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Assessing Organizational Safety Programs - Case Study on NASA

A Safety Management System (SMS), as defined by the Federal Aviation Administration (FAA), is the organization's approach to risk management and implementation of risk controls, and has four basic components: Safety policy, safety risk management, safety assurance, and safety promotion. Continually assessing organizational safety programs is vital to ensuring their efficacy and making improvements using lessons learned, and organization-wide feedback on SMS effectiveness or blind spots. A review should also be conducted if the context, mission, or stakeholders of the business have changed (Federal Aviation Administration, 2020). An SMS serves to integrate safety risk management measures into business processes and day-to-day operations, thus systematically improving safety, and should be continuously improved with lessons learned and feedback, and reviewed when the operation changes significantly. The National Aeronautics and Space Administration (NASA) is best known for space expl...
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The Human Factors Dirty Dozen: Lack of Resources

Introduction The Dirty Dozen is a list of Human Factors that are believed to be contributory to the majority of human error incidents. In this post, I will discuss the "Lack of Resources", which stands out amongst the dirty dozen as the one factor that primarily points to a systemic issue, whereas the rest tend to indicate an individual issue. Definition of Lack of Resources The Lack of Resources to do a particular job could refer to inadequate tools, time, personnel support, or even procedures, that prevent personnel from performing the required task (Muir, 2024). This could lead to personnel not meeting the job requirements or taking shortcuts in the attempt to make things work, to the detriment of job quality or personal safety. Needless to say, this is an undesirable situation, but what can be done about it? Identifying Lack of Resources. Lack of Resources can be especially challenging to identify as a root cause of a safety incident, since the symptom of the problem may ...
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This week, we'll be discussing the recent Flightglobal article on a runway incursion by a Flexjet operated Bombardier private jet, which caused a Southwest 737 to go-around from short final (Hardee, 2025). To facilitate the discussion, there is a good YouTube video by VASAviation showing the sequence of events animated real-time on an overlay of the airfield diagram, and with the radio calls in the background (VASAviation, 2025), which will be linked in the resources below. Referencing time stamps of the video, we will discuss what went right and what went wrong during the incident, in chronological order to learn and apply the lessons in our own area of operations. Timeline 1:35 The first right move to break the accident chain of events was made by the Midway Ground controller. The crew of Flexjet 560 had read back a complex taxy clearance incorrectly, and the clearance was repeated by Midway Ground. The second time around, Flexjet 560 performed a correct readback of the clearance...
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