Supervision

The Human Factors Working Group has determined that a mishap event can often be traced back to the supervisory chain of command. As such, there are four major categories of Unsafe Supervision: Inadequate Supervision, Planned Inappropriate Operations, Failed to correct a known problem and Supervisory Violations as shown in figure below.

(i) Inadequate Supervision: The role of supervisors is to provide their personnel with the opportunity to succeed. To do this, supervisors must provide guidance, training opportunities, leadership, motivation, and the proper role model, regardless of their supervisory level. Unfortunately, this is not always the case. It is easy to imagine a situation where adequate training was not provided to an operator or team member.

Conceivably, the operator's coordination skills would be compromised, and if put into a non-routine situation (e.g., emergency), would be at risk for errors that might lead to a mishap. Therefore, the category Inadequate Supervision accounts for those times when supervision proves inappropriate, improper, or may not occur at all.

Inadequate supervision is a factor in a mishap when supervision proves inappropriate or improper and fails to identify a hazard, recognize and control risk, provide guidance, training and/or oversight and results in human error or an unsafe situation.

(ii)Planned Inappropriate Operations: Occasionally, the operational tempo or schedule is planned such that individuals are put at unacceptable risk, crew rest is jeopardized, and ultimately performance is adversely affected. Such Planned Inappropriate Operations, though arguably inevitable during emergency situations, are not acceptable during normal operations. Included in this category are issues of crew pairing and improper manning.

For example, it is not surprising to anyone that problems can arise when two individuals with marginal skills are paired together. During a period of downsizing and/ or increased levels of operational committment, it is often more difficult to manage crews. However, pairing weak or inexperienced operators together on the most difficult missions may not be prudent.

Planned Inappropriate Operation is a factor in a mishap when supervision fails to adequately assess the hazards associated with an operation and allows for unnecessary risk. It is also a factor when supervision allows non-proficient or inexperienced personnel to attempt missions beyond their capability or when crew or flight makeup is inappropriate for the task or mission.

(iii)Failure to Correct a Known Problem: Failure to Correct a Known Problem refers to those instances when deficiencies among individuals, equipment, training or other related safety areas are "known" to the supervisor, yet are allowed to continue uncorrected.

For example, the failure to consistently correct or discipline inappropriate behavior certainly fosters an unsafe atmosphere and poor command climate. Failure to Correct Known Problem is a factor in a mishap when supervision fails to correct known deficiencies in documents, processes or procedures, or fails to correct inappropriate or unsafe actions of individuals, and this lack of supervisory action creates an unsafe situation.

(iv)Supervisory Violations: Supervisory Violations, on the other hand, are reserved for those instances when supervisors willfully disregard existing rules and regulations. For instance, permitting an individual to operate an aircraft without current qualifications is a flagrant violation that invariably sets the stage for the tragic sequence of events that predictably follow.

Supervisory Violations is a factor in a mishap when supervision, while managing organizational assets, willfully disregards instructions, guidance, rules, or operating instructions and this lack of supervisory responsibility creates an unsafe situation.

 

 
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