Monday, March 9, 2020

Avoid The SMS Traps

Avoid The SMS Traps

By Catalina9

There are several traps or hazards associated with a Safety Management System (SMS) program. The three major traps both the regulator and operators fall into are expectations, non-punitive reporting and human factors. The first trap is the expectation trap that applying opinion-based activities ensures regulatory compliance. The second trap is the non-punitive reporting policy trap applying an expectation of punitive actions, or an expectation that punishment is acceptable for illegal activity, negligence or wilful misconduct. The third SMS trap is the human factors trap that a root cause is the absence of a behavior within a defined timeline qualifying as either illegal activity, negligence or wilful misconduct.   

Expectations applied correctly is for a desirable outcome.
Job performance compliance with expectations are necessary in our daily interactions, any profession or areas of airline or airport operations. Driving down the highway there is an expectation that an operator of a private vehicle has a system is in place to travel at or below the speed limit, stay on the correct side of the road or comply with the standards of highway travel. In the trucking industry there is an expectation that operators have systems in place to calculate the weight loaded on the truck or the height of the vehicles. There are expectations that commercial long-haul trucks, at any time during their travel on the highways, have operational systems such as brakes, steering, lights or tires that are conforming to the standards. Just as in any other industry, there are expectations established for compliance with the Safety Management System regulations. Anyone could fall into the expectation traps, or hazards. Organizational titles with roles and responsibilities within SMS, or regulatory oversight does not ensure that a person applies expectations equally, without bias or suitability for size and complexity of the operations. SMS expectations may be applied different regionally or may be applied different based on a person’s background and experience. Expectations may be applied different based on what is expected politically, what is expected by supervisors, management or the Accountable Executive or may be applied differently based on comprehension of systems. The expectation trap becomes an extreme hazard to aviation when a finding, by internal or by external audits, is applied to the expectation itself, assuming this expectation to be the only acceptable behavior for regulatory compliance.      

A job performance review is not a review of legal or illegal activities.
Non-Punitive Reporting Policy:
The second SMS trap is the application of a non-punitive reporting policy. A non-punitive policy is to provide immunity from disciplinary action for employees that report hazards, incidents or accidents and ensure that the policy is widely understood within the organization. A non-punitive reporting policy is built on a just-culture, where there is trust, learning, accountability and information sharing. Within a just-culture an enterprise operates with training systems that includes learning areas about trust, learning processes, accountability and information sharing. Just-culture learning is about having documented processes in place to identify training requirements so that personnel are competent to perform their duties. With these simple steps any person may report hazards, incidents or accidents without fear of failures, or punishment. The report is entered into the SMS system as data. Data is fair and unbiased. Data is processed into information to be absorbed by one of the five senses. As information is absorbed by a person, that person gain knowledge. With knowledge a person comprehends one system, and multiple interacting systems. Other expectations of a non-punitive policy are to establish conditions under which punitive disciplinary action would be considered. Some of the most common conditions are illegal activity, negligence or wilful misconduct. There is an expectation that the Accountable Executive of an organization clearly defines when punitive disciplinary actions would be considered. Including the words “illegal activity, negligence or wilful misconduct”, or making these words policies, does not clearly define reasons for punitive actions. When Accountable Executives behave in a manner that implements these options, they are falling into an expectation trap that of an unsafe behavior since illegal activity, negligence or wilful misconduct are not within a job description or job-performance criteria.

An Accountable Executive implementing illegal activity, negligence or wilful misconduct as reasons for punishment contradicts a just-culture, where there is trust, learning, accountability and information sharing. Illegal activity is a behavior violating a regulation which the courts decision to establish guilt of illegal activity and it’s not an Accountable Executive’s role. For negligence to be applicable as a reason for punishment it must be established and defined what it is prior to the behavior takes place. Negligence after the fact is a biased interpretation of the action. An Accountable Executive who applies a negligence policy for a reason of punishment has established a policy accepting that their own enterprise only accept mediocracy. When wilful misconduct is implemented as a policy it must be establish prior to the event and clearly defined. An Accountable Executive who implements this policy, contradicts the non-punitive reporting policy expectation itself.

The intent of including illegal activity, negligence or wilful misconduct as reasons for punishment comes with good intentions. However, intentions are irrelevant in aviation safety. It’s actions that are relevant. With these policies implemented there are no reasons for reporting and only those who do not understand these policies will make reports. The expectation trap becomes an extreme hazard to aviation when illegal activity, negligence or wilful misconduct are applied as a reasoning and leave no room for trust, learning, accountability and information sharing. 

Human Factors is the domino effect of operations.
Human Factors:
The third SMS trap that is easy to fall into is the human factors trap. Aviation before SMS was simple. After an accident the pilot was blamed, and problem solved. …at leased in the eyes of regulatory oversight and the public opinion. SMS was fist implemented in Canada in 2006. Between 1903 and 2006 aviation safety was generally speaking a reactive process with the flying public unaware of the hazards.

After decades of improving airplane design and technology, pilot training and expectations, flying was sold as the safest mode of transportation. In the 70’ human factors research gained interest and the SHELL model was developed. This model is the interaction between Liveware (human interactions) and Liveware, Liveware hand Hardware, Liveware and Software and Liveware and Environment. The environment is the work environment and how user-friendly the workstation is. In addition, the environment is about climate, topography and weather. How a workstation is design is a positive addition in a goal to satisfy an expectation of the job description. However, the climate, topography and the weather all impact processes to satisfy a job performance expectation. Human factors are to analyze how success is reached, or how flight crew, or airport personnel behave to ensure that human factors expectations are met. That several performance parameters are met is not an indication that the crew followed processes or procedures. When a parameter is satisfactory to the management, e.g. on time departures, runway surface condition reporting or maintenance performed, it does not show how the tasks were met. It only shows that it was.

As an Accountable Executive, take a minute, if that is enough time, and write down all the rules a pilot or airport manger needs to be able to recall in their daily job. If an AE is not able to recall all rules, the enterprise has just fallen into the third SMS Human Factors trap. It is important to know what an undesired event in operations is. However, it is not practical within an SMS world to apply what went wrong to improve safety. Operations goes right most of the times. Pilots and airport personnel live by the GSD rule, or Get Stuff Done. Within any job sacrifices must be made and if rules and expectations are prohibiting job performance, the job falls into the GSD category. For an SMS to function the AE must comprehend all systems and become an interactive part of operations. An AE is not there as a rule maker for downstream enforcement, but as an oversight body comprehending why things goes right most of the times. When an enterprise finds out why things go right, that is when they have reached a level where continuous safety improvements are within reach.  The expectation trap becomes an extreme hazard to aviation when Human Factors are analyzed to errors only and not to success. Within any success lays at least one failure.


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