Monday, March 11, 2013

SMS is the Scapegoat!


SMS is the Scapegoat!

Since SMS was first introduced, it has been under fire as a terrible program that allows airlines and companies to “regulate themselves.” There is nothing further from the truth. The following is a recent article sent to me by a friend in Canada. The article comes from the Torstar News Service and relates to an incident that occurred with a Canadian carrier “Sunwing Airlines.”

OTTAWA—Ottawa’s push to let Canada’s airlines police the safety of their own operations is facing fresh questions after a federal watchdog criticized Sunwing Airlines for failing to report a potentially dangerous inflight incident.
In a new report, the Transportation Safety Board of Canada says Sunwing Airlines failed to report an inflight malfunction to safety authorities and was slow to learn the lessons of the March 2011 incident.
Sunwing Flight 531 was departing from Toronto en route to Cozumel, Mexico, with seven crew and 189 passengers on board when the pilots got erroneous airspeed indications during their takeoff roll. The problems continued during the climb as the stall warning sounded, suggesting the Boeing 737-800 jet was close to losing flying speed, and the instruments wrongly told the crew to put the aircraft into a shallow dive.
The crew ignored the erroneous warnings and maintained their climb before returning to Pearson airport for a safe landing.

Sunwing Boeing 737-800
It is clear that this was an emergency situation and potentially could have been a disaster. The pilot appears to have acted to assure the plane could return to the airport in a safe manner. 

At the heart of the investigation is Transport Canada’s safety management system, which puts more responsibility on individual airlines to track and assess risks and identify hazards within their own operations.
Except in this case, Sunwing Airlines didn’t see the incident as serious enough to warrant investigation by the airline’s own safety personnel and failed to report the incident as required to the safety board, the report says.
That led to a “missed opportunity to identify hazards and reduce risk.”
Yet the safety board’s probe of the incident, launched after air traffic controllers filed their own report, turned up several issues of concern.
The Heart of the Investigation is Transport Canada’s SMS?? What!  The incident took place in 2011. This was infancy of the SMS implementation and companies like Sunwing were in the “Phase in” period which means that the program was not fully implemented. Now, I must admit that Sunwing was very wrong in not investigating this incident internally. But, you can not blame Transport Canada’s SMS for this incident. I would like to know how many other incidents of this kind were reported under the old Audit system. 

While Boeing has warned airlines that airspeed failures are happening more often than expected, that information was not passed along by Sunwing to its own pilots.
And the safety board notes there is little guidance given to pilots on dealing with unreliable airspeed indications during a critical phase of flight — takeoff and initial climb — leaving them in the dark about the potential consequences.
The very problem raised here is common among non-SMS companies. SMS requires documentation “Control” which would dictate procedures for the distribution, maintenance and communication of notices, bulletins, forms, documents...etc within the company. Again this is a failure on behalf of Sunwing, who had not fully implemented their SMS yet. 

In this case, the weather was good, allowing pilots to guide the jet by using outside references. But the report cautions that the problem could have been more much serious if bad weather had forced the pilots to rely on the confusing cues presented by their flight instruments.
“Continued use of erroneous guidance in adverse weather could compromise flight safety,” the report said.
And the safety board says the multitude of problems encountered on this particular flight were not documented in the aircraft paperwork and “were not addressed.”
“The aircraft was returned to service without resolution of these defects and, as a result, airworthiness of the aircraft was not assured,” the report said.
Sunwing Airlines’ president Mark Williams agrees with the findings that the safety board should have been notified and that the airline’s safety management system should have flagged the incident for review.
But he says at the time, the safety management system concept was in its infancy, both within his airline and the industry as a whole.
“We’ve made lots of changes since that time because SMS is a system of continual improvement,” Williams said in an interview.
“A safety management system is something that is never finished. It’s a cycle of continual improvement. We’re always looking and fine-tuning it, looking at other people’s systems to try and continually make it better,” he said.
However, he takes issue with the safety board suggestion that the problems on the aircraft weren’t fixed before it was returned to service.
“The parts were immediately replaced on the aircraft before it went flying again,” he said.
It’s not the first time officials have raised concerns with the move toward safety management systems. In 2008, the auditor general warned that Transport Canada’s move to let the aviation industry police its own safety was done with no assessment of the risks involved.
In my opinion, this article has an apparent bias against SMS. The Aviation industry really does NOT police itself. All SMS companies are subject to Regulatory Assessments at any time. The actual assessment processes is more revealing to the company’s Safety Management than the old audit system. To blame SMS for this incident is a reach. It is a fact that SMS does not guarantee 100% accident free travel. But, if implemented properly, the company will have control of all of it’s processes and be able to determine when processes are going out of control BEFORE the incidents occur. A company merely having an SMS does not mean they are safe. The company must DO what they say they do in controlling their processes. SMS does work in improving safety and also profitability in all companies that implement and maintain it properly. Has SMS affected the accident rates among Canadian Aircarriers? Here are the words from Director General Civil Aviation, Martin J. Eley, at the Air Lines Pilots Association International 58th Annual Air Safety Forum. Aug 8, 2012. 

Martin J. Eley Director General Civial Aviation

“Last year, Canada saw the total number of accidents decline to the lowest recorded figure in modern aviation history.
This is despite the significant increases in air traffic. In fact, in the last few years, Canada has averaged more than 40 fewer air transportation accidents a year when compared to the previous ten year average.
These stats belong to all of those in the aviation community committed to making safety tomorrow even better than it is today.
With the number of accidents trending downward and air traffic trending upward, this means our traditional barometer of aviation safety – the accident rate – is also looking quite good.
Since 2000, we have seen a considerable decline in this rate. In 2000, Canada’s air transportation accident rate was nearly eight accidents per 100,000 hours flown; in 2011, this rate fell to fewer than six accidents per 100,000 hours flown. That’s a 25% drop.
The actual number is 5.3%, which is also the lowest it’s ever been.”

Your thoughts......

1 comment:

  1. The recognition of SMS systematically failures may not be sudden and obvious, but rather increments of insignificant changes. Who in the organization has the authority to decide what is not important enough to report?

    ReplyDelete

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