It Can Be Done
January 8, 2016 By Paul Dixon
Is it possible to create a working environment that is completely safe? Can we reduce the chance of errors, oversights, omissions and/or deviation to zero in our various workplaces, and in particular an aviation environment?
I think no. Does that mean we stop trying? Absolutely not! The theme for CHC’s 2016 Safety Summit is “Back to Basics: Prioritizing Safety in a Challenging Environment.” W. Edwards Deming said that focusing on quality would actually drive down costs. It was one of his 14 points of management. We could easily substitute the word “safety” for “quality” and likely have the same effect on the bottom line. You do not save money by “cheaping out” on safety programs. If you think that following safety guidelines is costing you money, have you ever seriously considered what not following those guidelines will cost you? Ask your accountant or insurance agent to enlighten you in this regard.
Safety Management Systems (SMS) and Crew Resource Management (CRM) in aviation came about for compelling reasons and we need to understand these reasons and be capable of applying the philosophy behind these programs to ourselves – and the situations we find ourselves in. Learning to look inward with a critical eye and maintaining equilibrium in environments where decisions have to be made with a high degree of accuracy when information is vague, incomplete or misleading is not easy and it can be extremely stressful at the best of times.
In my previous life, a friend and I read Transportation Safety Board (TSB) and National Transportation Safety Board (NTSB) reports for years, along with line-of-duty death reports for police officers and firefighters killed on the job. What we were looking at were the human factors that were at play in so many of these incidents. Frequently, the outcome of these events rested on a series of seemingly small and individually insignificant events that would have been deemed to be minor. Unfortunately these little things were interconnected and much like dominos falling, once they started tumbling they simply cascaded. Of course, hindsight is 20-20 and it becomes painfully obvious that simply removing any one domino from the string will stop the cascade.
The TSB report on the fatal crash involving an Ottawa transit bus and a VIA train in 2013 is a case in point. The bus had just departed a transit station heading downtown and was hit by the train, resulting in the death of the driver and five passengers. How is it possible that a bus operated by a municipal transit service could approach a level crossing when the gates were down, lights flashing, bells ringing and train rapidly approaching and collide with the train?
From the TSB report: “Although the crossing flashing lights, bells and gates had been activated more than 30 seconds earlier, the bells were not audible within the bus, and the driver’s view of the gates and flashing lights was obstructed by trees, shrubs, foliage, Transitway signage and the front corner pillars of the bus.” The TSB report goes on to comment that the driver had driven through this same spot 60 times in the previous 12 months, though from the varying times of his schedule he would have rarely encountered a train at this crossing. “Drivers who are familiar with a crossing and who have a “no trains” expectation tend not to look in either direction while approaching a crossing and are less likely to reduce their approach speed than drivers who are unfamiliar with a crossing.”
As a result, The City of Ottawa has since improved driver sightlines in the vicinity of the Transitway crossing by trimming or removing trees, shrubs and foliage. Signage has also been enhanced – including by the addition of an advance warning sign with a light that continuously flashes – and the posted speed limit in both directions approaching the crossing has been reduced to 50 km/h. There have been a number of lawsuits filed, so I’ll keep my thought to myself for the moment.
Look at this incident and deliberately do not use the word “accident” and compare it to your own situation at any time of your working life. We are the worst to objectively judge ourselves, but it doesn’t mean we shouldn’t try. How often do we walk by something at work that strikes us as being unsafe, but it doesn’t have an immediate impact on us – we just walk on by. How often did we forget to pass on something to the person who relieved us? If we’re already doing a good job on thinking safety, then the only way we will ever get better is by constantly striving to be the best. Think of Tony Kern’s Global War On Error, make it personal and start right now.
Paul Dixon is a freelance writer and photojournalist living in Vancouver.
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