As the air show industry suffers through another spike in fatal accidents, I’d like to offer some perspective as an air show pilot who also works as a consultant in the occupational health and safety industry with a background in Safety Management System (SMS) philosophy.
Generally, I’d like to talk about safety. More specifically, I’d like to discuss what air show professionals can do to work within some form of a safety management system.
The first – and, perhaps, most difficult – step is to get widespread agreement that using some form of SMS is both needed and desirable. Performers (myself included) are a sometimes apathetic bunch. “He screwed up and I wouldn’t make that mistake, so that couldn’t happen to me,” is a common attitude. But, the pilots who say to themselves that it couldn’t happen to them are, somewhat ironically, taking the first step toward having it happen to them.
An incident is more than a simple singular event. An incident is actually the sequence of events that have lead up to the outcome. In a publication entitled, Practical Loss Control Leadership, authors Frank Bird, George Germain and Douglas Clark write that, “Experience shows that a majority of incidents involve both substandard acts/practices and substandard conditions. Also, these are only symptoms. Behind the symptoms are the basic causes, the personal factors and job factors, which led to the substandard acts/practices and conditions. In effect, there are three levels of causes: (a) immediate causes, (b) basic causes and (c) lack of management system control factors.”
In other words, a series of failures is required to provide a final outcome. Using an icy sidewalk (immediate cause) as an example, we can soon see that an ankle was twisted (incident) because the individual may have been wearing inappropriate footwear (immediate cause). Looking further into the incident, we can see that a downspout from the roof has been depositing water onto the sidewalk (basic cause). This is a very simple example, but you can see that, if we were to remove any of the causes, the twisted ankle would have been less likely to occur. If the individual would have been wearing appropriate footwear, he or she may not have twisted their ankle. If someone were to have re-routed the downspout, the risk would have been mitigated.
Not wearing appropriate footwear is a substandard act, the ice is a substandard condition, and the position of the downspout is a substandard condition. All of this speaks to immediate and basic causes. The third level of cause is lack of management system control factors. In this example, a management system control factor would be something as simple as having a management policy to inspect the area, place sand/salt near trouble spots, and take action on items such as re-routing the down spout from the eve. But, if it isn’t written down, it doesn’t exist. And if it doesn’t exist, it cannot be managed.
A book entitled, The Ten Basic Principles of Safety by Dan Peterson succinctly summarizes the tenets of safety management:
- An unsafe act, an unsafe condition, and an accident are all symptoms of something wrong in the management system.
- We can predict that certain sets of circumstances will produce severe injuries. These circumstances can be identified and controlled.
- Safety should be managed like any other company function. Management should direct the safety effort by setting achievable goals and by planning, organizing, and controlling to achieve them.
- The key to effective line safety performance is management procedures that fix accountability.
- The function of safety is to locate and define the operational errors that allow accidents to occur. This function can be carried out in two ways: (1) by asking why accidents happen – searching for their root causes – and (2) by asking whether certain known effective controls are being utilized.
- The causes of unsafe behavior can be identified and classified. Some of the classifications are Overload (the improper matching of a person’s capacity with the load); Traps and the Workers decision to Err. Each cause is one which can be controlled.
- In most cases, unsafe behavior is normal human behavior; it is the result of normal people reacting to their environment. Management’s job is to change the environment that leads to the unsafe behavior.
- There are three basic subsystems that must be dealt with in building an effective safety system: (1) the physical, (2) the managerial, and (3) the behavioral.
- The safety system should fit the culture of the organization
- There is no one right way to achieve safety in an organization; however, for a safety system to be effective it must meet certain criteria.
- It must force supervisory performance.
- It must involve middle management.
- Top management must visibly show their commitment to the safety system
- It must have employee participation
- It must be flexible.
- It must be perceived as positive.
As I said before, we can sometimes be an apathetic bunch. We look at a tragic accident and convince ourselves that it couldn’t happen to us. Sadly, we are only looking at the tragic outcomes (or symptoms as mentioned above). The only way we can be reasonably sure that we are mitigating risk is by ensuring we have a safety management system in place that addresses not just the possible incident (ankle twist), but also the immediate (inappropriate footwear) and basic (ice on the sidewalk) causes, as well as the lack of management system control factors (no program in place to remove ice or inspect downspout regularly).
Put another way, it’s not enough to simply try harder to avoid hitting the ground. That approach cannot and will not work. Individually and as an industry, we must commit ourselves to understanding the root causes of air show accidents and then taking the necessary steps to mitigate the risks/causes that we have identified.
In addition to his air show business, Daryl Lowey is a safety consultant based in Didsbury, Alberta. He will be contributing additional Ops Bull articles in the coming weeks and months.