When we see Vitruvian Man (1490) we do not hesitate to associate this work as one of the greatest exponents of the Renaissance in Europe. Leonardo da Vinci's study of the ideal proportions of the human body could be considered the apogee of the era... the development of ideas, different artistic expressions, societies that were beginning to glimpse the foundations of capitalism and the need for technological development. How great were these needs? Immense. The world began an exponential scale of growth and there was no longer any monarchical system, court of holy office or creeds that could stop it.
The Middle Ages laid the foundations, however, the irruption of industrialization and technological growth itself occurred during the dawn of the Modern Age in Europe, more precisely in England. This phenomenon that changed the world forever is known as the Industrial Revolution. Between 1760 and 1840, growth exploded thanks to the abundance of raw materials and the great milestone of the time: the steam engine.
If you add the steam engine to transportation you get an unequivocal result: the railroad and steamships. Technified means of transport for cargo and passengers, with a complex system conception from its massification and provision of services. A paradigm shift for the time.
The railway industry set a precedent that today is a maxim in aviation almost three centuries after its discovery: the study of structural fatigue mechanics.
"...in 1829 the first studies on the effects of cyclic loads on mechanical components were initiated. However, ten years of studies had to pass before the French engineer Jean-Victor Poncelet (1788-1867) began to talk about material fatigue, without being able to fully explain the factors and development of this failure mechanics. Almost a decade more elapsed until the Scottish physicist and engineer William John Macquorn Rankine (1820-1872) analyzed and developed a postulate concerning the effect of stress concentrators on fatigue mechanics. In 1860, the chemical engineer Friedrich Wöhler formalized fatigue studies with all the elements known today, through the failure analysis of railroad axles...." (De Santis, A. P 253).
The succession of failures that Wöhler analyzed came from the collapse of the axles during usual routes, in which the maximum weights and limitations known for those railroads were respected. Since the 19th century, it is clear that strict compliance with standards and procedures is not enough to operate safely, is it not?
From the industrial revolution to date, systems have had to adapt to emerging realities, needs and hazards. This is how the first investigations of industrial accidents began to receive attention and incursions, those investigations at the beginning of the 20th century were linked to prevention. The concept of safety management was still a few years away.
Now, in a new century, the study of operational safety is based on the principles of identification and analysis of various factors present in the systems. With the 21st century in full swing, with its developments and problems, it is time to approach the subject with a different approach. In the evolutionary instance and the countless number of complex interactions, it is time to stop thinking of aviation as a mere transport instrument and treat it as a complex system.
By definition, it is understood that a complex system is composed of an infinite number of interconnected elements and variables, which generate interactions in a constant way. These interactions can be regular, chronological or random. There is no single pattern in a complex system. These interactions generate a volume of data and processes that are not usually visible to the operator, a fact that further increases the complexity of the situation.
So, it is clear that the concepts of complex system, high-risk industry and safety management are not the exclusive heritage of aviation, are they? Consequently, without safety management there is no prevention possible. It is common to hear self-proclaimed popes and pseudo-doctors of prevention claiming how to avoid accidents based on behavioral strategies. Some prophets talk about raising awareness, but the boldest pontificate on safety culture and human factors for all.
At the same time, the concept of "the new paradigm of operational safety" is repetitive, as much as magical solutions that would allow eliminating errors and failures in organizations. Shamanic, isn't it? A series of statements loaded with more marketing techniques than fundamentals related to safety management.
The reality is that the 21st century began with this paradigm called safety management. Where many have taken it for assimilated and implemented, however, we encounter daily inconsistencies that, at least, make us doubt that effective management. Attention, I am not referring to the individuals who are part of the aviation system; these are usually statements and institutional policies that remain in the enunciative plane. These policies are not only stated by service providers, operators and private companies... they are also the mission and vision of governmental entities around the world.
Travelling back a few years can provide a better understanding of this. Thomas Samuel Kuhn (1922-1996), physicist and philosopher of science, received his doctorate from Harvard University in 1949 and had a long and renowned professional career at the universities of California, Berkley, Princeton; until ending his professional days at the renowned Massachusetts Institute of Technology (MIT) in 1991. One of the main works published by Kuhn was "The Structure of Scientific Revolutions" in 1962. In that publication, Kuhn addressed the evolution of the natural sciences, there he postulated:
...the sciences do not progress following a uniform process by the application of a hypothetical scientific method. Instead, there are two different phases of scientific development. At first, there is a broad consensus in the scientific community on how to exploit the advances achieved in the past in the face of existing problems, thus creating universal solutions called paradigms....
From the 1960s to date, the concept of paradigm has been coined in multiple disciplines of science. Obviously, the aeronautical industry was not left out of this. As it usually happens with deep concepts full of fundamentals, they have been taken and applied to countless situations that are far from Kuhn's studies and postulates. However, safety management burst into aviation as a clear new paradigm.
Change management is one of the tools used by safety work to intervene in systems exposed to too rapid growth, methodological evolution, implementation of new paradigms, among other belief breaks. Beyond regulations, the International Civil Aviation Organization (ICAO) has encouraged the adoption of safety systems and their various tools.
Change management is intimately linked to the resilience engineering in which it is necessary to manage in this century. When talking about this concept, which is not very widespread in sectors other than those specific to operational safety, it is important to remember that one of the new paradigms is that we have ceased to be custodians of operational safety and have mutated to the management of complex systems in scenarios that mutate progressively and in which it is not possible to know all the interactions that may occur in time and space.
Based on the studies of Erik Hollnagel, Johan Bergstron and Sidney Dekker defined the foundations of resilience engineering linked to safety management. Foundations of Safety Science sets out unquestionable criteria that are indispensable for practical application in industry.
Systems are not inherently safe; operation involves coexisting pressures, economic objectives and conflicting interests, all of which are managed with limited resources. People and organizations have to generate safety within these dynamic circumstances ... Resilience engineering is inspired by fields beyond traditional disciplines ... Although this is not unique to this theory, resilience engineering also seems vulnerable to three analytical traps: a reductionist, a moral, and a normative one. (Dekker, P.391)
At times, it seems that the system is still chipping away at the definition of resilience in an unrelenting struggle to understand the adaptation of individuals to the new paradigms demanded by today's industry... at other times we are still stuck in defining and preventing error. It is impossible to think about managing change without adapting one's thinking to the dynamics of complex systems. Both human and financial efforts are in vain if the methodology is not adequate to a changing context of unexpected interactions.
Moments of crisis in organizations do not escape the concept of change management. The following is a case that, although it has economic, financial and legal connotations, had a direct impact on the safety.
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