SMS Patterns

 SMS Patterns

By OffRoadPilots

Unless patterns are implemented, regulatory compliance and safety in operations are achieved by random chance only and is not the result of a safety management system (SMS) and its processes.

The purpose of an SMS is to identify patterns and build these patterns. Patterns is what makes SMS unique. Incidents are trends in operational patterns, but their root causes may vary from event to event. The root causes of Cali air disaster on December 20, 1995, and Andes air disaster October 13, 1972, had different root causes, but both airliners flew a controlled flight into mountainous terrain. Often, but not always, a common denominator of a root cause is lack of situational awareness, or the flight crew failed to complete one task. Since both flight crews assumed they were tracking on their desired track, and on their way to their destinations, in their mind they had situational awareness.

When a root cause is determined to be the loss of situational awareness, solving the problem is a simple solution by storing situational awareness is a place where it cannot be lost. Situational awareness needs to be trained for to a point where a pilot knows which way is up, down, left or right. This can only be achieved by training, and when stored in a pilot’s mind, it cannot be lost. Just as a deep-sea diver needs to know which way is up, a pilot needs to know what lays ahead. A pilot needs to know their pattern by heart and use other tools to verify their actions. When flight 447 crashed on June 1, 2009, the flight crew attempted to leave a pattern without a tool to get out.

SMS patterns are the foundation of a safety management system. Trends and patterns are two distinct and different tools, each one tells their own important story of an SMS enterprise, and both are crucial tools for a successful SMS. A pattern has rules of which objects belong to the pattern and which objects do not belong to the pattern. Patterns are stable and reliable, and tasks have repetitiously been completed to their expected outcomes. Trends that are moving up, down, or sideways in number values, and when a value is above or below control limits, there is an unstable processes in the pattern.

Conventional wisdom is that a trend is when there are two of the same occurrences. When applying two occurrences as a trend, there could be a runway incursion one year, and another incursion three years later, which now makes runway incursion a trend for this operator. The four seasons, spring, summer, fall, and winter are patterns, but the air temperatures during seasons are trends. Aircraft automation are patterns, while operational functionality and reliability of automation are trends. When applying two events as the threshold for trends, overcontrolling of processes is the result. An overcontrolled process is unstable and cannot be stabilized by continued overcontrolling. Overcontrolling a process makes the result worst than a process in control containing errors. The only option is to ship the error or damaged goods and provide the same level service with that process. A process needs to be monitored adjusted for drift from assigned patterns, which is a different task than over-controlling and making process changes for a different output.

Constructing the base, or cornerstone, of a safety management system that is built on trends provides a weak support base for an SMS. That there are zero incidents does not imply that an SMS is effective. Trends, even stable processes, includes variables in its foundation and is unreliable for a system to be based on. A system needs to be built on patterns with a base constructed of repeatability, consistency, and accountability. Repeatability is its function for the same task to be repeated over and over again by any trained worker and producing the same outcome. Consistency is a system where ongoing tasks to performed at dependable intervals. Accountability is when repeatability and consistency are unaffected by common cause variations, or variations that are built into any systems for the system to function as intended, and for accountability to be applied as a long-term master planning tool.

Daily inspections and daily quality control are two patterns in airport operations, and they are building blocks for completing patterns. These patterns are laid out to paint a true picture of airport accountability and its expected outcome. Common cause variations do not affect accountability, since there is a built-in variables in the time it takes an airport operator complete their daily inspection. A daily inspection could vary between 20-30 minutes at a medium size airport. An inspection does not complete at 23 minutes every day. Another common cause variation is the time of day when an airport operator has completed their quality control task and communicate this to airside personnel. An airport’s daily quality control task may be completed between 4AM and 7AM but does not complete exactly at 4:35 AM every day. These variations are common cause variations built into processes, but are not flaws, or findings in patterns.

A supreme example of how critical patterns are to produce a desired result is cross-stitching. Cross-stitching patterns are designed and built before any operational tasks takes place. Cross-stitching comes with design patters which includes a final display of what an image or text will look like upon completion. Cross-stitching a wolf that comes in all different shades of grey is one of the most strenuous patterns to complete. A wolf pattern comes with explanations, directions, and process to follow to complete the pattern and by scaling down the process to one stitch at a time the pattern leads workers to a light at the end of the tunnel. A cross stich pattern may include thousands of stitches before the pattern is completed. The pattern is the foundation and is what a cross-stitching person has built their service and production upon. Their one goal is to complete the pattern. After a pattern is built, or the foundation for the cross-stitching output is finalized, that is when roles, responsibilities, expectations kick in, and tasks are assigned to individuals. As their work progresses and patterns are completed is the time to analyze a pattern for compliance with repeatability, consistency, and accountability.

An SMS enterprise lives by the same pattern concept as a cross-stitching person does. Airlines and airports have several patterns they need to complete at regular intervals, and it is not just one grey-wolf pattern. They have mountain-patterns, they have field-patterns, they have city-patterns, or anything else you can think of to be completed. When all patterns are designed and built, they can start building operational policies for each pattern. When policies are established, they can build processes, procedures, and acceptable work practices to move their design patterns out of the office and over to operations to be completed. When operations, at airlines or airports, have completed one pattern, that pattern is stored in records and a new pattern with the same image, or task, is to be produced over again by operations the next day. Just as a cross-stitching person hang their image on the wall, give it away as a gift or sell it, and then they do the same pattern over again with the same image. A pattern for an airplane to depart does not being at their taxi but begins several hours before departure for the flight crew to be rested and fit for flying.

One pattern often used by airport operators is to wait for the regulator to complete their inspection and assign them findings. When findings are identified, an airport operator develops and implement corrections, but then wait again for the next oversight inspection show up and issue more finings. This is a true story and true stories are good.

A regulator replied to an email that their responsibility is to inspect for regulatory compliance, and that they accepts that an active runway is compliant when it is 100% ice covered. Their email states about an icy runway that “there is no issue from a regulatory perspective...” The regulator accepts a pattern for an airport operator to operate with icy runways, as long as there is a pattern for the operator to publish a runway surface condition report when icy. What the regulator omitted was that the person managing the safety management system is required to identify hazards and carry out risk management analyses of those hazards. If an SMS manager recommend the hazard, and their accountable executive (AE) accepted the hazard, then an airport operator has been authorized to operate with an icy runway and must publish their NOTAM. However, it is not incumbent on airside workers, or an airport manger to accept that risk and publish a NOTAM without an SMS Manager’s recommendation and an AE’s acceptance of the hazard.

The regulator also omitted the regulatory requirement for an SMS manger to maintain a reporting system to ensure the timely collection of information related to hazards, incidents and accidents that may adversely affect safety. They omitted a regulatory requirement for an SMS manager to monitor the concerns of the civil aviation industry in respect of safety and their perceived effect on the certificate holder. After an intercontinental 8-hour flight an airline and its flight crew expect that their runway is

suitable for their operations, and that it is not covered with ice. Finally, the regulator also omitted in their reply that the required safety policy for an airport operator may commit to do what it takes for their airport environment and runway conditions to be compatible for the safe operations of an aircraft. SMS changed everything in airport and airline operations, but it didn’t change anything for the regulator.

With the implementation of the SMS, patterns became crucial for both regulatory compliance and safety in operations for airlines and airports, while trends are still the crucial component for regulatory compliance only. The regulator’s own guidance material states that “Runway conditions which may permit the safe take off and landing of one aircraft may not be suitable for another aircraft...,” and they left out that since the runway no longer is suitable for certain types of aircraft, an airport operator should change their Aircraft Group Number (AGN) to aircraft suitable for icy runway operation. This will put the level of service decision in the hands of the airport operator since it is ultimately their business decision. This certification level of service assists the flight crew to determine the suitability of the aerodrome for the intended operation.

A pattern established by the regulator is that they are only conducting oversight of regulatory compliance and not of safety in operations, which was always the case, and their role did not change with the implementation of the safety management system. What changed with the SMS, was that airlines and airport operators are now required to build their operational patterns for safety in operations and regulatory compliance.

Designing, building, and moving patters into operations is the foundation that a successful safety management system is built on. Patterns is the tool for operators to remain focused on tasks at hand, monitor and adjust drift, and to prevent overcontrolling of processes to adjust an outcome. Patterns is a tool established for repeatability, consistency, and accountability.

OffRoadPilots