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It’s Not the ‘System’s’ Fault

May 15, 2013  By Paul Dixon

I must confess, I had some reluctance as I headed off to my fourth CHC Safety & Quality Summit this past March in Vancouver, but I made a choice to try looking through new eyes and listen with new ears.

I must confess, I had some reluctance as I headed off to my fourth CHC Safety & Quality Summit this past March in Vancouver, but I made a choice to try looking through new eyes and listen with new ears.

I made a point of not going to presentations I’d seen before, no matter how enjoyable Scott Shappell can be (and his session is always a treat). As much as I want to think that everyone at the Summit is a safety zealot, we know in our hearts of hearts that there are still too many people in the choir who are simply mouthing the words – and I didn’t want to find myself in that scenario. Two weeks after the Summit, the Vancouver Sun ran an extensive three-part series on the shortcomings of the federal government’s shift of commercial aviation safety from a hands-on inspection regime to a largely self-guided compliance regime. The articles included several examples of what happens when smaller operators make conscious decisions not to follow the rules. All are real-life examples of this year’s CHC theme, “Predictive Safety to Avoid the Inevitable.”

Take a safety management system (SMS) for example. We all hear about its system failures on a daily basis. And it’s the same for the justice system, the health-care system, the education system. Something bad happens to someone and it’s all because the system failed them.

We’ve created the illusion of the “system” as an entity – a living, breathing creature of untold mythical proportions. My trusty Oxford dictionary offers more than a dozen possible definitions for the word “system,” with the first being “a complex whole.” Not a black hole, mind you, but a complex whole, “a set of connected things or parts.”


Read further and there’s also “a method of choosing one’s procedure in gambling.” There are gamblers with systems, oh yes. I knew a few of them in another universe. There were lots of systems, but none of them seemed to work no matter how convinced the developers of those systems were. Someone has to feed the racehorses and help those casinos pay their hydro bills. It might as well be them, as it won’t be me. That’s my system, but I digress.

The “interconnected parts” that make up the “complex whole” are the system of us, you and me. That’s where so many people miss the point when they talk about systems and systemic failure. It’s not the system that has failed; it’s one or more of the people within the system.

Author and speaker Dr. Tony Kern helped me re-adjust my attitude with his “Predictable is Preventable” presentation. You don’t have to be the Amazing Kreskin – forgive me for showing my age here – to make that prediction, but it’s something we see over and over again. It’s the myth of experience: that point in our lives or careers when we like to think we’ve seen it all and nothing’s going to get past us. What have we learned with an attitude like that? Well, we’ve learned to be non-compliant, especially with a SMS. We’ve likely learned to be non-accountable – let the next guy make the deficiency report. Above all, we’ve become satisfied with the status quo, comfortable in our little corner of the universe and good luck to anyone who tries to change us.

But step outside the aviation world for a minute and look at some of the major man-made disasters or near-disasters around the world. The “system” fails because only one person fails at some aspect of their job. It’s true, as major disasters such as Three Mile Island, Chernobyl, Piper Alpha, BP Texas City, Hinton rail disaster, Westray and more illustrate. Dig down into the reports and they are all systemic failures.

From senior management right through to the front-line employees, the cause of each of these events was triggered by human action or inaction. Often, a small mistake can be caught or corrected further along in the process, but when small mistakes are ignored they can easily add up to a tsunami.

Passing this message onto the younger generation will be critical for management teams in every facet of the aviation industry. And make no mistake – many of the upcoming “youngsters” in this industry are ready and willing to accept the challenge. It was very refreshing to see that these people were pumped to be there. Take Dylan Grymonpre for example. The aerospace engineering student from Carleton University in Ottawa and this year’s recipient of the Dr. Peter Gardiner Aviation Student Grant was absolutely thrilled to be a guest at the Summit. What I liked best was how excited he was to meet people who were just as excited as he was about his chosen field. It was like meeting old friends for the first time.

A friend I used to work with was once asked by her daughter, mustering all the saccharine sweetness of a 16-year-old, “Mom, were you sad when the dinosaurs died?” If I were asked that question, I would say that I was still waiting, but I’d be one happy fellow when the day arrives.

Paul Dixon is freelance writer and photojournalist living in Vancouver.


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