Where Birds Don't Fly

Airports initiated their first SMS phase-in implementation about 10 years ago and airline operators had started three years earlier. Over the years the Safety Management System has matured and operators, being airports or airlines, have improved drastically in skills and comprehension of SMS. During the infant stage of SMS, this new system was looked upon as the key to unlock the future, a world of safety and a system to reduce or even eliminate aviation accidents.  SMS was the key to the future, but no one knew what was behind the locked door. SMS is a brilliant system built on a solid foundation of collecting data for analysis. It takes time to build the SMS and it was to be phased in. One of the first plans were to phase-in over a 3-year period. After reviews and consultations, it was decided to implement over a four-year period with one phase annually.  The very first item on the list was the gap-analysis. Everyone was scrambling to find what they had in their own organization as s

Pilot error root cause is a simple way to identify the root cause off an incident. There is no root cause analysis required, there is no risk assessment required and there is no need for solutions. Anyone can come up with the pilot error root cause. Over the years, pilot error was the standard root cause and it still is in many organizations, large or small.  The cube on the left is a definition of pilot error. Reading newspapers, the general public seems to be a firm believer in pilot error as root cause and after every incident, major or minor, there is an outcry for more regulations. The other day a small training airplane crashed, and the community is looking for someone to blame. Finding someone to blame is simple, but there is a simple reason why it doesn’t work and why it cannot be a root cause: Pilot error is the messenger of the root cause and often it is the messenger who is blamed for the event.  Let’s apply taxiing as an example to analyze pilot error as root cause. On the