What I have tried to do
It was the beginning of November 2012. The conference hall in Santiago looked more like a stadium. One could barely see empty seats and participants were still entering. I saw Paolo who, after the death of his son in an aircraft accident, quit his job and joined in the work of the Flight Safety Foundation. Paolo also saw me and made his way around some people to reach me and started speaking with his throaty voice “Ciao Tzvetomir, such a success - the whole of South America is here. You know, you have saved many lives, just that you and the people you saved will never know it.”
In the beginning of 2004 I was tasked to facilitate "Safety Information Sharing and Safety Improvement" for EUROCONTROL
. A number of products emerged from this work - Safety Alerts, Safety Action Plans and Toolkits and, a little bit later, SKYbrary
. Another product was also envisaged, a magazine style of publication which would communicate ATM safety knowledge and debate to both pilots and controllers in an easy to read style.
We launched HindSight in 2005 and you are now reading the 24th edition of it. Twice a year our editorial team tries to assemble a special publication for you. A publication that attempts to respect two important guiding principles for what can and what cannot be published. What I call here The Yin and The Yang of safety. The Yang
This is the rational, logical, engineering point of view. Safety is achieved by a predefined structure of safety barriers. The barriers are sometimes redundant and sometimes support each other. You can invest in a rigorous stop-bars safety policy which will prevent an incorrect entry to the runway protected area or you can consider implementing Runway Status Lights to provide autonomous alerting to those who may be directly affected by a potential runway conflict that the runway is occupied.
In this way, in order to prevent runway collisions, we need a structure of safety functions which prevents runway incursions, prevents runway incursions to result in a runway conflict and ultimately to prevent a runway conflict leading to a runway collision.
Talking about safety structure and functions, in HindSight we particularly try to share with you the positive experiences of those who have developed and implemented new procedures or systems and can tell us what improvements these brought. Learning from good and bad, we also try to outline real incident and accident scenarios and investigate with you what information these failure stories tell us about the effectiveness of existing safety protections.
In sharing with you the technical part of safety, we “censor” only if the information about the standard procedures is misleading. We try to promote a healthy and constructive discussion with arguments based on facts and disagreements being a matter of opinion. The Yin
Of course, safety cannot be only explained by the structural design of safety protections. There is much more to human and systems behaviour than just the rational de-construction of safety functions, training, compliance with procedures and reliability of equipment. People working in aviation and influencing safety come with their social and personal identities; they can be big or small cogs in the “safety machine” but they are more than cogs or nodes in the network; people are also carriers of an identity which influences and is influenced by their working environment. In other words, there are strong cultural issues in the way we “do things around here”.
We try avoiding talking too much about safety culture directly in HindSight but instead aim to become part of this culture. We try to find those story-tellers and meaning-shapers that challenge and make explicit our underlying assumptions on how things work or don’t work. Our shared underlying assumptions, created slowly over the years, almost sub-consciously built in our daily life, are in fact our safety culture.
Case studies, “camp fire” stories, comments and discussions have, as we hoped, over time continually given you someone else’s cleverness that can enrich your understanding and maybe challenge your assumptions. Or they can cultivate an ethical dilemma. On the one hand, use of the construct “situation awareness” when investigating past runway collision cases where it may be more a label of the symptoms than the underlying reasons. On the other hand it can be a useful system design guide to help maximise the ease of runway conflict detection and interpretation by controllers, pilots or vehicle drivers.
When we share with you the stories we try to avoid emotional conflict on a personal level.
The Yin and Yang are seemingly opposite and mutually exclusive. But this is only at a superficial level. They are part of one and the same story about safety; it is just the point of view that may be different. Apart from the structural, constructivist point of view and the safety culture point of view there is also another perspective - the perspective of power and interests. I can proudly reveal that over the 12 years of HindSight production we have only had two partially successful attempts for “political” influence. Once we removed the statement that “using stop bars will not solve all your problems” and once we removed the name of an aircraft operator.
I have made this overview of HindSight because with the next edition it will have a new Editor-in-Chief. I am very confident that with Dr. Steve Shorrock in command, HindSight will be in very good hands. So my final Editorial is my report to you as a reader on what I have tried so far. I felt a responsibility to give my best to reduce the risk to peoples’ lives and to contribute to a cause I strongly believe in.
Paolo is not anymore with us. But his words are still with me and are reward enough for what I have tried to do. Enjoy reading HindSight!