Nothing To Learn

 Nothing To Learn

By OffRoadPilots

The Safety Management System (SMS) is the root cause of

the most recent midair collision. That a system is

named the “Safety Management System” is not a guarantee

or assurance that this system prevents accidents, or

that the system itself cannot be the root cause of an

accident.

The Safety Management System did not fail aviation

safety when this accident happened but operated as

intended and painted a true picture of aviation safety.

Aviation safety cannot be enforced, aviation safety is

neutral and does not take sides in safety, and no

matter how much we wish for an SMS to operate

differently and paint a different picture of aviation

safety it will always show the true picture.

There is nothing to learn here after the midair

collision, because it is a known fact that when two

aircraft intersect at the same location in a 3D format

the accident will happen and there will be no

survivors.

There is no justification for accidents to happen, not

even that we will learn from them and prevent future

accidents. The era of learning from accidents and

requiring accidents to happen at regular intervals was

eliminated by implementation of the Safety Management

System.

Airlines are required by regulations to operate with an

SMS, and the SMS therefore became the root cause of an

unexpected conflict of interest. At the time when SMS 

regulations came into force, everything in operations

is allocated to SMS. The aviation industry cannot pick

and choose when they want to apply and give credit to SMS and when not to include SMS.

Below is a clip from

a past post that

talked about how

hazards are mitigated

in 3D. The three

dimension (3D)

identification

process is measured

in time (speed),

space (location), and

compass (direction).

“One could define

risk management as

the identification,

analysis and

elimination of those

hazards, as well as the residual risks that threaten

the viability of an enterprise. The discussion of

whether it is possible or practical to eliminate

hazards are ongoing with opposing views.

Airports and airlines accept the inherent risks in aviation every time there is a movement on the field or in aero navigation. On the other hand, both regulators and professional auditors expect from the corrective action plans that an operator will make changes to

ensure that an occurrence never happens again. While it is unreasonable to expect the complete elimination of risk in aviation, it is also unreasonable to expect that all risks are acceptable.

It is a fine line to balance between what risks to eliminate, and what risk to accept. Risk acceptance, or elimination is a 3D identification process measured in time (speed), space (location), and compass (direction). 

When 3D thinking is introduced, a future

scenario can be designed, or the exposure level. Risk

mitigation then becomes an exposure level mitigation

and not the mitigation of the hazard itself.

This does not imply that the future can be predicted,

but it implies that data, information, knowledge, and

comprehension are vital steps to predict hazards that

affect operational processes. Exposure level mitigation

is currently a major part of risk mitigation, e.g.,

airside markings, markers, signs or lighting, or

aeronavigation flow into congested airspace and for

gate assignments.”

SMS AS ROOT CAUSE

The Safety Management System, while designed to enhance

aviation safety, can sometimes inadvertently become the

root cause of an aircraft accident. This paradox arises

because the SMS, in its essence, is a collection of

policies, processes, procedures and acceptable work

practices aimed at identifying, analyzing, and

mitigating risks. A Safety Management System operates

within the parameters set by those who design and

implement it, and it reflects the limitations of human

foresight and understanding.

When the SMS is followed strictly without allowing for

the flexibility needed to address unforeseen circumstances, it can lead to a false sense of

security.

Operators might become overly reliant on the SMS,

assuming that adherence to its protocols is a guarantee

of safety. This can result in complacency, where

critical thinking and situational awareness are

diminished, as individuals adhere to the letter of the

system rather than the spirit of safety it intends to

promote.

Additionally, the SMS might identify risks and

prescribe mitigations that are theoretically sound but

practically insufficient. If a system primarily focuses

on historical data and known hazards, it might not

account for novel or emergent risks.

The SMS could also create bureaucratic inertia, where

operators are slow to adapt to new information or

changes in the operational environment because they are

bound by established protocols.

In the case of a midair collision, the SMS might have

identified specific risks and established measures to

mitigate them, such as separation standards and traffic

management procedures. However, if those measures are

based on data that does not encompass the full scope of

scenarios, probability of exposure in 3D, or if the

operator does not recognize and respond to deviations

in real-time, the system's limitations become apparent.

The SMS, though functioning as intended, may

inadvertently contribute to an accident by providing a

false sense of security and by not fully addressing the

dynamic and complex nature of aviation operations.

While the SMS is a vital tool for promoting safety,

system designers are not infallible, and the SMS will

function as intended. SMS must be continuously reviewed

and adapted, and it should be complemented by a culture

of vigilance with predictive risk management.

PREDICTIVE RISK

MANAGEMENT

Predictive Risk

Management (PRM) in

an aviation Safety

Management System

involves the use of

data analysis and

trend monitoring to

analyze both identified hazards and latent hazards

before they manifest

into actual risks or incidents.

By employing advanced analytics, PRM seeks to identify patterns, anomalies, and emerging threats that are not immediately apparent through traditional safety measures.

PRM leverages historical data, real-time information,

and predictive algorithms to generate risk forecasts.

This proactive approach allows for preemptive actions,

improving the resilience of aviation operations. For

instance, PRM might analyze flight data to predict

mechanical failures, assess weather patterns to

anticipate turbulence, or study individual human

factors to prevent crew fatigue-related incidents.PRM extends the capabilities of the SMS by adding a

forward-looking dimension, enabling aviation operators

to stay ahead of arising events. This requires a robust

data infrastructure, continuous monitoring, and the

integration of insights into operational decision-

making processes in a 3D process.

MIXED OPERATIONS

In aviation operations, the presence of different types

of aircraft, such as large commercial jets, small

private planes, and helicopters, introduces special

cause variations that complicate SMS processes. These

variations arise because each type of aircraft has

distinct operational characteristics, performance

capabilities, and requirements, and their unique

characteristics are introduced into processes where

these characteristics do not exist.

Large aircraft generally follow more rigid flight paths

and require longer runways for takeoff and landing,

while small aircraft and helicopters have more

flexibility in their movements and can operate from

shorter or even improvised landing sites.

This disparity can create unpredictable interactions,

especially in congested airspace or near airports.

Helicopters, with their ability to hover and perform

vertical takeoffs and landings, introduce further

complexity, as their flight patterns can intersect with

fixed-wing aircraft in ways that are not typically

accounted for by standard separation protocols.Additionally, the differences in speed, altitude, and

maneuverability between large and small aircraft can

result in unexpected encounter scenarios, where

traditional traffic management procedures may not be

sufficient to maintain acceptable separation.

3D

An Aviation Safety Management System must be designed

to operate in a 3D environment, meaning it must account

for risks not only on the ground but also in the air,

where aircraft move in three dimensions, measured in

time (speed), space (location), and compass

(direction). This adds complexity to aviation SMS

compared to industries operating in only two

dimensions, such as road transport.

Hazard Identification

in Three Dimensions.

Hazards exist in all

axes (vertical,

horizontal, and

lateral movement).

Example. Mid-air

collisions or near

misses require

monitoring of

separation measured

in time (speed),

space (location), and

compass (direction)

by all parties

involved. This

monitoring is

initiated as soon as the aircraft depart and terminates upon landing. After landing an aircraft operates in a two-dimensional (2D) environment, which requires

different SMS analyses and mitigation than a 3D

environment.

Risk Management Across Multiple Altitudes.

Risks differ at ground level (runway incursions), low

altitude (bird strikes, wake turbulence), and high

altitude (pressurization failures, turbulence).

Example. A low-altitude hazard like wake turbulence

from a large aircraft can endanger aircraft arriving or

departing behind the aircraft and encounter wake

turbulence.

Integrated Real-Time Monitoring Systems.

SMS must integrate weather systems, radar, GPS

tracking, and onboard sensors to provide full

situational awareness.

Example. A microburst (sudden downdraft) at an airport

can create a severe hazard for landing aircraft.

Regulatory Compliance in a Three-Dimensional Airspace.

Different flight levels require different regulations

(e.g., controlled vs. uncontrolled airspace).

Example. A general aviation aircraft entering Class A

airspace (above 18,000 feet) without clearance poses a

risk to commercial jets.

Human Factors and Situational Awareness.

Pilots, ATC, and maintenance crews must be trained to

think in 3D risk terms rather than just linear (2D)

risks.

Example. A pilot descending into a busy airport must

track multiple aircraft at different altitudes and

approach paths.

Emergency Response and Contingency Planning.

Response plans must consider airborne emergencies, not

just ground incidents.

Example. An aircraft with an engine failure at cruising

altitude requires precise glide path calculations and

diversion planning.

An effective Aviation SMS in a 3D environment must

integrate real-time data, regulatory frameworks, human

factors, and technological solutions to manage risks

across all dimensions. By designing systems that

account for hazards measured in time (speed), space

(location), and compass (direction), aviation safety is

on track for significant improvements.

SAFEST MODE OF TRANSPORTATION

Conventional wisdom is that aviation is the safest mode

of transportation. This is a myth, because flying was

not the safest mode of transportation for passengers

onboard the most recent midair collision. If aviation

was the safest mode of transportation there would not

be any major accidents.

Flying is not the safest mode of transportation unless

we accept that major aviation accidents are needed to

justify numbers of accidents and statistics compared to

other modes of transportation.

While flying is touted as the safest mode of

transportation based on accident statistics, there are

valid arguments against this claim.

While airplane accidents are rare, when they do happen,

they tend to be catastrophic, with a high fatality

rate. Unlike car crashes, where survival is more

likely, aviation accidents often result in total

losses.

In a car, train, or a

boat, passengers or

crew have some

control over their

safety (e.g., wearing

a seatbelt, making

emergency maneuvers,

or evacuating). In an

airplane, passengers

have no control, and

pilots have limited

options once a

problem occurs at cruising altitude.

Air travel relies heavily on advanced technology,

automation, and human decision-making. A single

mechanical failure, software glitch, human factors,

organizational factors, supervision factors and

environmental factors have disastrous consequences.

Human fatigue, miscommunication, or system

irregularities have contributed to major aviation

accidents.

Airplanes have historically been targets for

hijackings. While security measures have improved, the

consequences of such events are much more severe than

other modes of transportation.Unlike cars or trains, where stopping or emergency exits are more accessible, planes have limited

emergency response options. If an issue arises mid-

flight, pilots must navigate a complex series of

decisions with little room for error in judgement.

While commercial aviation has strict regulations and

remains safe overall, these factors show why it may not

be the absolute safest mode of transportation in all

contexts.

The aviation industry has by implementing a Safety

Management System admitted that flying is not the

safest mode of transportation. If flying was the safest

mode, 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?

BUS VS AIRCRAFT

When analyzing the level of safety, we are comparing

apples and oranges, such as air travel to surface

travel. Aviation safety by continent can be analyzed,

safety by country can be analyzed, or can be broken

down to analyze safety by airlines or by airports.

The aviation industry needs to compare apples to

apples, and oranges to oranges, or in other words,

compare systems to systems. When we compare one system

to another system, the output and risk mitigations are

ineffective. A fish cannot fly and cannot be trained to

fly. A fish may therefore by comparison to a cat live a

safer life than a cat because it has never fallen out

of a tree. (NOTE: this is true to some extent. Severalyears ago, an airline filed a CADORS for being hit by a

fish while airborne).

A bus needs to be certified, and a bus driver needs a

driver’s license. An aircraft needs to be certified and

the pilot needs a pilot’s license.

A highway needs to meet standards and regulations, and

an airport needs to be certified, and meet standards

and regulations.

Safety analyses may

be of numbers of

deviations, minor

incidents, major

accidents or

fatalities. When

aviation is promoted

as the safest mode of

transportation, the

statistics is of

numbers of fatal

accidents.

While this is a fully acceptable analysis, it is also propaganda to promote aviation safety. 

The analysis of safest mode of transportation should be of the survival rate when experiencing a catastrophic event.

By establishing the criteria for comparison, safety

analyses for the safest mode of transportation, travelling by bus or aircraft, can be established.

NOTHING TO LEARN

Aviation safety can no longer accept that we need to

learn from aviation accidents. Aviation safety needs to

run with a predictable Safety Management System.

Learning from accidents belonging in the pre-SMS world,

when aviation safety needed accidents to find out what

was unknown, what could happen and how to improve

aviation safety.

There is nothing to learn from the most recent midair

collision, because the aviation industry already knew

that different incompatible systems, such as

helicopters, large aircraft and speeds, were forced

into one operating system, or operating environment,

and expected to cooperate and conform.

It is a disgrace to the families of victims to justify

that aviation accidents are needed because we learn

from them.

OffRoadPilots