Recently I went in the wrong direction while driving to an appointment. I didn’t realize my mistake until I arrived in the next town, which was only about 6 miles away from my intended destination. However, those six miles would cost me about 30 minutes of precious time since it was lunchtime traffic.
I have driven to this appointment twice yearly for the past twenty years. So, why did I get lost this time? As in this driving analogy, we must learn to stay focused, concentrate on the task before us, and be present in the moment, which is crucial in ensuring safety in various contexts. Let’s look closer at some Human Factors preconditions, such as distractions, missing the targets, and complacency, and how this familiar situation parallels conditions and factors that influence people and their behavior in safety-critical situations.
WHY?
1. Distractions
My mind was on family and work, not driving. At the beginning of the trip, I received a short phone call informing me of a problem. When the call ended, I was mentally trying to find possible solutions and outcomes for that issue. I was also contemplating what my schedule would look like when I returned from my appointment. This portion of my thought process was about the future.
2. Awareness
At one point, I even acknowledged to myself that I wasn’t conscious of the past few miles I had just driven. So, although I was somewhat aware of my mindset, I still did not contemplate that I was driving in the wrong direction. This portion of my thought process was about the past: miles that I had previously driven and the many routes and variables along the way.
3. Complacency
I subconsciously told myself, “I’ve done this a hundred times; no worries, I’ve got this.” My brain was on Autopilot. I jumped in the car and headed down the road. My arms and legs were physically driving, but my mind was not engaged. I was accustomed to this process, knew what acts needed to be performed, and dismissed any need for additional attention or consideration.
Does the situation above sound familiar? Has something similar ever happened to you on the job? I think we can agree, it is incredibly important to stay “present” in the current objective and in all aspects of life. Have you heard the saying: “We have been doing it this way for 20 years!”? Practicing self-examination and continuous improvement helps to keep focus and ensure we are in compliance, not only doing the job, but doing it within regulations and policies.
When encountering an unfamiliar maintenance or operational task, it is standard practice to research the policies, procedures, and processes needed; collect any tools, manuals, task cards, etc. required, and get prepared. This approach ensures that you have the necessary knowledge and guidelines to perform the task effectively and safely. It helps mitigate risks and ensures compliance with standards and regulations. Plus, understanding the rationale behind the procedures can offer valuable insights into the task at hand.
Admitting the tendencies to take familiar tasks or situations for granted will also help mitigate the potential for Human Factor errors, ensuring that tools, manuals, and checklists are consistently utilized so that safety and efficiency are supported through continuous awareness and diligence.
Although it is not a regulatory requirement, adding an Internal Evaluation Program (IEP) into a healthy/mature Safety Management System is the conduit to that continuous improvement process by self-examination, i.e., keeping focus. This enables us to increase management and employee responsibility awareness to stay in compliance with our policies and regulations and improve our workplace safety. It involves systematically reviewing and evaluating various components of the SMS to find strengths, weaknesses, and areas for improvement. An IEP questions processes and procedures for functionality and evaluates them for any hidden or not yet documented risks.
Key elements of an SMS Internal Evaluation Program:
Safety Policy: Reviewing the organization's safety policies and objectives to ensure they are clear, relevant, and aligned with regulatory requirements and industry best practices.
Safety Risk Management: Assessing how effectively the organization identifies, analyzes, and controls safety risks associated with its operations.
Safety Assurance: Evaluating the processes in place to monitor and verify compliance with safety policies and procedures, including audits, inspections, and performance monitoring.
Safety Promotion: Reviewing efforts to promote a positive safety culture within the organization, including training programs, communication strategies, and employee engagement initiatives.
Documentation and Record-Keeping: Ensuring that relevant safety-related documentation and records are maintained and accessible, including incident reports, risk assessments, and corrective action plans.
Continuous Improvement: Identifying opportunities for continuous improvement in the SMS, based on findings from internal evaluations, external audits, and feedback from stakeholders.
Building an Internal Evaluation Program usually consists of creating checklists designed to evaluate and assess the SMS against the operations policies, procedures, and various programs or operational functions. Keep it small; build a plan specific to your organization to evaluate particular areas throughout the year or over a period of time. These checklist evaluations are used to conduct audits or assessments, either by internal staff or external consultants with SMS expertise. The results are used to develop action plans to address any deficiencies or areas needing improvement, with the ultimate goal of enhancing safety performance and reducing the risk of accidents or incidents.
Values of an IEP
Reviewing processes, seeing procedures, and asking questions, undetected risks can be discovered which can be corrected before an event occurs.
Allows the opportunity for ineffective processes or procedures to be corrected and risks mitigated to an acceptable level.
Promoting processes and procedures that are working efficiently and including all personnel enhances the overall safety culture.
Take the time to double-check the directions -“How to?”
It may sound silly, but “Stop and ask for directions.” In other words, take the time to ensure you are clear on the task and know the tools needed, steps to take, and any changes since the last time you performed the task. A robust IEP is a continuous evaluation of your organization and its’ systems, taking oversight of the Safety Systems in place. It helps dispel the fact that routine compels complacency.
Special projects, something new and different, are always a reason for pausing and double-checking our confidence to complete the task. If it is a new task, we automatically accept “I don’t know how to do this” without shame, inferiority, or ego.
We need to build a safety culture that supports pausing to double-check for anomalies instead of backtracking and losing time at a minimum if you “go the wrong way.” Instead of having our brains or our operation on Autopilot, practice mindfulness and self-awareness. Regularly taking time to reflect on our actions, decisions, and experiences can help ensure that we are not simply coasting through life on autopilot but being actively engaged with the tasks at hand.
For more information on Internal Evaluation Programs, see:
FAA Advisory Circular AC 120-59B – Internal Evaluation Program; https://www.faa.gov/regulations_policies/advisory_circulars/index.cfm/go/document.information/documentID/1034950
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