Anniversary

 Anniversary

By Catalina9

This month is nine years ago since I wrote the first post, and 235 posts later there is no end of writing Safety Management System (SMS) stories. An SMS is a tremendous system, and asset to an enterprise, when applied as an oversight tool but can also its worst enemy when applied as a compliance tool. A high compliance score is often associated with safety in operations and if decisions are solely based on a compliance score, there is a risk to overlook, or assume, the inherent risks in aviation. An inherent risk is also a common cause variation. On the other hand, when SMS is applied as an oversight tool, it is applied to the outcome or results with an analysis of occurrences, or special cause variation. A line in one of the first posts is still true, that one grassroot method to evaluate the effectiveness of an SMS is to learn how many hazard reports an AE has submitted. In an enterprise where the AE is actively submitting hazard reports, there is a hope that other personnel also voluntarily submit reports. In an enterprise where the AE does not submit hazard reports, their organizational culture may come to reflect that behavior. This very first post is an interesting post about aviation safety and the “trial-and-error” method. 

Hazard comprehension has evolved over the years.

In prior years of aviation, hazard identification was short-sighted. If the hazard was not an immediate threat, the hazard was not of any concerns. In a later post, an aircraft was departing from a grass-strip and the general public with a breathtaking close view. An on-the-fly risk assessment at that time was that as long as the propeller is pointing away from me, I am safe. The physics of a departing taildragger was excluded from the risk assessment, since the public did not know about hazards involved.  When humans adapt to hazards, we establish subjective standards in hazard mitigation. Airports, airlines, pilots, mechanics, or aviation leaders also have the ability to adapt to hazards.  When human adapt, subjective standards are applied to hazard management, which is a scenario for hazard escalation. This is also true in an SMS world today, that without leadership, subjective, or opinion-based standards are applied to hazard mitigation. An example of an opinion-based hazard is that the Titanic was an unsinkable ship. In 1911, Shipbuilder magazine published an article on the White Star Line’s sister ships Titanic and Olympic. The article described the construction of the ship and concluded that Titanic was practically unsinkable. 

SMS is to know the next move to achieve desired result

One of the most difficult decisions for a brand-new SMS enterprise is how to manage interpersonal conflicts, or the reporting of another person for making mistakes. Everyone wants to be safe, and “arguing with safety” is considered to be an unacceptable behavior. When a person states that something is unsafe, or that an action must be initiated for the safety of a person, an aircraft, or the public, they have the upper hand, and many will agree to avoid being viewed as being against safety. In a previous posts, it was written about being SMS’d. When someone is SMS’d the person submitting the report expect that the other person will be blamed for any occurrences related to the issue. When using a hazard report to get someone SMS’d, it becomes just as ineffective as an attempt to eliminate all hazards. It’s not the correct tool, it does not improve aviation safety and the desired result is not reached. Even if a fully competent person is included in the equation, the outcome does not improve safety. A process may work great and all the pieces in the puzzle fits, but the design inputs are incorrect when placing blame one a person. An effective SMS root cause analysis consider at least human factors, organizational factors, supervision factors and environmental factors. When an SMS enterprise consider these factors against one single person who has been SMS’d, the outcome still reflects their organizational safety culture. One of the greatest hazards within an SMS is to assume that a person reporting an issue as a safety issue is correct.   

One of the few accidents where a speculative, or subjective cause still exists.

A prior post was about training and how training has evolved. Training is the foundation of a successful SMS. In the pre-SMS days, it was expected a pilot would know everything there was to know. If there was a question, the answer was that you should know since you have a license. Back then training was only a function of a regulatory requirement and was also viewed as waste of time. It's a misconception that training only has one function of learning, and that this function is to become qualified. Human culture associates training with learning, where learning begins in preschool, graduates to kindergarten, then elementary, and finally to high school. Each step is required as a level of learning to qualify for the next level. These are building blocks of learning moving from unknown to known. It's to instill knowledge in someone who didn't have that knowledge. Training has several other functions and cannot only be associated with learning, or lack of knowledge. Functions of training are associated with human performance, which again have multiple subsections. Some of these subsections are human behavior, organizational performance, human factors, medical performance, aviation performance, optimal operational design, interaction modeling and more. In an SMS world, the concept of training has evolved to a high level of importance and are components of both regulatory compliance and safety in operations. 

 

There are several interesting posts in this blog. Most of the posts are about the Safety Management System, and how aviation safety evolved into SMS. Several posts were used as reference when building one of the most successful SMS manuals. Several times a post would also ask a relevant and everlasting question: “Why does the Global Aviation Industry, being Airlines or Airports, need a Safety Management System (SMS) today, when they were safe yesterday without an SMS?” Take a minute and review the posts to learn how SMS has evolved within your enterprise. 

 

 

 

Catalina9