Where Birds Don't Fly

When competing in the Daytona 500, the key performance indicators are not how many errors each driver made during the race to lose, but how many laps they did better than the others to win. Each driver’s performance was compared to the other drivers in the race and the winner is the driver who performs better than everyone else. A safety management system (SMS) is in concept not any different than a Daytona 500. It is a race to perform at the highest level for operators to win their internal race to operate without regulatory findings. A regulatory compliant safety management system does not guarantee an accident-free environment, but both airport and airline operator must first adhere regulatory compliance to achieve success. There are no sound reasons to operate with regulatory non-conformances.  SMS performance assessment is a regulatory requirement, but it is not as obvious to pick a winner in an SMS as it is in the Daytona 500. After all drivers have crossed the finish line is...

Overcontrolling of a stable process for a result that is undesirable, or for a result that is extra good, the output that follows will be worse than if the process had been left alone. Overcontrolling or tampering with a process is to make immediate modifications to a process in good faith with the intent for the process to produce a desired result. Adjusting a process is to adjust a process for drift, or identified work practices that are moved away from the pattern designed. An adjustment to a process is to move the process back on track and to adjust for drift. Overcontrolling and adjusting processes are two different operational tasks. Overcontrolling makes the result worst, while adjusting maintains a process on a predetermined path. Control options are required to operate with a safety management system. These control options are designed, formalized, documented, and applied to all areas of operations for airports and airlines. Control options are used to maintain processes on tr...

Unless patterns are implemented, regulatory compliance and safety in operations are achieved by random chance only and is not the result of a safety management system (SMS) and its processes.  The purpose of an SMS is to identify patterns and build these patterns. Patterns is what makes SMS unique. Incidents are trends in operational patterns, but their root causes may vary from event to event. The root causes of Cali air disaster on December 20, 1995, and Andes air disaster October 13, 1972, had different root causes, but both airliners flew a controlled flight into mountainous terrain. Often, but not always, a common denominator of a root cause is lack of situational awareness, or the flight crew failed to complete one task. Since both flight crews assumed they were tracking on their desired track, and on their way to their destinations, in their mind they had situational awareness.  When a root cause is determined to be the loss of situational awareness, solving the problem...