Friday, January 26, 2018

The SMS Experience

Many operators may have experienced SMS as a burden to the operations and an administrative task only, while other may have experienced tangible positive results as a function of implementing a Safety Management System. Everyone wants to operate safe, but SMS doesn’t always seem to get the job done. Days of working with SMS only add to the issue of operational tasks and incidents and accidents still happens. Endless days and nights of hard SMS work doesn’t get the job done or pays off in safety. All the SMS work seems to be never-ending circles of tasks and the wheels are spinning in one place. Different methods are applied but all it does is to create irrelevant safety tasks. More and more safety tasks are added, more rules and policies are implemented but all it does is generating unnecessary tasks. At the end of the day SMS haven’t made a bit difference in safety and it has not moved away from what safety was several years ago. Year after year the focus was on safety management safety is status quo, or even with a negative support trend.

Thinking outside the box generates a conflict with what is expected to be in the box.
Air Operators or Airport Operators who implemented SMS have experienced frustration over SMS time and time over again. However, it is not possible to argue with safety and oppose regulations or policies with intent to make flying safer. Questioning safety doesn’t fit inside the box of safety expectations, safety policies or a mandatory safety regulation. Everybody says that safety is to think outside the box, but when it comes down to the nitty-gritty, outside the box processes are not accepted and findings are issued. Safety has become a tool to stay put inside the box without differentiate between regulatory requirements and operational safety processes. SMS has in its own way become its own enemy with miserable experiences for several operators and without a purpose. SMS is both being credited for 2017 to be one of the safest years in aviation history, while it is also being criticized for lack of effectiveness or lack of operational control when aviation accidents happen. SMS has ended up in a no-win situation and pushed out into no-man’s land.

If to determine the effectiveness of SMS is to count the “good” data, or to count the times when things goes right rather than the “bad” data SMS has an incredible high success rate since there are very few landing that ends up in a disaster. This view also brings up the old saying that “Any landing you can walk away from is a good landing.” Analysis of aviation safety is, and has been since the beginning, to count undesired data. It is crucial to aviation safety to comprehend undesired data for continuous improvement analysis. Data can be grouped into two groups:
1) Common cause variations (normal operations); and
2) Special cause variations (abnormal operations)
By the way, there are no “good” or “bad” data. Data is emotionless. It is all just data and nothing else.
When counting these variations there is an opportunity for the SMS to be retrieved from this no-man’s land and analyze data for continuous safety improvement. SMS itself cannot fail. It’s fail-free since all it does is to make a recording of operational policies, processes, procedures and practices. SMS is a selfie of the operations.

When SMS is applied to continuous safety improvements, is when SMS has become more than an administrative tool of shuffling reports to different managers and departments. Continuous safety improvements might not be immediate noticeable, but over time the continuous improvement will show in a reduction in common cause variations. The reduction of common cause variations is where the return on investment is and a tool to improve effectiveness at a current operational efficiency level. When applying SMS as a practical tool for improvements, and a tool for ROI on safety, that is when an SMS program becomes alive and makes sense.

Birds are the effect of landuse operations.
Let’s for a minute look at a scenario:  On approach to an airport there is a birdstrike causing damage to an airplane. An SMS report is filed, and the damages are repaired. The hazard associated with the SMS report is entered into a hazard registry, a response is submitted to the contributor, the report submitted to an appropriate manager, a risk assessment is conducted, the risk level is accepted or rejected, substitute and residual risks are assessed, a safety risk level is assigned in the hazard registry, a profile is generated of the associated hazard, the hazard is entered into objectives and goals records, criteria for investigation is determined, the investigation is conducted and concluded with an investigation summary, a root cause analysis is performed and includes contributing factors, a corrective action plan is assigned, a response to the contributor of the proposed CAP is submitted, including in the CAP are timelines, the CAP is assigned to a responsible person, a temporary SMS Ops Bulletin is issued for later to be implemented in the documentation, the CAP is implemented, monitored and assessed for performance goal and concludes with a response to the contributor that the CAP is closed. The air operator determined the root cause to be migratory bird season and the CAP to take change flight path when birds are in the area on approach or departure.

During the next 12 months the CAP is monitored, trending is applied, and a review is conducted of objectives and goals achievements and the hazard is re-issued a hazard priority to repeat the process as required. These are comprehensive tasks to address just for one type of hazard. At the end of the day there might not be any changes in safety improvement since year after year the birds are migrating across the same route and crossing the approach to the main runway.

In safety it's not the thought that counts.
When applying SMS processes as continuous improvement the air operator would include the airport in the CAP and review one or more CAPs generate by the airport operator, who is the expert of airport operations. These CAPs could ensure that there are no bird-feeding grounds or waters under final approach, the airport could conduct a bug-study for bird attractions and they could conducts study of cereal crops in the area that attracts birds and location of community landfills. When knowing these things, the airport has a opportunity to make changes to reduce bird activity in the area. By coordinating with the airport, the highest priority-level of hazards is mitigated or eliminated. If the bird-feeding grounds under final approach were to be removed, this would eventually lead to fewer birds in that area. The difference between the air operator only analysis, and the second, when the airport is involved, is that the airport is approaching it from a root cause prospective of a landuse issue, while the air operator is applying the root cause to airport operation for short term bird avoidance during operations.

Both root causes are valid and analyzing contributing factors with one goal in mind of continuous safety improvements. The continuous safety improvement factor is that each one of the root causes integrates with the other by analyzing a common variation of birds, but does this in two distinct and different ways.