Pathological state of aviation safety. Learnings from recent SpiceJet incidents.

 
Is there a formula or method which can be used to predict accidents? A spate of runway excursions, tail strike and finally an unfortunate accident claiming the life of a Spicejet technician. 

The “accident pyramid”, as depicted by H. Heinrich in the second edition of his book Industrial Accident Prevention: A Scientific Approach. Note the last sentence: “Moral — prevent the accidents and the injuries will take care of themselves”.

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F. Bird’s work revealed the following ratios in the accidents reported to the insurance company:

For every reported major injury (resulting in a fatality, disability, lost time or medical treatment), there were 9.8 reported minor injuries (requiring only first aid). For the 95 companies that further analyzed major injuries in their reporting, the ratio was one lost time injury per 15 medical treatment injuries.

SMS

The safest way to operate in any industry is to eliminate all hazards. Unfortunately, this is a virtually impossible task since the cost of such an operation would be prohibitive. The effort required to run such a system will make it inviable in every sense. A Safety Management System (SMS) is a systematic approach to managing safety, including the necessary organizational structures, accountabilities, policies and procedures. As per ICAO requirements, service providers are responsible for establishing an SMS, which is accepted and overseen by their State.

Prior to implementation of the ICAO Annex 19 SMS, the regulations were more prescriptive. One could either perform an action or not, it was black or white. With the implementation of the SMS, actions can be performed if the risk generated is acceptable interns of the product of frequency and probability. Therefore, if the SMS program is fully implemented, then risk based decisions could be taken. The SMS program would keep a track of the risk to ensure that it does not exceed the limits set by the system through a process of feed back and periodic review. Training of personnel and effective reporting through a healthy safety culture would make the system more robust and effective.

A typical safety risk analysis of Spice Jet operations would reveal the risk level as 5C due to the high frequency of major occurrences. This would typically entail immediate mitigating action by the operator/regulator or restrict operations. These measures are required to ensure that the operator gets their act together and ensures that the safety management system is working and more importantly effective.

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Note: The above table is not based on actual data but indicative of a likely scenario.

Image result for safety management system The SMS process actively looks out for hazards, evaluates them for the level of risk and implements control strategies. There is a review process which determines the effectiveness of the control process and determines the further strategy. This process ensures that the hazards are not out of sight and new or latent hazards that might pose a risk are trapped by the mitigation process. When looking for hazards, it is important  that all available data is used. This is one of the key principles of high reliability organizations (HRO). A HRO does not believe in simplifying data because the more the data , the chances of predicting or identifying a hazard are more and the effectiveness of the control strategy can be accurately measured. The importance of a good and through investigation provides key findings and determines the root causes for the occurrence. This also prevents any immediate or future similar occurrence. Most errors are attributed to human factors. Read More

Optical phenomenon called ‘Glory’ and ‘Chimera”

 
Glory

Have you ever been flying over a cloud deck and noticed a rainbow halo around the shadow of your airplane? Besides being pretty to look at, this ring-shaped rainbow – called a pilot’s halo or glory of the pilot because we’re usually the only ones who get to see it – should be a clue to you that the cloud holds liquid moisture.

Chimera

Dream limitless- Amit

Risk perception: my presentation at the Flight Safety Foundation conference

 
My presentation at the Flight Safety Foundation conference at Singapore 


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