SMS And Loss Of Situational Awareness
By Catalina9
Thinking
outside the box and brainstorming is an element of root cause analysis within
an SMS system. Two of the most applied tools are the fishbone analysis and the
5-Why’s. When applying brainstorming and outside the box thinking loss of
situational awareness concept takes on a different meaning than what conventional
wisdom expects, or even beyond what the industry accepts.
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| Time |
Loss
of situation awareness has a history of being identified as one of the primary
factors in accidents attributed to human error. Situational awareness may come
in different shapes and forms but is generally speaking identified as perception
of the elements in the environment within a volume of time and space, comprehension
of operational meaning and projection of operational status in the near future.
In other words, situational awareness is the Captain’s comprehension of where
the aircraft was, where it is now and where it’s going. In the old way of reactive
safety and prior to SMS, this was a simple opinion-based solution with the root
being contributed to the Captain. The root cause was simply that the Captain
had lost something while flying between point of departure and time of
incident. In addition, accident reports would state that the Captain had lost situational
awareness due to lack of performing certain policy or procedure tasks. That an
accident is inevitable if a Captain does not recollect, or performs a specific policy
or procedure is in itself a red flag of a high risk. While flying towards the
accident the Captain and flight crew may have complied with the definition and fully
comprehended their situational awareness, or they would have altered course to
avoid. Within a proactive Safety Management System, this retrospective view that
losing something in flight will cause an accident does not fit the SMS picture.
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| Information Overload |
Accepted
opinions for reasons of loss of situational awareness is that the Captain is
performing repetitious tasks and therefore expects a certain route and complies
with this expectation without comprehending ATC instructions or clearances. Another
opinion is that the Captain experiences an overload of data, processes
prioritized data into information, acquire knowledge from this information and
develops an image of comprehending the situation. The first example imply that
the Captain is inattentive to data received with an assumptional analysis to
the decision-making process. If a problem is defined incorrectly in an
assumptional analysis, all the subsequent steps of problem management, or
situational awareness comprehension, are not only irrelevant but possibly
harmful. The second example implies that the Captain is attentive to data
received with a data analysis decision-making process. A third opinion of loss
of situational awareness is that the Captain is behind the airplane and in some
instances so far behind that the Captain is occupying the last seat in the
passenger cabin. Loss of situational awareness is also applied to airport
operations and vehicle movements on the movement areas. None of these examples
are evidence that the Captain lost situational awareness, but rather that the
Captain conformed to different decision-making options
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| Space |
Loss
of situational awareness is more than a one-person lack of comprehension. It’s
a portion of a larger system comprehension where the operator plays a role and
has procedures in place to prioritize three tasks while flying. Most airlines
operate with an expectation that the Captain does not lose situational
awareness. However, an expectation has no powers to achieve and is neither a
goal nor a
process, but a wish for a virtual safe outcome. There are four systems that
affect the flight path of an airplane. They are the Topographical,
Environmental, Technical and Human Performance systems. In addition, as an
overarching system or a hub-system to operate within these systems is the
organizational system. During the pre-SMS days this system was reactive but
changed to a proactive system with an operating SMS.
People
can remember three items, but have to compute, calculate and recall anything
that are more than three items. When more than three tasks are required to be
repeated constantly it becomes an overload of data inputs for the flight crew
to recall sequences. There are three priority tasks that a Captain must be able
to recall at any time, during any normal flight or any emergency. The first is
the organizational policy task, which is to “fly the airplane”. The second task is the organizational process
task, which is to “fly the airplane”.
The third task is the organizational procedure task, which is, and you probably
guessed it, to “fly the airplane”.
Everything else the Captain does are trivial tasks.
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| Compass |
SMS
is a businesslike approach to safety with a business plan, or SMS plan. With an
operating Safety Management System the plan does not involve loss of
situational awareness, but plans for the factors and conditions generating organizational
expectations, or opinions, and information overload. There is no reason for any operator not to
treat every subsequent flight with the same respect as they treated the very
first flight the Captain successfully completed. It’s not loss of situational
awareness but system 3D comprehension measured in time, space and compass.
Catalina9
