--by Sabrina Woods, FAA Office of Accident Investigation and Prevention

Have you heard? There is this relatively new concept called Safety Management System (SMS) that is sweeping manufacturers and regulators alike. It is rapidly becoming the gold standard throughout the aviation industry. Our National Airspace System (NAS) is remarkably robust, safe, and efficient, accommodating 5,000-plus operations at any given moment, in and around over 5.3 million domestic and 24 million oceanic square miles of airspace. But we can always do better. That is where SMS comes in. It is a proactive, systematic, top-down approach to managing safety within an organization. But understand that none of it works if there isn’t a solid safety culture underpinning the effort.

Safety Culture Defined

“Safety Culture” is usually defined as a collection of beliefs, perceptions, and values that all employees share in relation to the risks that exist while conducting operations within an organization. It is what each person believes about the importance of safety and how he or she contributes in light of that belief. It is about understanding what risks are associated with the job, and what your responsibility is regarding that risk.

Safety culture, in and of itself, does not have a distinct classification. An organization can have a “bad” or “weak” safety culture just as readily as it can have a “good” or “strong” one. It is all about what the people believe and put into it that gives it its power. Many tragic accidents have occurred, in part, because of the lack of an effective safety culture. Chernobyl, the Challenger explosion, the Piper Alpha oil platform explosion, the Upper Big Branch coal mine disaster, and the Colgan Air Flight 3407 plane crash serve as just a few examples.

Complacency, poor decision making, workarounds, failing to follow procedures, ignoring trends, a reluctance to communicate concerns, and failing to respect human limitations are all hallmarks of a poor or weak safety culture. Each of the aforementioned accidents had these issues in spades and each resulted in horrible loss of life. The sad thing is that each disaster could have turned out vastly different, if not averted altogether, had there been a good safety culture in place.

Hallmarks of Good Safety Culture:

Commitment. First and foremost, a good safety culture is dead in the water unless there is a solid commitment to it. In the military, we had a saying about doing what is right, even when no one is looking. We use it to define integrity, but I think it works here as well. Building and sustaining a safety culture is not just about nodding along at the points that seem reasonable and make sense. It is about applying action to the words. It is also about staying committed to the task even when it might seem as though others have lowered their own vigilance. In aviation, it is about being concerned for the outcome of each flight and doing whatever is necessary to ensure everyone returns home safely every time.

Communication. You can always tell how well an organization is running by how it communicates within itself. Is communication effective — from those in charge, to the employees, and back again? Have the goals or mission of the organization been clearly delineated by those in charge? Do the people know that if they express a concern, it will be taken into account and addressed if needed? Someone once said that ideas are the currency of success. Safety culture needs a clear focus, constant ideas, assessments, and feedback to remain strong.

Teamwork. Safety works best if everyone involved feels like they are on the same team. No one likes it when they feel as though they have no say in what happens to them. Everyone — Big Boss to Worker Bee — has to be onboard and have buy-in for a safety culture to remain shipshape. All hands are on deck. That might have been a lot of nautical references, but you get the idea. If everyone on the team works toward the goal, everyone can benefit from the results. Plus, it takes a massive amount of energy to keep a good safety culture going. Not just one person can keep it up all the time. The load is lighter when it is shared.

Responsibility. With great safety comes great responsibility. Everyone in the organization has to have a sense of empowerment and accountability when it comes to identifying and managing risks. It just doesn’t do anyone any good if people walk right by hazards, day in and day out, without anyone feeling as though they ought (or are allowed) to do anything about them.

In one real world example, a flight crew for a part 135 operation found a main landing gear bolt broken on their preflight inspection. They immediately reported it. A few weeks later, in the same operation but on a different aircraft, an aircraft mechanic found a bolt completely missing from a main landing gear. He reported it. A few months after that, an aircraft experienced a catastrophic failure after landing when ALL SEVEN BOLTS from a main wheel failed, causing the tire to deflate and the wheel to separate. Enough was enough. In a massive coordinated effort, the operator’s principal airworthiness inspector, in conjunction with the aircraft certification office, researched, penned, and pushed a safety recommendation initiative to identify, uninstall, and recall all of the bad bolts. Not just on their own fleet — realizing that there were several other potentially affected Beech Jet 400s out there, they took it a step further. Because of the team’s hard work and commitment to safety, they got all of the bad bolts out of the supply system and they did it in record time. Now there are several subsequent initiatives to make sure nothing like this happens from the manufacturer again. Spider-Man’s Uncle Ben would be super proud. But seriously though, one responsible player in an effective safety culture could make the difference between a safe flight and a bad accident just waiting to happen.

Respect. Here is where I have to take a moment to put my human factors hat back on. If you’ve ever read any of my articles in past issues, you had to know it was coming. A safety culture is not anything unless there is healthy respect: Respect for the hazards and risks that are associated with doing business in the organization, and respect for the limitations of the human mind and body.

To reiterate what you likely already know, a hazard is anything with the potential to cause harm. In the previous example in the “responsibility” section, the hazard would be the bad bolts. A risk is the chance (low or high) that the hazard will actually cause harm. So the risk would be attempting to land on the bad bolts. If everyone in the organization doesn’t have the same level of awareness and regard for all of the potential hazards and risks — if the flight crew, mechanic, and airworthiness inspector had blown off the busted bolts instead of doing something about them — it can leave a significant gap in the safety culture that an accident can slip through.

Last, never forget that we humans have just as much potential to be a hazard as those perilous parts do. In the Colgan Air Flight 3407 accident, inattention, distraction, and fatigue played significant roles in the pilots’ failure to monitor airspeed. It resulted in their inability to diagnose an impending stall and apply appropriate corrective actions. This was likely not the first time the combination of these things happened in a cockpit. In an effective safety culture, we have to be mindful of what factors affect human performance and why. We can’t just assign blame and move on because in the end, it fixes nothing and can foster a culture of fear and reluctance instead of safety. Achieving zero human errors is impossible, but mitigating the risks associated with human error is totally doable so long as there is continuous effort, improvement, feedback, and respect.

Just a Party of One?

By now you might be wondering, but what does this safety culture thing have to do with me? I’m just one person and hardly an ‘organization.’ Totally valid, but I have news for you. You ARE an organization! Even if you mostly fly as a party of one (or maybe plus one if you fly with a friend/family member), you are part of a bigger, more dynamic whole. As such, you should want to build the best personal safety culture you can to continue flying safely.

It really isn’t just you, you know. Perhaps you rent your aircraft from the local FBO. That company is part of your safety organization. Or perhaps you own and have to rely on your trusty mechanic to keep your bird airworthy and flying high. He or she is part of your safety organization. Maybe you attend regular type club meetings, have a favorite flight instructor you use to keep up on the basics, or fly out of a towered airport and depend on air traffic controllers to keep you safe and separated. Every one of these people is part of your “organization of one,” and therefore part of your safety culture.

How Do You Do Safety?

Since safety culture is a collection of beliefs, perceptions, and values — what do you believe? How do you think a safe operation should go, and how should everyone involved conduct themselves? If any one person in your organization — the FBO personnel, mechanic, flight instructor, or controller — doesn’t put a high value on safety or do their due diligence in identifying and mitigating risks, the result can be disastrous for YOU.

Creating a strong culture is a matter of applying the good hallmarks in your mini organization. It is about staying engaged with all of the latest and greatest general aviation safety news. You are already on the right track just by picking up this magazine and reading through it! It is about chatting with your fellow aviators about experiences you have had and lessons you’ve learned. It is about “seeing” it and “saying” it and letting your FSDO know when something you encounter doesn’t seem quite right. It’s about taking advantage of every opportunity there is to better yourself as a pilot. It is about giving careful consideration to equipping the tools that heighten the level of safety for each flight (ADS-B Out anyone?) And lastly, it is about appreciating the fact that safety is hard work. It has to be nurtured and cultivated just like any living thing does.

Sabrina Woods is a guest writer for FAA Safety Briefing. She is a human factors analyst with the FAA’s Office of Accident Investigation and Prevention. She spent 12 years as an aircraft maintenance officer and an aviation mishap investigator in the Air Force.

This article was originally published in the July/August 2019 issue of FAA Safety Briefing magazine.