Saturday, July 23, 2022

Unlock the Secrets of SMS

 Unlock the Secrets of SMS

By OffRoadPilots

Secrets of the SMS are not all positive secrets but are also pitfalls to watch for and secretly hidden in processes. On the surface a safety management system (SMS) in aviation is a perfect system to avoid or eliminate accidents. When SMS in aviation was first sold to the aviation industry, it was sold as a tool, if an operator followed the rules, to reduce number of accidents. The sales philosophy was that if an operator didn’t have any major accidents, they would for sure have one in the future if they did not implement the safety management system. Their sales pitch intentions were honorable, and the regulator firmly believed what they sold to operators. Virtual and fictional accident cost scenarios were developed to prove how beneficial an SMS system would be in the future. The predication was that the cost of implementing and maintaining a safety management system would become less significant and well worth the investment when contrasted with the cost of doing nothing. Every operator, being airline or airports, fell for the sale pitch, until they discovered that accidents and incidents, including regulatory findings, still happened. 

The SMS in itself cannot fail since it paints a true picture of an enterprise. What could fail is accountability by enterprise leaders, managers, and personnel. Safety in aviation was in the past built on failures, and failures, or accidents, were expected to occur so that new safety improvements could be put in place. Continuous improvement to safety were designed and implemented after failures and major accidents. What a functional SMS does, is to move these failures from physical harm and accidents to virtual failures on the drawing board. When drawing board tests fail, the aviation industry saves the world from a whole lot of grief. SMS does not prevent aviation accidents, it just moves accidents from operations to the drawing board. A secret of the SMS is that flaws discovered in the design or application process may be assigned an opinion to minimize the finding and design a short-cut in the process to bypass the failure.  

The safety management system has generated vast gap between design and operations. This is not due to the design of the SMS itself but is due to output expectations and application in the organizational hierarchy. When the SMS is viewed as a tool to interfere with operations to ensure safety, it is brought down from the oversight level, and quality assurance, to the operational level where it does not belong. A system that is implemented where it does not belong is a failed system by the untrained eye. While it appears that the SMS failed, it is not the system that failed, but the implementation process. There is a time and place for everything. This statement is crucial for a safety management system to survive, and it is vital for the success of an SMS enterprise that an accountable executive comprehend time and place in processes. A secret of the SMS is that it paints a true picture of an organization, and when it is brought down to an operational level, it paints a picture of failed management as opposed to a failed SMS system. An SMS at the incorrect level is when findings are prescriptive and assigned to deviations in process outcome rather than to the process itself. 

An SMS integrated at the operations level is recognized by the strain it places on operations to behave in a manner incompatible with the operations itself. A practical example is the flight operational quality assurance system, or FOQA, that most airlines have integrated into their operations. One event trigger may be that an aircraft does not bank at an angle greater than 30 degrees in flight, and when it does, the captain is assigned a red flag and becomes a higher risk to the operations. The two options available in a strong crosswind when turning a visual approach base to final, may require a 35-degree bank to remain on the approach. However, due to the red-flagged policy, a captain may chose to remain at 30 degrees of bank and overshoot the localizer. If the bank is 35 degrees or greater, the captain will at a minimum be questioned and flagged. When placed at the incorrect level in the organizational hierarchy, the system does not fulfil its expectations for improvement to perfectionism in flying. A secret of the SMS when management fails a captain, is the system has identified operational management complacency who opted to comply with a faulty arbitrary rule rather then make operational decisions based on aeronautical science and aerodynamics, which deals with the motion of air and the way that it interacts with objects in motion, such as an aircraft. Attempting to achieve perfectionism in aviation is in itself a hazard to aviation safety.  

A safety management system is in principle a simple tool to provide for understanding and engaging in safe working practices. A safety management system defines what hazards exist in aviation, being airports or airlines, and is established as an oversight tool to identify if operational processes are in control to assess hazards with a reliable track record to cause an incident or accident. The weather is a factor with major impact on aviation safety. Weather is not just hazardous weather, but also a factor in achieving safety in operations. Rightfully so, icing and strong winds, are often associated with catastrophic accidents. However, by comprehending that these hazards are common cause variations, and will always be a part of weather systems processes, aircraft manufacturer, airport operators and airlines has a golden opportunity to place a safety management system where it belongs, at the organizational level of the accountable executive, and applied as a daily quality control and oversight tool. As a reminder, the role of an accountable executive to be responsible for operations or activities authorized under the certificate and accountable on behalf of the certificate holder, or board of directors, for meeting the requirements of all applicable regulations. 


An SMS system is designed to evaluate process expectations in operations. An aircraft on approach may experience a steady crosswind, but instantly, at the same time as the aircraft touches down, the wind velocity suddenly increases to triple strength and the aircraft crashes. A well-designed SMS system is designed to capture a common cause variation, such as a steady wind suddenly turns into a special cause variation and triple increase in speed. An airport applying their SMS, a special cause variation, such as approaching extreme winds, may be identified at an earlier point than what currently is the common process, and be tracked over an extended distance prior to reaching the runway. Accidents occur when an aircraft and a special cause variation converge at the fork-in-the-road. An aircraft is operating in a 3D environment and measured in time (hours-minutes-seconds), space (geographical location) and compass (direction). When a special cause variation, also measured in 3D, and an aircraft converges anywhere in a 3D environment, is when accidents occur. Another example of a common cause variation is snow removal in Canada. An airport operator is not required to publish in the aeronautical publications that they operate with a winter operations plan, since it is assumed, due to a common cause variation, that all airport operators will have a winter and snow removal plan. A special cause variation occurs when snow accumulation is extremely low. Parked machinery becomes fragile to the environment and professional skills are forgotten. This requires airport operators to substitute actual snow removal activities with training of their crews. A secret of the SMS is that it uncovers special cause variations of hazards within a process. 


The true secret of an SMS is that the system comes with the capability to find a needle in the haystack when applied at the correct level in the hierarchy.  




Saturday, July 9, 2022

Unintended Consequences of Training

 Unintended Consequences of Training

By OffRoadPilots

The law of unintended consequences is when a planned strategy fails. Sometimes an unintended consequence is winning the jackpot and mostly celebrated as flukes, but when a tragedy strikes, it is bad luck or murphy’s law. 

Training is to perform in harmony

The Safety Management System (SMS) regulations requires that there is a process in place for ensuring that personnel are trained and competent to perform their duties, that there are training requirements for the person managing the safety management system and for personnel assigned duties under the safety management system, and a method to determine the adequacy of training required. These training requirements are required for all personnel, including the Accountable Executive (AE). 


Conventional wisdom is that the only two requirements, roles, responsibilities, or duties for the AE is to support the SMS with human and financial resources. An SMS is ineffective and without an excuse if an AE remains untrained to comprehend their responsibility for operations or activities authorized under the certificate and accountable on behalf of the certificate holder for meeting the requirements of the regulations.


Training of the AE becomes a vital task for the SMS to be effective. An effective system is a system that is successful in producing a desired or intended result or outcome, and when the AE remains untrained, the intended result is not produced. In larger organizations, the AE, who also in most cases is the President and CEO, may receive limited training in lieu of relying on a third-party confidential adviser to the AE, in the same manner as the organization rely on accountants, lawyers or janitorial services for effectiveness. With no minimum personnel requirement to operate with an SMS, the AE of a small organization may be the same person who is managing the SMS. However, in larger organization, and when relying on a confidential adviser to the AE, the responsibility and accountability of the accountable executive are not affected by the appointment of a person to manage the safety management system. 


No person within an SMS enterprise is required to hold an “SMS license” to qualify for their positions under the SMS. A pilot needs to hold a pilot’s license, a mechanic needs to hold a mechanic’s license, with the only exception that an airport manager (APM) is not required to hold an APM license. Licenses are governed by standards that a person must meet to qualify for the license held, and to maintain the license. Requirement for SMS training is determined by the SMS manager, who establishes training requirements for the person managing the safety management system and for personnel assigned duties under the safety management system. The accountable executive approves by their responsibility for meeting the requirements of the regulations their own third-party training supplier, or internal training personnel. 


There are several purposes for training, some of which are to conform to regulatory compliance, it is to ensure indoctrination training, it is to learn new skills, it is refresher training, it is specialty training, or targeted training. Training takes form of theoretical training in a classroom setting, and as practical on-the-job (OJT) training, and concludes with a written, or practical competency test. A test also serves several purposes. One purpose is simply to pass the test. This is often accomplished by answering correctly one of multiple answers. A multiple-choice test is mere a test-taking skill, since there is no oversight of what process the candidate applied to answer questions correctly. Generally speaking, there are five methods, or processes to answer a multiple-choice test correctly. One method is by comprehending the subject, while another method is trained capability to select the correct answer by taking practice-tests with same or similar scenarios prior to the final test. Other methods are to answer correctly by elimination, answer correctly by keywords or answer correctly by multiple test-tries. Unless the subject comprehension method is applied, it is impossible to determine the adequacy of the training required as it relates to the candidate’s retention of SMS technical knowledge and subject matter. A practical test to verify quality of the OJT is not subject to the candidate’s test taking method but is subject to the examiner’s opinions. Both theoretical and practical tests have flaws, and both are unreliable as the only means to assess a candidate’s skills and the instructor’s ability to convey information to instill learning.

Unintended consequences occurs when human factors become unacceptable

Training of personnel is a specialty skill, it is a learned skill and it is an ongoing development skill. When it comes to using an untrained instructor to train other personnel, the instructor may resist to be moved out of their comfort zone and unable to train the new person to the expected comprehension level. peaking in front of a group of people is also one of the biggest fear a person has. An exceptional skilled and dependable person may not always be the best choice as the instructor to train new personnel, since their tasks in the past had been on their own development and improvement, and not on improving someone else. For a person with exceptional skills and knowledge, it may also become frustrating to accept that others still have a distance to go before they have reached the same level of ambition to achieve.


Another potential issue with assigning training tasks to a person who does not hold a position to train as a regular trainer is that there is often not enough time to do so adequately. In preparation for training an instructor needs to do research, design a training schedule, and develop target specific training to conform to an SMS enterprise’s safety policy and training objectives. There are SMS enterprises, both large and small, that believe training is busy-time, or waste of time since their personnel was already trained. In addition, refresher training that is not a part of a regulatory requirement may discourage and not allowed during regular working hours. When an SMS enterprise, or a person in a leadership position does not seek or take advantage of all training opportunities available to their personnel, an employee’s skills become stale.


Training in form of trivia may be just as effective than mandated, scheduled or required training. Trivia training does not include a competency test but is a self-evaluation of skills. Learning is a process to improve a just culture and does not necessarily need to be of technical knowledge or competency skill. Several years ago, when it was allowed to smoke in the airplane, a young flight instructor did the instructor flight test with an inspector who would smoke during the flight test. 

Later that day, the new instructor learned that the smoking was a distraction tool to learn how an instructor would respond to non-standard issues, or a special-cause variation. In addition, the final determination if the new instructor was fit, was for the flight test examiner to place the airplane in an inverted spin to learn how the candidate would react to a situation that a student could easily put an airplane into. These two tests were not a part of the flight test curriculum but was a part of the whole picture to assess if a new instructor was ready or not to take on students, and as an oversight system to assess reactions to a special cause variation.  


Unexpected consequences of training occurs when training is viewed as having reached the final qualification standard, it is when oversight becomes incidental to an activity, rather than viewed as a tool to accept imperfection in human behavior.



Line-Item Audits

  Line-Item Audits By OffRoadPilots A irports and airlines are required to conduct a triennial audit of the entire quality assurance program...