Risk Mitigation - Don't Forget the Follow-Up

During my evaluation of aviation entities, I often discover a theme of weakness during inspection audits. Many companies have developed risk mitigation strategies to handle most of the larger operational pieces. But, I continue to smell James Reason’s Swiss Cheese and notice those holes through which mistakes can line up, join arms and form an accident chain.
One of the most pronounced problems that I’ve noticed is the lack of follow through. There may be an appropriate process for dealing with risk, but leadership hasn’t established a means to fuel the effectiveness and dependability of the measure.
For example, during one appointment, I noted that the aviation operator had instituted an aircraft tracking system and delegated project managers to follow the helicopters during all flight operations. While this was a fantastic tool to alleviate operational risk, several enabling actions were omitted from the process.
  • The tracking devices were battery powered with no standard operating requirement to carry additional batteries or replacement intervals (prior to becoming drained).
  • There was no check-list established to determine operability or power status.
  • Flight crews were not provided with alternate communication devices other than cell phones.
  • There were no standard operating requirements for renewing the tracking subscription service.
  • Flight crews were not required by the operator’s procedure to test the tracking device.
  • A process for after-hours aircraft dispatch failed to include notification of the project manager.
  • There was no established, operator policy regarding the use and availability of company devices after hours.
Although the idea itself was admirable, the lack of ancillary control measures resulted in spotty dependability. The new safety improvement had only superficial risk blunting ability because so much foundational support wasn’t developed.
The vast majority of any operator’s decisions have these measurable strengths and weaknesses. Some of the leadership, employees and safety personnel will adequately address the “what ifs” in such a way that risk control measures achieve their goals. It is always the case that some will not. That is where the insidious and ever present potential for accidents increases. A strong Safety Management System (SMS) can help.
Having a safety department that can accurately analyze process weaknesses is an integral part of maintaining an accident-free environment.  Adequately addressing this subject could fill many pages. The most important take away from this brief article should be recognition of the importance of enacting follow-up procedures that protect and enhance the original risk mitigation measure.

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