The week before last, I finished a 4-year stint with the aviation safety regulator. Even though I'm heading back to industry, I'm not going to stop writing this blog. I believe that the role of the national regulator is the next safety frontier (not the last ;)) and I like the idea of exploring new territory. As the industry continues to explore concepts like safety management, systems-based this, risk-based that and outcome-based whatchamacallit as well as safety culture, we are all going to come to the realisation that safety can be greatly affected (more than we ever imagined) by the approach and actions taken by a national regulator.
Why do I think this?
Well, it goes back to that graph that I referenced in my first post here. I hinted that I had a few gripes with it, so let's get to them first and then I'll talk about the pearls which also reside within. Here it is again, to save you from scrolling to the bottom:
Alright, my first gripe is that I haven't seen any reference to actual data that shows these rate changes. The best long term trend I can find is this one by Boeing which shows an overall downward trend but nothing along the three "phases" shown in the stylised version often presented. I did, however, find this post which added a few little humps to their graph but I'm not sure I agree with that "hump" on the far right.
My second gripe is that while examples of this graph tend to consistently show three distinct phases, the labels often change. I've seen aircraft, technology, human factors, CRM, organisational culture, systems and a few others all slotted into their appropriate home in one of the phases. This inconsistency annoys me but maybe I'm being too picky1.
So let's turn this one around.
I agree with, what I think is, the underlying message - that safety improvements have been progressively found within a widening scope.
That brings my back to my gripes though. The above graph suggests that safety improvements can no longer be found using the methods employed during the previous phases. It leads you to conclude that technological improvements in aircraft technology or even basic human factors won't have an impact on safety thanks to the "levelling out" of that phase's accident rate. Why then do we work on systems like TAWS, GPS augmentation, FRMS, EFBs, etc.? Obviously work within those other phases continues and will yield safety improvements from time to time.
I've been pondering what would be a better measure and I keep coming back to Return on Investment (ROI). Unfortunately, I think using a measure a standardised as ROI would suggest a level of data integrity which doesn't exist - not in my analysis anyway. But the concept I want to get as that at any given time aviation safety professionals are exerting effort in one or more given areas and that effort is seeing a variety of results.
Generally, over time, a new area of effort will grow in its return as the "low hanging fruit" are picked, it will reach a peak as these become scarce and then it will tend to peter out. However, that is not to say that new discoveries might see spikes in that area's return in the time that follows its peak. I don't think that it will ever return to the peak because as that area's return waned, effort would have shifted to the next "orchard".
I've tried to capture this idea in graph of my own. I've plotted the Return on Effort (ROE) of several "phases" of safety improvement endeavour as an index of the peak return against time. It is, of course, completely theoretical and not based on any data - just my interpretation of aviation safety history. The graph shows the trend described above for a couple of phases I tend to identify as the major changes in safety improvement focus since aviation began (you may have others and I'd love to hear about them).
Now, back to that underlying message I agreed with above. I see each successive phase as considering a progressively wider scope. In the beginning we looked at the aircraft and then we started to consider the pilot and the aircraft. After this we started to look at the crew, first the co-pilot, then cabin crew and more recently even ground crew. The current battlefield tends to be dealing with the company as a whole.
Therefore, the key relationship for me is this widening of scope over time. To show this relationship I plotted the scope of the highest ROE over time.
And then I extrapolated the line to suggest that the regulator will be the next frontier of safety improvement effort. A couple of months ago, I blogged about the different levels of culture. Current efforts have primarily looked at organisational culture but as I pointed out these cultures are influenced by other levels of culture including the professional and national levels. As these interrelationships become better understood, I think we will find the influence of the regulator to be stronger than previously thought.
Now obviously, the regulator is currently doing stuff to influence safety - as did pilots and crews and companies. Each phase has not been about the introduction of these things but examining how these things influence safety.
The regulator phase has already kicked off. The State Safety Programme (SSP) concept is designed to modernise a regulator's approach to safety. While it is analogous to an operator's SMS, there is a level of complexity the regulator needs to address which is above that for the operator. How to deal with this complexity will be one of the major hurdles for the near future.
As sad as this may sound, I find this stuff fascinating and I'll be exploring it in my PhD and private research. I'll blog about it here and I'll start up my airport blogging again over at The Runway Centreline soon too. As this post suggests, I am still committed to the role of the regulator and dare I say to my former colleagues...
1 - An accusation often levelled at me by my wife!