It was a sad story actually, but I think this will be good to learn from it. After the Airasia QZ8501 crash of last month that killing all 162 people on board, Indonesia’s transport ministry had suspended 61 domestic flight routes due to violance in flight permit based on the audit report that had been conducted after the accident. Pro’s and contra’s were following the decision where the contra’s mostly thought it’s not quite related to the accident. Are you agree with that?
The facts that said there is no direct connection between the permit issue and the accident that most likely caused by a bad weather. However, even if the direct caused truely caused by the weather, or any technical problems, the root cause would not necessarily related to the direct cause. Why was that?
In risk management point of view, there are 3 level of cause that need another 3 level of remedial action:
First level is a symptom or direct cause, such as losing control due to waiting for ATC (air traffic control) approval. The only remedial action is doing any emergency action to correct the problem, if it is fail, then the accident or non-conformity take place. We define it as correction action.
Second level is the cause, such as limited fuel that cause the pilot must take up other that turn left or right to avoid the cumulonimbus cloud ahead. The remedial action shall prepare the flight plan accordingly that will consider the weather report to ask for extra fuel. We define it as corrective action.
Third level is the root cause, such as did not use the weather report to plan the flight accordingly that possibly will require more fuel for the flight. The audit found that the flight officer did not take the weather report, and some more the permit approval was not following the standard operating procedure. The remedial action shall propose the flight schedule as per procedure and following any procedure of flight accordingly such as take the update weather report before preparing the flight plan. We define it as preventive action.
You see, the preventive action is not necessary direct to the symptom or the accident. Because it is the potential cause that could be happen, or if we luck, it would be not happen. If you take a look carefully, the correction action take higher cost that the corrective one, and the corrective one will be higher than the preventive action cost. And most of all, losing your life could not be compared with money or any material things.
People will be easily understood those concept very well. I thoght, the pro’s and cont’s mostly because the decision tend to be reaction other than the preventive action as required. In this situation, people see it as the lack of discipline in the tranport’s department itselves in their role as the regulator. And people feels that the reason why the regulations were not obeyed by the related party is mostly because that regulation is not applicable, or at least economically is not applicable in the business practice.
I myself has gotten valuable benefit by evaluating and empowering the procedures and regulations in my organization. I work less stress, and so with my people in the organization, but with the higher performance and less cost. At the end, the organization become very competitive in the market and make our organization profitable in return.
In risk management point of view, there are 3 level of cause that need another 3 level of remedial action:
First level is a symptom or direct cause, such as losing control due to waiting for ATC (air traffic control) approval. The only remedial action is doing any emergency action to correct the problem, if it is fail, then the accident or non-conformity take place. We define it as correction action.
Second level is the cause, such as limited fuel that cause the pilot must take up other that turn left or right to avoid the cumulonimbus cloud ahead. The remedial action shall prepare the flight plan accordingly that will consider the weather report to ask for extra fuel. We define it as corrective action.
Third level is the root cause, such as did not use the weather report to plan the flight accordingly that possibly will require more fuel for the flight. The audit found that the flight officer did not take the weather report, and some more the permit approval was not following the standard operating procedure. The remedial action shall propose the flight schedule as per procedure and following any procedure of flight accordingly such as take the update weather report before preparing the flight plan. We define it as preventive action.
You see, the preventive action is not necessary direct to the symptom or the accident. Because it is the potential cause that could be happen, or if we luck, it would be not happen. If you take a look carefully, the correction action take higher cost that the corrective one, and the corrective one will be higher than the preventive action cost. And most of all, losing your life could not be compared with money or any material things.
People will be easily understood those concept very well. I thoght, the pro’s and cont’s mostly because the decision tend to be reaction other than the preventive action as required. In this situation, people see it as the lack of discipline in the tranport’s department itselves in their role as the regulator. And people feels that the reason why the regulations were not obeyed by the related party is mostly because that regulation is not applicable, or at least economically is not applicable in the business practice.
I myself has gotten valuable benefit by evaluating and empowering the procedures and regulations in my organization. I work less stress, and so with my people in the organization, but with the higher performance and less cost. At the end, the organization become very competitive in the market and make our organization profitable in return.