting to consequence and start responding to context.”
The context Conklin refers to is the connection between all the factors leading to a negative result in a complex operating environment. Having a deeper understanding of all the mission components and how the overall aviation system influences performance is critical to an individual or organization’s ability to create and implement the proper defenses.
Knowing each step needed to accomplish a task (in flight or on the ground) is a vital element of risk mitigation. We need to remove the guesswork and disorder from our daily operations to fully appreciate the potential for hazards.
When we look at industry safety management guidance regarding hazard identification, the system description is almost universally accepted as the primary method for initially understanding the aspects of the operation that might be exposed to harm. Unfortunately, many of us don’t spend the necessary time to complete this very important activity (i.e., we don’t do our homework). We skip it altogether, make only a cursory effort to finish it, or think it’s too late in our business life cycle to do it.
This approach often results in a reactive nature within our organization because we never consider or anticipate what might go wrong. Instead, we wait for the consequence rather than reduce the likelihood of a negative event by preparing for it beforehand.
As Conklin explains, “Focusing on the consequence is not the priority because it has already happened—it is too late to stop it. If we spend time reacting to the consequence, what we’re missing is the opportunity to respond to context.”
Remember, the context is all the factors contributing to or enabling the consequence. In other words, the context is the environment in which the failure is allowed to occur.
Using System Descriptions to Improve Safety Outcomes
The FAA describes systems as “integrated networks of people and other resources performing activities that accomplish some mission or goal in a prescribed environment.”
Any combination of elements can affect a system at any given time. This is especially true in our aviation system: operations are dynamic and often unscripted, resulting in risk being extremely fluid. As a result, the underlying processes or activities of your system need to have safety concepts integrated into their design if you are to expect optimal safety outcomes.
So, in developing your system description, ask the context question, “How does this happen, and what affects it?” for each of your work tasks. This step will help you better understand context and produce viable solutions or safety capacity..
Using a simple flowchart can help you visualize each of the steps in this process and account for all your system’s activities (see sample below). As an example, for a patrol-type mission, you might begin documenting the process with the crew brief, followed by the aircraft preflight. Then, add the start-up, taxi/takeoff/departure, enroute, on station, and so on. For each of these steps, you’ll want to brainstorm the different possible hazards and the factors contributing to them.
During the preflight, for example, you might list as potential hazards working at heights, fuel spillage, unfavorable environmental conditions (heat or rain), missing tools, and blown debris from nearby aircraft. Or, during the enroute phase you might identify the potential for bird strikes, engine failure, air traffic collision, weather-related issues, and airborne obstacles.
Once you’ve identified the hazards, you can assess the risk of them occurring and their potential impact. Last, you’ll want to identify the controls or mitigation that will reduce the likelihood of any of these hazards causing harm (such as additional training, alternative routes, new equipment, and the like).
Creating a flowchart may seem like a time-intensive way to document processes, and maybe that’s why so many organizations don’t complete this crucial step. Often, they say it’s too time-consuming; they have other, more important things to do; their operation is too small for it to matter; or they already know what they need to do. Everybody hates to do their homework!
It’s also common—when organizations do document their processes—for them to neglect to include the people performing the work and the process owners (typically the department or division leaders, such as the director of operations or the director of maintenance). Reasons given include the individuals are never available or it’s inconvenient to include them. But involving the people who perform the work will help you more effectively identify what takes place, because they’re the specialists and are closest to the potential hazards your system faces.
The Rewards of Doing Your Homework
I get that you’re managing a business and trying to generate revenue. However, I urge you to think of the impact an unanticipated hazard event resulting in damage, injury, or—worst case—a fatality could have on your organization. Looking beyond the harm to your reputation and finances, consider first your employees and families (yours and theirs), the emotional strain such an event could place on them, and the potentially lasting effects (if the event doesn’t cause you to cease your operation).
I can’t promise that completing a comprehensive system description will be a panacea, but I can promise that by composing one you’ll produce greater awareness, build engagement, and gain perspective on and better understanding of the context in which you operate. As a result, your organization will improve its margins for safety, produce more reliable outcomes, and create success by planning for the necessary support.
Numerous owners and managers who’ve completed system descriptions have told me they discovered various hazards and solutions they hadn’t previously thought of, despite being in business for many years.
Be aware: maintaining system descriptions is a continuous work in progress; you should expect to review them regularly for adequacy and change. With your processes documented, you now have an effective tool for training, budgeting, and demonstrating your diligence to the public, customers, insurance providers, lawyers, and regulators.
The work involved in following this approach to hazard identification isn’t overwhelming. For it to provide real perspective, however, every operator—large or small—must take it seriously. You’ll find it’s a much more effective and less costly method of risk management than waiting for the consequence to occur.
Our industry and your operation depend on the ability to effectively manage the risk exposures we encounter every day. By doing a little extra homework, you’ll be on a path to safety and reliability success.
Conklin said it best: “Create stability and have the capacity to fail safely.”