Sunday, October 30, 2022

Remote SMS Manager

 Remote SMS Manager

By OffRoadPilots

The person managing the SMS (SMS Manager) for an airline or airport has more opportunities to positively affect safety processes in an organization when there is a physical distance between the operator and SMS Manager. For the integrity of an SMS program, the person managing the SMS is expected to report directly to the Certificate Holder (CH) and remain independent and separate from both airline and airport operations. 


It is the CH who appoints a person to manage the safety management system, it is the CH who appoints the Accountable Executive (AE), and it is also the CH who maintain the safety management system. The CH is also the operator, or the operator my be any person in charge of operations, whether as employee, agent, or representative of the CH. The two executive positions as AE and SMS Manager play unique roles by their appointed positions to remain independent of airline or airport operator and preserve the integrity of the SMS. The CH appoints two positions to be responsible for meeting the requirements of the regulations on behalf of the certificate holder. Since their roles are to ensure regulatory compliance, these positions are at equal level in an organisation chart. That an SMS Manager is required to make progress reports to the accountable executive at intervals determined by the accountable executive is a component of the SMS and is not an organizational hierarchy position. However, the AE is the final authority for meeting the requirements of the regulations on behalf of the CH.

he Quality Assurance Program (QAP) is component of the SMS and maintained by the CH. The QAP Manager is not an appointed position by the CH but is an administrative position under the SMS Manager to manage and facilitate QAP responsibilities. By placing the QAP under control of the person managing the safety management system, the program’s integrity is achieved by its independence from the operator. A quality assurance program includes an audit function that consists of an audit of the entire quality assurance program carried out every three years, or a series of audits conducted at intervals set out in a controlled manual to be fully completed triennially. This audit function is performed by an operational independent source and by a person who is not responsible for carrying out operational tasks. An operator does not collect and assess data and performs an audit of its own performance unless the risk is accepted by the Regulator due to size, complexity, and nature of its operations. 

The role of an SMS Manager is to implement a reporting system for the timely collection of information related to observations, hazards, incidents, and accidents. Effective SMS Managers collect data in a timely manner and maintain safety compliance oversight by electronic means, rather than by unreliable paper documents.  An SMS Manager identifies hazards and carry out risk management analyses of those hazards. They investigate, analyze, and identify the cause or probable cause of all hazards, and also identify the root cause of special cause variations. SMS Mangers are required to implement a safety data system, by either electronic or other means, to monitor and analyze trends in hazards. The purpose of data collection and trend analysis in SMS is not to find errors, but to collect data to analyse how the system works compared to its expected outputs. As an example; checking the oil level, tire pressure, or adjusting rear-view mirrors in a vehicle is data collection to learn how a system function, and is not data collection to find errors. In addition, SMS trend analyses must be done within an SPC system (Statistical Process Control) which is not based on opinions or emotions caused by any graph charts. I often hear the phrase: "it is nice that the graph has a downward trend” A downward trend could be a latent hazard ready to explode, or it could be a safety improvement. One does not know if it is a safety improvement or not just because the graph is trending downward. An invaluable program to use is to apply p-control charts and xmr-control charts. These two control charts supplement each other with performance (80/20 rule) and timely delivery (UCL - LCL). A primary responsibility for an SMS Manager is to monitor. SMS Managers also monitor and evaluate the ongoing results of corrective actions, monitor the concerns of the civil aviation industry in respect of safety, and determine the adequacy of the training required. Monitoring is achieved by collecting data daily, or more frequently due to size and complexity, and applying control charts to identify drift in operations. Every role and responsibility of an SMS Manager has already been established as a remote function, even if operations and safety share the same office. 

The safety management system in aviation is a product of a continuing evolution in aviation safety. Early aviation pioneers had little safety experience, or practical experience to guide them. Over the years, each reactive approach to occurrences has led to significant gains in safety. However, even with these significant advances, the term "organizational accident" was developed to describe that accidents are related to organizational decisions and attitudes. SMS is an approach to improving safety at the organizational level. A superior SMS Enterprise applies this concept and include system analyses to examine its operations, its impact on sub-systems, and the effect of decisions implemented. SMS allows an organization to adapt to change, increasing complexity, and limited resources. SMS is also about enhancing organizational policies and processes, the organizational culture of leadership management and forward-looking accountability. 


The role of a person managing the safety management system is about processes, and to what level operational processed conforms to regulatory compliance, standard compliance and their safety policy. Since it’s all about processes, an SMS Manager located off-site has greater opportunities to analyze processes independently of operations. A pre-SMS process only expectation was that a safety officer had unlimited powers to fix all unsafe conditions and to make stern statements of the issues. The pre-SMS culture is still alive in SMS organizations, and with the SMS Manger in the office every day, there is a temptation to just “say hi” and ask for an immediate fix. With the SMS Manager at a remote location, this temptation is removed, and the SMS manager has more time to focus on processes. In a successful and effective SMS Enterprise, the person managing the SMS is a confidential adviser to the AE, located in a physical remote location from the operator, independent of operations and is without bias ties to oversight and management by an SMS Enterprise. In other words, a successful SMS Enterprise are using expertise services of a contracted SMS Manager, just as they are contracting other expertise third-party services. This enables the SMS Manager to freely, and without interference, to establish unbiased processes to be presented to the AE for acceptance or rejection. If rejected, the AE must alter identified processes to their own liking, and sign-off in a risk assessment, or system analysis, that the recommendation by SMS Manager was rejected. 

One reason for a safety management system to go off the rails, is that emotions are applied to safety, rather than data, facts and processes. A remote located SMS Manger has a-million more opportunities to successfully keeping SMS on track, than what an in-office employee has.  


There are three tools that an SMS Enterprise cannot effectively function without: The SMS Memory Jogger for out-of-control tests, SPCforexcel to analyze trends in performance and delivery, and SiteDocs as an electronic data collection tool.




Sunday, October 16, 2022

System Analysis

 System Analysis

By OffRoadPilots

A System Analyses is Safety Risk Management (SRM) and is the highest achievable level of a successful Safety Management System (SMS). Systems analysis is the process of studying a system and its interacting systems. System analysis projects are fundamental to define problems or issues, discover opportunities for incremental improvements, and to publish directives or operations plans. System analyses are what makes the SMS a common-sense approach to incremental process changes

When applying safety risk management an SMS enterprise conducts system analyses for implementation of new systems, revision of existing systems, development of operational procedures, and for identification of hazards or ineffective risk controls. When conducting a system analysis, an SMS enterprise considered function and purpose of the system, the system’s operating environment, an outline of the system’s processes and procedures, personnel, equipment, and facilities necessary for operation of the system maintain processes to identify hazards within the context of the system analysis. 


The context of a system analysis is the circumstances that form the setting for an event or observation in terms of which it can be comprehended and assessed. A system analysis is more than checkbox completion, is a comprehensive task to analyze details of how each system interacts with other systems within the analysis. A system analysis includes analysis of common cause variations but excludes special cause variations from the analysis. A common cause variation is a variation required for the system to function as intended. Common cause variations are controlled and managed for the process to produce a desired output. The difference between an intended output and desired output is that an intended output is a process where common cause variation is without control action, and a desired output is a process with a control action applied. 

The vast majority of issues come from common causes of variation, due to the way processes are managed on a day-to-day basis. If special causes of variation are present, a root cause analysis mut be conducted to identify the issue and for a process to change course of action. The only effective way to separate common from special causes of variation is through the use of SPC control charts. A process is in statistical control when only common cause of variations are present and this is determined by examining SPC control charts. When there are no points above or below the upper and lower control limits and without trends, then a process is said to be in statistical control.


For a system analysis to be effective and make a difference, an identified hazard is within the context of the system analysis. The context of an analysis is the area, or segment of operations affected by the event or observation. A new gate assignment at an international airport may affect flight operations, dispatch, and maintenance, while a new parking location for a single engine freight carrier, the pilot might be the only context of a system analysis. 


Within a safety management system there are five generic features to characterize a SMS. There is a comprehensive systematic approach to the management of aviation safety within an organization, including the interfaces between the company and its suppliers, sub-contractors, and business partners. There is a principal focus on the hazards of the business and their effects upon those activities critical to air operations or airport safety. In addition to the safe operations of aircraft or airport, there is full integration of safety considerations into the business, via the application of management controls to all aspects of the business processes to safety critical areas. It is crucial for the success of an SMS that there are active monitoring and audit processes to validate that the necessary controls are in place, and to for a continued commitment to safety. The fifth characteristics of an SMS is the use of quality assurance principles, including improvement and feedback mechanisms or tools. 

An SMS enterprise must operate with a process to identify hazards and associated risks, analyze risks, and develop new risk controls that affect multiple processes, or hazard owners, within its organization. A final risk acceptance may be made at a management level above the process owner, by a committee, or by the accountable executive. Processes may be decided by the process owner, while policies are decided on management level. A comprehensive system analysis requires technical knowledge of areas within the context of the analysis and how identified hazards affect those areas. 


A system analysis is an invaluable tool when maintaining a safety management system. At the time of the SMS phase-in implementation, operators were required to conduct a gap-analysis, which is very different from a system analysis. System analyses are ongoing and applied at stages parallel to the process flow. Processes in an SMS system is to operate pursuant to a safety management plan, maintain documentation management, safety oversight, training, quality assurance and emergency response preparedness. For each one of these SMS sub-systems, or components, a system analysis is conducted and applied to air operations or airport operations prior to a complete system analysis of the SMS. 


Audits are prerequisites for a full SMS system analysis. Audit results are unbiased, they are based on facts and paint a true picture of operational processes. Each system, or sub-system audited, becomes an independent system analysis. At the conclusion these systems are combined and will paint a picture of flaws in the operations, or paint a picture of an operation where common cause variations are managed and controlled.   




Saturday, October 1, 2022

SMS Bulletins

 SMS Bulletins

By OffRoadPilots

Safety Management System (SMS) Bulletins is published for current issues and areas of concern. Areas of concern may be based on data and facts, or just an opinion of the SMS bulletin publisher. Opinions are forward looking, while data and facts are backwards looking. One is just as important as the other. For SMS bulletins to be effective they should be published regularly. Just as a newsletter in a small or medium SMS Enterprise, a SMS bulletin communique should be expected to arrive in the inbox monthly

An active safety culture can be considered as the heart that is vital to the continuing success of an SMS, and it gives the dynamic energy needed for a system to provide a continuous cycle of incremental improvement. This can only be developed by leadership, commitment and setting a good example. When an SMS bulletin is published at irregular intervals, or not published at all, is an appearance of a level of commitment to SMS below what is expected of the workers. SMS bulletins offer options to management to justify a safety management system that is versatile, flexible, and fluid. A rigid SMS system is a hazard to aviation safety, while a versatile, flexible, and fluid SMS system leaves room for incremental improvements. A grassroot SMS with left-out checkboxes, but with 100% buy-in is infinitely better than a perfect high-level system with all checkboxes completed but are without commitments. Publishing a bulletin about cognitive lockup, is one example of an ongoing human factors campaign.

SMS bulletins are issued by the person managing the safety management system as a data point to conform to regulatory compliance by monitoring the concerns of the civil aviation industry in respect of safety and their perceived effect on the certificate holder. An SMS is generally defined as a formalized framework for integrating safety into an organization's daily operations, including the necessary organizational structures, accountabilities, policies, and procedures. SMS is a tool that becomes part of an organization's culture, and of the way people go about their work. While individual personnel routinely make decisions about risk, SMS focuses on organizational risk management, human factors, supervision factors and environmental factors, and includes and supports the decision makers. An SMS is scalable and can be designed to meet the needs of a given operation in a way that respects the scop and nature of their work. An SMS bulletins fits in by addressing areas of interest within the scope and nature an SMS enterprise. The scope and nature of an organization are best known by the operators themselves and SMS bulletins are excluded from a one-fit-all. 

An SMS bulletin is a communique with a link to the SMS Safety Policy to provide for a bulletin with accountability. Accountability is a place where there is trust, jut culture, learning and information sharing. An SMS bulletin builds trust between human interactions, human and hardware interactions, human and software interactions and human and the operating environment. An SMS bulletin builds faith in the internal SHELL model. Bulletins are often viewed as a tool to communicate immediate threats to aviation safety, approaching hazards (e.g hurricanes or winter storms), or to communicate common errors by personnel. While these are valid events to publish bulletins, within a safety management system a bulletin is a tool to instill operational awareness of daily regular tasks.     


SMS bulletins are tools to instill awareness and competency in daily operations. When the reasoning for a task is that “we have always done it this way and had no accidents”, it is often forgotten that several years ago multiple fatal accidents happened. Human behavior is to suppress what is unpleasant. SMS bulletins is a path to accountability in a just culture. A common human behavior is to believe that we are quite skilled at multi tasking. Nothing could be farther from the fact. The concept of effective multi tasking is simply a common misbelief, with no basis in science. Task sequencing is very different than multi tasking. This misbelief has led to aircraft accidents. It could be possible that the main component this human limitation is cognitive lockup, which is the tendency of operators to deal with disturbances sequentially. Cognitive lockup can also be defined as holding on to a task or sticking to a problem, which yields a reluctance to switch to an alternative task or problem. An extremely high-profile event exemplifying this was the December 1972 EA L1011 Flight 401 accident when the crew was troubleshooting a malfunctioning landing gear indicator light.

Cognitive lockup happens when the operator focuses on an immediate threat or fault and forget the other interacting systems. Attention tunneling accompanies cognitive lockup narrowing of focus on the immediate threat to the exclusion of other simultaneous competing task demands, e.g., focus on gear light vs. flying the aircraft. Cognitive lockup also yields to emotional hijacking when brain disagree with the actual experience. The brain declares an emotional emergency, causing a reduction in the rational brain’s problem-solving capabilities. Mitigations to cognitive lockup is to recognize of separate external pressures upon pilots’ time and task. Recognition of high cognitive lockup threat during the different phases of flight and especially during critical phase of flight such as arrivals and departures. 


Training in recognition and skillset of positive task switching brief evaluation of task priority assessment. Development and training with decision support tools and practice apply these tools regularly in training. Cognitive lockup is not only applicable to pilots, but also to airside crew and air traffic services personnel. Human factors training is also a regulatory requirement before being assigned tasks airside to optimize the human factors interface within the concept of SHELL. 




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