How Safety lapses hit Boeing's reputation Boeing 737-Max - Report conveys the findings and recommendations of the Organization Designation Authorization (ODA) Expert Review Panel
Vídeo- How Safety lapses hit Boeing's reputation
Figure - Accident with 737 - MAX
The Expert Panel concluded
that recommendations for The Boeing Company3
(herein referred to as “Boeing”) and
the FAA are consistent with the requirements of the Act and with the public interest in
aviation safety. The Expert Panel expects that the FAA Administrator will review the
recommendations and reinforce them as appropriate.
A summary of the Expert Panel’s work is as follows:
• The Expert Panel observed a disconnect between Boeing’s senior management
and other members of the organization on safety culture. Interviewees, including
ODA Unit Members (UM), also questioned whether Boeing’s safety reporting
systems would function in a way that ensures open communication and
non-retaliation. The Expert Panel also observed inadequate and confusing implementation of the five components of a positive safety culture (Reporting
Culture, Just Culture, Flexible Culture, Learning Culture, and Informed Culture).
• The Expert Panel found Boeing’s SMS procedures reflect the International Civil
Aviation Organization (ICAO) and the FAA SMS frameworks. However, the
Boeing SMS procedures are not structured in a way that ensures all employees
understand their role in the company’s SMS. The procedures and training are
complex and in a constant state of change, creating employee confusion
especially among different work sites and employee groups. The Expert Panel
also found a lack of awareness of safety-related metrics at all levels of the
organization; employees had difficulty distinguishing the differences among
various measuring methods, their purpose, and outcomes.
• Boeing’s restructuring of the management of the ODA unit decreased
opportunities for interference and retaliation against UMs, and provides effective
organizational messaging regarding independence of UMs. However, the
restructuring, while better, still allows opportunities for retaliation to occur,
particularly with regards to salary and furlough ranking. This influences the ability
of UMs to execute their delegated functions effectively.
• The Expert Panel also found additional issues at Boeing that affect aviation
safety, which include inadequate human factors consideration commensurate to
its importance to aviation safety and lack of pilot input in aircraft design and
operation.
More informations:
Video Boeing CEO in the US Senate
For more information, videos, and complementary materials, about Safety, access the links at the end of this post.
Are we paying attention to the essential issues for the Safety of Organizations?
How many lives, what social, environmental, patrimonial impact, in the image of the organization and others, would be spared?
It is important to look into these issues, and to deepen academic studies, with application in companies, to develop proposals to avoid these tragedies.
Below is the proposal for preventing and mitigating major and fatal negative events, which I developed based on studies and applications in organizations.
It is important to present models, principles and structured forms, together with lessons learned from Major and Fatal Negative Events, which facilitate the analysis of these tragedies, That's why I created the Prevent Tragedy Course - Proactive Safety, Risks, and Emergencies Methodology (ProSREM).
I developed ProSREM, in my Ph.D., in Production Engineering at UFRJ, and used as academic bases: Ergonomics, Resilience Engineering, Integrated Management Systems (Quality, Safety, and Environment), among other methods and tools, and my database to build this proposal, was the biggest and fatal negative events, prominent in the world and in Brazil, I apply this methodology at Fiocruz, where I am a public servant and in organizations, companies, sectors, and activities.
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washington.fiocruz@gmail.com
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Prevent Tragedy Course - Reports of professionals from the course's study cycle:
- They liked the proposal, it lacks this approach with application in the industry (deficiency in the training), very didactic, motivating for the theme, bringing reality, bringing disasters, it could be avoided, ANDEST (National Association of Teachers in Engineering Safety at Work in Brazil) identified a deficiency in risk management in the training of the safety eng., posts of proactive safety are important, you raise the ball, it is up to people to absorb the lessons of the post, I encourage them to understand what happened, think about all the aspects, awaken this need for analysis.
RISK MANAGEMENT modules, AND THE PROACTIVE SAFETY METHOD, RISKS AND EMERGENCIES.
Module 1, UNDERSTANDING AND PREVENTING TRAGEDY:
Module 2, THEORY OF THESE TRAGEDY - SHORT VERSION:
Module 3, CASE STUDIES OF THESE TRAGEDY:
Module 4, EXERCISES AND ACTIVITIES, TO UNDERSTAND AND PREVENT TRAGEDY:
Article approved in JRACR journal - The Sociotechnical Construction of Risks, and Principles of the Proactive Approach to Safety
Participate, specialize and support the dissemination of this initiative.
Washington Barbosa
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