This document discusses the relationship between quality and safety, using the aviation industry as an example. It defines quality as meeting requirements, and safety as controlling recognized hazards to achieve an acceptable level of risk. Two aviation accident case studies show how lapses in quality procedures led to safety hazards and accidents. The document argues that quality and safety are interlinked, with safety serving as an indicator of an organization's quality system. An effective quality system uses a plan-do-check-act cycle to ensure requirements are met, while safety systems aim to identify and minimize risks. The conclusion is that high quality and high safety standards are mutually dependent.

1. QUALITY MANAGEMENT SYSTEM COURSEWORK
CITY UNIVERSITY LONDON
Table of Contents
1 Introduction........................................................................................................................................... 2
2 Aviation ................................................................................................................................................. 2
3 Definition ............................................................................................................................................... 2
3.1 Quality ........................................................................................................................................... 2
3.2 Safety ............................................................................................................................................. 3
4 Relationship ........................................................................................................................................... 4
5 Case Studies........................................................................................................................................... 5
5.1 Case Study 1 BA5390 ..................................................................................................................... 5
5.1.1 Background............................................................................................................................ 5
5.1.2 Analysis .................................................................................................................................. 5
5.2 Case Study 2 CAL 1611 .................................................................................................................. 5
5.2.1 Background............................................................................................................................ 5
5.2.2 Analysis .................................................................................................................................. 6
5.3 Summary of Analysis ..................................................................................................................... 6
6 Systems.................................................................................................................................................. 7
7 Conclusion ............................................................................................................................................. 7
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Quality and Safety are 2 sides of the
same coin.
1 Introduction
This report is presented towards analyzing the statement “Quality and Safety are 2 sides of the same
coin”. For the analysis, this report focuses on the Aviation Industry in which quality and safety share a
complex relationship. The report also analyses 2 case studies of accidents in the aviation history in
retrospect to differentiate the Quality and Safety objectives in the processes employed within the
aviation industry. The report also briefly introduces the 2 Systems Quality System and Safety System
that have been introduced in the aviation industry.
2 Aviation
Aviation is a strongly regulated industry and among one of the industries where Quality and Safety are
complexly interrelated. The regulators of aviation have a single prime focus of achieving safe
transportation of passengers. With this focus regulators across the world have developed various
mandatory requirements that an Airline has to meet in order to operate. To ensure safe operations of
Airlines the regulators under OPS 1.035 defined the requirement of a Quality System. It should be noted
that QMS (Quality Management System) must be implemented achieve Safe Operational Practices i.e. to
achieve the Safety requirements for Aviation Transport.
3 Definition
3.1 Quality
ISO 9000 defines Quality as “Degree to which a set of inherent characteristics fulfils requirements”1.
With reference to the Airline Industry taken as an example in this report, the requirements mentioned in
the above definition can be divided as
1) Customer’s Requirements
a. The requirements of Customers in an Airline can be Fares, On-Time Performance (OTP),
Safety, Customer Service and Care, In Flight Food and Drinks, Seat Comfort and more.
These requirements can either be Stated, Implied or Obligatory. E.g.: On-Time
Performance with regards to ensuring the airline meets its departure time and arrival
time as printed in the ticket is a stated requirement, safety is an implied requirement
and In Flight Food and Drinks will be an Obligatory requirement for a full service airline.
1
http://www.praxiom.com/iso-definition.htm#Quality
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2) Regulatory Requirements
a. These requirements are very strongly stated by the regulators when issuing an Air
Operator Certificate (AOC) to an Airline as along with Continuing Airworthiness
Requirements stated by regulators that an Airline has to continuously comply with and
which is further overseen by an Audit (internal and regulatory).
3) Airline’s Requirements
a. These requirements are stated within the Airline’s manuals. These requirements are the
processes, procedures, accountabilities, responsibilities that are supposed to be
followed and acknowledge by its employee’s.
3.2 Safety
Oxford dictionary defines Safety as “the condition of being protected from or unlikely to cause danger,
risk or injury”2. Another definition which most aptly suits the Aviation industry can be found in
Wikipedia as “the control of recognized hazards to achieve an acceptable level of risk”3. Since Safety is
related towards the control of risk, it can be measured by determining the degree of risk an organization
is subjected to. The “risk” as mentioned in the above definition would differ from organization to
organization and in the presented report, the “risk” associated with an Airline can be as follows,
1) Operational
a. Risks associated with operational procedures.
2) Resources
a. Risks associated with inadequate resources.
3) Personnel
a. Risks associated with inadequate training of personnel, negligence of personnel while
performing work, risks related to human factor errors.
4) Airworthiness
a. Risks associated with improper procedures of maintaining airworthiness.
It is worthwhile to note that in practicality there can never be a Zero Risk organization; however the
level of control over the exposed risk is an indicator for Safety. It would be worthwhile to note that
ICAO Doc 9859 released a Safety Management Manual in 2006 revised in 2009 which superseded the
ICAO Doc 9422 Accident Prevention Manual.
2
http://oxforddictionaries.com/definition/safety?q=Safety
3
http://en.wikipedia.org/wiki/Safety
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4 Relationship
As defined above Quality is focused on meeting Requirements, and Safety becomes a key requirement
for an Airline. Safety is the level of existence of a Hazard, where Hazard is an output of procedure
deviations, human errors, inherent gaps, communication a other like factors.
and
Safety needs to be measured in order to identify the levels of risks; this can be achieved at selecting
various points in a procedure or at the end of a procedure. The measurement of risks will act as an
indication with regards to the procedure or product is in line with meeting the requirements.
he
Once the measurement is done, the findings of the measurements will serve as a feedback to the
organization to look at the procedures and processes and take necessary action to decrease the risks to
an acceptable level. In summary, safety measurement serves as an indicator control point and
feedback point to the organization towards the Quality of the processes and procedures within the
dback
organization.
The PDCA Cycle that forms the basic structural framework for an Organization’s system towards
monitoring and managing quality within the organization is presented below along with the position of
safety indicator in the Cycle.
• Plan – Procedures are set up
in accordance with the
Plan requirements
nts and
documented
• Do – Procedures are
performed in accordance
Act Do with the documented
procedures.
• Check Checks
–Checks are
performed to measure the
Check degree of conformance with
the requirements, Safety
Risks and Hazards are
Fig. 1 PDCA CYCLE identified here and
measured to identify if
acceptable.
• Act- Based on feedback from
Checks, procedures are
reviewed in order to
incorporate feedbacks
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5 Case Studies
5.1 Case Study 1 BA53904
5.1.1 Background
On 10th June 1990 during a scheduled flight BA 5390 from Birmingham to Malaga (Spain)
carrying 81 passengers, the aircraft suffered explosive decompression at 17,300 feet. The
commander of the flight had been partially sucked out of his windscreen. The copilot landed the
aircraft safely at Southampton Airport. There were no casualties in this accident.
The investigation of the accident highlighted that the shift manager who was responsible for
performing the maintenance on the aircraft had carried out replacement of the windshield had
erroneously used bolts having a smaller diameter as compared to the correct bolts that had to
be installed on the windscreen.
These bolts could not hold the windscreen at 17,300 feet due to differential pressure and
resulted in the windscreen breakage which caused the raid decompression.
5.1.2 Analysis
The accident of BA5390 is a classic example of Quality complacency in an organization leading to
a Quality Lapse which developed a Hazard and lack of hazard identification and measurement
from the airline and the manufacturer resulted in an accident. The procedures carried out by the
shift manager were not as per the requirements of the Procedures recommended by the
Manufactures and documented by the Airline. This non conformity to the procedure (Lapse of
Quality) leads to the Hazard of windshield failure. It can be argued that the accident could have
been avoided if a check would have been carried out after the completion of the windshield
replacement (Risk Measurement) or the manufacturer of the Aircraft would have included the
Windshield replacement process as a part of double inspection task (Risk Measurement).
5.2 Case Study 2 CAL 16115
5.2.1 Background
On 25th May 2002, China Airlines (CAL) Flight CI611 crashed into the Taiwan Strait due to midair
disintegration and causing death of all 225 occupants in the flight.
The investigation revealed various factors causing the crash which included an incorrect
permanent repair carried out by the Maintenance team on the aircraft on 23rd May 1980 due to
4
Aircraft Accident Report 1/92, Air Accidents Investigation Branch, Report on the Accident to BAC One-Eleven, G-
BJRT over Didcot, Oxfordshire on 10 June 1990 http://www.skybrary.aero/bookshelf/books/636.pdf
5
Aviation Occurrence Report Volume 1 ASC-AOR-05-02-001 In-Flight Breakup over the Taiwan Strait northeast of
Makung, Pengshu Island, China Airlines Flight CI611 Boeing 747-200, B-18255 May 25, 2002
http://www.asc.gov.tw/downfile/CI611_Report_English_VOL_1.pdf
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a tail strike on 7th Feb 1980. Another revelation was improper documentation and records which
resulted in loss of evidence during the investigation.
5.2.2 Analysis
The accident of China Airlines is an example of continuous Quality lapses and safety lapses at
various stages over 20 years that increased the level of risk and resulted in a crash with loss of
life. The maintenance work carried out by the Engineers on 23rd May 1980 was not in
accordance with the Boeing SRM (Structural Repair Manual) and furthermore the incorrect
repair was not noted or highlighted during various quality audits and inspections carried out by
the Airline and the Regulatory Authorities did not reveal any non conformance of procedures
followed by China Airlines. The visible marks on the area repaired were visible by naked eye
indicating a pressure leak through a crack, however no action was taken to correct the same.
The incorrect procedure (lapse of quality) of performing the repair resulted in development of a
Hazard which resulted in an Accident occurrence (safety lapse). It can again be argued that if the
Repairs would have been carried out as per the documented RSM (Quality) it would have
eliminated the Hazards. In addition to this if Safety inspections were able to identify the Hazards
while performing Aircraft Inspections before release to service it would have resulted in
lowering the probability of the accident occurrence.
5.3 Summary of Analysis
The summary from the Analysis in context of this report can be depicted in Fig 2 and Fig 3 Below. A
Quality Lapse in the organization led to a Safety implication and at the same time, the safety
implications were not measured or observed in order to provide a feedback to the organization to
mitigate the quality lapse.
Fig. 2 as below shows how a procedure deviation developed a hazard which resulted in an
accident.
Procedure Hazard Accident
deviation development occurance
Fig.2 Accident Occurrence
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Fig. 3 shows below how Quality System using Safety as an indicator would have affected the Accident
occurrence.
Feedback of Hazard
Rectify deviation development
Quality Check Safety Check
Reduced
Mitigate
Procedure Accident
Hazard
deviation occurence
development
probability
Fig.3 Quality System involvement
6 Systems
Quality system aims at meeting the requirements both intrinsic and extrinsic. An organization trying to
achieve Quality needs to ensure that all its processes and procedures are Planned, Executed, Checked
and Corrected. This can also be referred to PDCA Cycle PLAN, DO, CHECK and ACT. A system of Quality
aims at ensuring at the very start of a process that the process will meet the various requirements.
Safety system aims at identifying the risks and hazards and minimizing the risk to an acceptable level for
the organization. Safety serves as an indicator for an organization to review its procedures, processes
and its Quality system to find the root cause of the hazard buildup and to mitigate the hazards.
7 Conclusion
From the presented report it would be appropriate to conclude that Quality and Safety have distant yet
interlinked objectives. Safety is a benchmark indicator towards Quality of an Airline and to a large extent
for an airline. Regulators across the world have focused Safety as the sole primary objective that needs
to be fulfilled and maintained by having Quality and Safety Systems in an organization. Quality cannot
be achieved without having High Safety Standards and vice versa, High Safety Standards cannot be
achieved without having Quality within the operations and processes. Thus it would be apt to say that
“Quality and Safety are 2 sides of the same coin”.
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