Measure Why Things Go Right

 Measure Why Things Go Right

By OffRoadPilots

The safety management system (SMS) to learn what goes right every day but very

quickly became a tool to catch failures by airport and airline operators. When the

safety management system was sold to the aviation industry, it was promoted as a

tool to help operators identify safety risks before they become bigger problems, or

accidents. A safety management system does not predict when future accidents

will happen but when used correctly it is a system that prevents accidents. An SMS

does not predict a specific time (speed), space (location), and compass (direction)

when an accident will occur, and prevented accidents goes unnoticeable. Since

prevented incidents and accidents goes unnoticed it does not make sense that a

successful SMS must focusing on capture such data.

A safety management

system is a modular system

built on two fundamental

modules. Each one of these

two modules function

independently of the other

module, but both modules

need to be designed and

developed before a safety

management system is

implemented. Modules are

furnished with blueprints,

purpose descriptions, guidance directives, monitoring systems, planned outcome,

corrective action plans (CAP) and followup guidance. These two modules are linked

to complete their purpose to navigate the safety management system through

regulatory and operational requirements.

The two linked modules of a safety management system are the regulatory

oversight module, and the operational process management module. The

regulatory oversight module is applicable to the accountable executive (AE), and the operational process management module is applicable to the person who is

managing the safety management system (SMS manager). Since both positions are

appointed by the certificate holder (CH), their roles and responsibilities are to

maintain compliance on behalf of the CH.

Duties of an accountable executive to be responsible for operations or activities

authorized under the certificate and accountable on behalf of the certificate

holder for meeting the requirements of the regulations. Within the regulatory

compliance module, the AE has available blueprints, purpose descriptions,

guidance directives, monitoring systems, planned outcome, corrective action plans

and followup guidance as their regulatory compliance toolboxes. Assessing the

regulatory module for compliance is a snapshot in time of applied regulatory

requirements. Regulatory compliance are still-pictures of tasks, while operational

compliance are live videos of tasks.

A regulatory requirement of a

safety management system is

to include a safety policy on

which the system is based and

must meet specific regulatory

requirements. A safety policy

may also be known as the

SMS policy.

A safety policy is a statement

of what an organization is

committed to in regards to

establish processes with desired outcome, or safety in operations. A safety policy is

signed on behalf of the certificate holder by the accountable executive. An SMS

policy clearly states intentions, management principles and aspirations for

continuous and continual improvement of process outputs, and level of safety.

Continuous improvements are to make adjustments to current processes, while

continual improvements are to change the process. An example of continuous improvement is the change from handwritten reports to typewriter reports, and an

example of continual improvement is the change from paper documents to

electronic documents. Continual improvements may not always improve processes

and outcome as expected.

Process improvements are achieved through documented policies describing what

organizational processes and structures it will use to achieve the SMS. An SMS

policy should also contain a statement outlining the objectives and expected

outcomes to achieve through its SMS. The safety policy must be seen to have

value, it must be the philosophy that everyone adheres to in their everyday

activities, and it must be clear and practical for compliance and practical to read.

An SMS policy forms the foundation for an operator to furnish the regulatory

compliance module. A safety policy is guidance for accountability from the AE to

managers accountability and accountability by all personnel.

A safety policy includes safety objectives that clearly define what an operator

expects to achieve with its SMS. The objectives, as well as a top-level statement

regarding commitments to achieve improvements in safety, forms the basics of a

safety policy. Objectives must be clear and achievable and define the limits within

which an operator is operating. Objectives are unambiguous, well documented,

and readily accessible.

Roles and responsibilities for an AE is to maintain oversight how the SMS policy

function as a tool for regulatory compliance, as opposed to a tool to focus on what

went wrong and incidents. An SMS policy is stable and does not change with

process outcome. The role of an accountable executive is to design, develop and

apply daily oversight compliance systems.

When an SMS is used as a tool to focus on what went wrong, the SMS policy

excludes the seven principles of compliance, which are blueprints, purpose

descriptions, guidance directives, monitoring systems, planned outcome, corrective action plans and followup guidance. An SMS policy does not include a blueprint to induce occurrences, it does not include a purpose description of occurrences, it does not include guidance directives of how to initiate occurrences, it does not include a monitoring system to monitor that operations is on the right path for an occurrence, it does not include a planned outcome for occurrences, it does not include corrective action plans when occurrences did not happen, and it does not include followup guidance of CAPs to induce occurrences. A focus tool within a policy, is of what happen, since something was happening and replaced

what did-not-happen.

When an SMS is used as a

tool to focus on what when

right, the SMS policy

encompasses all seven

compliance principles are

active contributors. When

things go right, the blueprint

becomes the overlay

snapshot in time of the

regulatory requirement to

operate with a safety policy.

A safety policy may include

daily inspections at airports,

and performing the daily inspection is therefore allocated to the safety policy. In the operational module, the daily inspection process is the blueprint of the process

and tasks to be performed. Completed items on the daily inspection checklist is

allocated to the performance of the safety policy as what went right. When

hazards are discovered, such as debris on the runway, the debris is assigned to

what went right during the inspection. That debris are runway hazards are

incidental to the performance of the task which captured the debris.

The regulatory module is applying the safety policy to a purpose descriptions,

which could be as simples as to maintain regulatory compliance. In the operational module, the purpose description is applied a safety in operations. Guidance

directives are applied in the regulatory module to the text of how to apply the

safety policy, and in the operational module, are applied as airside operations

plans. The regulatory module apply monitoring systems to the safety policy to

capture drift of the policy, or changes in the interpretation of the policy, and in the

operational module it is monitored as a quality control system, what tasks are

completed, when they are completed, where they are completed, who (position)

are completing the tasks, why they are completed and how they are completed.

The planned outcome of a safety policy is in the regulatory module an outcome

that the safety policy is in existence and communicated to all, and in the

operational module, drift from the planned outcome is recorded, analyzed and

root cause assigned for a CAP. Corrective action plans in the regulatory module are

corrections to existence and communication of the safety policy, and in the

operational module, the CAPs are applied to operational processes the are

deviation from the safety policy. Deviation from the safety policy could be to

remove debris on the runway without recording it in the SMS system. Followup

guidance in the regulatory module is to have a system in place to capture new

regulations, and in the operational module, new processes are designed to

conform to the new regulations.

In both the regulatory module and the operational module, the same method is

applied to other regulatory requirements. An SMS is required to include a process

for setting goals and for measuring those goals, a process for identifying hazards

and managing the associated risks, a process for training of personnel and that

they are competent, a process for reporting and analyzing hazards, incidents and

accidents and for taking corrective actions, a document containing all safety

management system processes and a process for making personnel aware of their

responsibilities with respect to them, a quality assurance program, a process for

conducting periodic reviews or audits of the safety management system and

reviews or audits, for cause, of the safety management system, and any additional

requirements for the safety management system that are prescribed under the

regulations. Placing these items into both the regulatory module and theoperational module is hard work and a comprehensive task. However, when all

tasks are completed, it is a simple task to follow the compliance path.

Measuring what goes right is

a more complex task than

measuring failures. It is more

work to identify and build

systems than it is to tear

down systems to fail. The

regulatory requirement to

have a process in place to

capture hazards is not a

process to fail a system but is

a process to make a system

successful by the fact that

hazards were captured.

It is also difficult to measure what went right when a system did not capture a hazard and resulting in an incident. An example of something that went wrong could be if a daily runway inspection did not capture debris on the runway, causing an incident and nothing went right. The easy way out is to capture the incident and focus on the failure.

When measuring what went right, move the occurrence to the regulatory module

and the operational module. Conduct a special cause variation root cause analysis

as appropriate to scope of airport operations, with a corrective action plan to

include human factors, organizational factors, supervision factors or environmental

factors. After an occurrence, the air operator conducts a root cause analysis of

aircraft operations, and the airport does one for airport operations. After tasks are

completed in both the regulatory module and the operational module, record the

failure to discover debris on the runway as an item that went wrong.

Measurements are neutral.When things go wrong does not give an operator an excuse to focus on failures, but it becomes a part of an intergraded system to measure the reliability why

things go right.

OffRoadPilots