Sunday, February 24, 2019

SMS And Loss Of Situational Awareness

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.

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.

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


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.

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.


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