Safety Interactions are Driving on Friction
By: Sergio Romero
“…friction is the force that resists this forward movement…”
Beachwells. Australia
The flood in the cockpit comprises smoke, horns, rings and automated voices. Still, the
performance of the crew is within acceptable limits. But as the circumstances develop and
most of the time it constitutes a surprise or a sudden event for the crew members, the
available defenses are knowledge, experience, including construction of such a knowledge,
training quality and decision making, among others. As the wrong engine is cut off, and the
steep banking cannot be avoided, this does not only mean the defenses did not drive enough
friction or that they were not aligned to overcome this about-to-come crash, but also that
downward forces, gravity, drag and all the consequences of this undesired event defeated
the crew. Searching into the memories, the manuals, the procedures, and the struggle of
probably the first-time real encounter with an emergency like this will be well written as a
statement of probable cause in some aircraft accident report.
However, where did all of this really begin? Is it considering ICAO’s Annex 13 SARPs when,
regarding the conclusions of the investigation report, it says, “The list of causes and/or
contributing factors should include both the immediate and the deeper systemic
causes and/or contributing factors”? Many of us that investigate, analyze and manage
safety performance inside our aviation organizations and try to enhance the flight safety are
reading the document from the last page to the beginning. In addition, it might be wrong
though it appears to be reducing time and efforts. Well, it just reminds my little daughter.
She caught me many times in the middle of a David Mamet film, and as smart, as she is,
she was always telling me the end of the story. Nevertheless, my reply to her was constant
repeatedly as his lovely curls “the details and the story itself makes the difference,
Blackie”.
It is clear that when an aviation accident occurs, the puzzle is hard to turn into one clear
visible picture. Everything is torn down into small and blurred pieces. And every one of such
pieces mean the latent conditions that were going without monitoring. These are the deeper
systemic causes that ICAO needs or mandates us to analyze and to share to improve the
system. Of course, all of these collides naturally the direct and primary (instinctive)
objectives of some organizations: Profits, quick-to-recover ROIs, and aggressive
modification of production conditions. Can we go by the book at this instance? We must!
What are these deeper conditions that I saw in many aviation organizations?
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Lack of a management system culture.
Constant cover-the-hole-that-it-just-eroded culture.
Corrective but not preventive management bias.
Prioritization on momentary tasks against a PDCA culture.
At this stage, it is clear that
when we talk about the SMS
or any management system,
whose purpose is to prevent
accidents, latent conditions,
culture, management styles
or many other contributing
factors, organizations are
undergoing a smash between
two surfaces: The first one is
the defenses as set or the
organizational framework. The second one is how humans follow or execute the procedures
within the organizational framework. Thus, we are talking here about friction, or to be more
precise, safety-based operational friction. What is the classical definition of this term?
Friction is a force between two surfaces that are sliding, or trying to slide, across each other.
On that sense, we have:
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The set defenses or the organizational framework, which is one surface.
The way humans follow or execute the procedures within the organizational
framework; i.e. traditions, culture, artifacts, symbols and hardware, which form the
second surface.
During the operational requirements and its pertinent performance by the organization,
human beings show criteria, experience, knowledge and mainly attitude. So, we struggle to
have available a standardized-based performance for operations, administration or safety.
However, if this is not supported, as ICAO mandates, by a continuous endeavor, resources
are wasted and effectiveness is even impossible. In this scenario, we are at a theatre
showing the smashing between these two surfaces. What is the role of the SMS? It is the
force that is opposite to the way humans try to execute the tasks. According to a publication
by BBC, “the amount of friction depends on the materials from which the two surfaces
are made. The rougher the surface, the more friction is produced. Friction also
produces heat. If you rub your hands together quickly, you will feel them get warmer”.
Therefore, to make a review, we have the requirements and the organizational framework.
We also have the way we perform such requirements pursuant to traditions, culture, artifacts
and symbols. These previously mentioned are the two surfaces. These two surfaces are
interacting each other so organizations can achieve their purposes or try to do it. This
interaction by nature is the safety-based operational friction, which in turn defines the quality
of safety through its roughness or strength. It means the rougher (stronger) the surface; i.e.
the quality, continuous monitoring and reporting and management of latent conditions and
culture, the more friction (or safety) is produced; i.e. the proper balance or negentropy is
achieved, so safety is organizationally managed to acceptable level of risks. What for? To
avoid being defeated by hazards, to watch in preventive mode the operational environment
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and at the proper dimensions; i.e. the difference between causes and consequences is fairly
where does it all begin in the organizational management of the operation and not in the
operation itself. Once we manage that knowledge, we will be preventing instead of correcting
all the time, which means the operation is expensive, not profitable and unsafe.
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