Now, the airline with the loose track cover likely had a
form of SMS in place and my wife’s incident was very likely not the fi rst. I base that on the quick response and the action taken to eliminate the hazard. All too often we need more than one “poke-reminder” before we react to a hazard. At least they likely had a system in place to do a risk analysis of the potential hazard and likely determined that the cost to eliminate the hazard was minimal. Persons who know about the hazards, according to the earlier study, indicated that the supervisors being close to the “worker bees” knew 74%. Middle management’s knowledge dropped to a whopping 9%, while the man with the money at the top was aware of only 4%. An SMS requires him to put a system in place so that he can no longer say “I didn’t know” after an accident occurs. I’d like to devote the next few articles into what can make for a successful SMS that ensures that the small stuff does not become big stuff . Can you say that yours is doing that? If not sure, stay tuned.
Gordon Dupont worked as a special programs coordinator for Transport Canada from March 1993 to August 1999. Prior to working for Transport, Dupont worked for seven years as a technical investigator for the Canadian Aviation Safety Board (later to become the Canadian Transportation Safety
Board). He saw fi rsthand the tragic results of maintenance and human error. Dupont has been an aircraft maintenance engineer and commercial pilot in Canada, the United States and Australia. He is the past president and founding member of the Pacifi c Aircraft Maintenance Engineers Association. He is a founding member and a board member of the Maintenance and Ramp Safety Society (MARSS). Dupont, who is often called “The Father of the Dirty Dozen,” has provided human factors training around the world. He retired from Transport Canada in 1999 and is now a private consultant. Visit
www.system-safety. com for more information.
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