Escalation is widely recognized as essential to safety. Yet many safety events reveal the same pattern: escalation happened too late—or not at all. The common assumption is that someone chose not to escalate. More often, the reality is simpler and more concerning: the individual didn’t recognize they were at a decision point that required escalation.
Most safety events in MRO environments don’t begin with a lack of technical skill. They don’t happen because people don’t care. And they rarely occur because procedures didn’t exist. They begin at decision points—moments when conditions change, uncertainty appears, or assumptions quietly replace verification.
Most Part 145 organizations are highly compliant.
Audits are passed. SMS programs are in place. Procedures are documented.
And yet, safety events still occur.
This creates a quiet frustration among leaders: If compliance didn’t fail, what
did?
