The Director General Civil Aviation,
I am an aviation professional with over 30 years of aviation experience. I write an aviation blog mindFly which is globally the few ones to focus on ergonomics and the human factor.
I share everyone’s concern towards safety in aviation and the urgency to take action to assure safety. Through this letter, I would like to draw your attention towards certain aspects of safety and promotion of safety culture enshrined in the DGCA India’s State Safety Policy and International Conventions. These tenets of safety are vital to promoting a safety culture in Indian aviation. Even though we may comply with operational & design requirements mandated by ICAO Annexes, the ICAO Annex-19 calls for systematic handling of safety. Meeting the minimum requirements mandated by ICAO does not always assure safety. If for e.g. the airport is located on a tabletop, then sufficient buffers are needed over and above the minimum ICAO Annex-14 requirements.
I quote the India Safety Policy ” DGCA will implement proactive and as far as possible predictive strategies encouraging all stakeholders/ service providers to understand the benefits of a safety culture, which should be based on an inclusive reporting culture. DGCA will foster and assist stakeholders in developing comprehensive Safety Management Systems (SMS) and will develop preventive safety strategies for the aviation system in an environment of a “just culture”.
The Air India Express IX1344 accident and a spate of occurrence in the year 2019, the suspensions of the flight crew has widened the rift that was preventing the development of a safety culture. The development of the safety culture in India is still in its infancy. The unfortunate part is that the harsh measures adopted by DGCA to curb the incidents were against the concept of just culture and even against all documented procedures in the DGCA safety and enforcement manuals. The suspension of aviation document for contravention of a provision of the Aircraft Act/Rules is the most severe administrative sanction the DGCA can impose. Suspension action is taken where continued use of the document would create a hazard to aviation safety. The suspension of license without having determined if the act was due to gross negligence/willful violation or not is in my opinion against the principles of state safety, and neither administratively correct nor legally tenable.
I would request you to please review the incidents from the human factor perspective to determine the root causes. All occurrences have ‘human factor’ as one of the leading cause. There are multiple contributory causes to any occurrence and these causes have a certain weightage which adds up and to lead to the breach of safety barriers. It would be judicious to address the real cause/s rather than the symptom. I would also emphasize on ensuring that the functioning of the Safety Management System is in the true sense since it is the overarching concept of safety as mandated by ICAO Annex 19 and Indian Aircraft rules 1937.
Unstable approaches, for example, have a psychological aspect too. I have written a paper ‘Failure to switch task and cognitive lockup’, which has been published by the U.K. Flight Safety Committee magazine ‘Focus’ this year. A link to the paper is in the article https://www.ainonline.com/aviation-news/business-aviation/2019-02-22/ainsight-psychology-unstable-approach
Even a non-traditional work environment builds on traditional values and concepts. Trust is one of those values that are of increasing importance. In order to build and promote safety culture, there is an urgent need to build trust amongst the stakeholders. Steven Covey author of ‘Speed of trust” has observed that in poor-performing work cultures low trust often masquerades as bureaucracy, dysfunction, inefficiency, turnover or disengagement. Leaders mistakenly dismiss trust-building as a secondary focus, concentrating on the wrong cause — when the trust should actually be the primary focus.
Although work is still conducted largely by people, or at least with their involvement, the system of work is remarkably dehumanised. The human aspect has been overridden by production pressures, processes and “controls” that imply management does not trust the workers; that workers do not share the same values and motivations as business owners. As a result, we often see people treated as units of labour without recognition of personality, creativity, innovation and any variety or diversity. (EY report on HSE safety culture)
The lack of trust, or the creation of distrust, also seems to be a common element in industrial relations the disputation was a co-operative relationship of common goals have been fractured to the extent that mechanistic and combative conversations are relied upon for issue resolution. This is an extremely costly and unproductive way to operate a business.
If we subscribe to Stephen M. R. Covey’s views, we can deduce that poor safety performance is actually a symptom of low levels of trust. Instead of being an outcome of safety maturity, increasing trust is a fundamental driver of safety maturity and business outcomes.
Widely known as the Hudson Safety Maturity Model, the “Original Framework of Safety Culture Maturity” was published in Safety Science in 2005 by Matthew Lawrie, Dianne Parker and Patrick Hudson. The framework builds on earlier research conducted by the trio in 2000/2001 and has been vigorously tested and trialled with the Oil & Gas industry, resulting in the Shell Hearts and Minds program. The framework sets out five stages of maturity based on commitment and cares for colleagues. By climbing the evolutionary ladder of safety maturity, organisations experience increased trust and their leaders, managers and workers become increasingly informed.
In the pathological stage, management believes accidents are caused by stupidity, inattention and, even, wilfulness on the part of employees. Fine sounding messages may flow from on high, but the majority still reflect the organisation’s primary aims, often with ‘and be safe’ tacked on at the end.
The reactive stage is where safety becomes a priority after an accident. It can be a temporary stage for otherwise pathological organisations, or it can develop into the calculative stage, where an organisation puts safety processes and systems into operation. ‘Calculative cultures both have a process and use it,’ Hudson says.
Calculative organisations run the risk of going through the motions of safety management, Hudson says. He notes that ‘on the Deepwater Horizon, 110 staff on board were submitting an average of over 100 safety job cards every day—nearly one per person, per day—not that it helped.’
The transition to becoming a proactive organisation involves making the processes and systems that are now in operation truly effective. Proactive organisations use their processes and systems to anticipate safety problems before they arise.
In the generative culture, all these elements come to fruition. In the proactive culture, the top of the organisation is still driving safety but has created the potential to let those who are the subject matter experts take responsibility and accept it as well.
CIVIL AVIATION REQUIREMENTS SECTION 1 – GENERAL SERIES ‘C’ PART I Issue II, 27th July 2017 with the subject, Establishment of a Safety Management System (SMS) defines just culture: It is a culture in which personnel are not punished for actions, omissions or decisions are taken by them which are commensurate with their experience and training, but where gross negligence, wilful violations and destructive acts are not tolerated. Safety culture is a part of SMS and as Robert L. Sumwalt, Chairman of NTSB summarises, SMS is managing safety, the way we manage other vital business functions. Trust is essential because of it enables employees to report safety concerns without fear of retribution. The way to instil trust is to ensure you have a just culture.
In light of the recent accidents, there is a need to instil objectivity in the risk assessments and not to limit the safety efforts to the bare minimum standards required by the ICAO Annexes. There will be support required from all stakeholders and collectively the industry can standup and forge together to meet the challenges. Since the overarching principle is establishing and running an effective safety management system, the maturity of which is displayed by a flourishing generative safety culture where an honest and responsible worker or entity does not fear punitive action for just negligence and contributes in every way to make the system more robust and effective.
I hope my views are taken in a positive way and I am sure that there are many like-minded people who will be willing to help.
Capt. Amit Singh FRAeS
12 Aug 2020