18 Mar 2020 18:00


The tie and tone of voice do not match in this skinny human being full of surprises and aces under the sleeve. The office is small and restrictive, but I have to make the interview to investigate an event. This story will change my mind. After years came over, I was able to understand this. I was the new Safety Manager for this airline, and need to talk to this guy. It was a polite evening embedded with the shadow of something hidden. “Speed, speed” was a word hitting my head. The first officer told this word more than twice during the approach, but the skinny guy was frozen, though the stick shaker was flickering hard. As we all know, this was not the first time. Procedure violations can be traced from a “culture” of many times before an incident or accident can just happen. Do you guys think then incidents/accidents just happen?

In previous articles I wrote, it is clear I am concerned and interested in the systemic approach to better understand the nature of accidents. What I try to do in my job of Safety Manager is to achieve strong organizational safety systems, instead of walking with my whip ready to spank the pilots or engineers. What could be said about it? I would like to run two runways after Professor James Reason’s insights on the nature of accidents: The Person approach and the System approach.

I found some statements from Professor Reason I like to share with you guys. I took these from his publication Human error: models and management. It says that “if something goes wrong, it seems obvious that an individual (or group of individuals) must have been responsible. Focusing on the individual origins of error it isolates unsafe acts from their system context. Countermeasures are based on the assumption that though we cannot change the human condition, we can change the conditions under which humans work. A central idea is that of system defenses. All hazardous technologies possess barriers and safeguards. When an adverse event occurs, the important issue is not who blundered, but how and why the defenses failed.”

What we discovered of this incident after plenty of interviews before the flight data analysis was ready was:

a)        Lack of ADM;

b)        Poor CRM capability;

c)         Lack of proficiency;

d)        Shortage of pilots;

e)        Training management just for delivering courses and keep pilots current; and

f)         Pilot performance during check rides not analyzed.

Obviously this story not only changed my mind, but this reinforced my concern on the organizational attitude, on the defenses we have to set. It is a work based on risk management. We cannot define, design, and set defenses if we ignore the hazards and consequences and the risks therefore we face.

We are not talking here about covering personal responsibilities or avoiding touching the fundamentals of safety accountability. We are required to recall two environments:


1)         Regulations. It is the blueprint where everything works. Specifications and design just work fine. But I dare you to tell me if this is enough.

2)     Risk Management. It is the actual management, wherein with a systemic approach you manage things with direction and control. I also dare you not to manage your airline with this. Do you think regulations are enough?


And what about managing an airline not taking into account hazards and inherent risks, along with the human nature, as well as the organizational culture and behavior, without setting defenses, just blaming people though feedback (human performance) is claiming, in fact, shouting your safety system is torn down!