Safety Insights

Success and Failure Stories of Practitioners

Nektarios Karanikas, Maria Chatzimichailidou, Nektarios Karanikas, Maria Mikela Chatzimichailidou, Maria Chatzimichailidou, Nektarios Karanikas, Maria Mikela Chatzimichailidou

• Publisher: Productivity Press
• Year: 2020
• eBook ISBN: 9781000194555
• Topic: Business
• Subtopic: Gestione industriale
• Index: Business

Public safety, as well as the safety of products and services, is of paramount importance and interest to individuals, organisations and society. Safety successes are achieved every second, but we take them for granted and we do not appreciate the challenges professionals meet to make the world as safe as possible. Safety failures are less frequent but become focal points of stakeholders and the public with a tendency to blame and not comprehend the context and the hard decisions professionals have to make when balancing safety with competing goals.

This edited book includes case studies from industry practitioners exactly as they experience them without relying on the understanding of researchers who conduct studies and try to map the overall situation per case based on multiple interviews, observations and questionnaires. Included are case studies from the aviation, construction, oil and gas, telecommunications, transportation, health and public safety industries. They are stories told by frontline practitioners who work to keep the public safe.

In each chapter, the author, based on his/her professional experience, shares two real cases, one "success" and one "failure", explaining the background and approach, and critically reflecting why his/her initiatives and activities worked or didn't work. They are descriptive of the case, context and tools, techniques, methods and approaches followed and include the valuable safety lesson learned. This book is a forum for professionals to express and share with others their knowledge and experience usually found implicitly or hidden under formal and informal practices.

Chapter 1

System Knowledge: Most of the Times Adequate but Sometimes Insufficient

Aikaterini Karakatsani

Contents

Safety and Other Objectives: They Do Not Have to Conflict

Missing the Fine but Important Details

Notes

Both my safety stories refer to the part of my aviation career as a flight dispatcher for a commercial airline. Working in commercial aviation is extremely exciting and challenging, especially for flight dispatchers who are like the eyes and brains of the pilots on the ground. During this period, I was responsible for creating and assisting in flight planning. My duties included the consideration of various parameters, including aircraft performance and loading, en-route winds, forecasts for thunderstorm and turbulence, airport conditions and airspace restrictions. We could say it is the ideal job for those who love aircraft but are afraid of heights but definitely for those who want to, at least, improve, if not ensure, the safety of flights. Day and night shifts were different in the period when I was working as a flight dispatcher. The big difference between day and night shifts was that during the latter, I was working alone in the office. Theoretically, after all the training I had undergone as a flight dispatcher, I was aware of what scenarios to expect and contingency plans to implement.

As passengers, when we hear a pilot’s announcement about, for instance, a route change or a diversion to an alternate airport to avoid adverse weather conditions, most likely it is a flight dispatcher in the airline operation centre who has assisted the flight crew in making an informed decision. Flight dispatchers not only plan a flight but also monitor it, and they are prepared to instantly provide almost any necessary information and assistance to the pilots. Occasionally, this creates an impression or illusion that they are on the flight deck. In reality, they are thousands of miles away from the aircraft, inside an office. However, the pilots in command of the aircraft with support from other flight crew members make the final decision, depending on the information provided by a flight dispatcher.

Safety and Other Objectives: They Do Not Have to Conflict

A winter night, an MD80 aircraft was operating a scheduled flight from the Canary Islands to the northeast of the United Kingdom. The weather conditions were normal and the aircraft departed on time. The flight time was about four (4) hours. Approximately in the middle of the flight route, the pilot in command (PIC) contacted the dispatch centre through a selective calling system to declare an abnormal operational situation as he had received an abnormal engine indication. The aircraft was running out of fuel mid-air without any apparent cause. During the first critical seconds of the conversation, my primary concern was a possible ‘fuel starvation’ or ‘fuel exhaustion’ situation. The difference between the two cases is that during fuel starvation there is fuel, but for some reason, it cannot reach the engine; it is, therefore, possible in some cases to re-establish the flow of fuel and to regain engine power. On the other hand, when fuel exhaustion occurs, there is no fuel remaining to supply the engines, which is the worst-case scenario of this type of situation.

The PIC predicted that there was a fuel leakage due to a technical defect causing fuel starvation. The early recognition of the problem by the PIC was vital to deal with this difficult situation; we had to collaborate towards performing an emergency landing. The next step was to discuss all actions that could minimise aerodynamic friction and keep the aircraft airborne as long as possible until it could land at an alternative airport. In cooperation with the PIC, I collected all necessary information such as aircraft coordinates, flight levels and remaining fuel as well as wind speed and direction. Taking all that data into consideration, I suggested the PIC perform an emergency landing at London Gatwick airport (code LGW). The PIC did not agree with this decision and counter-suggested London Heathrow airport (code LHR) as a better option due to its shorter flight distance from the current airway point of the aircraft. The tone of his voice made me realise his sense of responsibility, along with a sense of urgency under these very critical moments. The PIC had to make a correct and quick decision for the safety of the flight. This moment I felt very stressed. Neither by him nor by the situation, but by myself. The most significant stress in such cases is not coming from the possible outcomes of abnormalities but the pressure we exert on ourselves to be able to cope during the development of an event and the confrontation of the emergency.

I had to properly substantiate my recommendation for landing at LGW with information and data related not only to flight safety but also to the operational impact. In LGW, the airline had ground and fuel service contractors and the aircraft would be offered immediate assistance to avoid significant time deviations and exceeding crew duty hour limits. In LHR, instead, due to the emergency situation, the aircraft would still be allowed to land, but the airport slot restrictions would not allow a departure for at least the next 24 hours. This would not cause a safety impact but an operational disruption. LHR was a hub airport, one of the busiest airports in the world, with global flight connections. Each airport slot grants the airline full use of runways terminals, taxiways, gates and all other airport infrastructure necessary to conduct flights. With LHR operating at almost 100% capacity, it’s complicated for an airline to attempt to obtain a slot. Without a slot, it’s impossible to operate a flight to or from the specific airport. If the plane landed at LHR, the aircraft would stay on the ground until we would be able to obtain a slot for departure. This would cause a significant flight delay, unavailability of the crew due to exceedance of maximum duty hours, compensation to passengers and effect on the aircraft's next schedule. At this point, I hope the reader understands that safety cannot be approached in isolation from the whole operational envelope of an organisation; instead, safety must align with all business objectives and be managed in conjunction and harmony with them.

Of course, the PIC was in charge of making the final decision based on the information provided from my side, but I had to ensure he would consider the operational parameters as well. Finally, the PIC consented and performed a safe landing at LGW. The duration of our discussion was approximately four (4) minutes. After the end of the communication and before the aircraft landed in LGW, I contacted all relevant parties in LGW (i.e. the local airport authority and the ground service and fuel service providers) and made all necessary arrangements for a quick turnaround. I created and filed a new flight plan from LGW to the final destination where the aircraft was based, and the airline had 24-hour engineering assistance. The PIC called me from LGW and thanked for the assistance and quick response while confirming the accurate information about the availability of all services, which were provided at the airport without any problem or delay. From my side, I thanked him as well and emphasised the point that the early recognition of the problem was the key to deal with this challenging situation and to make a quick decision.

However, during my conversation with the PIC, I could not skip clarifying that my persistence was not an indication of disrespect but a result of a high sense of responsibility relating to my duties and willingness to resolve the situation in the most effective way and least possible negative implications. The PIC completely understood my positions. The only difference was that at that critical moment, he considered the safety parameters as a priority. During an emergency, safety comes first. Flight crews want safe flights as everyone performing or using a service within safety-critical environments. Notably, obtaining a slot at an airport is part of planning a flight and not part of managing an emergency. However, when time allows and depending on the nature of the emergency, overall operational parameters can be examined and reconciled with safety objectives. This, indeed, does not mean that safety is not a priority; it means that when the circumstances allow, any options to deal with an emergency must be explored holistically. My perspective is that safety and other objectives of organisations always go in tandem unless safety is threatened imminently and conflicts severely with the achievement of other desired outcomes. In the latter case, safety must and should be positioned first in the priority list.

By evaluating this case retrospectively, I concluded that the need to make a quick decision requires prior and updated knowledge of the technical and operational factors while taking into account the personal perspectives of the professionals involved. The PIC had the knowledge of how much fuel was being consumed. Many variables can influence the fuel flow, such as flying at different flight levels to those initially planned. If these variables had not been considered, the pilot’s awareness of the remaining usable fuel might have been incomplete, even inexistent. Maintaining fuel supply to the engines during flight relies on the pilot’s knowledge of the aircraft’s fuel supply system and reduces the probability of fuel starvation, especially during a critical phase of the flight. From my side as a flight dispatcher, I had the knowledge and expertise from the operational point of view, which was adjusted with the information, knowledge and expertise of the PIC. This combination should result in an effective solution, and so it did. Apart from the weather conditions, the aircraft’s remaining fuel and the shortest route airport, the effective and quick aircraft ground servicing was also an important parameter that had to be considered. Even though I knew that the PIC is in charge to make the final decision, I needed to ensure that he is aware of all aspects and options. That moment I felt as if I were in the cockpit with him, managing the same anxiety and sharing the same feeling. The feeling that the right decision should be taken for the safety of the passengers and the crew and the minimum disturbance of flight operations. Teamwork and shared awareness prevailed in this case without the tiniest sight of complacency.

When wondering whether there were alternative choices and decisions to manage this incident, I conclude affirmatively. The pilot in command holds the ultimate responsibility for a flight from all aspects. He could have decided to land at the other alternative airport as the first option considered without contacting the dispatch centre. Instead, he requested assistance and/or a piece of advice. In case he made his decision without consulting with the dispatch centre, we would have to face the operational effects, but there would not be any safety impact, and this is what eventually matters. I would respect this decision and try to assist the best way I could even, as explained above, landing at LHR would cause a lot of adverse cascade effects. Operational disruptions may occur anytime for various reasons and must be managed in an effective way. When it comes to a safety impact, the priorities automatically change and the best decision is the one which will reduce the safety risk impact.

Nevertheless, I appreciated the fact that a very experienced captain counted on my assistance as a flight dispatcher. As per our conversation after the event, I highly valued his position that safety needs to be managed and its balance with other aspects of operations does not occur by chance. From my point of view, I would follow exactly the same rail of thought under the specific circumstances, even though many years have passed from this event. In cases where an unfortunate event occurs, the first step is to detect the proximal cause and remedy it before it passes through different layers and leads to a serious incident or accident. This is what we achieved through teamwork and effective communication without harming the rest of the operational aspects.

If I close my eyes and travel back in time, I see myself through a mirror. On the one side of the mirror, it is me, a flight dispatcher with only a few years of experience, alone in the office struggling with anxiety, having to develop and recommend a plan in a very tight timeline and demonstrating a high sense of responsibility and teamwork. On the other side of the mirror is the PIC, a captain with many years of experience and responsible for an aircraft, passengers and crew facing an unpleasant situation and asking for my assistance. When the aircraft returned to its base, we were smiling at each other and showing gratitude to each other. This is something I am proud of and I will never forget. That winter night, I realised that sometimes it is not enough to just know what to do but how fast you are going to do it. You must occasionally overcome all odds and just do it by combing knowledge with quick decision making.

Missing the Fine but Important Details

During my career as a flight dispatcher, there were several moments that Murphy’s Law was coming into my thoughts. Usually, trouble was coming from several directions at once and most of the time during the night shifts when I was alone in the office. Just after midnight, an aircraft (MD80) was operating a scheduled flight from a Scandinavian country to North Iraq. The aircraft departed with an hour delay due to weight limitations and adverse weather conditions. The flight duration was 4.5 hours. The planning and preparation of this flight included several overflight permissions and a demanding flight plan, which had to consider the unfavourable weather conditions and the necessary fuel quantity to perform a direct flight with a fully loaded aircraft. Approximately one (1) hour before the estimated time of arrival, the PIC contacted the dispatch centre through a selective calling system to declare an abnormal operational situation. The aircraft had lost communication for the last three (3) minutes with Air Traffic Control (ATC). Aeroplanes communicate with the ground at fixed radio frequencies, which the pilots change manually as the aircraft moves from one air traffic control zone to another so that to receive instructions from the respective ATC services of the region. This system, for some unexpected reason, did not work.

According to the European Organisation for the Safety of Air Navigation,¹ commonly known as Eurocontrol, loss of communication between aircraft and ATC may occur for a variety of reasons, some of them being technical and others related to degraded human performance and job-related aspects of pilots and air traffic controllers (e.g. high workload). Aircraft loss of communication with ATC usually happens in one of the following circumstances: malfunction of communications equipment, mismanagement of communications equipment and radio interference. Moreover, someone might not be aware of whether any loss of communication is transitory or prolonged. Either way, such an event has obvious importance for flight safety.

Also, losses of communication can differ significantly in length; it is, nonetheless, those with an impact on daily ATC operations, which have drawn attention to the deviations and malfunctions and led to research and studies about their resolution. Communication losses affect all aviation segments. The phenomenon is not confined to a few aircraft operators or radio communication types. In the thousand reported events which have disrupted ATC since 1999, more than 300 airlines, 12 radio types, 180 sectors and 190 channel frequencies are represented. One of Eurocontrol’s main priorities is to progress with the deployment and usage of suitable equipment in aeronautical navigation service providers, airspace users’ offices and military reporting centres to gather from all relevant parties the necessary incident information to enable understanding and reduction of loss of communication occurrences.

Back to my story, all possible causes were discussed with the PIC; radio interference was removed from the equation and mismanagement of equipment was examined, but no deficiencies were detected. Last but not least, equipment malfunction was not possible to identify and no alerts or messages suggested any relevant problem. It was a very stressful moment considering all the possible effects since the pilot was unable to pass and receive useful information to the ATC. This situation could be interpreted as a security threat and result in a military interception.² Having calculated the exact aircraft’s take-off time and flight plan parameters as well as the latest weather condition forecast over the specific area, I tried to identify the aircraft’s airway and waypoint. Simultaneously, I made contact calls to the ATC centre in the aircraft’s vicinity and informed them accordingly about the situation.

The fact that there was nothing more I could do to manage this situation and ensure the safety of the flight was one of my biggest fears as an aviation professional, and I viewed it as a personal ‘failure’ despite not contributing to the problem directly, however unintentionally I had played a role in this, as I explain below. Nonetheless, although according to Murphy’s Law ‘if something can go wrong, it will’, on the positive side of ...

Table of contents

• Cover
• Half-Title
• Title
• Copyright
• Dedication
• Contents
• Preface
• Editors
• Contributors
• 1 System Knowledge: Most of the Times Adequate but Sometimes Insufficient
• 2 Safety Interventions: How Can We Make Them Worth the Effort?
• 3 Only a Few Seconds to Change the Course of an Event
• 4 How Could the Use of Technology Support Safety Management Programmes?
• 5 How to Eat an Elephant: Implementing Organisational Culture Change
• 6 Is Safety Part of Your Business Model? Turning a ‘Simple-to-Fix’ Safety Incident into an Opportunity for Everyone
• 7 The Development of Mental Health Proxy Teams and a Relationship That Threatened the Quality of a Safety Investigation
• 8 Passenger Experience and Safety Systems
• 9 Safety Numbers and Safety Differently
• 10 Infrastructure Projects as Complex Socio-Technical Systems
• 11 The Two Sides of the Same Coin
• 12 Learning from Incidents: Mind the Whole Set of Dimensions
• 13 Necessary Incompliance and Safety-Threatening Collegiality
• 14 Are the Stakeholders on Your Side or Not?
• 15 Making Safety a Priority
• 16 The Practical Value of Ensuring Effective Interfaces and Workforce Engagement
• 17 Just When You Thought You’d Done Enough
• Index