Are we really learning organisations? Is it possible to measure how good (or not) an investigation into a ‘human in the system’ event has been? Should there be a minimum qualification level achieved before being ‘let loose’ on an interview? Does peer review prior to report release take place in your organisation and does the Event Review Group really analyse whether the root cause(s) have been identified? I’m interested in your thoughts please.
Good Investigations
Comments (3)

Hello Silas,
I believe that we are learning organisations but it is not administrated and therefore hard to proof. Through my experience in the GA I learned that administration, reporting, analysing and information sharing is not at the same level as in the Airliner industry. You talk about an "Event Review Group" for example... small companies normally do not have these kind of groups and do not have budget/personnel/time to have these groups.
Many MRO's in the GA industry have good workmanship and there is control/back up on the workfloor. Going to SMS in these kind of companies requires culture change and an efficient structure to administrate, analyse and report. These companies generally have a hard time earning a bit of money, adding more and more administrative work could actually create more risk instaed of improving safety because the focus will shift towards "compliance on paper". The NAA's will be happy because "on paper" all is good, but did it actually improve quality on work performed?
The GA industry is actually very interesting. It ranges from private operations in a Cessna 172 and Part 66 sign off up to and including business jets flying commercially. In between there are many kinds of aircraft types and operations. Imagine the daily struggles to keep complex powered aircraft, build in late 70's with many STC's, airworthy and compliant...

Hi Hans and thank you for your comment, in particular the 'hard time earning a bit of money' which really struck a chord with me. Employing staff to carry out the additional workload of analysing reports, trending, conducting proactive hazard ID sessions, preparing for safety meetings, conducting safety training and then promoting safety is not likely to be possible. Therefore, if a Safety Management System is not simply going to be the creation of artefacts to satisfy a regulator then we have a dichotomy of wanting to change the culture and switching from re-active to pro-active but no one available within the business to conduct the work. Perhaps SMS is only possible within organisations over a certain number of staff? I believe there may be a gap in the market for an inexpensive "train the trainer" course on how to design and embed an SMS with minimum resources. Attendance by both the Accountable Manager and nominated Safety Manager would be essential though.
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"Perhaps SMS is only possible within organisations over a certain number of staff?"
I don't think so, I think the difference will be the setup and control within the company. I am trying to setup a system within our company and I do think we will get a good system going but it takes time...
"Attendance by both the Accountable Manager and nominated Safety Manager would be essential though."
Absolutely, it starts with the AM. Then there is the Quality Manager, whom in GA world is also the Safety and Compliance Manager, to design, train, implement and audit the system throughout the company.
For sure, the system should not be something to satisfy a regulator. If we would do that then we all miss the boat... The goal is simple and the SMS should support that and not become a burden for a company.