Sunday, September 23, 2018

SMS Environmentally Friendly

SMS Environmentally Friendly
By CatalinaNJB

SMS is the new business model to ensure quality assurance of all processes within an enterprise. SMS is not restricted to safety process only, but also to financial processes, operational processes, regulatory compliance and environmental processes. Environmental processes are more than the environment itself and how excessive weather changes have directly and daily impact on operations. SMS is Quality Leadership of processes within an Enterprise’s environment system in the SHELL (Software – Hardware – Liveware – Liveware) operational model and how human factors are affecting job performance. Human factors is the single overarching factor determining success or failure of a business. SMS as a Quality Leadership tool is applied to continuous process improvements. When regulations are amended an effective SMS is applied to implement new processes and monitor, not only the effectiveness of the processes, but also the effectiveness, or ineffectiveness of the new regulations. SMS is a fabulous Quality Leadership tool.  
SMS is growing other directions than safety management.
One new proposed aeronautical regulation is a regulation working to achieve carbon neutral growth for international aviation from 2020 onwards. This is a t is a market-based measure requiring air operators, both commercial and private, to purchase eligible emission units on the open market to offset a portion of their emissions. Forecast advances in aircraft technology, operational improvements and a greater use of sustainable aviation fuels will not be enough to ensure carbon neutral growth from 2020 onwards. Since airlines fly internationally every day, having common international rules that ensure all airlines receive equal treatment is important.
A new proposed regulatory amendment with a requirement for airplane operators offering international flights with more than 10 000 tons of total annual carbon dioxide emissions is coming down the pike. Airplane operators will be required to develop and submit an Emissions Monitoring Plan to the Regulator in order to set out the operator’s specific approach to monitoring. 
Airplane operators will be required to monitor and record fuel use according to the eligible monitoring method chosen in their Emissions Monitoring Plan and approved by the Regulator, on an annual basis. Enterprises will also be required to develop and submit an Emissions Report for the previous year on an annual basis. Verification is a third requirement. Verification is also Quality Assurance. Operators will be required to engage an accredited third-party verification body for the verification of the annual Emissions Report. The verification body would ensure completeness and accuracy of information in the report. The operators will then be required to submit a copy of the Verification Report to the regulator and authorize the verification body to also submit copies of the Emissions Report and Verification Report to the regulator. A robust system is required to ensure compliance with these complex monitoring and reporting requirements and your existing SMS is in the toolbox already. 
Unlimited SMS opportunities are just raising above the horizon.
When the time comes, air operators must be compliant with the emission regulations. Four of the components of an SMS are the Safety Management Plan, Document Management, Safety Oversight and Training. These components may be called pillars and Safety Policy, Safety Risk Management, Safety Assurance and Safety Promotion. What the SMS is named is irrelevant. What is relevant is that with an effective SMS in place the air operators have in place effective tools to establish an emission policy, reporting oversight, safety risk management, quality assurance and training of all personnel involved. The regulation is applicable to airplane operators but is also a tool for airport operators to monitor and review their own airfield emission reports. Derived from these reports, airports may voluntarily propose airside operations policies in establishing a carbon dioxide emissions baseline for continuous improvements. 


Monday, August 27, 2018

SMS Takes the Pressure Off Your Busy Schedule

SMS Takes the Pressure Off Your Busy Schedule
Post by CatalinaNJB
After several years of SMS, the time is now for airlines and airports to embrace SMS and for SMS to be managed by experts in the field. There are many who will take on the title as SMS Manager, or Director of Safety, but there are few who are qualified. With a high demand for qualified personnel, it is busy task find someone with world class experience. 
SMS has become an extremely specialized field and there are only a handful of experts who comprehend SMS strategies and solutions of both the operational side and the regulatory side, in addition having the skills to implement a practical solution of regulatory processes. There was no one who had expected the SMS 10 – 15 years ago to take this path. Back then, SMS was sold as a data entry tool only where technical expertise knowledge no longer would be required. However, SMS is on a different level than any other QA Programs in that it must assess human factors, human performance and job performance as it relates to safety critical areas and safety critical functions. The quality and performance of a tangible product can easily be assessed, while the intangible forces applied to SMS requires other assessment tools. Some of these tools are comprehensive risk level assessment tool, a PDCA tool, a SHELL model assessment tool and SPC tools. In addition, a tailored SMS expectations references handbook is needed for the SMS processes to effectively comply with regulatory requirements and practical applications. 
As more and more airports and airlines are finding themselves wrapped up in regulatory findings, in addition to failing their own audits, this is the time to ensure a regulatory compliant SMS. Over a few years there are examples of the regulator placing operators under enhanced monitoring, taking certificate actions and issuing SMS findings that affects the bottom line. 
The beauty of SMS is in its reflections
Have you ever stopped for a minute and reflected over why the Global Aviation Industry, being Airlines or Airports, needs a Safety Management System (SMS) today, when they were safe yesterday without an SMS? Can you imagine if you knew 10 years ago, what you know now? What mistakes would you have avoided? What opportunities would you have capitalized on? 
An enterprise needs an SMS to take the pressure off their Accountable Executive busy schedule. In the old days of safety, all safety tasks were placed on one person to remember, to action and the implementation of CAPs. Most of these tasks became fire-fighter tasks to put the fires out whenever there was an incident or hazard reported. Very few enjoyed this responsibility and it also interrupted the businesses to an extensive degree. However, for decades this was the one and only acceptable approach and there were no changes in how safety was managed, except for changes in how to put the fires out.  The NextGen of aviation safety, SMS is the change that took place some years ago.
While they were not called Accountable Executives in the old days, they were the Directors, CEOs, CAOs, Presidents, Managers, or Business Owners who had accepted the responsivity to ensure the safe operations of their enterprise. After an incident or major accident, their busy schedules were interrupted by visits from the regulator for compliance inspections. As they had to explain these embarrassing incidents to both the regulator and the public, which in hindsight became even more of an embarrassment to the company, they wasted valuable time away from leading the enterprise forward in a positive light and safety in operations. While all this was happening, there were financial loses draining the cashflow and company equity. The enterprise had now become unstable and management had grave concerns about their future. 
Today, any enterprise required to implement SMS 10-12 years ago are still follow their old path and putting out fires more than changing the root causes. Some operators did not make the right decision at the fork in the road by embracing the Safety Management System. They continued safety in operations without applying their own SMS principles. If they had known back then what they know today, they would have avoided mistakes and created opportunities they could have capitalized on. They would have celebrated their wins, recognized people who have created results, generated a network of specialists and learned new strategies from one of the best in the world while operating an amazing enterprise.
When you find the purpose road you will embrace SMS.
The purpose of SMS, and why is it needed today, is to take the pressure off your busy schedule. SMS is in concept very simple, but more complex and specialized in operations than an enterprise’s computer network, flight crew scheduling, airport operations or their regulatory compliant accounting system. SMS has since the beginning been assigned to unqualified people, since there were very few qualified. Junior employees proudly took on the title as SMS Manager, but very few comprehended what it entailed. Today there are experts available to take on any SMS system and proudly move it forward in a way that literary takes the pressure off your busy schedule. A CEO, President or Director of any organization does not daily worry about their computer system or accounting system during normal operations. They receive reports, review facts and move forward in their busy schedule. SMS is no different than other support systems in an organization, except that it was often assigned to unqualified personnel who did not comprehend how to move it forward. 
By embracing SMS and assigning SMS to experts it becomes a businesslike approach to safety. When SMS is a businesslike approach, the Accountable Executive does not require a fire extinguisher for daily operations, since world class experts and specialists take care of SMS. This is not a fantasy world, but facts and the real world where world class experts keep an enterprise regulatory complaint and maintains safety in operations processes. Now, the pressure is off your busy schedule. 


Sunday, August 12, 2018

The Path of SMS

The Path of SMS

Post by CatalinaNJB

Vision yourself in a restaurant, with family, friends or someone special. It’s a wonderful atmosphere, theplace is spectacular, friendly personnel and everything is a million times better than expected. You arewaiting for the meal to be served when you hear the rattling noise of falling trash cans. The next thingyou know your meal is served on a bacteria infected lid of a trash can. Your meal is also served with anote stating that you must consume this meal to avoid a restaurant departure fee. You feel alone and trapped without a place to go.

This is how SMS was introduced to the aviation industry 10-12
First Impression of SMS.
years ago. It is a wonderful safety tool and the best thing thatever happened to safety, but it was served on top of the lid of atrash can. Nobody wanted to touch it or learn more about it. If that wasn’t enough, airlines and airports were trapped within their own four walls to accept regulatory designed expectations.There were no doors through the walls or a way out of the
expectation trap.

I was introduced to the Safety Management System (SMS) at a young age and before SMS became industry standard after I had witnessed a towing airplane and a glider crashed. The pilot of the glider airplane pulled the air-brakes at about 300 FT, the towing airplane stalled, and both crashed in the lake.This event triggered my understanding and comprehension of a safety management system where human factors, supervision factors, organizational factors and environmental factors systems are fundamental when conducting root cause analysis and corrective action plans for continuous system improvements. I studied SMS and became an expert in SMS by asking questions and learn from the best. 
I studied Transport Canada Staff Instruction, SI SUR-001 and found answers to 79 fundamental question of what an SMS is, where in the operational system an SMS fits in, when, as it relates to time and location, the SMS is applicable, who the SMS is applicable to, why it must be regulatory implemented to become effective, unless there is accountability and a commitment to a voluntary standard and how to apply SMS as a profit generating tool. I studies SMS until I could master SMS in the four circles of comprehension. 
I learned that collecting data is crucial to a successful SMS. Data is the first circle of comprehension, leading to the second circle of comprehension which is information, which creates an opportunity to derive a third circle of knowledge, after which the doors opens to the comprehension level of one autonomous system or interaction of several systems. These circles could become disproportionately imbalanced, in that there is either a lack of balance of inputs and outputs in one or more of the circles, or there is not enough space available within one circle itself to absorb the inflow of data, information or knowledge. When there is an overflow imbalance, SMS becomes overwhelming and unbearable.  
An effective SMS policy is based on a vision.
When SMS was first introduced it became an overflow of data and information to the point where it became unbearable.  At that time there were very few and no local experts or strategy solutions specialist available who comprehended the Safety Management System. The path moved forward without a vision of where it was going. Without a definite vision this lead to organizations continuing on an obscured trail leading to the end of a cliff. Travelling on this path did not and does not imply that an enterprise became unsafe in operations, but it implies that it was the simpler decision to make when they arrived at the fork in the road. The path chosen caused enterprises to revert to pre-SMS processes, disregarding defined regulatory expectations and moving in a direction of regulatory non-compliance. 
SMS is a fabulous tool. However, the missed opportunity when SMS was first introduced and in developing a profitable Safety Management System was for operators to define why the Global Aviation Industry, being Airlines or Airports, needs a Safety Management System (SMS) today, when they were safe yesterday without an SMS. 


Monday, July 30, 2018

Root Cause Analysis

Root Cause Analysis
Post by CatalinaNJB
When the root cause of an accident is determined to be that a pilot failed to act on something, whatever this failure might be, the root cause analysis becomes a simple task of making that statement. The root cause could be assigned by management or by the pilot and accepted by management in their root cause analysis. A pilot may state that: “I inadvertently failed to meet the pilot-in-command requirements for a tailwheel airplane…” or a statement of: “The failure of the pilot to maintain adequate clearance with the terrain during aerobatic maneuvering.” Other root cause human error failure could be that: “The pilot failed to maintain clearance with a fuel truck and failed to request a marshaller and wingwalkers”.  With any of these root cause statements accepted by management, the root cause analysis is completed, the file is closed and put on the shelf with comments of “no further action required. “Assigning root cause of failure not to perform a specific task, or two, is acceptable practice in the aviation industry from an airport, to the smallest air operator, a major carrier or a freight operator. 
The root cause of a nonconformance, a logistics interruption, an unplanned event or an undesirable event is the course of action selected at a decision point, or when arriving at the fork in the road within a system.
There is a lot of talk about an SMS system, but nobody explains what it is. The regulator gives system findings but does not identify the system that failed. Well, they might say that the SMS system failed to conform to regulatory requirements, but that doesn’t explain what system failed. Operators make corrective actions to fix the system that the regulatory had identified as failed, but do not identify what system they are correcting. SMS is at the verge of falling apart, since there were no tangible goals to aim for after the SMS itself had been implemented. The only goal was to implement SMS and no there are no goals anymore. SMS has become a circle of opportunities. As we all know, travelling the circle of opportunities only lead to the same place as we were before. The SMS is lacking visions, goals and root cause guidance that makes a difference.   
SMS fell out of the sky since there was no visions after implementation.
A root cause cannot be assigned to a task that was not performed. E.g. the pilot failed to follow procedures. If this is the true root cause, the conversation ends here. It is not possible to make improvements to the task itself when it wasn’t performed. A better way to state the root cause would be for an operator to state that the pilot acted willfully when omitting procedures during aircraft operations. 
Now we are cooking… at least there are events to work with for the root cause. This root cause must include that it was done willfully, or we are back to the first scenario that the pilot failed to follow procedures. Now that it has been established that the pilot acted willfully, there is an opportunity to change this willful behavior. Often, this is managed by firing of the pilot, or placing the person on unpaid leave for a day, week, or two. At least the operator feels that they are doing the right thing when punishing someone who willfully caused an incident. The only thing for the operator has left to do is to write a letter to the pilot’s file, or cause of firing, that the pilot acted willfully when causing the incident. The only barrier to this letter is that most operators reject the option to make it official. 
So, if an operator rejects to publicly and officially state that a pilot acted willfully, there is no possible way to address this root cause by blaming the pilot. In addition, the operator must then also assess other areas of operations for willful behavior that could have caused this system failure.  There are no reasons to include any of the standard phrases of willful misconduct, reckless behavior, criminal intent or illegal substance use, since none of these are job performance criteria and are not performed as a part of a Safety Management System.  Job performance criteria within an SMS system are safety critical areas and safety critical functions. 
Assigning wrong root causes over time chips away a perfect Safety Management System
The only time when a true root cause analysis can be conducted, and a real corrective action produced, is when an operator accepts accountability and the fact that an omission of something is not a root cause. With acceptance of accountability, an operator needs to exit their endless travel in the circle of opportunities and make real system changes. A root cause must be assigned to the system and not to a process, procedure, practice or expectation. The simple reason for this is that systems that are built with inherent flaws do not improve by making changes on any level below the system level itself. E.g. If the system doesn’t require a risk management analysis, there is no tools available for the operator to comprehend a latent hazard in the process. 
Let’s for a make up a virtual scenario where the finding was that a pilot failed to follow procedure and hit a fuel truck when taxiing. This is a small operator, operating out of a small airport and with a designated parking sport for loading and unloading freight. One day there is an event with 400 arrivals at this airport that normally has 50 or fewer movements per day. This event would last for one week.  For this to work out for these new airport guests, the airplane is moved to the back and behind the hangars for all business jets to be parked in a preferred location.  The pilot of the must taxi behind a hangar, make a 90 turn and then taxi between a hangar and the business jets. The pilot has 7 FT clearance to business jets. For several days the pilot taxied this route without any issues. Then, one day a fuel truck is parked next to the hangar and the clearance is reduced to 2 FT. The pilot observes the parked fuel truck coming around the corner, but the left wing strikes it. An immediate response from the pilot is that it was pilot’s fault, with the same response from the operator. Problem solved… or maybe not. 
A root cause analysis would show that there was a system failure of the logistics system, in that several parties missed their opportunity to exercise their accountability to safety and to conduct their own safety risk assessment of the changes. The airport, operator, freight customer and fuel operator all assumed this to be normal operations and that mitigation would not be required.  Highways do a safer job than aviation, in that they mitigate the changes with traffic cones, speed and other accountable actions. The aviation industry has missed their opportunities of being accountable to safety. These missed opportunities were contributing factors to the incident. 
This logistics system includes the air operator safety office, accepting the taxi route without mitigation, the airport authority which had an incomplete assessment of the taxi route form the new parking area to ensure that their customers had taxi clearance, the airport authority provided incomplete communication to flight crew of business jets that there is a frequent use taxi route in front of parked aircraft, the marshaller of business jets for parking had incomplete training in marshalling business jets where to park for taxi clearance, the fuel vendor provided incomplete training to fuel truck operator where to park for taxi clearance and the system of the freight operator missed an opportunity to mitigate the back-alley parking and standard departure times for non-standard operating conditions with a longer and complex taxi route.  
It was the system itself that failed by established expectations of normal operations without mitigation or elimination of hazards with an abnormal. A root cause cannot be that a pilot failed to perform. A root cause is tagged to the system level for the parties involved to discover the facts and effects of abnormal taxi operations and to mitigate or eliminate these facts. Somewhere there is someone who owns that root cause. When there is a comprehension of the true root cause an operator can exit their travel in the circle of opportunities and discover the benefits of SMS with continuous improvement of return on investment. In addition, a causal effect of temperature was overlooked with the temperature in the cockpit being 100°F, or 38°C. 


Wednesday, July 25, 2018



On July 19, A duck boat sightseeing vessel capsized and sunk on Table Rock Lake in Branson Missouri after a thunderstorm created turbulent waters and high winds. 17 people died. The duck boat industry is one of the few public transportation services that regulators do not require Safety Management Systems, SMS. If Ripley Entertainment, the company that owns the duck boat service, had SMS, this tragedy could have been avoided. Here is the evidence why: 
Duck boats in Branson Missouri 
SMS requires hazard identification, incident analysis and risk assessment. In this case here are the facts. 
Ignoring Risk Factor Data
A witness’s video of the Branson duck boat just before it capsized suggests that its flexible plastic windows might have been closed and could have trapped passengers as the hybrid boat-truck went down. It does not show passengers jumping clear. In 1999 the NTSB recommended that all Duck boat "...canopies be removed and mandatory use life vests for each passenger." NTSB went on to suggest that the canopies could entrap passengers if the boat sank. This was the major cause of deaths in the Branson tragedy. Duck boat companies chose not to take this risk factor seriously.

"There is always a trail of things going out-of-control before every accident." 

The Coast Guard prohibited the vessel from operating from January 2015 to April 2015, but the report does not state a reason other than "hazardous/unsafe condition." Another report from February 2015 cited leakage in a wheel well caused by sealant failure.

The owner of an inspection service in the St. Louis area said he issued a written report in August 2017 to the Branson duck boat operator, Ripley Entertainment, after inspecting two dozen boats. In the report, Steve Paul of Test Drive Technologies explained that the vessels' engines — and pumps that remove water from their hulls — might fail in inclement weather
Duck boats have a history of fatal and less serious accidents. It's often led to criticism about their design and use as tourist vehicles. For example, 13 people died after a duck boat sank on Lake Hamilton near Hot Springs, Arkansas in 1999.
The owner of the Branson Duck boat operation admits that the boat should have NOT been in the water. Andrew Duffy is an attorney whose firm represented victims of a deadly 2010 duck boat crash in Philadelphia. He and other lawyers with his firm have called duck boats "death traps" and called for them to be banned. They have specifically pointed to the canopies as problematic.
In 2015, five college students were killed and 69 others were injured in Seattle after a duck boat collided with a bus. Ride the Ducks International of Branson, which operated the Seattle boats, was fined $500,000.

In 2010, a barge plowed into a duck boat that had stalled in the Delaware River in Philadelphia.Two of the 37 people on board drowned. They were 16- and 20-year-old Hungarians visiting the United States through a church exchange program.

All these facts lead to Root Cause Analysis and subsequent Corrective Actions. Unfortunately the Corrective Action suggested by the NTSB were not implemented. 
Using the Deming “Interaction of Forces,” lets examine the facts.

The Machine....additional risk factors.....ignored. 

Duck boat design is inherently unsafe

Duck boats were designed for military use during WWII and never considered for private or commercial use. Here are some of the problems with Duck boats:

1. Tend to be top heavy which leads to easy capsizing. 

2. They take on water easily and require a fairly powerful bilge system.

3. Not designed to have ridged canopies or windows. 

In addition. In August 2017, mechanical inspector Steven Paul saw a glaring problem when he examined the duck boat.One of the most prominent things I found was the exhaust being in front of the vessel, which -- according to Department of Transportation standards -- would not pass regulation," he told CNN's "New Day" on Monday. "The exhaust has to come out past the passenger compartment.” When he saw footage of the boat sinking, Paul said "with the exhaust coming out the front and going down below the water line, the waves are obviously pushing water up in that exhaust." If water gets in the exhaust, he said, "the engine is eventually going to stop."

Methods...NOT following Procedures.

The amphibious vessel changed the route it took on Thursday, Missouri Attorney General Josh Hawley said Saturday. The boat capsized as a storm and high winds lashed the lake. Investigators want to know "when did the driver and (captain) of this vessel know about this storm forecast? When did they decide to alter the route of the boat?" he said. "Because they did alter the route of the boat. When did they decide that? Why?"

Environment ......Risk Factors ignored.

Severe storms were quickly approaching

The first storm warnings came the morning of the incident about 11:20 a.m., when the National Weather Service in Springfield issued a severe thunderstorm watch, which was scheduled to last until 9 p.m. A former president of the American Meteorological Society said the radar "clearly showed a very large complex of storms approaching the lake." Specifically, Branson straddles the line separating Stone and Taney counties.  A more serious alert, a severe thunderstorm warning, was issued for Stone County at 6:07 p.m., and was extended to including neighboring Taney County at 6:32 p.m., about the same time the duck boat is believed to have entered the water. That's also about the time the storm struck Table Rock Lake.

People and Methods…lack of Policy, Procedures and Training. 

Interviews with survivors indicate that there was mention of life jackets and where they were located. The decision to go ahead even though the wind had picked up to 45 miles an hour, indicated either a lack of policy or ignoring of policy. If the company had a proper safety risk profile, all the risk factors should have been mitigated. We will, of course, find out more as the investigation continues. 
Programs are created and put into place for a reason. SMS was implemented as a result of the Exxon Valdez accident. Unfortunately we are very good a reacting when a tragedy takes place. Hindsight is always 2020. In the world of Safety and Quality, we must study data. Not to merely record it but, to use it to develop and improve Safety and Quality. I am sure now, there will be changes in the regulation of this industry. We in the Aviation and other industries need to be reminded that what we do in SMS has life saving implications and we must never wane from our diligence in promoting and continuously improving it. 

Author: Mr. Dennis Taboada M.eng, CQE,CQM

Sunday, July 15, 2018

How To Build A Safety Policy

How To Build A Safety Policy
Post by CatalinaNJB

A Safety Policy in an effective Safety Management System is a forward-looking policy, the policy is organizational guidance maternal for operational policies and processes, a road map, a vision of an end-result with increased profit margin or higher return on investment and a plan to prepare each flight or operations at an airport to be completed without an incident. One of the questions a safety policy must answer is the reason for implementing a safety management system when an operator is operating safely without incidents, without a safety policy and without a Safety Management System. A safety policy is not about the operator’s commitment of safety, or what an organization is committed to in regards to the safety of operations, but rather how the organization is committed to make safety work. 
If the Safety Policy does not build the future, it doesn’t build anything
Building a safety policy needs a blueprint just like the construction of a building or building a road. Without a safety policy blueprint, or directions, the policy could become anything but a safety policy. A safety policy blueprint is to establish directions for the policy, directions for the accountable executive and all personnel. A blueprint is to avoid making the policy a safety-first priority policy, which could take the policy all over the map without directions as long as it was determined to be safe by someone’s opinion. If a safety policy states that safety must be first priority it must be accompanied by a safety risk level assessment of how safety always will be a priority. Safety cannot be a priority, since there will always be an inherited risk in aviation. When safety is an organizational priority operations becomes incidental to safety, or takes second place. In an organization where safety is priority there is no activity, since there are risks involved at the moment an aircraft is in motion or at the moment when an airport operator is on the field. If there is a risk present, safety is no longer the priority. However, when there are acceptable safety risks levels defined, then safety is paramount and safety can be achieved in operations. 
The first building block in a safety policy is to decide and commit to what the purpose of the policy is. A safety policy that is paramount is a policy with a purpose, it is a practical policy that personnel comprehend, it is a vision of the future and a vision of where the organization is headed, and a commitment to safety with zero tolerance to compromise safety. The base and first building block in a safety policy is to make safety paramount where there zero tolerance to compromise safety, or acceptable short-cuts. 
The second building block of a safety policy is to establish safety critical areas and safety critical functions. Without safety critical areas in the policy there are no criteria established to develop safety goals and objectives. Safety critical areas are your tools as an operator to establish measurable goals, and to develop steps of objectives to reach these goals. With step one and two completed, we know what direction we are headed and where we are going. 
The third building block of a safety policy is to get everyone onboard, or on the same page. It is a comprehensive task to get everyone onboard and to agree. That someone disagree with the SMS process does not imply that they are against safety. As a matter of fact, a Safety Management System that does not allow for personnel to disagree or question the system itself, has become a failed safety management system. Any safety opinion given, or process decisions made, must be backed up with documented data and facts. That there are individuals who disagree with is safety decisions an the SMS, is because the Director of Safety or Accountable Executive not been able to deliver, backed up, or communicate their safety improvements with reasons, facts or data. There will also be times in an organization where management is incorrect and personnel in the field have the better and safer solutions. 
Leadership in safety management is to guide with clear directions
Safety Management System requires leadership. This leadership is not only for safety improvements, but leadership when implementing policies that will be acceptable to all personnel. SMS is not a paperwork program to document safety records, but a live program, and a program in motion. SMS is a program where hazard, incident and accident reports are submitted for assessment, investigation and risk analysis to improve safety in operations. 
One option to establish a reason for personnel to buy the SMS is to include a confidential reporting system for all personnel. A confidential reporting system is not an anonymous reporting system, but a reporting system with limited access at the receiving end. This system is not to mislead operational management, but a system made available to address the issue as a safety issue rather than as an operational issue. In addition, operational management has agreed on, by the implementation of SMS, that none of these reports are available to use for punitive actions against a person. The question many asks is if this is a “get out of jail free” card, or where is the line in the sand drawn. 
It is oversimplified to state that there is no disciplinary action unless the act was illegal activity, negligence, willful misconduct. When the bar for disciplinary action is set at illegal activity, negligence, willful misconduct, any report submitted will be below that bar, or will not cross the line drawn in the sand. By implementing these activities in the safety policy, the policy itself becomes an obstruction to safety. Disciplinary actions may be the only option, even if the action was not illegal activity, negligence, willful misconduct. For a moment, let’s assume that an aircraft taxiing at a higher than normal taxi speed, and the flight crew is pre-occupied with after landing checks. During the taxi the aircraft strikes a taxiway edge lights, misses the turn in the taxiway, then taxi across the island of grass and enter the taxiway on the other side. When the reports comes in to safety department, the report states that the taxi was slow, flight crew was blinded by another aircraft and by the time they realized they were off the taxiway the aircraft was entering back onto the taxi way on the side. When reading this report, the operator has no way of knowing if this was either an illegal activity, negligence or willful misconduct. An operator may assume that it was, but it is not an illegal activity, negligence or willful misconduct unless the notice of suspension or termination states this specifically. There are very few operators that would make such bold statements in a termination report.  By raising the bar to this level, there is no room for safety improvements. In the virtual example above there is lots of room for disciplinary actions when the operator, during the investigation, discovers that the flight crew did not make true statements. 
On the other side, when the bar for unacceptable activities is set at the level of Safety Critical Areas and Safety Critical Functions, there are opportunities for safety improvements. Pilots may be offered refresher training, stress management training, operational policies review training or other training to improve skills and accept safety as being paramount. By defining safety critical areas, flight crews, maintenance crews and others know what these areas are and they may establish their own goals in their tasks of duties to improve safety. 
These are the three first steps, or building blocks of an effective Safety Policy. Without safety being paramount, there is no strategy for safety in operations. Without safety critical areas there are no defined goals for safety in operations. Without personnel accepting and participating in an organizational safety management system, there are no human resources available for safety in operations.  


Friday, July 13, 2018

So..Your SMS is not Continuously Improving.....Chill Out!

So..Your SMS is not Continuously Improving.....Chill Out!

The Greyhound is the fastest dog in the world, but they need to chill out too. 
After working with dozens of different enterprises, implementing Safety Management Systems, SMS, and Quality Assurance Programs,QAP, I have discovered several reasons why the SMS/QA stops working after a while. 

The following are some reasons you need to examine in your own company:

Loss of Interest in the Regularly Scheduled Safety Meetings:

When an SMS is first implemented, everyone is on board and enthusistic about the Process so the weekly safety meeting are well attended. Over time people begin to lose interest in the weekly safety meetings. Managers start falling back into their pre-sms modes. It is imperative that upper management stress the importance of the participation in the weekly meetings. These meetings are where we roll up our sleeves and really look at the reports and analyze root cause. The result of the weekly meetings should be corrective action plans that actually provide the action to continuous improvement.

The Deming Cycle for Continuous Improvement
Hazard/Incident reports as well as audits results drive the Risk assessment, Root Cause Analysis and Corrective Action Plans that are results of the weekly meeting. 

This is the engine of the SMS. See

Reduction of DATA Collection

There are some great SMS Software programs. I have experienced SMS Pro and Vortex and found these to be excellent programs. But, "Garbage in - Garbage out." In order to maintain "CONTROL" we need to consistently measure our processes to provide quality data. Yearly audits just don't cut it. 

A consistent audit verification program provides excellent data to enter into the SMS engine analysis system. The Hazard and Incident reporting system must be encouraged by middle and upper management. A good SMS Software program will keep track of the progress of each report, communicate to key people, and help the SMS manager to control the flow and completion process of each report. 

Poor Corrective Action Plan implementation

Once the Causal factors have been determined through a robust Root Cause Analysis, RCA, it is important that the corrective action be "realistic" and supported by upper management. Of all the impediments to a successful continuous improvement program, lack of follow-through on the corrective action plan is the highest.  All CAPs should be monitored and checked by the Quality Assurance department to make sure that what we said we would do is actually what we did.

Turn Over

According to the United States Small Business Administration,SBA, "..employee turn-over is the highest cost to a small business." Because of this reason, it is important that your enterprise have a "system" of control. All job functions throughout your company must be controlled through robust procedures. New employees need to be taught to depend on procedures to perform functions. Do things by the book. 

Dr. Joseph Juran, Founder of the famous Juran Institute 
Dr. Joseph Juran, " all processes should be so well documented that you could replace an entire department with new employees and you should be able to make the same product with the same quality..." The "system" approach assures that processes are not people dependent. 

In addition, new employees must hired and trained with the same or greater commitment to the SMS. It is the job of management to permeate the organization with a safety oriented culture.

Communication breaks down

Its so easy to fall back into old habits. Managers get absorbed into their day-to-day routines. Communication begins to slow down between the SMS teams and we begin to forget the importance of robust safety communications between departments. Management needs to continually emphasis to the workforce the importance of reporting incidents and hazards. 


Entropy defined, "lack of order or predictability; gradual decline into disorder." How do we fight entropy in our system?  The secret is constant renewal of Goals and Objective. As we gain control of an area or process, identified as high risk areas, we need to replace the goals and objectives with new ones that come from our Safety Risk Profile and Hazard Registry, ( see goals and objective from your Safety Risk Profile.) 

Another tool to fight entropy is training.  There should be constant and robust training offered throughout the organization. Training not only equips people to do a job, but it is also a very effective tool of communication. Many policies can be reinforced in the training courses. 

Entropy can be fought off through recognizing success stories within the organization. Remember we are collecting data through reports and audit results. Well, do we recognize areas that pass their audits. SMS and Quality Assurance is often looked at as a system that recognizes failure. We should applaud success as well. 

In my 30+ years implementing Quality and Safety Management Systems I can testify to the fact that if we remain diligent, we can achieve a true process of continous improvement. We have many success stories to back up this claim. It is up to management to recognize this and support it in order to make the organization successful. 

The SMS Memory Jogger II 
Dennis Taboada, M.eng.,CQE,CQM                                                                                                 CEO, President DTI Training Consortium Atlanta USA and DTI Training Canada Ltd. Richmond BC Canada

Suggested Reading: "The SMS Memory Jogger II." Available at Publisher GOAL/QPC , search SMS. Also,

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