Nothing To Learn

The Safety Management System (SMS) is the root cause of the most recent midair collision. That a system is named the “Safety Management System” is not a guarantee or assurance that this system prevents accidents, or that the system itself cannot be the root cause of an accident.

The Safety Management System did not fail aviation safety when this accident happened but operated as intended and painted a true picture of aviation safety.

Aviation safety cannot be enforced, aviation safety is neutral and does not take sides in safety, and no matter how much we wish for an SMS to operate differently and paint a different picture of aviation safety it will always show the true picture.

There is nothing to learn here after the midair collision, because it is a known fact that when two aircraft intersect at the same location in a 3D format the accident will happen and there will be no survivors.

There is no justification for accidents to happen, not even that we will learn from them and prevent future accidents. The era of learning from accidents and requiring accidents to happen at regular intervals was eliminated by implementation of the Safety Management System.

Airlines are required by regulations to operate with an SMS, and the SMS therefore became the root cause of an unexpected conflict of interest. At the time when SMS regulations came into force, everything in operations is allocated to SMS. The aviation industry cannot pick and choose when they want to apply and give credit to SMS and when not to include SMS.

Below is a clip from a past post that talked about how hazards are mitigated in 3D. The three dimension (3D) identification process is measured in time (speed), space (location), and compass (direction).

“One could define risk management as the identification, analysis and elimination of those hazards, as well as the residual risks that threaten the viability of an enterprise. The discussion of whether it is possible or practical to eliminate hazards are ongoing with opposing views.

Airports and airlines accept the inherent risks in aviation every time there is a movement on the field or in aeronavigation. On the other hand, both regulators and professional auditors expect from the corrective action plans that an operator will make changes to ensure that an occurrence never happens again. While it is unreasonable to expect the complete elimination of risk in aviation, it is also unreasonable to expect that all risks are acceptable.

It is a fine line to balance between what risks to eliminate, and what risk to accept. Risk acceptance, or elimination is a 3D identification process measured in time (speed), space (location), and compass (direction). When 3D thinking is introduced, a future scenario can be designed, or the exposure level. Risk mitigation then becomes an exposure level mitigation and not the mitigation of the hazard itself.

This does not imply that the future can be predicted, but it implies that data, information, knowledge, and comprehension are vital steps to predict hazards that affect operational processes. Exposure level mitigation is currently a major part of risk mitigation, e.g., airside markings, markers, signs or lighting, or aeronavigation flow into congested airspace and for gate assignments.”

SMS AS ROOT CAUSE

The Safety Management System, while designed to enhance aviation safety, can sometimes inadvertently become the root cause of an aircraft accident. This paradox arises because the SMS, in its essence, is a collection of policies, processes, procedures and acceptable work practices aimed at identifying, analyzing, and mitigating risks. A Safety Management System operates within the parameters set by those who design and implement it, and it reflects the limitations of human foresight and understanding.

When the SMS is followed strictly without allowing for the flexibility needed to address unforeseen circumstances, it can lead to a false sense of security.

Operators might become overly reliant on the SMS, assuming that adherence to its protocols is a guarantee of safety. This can result in complacency, where critical thinking and situational awareness are diminished, as individuals adhere to the letter of the system rather than the spirit of safety it intends to promote.

Additionally, the SMS might identify risks and prescribe mitigations that are theoretically sound but practically insufficient. If a system primarily focuses on historical data and known hazards, it might not account for novel or emergent risks.

The SMS could also create bureaucratic inertia, where operators are slow to adapt to new information or changes in the operational environment because they are bound by established protocols.

In the case of a midair collision, the SMS might have identified specific risks and established measures to mitigate them, such as separation standards and traffic management procedures. However, if those measures are based on data that does not encompass the full scope of scenarios, probability of exposure in 3D, or if the operator does not recognize and respond to deviations in real-time, the system's limitations become apparent.

The SMS, though functioning as intended, may inadvertently contribute to an accident by providing a false sense of security and by not fully addressing the dynamic and complex nature of aviation operations.

While the SMS is a vital tool for promoting safety, system designers are not infallible, and the SMS will function as intended. SMS must be continuously reviewed and adapted, and it should be complemented by a culture of vigilance with predictive risk management.

PREDICTIVE RISK MANAGEMENT

Predictive Risk Management (PRM) in an aviation Safety Management System involves the use of data analysis and trend monitoring to analyze both identified hazards and latent hazards before they manifest into actual risks or incidents.

By employing advanced analytics, PRM seeks to identify patterns, anomalies, and emerging threats that are not immediately apparent through traditional safety measures.

PRM leverages historical data, real-time information, and predictive algorithms to generate risk forecasts. This proactive approach allows for preemptive actions, improving the resilience of aviation operations. For instance, PRM might analyze flight data to predict mechanical failures, assess weather patterns to anticipate turbulence, or study individual human factors to prevent crew fatigue-related incidents.

PRM extends the capabilities of the SMS by adding a forward-looking dimension, enabling aviation operators to stay ahead of arising events. This requires a robust data infrastructure, continuous monitoring, and the integration of insights into operational decision-making processes in a 3D process.

MIXED OPERATIONS

In aviation operations, the presence of different types of aircraft, such as large commercial jets, small private planes, and helicopters, introduces special cause variations that complicate SMS processes. These variations arise because each type of aircraft has distinct operational characteristics, performance capabilities, and requirements, and their unique characteristics are introduced into processes where these characteristics do not exist.

Large aircraft generally follow more rigid flight paths and require longer runways for takeoff and landing, while small aircraft and helicopters have more flexibility in their movements and can operate from shorter or even improvised landing sites.

This disparity can create unpredictable interactions, especially in congested airspace or near airports.

Helicopters, with their ability to hover and perform vertical takeoffs and landings, introduce further complexity, as their flight patterns can intersect with fixed-wing aircraft in ways that are not typically accounted for by standard separation protocols.

Additionally, the differences in speed, altitude, and maneuverability between large and small aircraft can result in unexpected encounter scenarios, where traditional traffic management procedures may not be sufficient to maintain acceptable separation.

3D

An Aviation Safety Management System must be designed to operate in a 3D environment, meaning it must account for risks not only on the ground but also in the air, where aircraft move in three dimensions, measured in time (speed), space (location), and compass (direction). This adds complexity to aviation SMS compared to industries operating in only two dimensions, such as road transport.

 

Hazard Identification in Three Dimensions.

Hazards exist in all axes (vertical, horizontal, and lateral movement).

Example. Mid-air collisions or near misses require monitoring of separation measured in time (speed), space (location), and compass (direction) by all parties involved. This monitoring is initiated as soon as the aircraft depart and terminates upon landing. After landing an aircraft operates in a two-dimensional (2D) environment, which requires different SMS analyses and mitigation than a 3D environment.

Risk Management Across Multiple Altitudes.

Risks differ at ground level (runway incursions), low altitude (bird strikes, wake turbulence), and high altitude (pressurization failures, turbulence).

Example. A low-altitude hazard like wake turbulence from a large aircraft can endanger aircraft arriving or departing behind the aircraft and encounter wake turbulence.

Integrated Real-Time Monitoring Systems.

SMS must integrate weather systems, radar, GPS tracking, and onboard sensors to provide full situational awareness.

Example. A microburst (sudden downdraft) at an airport can create a severe hazard for landing aircraft.

Regulatory Compliance in a Three-Dimensional Airspace.

Different flight levels require different regulations (e.g., controlled vs. uncontrolled airspace).

Example. A general aviation aircraft entering Class A airspace (above 18,000 feet) without clearance poses a risk to commercial jets.

Human Factors and Situational Awareness.

Pilots, ATC, and maintenance crews must be trained to think in 3D risk terms rather than just linear (2D) risks.

Example. A pilot descending into a busy airport must track multiple aircraft at different altitudes and approach paths.

Emergency Response and Contingency Planning.

Response plans must consider airborne emergencies, not just ground incidents.

Example. An aircraft with an engine failure at cruising altitude requires precise glide path calculations and diversion planning.

An effective Aviation SMS in a 3D environment must integrate real-time data, regulatory frameworks, human factors, and technological solutions to manage risks across all dimensions. By designing systems that account for hazards measured in time (speed), space (location), and compass (direction), aviation safety is on track for significant improvements.

SAFEST MODE OF TRANSPORTATION

Conventional wisdom is that aviation is the safest mode of transportation. This is a myth, because flying was not the safest mode of transportation for passengers onboard the most recent midair collision. If aviation was the safest mode of transportation there would not be any major accidents.

Flying is not the safest mode of transportation unless we accept that major aviation accidents are needed to justify numbers of accidents and statistics compared to other modes of transportation.

While flying is touted as the safest mode of transportation based on accident statistics, there are valid arguments against this claim.

While airplane accidents are rare, when they do happen, they tend to be catastrophic, with a high fatality rate. Unlike car crashes, where survival is more likely, aviation accidents often result in total losses. 

In a car, train, or a boat, passengers or crew have some control over their safety (e.g., wearing a seatbelt, making emergency maneuvers, or evacuating). In an airplane, passengers have no control, and pilots have limited options once a problem occurs at cruising altitude. 

Air travel relies heavily on advanced technology, automation, and human decision-making. A single mechanical failure, software glitch, human factors, organizational factors, supervision factors and environmental factors have disastrous consequences. Human fatigue, miscommunication, or system irregularities have contributed to major aviation accidents. 

Airplanes have historically been targets for hijackings. While security measures have improved, the consequences of such events are much more severe than other modes of transportation. 

Unlike cars or trains, where stopping or emergency exits are more accessible, planes have limited emergency response options. If an issue arises mid-flight, pilots must navigate a complex series of decisions with little room for error in judgement. 

While commercial aviation has strict regulations and remains safe overall, these factors show why it may not be the absolute safest mode of transportation in all contexts.

The aviation industry has by implementing a Safety Management System admitted that flying is not the safest mode of transportation. If flying was the safest mode, why does the Global Aviation Industry, being Airlines or Airports, need a Safety Management System (SMS) today, when they were safe yesterday without an SMS?

BUS VS AIRCRAFT

When analyzing the level of safety, we are comparing apples and oranges, such as air travel to surface travel. Aviation safety by continent can be analyzed, safety by country can be analyzed, or can be broken down to analyze safety by airlines or by airports.

The aviation industry needs to compare apples to apples, and oranges to oranges, or in other words, compare systems to systems. When we compare one system to another system, the output and risk mitigations are ineffective. A fish cannot fly and cannot be trained to fly. A fish may therefore by comparison to a cat live a safer life than a cat because it has never fallen out of a tree. (NOTE: this is true to some extent. Several years ago, an airline filed a CADORS for being hit by a fish while airborne).

A bus needs to be certified, and a bus driver needs a driver’s license. An aircraft needs to be certified and the pilot needs a pilot’s license.

A highway needs to meet standards and regulations, and an airport needs to be certified, and meet standards and regulations.

Safety analyses may be of numbers of deviations, minor incidents, major accidents or fatalities. When aviation is promoted as the safest mode of transportation, the statistics is of numbers of fatal accidents.

 While this is a fully acceptable analysis, it is also propaganda to promote aviation safety. The analysis of safest mode of transportation should be of the survival rate when experiencing a catastrophic event.

By establishing the criteria for comparison, safety analyses for the safest mode of transportation, travelling by bus or aircraft, can be established.    

NOTHING TO LEARN

Aviation safety can no longer accept that we need to learn from aviation accidents. Aviation safety needs to run with a predictable Safety Management System. Learning from accidents belonging in the pre-SMS world, when aviation safety needed accidents to find out what was unknown, what could happen and how to improve aviation safety.

There is nothing to learn from the most recent midair collision, because the aviation industry already knew that different incompatible systems, such as helicopters, large aircraft and speeds, were forced into one operating system, or operating environment, and expected to cooperate and conform.

It is a disgrace to the families of victims to justify that aviation accidents are needed because we learn from them.

  

 

OffRoadPilots