Safety-II: Building safety capacity and aeronautical decision-making skills to commit better mistakes

The paper instils a vanguardist discussion on Safety as Capacity within the context of air operations. While industry-accepted metrics tend to focus on the absence of accidents, contemporary specialists find it somewhat paradoxical to measure safety by its absence. Additionally, the work challenges the simplistic linear perspective to an undesirable occurrence in the dynamic and complex aeronautical context. In an era when many accidents are attributed to human error, it is fundamental to understand why people do what they do. This approach within the paper focuses on human performance (the positive outcome of human management of variability) rather than human error.

In contrast to risk, capacity is manageable. An undesirable aviation safety occurrence consists of three phases: the context (manageable), the consequence (the event), and the retrospective. Reactive Safety is at the consequence. Safety Capacity is at the management of context.

On the other hand, efforts to suppress reportable events via the pursuit of error-free, perfected operations may produce superficial positive metrics disconnected from line reality. Mindfulness is due. Zero-event cultures tend to promote veiling of the current state-of-safety as capacity within the organization. It stimulates opportunities for unexpected catastrophic events to lie unmanaged. Because the dynamics of minor events linger unaddressed, unreported, or unknown, threats remain alive and are often treated as unimportant when corroborated by the non-linear correlation with the absence of catastrophic events.

In this context, associated with the absence of reported undesirable events or conditions, a reduction of meaningful data acquisition will follow. It is a vicious cycle. At the outset, very few people want to break the bad news and challenge a “perfected” safety system. The historical absence of events can be erroneously and dangerously perceived as a positive condition of organizational safety maturity. However, there is no direct correlation between the absence of past events with respect to the potential emergence of a future catastrophe. Safety considerations from a retrospective, post-factum, analysis of a mishap are disputed concerning their limited gains if projected toward the next potential event.

Safety Capacity’s interest is in the system’s capacity to fail safely. The substantial change is from “if it fails” to “when it fails”. Moving away from the traditional perspective of extinguishing events, more assertive questions and solutions are directed at preparing the system’s response to the failure instead of attempting to avoid it. The consequence (event) can’t be managed, but the system’s response to failure, the context, certainly can.

In creating Safety Capacity, in the management of context, the organisation understands that the operations are not inherently safe and contain parts readily aligned to failure. Firstly, the continuous improvement efforts focus on the system, not the workers. People are at the solution’s core as safeguards and barriers to undesirable events.

The proposed benefit of this study is to empower the crew with safety-enhancing autonomy. A preliminary Organisational Safety Capacity Assessment Card is offered as a tangible tool to serve as a situational awareness instrument for the pilot and the corporation by directing attention to the broader safety-relevant aspects of the organisational environment rather than as a flight risk assessment device. Additionally, it assists pilots to ask better questions and possibly generates a momentum of change toward a positive safety culture.


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