Considerations presented by Steve Bentley FRAeS CEO of Sofema (www.sassofia.com). Steve has over 50 years of experience in Civil Aviation and has been working for more than 25 years in the spheres of Quality, Safety & Aviation Training.
Issue No. 1 – Regulators often fail to appreciate the role of vocational and competence-building regulatory training courses even some are requesting that organisations providing such training should hold approval to deliver when none in fact exists.
Why is it an issue?
Because if the Regulatory Authorities fail to understand that the role of competence management must sit firmly with the organisation, it weakens the integrity of the aviation safety system.
Instead of asking for a “nonexistent” certificate of approval for a regulatory training organisation the correct approach is to ask referenced organisation the following questions:
1/ Have you established what training your organisation requires to effectively ensure compliance with all regulations and to meet your organisational objectives?
2/ Where is this documented?
3/ How do you as an organisation assess that the requested external training meets your objectives?
4/ How does your organisation assess delegates who have completed the training?
(Note: www.SofemaOnline.com provides FOC enrollment to Quality Managers and Regulatory Authority Inspectors for the purpose of Assessment)
Concerning External Training Providers, please note the following:
It is not possible to approve an “external” organisation as a third party to be licensed to deliver regulatory and competence-related training. Such a process would be detrimental and would reinforce the misunderstanding that in some way the organisation is removed from the need to assess and validate the training standards or acceptance of delivery.
- a) The receiving organisation should be 100% responsible for compliance with the regulations and for competence management of its staff.
- b) An external regulatory training organisation is in fact a “service provider” and it is up to the receiving organisation to ensure the service meets its needs and expectations.
- c) Such approval therefore can only come from the receiving organisation
Whenever an organisation asks for training approval from a regulatory training company as a service provider, they are sharing that they do not understand the above or the role of indirect approval where the organisation is 100% self-responsible.
Issue No. 2 – Concerning Root Cause
A number of Regulatory Authorities when providing a finding ask the receiving organisation for the Root Cause of the problem
Unfortunately, this is not correct as it implies in some way there is a single Root Cause. This typically causes must confusion across the business with some people believing there must always be a “single” Root Cause of a particular issue or problem.
- In fact, as we will quickly see there can indeed be multiple root causes associated with a single problem.
- Part of the purpose of the Root Cause Analysis is to also understand the causal (contributing factors) that impact a particular event.
Please consider the following Definition:
A root cause is the deepest, most fundamental, earliest cause that led to a particular problem within a particular area – noting that multiple areas can conspire to create a problem – therefore we can indeed have multiple root causes for a given problem.
Any root cause should be both tangible and meaningful to the overall Root Cause Process. (Ideally, we should be able to address the root cause means to correct the anomaly in a way which provides a positive outcome.)
It does not really matter how we identify the nature of the issue – the point is that if we only address the symptoms, we are likely to see the underlying problem repeat or reoccur even multiple times and with additional costs.
If we can look below the surface at the fundamental causes, and address the underlying system and process causes we should be able to make the issue go away completely and at the same time often bring financial benefits or savings to the organisation.
What is our interest in Root Cause?
We cannot afford to fix every problem we face – in fact, some issues we have to learn to live with and for other problems, we take action which provides a “partial solution”.
So we are looking for solutions that both deliver and also provide us with the optimum return on investment (ROI) and ideally achieve a fix which provides a solid and positive solution which prevents re-occurrence.
In our Aviation Systems, we are always going to need to get to the root cause of any problem or series of problems with the best RCA being carefully mapped to consider all potential causes.
Dealing with Contributing Factors adds Value to the Aviation System
Addressing both Root Causes and Contributing Factors associated with a particular event should provide the strongest possible mitigation and minimize its re-occurrence.
- Important note: Regulatory Authorities can help this objective by asking for Root Causes and Contributing Factors to be identified and addressed.
Typical Root Causes found in our Aviation Systems include the following:
Related to Physical Causes – This is when there is a specific failure of the infrastructure or a mechanical mechanism – so we can clearly see that we have a failure. This is only the very beginning of the story – the next question to ask is why.
Related to the Human Interface Causes – This considers the possibility of human error. Many events involve various human errors which need to be explored to understand the precursors as for sure it is highly likely that it was not intentional.
Related to Organizational causes – When considering this aspect we are looking at failures in some way in the system, process, or even the underlying policies that are used to drive the decision-making process.
Issue No 3. – Human Factors Can Never be an Acceptable Root Cause
Many organisations close a regulatory finding by claiming the Root Course is Human Factors of some description. Unfortunately, the Regulatory Authority accept this when in fact it should be rejected.
Asking the why question with Human Factor Related Causes
Regardless of the Human Factor Proposed for a given event it is always possible to ask the why question and to move deeper into the subject.
- To share that empirical evidence has shown that under normal conditions, we can make between three to seven errors per hour. Under stressful, emergency, or unusual conditions, we can make an average of 11 errors per hour.
- Whilst Human Error is an inevitable consequence of our human engagement with the aviation system or various business processes, we should not be willing to accept the term Human Error as an acceptable root cause of an event.
Let’s consider why Human Error is NOT an Acceptable Root Cause
Essentially it is because the acceptance that Human Error was involved in an unwelcome event may imply that whatever has happened is beyond our control and it can therefore happen again! (which clearly is not an acceptable outcome.)
Whenever we encounter an incident or accident which involves a trained and competent person who is engaged in the normal work environment, experiencing or implicated as the direct cause of such an event, we often find also that there are also additional system factors involved.
In the final analysis, solutions that address Human Error directly such as remediation and training, are weaker solutions whereas solutions that address the system such as changes in the process or procedure are usually much stronger.
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