Learning from aviation - PART 1 - risk management
In this blog we will try to predict what problems the private space companies might have and compare the space flight with it's older brother, the aviation.
The aviation had a similar history to private space exploration. If we skip the "lighter than air" part of the aviation history, we can see that the commercial use of aviation had a relativelly modest beginning. From the brave "barn stormers" and pilots who flew the post from one part of the country to another, to brave individuals daring to cross the Atlantic, the aviation became more and more a public transport thing and less and less an exclusive thing for rich and/or crazy individuals.
There were many problems during the evolution of air travel. As the space travel can be considered as the "next step in evolution" of the air travel, the following blogs will deal with the major problems and errors encountered in the aviation world. This knowledge was more than often written in blood and we think that it would be a waste if the space industry didn't take the lessons from other people's mistakes.
PART 1 - risk management
In order to understand the basic concept of risk management, let's ask ourselves a few questions:
What is a risk?
There are many definitions of risk, however this one is very suitable for the aerospace world:
"A probability or threat of damage, injury, liability, loss, or any other negative occurrence that is caused by external or internal vulnerabilities, and that may be avoided through preemptive action.
Can we have space or flight operations without any risk?
No. Each time we take off, turn on an engine or even test a component of a system we are doing it with a risk that something bad would happen. The ONLY time when we have no risk is when we don't fly or do anything at all. Each action in aerospace industry contains many inherent risks.
If we cannot avoid risk, what can we do, what must we do?
We can manage the risk. To manage a risk means that we know:
- what are the limits of acceptable risk?
- how risky is our operation - how far are we from the limit of unacceptable risk?
- what is our trend? Are we going to be more risky if we continue like this?
- what are the methods of measuring our risk level?
- if we are in the unacceptable state, how do we change that, if we are good, how do we maintain and improve that state?
EVOLUTION OF RISK MANAGEMENT THROUGH AVIATION
The aviation went through several phases of risk management, even though the first measures could be observed as funny when looking in the back through the binoculars of the 21st century.
Once the production of airplanes became larger and larger, many brave men started flying. Of course, the training was done on a personal basis, and there were no actual rules and regulations how to perform a safe flight.
This was the era of aviation when the pilots were "barnstorming" and many of them got killed because they didn't observe basic common sense rules for survival, such as, don't fly through a building with your airplane. Soon the authorities were formed in the advanced countries, providing restrictions for minimum flight altitudes and other relevant issues.
As the general public saw flying as being very dangerous, the first commercial airlines would provided nurses on their flights, to show that the flights are safe. The duties of the nurses eventually evolved in the duties of flight attendants.
Once the public started flying, the major cause of the accidents were the technical problems, either maintenance, design or fatigue. For example, the effect of fatigue on material was discovered while we were already in the jet era! Years passed and the airplanes got better and better. Faster and more demanding.
The next era saw a great increase of flying. We had jet aircraft flying at ten kilometers altitude with 800 kmh speeds all over the worlds. This era was marked with human factors related incidents. The pilots were not trained to fly as a team. The hierarchy division between the Captain and other crew members was very often too big, and many accidents could have been avoided by simply pointing out the problem to the Captain, offering a different opinion, or observing good airmenship standards. This era provided us with the Crew Resource Management, a concept in which the crew is trained to work as a team, with the Captain as the team leader. Communication skills, active decision making, situational awareness and standardization are being greatly encouraged.
All of the described methods of increasing the flight safey were more or less a reaction to a set of problems which have already caused accidents and incidents.
Aviation safety experts realized that more energy must be invested in recognizing new problems and preventing them from causinygANY accident, not just to wait for something to happen in order to respond and make a corrective action. In the last two decades, the majority of the accidents happened because of the errors of the system. The next step in the evolution of safety in aviation calls for system wide improvements and making sure that the system works correctly. This phase started with the implementation of the Quality System, and at this point in time it has evolved into the Safety Management System.
SMS - Safety Management System
SMS is a system which helps us to manage the risks. First of all, we must have a measurable system of determining the risks. Each risk is preceeded by a hazard. A hazard can be described as an unwanted situation, or a quality, which could lead to a risk.
Here is an example, a hazard is an open drainage hole in the road. The question is, how do we quantify this hazard, how do we know if this is acceptable for us or not?
Each hazard can produce one or more risks, and each risk has two distincive characteristics, the probability and the severity of the risk.
For example, our hole in the road can produce a hazard that a car hits it and gets damaged, but also that a man falls in and gets seriouselly injured.
If we start to analyze the first risk, we can see that the probability of a car hitting it is medium, because the road is well lit at night, and the severity is medium because we cannot be sure what kind of damage will happen, but we are sure there will be some damage. Once we evaluate the probability and severity we will know if our risk is acceptable or not, because these two characteristics can be translated into a number, using a mathematical formula.
This is a matrix how to determine whether a certain risk is acceptable or not:
This is a simple guide how to evaluate hazards, recognize risks, evaluate risks and perform corrective actions:
Now when we know the basics, what do we do?
We have to stay on top of things, in three different ways:
- reactive - we must have a system to collect the data related to safety and quickly react to any potentially dangerous situation
This should include establishing an annonimous safety reporting system, raising the reporting culture within the team and monitoring data.
In our case it would mean that a car has already hit the hole in the road, and we decide to mark the hole and decrease the probability of a risk or to fix it and decrease the severity
- proactive - we must establish a system to recognize hazards even before an accident/incident has occured.
In our example, this would mean marking/fixing the hole BEFORE any car hit it.
- predictive - we must establish a system in which we forsee new threats, especially with the new technologies and new operations.
In our example, this would mean establishing a system to maintain the roads so the hole never occurs.
So how do we know if we are a safe company or not?
By using a mathematical formula for quantifiyng each risk (severity*probability*in house determined factors) we can put the average of all risks on a graph.
By using this graph we can visually see if our company is above or below our acceptable risk level, and the trends. This can work only if all of the three ways of risk management are in place, reactive, proactive and predictive.
I hope space industry will have the SMS and risk management established by learning from aviation's mistakes. In the next blog we will talk about human factors and the SOP.