Aviation Manager’s Toolkit: Understanding Safety Management Systems: Organizational Blindness in Aviation Management and Leadership

By Harun Soylu

Are always good people doing good things and bad people doing bad things?
What is organizational blindness, and how do you protect it?
In this book, you will learn how good people do bad things even without recognizing it.
Pressures in the aviation environment are explained.
Real-life case studies are discussed, and the reader of the book is expected to have certain knowledge about the forces in organizations and a basic understanding of the aviation domain.
Aviation SMS (Safety Management Systems) is the formal, top-down, organization-wide approach to managing safety risk and ensuring the effectiveness of safety risk controls.
An aviation safety manager is required to understand these forces, and organizations are expected to realize their own blindness and manage these associated risks.

• Language: English
• Publisher: Partridge Publishing Singapore
• Release date: Dec 29, 2023
• ISBN: 9781543781168

Harun Soylu

Harun Soylu,is an experienced Aeronautical Engineer graduated from Istanbul Technical University, Turkey in 2004. He is holding MBA degree from Geneva Business School, Switzerland in 2017. Author has several years experience in software developing in Linux environment. He has been working in aviation maintenance since 2005 under different roles and responsibilites.

Book preview

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Aviation Manager’s Toolkit:

Understanding

Safety Management Systems

Organizational Blindness in Aviation Management and Leadership

HARUN SOYLU

Copyright © 2024 Harun Soylu. All rights reserved.

All rights reserved. No part of this book may be used or reproduced by any means, graphic, electronic, or mechanical, including photocopying, recording, taping or by any information storage retrieval system without the written permission of the publisher except in the case of brief quotations embodied in critical articles and reviews.

www.partridgepublishing.com/singapore

Because of the dynamic nature of the Internet, any web addresses or links contained in this book may have changed since publication and may no longer be valid. The views expressed in this work are solely those of the author and do not necessarily reflect the views of the publisher, and the publisher hereby disclaims any responsibility for them.

ISBN

ISBN: 978-1-5437-8117-5 (sc)

ISBN: 978-1-5437-8116-8 (e)

12/18/2023

Declaration of Authorship

"I hereby declare:

•That I have written this work on my own without other people’s help (copy-editing, translation, etc.) and without the use of any aids other than those indicated;

•That I have mentioned all the sources used and quoted them correctly in accordance with academic quotation rules;

Date: 27 Nov, 2023

Name: HARUN SOYLU

Signature:

Acknowledgements

First, I thank to my wife, both of my kids and all other family members including my father and mother whom they are always supporting me to carry out my studies.

Contents

Chapter 1: Introduction to Organizational Blindness and Safety Management Systems

Chapter 1.1: Dunning–Kruger Effect

Chapter 1.2: SMS Safety Culture and Silo Mentality

Chapter 1.3: The Abilene Paradox

Chapter 1.4: Halo Effect

Chapter 1.5: Authority Pressure and Milgram Experiment

Chapter 1.6: Role Pressure and Stanford Prison Experiment

Chapter 1.7: Peer Pressure and Solomon Ash Experiment

Chapter 1.8: Time Pressure

Chapter 1.9: Invisible Gorilla

Chapter 1.10: Streisand Effect

Chapter 1.11: Bystander Effect or the Genovese Syndrome

Chapter 1.12: Hindsight Bias

Chapter 1.13: Practical Drift

Chapter 1.14: Cosmetic Compliance

Chapter 1.15: Safety Leadership

Chapter 1.16: Difference Between Wish and Goal

Chapter 1.17: Risks with Aggressive Production Targets

Chapter 1.18: Iceberg of Ignorance

Chapter 1.19: Micromanagement:Myway or Highway

Chapter 1.20: Seven Signs of Ethical Collapse

Chapter 2.1: Challenger Space Shuttle Explosion and The Rogers Commission Report

Chapter 2.2: MS Herald of Free Enterprise

Chapter 2.3: Air Ontario Flight 1363

Chapter 2.4: Continental Express Flight 2574

Chapter 2.5: Fairchild Air Force Base B-52 crash

Chapter 2.6: Rockwell-MBB X-31 Program

Chapter 2.7: Pinnacle Airlines Flight 3701

Chapter 2.8: Royal Air Force Nimrod crash

Chapter 2.9: Colgan Air Flight 3407

Chapter 2.10: Gulfstream G650 Accident During Experimental Test Flight

Chapter 2.11: CHC Helikopter Service Flight 241 Crash

Chapter 2.12: Liberty Helicopters’ AS350-B2 Ecureuil Crash

Chapter 2.13: Safari Aviation Airbus AS350 Helicopter Crash

Chapter 2.14: Boeing 737 MAX groundings

Chapter 2.14.1 Lion Air Flight 610

Chapter 2.14.2 Ethiopian Airlines Flight 302

Chapter 2.14.3: Boeing new Safety Plan

Chapter 3.1: SMS in Continuing Airworthiness

Chapter 3.2: SMS Standard SM-0001

Chapter 3.3: Noah Principle

Chapter 3.4: Hofstede Cultural Dimensions

Chapter 3.5: SMS in Part 145 Organizations and Fatigue Management

Chapter 3.6: Useful Quotes with SMS

Chapter 1

Introduction to Organizational Blindness and Safety Management Systems

After the second World War, United States and the Soviet Union engaged in a severe race in space. USA president Ronald Reagan formally launched the International Space Station program in 1983. The president also introduced the Teacher in Space Project (TISP), a NASA initiative aimed at promoting science, math, and space exploration among students and teachers. America’s first teacher in space candidate, Sharon Christa Corrigan McAuliffe, was selected to ride on the shuttle to instruct kids back on Earth. Following several interruptions and delays throughout the planning stage of the Challenger Space Shuttle program, NASA management ultimately chose to launch on January 28, 1986. Four other engineers from NASA contractor Morton Thiokol, together with Bob Ebeling, who was the subject matter expert engineer of the Solid Rocket Booster, attempted to stop the launch. The technical judgement and decisions by experts engineers were overruled by NASA management.[1] Bob Ebeling arrived at his house the day before the launch and told his wife, It’s going to blow up. The next day, Bob Ebeling and his colleagues watched explosion of spacecraft on a giant live television screen and they knew exactly what had happened. Even 30 years after the Challenger accident, Bob Ebeling continues to place the blame on himself. In 1986, he said, I could have done more, I should have done more as he was watching the haunting images of the Challenger Space Shuttle disaster on the television.

The numerous system failures in communication, engineering safety, decision-making, and organizational safety structure were dramatically illustrated by the Challenger disaster. The Challenger Space Shuttle disaster and TWA Flight 514 are recognized as significant events that highlight the need for a more thorough, proactive and scientific approach to safety.[2]

Past experiences have demonstrated that lessons are forgotten when important personnel and management structures shift.[3] It is imperative that the important lessons learned from the Challenger accident review are not neglected. We have to keep them alive and accessible so that:

•Support engineers in incorporating safety into their critical designs.

•Provide checklists for development testing and trade studies.

•Assist in organizing plans and procedures for validation and verification.

•Pay close attention to areas of high risk within management systems.

•Provide punch lists so that real-time risk assessments can be used to evaluate waivers and deviations.

•Determine and create comprehensive corrective measures to address management weaknesses revealed by errors, malfunctions, mishaps, accidents, and safety issues.

•Support in setting management priorities in areas that are especially prone to important mistakes and human error.

•Help evaluate safety risk conditions.

On Saturday, February 1, 2003, seventeen years after the Challenger Space Shuttle explosion, Space Shuttle Columbia broke apart as it reentered the atmosphere over Texas and Louisiana, killing all seven of the astronauts on board. It was the second disastrous Space Shuttle mission. Both the Challenger and Columbia accidents involved organizational issues in addition to technical problems.[2]

In conclusion, the Challenger Space Shuttle explosion can be seen as a turning point that led to the creation of SMS (Safety Management System). This disaster is regarded as SMS’s pivotal moment and the first significant instance of a known conflict between engineering judgment and management. We are going to look into organizational blindness and discuss about further case studies. We will investigate the forces that people encounter in order to better understand the fundamentals of SMS and organizational failures.

Chapter 1.1: Dunning–Kruger Effect

In accordance with objective criteria, peer performance, or the performance of people in general, people with limited knowledge or competence in a given intellectual or social domain tend to greatly overestimate their own knowledge or competence in that domain. This cognitive bias is known as the Dunning-Kruger effect in psychology.[4] According to the researchers for whom it is named, psychologists David Dunning and Justin Kruger, the effect can be explained by the fact that individuals who demonstrate the effect do not have the minimum level of the same type of knowledge or competence, which is a prerequisite for the metacognitive ability to identify deficiencies in one’s own knowledge or competence. Such people typically believe they are not deficient because they are not aware of their deficiencies, which is consistent with the general tendency for people to choose what they think is the most reasonable and optimal option.

In the research discussed in Dunning and Kruger’s paper Unskilled and Unaware of It: How Difficulties in Recognizing One’s Own Incompetence Lead to Inflated Self-Assessments, (1999) four groups of young adults were tested in three areas: humor, logic (reasoning), and grammar.[5] Their predictions that incompetent people will dramatically overestimate their ability and performance relative to objective criteria in comparison to their more competent peers, that they will be less able...to recognize competence when they see it (whether it be in