Dealing with Unpredictable Events

This is a sub article to the master article on Resilience and it will consider good practices for communications between organisations.  

In dealing with unpredicted events, the organisation’s or indeed the system’s resilience is a key factor in ensuring safety. A ‘Resilience Analysis Grid” (Hollnagel, 2018) is a method of considering an organisation’s resilience. It proposes that the organisation’s ability to anticipate, monitor, respond to and learn can be assessed through developing a series of questions relating to each of these aforementioned factors. Further information on the approach can be found on Erik Hollnagel's website.

The starting point

Questions relating to these four abilities can be used as a starting point, and even assessed using a Likert-type scale from excellent (5) to deficient (1). Alternatively, they could be aligned with common oversight processes and be assessed as not present, present, suitable, operating and effective (PSOE). More detailed questions to support the assessment of each ability can also be developed, but these will very likely be dependent on the individual organisation.

• Ability to respond – How ready is the organisation to respond and how able is it to respond when something unexpected happens?
• Ability to monitor – How well is the organisation able to detect changes to work conditions that may affect the organisation’s ability to carry out current or intended operations?
• Ability to anticipate – How large an effort does the organisation put into what may happen in the future? Is anticipation a strategic concern?
• Ability to learn – How well does the organisation make use of formal and informal opportunities to learn from what happened in the past?

In normal circumstances, an additional dimension of resilient performance can be posited: Adaptability the recovery and return to some state of stability. In other words, how well can the organisation recover, or return to a state of stable system performance, from a disturbance, circumstance, or variation from what was normative pre-COVID 19, in a way that is conducive and compatible to the new COVID-19 operating environment?

How the organisation adapts and how it adjusts the system’s performance to new conditions is fundamental. Hence, for the organisation, it means adapting to sustain the operation in new circumstances, where the interactions and dependencies have changed. Fundamental to understanding resilient performance, is that challenges and disturbances occur as part of the pattern of everyday variation in operations, not just where safety is a concern.

One must consider whether the aviation system is in an extended period of recovery to the old state or transitioning to a new state? Sustaining operations through surprise events such as changing quarantine measures or new health safety mitigations requires adaptation. Organisations will need to adjust performance to cope with the prevailing conditions.

In applying principles of resilience to an organisation (or a regulator), it is important to realise that resilient performance is not something that an organisation has, it is something that the organisation does.  

Therefore do these things:

• Do create a working environment/ organisational climate where people can exchange ideas. Staff should be able to tell their supervisors and managers how things are going;
• Do learn from the current operational environment to understand what the new competing priorities and trade-offs are. This will enable the creation of new strategies to support day to day decision-making and management of work;
• Given that the system is changing too rapidly to rely solely on past data, do make qualitative risk assessments of what is working and what is not;
• Do communicate with and learn from other organisations, regardless of whether they are from the same aviation domain or not. This becomes particularly important where interfaces exist between many different organisations, such as at airports or between ANSPs and airlines. Groups might be established, or already exist, that can not only share experiences but also seek to anticipate and reflect as circumstances continue to change;
• Do consider that existing strategies and techniques can be repurposed for the new situation, for example thorough risk assessment is still required, but its subject matter and scope may have changed. In these cases, be sure to engage with experts experienced in the relevant subject matter;
• In addition to the routine monitoring of safety performance, safety departments need to invest time in analysis for discovery, in order to identify emerging hazards.

And don’t do these things:

• Don’t abandon pre-existing safety management and identified hazards. Not only will conventional monitoring methods identify new issues, but many safety issues present before the pandemic are still relevant, or may be found in different ways. The causes and context could be different but the outcomes may be the same;
• Don’t stop monitoring your usual safety performance indicators, but ensure that they are adjusted to account for reduced traffic levels;
• Don’t stop doing safety activities or adjust procedures without applying risk assessment and change management. The procedures and processes that are in place are likely to be mitigations from earlier risks. If these are stopped or changed, as staff leave or other issues arise, previously mitigated risks may return;
• Don’t decrease meetings & communications opportunities, even if there are now fewer staff;
• Don’t rely solely on past outcomes as being predictive of future performance;
• Don’t over-emphasise production at the expense of safety;
• Don’t forget the opportunities for safety improvement.