Sunday, May 1, 2022

The Unintended Consequences of a Non-Punitive SMS Policy

 The Unintended Consequences of a Non-Punitive SMS Policy

By OffRoadPilots

An SMS enterprise is required to implement a non-punitive reporting policy. The intent of this policy is that more incident reports or near misses will be submitted to management when there is a policy in place that a contributor will not be reprimanded, fired, criminally charged, or other punitive actions, such as a reduction in pay or benefits, will be taken against them. An implied benefit from a non-punitive reporting system is that an operator, being airline or airport, will learn from the content of these reports and implement changes to operations as needed for safety improvements. 

A non-punitive policy that needs to be decoded is not a policy.

An objective of a non-punitive SMS policy is to support the overarching SMS policy goals of an SMS enterprise. Examples of an SMS policy goals are to have a goal-setting process in place, processes for live hazard identification, reporting and corrective actions, processes to train personnel, a process to operate with a daily quality control program as a prerequisite for their quality assurance program, processes for conducting periodic audits of the safety management system, or a non-punitive reporting policy. Conventional wisdom is that the non-punitive reporting policy is the only element of an SMS policy that ensures reporting disclosure of all near misses, incidents, or hazards. When an SMS enterprise is relying on their non-punitive reporting policy as their only tool for sole-source reporting, they are taking the SMS down the wrong path. Sole-source reporting is reporting of an event that otherwise would be unknow to the operator since no other person had knowledge of the event to report it. A sole-source report could be an IFR altitude deviation in uncontrolled airspace, or operational deviations out of a remote airport without air traffic services.  


Negative thinking generates an incorrect root cause.

A non-punitive reporting policy is a crucial tool for an SMS enterprise, but it is not, and cannot be the only tool for sole-source reporting. If there is no benefit for the contributor to report, the intervals between receiving reports are imaginary, theoretical, virtual, or fictional when solely based on a non-punitive policy. There is no benefit for a contributor to report an undetected event that was corrected. Individuals reporting more reports than other is actually a red-flag and does not contribute to safety but is a contributor for suspicions. Suspicion or qualification assumptions is a hazard to incremental safety improvements. A negative mind, such as suspicion, attracts negative behaviors. Negative thoughts are the greatest resource for destroying success. The greatest enemies to success are negative thoughts of all kinds. They hold you down, tire you out, and take away all your joy in life. From the beginning of time, negative thoughts have done more harm to individuals and societies than all the plagues of history. One of the most important goals is to remove all negative thinking about operational personnel. A non-punitive reporting process foster negative thinking in an organization. Some of the causes for negative thinking are rationalization, which causes automatic negative thoughts. When you rationalize, you attempt to give a socially acceptable explanation for an otherwise socially unacceptable act. Rationalization is to explain away or put a favorable light on something that you have done that you feel bad or unhappy about. Rationalization cast yourself in the roles of the victim, and you mark the other person or organization into the oppressor.


Negative thinking applies to all organizational structures and to small and large organizations. When information is analyzed by emotions rather than data analyzed within a statistical process control system, the findings will lead to an incorrect conclusion. When incorrect conclusions are applied to incremental safety improvements, safety improvements become random. Relying on an SMS manager’s random skills for safety improvements is a hazard in itself. As an example, when analyzing the root cause for aircraft wing strikes while towing between a sample of operators, negative thinking affects the root cause finding. In this example, a graph shows one operator with several more wing strikes than another operator and another operator shows several more days without a towing strike than the rest of the group. When analyzed in the negative thinking mode, the root cause is to enforce towing policies for operators with higher towing strike events and fewer days since a strike occurred. When analyzed as data and applying an SPC analysis, the processes between operators are in-control. Negative thinking applied an enforcement root cause, while an SPC analysis shows in-control processes. After it was concluded that the right thing was to enforce towing policies, one operator in the group asked what the other operator without strikes did correctly. When asked, the answer was: “We don’t tow, since we don’t have hangars to move aircraft in and out of”. 

Sometime ago, several news papers published a report that a stash of cocaine was found by a maintenance worker in the plane's avionics bay. The flight crew reported to the authorities that they found illegal drugs on the plane, and then they were detained and arrested by the local authorities for possession of illegal drugs. The flight crew reported in good-faith and under the assurance of the company’s non-punitive policy their findings to the authorities. Their reporting of a finding caused them to be arrested. 


When SMS was implemented as a regulatory requirement several years ago, the regulator acted as a consultant and advised operators to write a non-punitive policy to include conditions under which punitive disciplinary action would be considered, e.g., illegal activity, negligence or wilful misconduct. Transporting illegal drugs in aircraft is an illegal activity, it is negligence, and it is wilful misconduct, so the non-punitive policy does not apply to the flight crew. Some might say that the crew did not know about the drugs. However, the expectation applied to a non-punitive policy did not include to have knowledge of, as a condition for the policy to be applied. The non-punitive policy failed this flight crew considerably. When implementing the SMS recommendations, operators did not include in the non-punitive policy that the policy is only applicable in a jurisdiction where the policy is accepted, or by international agreements. In addition, the regulation itself was not applied to the non-punitive policy. The regulation sates in part: “…including the conditions under which immunity from disciplinary action will be granted…”   The regulation states that immunity is not granted unless specifically granted by the operator. When SMS is elevated to a level without accountability by the operator, and to a level where a person acting in good faith when reporting is punished, there is no just-culture in operations. Without just-culture there is no safety management system. 


The unintended consequence of a non-punitive policy is to foster negative thinking, and the promise to grant immunity in other jurisdiction than of the SMS enterprise. 





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