When SMS is Flawed

A safety management system (SMS) is a system which paints a true image of airports and airline operators and does not fail, but when an SMS is abused, it becomes a flawed system because it is painting a precise view of an SMS enterprise. A flawed SMS is a misjustice to the SMS, since all what an SMS does is to paint a picture of an SMS enterprise. A flawed SMS is a flawed SMS enterprise. 

A simple tool to recognize a flawed SMS is to analyze the ratio of special cause variations to daily quality control processes. An SMS with perfectly aligned datapoints is a flawed SMS. Every data point measured show some degree of variation, no matter how much we try to control variations. It is impossible to attain identical results for two each task of a process. Each result is different, even if the difference is microscopical. A microscopical variation is invisible or indistinguishable without the use of a microscope, or detailed process analysis. Variation may be defined as a numerical value used to indicate sample variations. Variance is a measurement of how data, or acceptable practices are distributed about an expected value or the mean. If a variance of zero is attained indicates that results are identical which is an uncommon condition. Variations points show data points spread out from each other and the mean, and a smaller variation indicates that the data points are closer to the mean. Variations from the mean are positive values. 

A flawed safety management system is founded in the design and development of the foundation of the SMS. An SMS foundation must be strong enough to carry the weight of the SMS structure, which is incidental to the SMS foundation. When there are flaws in construction of the foundation, the structure itself will eventually crumble and fall. Any attempt to repair, rebuild, or change the structure does not improve the foundation on which it is built. SMS was railroaded in its infancy and left on an abandoned spur. The current SMS is flawed and is not an SMS but a parody of the intent of a safety management system, which makes it acceptable to the aviation industry. 

A news story just recently reported an incident where the safety management system failed to prevent the incident. Actually, and correction, it was not the SMS that failed, but the parody of the SMS implemented by the aviation industry, both airlines and airports. There is no justification for this incident to happen when operating with an actual SMS. Flight 334 [airline reported as flight 345] was aborted after the jet made contact with a CC-130H Hercules while taxiing for departure, resulting in the damaged wingtip. An incident at the Valley Airport on Wednesday involved an airliner and a military aircraft. The airport authority brushed it away as a minor incident. A representative from the airline confirmed the incident, involving flight 345 with a comment that the aircraft made contact with a parked CC-130H Hercules while taxiing out for departure.

A parody of a safety management system is unaccountable and needs incidents to justify its existence. A true SMS does not need incidents since a true SMS analyze daily quality control processes and why things go right as opposed to why things to wrong. Without incidents there is no justification to operating with a system that prevents incidents. This is an acceptable approach by the regulator, who in their own words states that “SMS is based on the idea that you can always find better ways to prevent hazards, so the system will always be changing.”  In addition, airports receive regulatory findings when they are unable to provide evidence of incidents to populate their hazard register. 

Conventional wisdom is that an SMS is an organized approach to managing safety. It sets out the organization's structure, identifies the accountabilities and responsibilities of all personnel and documents polices, processes, procedures, and acceptable work practices to manage safety effectively. An effective SMS identifies hazards that could affect airlines or airports, assess the hazards, and prioritize safety critical hazards for mitigation measures to reduce the risk level to as low as reasonably practicable (ALARP). Reasonably practicable involves weighing risks against the trouble, time and money needed to control it. ALARP describes an acceptable level of risk control. 

Using "reasonably practicable" allows SMS enterprises to establish objectives and goals holders, as opposed to prescriptive requirements. This flexibility is an advantage, but it has its drawbacks. Deciding whether a risk is ALARP can be challenging since it requires SMS enterprises to make commitments to processes by exercising sound judgement. A tool for airline or airport operators to evade accountability is to use industry acceptable practices when deciding acceptable risk levels. Due to common cause variations, an acceptable risk level at one airport may not be acceptable for another airport. An airport in the high Arctic may assess the same risks differently than an airport in a metropolitan area, or an airport located at 9,200 feet ASL may assess risks differently than the other two. There are inherited risks in aviation, or common cause variations risks since a manmade object is transitioning from a gravity-controlled environment on the ground into a gravity management environment in the air which is manually controlled by Pitch, Roll and Yaw. 

When identifying contributing and root causes, airports and airlines are expected to consider human factors, organizational factors, supervision factors, and environmental factors. It is vital that airports and airlines maintain the confidence of the travelling public. Through the safety management system, they are committing to provide a systemic, explicit, and comprehensive process for managing safety risks. By embracing the safety management system, they are accomplishing inclusion of safety as an integral part of their culture and recognizing that safety is paramount. Safety cannot be a priority since there are inherent risks in airline and airport operations. However, safety is a priority as it relates to regulatory compliance in a static environment. A static environment is a set of conditions such as regulations and standards, events, and surroundings that don't change. In theory, once understood, a static environment doesn't offer new or surprising elements. A static airline or airport environment is any system that is intended to remain unchanged by users and administrators. 

Human factors, organizational factors and supervision factors are based on studies that evaluates and comprehend human interactions and human behaviors in relation to other human and environmental within a workplace system. Conventional wisdom is that human errors quals human factors. Human error is a sub-category of human factors. Human factors are how the five senses generate reactive or proactive actions by vision, hearing, smell, taste, and touch. The sub-category human error is commonly applied as a failure to comply with a prescriptive requirement depending on the outcome by flight crew reactions. When an outcome does not generate an incident, a pilot is praised for their action. On the other hand, should the outcome generate an incident, the same action taken by a pilot is assigned as pilot error and the pilot is terminated. When operating with a parody SMS, or an SMS without accountability and action is fully acceptable, since it was the pilot who caused the incident. When operating with a true SMS the outcome is incidental to operating processes. 

The SHELL model is the foundation of human factors, organizational factors and organizational factors interactions with airline and airport operations. There are three sub-categories of environmental factors. 

1. Designed environment as it relates to a user-friendly environment, design and layout environment, accessibility environment, and tasks-flow environment. 

2. Social environment as it relates to distancing, experiences, culture, and language. 

3. Climate environment as it relates to geo location, weather, and temperature.

Human factors, organizational factors and supervision factors interacts with environmental factors in addition to interactions within each one of the factor. E.g. pilots interacts with other personnel, management interacts with other managers, and supervisors interact with other supervisors. 

Vision affects human behavior to take reactive or proactive actions. Vision is an observation of a condition or event, and a reactive behavior is a reaction to avoid, investigate or approach. Vision generates a proactive behavior in anticipation of an event. As an example, when driving on the highway and a wildlife approaches, there is an anticipation of what direction of travel the wildlife may take and the driver takes anticipated actions. 

Hearing affects human behavior to take reactive or proactive actions. Hearing is an interpretation of a condition or event, and a reactive behavior is a reaction to avoid, investigate or approach. Hearing generates a proactive behavior in anticipation of an event. As an example, when hearing a loud noise there is an anticipation of what future event may happen based on the noise and person takes anticipated actions. 

Smell affects human behavior to take reactive or proactive actions. Smell is an interpretation of a condition or event, and a reactive behavior is a reaction to avoid, investigate or approach. Smell generates a proactive behavior in anticipation of an event. As an example, when smelling a strong or unknown odor, such as smote and anticipate a fire, there is an anticipation of what effect the underlying cause is, and a person takes anticipated actions. 

Taste affects human behavior to take reactive or proactive actions. Taste is an interpretation of a condition or event, and a reactive behavior is a reaction to avoid, investigate or approach. Taste generates a proactive behavior in anticipation of an event. As an example, when the taste is pleasant there is an anticipation of a pleasant future, and a person takes anticipated actions. Where the taste is unpleasant, there is an anticipation of an undesirable future, such as when water taste differently than normal. and a person takes anticipated actions. 

Touch affects human behavior to take reactive or proactive actions. Touch is an interpretation of a condition or event, and a reactive behavior is a reaction to avoid, investigate or approach. Touch generates a proactive behavior in anticipation of an event. As an example, when touching warm water, the anticipation is that prolonged contact is safe, while touching boiling water, the anticipation is that prolonged contact is unsafe, and a person takes anticipated actions. 

Airport and airline operators are required to operate an SMS for taking corrective actions to prevent recurrence of hazards, incidents, and accidents. When developing corrective action plans operators are expected to consider human factors, organizational factors, supervision factors and environmental factors. In addition to be linked to regulatory requirements, a corrective action plan is also linked to the safety policy. If the foundation of an SMS excludes these factors, the safety policy cannot be linked to the any corrective action plan. A true SMS links these factors to the safety policy, which is linked to the certificate holder. 

The strength of a safety policy is highly dependent on the sub-grade it is built on. When building a runway, the surface may be of concrete, but becomes unstable if the sub-grade does not support the concrete. The surface of a runway built in the sub-Arctic becomes flexible, and with special cause variations if the sub-grade does not account for the permafrost below the surface. Building an SMS policy is no different in that the foundation must support the policy. 

In a hierarchy of human factors, organizational factors, supervision factors and environmental factors, human factors is the most flexible, or adaptable factor when compared to the other factors. Organizational factors are rigid by design and roles and responsibilities defined in the organizational chart. Common cause variations are reliable, e.g. SMS bulletins and hazard prioritization, within an organizational hierarchy. Change management within the hierarchy are special cause variations. Supervision factors are rigid by operational requirements. Common cause variations are reliable, e.g. quality control, within supervision factors. Corrective action plans are special cause variations within supervision factors. Environmental factors are ridged by geolocations and design. Common cause variations are reliable, e.g. seasonal weather, or checklist design, within environmental factors. Human factors are unique in that they are adaptable to the other factors. Common cause variations rarely exist within a human factors environment, while special cause variations are frequent. Roles and responsibilities of the certificate holder is to conduct change management for organizational, supervision and environmental factors to adapt to human behaviors, or human factors. An example is to install fire extinguisher, which are applicable to organizational, supervision, and environmental factors, for human factors to take the action in the event of an inflight fire.

The top layer of a true SMS is environmental factors, which is the most rigid factor. First sub-grade layer is organizational factors, which is the first responder to the top layer, or environmental factors. The second sub-grade layer is supervision factors, which supports organizational factors, and the third sub-grade layer is human factors, which must adapt when any of the other layers above str unable to support the safety policy. 

An SMS is flawed because the true SMS was railroaded and parked on an abandoned spur. Unless the spur is known, it is impossible to find the true SMS by following the tracks backwards. When a CAP is linked to something that does not exist, such as the four foundation factors of what an SMS policy is built on, the CAP does not improve safety. When a flight crew chose to follow a painted taxilane and clip the wing of their aircraft is a special cause variation and an indication that both airports and airlines are operating with a flawed SMS without accountability. 

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