By: Sergio Romero
“…friction is the force that resists this forward movement…”
Beachwells. Australia
The flood in the cockpit comprises smoke, horns, rings and automated voices. Still, the performance of the crew is within acceptable limits. But as the circumstances develop and most of the time it constitutes a surprise or a sudden event for the crew members, the available defenses are knowledge, experience, including construction of such a knowledge, training quality and decision making, among others. As the wrong engine is cut off, and the steep banking cannot be avoided, this does not only mean the defenses did not drive enough friction or that they were not aligned to overcome this about-to-come crash, but also that downward forces, gravity, drag and all the consequences of this undesired event defeated the crew. Searching into the memories, the manuals, the procedures, and the struggle of probably the first-time real encounter with an emergency like this will be well written as a statement of probable cause in some aircraft accident report.
However, where did all of this really begin? Is it considering ICAO’s Annex 13 SARPs when, regarding the conclusions of the investigation report, it says, “The list of causes and/or contributing factors should include both the immediate and the deeper systemic causes and/or contributing factors”? Many of us that investigate, analyze and manage safety performance inside our aviation organizations and try to enhance the flight safety are reading the document from the last page to the beginning. In addition, it might be wrong though it appears to be reducing time and efforts. Well, it just reminds my little daughter. She caught me many times in the middle of a David Mamet film, and as smart, as she is, she was always telling me the end of the story. Nevertheless, my reply to her was constant repeatedly as his lovely curls “the details and the story itself makes the difference, Blackie”.
It is clear that when an aviation accident occurs, the puzzle is hard to turn into one clear visible picture. Everything is torn down into small and blurred pieces. And every one of such pieces mean the latent conditions that were going without monitoring. These are the deeper systemic causes that ICAO needs or mandates us to analyze and to share to improve the system. Of course, all of these collides naturally the direct and primary (instinctive) objectives of some organizations: Profits, quick-to-recover ROIs, and aggressive modification of production conditions. Can we go by the book at this instance? We must! What are these deeper conditions that I saw in many aviation organizations?
Lack of a management system culture.
Constant cover-the-hole-that-it-just-eroded culture.
Corrective but not preventive management bias.
Prioritization on momentary tasks against a PDCA culture.
Picture Adapted from the website "BBC Bitesize"
At this stage, it is clear that when we talk about the SMS or any management system, whose purpose is to prevent accidents, latent conditions, culture, management styles or many other contributing factors, organizations are undergoing a smash between two surfaces: The first one is the defenses as set or the organizational framework. The second one is how humans follow or execute the procedures within the organizational framework. Thus, we are talking here about friction, or to be more precise, safety-based operational friction. What is the classical definition of this term? Friction is a force between two surfaces that are sliding, or trying to slide, across each other. On that sense, we have:
The set defenses or the organizational framework, which is one surface.
The way humans follow or execute the procedures within the organizational framework; i.e. traditions, culture, artifacts, symbols and hardware, which form the second surface.
During the operational requirements and its pertinent performance by the organization, human beings show criteria, experience, knowledge and mainly attitude. So, we struggle to have available a standardized-based performance for operations, administration or safety. However, if this is not supported, as ICAO mandates, by a continuous endeavor, resources are wasted and effectiveness is even impossible. In this scenario, we are at a theatre showing the smashing between these two surfaces. What is the role of the SMS? It is the force that is opposite to the way humans try to execute the tasks. According to a publication by BBC, “the amount of friction depends on the materials from which the two surfaces are made. The rougher the surface, the more friction is produced. Friction also produces heat. If you rub your hands together quickly, you will feel them get warmer”.
Therefore, to make a review, we have the requirements and the organizational framework. We also have the way we perform such requirements pursuant to traditions, culture, artifacts and symbols. These previously mentioned are the two surfaces. These two surfaces are interacting each other so organizations can achieve their purposes or try to do it. This interaction by nature is the safety-based operational friction, which in turn defines the quality of safety through its roughness or strength. It means the rougher (stronger) the surface; i.e. the quality, continuous monitoring and reporting and management of latent conditions and culture, the more friction (or safety) is produced; i.e. the proper balance or negentropy is achieved, so safety is organizationally managed to acceptable level of risks. What for? To avoid being defeated by hazards, to watch in preventive mode the operational environment and at the proper dimensions; i.e. the difference between causes and consequences is fairly where does it all begin in the organizational management of the operation and not in the operation itself. Once we manage that knowledge, we will be preventing instead of correcting all the time, which means the operation is expensive, not profitable and unsafe.