SMS Reviews

SMS Reviews

By OffRoadPilots

A role for an accountable executive (AE) are to review their safety management system (SMS) and determine their SMS deviation from its planned course and path. A fully functional SMS cannot fail since it paints a true picture of operations, and any deviations from the path come from operational drift. An SMS enterprise operate with processes for conducting reviews or audits of their safety management system at regular intervals, and reviews or audits for cause or on- demand, of the safety management system when there are planned deviations from their current SMS. In addition to reviews and audits of deviations, an SMS enterprise operates with processes for reviewing the safety management system to determine its effectiveness. The first step to determine an SMS effectiveness is to determine what an effective SMS looks like. 

There are several views of what an effective safety management system should look like, and one effective SMS may be different for one organization to another. Effectiveness also changes with new tools, new inventions, or changes in expectations. A simple example are the changes from a paperformat SMS to electronic SMS and to a live cloudbased and automated SMS. The foundation of an effective safety management system is that the system conforms to regulatory requirements. Regulatory requirements are the foundation for an effective SMS, the foundation for airline or airport operations, and the foundation for issuance of their operating certificates. There are twelve factors of building blocks forming the platform for an effective SMS. A factor is circumstance, fact, or influence that contributes to a result or outcome of the SMS. When one of the blocks drift away, or deviate from its path, there is a change in the effectiveness of an SMS. The twelve building blocks are human factors, organizational factors, supervision factors, environmental factors, trust factors, learning factors, accountability factors, information sharing factors, data factors, information factors, knowledge factors and comprehension factors. When combined in one system, these blocks of interacting systems form the foundation for SMS effectiveness to be built.

Conventional wisdom is that after a goal is established, the next steps in the processes are to wait for the goals to be reached. Goals are not reached by doing nothing but are only reached by hard work. Operating with a safety management system is hard work and it is without a guarantee that this hard work will payoff, or that future accidents are eliminated. SMS is hard work by applying a daily quality control system and monitor processes for drift within its path and deviates outside of its path. Operating with an effective SMS, or a high-performing SMS is also hard work and requires strategic operating processes.

Several items are tools to operate with an effective SMS. A formalized safety policies is the first step to a successful SMS. Effective and regular communication about safety is another sign of a successful SMS. Having safety policies that are frequently communicated and accessible to everyone is important. An accountable executive is the base of support for behavior-based safety and accountability. It is crucial for an effective SMS that habits around safety are established. An SMS enterprise must focus on behavior-based safety, which is a safety methodology that focuses on improving safety through habit creation.

Unsafe behavior, or deviation from processes, are naturally habitual for workers, and they are often unaware of their own unsafe behaviors. Oftentimes, an activity has been done the wrong way for so long that workers do not consider an incorrect behavior in many cases. SMS organizations can create acceptable behavior by forming positive habits while breaking old ones. According to behavioral expert James Clear, it takes 66 days on average to develop a new habit. That means that time must be dedicated to continuous improvement in order to achieve results. The three main triggers to change habits are reminder (the trigger that initiates the behavior), routine (the behavior itself, or action taken), and reward (the benefit gained from doing the behavior). An SMS enterprise with an outstanding safety records has developed a systematic method to measure what is going on throughout their entire operation. It enables them to quickly and easily understand why something went wrong when it does.

The ability to identify high-risk situations quickly and precisely should be on every SMS manager’s and AE’s checklist for safety performance. Leading indicators can provide insight for an SMS enterprise to predict what could happen and take action to avoid accidents or incidents from occurring. SMS enterprise with low injury rates equip their workers for success and they do so through more than just processes and safety management programs. They leverage cutting-edge tools and systems to keep workers prepared and ready to handle whatever they need to. The most impactful safety management system is one that links worker with easy access the information they need and report an issue. SMS enterprises needs SMS managers who recognize the importance of continuous learning and schedule regular learning activities. Learning should be easy, practical and be tailored to expected job performance. Workers that may become leaders also needs to be prepared with tasks, tools, and support to take on leader roles when they are ready. Learning activities for managers, supervisors and workers should instill knowledge of proper practices, develop awareness of how to manage hazards to reduce risks, and gain specialized skills when their specific roles require unique preparations. The foundation of learning is for personnel to know where their comfort zone is, that they must step outside of their comfort zone, and have the tools, skills, and support required to move forward beyond their comfort zone.

Empowering personnel through the safety management system yields tremendous outcomes for an SMS enterprise. Often, the challenge with a safety management system is when focus is on preventing injuries by highlighting how bad things can get and scaring workers straight. Scaring people and information overload does very little to motivate workers to perform better. This results in a fear- based culture rather than one based on success, thus reducing the morale. A successful safety management system consistently promotes proper safety through continuous education, consistent reinforcement, and ongoing improvements.

It is natural to want to get the job finished on schedule, or even ahead of time, but with a “get it done quick” attitude is the focus, there is an increased risk for incidents to happen. Personnel may take shortcuts to “get the job done” and deviate from a specified path. Shortcuts may not be a wrong process to complete the job, but a shortcut is a deviation from a planned process with an acceptable track record. A shortcut is overcontrolling a process and over time, overcontrolling processes may cause other or additional hazards that are unknown and unaccounted for. An accident impacts productivity more than anything in a 

The review of a safety management system is ongoing in the daily quality control system. When it is time for a complete review for effectiveness, all data is already surveyed, determined, collected, recorded, classified, and reported in the safety management system. The final step in assessing the effectiveness of an SMS is to allocate goals to sensitivity levels.

OffRoadPilots

SMS Owners

 SMS Owners

By OffRoadPilots

Two owners of a safety management system (SMS) are flight operations and airport operations. In their own area of operations, they are the hazard owners and hands-on process control managers. With the implementation of SMS operational safety was moved away from the safety manager’s office and to areas of operations where they belong. In addition to social media opinions, there are still aviation managers who believe that a safety manger’s role is to keep everyone safe, it is their role to establish acceptable risk levels, and that it their role to overrule operations mangers and airport mangers if a safety manager decided a decision to be unsafe.

A safety management system is about processes and daily work practices. The final authority for risk acceptance is the accountable executive (AE). It is important to know that an SMS is not the magic wand that prevents future accidents from happening but is a tool to lay out the path for success. The first task on this path is to develop work practices with an output that conforms to regulatory requirements. One daily task may combine compliance with several compliance requirements. Another task is to develop work practices that conforms to safety in operations. Safety in operations is more than preventing accidents, it is also reliability of operational tasks. This could be reliability of the daily inspection at an airport, reliability of developing aside operations plans, or reliability to communicate non-standard airside work practices and decisions in a timely manner to the SMS manager and AE. A healthy SMS is not about prohibition and restraints but is about communication and accountability.

Taking ownership at work is to take initiative and responsibility for success or failure of SMS enterprise. SMS teams needs players willing to step up and take ownership of mistakes or challenges, as opposed to wanting to blame others for any issues. In practice, taking ownership within an SMS system means being proactive, solution-oriented, accountable, and committed to continuous improvement. Anyone who takes on ownership at work are prepared and ready to take on whatever challenges come their way. They have strong problem-solving skills and anticipate problems to prevent them before they happen, rather than waiting for things to go wrong and scrambling to fix them. They are also looking for ways to improve things. They're the ones who come up with new ideas and find creative solutions to complex problems. Workers who take ownership also take responsibility for their own actions. They own their mistakes and take responsibility for their successes. SMS team members don't shy away from accountability, they embrace it. Ownership is key to having a high-performing team. When a worker buys into the SMS, and its vision and they feel that they have a stake in its success, they are more likely to be engaged in their work.

There is a difference between a worker taking initiatives and a worker accepting a risk or developing risk controls outside of their area of responsibility. Accepting or rejecting a risk is the role of an accountable executive. A worker’s initiative is not to make changes that affects operations, but to take initiatives to communicate suggestion, hazards or options with managers and the accountable executive when issues arise. It is also to make initiatives and take actions when there is an apparent threat to personnel, equipment, or structures. Such action could be to initiate a missed approach without being instructed by ATC.

Unknowingly to the flight crew their airliner on final approach was lined up on the taxiway with several sequenced aircraft for departure. The flight crew observed lights, that they thought were aircraft on the runway. They made an inquiry to the tower who informed them that the runway was clear. Within an SMS world, a pilot is allowed to conduct a missed approach even if they are wrong in their assessment of an apparent danger. An airside ground vehicle with a clearance to cross a runway, may decline the clearance if there is something they have concerns about, even if their concern was not an actual issue. Taking initiatives within an SMS enterprise is to take initiative without consideration for punitive actions, or to take initiative for actions that later was shown not to be necessary.

The safety management system was sold as the solution for airlines and airports to identify risks before they become bigger problems, and that the regulations was required as an extra layer of protection to help save lives. When the safety card is played, i.e. that the regulation will “save lives”, is a red flag since their safety statement is without merit for an effective safety management system. It sounds good that SMS will save lives, but accidents have still happened after SMS was implemented. SMS was, and still is, sold as “saving lives” tool. If this statement is true that an SMS actually saves lives, it is not the fault of an SMS operator when there are occurrences.

In 2011 an SMS enterprise crashed an airliner. In this instance their SMS did not prevent the accident from happening. The aircraft was cleared to descend out of controlled airspace for an approach. The crew initiated the pre-descent checklist and the FO contacted the terminal controller and provided an ETA, with their intentions to conduct a Runway 35 approach. The crew then contacted tower controller, who advised them of the altimeter setting, winds, and instructed them to report 10 nm final for Runway 35. The crew asked tower controller for a runway condition report and was advised that the runway was a little wet and that no aircraft had used it during the morning. The crew initiated the in-range checklist, they configured the aircraft for approach and landing, and initiated the landing checklist. At 10 NM final for Runway 35 the captain called for the gear to be lowered and for flaps 15. At this point in the approach, the crew had a lengthy discussion about aircraft navigation. The aircraft flew a controlled flight into terrain about 1 NM east of the runway.

Another incident that an SMS was unable to prevent, was a taxiway overfly at a busy airport. An aircraft was cleared to land on runway 28R but instead lined up with parallel taxiway. Four air carrier airplanes (a Boeing 787, an Airbus A340, another Boeing 787, and a Boeing 737) were on the taxiway sequenced for takeoff. On approach the flight crew contacted ATC with a concern that there were aircraft lights on RWY 28R, and ATC informed them that the runway was clear. The flight crew of one of the sequenced aircraft then informed ATC that the approaching aircraft was “on the taxiway”. The tower controller instructed the incident flight crew to go-around. The approaching airplane descended to an altitude of 100 ft above ground level and overflew the first airplane on the taxiway continued its descent to 60 ft overflying the second airplane on the taxiway before starting to climb.

The flight crewmembers had recent experience flying into this airport at night and were likely expecting the airport to be in its usual configuration, but on the night of the incident, parallel runway 28L was scheduled to be closed. The captain later stated that, as the airplane approached the airport, he thought that he saw runway lights for runway 28L and thus believed that runway 28R was runway 28L and that taxiway C was runway 28R. The captain asked the first officer to contact the controller to confirm that the runway was clear, at which time the first officer looked up. By that point, the airplane was lined up with taxiway C, but the first officer presumed that the airplane was aligned with runway 28R due, in part, to his expectation that the captain would align the airplane with the intended landing runway. Neither flight crewmember recognized that the airplane was not aligned with the intended landing runway until the airplane was over the airport surface, at which time the flight crew initiated a low-altitude go-around.

Both incident airlines were operating with a regulatory conforming safety management system, but their SMS were unable to prevent the incidents. There are several reasons, or justifications, for these occurrences, but one fundamental SMS principle lost in the equation, was for the rightful owner to take ownership of their SMS and do something about it. In the second example, both ATC and one of the sequenced flight crew took ownership and prevented a disastrous outcome. SMS ownership is what made a difference, and SMS ownership is what prevented a major accident. SMS in itself did not prevent any of these occurrences, but taking ownership of progressing events would have made a different outcome.

A successful SMS is built on a foundation that personnel accept their roles as hazard owners. An SMS that does not identify its rightful hazard owners is an ineffective tool. A captain is the final authority and decisionmaker of a flight and this principle must not change. Everyone else need to accept that the captain is the final authority, and that other flight crew members have other ownership roles.

An accountable executive is the owner of regulatory compliance and safety in operations. However, an AE is not the owner of an SMS manager, and when they reject a recommendation from an SMS manger, the AE must take ownership and develop their own action to implement in their safety management system. Just as a CEO of a corporation may reject a recommendation made by an accountant or lawyer, a CEO, or AE may also reject a recommendation by an SMS manger and design their own action plan. Ownership is different than authority. Authority is to make decisions on behalf of someone else, while ownership is applied to a floating task for a person to pick up. Ownership is not an action that someone else need to do but is an action that I need to do at this moment.

An accountable executive is the owner of all hazards, director of flight operations is the owner of all flight hazards, director of maintenance is the owner of all maintenance hazards. In addition to these SMS owners, each person within these departments are the owners of hazards as they are applicable to their job performance expectations.

OffRoadPilots