SMS Most Wanted

SMS Most Wanted

By OffRoadPilots 

A safety management system includes a list of the ten most wanted fugitive hazards and they are on the run. The most wanted hazards are identifiable hazards, but airports or airlines are unable to locate the whereabouts of their solutions. Hazards are locally different in the operational environment of airport or aircraft operation based on locations, destinations or flight conditions and require an operating environment specific safety risk management system applied.

Conventional wisdom is that hazard is a condition, when left unattended becomes a risk that foreseeable could cause harm to personnel or contribute to an incident or accident. The person managing a safety management system (SMS) has an obligation to identify hazards and carry out risk management analyses of those hazards. When the whereabout of hazards are unknown there are no requirements to carry out risk management. Make sense. The person managing the SMS is also responsible for implement a reporting system to ensure the timely collection of information related to hazards, incidents and accidents that may adversely affect safety. This responsibility does not include collection of all hazards, but only hazards that may adversely affect safety. If a condition is an actual hazard to aviation safety is either determined by emotions or data. When emotions are the determining factor, most activities relating to aviation are hazardous. When data is applied as the determining factor, only past occurrences are applied to hazard identification. Both these hazard identification systems come with one built-in flaw, which is that they are a accepted hazards because someone reported it, or because of past results. What is missing is the identification, or the whereabout of the hazard itself.

That an aircraft did not slide off a runway when landing on a 100% ice covered runway did not eliminate ice on runway as a hazard because it went unreported or the aircraft arrived without an occurrence, but it became one of the most wanted hazards within the decisionmaking process used by an airport operator and aircraft operator. When an airport operator is using a safety data system to monitor and analyze trends in hazards, incidents and accidents, the value of their trend analysis, or return on their investment, is shaped by their decisionmaking process.

The ten SMS most wanted hazards are identified within an SMS Enterprise’s

1. Decisionmaking process;

2. Hazard classification process;

3. Risk level process;

4. Root cause process;

5. Differences identification process;

6. Humanfactorsprocess;

7. Organizationalfactorsprocess;

8. Supervision factors process;

9. Environmentalfactorsprocess;and

10.System analysis.

A decisionmaking process is a learned process and highly customized to any specific tasks. A pilot may be responsible for the safety of a flight, but for large airlines the decisionmaking process rests with dispatch and management. A decisionmaking process to release an aircraft for departure is a learned process and must fall within approved parameters. Decisionmaking processes for airlines with operational dispatch may not necessarily be a decisionmaking process but are performed based on internal compliance processes to conform to regulatory requirements.

An on-demand and smaller air operator, operating aircraft under 12,500 lbs was using a similar method as their decisionmaking process. Since their routes were pre-established between the same airport and in the same sequence, they applied a standard time enroute and fuel consumption for each flight and applied the same fuel weight for VFR and IFR conditions based on the most critical condition of flight. Without a regulated dispatch, this process was unacceptable. When a decisionmaking process becomes a product of compliance, as opposed to safety limits and parameters, one of the ten most wanted hazards are disguised within the process itself.

The hazard classification process is a process to establish safety critical areas and unacceptable behaviors while performing airside tasks at an airport or operating an aircraft. A safety critical area is an area of airport or airline operations which for the purpose of safety or immediate threat to aviation or personnel should be fail- free. Conditions affecting safety critical areas and establishing unacceptable safety risk levels are unacceptable behaviors for continued operations. Hazard classification are the safety critical area and the safety critical function. A safety critical function is the activity or task performed within the safety critical area. An aircraft is taking off from a paved runway is a safety critical area. As the aircraft rotate and transitions into a 3D environment is a safety critical function of that area. Rotation becomes the function to focus on for both airlines and airport operators. Since both airlines and airports operates with declared distances and point of rotation becomes the critical point of action for airlines, and the clearway the critical point for airport operators.

The purpose of a differences identification process is to identify hazards locally. A process where one-fit-all process does not support a safety management system. An airlines may depart one airport within a set of hazards parameters, while these parameters may be invalid at their next departure point. Airport operators may assess a risk differently for each runway end with the same hazard classification. The most wanted hazard within differences are operational assumptions.

The risk level process is to analyse probability of occurrence (likelihood that a defined hazard will affect the outcome), severity (caused by the occurrence) and exposure of an identified hazard (level of exposure while performing a task). An aircraft is exposed to the same hazards through the entire flight, but one hazard may be more severe during a defined phase of flight. An engine failure may cause a more severe outcome if it happens on takeoff than if it happens in cruise flight. The most wanted hazard is hidden in the justification of likelihood that hazard will affect an operational task. When likelihood is the perfect number probability, but so complex to calculate that it is unrealistic to use it, the hazard lay within the likelihood itself. When calculating the likelihood of an occurrence with a statistically probability of 10-7-10-9 that it will occur includes an analysis of indefinite factors within the affected systems with a probability to activate a hazard. Such an analysis would include the probability that an engine attachment bolt would share off during takeoff due to incorrect installment process. Without justification documented by mathematical calculations the likelihood selection is invalid and a hazard in itself. It has been said that an aircraft is exposed to an engine failure at every takeoff. The hazard of an engine failure exists, but until the engine fails the flight crew is not exposed to an engine failure. The Titanic was not exposed to an iceberg until the iceberg approach its path. Airport operators are also affected by the hidden hazards within their risk level process. The most wanted hidden hazard in the airport operator’s risk level process is to apply the number of times things went wrong in their calculation as opposed to the reasons why things went right. When it is known why things go right, then drift and changes are based on a platform to be analysed.

The purpose of a root cause process is to establish an area, or factor, within operations to target corrective actions. Targeted corrective action plans are more successful in generating expected changes than randomly applied corrections to randomly selected areas. A root cause is allocated to human factors, organizational factors, supervision factors, or environmental factors. 

The first step in a root cause analysis is to determine if it is withing scope, control and authority of the SMS enterprise. The litmus test is if the Accountable Executive can freely apply human and financial resources to implement a corrective action plan. An AE at an airport has this authority to apply human and financial resources to airside operations, but does not have this same authority over a construction contractor doing work at the airport. An airline may use towing vendors to move their aircraft, but it is not within the airline’s scope and control to determine the root cause within the towing contractor’s operations system. Two commonly used root cause analysis processes are the 5-WHY process and the fish-bone process. The 5-WHY process is most effective if analyzed within a 5x5 matrix.

When there is only one path to the answer in the 5-WHY process, the first question determines the root cause outcome if the WHY is asked five times, or 100 times. Within a 5x5 matrix there are five first-questions asked, and each question is different. When applying the fish- bone process, there are unlimited brain-storming opportunities. When a root cause is applied outside scope and control, limited reasonable questions are answered, and unless opportunities for a hazard to be activated are exhausted, the most wanted hazard in a root cause analysis is on the run within overcontrolled processes.

The most wanted hazards within Human Factors, Organizational Factors, Supervision Factors, and Environmental Factors are found within the answers to the WHAT-WHEN-WHRE-WHY-WHO (position) and HOW questions.

HUMAN FACTORS are human reaction triggered by eyesight, hearing, taste, touch, or smell. It is human behavior, personal attitude with respect to situation, person or thing, values, beliefs or a just culture environment. Human factors are character and emotions, and other factors affecting the decision-making process and output.

ORGANIZATIONAL FACTORS is the organizational environment a person works within and as it relates to interactions defined in the SHELL model.

SUPERVISION FACTORS are direct supervision, remote supervision, or self- supervision. General types of supervision and leaders are structural, participative, servant-leader, freedom-thinking, and transformational leader.

ENVIRONMENTAL FACTORS are operational environment, topographical environment, climate environment, geo-environment, level of just-culture environment, or workstation environment.

WHAT
HUMAN FACTORS - Human behavior, performance, and reaction to event ORGANIZATIONAL FACTORS - A framework to outline authority, accountability, roles, responsibilities, and communication processes.
SUPERVISION FACTORS - Function of leading, coordinating, and directing the work of others to accomplish the objective.
ENVIRONMENTAL FACTORS - Design and performance environment of design applicability for job performance and encouraging engagement or disengagement in task-result oriented activities.

WHEN
HUMAN FACTORS - Aviation safety process and decision making. ORGANIZATIONAL FACTORS - Design of process and application of process in the operational environment.
SUPERVISION FACTORS - Daily, within the regular working hours of personnel, with result-oriented applications.
ENVIRONMENTAL FACTORS - Daily, within working hours in Operations, Maintenance, Flight Following or as assigned location.

WHERE
HUMAN FACTORS - Operations and within operational management personnel. ORGANIZATIONAL FACTORS - Management policies and operational processes. SUPERVISION FACTORS - Organizational management in a hierarchy of organizational.
ENVIRONMENTAL FACTORS - Operations, Maintenance, Flight Following or as assigned.

WHY
HUMAN FACTORS - Human factors knowledge is used to optimize the fit between people and the system in which they work to improve safety and performance. ORGANIZATIONAL FACTORS - Establish an organizational culture for operational processes and expectations for level of safety in operations.
SUPERVISION FACTORS - Establishing authority, accountability, roles, and decision authority within the operational processes.
ENVIRONMENTAL FACTORS - Establishing and maintaining an environment where personnel have access to design tools and encouragement of performance engagement.

WHO [position]
HUMAN FACTORS - Anyone with operational or SMS roles and responsibilities in operations, maintenance or flight following or other personnel when designing operational processes.
ORGANIZATIONAL FACTORS - Established, maintained, communicated, and assessed by all Directors and managers reporting to the Safety Management System are responsible for activities on behalf of the Accountable Executive. SUPERVISION FACTORS - The Accountable Executive is responsible for operations and activities on behalf of the certificate holder. All Directors and managers reporting to the Safety Management System are responsible for activities on behalf of the Accountable Executive.
ENVIRONMENTAL FACTORS - Applicable to all personnel, where the Accountable Executive leads with a Safety Policy and objectives and goals safe operation.

HOW
HUMAN FACTORS - Application of processes and tasks for both reactive management and proactive management.
ORGANIZATIONAL FACTORS - The delivery of structured processes within the organization.
SUPERVISION FACTORS - Processes within the basic types of supervision. General types of supervision and leader are: Structural, Participative, Servant-Leader, Freedom-Thinking and Transformational Leader.

ENVIRONMENTAL FACTORS - Safety operational systems designed for timely delivery within the SHELL model, designed to achieve user friendliness, and for personnel to stay informed during process application.

A System Analysis is a comprehensive analysis of systems, their sub- subsystems, departments and divisions and on- demand processes. System analysis processes are processes to identify hazards within the context of the system analysis. A system analysis is applied to analyses when considering implementation of new systems, revision of existing systems, or design and development of operational procedures, or identification of hazards, ineffective risk controls through the safety assurance processes, or change management. In addition to a system analysis is of the entire safety management system, a system analysis includes operations or activities authorized under the certificate, and analysis of vendor’s who are performing tasks affecting how the aviation industry perceive the certificate holder and accountable executive performance. A system analysis is applicable to vendors and third-party contractors limited to their tasks of operations. In the unlikely event of an incident, a vendor or third-party contractor may conduct their internal root cause analysis and submit to the airline or airport operator. The inclusion of a system analysis of vendors and third-party contractors operational process does not affect the scope, control and authority of an airline or airport root cause analysis.

The most wanted hazard within a system analysis are hazards beyond scope, control and authority of a certificate holder and their accountable executive.

OffRoadPilots

Elevated Runway Edge Lights By Inversion

 Elevated Runway Edge Lights By Inversion

By OffRoadPilots

When operating in the arctic, subarctic, mountainous areas, or sparsely settled areas, airlines and airports needs a safety management system (SMS) that includes optical illusion by inversion, optical illusion by sun angle, and optical illusion known as the black-hole effect. An optical illusion is real and the same as a mirage. A mirage is a real optical phenomenon that can be captured on camera since light rays are actually refracted form the false image. A mirage occurs when there is a temperature inversion. An inversion is when air at higher altitudes is warmer than the air below. When the air below the line of sight is colder than the air above it and when passing through the temperature inversion, the light rays are bent down, and so the image appears above the true object. Mirages tend to be stable, as cold air has no tendency to move up and warm air has no tendency to move down. Mirages make objects below the horizon, or outside of a normal line of sight, visible at the horizon. A sun angle optical illusion is when color of rocks in mountain combined with sun angle make a large mountain range impossible to see.

The black hole illusion is a nighttime illusion that occurring when only the runway is visible to pilots without surrounding ground lights. With this illusion there is a tendency, or a trap, for pilots to estimate an incorrect required descent angle and causing the approach to be lower than required for the runway. Another illusion caused by the black hole conditions on dark nights with no moon or starlight, or without a visible horizon, triggers pilots to believe that are on approach slope since they have a steady view of the runway in their windshield, causing them to fly a longer and shallower approaches than needed to clear obstacles. Unless a pilot has up to date knowledge and is intimately familiar with

the airfield, thorough pre- approach study and preparation is required to mitigate the black hole hazard. Today, there are online tools and maps available for pilots to become familiar with approaches and departures at most aerodromes and certified airports.

The same black hole illusion occurs during takeoff when the acceleration g-force is applied to the pilot and their cllimbout angle appears as a steeper than normal. On a dark night, without moonlight or starlight, and without a view of the horizon due to the black hole illusion, a tendency is to reduce aircraft pitch and departure angle may be lower than required to clear obstacles or could even be a negative angle. A contributing factor to a King Air accident in 2007 after a missed approach was caused by the illusion of a climb, when the aircraft was descending.

It is a regulatory requirement for an airport operator to identify in their airport emergency plan potential emergencies within a critical rescue and fire-fighting access area that extends 1000 m beyond the ends of a runway and 150 m at 90° outwards from the centreline of the runway, including any part of that area outside the airport boundaries. It is also a regulatory requirement for an airport operator to identify emergencies that can reasonably be expected to occur at the airport or in its vicinity and that could be a threat to the safety of persons or to the operation of the airport. Optical illusions are real and therefore reasonable to be expected to occur for arrivals and departures. The question to answer is how far away from the airport, beyond the 1000 m distance and 150 m from centerline mark an airport operator assess to be reasonable to initiate an emergency response. In 2017 an aircraft crashed and came to a rest beyond a point 150 m from the extended centerline. Since the airport was operating with a safety management system it was reasonable expect that they would initiate their emergency response plan at that time.

It is also reasonable to expect that airports identify their outer identification surface as their outer limits of primary responsibility and with a responsibility to assist upon request beyond that distance. In 2011 an airplane crashed about 3000 m from an airport and 280 m from the extended centerline, and the airport responded to the accident. In another accident in 2011 an aircraft crashed 1500 m from the centerline and the airport activated their response. A safety management system must be tailored specifically to each airport and that airport emergency plan definitions of distance in its vicinity will vary. Since the regulations are not broad enough to cover every detail of airline or airport operations, their SMS must include a practical application of their plan to address hazards and operational tasks. A rule of thumb for an effective SMS is if the regulations does not require it, this now becomes the very same reason why it is incumbent on airlines or airports to do it.

There are several non-certified aerodromes and remote airports operating without vertical or lateral guidance to their runways. At night, a lighted object, e.g. tower, may appear to be just a few miles ahead of an aircraft in cruise flight, while the actual distance could be 100 miles. When pilots are relying on visual clues as their vertical and lateral guidance, there are times when their aircraft has drifted away from an extended centerline or is low or high on approach. In 1993 a twin engine aircraft approach to an airport at night had the runway in sight at 1200 feet, with a flight visibility near minima. On final approach the crew descended blow a virtual glidepath and aircraft crashed in a hilly and snowy terrain located 5 km short of runway 26. Other examples are major carries approaching low on approach to international airports or lined up on the taxiway for landing. Optical illusions could happen at any airport, but there is a higher probability that an aircraft will be low, high, or drifted away from centerline on approach to airports without vertical and lateral guidance systems.

A guidance approach system installed an several airports is the Precision Approach Path Indicator (PAPI), which is a vertical guidance system for aircraft on final approach. Flying the glidepath of a PAPI keeps aircraft within the obstacle protected surface as long as the airport operator is applying their safety management system processes to monitor for unknown, or new obstacles. An optical illusion created by a PAPI system is when there is frost on the PAPI lenses, and their lights are deflected.

A rule of thumb when flying approaches without PAPI installed is to be 1000 feet above the runway at 3 NM and to maintain runway edge lights visible in a fixed view. The illusion without guidance is that an aircraft is too high when the actual altitude may be below the safe approach angle. In Canada, airports standards are only applicable to airports serving scheduled service for the transport of passengers. An aerodrome serving large airlines, with hundreds of passengers onboard, is not required to comply with the Canadian Aviation Regulations standards compliance. This is a flaw in the regulatory system when the method of how tickets are purchased determines monitoring of safety at destination or departure airports. If the same principle was to be applied to highway travel, speed limits would only be applicable to national bus carriers with paying passengers.

Requirements for a certified airport to install PAPI is that they conduct a risk assessment within their SMS to establish the need for a PAPI. One airport determined by their risk assessment that a PAPI was not to be required since there were no data supporting low, high, or off-centre approaches to their airport. When such data is not collected, risk analyses become simple, but do not paint a true picture of their operations. The absence of incidents is not an indication of a healthy safety management system, or a healthy operational environment. Most times things go right because human factors come with built-in resilience, or the ability to correct errors, or bounce back after an occurrence. An occurrence is not just that an aircraft crash, but also when an approach is flown below the slope of a standard approach path. When occurrences go unreported it makes it a simple to fill in the SMS compliance checkboxes, but optical illusions are occurrences to be reported.

On a dark October night an aircraft was on approach to an airport in the Arctic. That night it was a temperature inversion causing an illusion that runway edge lights were raised well above ground level. When runway lights were elevated, they could be seen from a farther distance and appear to be closer. This night the runway lights were raised by optical illusion to a heigh where they could be seen above a mountain range that normally would obscure the lights at this distance. Since the lights were visible, the position of the aircraft was determined to be inside the mountain range and safe of obstructions. However, within a few minutes the airplane crashed, since the viewed runway edge lights was an illusion, and they were still on the backside of the mountain.

In addition to natural made optical illusions, there is a man-made optical illusion that, at night, when an aircraft is parked on the runway in the same direction as an approaching aircraft, makes the park runway aircraft invisible.

Optical illusions are real. Only by knowing of their existence, learning about the nature of this phenomena, and verifying position by aircraft instruments can it be determined that they are illusions. When flying on visual clues illusions are real, aircraft may be invisible and runway edge lights may be elevated several feet above their actual ground level location.

OffRoadPilots