Sofema Aviation Service (SAS) www.sassofia.com considers key aspects of Just Culture within an EASA Part 145 Organisation.
Considering – Errors and Violations
What do we mean by Error: An action or inaction that leads to deviations from the person‘s intentions or expectations.
Effective SMS implementation dependent upon a clear, mutual understanding of errors and violations and the differentiation between the two. – The understanding of Intent !
While an error is unintentional, a violation is a deliberate act or omission to deviate from established procedures, protocols, norms, or practices.
Now Consider the Difference between the following Violations:
– Personally, Optimizing Violations
– Organizationally Optimizing Violations
Note – Errors or violations may result in non-compliance with regulations or approved operating procedures.
The Problem – Punitive measures taken in response to acts of non-compliance may lead to a reduction in the reporting of errors in the absence of other processes.
The Challenge – To consider whether acts of non-compliance are the result of a violation or inadvertent error when determining what action is appropriate.
Normal Criteria to Consider the appropriate degree of “Punishment”
The criteria normally being whether non-compliance is the result of an Error, Willful Misconduct, or Gross Negligence.
Considering Errors
Humans will commit errors regardless of the level of technology used, the level of training, or the existence of regulations, processes, and procedures.
An important goal then is to set and maintain defenses to reduce the likelihood of errors and, just as importantly, reduce the consequences of errors when they do occur.
To effectively accomplish this task errors must be identified and reported and analyzed so that appropriate remedial action can be taken.
Errors can be divided into the two following categories:
– Slips & Lapses / Mistakes
Slips and Lapses are failures in the execution of the intended action. – Slips are actions that do not go as planned, while lapses are memory failures.
For example, operating the flap lever instead of the (intended) gear lever is a slip. Forgetting a checklist item is a lapse.
Mistakes are failures in the plan of action. Even if the execution of the plan was correct, it would not be possible to achieve the intended outcome. – Safety strategies must be put into place to control or eliminate errors.
The strategies to control errors leverage the basic defenses within the aviation system. These include:
Reduction Strategies provide direct intervention to reduce or eliminate the factors contributing to the error. Examples of reduction strategies include improvement of ergonomic factors and reducing environmental distractions.
Capturing Strategies assume the error will be made. The intent is to capture the error before any adverse consequences of the error are felt.
Note – Capturing strategies are different from reduction strategies in that they utilize checklists and other procedural interventions rather than directly eliminating the error.
Tolerance strategies refer to the ability of a system to accept that an error will be made but without experiencing serious consequences.
The incorporation of redundant systems or multiple inspection processes are examples of measures that increase system tolerance to errors.
Since the performance of personnel is generally influenced by:
- Organizational,
- Regulatory and
- Environmental factors.
To be effective safety risk management must include consideration of:
- Organizational policies,
- Processes and procedures related to communication,
- Procedures,
- Scheduling of personnel,
- Allocation of resources and
- Budgeting constraints that may contribute to the incidence of errors.
• Violations:
• Violation: a deliberate act of willful misconduct or omission resulting in a deviation from established regulations, procedures, norms or practices.
• While violations are intentional acts, they are not always acting of malicious intent. Individuals may knowingly deviate from norms, in the belief that the violation facilitates mission achievement without creating adverse consequences.
• Note – Non-compliance is not necessarily the result of a violation as deviations from regulatory requirements or operating procedures may be a result of an error.
• Situational violations are committed in response to factors experienced in a specific context, such as time pressure or high workload.
• Routine violations become the normal way of doing business Such violations are committed in response to situations in which compliance with established procedures makes task completion difficult.
• Due to practicality/ workability issues, deficiencies in human-technology interface design, and others that cause persons to adopt – workaround procedures, which eventually become routine.
These deviations, referred to as drift, may continue without consequence. But, over time they may become frequent and result in potentially severe consequences.
In some cases, routine violations are well-grounded and may result in the incorporation of the routine violation as an accepted procedure after a proper safety assessment has been conducted and it shows that safety is not compromised.
Next Steps
Please see www.sassofia.com or www.sofemaonline.com or email team@sassofia.com for questions, comments or guidance
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aviation, Aviation Maintenance, Safety Management System, EASA regulations, EASA Part 145 Organisation, SAS blogs, EASA Part 145 SMS, Non-Punitive Disciplinary Policies
