Friday, June 14, 2019

Why SMS Findings Are Not Real


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.

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