Signal Charlie

Dedicated to the continuous improvement of aerospace safety

Archive for the ‘Safety Management Systems’ Category

Defensive Posturing

leave a comment »

The main hazard during flight training (or any flying for that matter) is letting the aircraft get to an unrecoverable state, and the way to prevent that is defensive posturing. Defensive posturing is the mental attitude and associated physical actions that ensure that an aircraft never reaches an undesired state. Maintaining a defensive posture to manage threat and error is the key to flying smart.

Read Kent Lewis’ Article on Defensive Posturing.
Special thanks to Barbara and David Mikkelson and Snopes for the amazing photos and story behind them.

Written by Clark

April 6, 2007 at 12:20 pm

SMS for Helicopter Operators

leave a comment »

I met John Kemp at a recent Human Factors conference, he is the Director of Safety for Era Helicopters. They have established a SMS program and have a nice website to look at, that lays out the basics of their program and commitment to quality.
Check it out
Era HelicopterEra Helicopters

Written by Clark

March 31, 2007 at 5:23 pm

Runway Safety Forum

leave a comment »

Well, considering the worst aviation disaster of all time was a collision on the ground, these forum notes should be required reading for all pilots, controllers and personnel operating ground vehicles on the airport.

Thank you NTSB for sponsoring this Runway Incursion Forum.

To everyone who operates on the airport surface area: slow down, look and listen. Be sure to notify airport managers if you discover poorly marked areas, missing signs, etc. Take the initiative to identify all hazards that can cause injury and damage to property.

Hey, all you airports out there, buy some paint and get the enhanced markings put down!

Written by Clark

March 30, 2007 at 8:50 pm

NASA Aviation Safety Reporting Program

leave a comment »

Here’s a brief I found on NASA ASRS, a confidential reporting system that is improving our aviation system. The program is funded by the FAA and administered by NASA. Due to its existence outside the fiscal scope of both organizations, funding has always been a critical issue for this program. There is no more effective weapon against aviation mishaps than ASRS and the quality information that it generates. When you talk about system safety and human factors research, you have to mention the ASRS program, or you will explode. Check it out. It deserves your interest and support.


NASA ASRS Check out their site, fill out a report, search the database, read Callback

Written by Clark

March 27, 2007 at 2:35 pm

National Center for Aircraft Technician Training (NCATT)

leave a comment »

I just found this great aviation maintenance program, almost in my backyard. What is important about the work they are doing is development of standards for technicians. From there information can be gathered and analyzed, then used to guide continuous improvement of the aviation system.

Fly Smart

NCATT project headquarters is located at Tarrant County College under the direction of Floyd Curtis, division chair of TCC Aeronautical Training. TCC partner institutions in this project include Embry-Riddle Aeronautical University, Pennsylvania College of Technology, San Jose State University, Weatherford College and the United States Air Force. “It’s important to note that NCATT is an aviation industry formed and governed organization, established to serve our industry,” said Curtis. The aviation industry stakeholders along with the NSF partners have established:

Industry standards for training and certifying Aircraft Electronics Technicians;
Curriculum supporting the national standards;
An industry developed and recognized certification program for aircraft electronic technicians; and
An accreditation for institutions meeting the established standards.

Learn more about NCATT

Written by Clark

March 27, 2007 at 11:06 am

ICAO Ten Steps to a Safety Management System

leave a comment »

Excerpts from “Ten Steps to create a Safety Management System”, from the ICAO Safety Management Manual (SMM)

Experience, communications, resources.

All parties engaged in, and committed to the SMS. Safety information is actively sought, safety is a shared responsibility, safety-related information is disseminated to all affected personnel.

The organizational structure facilitates:
— lines of communication
— a clear definition of authorities, accountabilities and responsibilities.

Formal mechanisms (such as safety assessments and safety audits) are in place for the systematic identification of hazards. 

Criteria are established for assessing risks. Risks are analysed and ranked. Viable risk control measures are evaluated. Management takes action to reduce, eliminate or avoid the risks. Staff are aware of the actions taken to avoid or eliminate identified hazards. Procedures are in place to confirm that the actions taken are working as intended.

Each hazard and incident report is evaluated with further safety investigation as necessary. Safety lessons learned are widely disseminated.

Analytical tools (and specialist support) are available to support safety analyses.

Recognize that all levels of the organization require training in safety management and that the needs vary across the organization.

The SMS is well documented in a safety management manual. Documents are updated regularly and are readily available to those who need them. Safety databases are used to support safety analyses and performance monitoring. 

Safety performance indicators are agreed upon and realistic safety targets established. Adequate resources are allocated to the safety oversight and safety performance monitoring functions. Input is sought and provided without fear of repercussion. Regular safety audits are conducted in all operational areas of the organization.  Safety oversight includes the systematic review of all available feedback, for example,safety assessments, quality assurance program results, safety trend analyses, safety surveys and safety audits. Findings are communicated, and reform measures are implemented as required to strengthen the system.

Ten Steps

Fly Smart

Written by Clark

March 25, 2007 at 9:53 am

Human Error by James Reason

leave a comment »

I just received the book Human Error by James Reason, which focuses on the understanding of human error mechanisms. It is in its 17th printing, 1990-2006. If you have not read this book, leave this webpage immediately, go to amazon and order it…now…do it. Then come back here.
Any time you read about latent and active error, you are reading about the works of Reason and Rasmussen, and about what happens when theory meets practice.
Here’s a Personal Perspective ppt presented at a Human Factors seminar in Helsinki 2006. Enjoy.

Fly Smart

Written by Clark

March 24, 2007 at 8:48 pm

Threat and Error Management in a Nutshell

leave a comment »

The Threat and Error Management Model was developed by Dr Bob Helmreich and the UT Human Factors Project and is the 6th Generation of CRM

Here’s the model in a nutshell…

Focused on future events


-Operational factors-Aircrew, supervisory, maintenance, ATC,…

-Environmental factors-Turbulence, low vis, ice, rain, night time…

Operational and Environmental factors are managed through proper planning at…

-Strategic Level-Flight Ops Manual, OpSpecs, Aircraft Manuals, Training

-Tactical Level-Contingency options, Resource Management

Effective communication is key, before, during and after event

Focused on current and past events

First Goal: Avoid

-Develop plan

Second Goal: Manage

-Manage workload
-Maintain Situational Awareness & Assessment

Third Goal: Mitigate

-Limit adverse consequences


Comparing actual flight path and system performance to
intended path and performance

Ensure actions result in desired outcome

Error avoidance – Detection – Mitigation

One tool to use = “CAMI”
Confirm automation input
Activate system
Monitor performance
Intervene to prevent undesired states

TEM is the next generation of Team Resource Management

Here is a TEMM ppt prepared by the UTHFRP with two case studies.

Fly Smart

Written by Clark

March 18, 2007 at 8:58 pm

Aviation Leadership

leave a comment »

-the art of operating of aircraft

-the position or office of a leader, a person who inspires or guides others
-the capacity or ability to lead
-to show the way to by going in advance, guidance, direction
-to guide behavior or opinion

Acquiring aeronautical knowledge, airmanship skills, utilizing resources, building experience and proficiency are all part of a continuous improvement process. Navigation has been reduced to calculator simplicity. Modern autopilots and electronic displays have significantly reduced a pilot’s workload. Aircraft are designed safer. These factors have combined to reduce the mishap rate, but what is key to further reduction is the study and application of leadership skills. Aviation today requires administrative management and aeronautical decision making skills (leadership) as prerequisites for safety and efficiency, to realize the best return on your core foundation.

Here’s a review of some Aviation Leadership traits and principles.

Written by Clark

March 18, 2007 at 6:12 pm

FAA AC on Safety Management Systems

leave a comment »

What are the safety benefits of a Safety Management System (SMS)?

    Quality management approach to controlling risk.
    Organizational framework to support a sound safety culture.
    For general aviation operators, an SMS can form the core of the company’s safety efforts.
    For certificated operators such as airlines, air taxi operators, and aviation training organizations, the SMS can also serve as an efficient means of interfacing with FAA certificate oversight offices.
    SMS provides a detailed roadmap for monitoring safety-related processes.

A Systematic Managerial approach to Safety is even more important to a basic weekend or business flyer. You need to maximize the return on investment of your limited resources.

    SMS is a template that will enable you to establish cooperative, personal partnerships with the FAA, aircraft manufacturers, training and educational institutions, service providers, and aviation advocacy groups.
    Establish a proactive, learning safety culture that taps into these resources and keeps you informed about emerging hazards within the National Airspace System.
    Develop a plan and show it to your insurance agency, you might even get a discount for “Defensive Flying”.

Here is a SMS ppt I developed from the FAA Advisory Circular 120-92
Introduction to SMS for Air Operators

Key concepts are communications, just culture and continuous improvement.

Fly Smart

Written by Clark

March 18, 2007 at 5:44 pm