Why SMS Findings Are Not
Real
How often have you asked yourself if
inspectors know what they are doing when issuing another finding that they
can’t explain. When you ask for the finding reason, they give an answer that
make you feel incompetent as an operator, but you are not. Whatever their
comments imply, you are the expert of your operations and the application of
SMS. That’s just the way it is. An operator works with Best Practices, which
the regulator does not have regulatory authority over.
When inspectors tell you that they are
there to help you, their help is to lower your self-esteem and operational
confidence. When an inspector asks the operator to voluntarily temporary give
up their certificate, they will hand it over without asking one single question
or object to the request. A certificate is not only your livelihood but also
several other families’ livelihood. When you give away your certificate you are
giving away your pride in what you and your team have built and accomplished.
They demand a temporary voluntarily surrender of your certificate since they
don’t have grounds to stand on to bring it forward to enforcement.
SMS
expectations are what triggers the issuance of findings. Not only process
findings, but also system findings. An expectation is nothing else but a stated
opinion. This is defined in their SMS guidance material. Safety is defined as
the condition to which risks are managed to an acceptable level; where
acceptable level from the regulator’s perspective is ongoing compliance with
regulatory requirements.
Think about that for a second how it makes
sense to apply an intent, or forward-looking opinion to issue a finding against
your systems. Without comprehending the system, the regulator is issuing
nothing else but forward-looking intent and opinion findings.
 |
| That the peppers penetrate the water surface doesn't make water a system failure |
When inspectors are issuing findings,
they are required to base their finding on the predicted likelihood and
severity of a hazard. Unless the inspector can document an unconditional
likelihood that a hazard will produce a severity beyond an acceptable severity
level, there is no regulatory finding. If the hazard did not cause, or produce
the predictable outcome, the inspector had issued an invalid finding.
There is no definition of safety in the
Regulations. Without an explicit and specific definition of what safety
actually is, it is impossible to issue one single regulatory safety finding.
Yea, you might be right that there is conventional wisdom out there that safety
is to be free from harm or destruction, but that does not make safety a part of
the regulations. This makes it an opinion only. An inspector cannot issue other
than regulatory non-conformance findings.
Over the years I have conducted several
surveys and in one survey the task was to identify one hazard when flying the
approach to Lukla, Nepal. This survey gave a very interesting and unexpected
result. The survey documented a range of hazards, from that there is no hazards
or safety issues with the approach to the extreme hazard, that this is the
world’s most dangerous approach. In the eyes of the beholder, safety ranges on
the widest possible scale from no safety issue, to the world’s most dangerous
safety issue. When an inspector makes a safety finding, they make it as seen in
the eyes of the beholder and not as a fact.
 |
| When the clock stops ticking it's not the system that failed, but observer's opinion |
When inspectors are issuing
findings, they are required to analyze all observations and issue system
findings. The purpose of the analysis is to determine if there are any findings
of regularly non-compliance and, if so, to develop an understanding of the
exact extent and nature of the findings. This understanding by the inspectors,
will allow the them to group non-compliances by expectation and regulatory
requirement and bring it forward to complete findings at the system level.
Take for example the SMS Safety Policy. There is an expectation
that an enterprise has a safety policy in place that is followed and
understood. In the regulations it states that a safety management system shall
include a safety policy on which the system is based. The effectiveness of this
Safety Policy is not the moving range of incidents or accidents an enterprise
experiences, but how a part of the Safety Policy becomes applicable to each
specific Corrective Action Plan for continuous safety improvements. A
Corrective Action Plan that is not referenced or linked to the Safety Policy is
not only an invalid CAP, but also a system finding that an SMS is not based on
the SMS Policy.
 |
| A system not understood until is is comprehended |
Inspectors may
inspect previous CAPs and their references to the Safety Policy to determine if
the SMS is based on the Safety Policy. However, inspectors are required to
predict the effect a hazard has on future operations and not what the operator
did in the past. The inspector cannot issue system findings, since there is
nobody who can predict the future. What they can do, and what they should do,
is to issue a process finding with an explanation to the operator, being
airline or airport, that unless they change their Safety Policy and continue
with the same processes, their SMS system is not based on their Safety Policy.
With this finding any operator has an opportunity to make changes for both
regulatory compliance and continuous safety improvements. With a system finding
issued, there is no room for continuous regulatory, or safety improvements.
Catalina9
