Why SMS Does Not Prevent Accidents
By OffRoadPilots
The safety management system was sold to the aviation
industry, both airports and airlines, as a system to
reduce, or prevent all future accidents.
The following is a quote from a regulator about
aviation accidents. “
…as the aviation industry grows
and departures increase, the total number of accidents
will also increase."
Even though there has been a reduction in the accident
rates, this expectation is based historical data, and a
calculated accidents ratio each time one aircraft is
added to a random global fleet. There is an expectation
within the global aviation industry that adding one
aircraft anywhere adds an accident hazard to the
industry as a whole, or in other words that every
aircraft carries a fraction of an accident hazard
onboard. Since the aviation industry lives in a 3D
environment there is an inherited risk in flying.
The regulatory body
continues to say:
“While the current
rate of accidents is
at an all-time low,
it is assumed that
any appreciable
increase in the
total number of
accidents would be
unacceptable to the
general public. To
avoid this situation, we will need to reduce the accident rate
even still. Considerably, the steady improvement in the accident rate was attributable to improvements to
technology, such as the introduction of more reliable
engines and navigation systems. However, the majority
of today’s accidents can be attributed to human or
organizational factors. With a few notable exceptions,
there is little opportunity for technological solutions
to the types of accidents. Safety management systems,
on the other hand, offer the most promising means of
preventing these types of accidents.”
The safety management system in aviation (SMS) is
internationally recognized frameworks that help
operators, both airports and airlines, to identify
safety risks and prevent potential accidents.
The term "prevent" generally means to stop something
from happening or to hinder the occurrence of an event
or action. It involves taking measures or actions to
avoid or block a particular outcome. Prevention can be
applied in various contexts, such as preventing
diseases, accidents, conflicts, or any undesirable
situation.
A safety management system is a formal framework
designed to foster a culture of safety within an
organization. It sets out individual roles and
responsibilities, and accountabilities for safety. It
is designed both to increase awareness of various
safety aspects that relate to daily activities and to
establish formal lines of communication within the
organization for sharing information about hazards.
When operating withing an organization to improve
awareness, accountability and communication, an SMS
allows an organization to identify safety risks before
they escalate and become serious problems.
The measurable safety objectives and periodic internal
audits included in an SMS promote continuous learning
within the organization, as well as constant system
improvements. Putting an SMS in place usually involves
a commitment from senior management for approving the
organization’s safety policies and objectives, and for
providing oversight, among other factors. Introducing
an effective SMS poses its own challenges, but once in
place, the SMS plays a major role in preventing
accidents.
Until the 1960s, safety approaches in high-risk
industries were based on reliability engineering, a
field that studies and evaluates the probability of
equipment failure. Improvements in safety were
primarily informed by accident investigations, which
provided data about the likelihood of such events.
Increased public awareness of industrial hazards in
throughout the 1960s led to establishing a scientific
approach to accident prevention. Studies in this area
helped to identify some key factors in industrial
safety, namely, the causes of accidents, the interface
between humans and machines, the role of management,
and the relationship between the economics and
efficiency of safety. This research paved the way for
the development of SMS.
SMS approach relies not only on accident prevention,
but also on a systematic process for identifying and
controlling hazards derived from what is known as
“process safety.” Process safety has its roots in situation, we will need to reduce the accident rate
even still. Considerably, the steady improvement in the
accident rate was attributable to improvements to
technology, such as the introduction of more reliable
engines and navigation systems. However, the majority
of today’s accidents can be attributed to human or
organizational factors. With a few notable exceptions,
there is little opportunity for technological solutions
to the types of accidents. Safety management systems,
on the other hand, offer the most promising means of
preventing these types of accidents.”
The safety management system in aviation (SMS) is
internationally recognized frameworks that help
operators, both airports and airlines, to identify
safety risks and prevent potential accidents.
The term "prevent" generally means to stop something
from happening or to hinder the occurrence of an event
or action. It involves taking measures or actions to
avoid or block a particular outcome. Prevention can be
applied in various contexts, such as preventing
diseases, accidents, conflicts, or any undesirable
situation.
A safety management system is a formal framework
designed to foster a culture of safety within an
organization. It sets out individual roles and
responsibilities, and accountabilities for safety. It
is designed both to increase awareness of various
safety aspects that relate to daily activities and to
establish formal lines of communication within the
organization for sharing information about hazards.
When operating withing an organization to improve
awareness, accountability and communication, an SMS allows an organization to identify safety risks before
they escalate and become serious problems.
The measurable safety objectives and periodic internal
audits included in an SMS promote continuous learning
within the organization, as well as constant system
improvements. Putting an SMS in place usually involves
a commitment from senior management for approving the
organization’s safety policies and objectives, and for
providing oversight, among other factors. Introducing
an effective SMS poses its own challenges, but once in
place, the SMS plays a major role in preventing
accidents.
Until the 1960s, safety approaches in high-risk
industries were based on reliability engineering, a
field that studies and evaluates the probability of
equipment failure. Improvements in safety were
primarily informed by accident investigations, which
provided data about the likelihood of such events.
Increased public awareness of industrial hazards in
throughout the 1960s led to establishing a scientific
approach to accident prevention. Studies in this area
helped to identify some key factors in industrial
safety, namely, the causes of accidents, the interface
between humans and machines, the role of management,
and the relationship between the economics and
efficiency of safety. This research paved the way for
the development of SMS.
SMS approach relies not only on accident prevention,
but also on a systematic process for identifying and
controlling hazards derived from what is known as
“process safety.” Process safety has its roots in business ethics, commitment to health, safety, and environmental protection. This has since been adopted by industries in several counties.
In the aviation
industry, factors
like increased
traffic, constant
technological
change, the limited
opportunities for
infrastructure
investment have
driven the need for
a more effective
approach to safety.
Another driver of
change is research findings that organizations can
comply with the regulations yet fail to manage risks at acceptable levels. It’s crucial to aviation safety to
comprehend that regulatory compliance does not equal
safety in operations.
The SMS approach is considered a better way to motivate
airlines and airports to manage their own risks,
because it makes them accountable and responsible for
the human, organizational, technical, and environmental
factors that lead to accidents. An oversight strategy
is to maintain and improve the safety of the aviation
system with the resources available. The aviation
industry, including certified airports, non-certified
aerodromes, scheduled airlines and on-demand air
charters must accept accountability and be responsible
for the proactive and systematic management of the allows an organization to identify safety risks before
they escalate and become serious problems.
The measurable safety objectives and periodic internal
audits included in an SMS promote continuous learning
within the organization, as well as constant system
improvements. Putting an SMS in place usually involves
a commitment from senior management for approving the
organization’s safety policies and objectives, and for
providing oversight, among other factors. Introducing
an effective SMS poses its own challenges, but once in
place, the SMS plays a major role in preventing
accidents.
Until the 1960s, safety approaches in high-risk
industries were based on reliability engineering, a
field that studies and evaluates the probability of
equipment failure. Improvements in safety were
primarily informed by accident investigations, which
provided data about the likelihood of such events.
Increased public awareness of industrial hazards in
throughout the 1960s led to establishing a scientific
approach to accident prevention. Studies in this area
helped to identify some key factors in industrial
safety, namely, the causes of accidents, the interface
between humans and machines, the role of management,
and the relationship between the economics and
efficiency of safety. This research paved the way for
the development of SMS.
SMS approach relies not only on accident prevention,
but also on a systematic process for identifying and
controlling hazards derived from what is known as
“process safety.” Process safety has its roots in situation, we will need to reduce the accident rate even still. Considerably, the steady improvement in the accident rate was attributable to improvements to
technology, such as the introduction of more reliable
engines and navigation systems. However, the majority
of today’s accidents can be attributed to human or
organizational factors. With a few notable exceptions,
there is little opportunity for technological solutions
to the types of accidents. Safety management systems,
on the other hand, offer the most promising means of
preventing these types of accidents.”
The safety management system in aviation (SMS) is
internationally recognized frameworks that help
operators, both airports and airlines, to identify
safety risks and prevent potential accidents.
The term "prevent" generally means to stop something
from happening or to hinder the occurrence of an event
or action. It involves taking measures or actions to
avoid or block a particular outcome. Prevention can be
applied in various contexts, such as preventing
diseases, accidents, conflicts, or any undesirable
situation.
A safety management system is a formal framework
designed to foster a culture of safety within an
organization. It sets out individual roles and
responsibilities, and accountabilities for safety. It
is designed both to increase awareness of various
safety aspects that relate to daily activities and to
establish formal lines of communication within the
organization for sharing information about hazards.
A Boeing 737-800 the flight crew encountered
directional control issues after touchdown, and the
aircraft did not decelerate as expected. The aircraft
overran the end of the runway by approximately 500 feet
and came to rest in the mud. There was some minor
damage observed on the left engine of the plane,
however there was no observed damage to the landing
gear. The crew and passengers did not sustain any
injuries.
A de Havilland DHC-8-314 aircraft encountered a
tailstrike upon landing. The tail contacted the ground
and the "Touched Runway" annunciator illuminated. The
aircraft subsequently taxied to the apron.
An Airport Authority maintenance vehicle was on the
taxiway when it was requested to work on the runway.
The maintenance vehicle was instructed to taxi on the
taxiway and to hold short of the runway, and therefore
was not authorized to cross runway without further
instruction. A Boeing 737 MAX was on approach to land
when the maintenance vehicle proceeded past the hold
short line and crossed the active runway.
An RJ-900 aircraft began its takeoff to the left of the
runway centerline, where it contacted 3 runway edge
lights before its trajectory was corrected. During the
aircraft’s climb, a fuel imbalance was detected. The
flight crew was not able to correct the imbalance and
subsequently shut down the right engine. An emergency
was declared, and the aircraft diverted to the nearest
suitable airport. Airport rescue and fire flighting
(ARFF) personnel advised that a tire was deflated, and
smoke was coming from the wheel. The left main landing gear was sprayed by ARFF, and the smoke dissipated.
Passengers were disembarked and transported to the
terminal.
Shortly after landing an Airbus A330-343 the bogie beam
failed on the right main landing gear. At the same
time, indications of a right main landing gear
malfunction were displayed in the cockpit. The aircraft
continued its landing roll, with the right gear shock
strut scraping the runway, and came to rest on the
runway.
These are just a few examples of how the safety
management system were incapable of preventing
incidents. The airline industry expects incidents to
occur, while there are no justifications for any
incidents.
A question the aviation industry needs to ask is why
the SMS failed to prevent accidents. The answer is
simple, the SMS did not fail, and cannot fail, since a
safety management system paints a true picture of
operations. Incidents occurs because the system is
designed and developed with that purpose. Human errors
may still be the cause, but with the introduction of
the SMS, human errors were moved from the cockpit,
airside, amd maintenance floor environment to the
office of the accountable executive.
Human error is a symptom of trouble deeper inside a
system or an organization. On the other hand, human
error is also a symptom of a successful organization.
There are organizations where human errors are
integrated with the system and need to be there for the
organization to exist and prosper. It is the system
itself that is set up for human errors.
Conventional wisdom
is that human error
is a” bad” thing
when using emotions
to describe an
event. Human error
is a sub-category of
human factors. Simplified, human factors are how a
person react when one or more of the five senses, vision, hearing, smell, taste, and touch are triggered. Human factors are also how external forces, or events,
e.g., fatigue, weather, illumination and more, affect
performance.
In an organization where there are overwhelming events
of human errors, the organization operates within a
system that is prone to these errors. Two examples are
Daytona 500, or Reno Air Races, where the systems (race
to win) are setting each driver and pilot up for human
error, or a crash. Both the Daytona 500 and Reno Air
Race organizers have requirements and systems in place
to reduce harm to drivers, pilots, or spectators.
These systems are designed for human errors, or for
safety to fail.
Imagine how successful Daytona 500 would be if the
speed was limited to 50MPH, or if the Reno Air Race
required airplanes to fly between gates separated a
mile apart.
Operating with an SMS does not prevent incidents or
accidents and data in above examples shows that fact.
If operating with an SMS automatically prevented
incidents there would not be any incidents. However,
the regulator and the aviation industry, both airlines
and airports, do not accept occurrence free operations.
After an airliner crashed into a parked aircraft while
taxiing, the airline accepted that this incident had
occurred with a justification that the flight crew was
taxiing as instructed by ATC across an apron with non-
standard markings.
A special cause variation at an airport does not
justify an airline occurrence, and an airline special
cause variation does not justify an airport occurrence.
Special cause variation, also known as assignable cause
variation, refers to variations in a process that are
not inherent to the process itself but are caused by
specific identifiable factors. In statistical process
control and quality management, understanding and
distinguishing between common cause variation and
special cause variation are essential for improving
processes and achieving consistency in outcomes.
Special causes variations are specific and identifiable
factors that can be traced to a particular source or
event. This could include a machine malfunction, a
sudden change in environmental conditions, or an error
in the manufacturing process.
Special cause variation is typically unpredictable and
sporadic. It does not follow a consistent pattern and
can happen unexpectedly.
A safety management
system does not
prevent accidents
since the accountable
executive (AE) allows
for an incident prone
system to be
operational. A flaw
in the SMS
regulations is that
the accountable
executive as an
unqualified person has the final authority to accept or reject operational processes, and without having the
expertise, education and training required for statistical process control and process mitigations. A true example of an unqualified AE is when the SMS
manager’s recommendation to use a random sampling
generator and apply the 95% confidence to the
population where rejected, and an equal number of
aircraft with documented compliance were selected, and
the final report identified no other burned exhaust
pipes.
If the confidence level is established at 95%, a
calculated statistical value that was based on a sample
is also true for the whole population within the
established confidence level with a 95% chance. In
other words: the chances are very high that the
arithmetic mean (as a statistical value) of a
population is exactly within the margins of error which
were established for the survey based on a sample.
The key to a successful safety management system is
where there is free speech, there is trust, leaning,
forward-looking accountability and information sharing.
Free speech does not come without responsibilities, and
responsibilities quadruples with a person as their
position is moved upwards in the SMS enterprise
hierarchy.
SMS is a tool to prevent accidents, but as with any
other tool, when used incorrectly the output does not
perform as expected.
OffRoadPilots
