What is a Safety Event?

“We just had a safety event; I should fill out an ASAP.”

Hopefully, that thought sounds familiar, and you have followed through and engaged with the Aviation Safety Action Program (ASAP). This thought begs the question: “What is a safety event?” Or, more specifically, “How do we define safety?”

The Old Definition

Safety frequently falls into the “you will know it when you see it” category. Dig a little deeper, and most people define safety as an acceptably low rate of mishaps or other accidents. By this definition, then, safety is defined by the “lack of danger.” This definition lacks specificity and direction, causing problems for proactive safety reporting and investigations.

Defining safety by a lack of danger requires an arbitrary threshold at which an organization or individual begins to care about the rate of mishaps. Nearly any supposition from this perspective requires a subjective demand from the one making the claim. Even the claim, “One mishap is too many!” begs the question, “Over what timeline?” It is impossible to expect an organization to have no mishaps forever—or perhaps no Class A mishaps. But how do we decide when several million dollars in damage must be avoided, but a mere million is acceptable? Without specificity in language, we quickly take on ambiguity and lose track of overall safety.

Defining safety in terms of danger also presents a concerning lack of direction: “If I’m supposed to be avoiding a negative, what exactly am I supposed to be doing?” If you have kids, you’ve probably experienced this phenomenon: “Stop hitting your brother!” inevitably leads to more fighting, as children struggle with not doing something rather than doing something. The adult version of this concern is, “Don’t think about penguins.” In the safety realm, this is like saying that if nothing “bad” happens for a while, we must be running a safe operation. However, does it really make sense to measure something by its absence? Is this even effective? There must be a better way.

An Alternative Perspective

We are pleased to say there is another way we can start thinking about safety. You might have read about it in our team’s previous article on Safety I vs. Safety II (a concept described in Erik Hollnagel’s book by that same title). Safety I, at its core, focuses on what goes wrong, whereas Safety II focuses on what goes right. Traditional safety systems often spend a lot of time focusing on what happened during mishaps (relatively rare events) rather than focusing on what can enable good outcomes.

Another way to think about safety is as the act of responding correctly to a hazard. Instead of “mishap crew error,” think “crew saves the day.” Our team recently attended the Aviation Safety InfoShare Conference—a gathering of prominent industry and government aviators and safety professionals to share best practices in safety. In one main session, a briefer shared this perspective: He acknowledged that yes, human limitations often contribute to accidents, but he made the critical note that one hundred percent of successful operations are due to human capabilities. That is, what humans do right! As an aircrew member, your ability to predict, adapt, and focus on mission accomplishment in the complex and dynamic aviation environment is a crucial component of the alternative perspective of safety. Therefore, understanding how you do things right, thus actively participating in safety as a process, is crucial.

Safety is a Process

Threat and Error Management (TEM) defines safety not as a passive state of security, but as an additive process. In this view, safety is a measurable presence of resilience, built layer by layer through the active application of countermeasures. Every time you, as a crew, utilize effective Crew Resource Management—such as a thorough pre-flight briefing, cross-checking a flight computer entry, clarifying a confusing Air Traffic Control clearance, or maintaining high situational awareness—it adds a protective layer to the mission. Safety is then measured by the presence of these systemic defenses and the capacity of you and your crew to anticipate, detect, and recover from anomalies, rather than by the simple absence of a mishap.

How can we see this TEM process in action? You see it every day as you fly the line. Air Mobility Command (AMC) Headquarters depends on your input (such as through ASAP inputs) to communicate how you actively “do safety.” Your ASAPs show us—and in turn, the rest of AMC—examples of “safety in action.” When you tell us the threats and errors you encounter and the capabilities you use to identify and mitigate them, you play a critical role in AMC’s ability to learn from the “alternative view” of safety as a process.

What is a Safety Event?

Any time you recognize a hazard in the flying environment or in aircraft performance, it is a safety event. As we have discussed above, if safety means doing something that identifies or mitigates that hazard, we want to know what you did or believe you should have done. We would rather have one hundred different ways that crews responded to an issue with positive outcomes than miss one important event another crew could have learned from.

A critical truth about the “alternative view” of safety is that almost all missions end well. Therefore, we need to learn from those. Learning only from rare mishap events means learning only occurs rarely. Minor but unpredictable variations occur on every flight. When you tell us what you encountered and how you achieved a successful outcome, the whole organization learns about how missions actually get done, not how we imagine they get done. Harnessing what we learn from this—what it takes for things to go right—provides exponentially more data points on how safety occurs, meaning that, as an organization, we have the data to make continuous, incremental improvements over time rather than reacting to a single failure.

In Summary

The old view of safety defined it as the absence of negative events. The alternative perspective conceptualizes safety as a process, made up of “what goes right.” Human capability is the critical resource, and knowing what humans do right on a daily basis helps the whole organization “do safety” better. So, help us move this forward! Send us an ASAP telling us how you faced a hazard and what you did to safely get the mission done.

ASAP Call to Action!

Tell us how you are doing safety.

Hints for recognizing safety events include:

1. Did you just succeed on a mission despite unexpected threats or errors?
2. What adjustments did you make to get the mission done based on the demands of the situation?
3. Things go right because of how humans manage variability in complex situations. Did you recently do that?

Tell us what the situation was and how you managed the variations (potential hazards or errors) to complete the mission.

Reminder: What is ASAP?

ASAP is an identity-protected, self-reporting system that provides you with an opportunity to report safety issues and errors without fear of reprisal (DAFI91-225, para. 3.1.1). Further, it provides AMC staff a looking glass into your everyday realities with getting the mission done.

What happens when I submit an ASAP?

Here is the ASAP lifecycle:

1. You submit the ASAP on the SAFEREP site (https://saferep.safety.af.mil/) or mobile application.
2. We act as gatekeepers. We de-identify your entry and forward it to the appropriate subject matter experts for awareness/action.
3. If you provided your contact information, we close the loop and let you know what we learned from the office that took it for action.
4. Each month, we publish a newsletter with every ASAP submitted from the previous month, highlighting and expanding on ASAPs with the broadest relevance for Hangar
   Fly discussions.
5. We elevate actionable ASAPs and trending issues for review and action by AMC leadership at various levels.

**Did you know? ASAP is an aviation industry standard!**

References

DAFI91-225 Aviation Safety Programs, 31 Jan 2022 (Incorporating Change 1, 1 Aug 2023)

Flight Safety Foundation. 2021. Learning From All Operations: Expanding the Field of Vision to Improve Aviation Safety. https://flightsafety.org/toolkits-resources/learning-from-all-operations/.

Hollnagel, E. 2014. Safety-I and Safety-II: The Past and Future of Safety Management. CRC Press.