Changes involving an operator’s policy, procedure, manual, service bulletin, airworthiness directive, checklist, placard, etc., intended for safety improvement, could paradoxically result in an unintended, dormant hazard. It’s amazing how far-reaching even seemingly minor changes can be throughout an organization.
A later operating event might trigger a situation leading to a human or organizational error and an aircraft accident or serious incident. The root cause is “the devil in the detail” — a problem with planning, documentation, paperwork or implementation of the change.
Managers, the operator’s decision makers, may not possess the skill, intuition and discipline to fully think through the consequences of changes.
This is especially the case if they haven’t investigated accidents and incidents or are not naturally prone to think outside the box. Airlines and large operators usually have staff to handle changes. But the small operator’s chief pilot/owner h…
