When SMS is Flawed
By OffRoadPilots
A safety management system (SMS) is a system which paints a true image of
airports and airline operators and does not fail, but when an SMS is abused, it
becomes a flawed system because it is painting a precise view of an SMS
enterprise. A flawed SMS is a misjustice to the SMS, since all what an SMS does is
to paint a picture of an SMS enterprise. A flawed SMS is a flawed SMS enterprise.
A simple tool to recognize a
flawed SMS is to analyze the
ratio of special cause
variations to daily quality
control processes. An SMS
with perfectly aligned
datapoints is a flawed SMS.
Every data point measured
show some degree of
variation, no matter how
much we try to control
variations. It is impossible to
attain identical results for
two each task of a process. Each result is different, even if the difference is microscopical. A microscopical variation is invisible or indistinguishable without the
use of a microscope, or detailed process analysis. Variation may be defined as a numerical value used to indicate sample variations. Variance is a measurement of how data, or acceptable practices are distributed about an expected value or the mean. If a variance of zero is attained indicates that results are identical which is an uncommon condition. Variations points show data points spread out from each other and the mean, and a smaller variation indicates that the data points are closer to the mean. Variations from the mean are positive values.
A flawed safety management system is founded in the design and development of
the foundation of the SMS. An SMS foundation must be strong enough to carry the
weight of the SMS structure, which is incidental to the SMS foundation. When
there are flaws in construction of the foundation, the structure itself will eventually
crumble and fall. Any attempt to repair, rebuild, or change the structure does not
improve the foundation on which it is built. SMS was railroaded in its infancy and
left on an abandoned spur. The current SMS is flawed and is not an SMS but a
parody of the intent of a safety management system, which makes it acceptable to
the aviation industry.
A news story just recently
reported an incident where
the safety management
system failed to prevent the
incident. Actually, and
correction, it was not the
SMS that failed, but the
parody of the SMS
implemented by the aviation
industry, both airlines and
airports. There is no
justification for this incident
to happen when operating
with an actual SMS. Flight 334 [airline reported as flight 345] was aborted after the
jet made contact with a CC-130H Hercules while taxiing for departure, resulting in
the damaged wingtip.
An incident at the Valley Airport on Wednesday involved an airliner and a military aircraft. The airport authority brushed it away as a minor incident.
A representative from the airline confirmed the incident, involving flight
345 with a comment that the aircraft made contact with a parked CC-130H
Hercules while taxiing out for departure.
A parody of a safety management system is unaccountable and needs incidents to
justify its existence. A true SMS does not need incidents since a true SMS analyze
daily quality control processes and why things go right as opposed to why things to
wrong. Without incidents there is no justification to operating with a system that
prevents incidents. This is an acceptable approach by the regulator, who in their
own words states that “SMS is based on the idea that you can always find better
ways to prevent hazards, so the system will always be changing.” In addition,
airports receive regulatory findings when they are unable to provide evidence of
incidents to populate their hazard register.
Conventional wisdom is that an SMS is an organized approach to managing safety.
It sets out the organization's structure, identifies the accountabilities and
responsibilities of all personnel and documents polices, processes, procedures, and
acceptable work practices to manage safety effectively. An effective SMS identifies
hazards that could affect airlines or airports, assess the hazards, and prioritize
safety critical hazards for mitigation measures to reduce the risk level to as low as
reasonably practicable (ALARP). Reasonably practicable involves weighing risks
against the trouble, time and money needed to control it. ALARP describes an
acceptable level of risk control.
Using "reasonably practicable" allows SMS enterprises to establish objectives and
goals holders, as opposed to prescriptive requirements. This flexibility is an
advantage, but it has its drawbacks. Deciding whether a risk is ALARP can be
challenging since it requires SMS enterprises to make commitments to processes
by exercising sound judgement. A tool for airline or airport operators to evade
accountability is to use industry acceptable practices when deciding acceptable risk
levels. Due to common cause variations, an acceptable risk level at one airport may
not be acceptable for another airport. An airport in the high Arctic may assess the
same risks differently than an airport in a metropolitan area, or an airport located
at 9,200 feet ASL may assess risks differently than the other two. There are
inherited risks in aviation, or common cause variations risks since a manmade
object is transitioning from a gravity-controlled environment on the ground into a
gravity management environment in the air which is manually controlled by Pitch,
Roll and Yaw.
When identifying contributing and root causes, airports and airlines are expected
to consider human factors, organizational factors, supervision factors, andenvironmental factors. It is vital that airports and airlines maintain the confidence
of the travelling public. Through the safety management system, they are
committing to provide a systemic, explicit, and comprehensive process for
managing safety risks. By embracing the safety management system, they are
accomplishing inclusion of safety as an integral part of their culture and
recognizing that safety is paramount. Safety cannot be a priority since there are
inherent risks in airline and airport operations. However, safety is a priority as it
relates to regulatory compliance in a static environment. A static environment is a
set of conditions such as regulations and standards, events, and surroundings that
don't change. In theory, once understood, a static environment doesn't offer new
or surprising elements. A static airline or airport environment is any system that is
intended to remain unchanged by users and administrators.
Human factors,
organizational factors and
supervision factors are
based on studies that
evaluates and comprehend
human interactions and
human behaviors in relation
to other human and
environmental within a
workplace system.
Conventional wisdom is that
human errors quals human
factors. Human error is a
sub-category of human factors. Human factors are how the five senses generate
reactive or proactive actions by vision, hearing, smell, taste, and touch. The sub- category human error is commonly applied as a failure to comply with a prescriptive requirement depending on the outcome by flight crew reactions.
When an outcome does not generate an incident, a pilot is praised for their action.
On the other hand, should the outcome generate an incident, the same action
taken by a pilot is assigned as pilot error and the pilot is terminated. When
Human factors is a resilient system.operating with a parody SMS, or an SMS without accountability and action is fully acceptable, since it was the pilot who caused the incident. When operating with a true SMS the outcome is incidental to operating processes.
The SHELL model is the foundation of human factors, organizational factors and
organizational factors interactions with airline and airport operations. There are
three sub-categories of environmental factors.
1. Designed environment as it relates to a user-friendly environment, design
and layout environment, accessibility environment, and tasks-flow
environment.
2. Social environment as it relates to distancing, experiences, culture, and
language.
3. Climate environment as it relates to geo location, weather, and
temperature.
Human factors, organizational factors and supervision factors interacts with
environmental factors in addition to interactions within each one of the factor. E.g.
pilots interacts with other personnel, management interacts with other managers,
and supervisors interact with other supervisors.
Vision affects human behavior to take reactive or proactive actions. Vision is an
observation of a condition or event, and a reactive behavior is a reaction to avoid,
investigate or approach. Vision generates a proactive behavior in anticipation of an
event. As an example, when driving on the highway and a wildlife approaches,
there is an anticipation of what direction of travel the wildlife may take and the
driver takes anticipated actions.
Hearing affects human behavior to take reactive or proactive actions. Hearing is an
interpretation of a condition or event, and a reactive behavior is a reaction to
avoid, investigate or approach. Hearing generates a proactive behavior in
anticipation of an event. As an example, when hearing a loud noise there is an
anticipation of what future event may happen based on the noise and person takes
anticipated actions.Smell affects human behavior to take reactive or proactive actions. Smell is an interpretation of a condition or event, and a reactive behavior is a reaction to
avoid, investigate or approach. Smell generates a proactive behavior in anticipation
of an event. As an example, when smelling a strong or unknown odor, such as
smote and anticipate a fire, there is an anticipation of what effect the underlying
cause is, and a person takes anticipated actions.
Taste affects human behavior to take reactive or proactive actions. Taste is an
interpretation of a condition or event, and a reactive behavior is a reaction to
avoid, investigate or approach. Taste generates a proactive behavior in anticipation
of an event. As an example, when the taste is pleasant there is an anticipation of a
pleasant future, and a person takes anticipated actions. Where the taste is
unpleasant, there is an anticipation of an undesirable future, such as when water
taste differently than normal. and a person takes anticipated actions.
Touch affects human behavior to take reactive or proactive actions. Touch is an
interpretation of a condition or event, and a reactive behavior is a reaction to
avoid, investigate or approach. Touch generates a proactive behavior in
anticipation of an event. As an example, when touching warm water, the
anticipation is that prolonged contact is safe, while touching boiling water, the
anticipation is that prolonged contact is unsafe, and a person takes anticipated
actions.
Airport and airline operators are required to operate an SMS for taking corrective
actions to prevent recurrence of hazards, incidents, and accidents. When
developing corrective action plans operators are expected to consider human
factors, organizational factors, supervision factors and environmental factors. In
addition to be linked to regulatory requirements, a corrective action plan is also
linked to the safety policy. If the foundation of an SMS excludes these factors, the
safety policy cannot be linked to the any corrective action plan. A true SMS links
these factors to the safety policy, which is linked to the certificate holder.The strength of a safety policy is highly dependent on the sub-grade it is built on.
When building a runway, the surface may be of concrete, but becomes unstable if
the sub-grade does not support the concrete. The surface of a runway built in the
sub-Arctic becomes flexible, and with special cause variations if the sub-grade does
not account for the permafrost below the surface. Building an SMS policy is no
different in that the foundation must support the policy.
In a hierarchy of human
factors, organizational factors,
supervision factors and
environmental factors, human
factors is the most flexible, or
adaptable factor when
compared to the other factors.
Organizational factors are rigid
by design and roles and
responsibilities defined in the
organizational chart. Common cause variations are reliable, e.g. SMS bulletins and
hazard prioritization, within an organizational hierarchy. Change management within the hierarchy are special cause variations. Supervision factors are rigid by
operational requirements. Common cause variations are reliable, e.g. quality
control, within supervision factors. Corrective action plans are special cause
variations within supervision factors. Environmental factors are ridged by
geolocations and design. Common cause variations are reliable, e.g. seasonal
weather, or checklist design, within environmental factors. Human factors are
unique in that they are adaptable to the other factors. Common cause variations
rarely exist within a human factors environment, while special cause variations are
frequent. Roles and responsibilities of the certificate holder is to conduct change
management for organizational, supervision and environmental factors to adapt to
human behaviors, or human factors. An example is to install fire extinguisher,
which are applicable to organizational, supervision, and environmental factors, for
human factors to take the action in the event of an inflight fire.
SMS is about the future and not the past.The top layer of a true SMS is environmental factors, which is the most rigid factor.
First sub-grade layer is organizational factors, which is the first responder to the
top layer, or environmental factors. The second sub-grade layer is supervision
factors, which supports organizational factors, and the third sub-grade layer is
human factors, which must adapt when any of the other layers above str unable to
support the safety policy.
An SMS is flawed because the true SMS was railroaded and parked on an
abandoned spur. Unless the spur is known, it is impossible to find the true SMS by
following the tracks backwards. When a CAP is linked to something that does not
exist, such as the four foundation factors of what an SMS policy is built on, the CAP
does not improve safety. When a flight crew chose to follow a painted taxilane and
clip the wing of their aircraft is a special cause variation and an indication that both
airports and airlines are operating with a flawed SMS without accountability.
OffRoadPilots
