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Carbon Lake SMS (CARBON LAKE SMS)
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SMS Business Solutions
SMS Business Solutions

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Review Your Safety Policy
There is an expectation that the safety policy is reviewed periodically for continuing applicability. A safety policy establishes guidance for safety objectives and goals for the safe operation of an airport or aircraft. A safety policy is a practical applied document and tailored to each operator for the purpose of being accepted by all personnel within the organization. Policies that are not accepted by all personnel are impractical to operations and more of a deterrent to safety than no policy at all. A policy that is influenced by a third-party requirement is a not an unfettered policy and is also a deterrent for the safe operation of an airport or aircraft.
A Safety Policy Review is based on data only.
The expectation that the safety policy is reviewed periodically is to identify processes that has influenced the policy and that the policy is still applicable to detected, or undetected changes of operations. There are several parties involved in airport or airline operations, from tenants, customers, auditors and the environment itself. When there is interference in development, or maintenance of a safety policy the policy sets the stage for unexpected, or undecided results.
When operational changes go undetected they becomes “normal” to operations. A policy may at first sight appear to be applicable indefinite, since at the time of implementation its intentions were to promote safety and if the policy is questioned, or reviewed it could appear to be an attack on safety itself. Over the history of aviation, it has been unheard of to question safety. However, by allowing for a safety review of the policy, or in other words question safety, new doors are opened for continuous improvement to aviation safety.
Almost safe doesn't cut it.
Reviewing the safety policy is a responsibility of the accountable executive. This does not necessary imply that the accountable executive, who often is removed from the operational processes, does the actual review, but implies that the accountable executive accepts accountability to the safety policy itself.
This renewed safety policy is then signed by accountable executive and promoted throughout the organization with explanation of why these changes were necessary for the safe operations of airport or aircraft.


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Processes as Profit Generators or Destructive Applications?
Bush pilots are regularly operating single and multi engine airplanes into remote areas and places where the birds don’t fly. These airplanes are operated on wheels, skis or floats and on unprepared airstrips, gravel bars, mountain meadows, rivers or lakes, both summer and winter.
When a bush pilot prepare for a flight, a Risk Assessment is done, but may not documented. A bush pilot knows that even if the flight goes to a place where they have been several times before, this flight may encounter other challenges than previous flights. Each flight is a new flight and risks must be assessed continuously as the flight progresses.
A process is like an old airplane, it must be maintained to be operational safe.
Then a bush pilot may go where “the birds don’t fly”
An operator may have flown for 30 years of more without any accidents, but possible a few incidents. Processes have been established and applied, and they work well. Over years customers were satisfied with service and come back and even recommend the operator to friends and family.
With the introduction of Safety Management System (SMS) a new intersection on was made on the road to safety. Some operators were looking forward and found the road-signs when they arrived at the fork in the road, while others were looking back, admiring the past and missed the signs of directions and continued down this old road. On this old road there were not places to stop and maintain the system. If a system is not maintained and no matter how well the system had performed in the past there will be a time when it becomes beyond repair.
Someone sitting on the fence might be in a better position to review and trace the merits of a process.
Then, who decide what process works and should be acceptable? Is it an operator who has flown in bush country, high mountains, off lakes and rivers for 30 years without an accident? Or is it the operator who was looking forward, followed the signs and changed their processes? It could be both or none of the above. What decides if the process works and is acceptable is the process itself.
The process must on its own merits conform to regulatory requirements. These merits may be established by reviewing and tracing the process backwards from end to beginning. A process needs a trigger to be activated which could be human, organizational or environmental factors. The process management are human operational inputs that must conform to regulatory requirements.
After the process has been executed and come to a completion, that’s when it is possible to assess and determine if the process conformed to regulatory requirements and if the output was regulatory compliant. After that, make a risk projection based on the processes fail to pass ratio. The objective is to keep as many as possible of the organizational processes regulatory compliant.
When making a bond-fire the choice of location, effectiveness and fuel inputs are based on risk-assessment. What choices of inputs are given to organizational processes?
When a process is applied to what it was intended for, it is a fire producing energy and revenue. Should the same process be applied for other than intended for, it becomes a fire of destruction.

Birdseye59604
http://www.c6lsolutions.com/
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Processes as Profit Generators or Destructive Applications?
Bush pilots are regularly operating single and multi engine airplanes into remote areas and places where the birds don’t fly. These airplanes are operated on wheels, skis or floats and on unprepared airstrips, gravel bars, mountain meadows, rivers or lakes, both summer and winter.
When a bush pilot prepare for a flight, a Risk Assessment is done, but may not documented. A bush pilot knows that even if the flight goes to a place where they have been several times before, this flight may encounter other challenges than previous flights. Each flight is a new flight and risks must be assessed continuously as the flight progresses.
A process is like an old airplane, it must be maintained to be operational safe.
Then a bush pilot may go where “the birds don’t fly”
An operator may have flown for 30 years of more without any accidents, but possible a few incidents. Processes have been established and applied, and they work well. Over years customers were satisfied with service and come back and even recommend the operator to friends and family.
With the introduction of Safety Management System (SMS) a new intersection on was made on the road to safety. Some operators were looking forward and found the road-signs when they arrived at the fork in the road, while others were looking back, admiring the past and missed the signs of directions and continued down this old road. On this old road there were not places to stop and maintain the system. If a system is not maintained and no matter how well the system had performed in the past there will be a time when it becomes beyond repair.
Someone sitting on the fence might be in a better position to review and trace the merits of a process.
Then, who decide what process works and should be acceptable? Is it an operator who has flown in bush country, high mountains, off lakes and rivers for 30 years without an accident? Or is it the operator who was looking forward, followed the signs and changed their processes? It could be both or none of the above. What decides if the process works and is acceptable is the process itself.
The process must on its own merits conform to regulatory requirements. These merits may be established by reviewing and tracing the process backwards from end to beginning. A process needs a trigger to be activated which could be human, organizational or environmental factors. The process management are human operational inputs that must conform to regulatory requirements.
After the process has been executed and come to a completion, that’s when it is possible to assess and determine if the process conformed to regulatory requirements and if the output was regulatory compliant. After that, make a risk projection based on the processes fail to pass ratio. The objective is to keep as many as possible of the organizational processes regulatory compliant.
When making a bond-fire the choice of location, effectiveness and fuel inputs are based on risk-assessment. What choices of inputs are given to organizational processes?
When a process is applied to what it was intended for, it is a fire producing energy and revenue. Should the same process be applied for other than intended for, it becomes a fire of destruction.

Birdseye59604
http://www.c6lsolutions.com/
Photo

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Non-Punitive Policy Is Enterprise Accountability

An applicant for, or an operator of an airport or airline certificate is required to have in place a non-punitive for reporting of hazards, incidents, or accidents and is one of the elements of a Safety Management System (SMS). A non-punitive policy is a policy for an airport or airline to allow for free flow of reports in a Just Culture and collection of data within the organization. In a Just Culture environment, a contributor may not fear repercussion from supervisors, managers or other personnel for reporting. A non-punitive policy is not a get-out-of-jail free card, but a policy of organizational accountability.

A non-punitive policy is a policy for the internal reporting of hazards, incidents and accidents, including the conditions under which immunity from disciplinary action will be granted. The fundamental of a non-punitive policy is that it is unconditional with “no strings attached” and with pre-established conditions for when immunity for disciplinary actions are granted.
It may be tempting to simplify a non-punitive policy and apply conditions when immunity is not granted. Some of these conditions could be illegal activity, negligence or willful misconduct.
A non-punitive policy must be understood.

When applying these conditions, a fundamental principle of accountability in a Safety Management System is jeopardized. These are conditions which places the burden of proof on the last link in chain of events without considering human factors, organizational factors, environmental factors and supervision factors.

In most judicial systems illegal activity is an act committed in violation of law where the consequence of conviction by a court is punishment and where the punishment could be as serious one such as imprisonment. An illegal activity is not a fact until convicted by a court. The basic principle is innocent until proven guilty. It is therefore impossible to apply illegal activity to job performance evaluation and make it a condition of a non-punitive policy.

Negligence is failure to take proper care in doing something. When applying this as a condition of a non-punitive policy it becomes a decision by a supervisor who was not present at the time of incident, or accident. The supervisor was not in the moment of events and included in the ongoing decision making process at the time. Applying negligence as a condition to a non-punitive policy places the burden of proof on person involved without considering human factors, organizational factors, environmental factors and supervision factors.

Any act, or failure to act, by a person that was intended to cause harmful consequences to the safety or property of another person is willful misconduct. When assessing for willful misconduct an evaluation of the mindset at the time of event is required and based on supporting data collected. Applying willful misconduct as a condition to a non-punitive policy places the burden of proof on person involved without considering human factors, organizational factors, environmental factors and supervision factors.
An enterprise has established a maze for options when applying illegal activity, negligence or willful misconduct.

A non-punitive policy is only credible, without bias and with organizational accountability when including pre-established conditions for when immunity for when disciplinary actions are granted. These conditions are based on job performance criteria, job descriptions with associated tasks and the intent of job performance outcome. When applying organizational accountability, personal accountability and that mistakes are not accepted to a non-punitive policy, the policy considers human factors, organizational factors, environmental factors and supervision factors to ensure correct training and competence.
http://www.c6lsolutions.com/

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Non-Punitive Policy Is Enterprise Accountability

An applicant for, or an operator of an airport or airline certificate is required to have in place a non-punitive for reporting of hazards, incidents, or accidents and is one of the elements of a Safety Management System (SMS). A non-punitive policy is a policy for an airport or airline to allow for free flow of reports in a Just Culture and collection of data within the organization. In a Just Culture environment, a contributor may not fear repercussion from supervisors, managers or other personnel for reporting. A non-punitive policy is not a get-out-of-jail free card, but a policy of organizational accountability.

A non-punitive policy is a policy for the internal reporting of hazards, incidents and accidents, including the conditions under which immunity from disciplinary action will be granted. The fundamental of a non-punitive policy is that it is unconditional with “no strings attached” and with pre-established conditions for when immunity for disciplinary actions are granted.
It may be tempting to simplify a non-punitive policy and apply conditions when immunity is not granted. Some of these conditions could be illegal activity, negligence or willful misconduct.
A non-punitive policy must be understood.

When applying these conditions, a fundamental principle of accountability in a Safety Management System is jeopardized. These are conditions which places the burden of proof on the last link in chain of events without considering human factors, organizational factors, environmental factors and supervision factors.

In most judicial systems illegal activity is an act committed in violation of law where the consequence of conviction by a court is punishment and where the punishment could be as serious one such as imprisonment. An illegal activity is not a fact until convicted by a court. The basic principle is innocent until proven guilty. It is therefore impossible to apply illegal activity to job performance evaluation and make it a condition of a non-punitive policy.

Negligence is failure to take proper care in doing something. When applying this as a condition of a non-punitive policy it becomes a decision by a supervisor who was not present at the time of incident, or accident. The supervisor was not in the moment of events and included in the ongoing decision making process at the time. Applying negligence as a condition to a non-punitive policy places the burden of proof on person involved without considering human factors, organizational factors, environmental factors and supervision factors.

Any act, or failure to act, by a person that was intended to cause harmful consequences to the safety or property of another person is willful misconduct. When assessing for willful misconduct an evaluation of the mindset at the time of event is required and based on supporting data collected. Applying willful misconduct as a condition to a non-punitive policy places the burden of proof on person involved without considering human factors, organizational factors, environmental factors and supervision factors.
An enterprise has established a maze for options when applying illegal activity, negligence or willful misconduct.

A non-punitive policy is only credible, without bias and with organizational accountability when including pre-established conditions for when immunity for when disciplinary actions are granted. These conditions are based on job performance criteria, job descriptions with associated tasks and the intent of job performance outcome. When applying organizational accountability, personal accountability and that mistakes are not accepted to a non-punitive policy, the policy considers human factors, organizational factors, environmental factors and supervision factors to ensure correct training and competence.
http://www.c6lsolutions.com/

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Risk assessments are tools to prioritize risks and assign risk values to specific events. Higher risks values have greater safety impact to operations and are affecting operational processes more immediate than lower risk factors. A high number is an immediate shutdown, while a low number that no action is required. A risk is an active condition, but if left alone without mitigation or removal, will cause harm to person or property.

The risk value number is a factor derived from a risk matrix with assigned categories of probability, severity and exposure. This formula is calculated by probability x severity x exposure = risk factor. Risk factors are assigned numbers for acceptance, mitigation, or not acceptable and colored green, yellow and red respectively. A risk is not a latent hazard, but an active condition at the time and location of intercepting an airport, or aircraft in flight or taxiing At one end of the spectrum there are visual clues of exposure to hazards. Some of these hazards are birds and freezing rain. Birds is a hazard, but does not become a risk until there is an intersecting path between birds and aircraft. Freezing rain is another identified hazard, but not does not become a risk until it is in the path of a flying aircraft, or falling at the airport. When exposures are applied to birds and freezing rain, these risks compute to higher risk value number and are mitigated, or avoided. An aircraft is only exposed to birds, or freezing rain when these hazards are on an intersecting path with an aircraft, and an airport is only exposed when birds are at the airport, or freezing rain are falling. At any other time, birds and freezing rain are no risks, but identified hazards.

At the other end of the spectrum there are non-visual clues, but assumed exposures to risks. These risks are more difficult to assess, since they contain probability hazards that are not active events affecting an airport or aircraft. These hazards are not to be ignored, but to be assessed differently than visual clues risks in the exposure of a risk assessment.

Pilots train extensively to manage engine failures at rotation, climb-out, departure, approach, or in-flight. The reasoning for training is that there is a virtual reality of probability that a modern aircraft engine could fail during any of these phases of flight. When an aircraft is setting thrust for take-off, that aircraft, or pilots are not exposed to an active risk of an engine failure. They are only exposed to the hazard within the system for an engine failure. If airlines are applying an engine failure exposure factor to take-off and departure, they are incorrectly assigning a risk, or an active hazard to the initial phase of flight. Aircraft and pilots are only exposed to an engine failure at the time and location of when the engine operating system is intercepted by an external event. Just as birds and freezing rain, there is no exposure until the hazard becomes an active event. If there is a possibility for an aircraft engine failure, the principle of Zero Tolerance to Compromise Aviation Safety is jeopardized. When aviation safety is compromised, the flight cannot continue.

In a virtual reality world anything can happen, any scenarios can be introduced and any outcome are possible. During the first 100 years of aviation, when data were limited and SMS was not included in planning, engines quit, wings fell off and preventable accidents happened. Aviation today is totally changed where data is analyzed, proactive measures are taken, processes are assigned confidence levels and mathematical equations and statistical process control are foundation for safety assessment. From the manufacturing of an engine, NDT testing of parts, installing on aircraft and to flight operations, every step has multiple quality control and safeguarding processes, including quality assurance and quality assurance of the QA program itself. The aviation industry is moving into the new era of safety, from doubting the production quality to the reality where it is inconceivable that an engine will fail. With this in mind, when an aircraft sits at the threshold and sets take-off thrust, there is a 100% confidence level that the engines will function as designed. There are other external and accountable events causing engines to fail.


When applying engine failure to a take off exposure, risk management is incorrectly making assumptions that engines fails without pre-existing conditions being present, or that incomprehensible hazards intercepted the engine at the time of takeoff, or that the failure was caused by an unforeseen event. With the millions of safety processes included in manufacturing, training and operations an engine does not just fail on its own.
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