FC5250

CHIRP has commented before on the need to have robust policies for a defined cycle of regular changes to documents rather than a series of ad hoc updates.  The frequency of such updates depends on the nature of the change (routine, urgent, administrative etc) and, in this case, it seems that rational decisions about how to incorporate the changes were unfortunately derailed by an administrative error that led to them not being properly promulgated. One of the purposes of simulator checks is to refresh crews on recent changes and so this fail-safe activity worked in this case but it is concerning that some crews may have unintentionally been operating in contravention to their OM-A because they weren’t aware of the changes.

CHIRP is heartened to see that the company is investigating why the administrative error was made, and also why the failure to promulgate was not evident. A change as significant as a revised Stable Approach Policy would hopefully have been considered within the company SMS processes and this should have highlighted the importance of robust promulgation channels. In any such investigations, it’s important to distinguish between errors and mistakes: in ‘Just Culture’ safety terms, ‘mistakes’ are symptomatic of people misunderstanding the task and potentially requiring further guidance or training, whilst ‘errors’ indicate that there are systemic problems that induce people to do the wrong thing. It behoves all organisations to mitigate as many systemic inadequacies as possible so that errors are reduced; in the circumstances of this report, this may identify safeguards that could be introduced to ensure that critical documentation is not lost in the system but properly highlighted to those who use it.