Now, before you grab your torches and pitchforks, hear me out.
In many industries, but aviation in particular, an excellent safety record is a competitive advantage. In high reliability organizations (HROs), such as airlines, safety is paramount to organizational success. After all, a single accident, no matter how rare, could have catastrophic consequences, whether in terms of cost of life or liability. This is because the primary, secondary and tertiary victims are not the ones who made the dangerous decision, but they must bear the brunt of the outcome.
Airlines, manufacturers and their union representation groups spend millions of dollars each year researching and developing safety protocols and procedures. This is frequently supplemented by public sources such as military research, information from regulator investigations and publicly funded research projects. With effective security protocols ranking so high on the list of things that affect the health of an organization, it would follow that they would be closely guarded trade secrets.
Except they’re not.
As the aviation industry becomes more technologically complex, the risks and consequences of safety system failure increase. Over the last century, safety science has evolved from linear blame-the-operator thinking to complex sociotechnical modeling aimed at determining active and latent failures within an event. To reflect this growth and better achieve its goal of ensuring the world’s most efficient and safest airspace, the Federal Aviation Administration (FAA) in 2015 changed its compliance philosophy from a strictly enforcement role to a role encouraging collaboration on security among its sponsors. In administering its objective, the FAA has made available to the aviation community several safety programs, some mandatory (such as internal safety management systems), others voluntary, to better improve safety culture, sharing of best practices and data collection.
Industry players, whether large commercial operators, general aviation providers such as private business flight services or tour operators, or anywhere in between, have quickly recognized the benefits of internal security programs. Thinking about aviation safety grew out of the need for the civil aviation industry to meet the public’s demands for service in the post-war years, during World War I and World War II. Advances in technology, understanding of human factors and procedures were a direct result of accident investigations and spurred the development of infrastructure and research. Early safety processes focused on the consequences of an accident, but this reactive measure of thinking often resulted in recommendations addressing the specific active failure (what was specifically wrong), rather than latent or underlying factors. – underlying (what contributed to or aggravated the failure). caused the failure. Internal safety programs have enabled organizations to capture safety-related information, standardize risk management processes, and proactively share resources regarding hazard identification and mitigation.
To assist the aviation community in developing safety programs, the FAA has issued Advisory Circulars (ACs) that provide guidance on the development, implementation, and administration of safety programs. Professional organizations and unions have also proposed standards for safety programs that, although voluntary, often become industry standards, sharing best practices and procedures and providing a clearinghouse of information for organizations facing similar risks.
One of the most commonly used safety programs is the FAA’s Aviation Safety Reporting System (ASRS). The crash of TWA Flight 514 on December 1, 1974, focused attention on the need to gather comprehensive safety information and make it available to all parties. TWA Flight 514 struck a small mountain 25 miles from Dulles International Airport, killing all those on board. The ensuing investigation revealed, among other causes, a lack of clarity in the mapping and terminology of the approach. United Airlines had a similar accident six weeks before, narrowly avoiding the mountain, but its internal safety program flagged the error and sent corrective actions to its crews; TWA did not have access to this information.
Even before the National Transportation Safety Board’s (NTSB) formal probable cause assessment, the FAA determined the need for a national safety information program with the goal of collecting, analyzing, and distributing information to users of the National Airspace System (NAS), as well as identify and mitigate hazards in the NAS. Currently, ASRS is available to all NAS users to voluntarily and anonymously submit security-related information. Administered by NASA, a non-regulatory organization, the information is anonymized and analyzed; NASA’s role is to facilitate the collection of information because it ensures the non-punitive nature of the good faith submission of safety information, making the information more complete to the extent that the authors are not encouraged to hide details.
In practice, the Aviation Safety Action Program (ASAP) is similar to the ASRS. It is available to certified employees (airlines, manufacturers, air traffic controllers, etc.) who voluntarily engage in the program. More limited in scope than ASRS, the purpose of ASAP is to provide employees of eligible entities with a means of reporting safety-related information directly to an Event Resolution Committee composed of representatives from the FAA, the company and unions in order to identify the precursors of accidents, unclear or ineffective procedures. Strategies. Journalists have protections similar to those in the ASRS, and information is aggregated to identify potential dangers in the NAS.
Beginning in 2008, the FAA and its industry sponsors developed a biannual convention known as InfoShare, where airlines, labor groups, and industry participants openly share safety-related information and discuss high-risk events. The primary goal of these events is to share information they have gathered about the hazards they face, as well as best practices for mitigating the identified hazards.
Information sharing on this scale had to happen organically. No amount of regulation could have forced it into existence, but the collaboration facilitated by the regulator (once they realized brute force didn’t work…go figure), allowed the industry and the FAA to become more nimble and proactive , rather than punitive and reactive. Perhaps other industries and agencies could learn a lesson (looking at you, healthcare, with your notoriously high accident rates and draconian investigation methods).
Dennis Murphy is a professional airline pilot with experience in aviation safety, accident investigation and causation. When he’s not flying a 737, he enjoys the company of his wife, their dogs, cats and bees.
