A million reasons for Safety Management Systems

Straw Poll Makes us Think

A recent straw poll asking what people knew about Safety Management Systems (SMS) in aviation produced some surprising answers. This got me thinking about why anyone would go to the trouble and expense of introducing SMS when it is currently not mandatory for on-demand (FAA Part 135) operations in the USA.

Some know "What", few know "Why"

Quite a few responders to the poll said they had good knowledge about what SMS is, but it is clear very few understand why. Quite by chance this video by the comedian Michael Jr. popped up. Watch the video then read on.

Know Your Why

Everybody's Doing It?

There may be a million reasons why anyone would introduce SMS, but "everybody is doing it" is most certainly not one of those reasons. At the first International Helicopter Safety Symposium in Montreal, September 2005, one of the speakers referred to the fact that we had already plucked the low hanging fruit in safety. Using a safety system for many decades that had consistently failed to reduce accident rates, it was agreed at that meeting to form the International Helicopter Safety Team (IHST) It set an aggressive goal of reducing the worldwide helicopter accident rate by 80% in 10 years (by 2016) There has been some success, with a notable reduction in accident rates globally.

Out With The Old

NTSB: Stall Warning Sounded Before Phenom 100 Crash

So what was the old system? Well think about it, we'd see pictures of smoking holes in the ground surrounded by accident investigators. Given time, hopefully those investigators would find a cause and make recommendations to prevent recurrence of that specific accident. But were those recommendations followed, and if so did they do as expected, i.e prevent a recurrence of that accident? This kind of tombstone safety management has failed to reduce accidents down to the ideal of zero. No doubt changes in technology, procedures, and training have made aviation the safest way to travel. But is it not a disgrace that we have to climb on the backs of so many dead people before anything gets done?

In With the New

How can we change from being reactive, that is after the crash, to proactive, that is before the crash, in our efforts to keep us safe? This is the key to SMS, the "Why". We are beginning see the "What" of SMS in that it is a systematic approach to managing safety, including the necessary organizational structures, accountabilities, polices and procedures. Wow! What a mouthful! OK, so Mom and Pop Aviatiors Inc. decide they need this, and simply copy and paste someone else's manual calling it their own. Job done? Nope... for the simple reason that neither Mom nor Pop actually understand the "Why" of the whole thing. Nor, indeed, do they understand the "What", either. And in any case isn't the "what" they're now doing exactly the same as "what" they've been doing so badly for so many years?

Risk Management and Safety Assurance

Risk management, somewhat new in concept, is how we can become proactive. Before the crash, identify risks, do something to avoid or minimize (mitigate) those risks to an acceptable level, and then make sure that what we did works! This checking back has not been part of safety before. You may have heard aviation companies boast that they are much safer than their competitors simply because they've never had an accident. WRONG! They are just lucky, because the statistics prove them wrong. On the other hand, if they practice effective safety assurance, they can rightly say, "We are safer than our competitors, and we can prove it."

Is it All About Costs?

I am an unabashed cynic. We all know that manufacturers have often been caught out not recalling something they've known about simply because it was cheaper to pay compensation to those hurt. When the accountants (or bean counters) get to the point where they decide it would be cheaper to recall that faulty motor car, or whatever, then and only then do they do it. Anyone with an interest in aviation history know that the cargo door design flaw in the DC 10 eventually led to the demise of McDonnall-Douglas. They knew about it, did nothing, and paid the price in lives lost.

Stand Head and Shoulders Above the Rest

So I would say to Mom and Pop that if they really want to stand head and shoulders above all the rest, they need to consider what they do to prevent accidents, to become clear-headed about why, and to set their standards high and then make sure they achieve those high standards. This involves an enormous commitment to working at it in every aspect of their business. This will pay huge dividends when the regulators announce that SMS is mandatory, because by that time it will be too late to go through the growing pains that all face when completely redesigning the way they manage safety. As they continue to convert their large fortune into a small one in aviation, they can at least sleep soundly at night knowing they are doing their best at preventing accidents.

More Information:

There are many resources out there. Try the USHST links page first.

HERALD OF FREE ENTERPRISE - Ships and Planes and Managers who don’t know!

HERALD OF FREE ENTERPRISE

Ships and Planes and Managers who don’t know!

Have you ever wondered if a pilot in command can learn safety lessons from a ship's captain? The answer is unreservedly yes because the similarities between the two professions are remarkable. Both are in command. Both are ultimately responsible for the safety of their vessel, their crew, and their passengers. And strangely enough in many cases they are working for people who are not experts in their profession. One of the requirements of a Safety Management System (SMS) is to define an accountable executive, he who controls the purse strings. How many pilots are working for pilots? For that matter, how many sea captains are working for sea captains? In both cases not many.

The historical lesson we can take from previous accidents in either field, whether in the air or on the sea, cannot be more clearly highlighted than by a study of the Herald of Free Enterprise Disaster. This was a roll-on roll-off ferry that capsized on 6 March 1987 causing the deaths of some 188

Figure 1 Herald of Free Enterprise 

persons because it left port with the bow doors open.  This was, as are many transportation accidents, a human error accident. The report into this accident (UK Department of Transport MV Herald of Free Enterprise Report of Court No. 8074, MV Herald of Free Enterprise) said, “At first sight the faults which led to this disaster with the aforesaid errors of omission on part of the master, the chief officer, and the assistant boatswain…" (Report paragraph 14.1) As usual, this is not the whole picture. Somewhat controversial for the time, the report's authors created somewhat of a precedent of adding the cause, "Failure of Management", to the list of causes. The most damning piece of the report is, "…all concerned in management, from the members of the board of directors down to the junior superintendents, were guilty of fault in that all must be regarded as sharing responsibility for the failure of management. From top to bottom the body corporate was infected with the disease of sloppiness."

To best illustrate this failure of management the report examined in detail the consideration that had been given, at the request of the sea captains, to fitting an indicator system to show whether the bow doors were open or closed. The captain's concerns were repeatedly documented and yet rejected for the reasons of costs or even trivial, sarcastic, and frankly incredible statements such as, “do not we pay somebody to close the doors?" Another management failure was the lack of clear orders for the crews and their officers. In short, nobody was actually ordered to close the doors. There was evidence that on many occasions the ships had been overloaded, that they sailed incorrectly ballasted and therefore unstable, and that these shortcomings had been drawn to the attention of management on many occasions by the captains.

So who were these captains working for? The report states, "… those charged with the management of the company's fleet were not qualified to deal with many nautical matters and were unwilling to listen to their masters, who were well qualified." Does this sound familiar to many a pilot? How many pilots work for management qualified to deal with aviation matters? Are not many aviation companies run by those with degrees in business, or accountancy, or almost anything except aviation? Surely this must lead to the same frustrations the ferry captains must have felt at the lack of action on serious concerns and other safety issues they had raised with management?

So is there a possible way to solve the issue of specialists working for layman? This whole story of the Herald of Free Enterprise was actually a pivotal point in the history of safety management. The introduction of safety management systems to the transportation industry in particular has many attractive features. Perhaps the most important has already been mentioned; the identification of the accountable executive. This defines, perhaps for the first time, the desk upon which Harry S Truman's sign, “the Buck Stops Here,” must sit. Part of the measure of a safety culture is the attitudes and commitment of management toward safety; having committed to adopting SMS that attitude is by design subject to change.

So if we are truly to learn from this tragedy management must listen to those who are experts in their appropriate field, react to hazards identified by their experts, and prove that they really are committed to safety by their actions not by their words. Pilots can learn from this too, for they are in the best position to find hazards both in the air and on the ground. They only have themselves to blame if they do not report these hazards.

So has your organization recently adopted SMS? Have you had your Herald of Free Enterprise moment? Have you noticed your management responding more positively to your concerns than before?