“It is almost as difficult to make a man unlearn his errors as his knowledge."
Charles Caleb Colton
The hearing room is crowded and controlled in a mess of these tears I see scratching this mother’s face or this husband touching his wife's shoulder trying to contain a sea of sobbing despite technical aviation standards and knowledge. What must be told to the relatives of this air crash? I am sitting at the desk in my office looking for an answer, and I might be failing to find a wise reply though all these years of researching, managing and lecturing pilots, engineers and flight attendants on Human Factors, Risk Management, and Safety Culture; after all these years of interviewing them with my checklist to find contributing factors of an accident. And the flashback of the husband touching that shoulder shouted silently at me that facts are the active failures; details are the latent conditions, and these should be where we must be focused on!
I was at a humble CEO’s office of a rich airline. His secretary called me. I used the elevator and as I was scrambling with nostalgia for my wife and kids the office door invited me to enter and learn from this young man. We talked about all the figures of standards non-compliance I obtained. I was reluctant and this precondition could not prevail when he told me: Well, Sergio, this battle just begun, and I will support you. It is clear that a safety culture cannot be true overnight! He was right indeed. And it is not easy to make theory fits practice. You have to look into your memories. All the readings, all the classes you delivered, all the organizations you managed are nothing when the holes in the defenses aligned, as Professor Reason explains.
Then, I remembered I was a safety advisor off my country, and everything was going “average”, but again I had the opportunity to learn from this little story: It was the last day of a safety tour I was contracted to lead, so the company could be able to begin the SMS implementation. We worked on the Gap Analysis, Safety Policy promotion, a SMS lecture, and a Hazard Identification Workshop, wherein all engineers of the repair station performed a hangar inspection with me. After the de-briefing an engineer approached to me, shook my hand and hit me with this: I feel great about all what we did during these days. I did not know what a safety manager job was. We are now aware of all the safety concepts we practiced, Sergio. But what will happen tomorrow when you will be at home? Are we going to still talk about safety? Indeed, are we going to make it happen after you leave?
That was when I began to understand what aviation safety was. The concept “state” hammered my brain along with the quality’s concept of “grade”. But we are not talking here about something written in a book, pamphlet, regulation or a PowerPoint presentation in a neat and elegant fashion. Since state is involved in the definition, aviation safety is not a concept to be explained omitting the dynamic nature. It's not a matter of who's delivering more presentations or how fancy they are. I feel it’s just like cockpit instruments parameters going up and down during the flight. What must be done? We must be able to control parameters remain in the green range. This means risk-controlled operation. But a rich amount of ethics must be taken into account. Let’s talk about the engine start temperature reaching almost the allowable threshold three days in a row. While the value the crew observed was high pursuant to the manual, it was still allowable, and it was just a figure written in a record. What actions were taken? If it’s still allowable, hit it! And again the flashback hits me stronger. What could we tell next of kin when an accident occurs?
When we want to best explain aviation safety, we
need to think about and live for those tears, sobbing and mourn from these
relatives. And that includes not only the academic explanations and the coffee
breaks given at the lectures, but also all the processes of commitment to
ethics from top to bottom in any airline or maintenance organization. Why do I
mention this before anything else? Because the lack of ethics rules everything
in safety since its consequences are stronger than a safety policy, the
compliance with regulations or even the risk management. We must operate
pursuing protection of passengers' lives from the origin to the destination,
including all the aeronautical organization’s ethics-based management and
processes, and recalling that facts are the active failures; details are the
latent conditions, and these should be where we must be focused on!