Why Repeat Safety Incidents Are a Big Concern
Repeat safety incidents are extremely indicative of management’s safety performance in mitigating safety concerns.
Having repeat safety incidents is clear evidence that management is “missing” or “overlooking” something when they are correcting reported safety concerns. This is bad for safety performance, and it’s bad for audit performance.
On the other hand, the lack of repeat incidents indicates that whatever you are doing to mitigate safety concerns, it’s working. The most important factors in mitigating safety concerns are:
- Proper risk controls;
- Efficient risk control implementation process with corrective-preventative actions; and
- Way to monitor performance of risk controls.
With the above 3 bullet points in place, you can expect to see few repeat incidents. Here are 5 ways that these above bullet points help stop repeat safety incidents.
1 - Understand Hazard/Risk Occurrence Life Cycle
Understanding the life cycle of safety incidents is the most important first step in learning how to avoid repeat safety incidents. By “life cycle,” we are talking about a safety mishap from the very beginning (root causes) to the end (consequences).
This process is the following:
- Hazardous sources (root causes) act as starting point for adverse flow of events;
- Initiating mechanisms interact with hazardous sources and increase threat level to target(s) (person, aircraft, etc.);
- Lack of identification to prevent hazard from occurring;
- Hazard occurrence, whereby the “dangerous condition” actualizes in the environment, resulting in the environment being outside an acceptable level of safety;
- Breakdown of risk controls or lack of response to adequately bring the hazard (dangerous condition) back into an acceptable level of safety;
- Risk occurrence happens, involving damages to persons, aircraft, machines, etc.
Risk controls aim to prevent hazard occurrence and risk occurrence by implementing risk controls that:
- Cut danger off at the ankles by controlling root causes;
- Increase hazard identification ability to stop hazard occurrence during moments of escalating danger; and
- Increase ability to respond to hazard occurrence with risk controls and safety training.
Understand these three implementations of risk-controlled should also aid you in reviewing how well a particular hazard/risk is controlled.
2 - Ensure Risk Controls Address Root Causes (If Possible)
It is highly recommended that, where possible, you mitigate safety concerns by implementing risk controls that control the root causes of safety concerns. A more concrete way of saying is that:
- Risk controls should, where applicable, address hazardous sources.
A hazardous source should not be confused with a hazard. A hazard indicates an inherently dangerous condition. A hazardous source is inherently benign but can become dangerous. Moreover, multiple hazardous sources will generally produce a single hazard occurrence.
A great example of a hazardous source is a flock of birds. By themselves, they are harmless. Place them close to a flying aircraft, and they are a hazard. The same is true of other things like mountains, power lines, etc.
Addressing the root causes with risk controls often involves creating corrective actions that are DETECTIVE and PREVENTATIVE in nature, such as:
- Bird radar;
- Powerline lights;
- Scarecrows on runway;
- And so on.
Root cause analysis should be conducted on the reported safety issues to ensure that no applicable root causes are going unaddressed. If addressing a hazardous source is not possible, risk controls should also aim to address preventing hazard occurrence or adequately bring safety into an acceptable range after hazard occurrence.
Related Articles on Root Cause Analysis in Aviation SMS
- Understanding "Root Cause Analysis" Charts in Aviation SMS Dashboards
- Is Root Cause Analysis Proactive or Reactive?
- 3 Methods for Root Cause Analysis in Aviation SMS
3 - Stress Test Risk Controls with Emergency Drills
Emergency drills are a prime opportunity to proactively seek out risk controls that are not performing as they should. Emergency drills are used to “stress test” various elements of your emergency response plan (ERP).
An ERP is a comprehensive document that covers all high-risk safety concerns. Oftentimes, ERPs are used to address a handful of the most catastrophic safety concerns (bomb threat, aircraft collision). However, ERPs are best used to address a whole number of catastrophic AND high-risk concerns, like:
- Fires;
- Internet server failure;
- Fuel spills;
- Major loss of data;
- And so on.
Risk controls that relate to high-risk safety concerns are some of the “most important” controls in your organization, as they prevent the highest damage safety incidents. Doing drills assures that these controls are performed.
4 - Regularly Review and/or Inspect Risk Controls
Regularly reviewing and inspecting risk controls is something every program should do. This involves a couple of things:
- Managers are responsible for each risk control; and
- Each risk control has review documentation.
Reviewing risk controls has three goals, to identify:
- Dated risk controls that need to be updated;
- Lack of risk control; and
- Obsolete risk controls.
Having relevant risk controls and up-to-date in your SMS program is like having a strong immune system.
Related Articles on Root Cause Analysis in Aviation SMS
- What Is a Risk Control in Aviation SMS: Meaning, Purpose, Application
- How to Conduct Root Cause Analysis in Aviation SMS
- How to Monitor and Control Risk in Aviation SMS
5 - Monitor Performance of Risk Controls
Whereas regularly reviewing risk controls is done periodically, monitoring risk controls is an activity that happens daily as issues are submitted.
When issues are submitted, quality SMS programs will have little trouble identifying risk controls that are relevant to the issue. At this point, controls should be rated as:
- Affecting a POSITIVE outcome; or
- Contributing to a NEGATIVE outcome.
Risk controls with negative outcomes should be closely scrutinized and investigated further. Risk controls with negative outcomes on repeat incidents need to be replaced.
This guide should prove a valuable resource to help you monitor your SMS program, including risk controls:
Last updated January 2024.
