Our Industry continues to face multiple challenges, including the obligation to comply with a significant regulatory burden but it does not stop there! Other initiatives abound introduced by for example IATA (IOSA) and other niche compliance & SMS drivers (ISBAO & ISBAH for business operators).

With Safety Management Systems, we have superimposed on this story of “compliance” a need to identify exposure in a different way using forward looking techniques where typically we identify gather data to evaluate the risk and exposure to “all” perceived hazards.

A Discussion Document by Steven Bentley - MD of Sofema Aviation Services

Do we agree the purpose of an Aviation SMS?

1/ According to ICAO

ICAO Doc9859 para 2.13.2 - ‘A hazard is generically defined by safety practitioners as a condition or an object with the potential to cause death, injuries to personnel, damage to equipment or structures, loss of material, or reduction of the ability to perform a prescribed function.’

ICAO Doc9859 para 2.14.2 - ‘Safety risk is the projected likelihood and severity of the consequence or outcome from an existing hazard or situation.’

There are many misconceptions and misunderstandings regarding Aviation Safety Management Systems (SMS) and Quality Management Systems (QMS).

The following is intended hopefully to clear up this misunderstanding:

QMS and SMS - Offers many common methods and techniques, but provides different outcomes an objectives:

Sufficient competent resources are critical to the success of both the CM system and the SMS. It is also important to realize that essentially the role of both QMS and SMS is to provide a service to the management team to understand both the non-conformities and risks which they face within the business areas.

The effectiveness of the Safety Management System is directly connected to the management of Competence throughout the organisation.
 
The goal of an effective safety Management System (SMS) competence management system is to:
 
a) Reduce risks
b) Ensure compliance with all legal and other regulatory requirements
c) Comply with the organisation’s business objectives and ensure contractual commitments
d) Empower individuals to deliver their job role obligations in a safe, efficient and effective way
 
Delivering functional safety relies on a complex mix of Process Procedures, oversight mechanisms, Human Factors and the impact of the Safety Culture within the workplace. Competence can be negatively affected by aspects of physical, medical or mental fitness which should also be considered on an ongoing basis.
 
Competence is an essential attribute when considering behaviours in a non-normal situations.
 
For a person to be considered competent, they need appropriate qualifications, together with experience, and other “soft skills” appropriate to their job role.

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It is accepted within our aviation community, that the vast majority of aviation accidents (at least 80%) are directly caused by human action or more precisely by human error. However it would be wrong for us to assume that this is simply a manifestation of personal carelessness or even incompetence, rather we should try to consider that the human error itself is actually the final element of a chain of events.

In fact a major element which hitherto was not given sufficient consideration is the role of the organisation in aircraft incidents and accidents. Often the root cause or contributing factors are embedded within the organisations process and procedures. Unfortunately with hindsight we are often able to understand the existence of numerous latent “exposures” (sometimes too late!).

What do we mean by Root Cause? Often people have a bias to stopping at an event, which itself has enables or causes, however with practice it becomes easier to work through the process and achieve meaningful results.

Let’s take some time to De-Mystifying Root Cause, when we talk about Root Cause we are simply trying to understand why a “something” has happened – what where the fundamental causes and on the journey to discover as many of the contributing factors as we can.

So the focus is on “Why” and “How” a particular event or condition occurred so that we can develop the correct understanding.

Considerations related to the delivery of Safety Systems

Where is your organisations current focus? Is it on compliance or Performance?

This is a significant question because whilst compliance is of course mandatory it is through performance related developments that we are able to optimise and drive significant savings within the organisation, whilst at the same time ensuring we deliver a safe and effective business environment.

Where does safety come from?
People or Procedures?

Well simply implementing process and procedure is not in itself going to provide an effective solution to the needs of the organisation.
We rely on people to deliver our safety management system and this in turn requires a specific and viable organisational culture and senior led behaviour.

Let’s get real!

Question – Is SMS is all about Compliance?
Answer – No – It’s about Managing Risk.

Safety management goes far beyond traditional compliance led approaches to auditing.
So a Safety Management System has to identify potential safety risks and Hazards. At the heart of any effective Safety Management System is a formal Risk Management process that identifies hazards and assesses and mitigates risk.
The next step is to mitigate or manage any risks identified to an acceptable or tolerable level. An essential aspect being the management of risk generated by Contract or Sub Contracted organization particularly where this may directly impact the organization.

Question – Is SMS is just an extension of the Quality System?
Answer – No – Safety Auditing is very different. In fact Safety Auditing is very subjective, almost holistic. Safety Auditing is looking at Risk or in other words the potential exposures, faced by the Organisational system.

We are very pleased to announce the availability of our latest training which provides for an opportunity to update regarding both the status and effectiveness of your organisational SMS.

Building on the successful release of several Aircraft Maintenance Planning and Production Planning Courses we are pleased to offer this opportunity to provide for a review and update of SMS best practice processes to be developed within your organisation.

Developed to be completed in one day Safety Management System Overview and Recurrent provides for a comprehensive review of the overall effectiveness of your SMS.

We have watched Safety Management Systems grow following an understanding that the reality today is that the major cause of accidents is related to human error which in some way is able to impact the overall process increasing the level of risk and exposure.

Do we agree on what we mean we talk about the management of change in connection with our Safety Management System (SMS)?

Essential we are talking about changes within the business which may in some way increase our exposure to risk!

Unfortunately within the business many changes take place which are not considered for the impact that they may create related to increased risk, any lack of communication or in fact even perceived lack of communication (yes perception can lead to negative outcomes) may have negative connotations or worse!

Change Management is an area which deserves more attention than often it receives, the more visibility we provide and the more attention we give to the change then the more likely we will be to address the underlying issues.

What do we mean by developing a consistent approach?

Well, we want our approach to be system driven and not overly reliant on individuals. Means we want the outcomes to be as independent as possible from the people.

For this to happen a number of elements need to be in place:

a) Procedures

The procedures which describe the methodology employed need to be in sufficient detail to enable all the users to work with them in the same way. We are always going to have a significant degree of subjectivity in our approach to SMS but this does not preclude the development of effective procedures.

What is the goal of the Aviation Safety Management System - SMS?

Well quite simply it is to:

a) Identify hazards or exposures across every area and facet of the business (ideally considering also financial exposure)
b) Assess the risk in respect of each hazard and how it is currently perceived or how it may be perceived in the future to the organisation, department or person (This is an extremely subjective activity and requires a strong degree of competence)
c) To develop appropriate mitigations to deliver an improvement which will take the risk to the lowest level possible (ALARP) using organisational tools to test or measure proposed solutions so that they are cost effective

What do we mean by internal reporting system?

Well firstly to understand the difference between Reactive Driven reporting and Proactive Driven Reporting. With the former clearly something has happened and we need to communicate with the authorities to advise them regarding what has happened.
With the latter we have a situation whereby we are trying to proactively identify hazards and exposures where the risk may be considered a salient feature.

By identifying and measuring the risk in a meaningful way we can proceed to develop a greater understanding and as a consequence create appropriate mitigations which can lessen the exposure to the underling risk.

Creating the process

Step 1 then is to have an internal reporting system which meets the company’s needs – the focus should ideally be on the gathering of information (our SMS is heavily reliant on Data) rather than the complexity of the submitted documentation – often simple is better.
We are trying to provide a simple mechanism which we will then encourage people to use in a meaningful way. A simpler system removes one of the barriers to avoid reporting (complaints that it is too bureaucratic).

In the context of Aviation Safety Management Systems (SMS) we usually talk about Safety Culture as being an integral part of the SMS process, but do we have a shared understanding of what we mean when we talk about Safety Culture.

Essentially it is how we feel personally about the risk faced regarding a particular hazard (although we do not view it in these terms) – think about it next time you jump an amber traffic light!

This personal behaviour is impacted by various external influencers for example – our national psyche, family values, work place norms, peer pressure etc.

We “should” all agree that an effective aviation Safety Management System establishes clear safety roles and responsibilities throughout the organization.

Moreover it should also be understood that we must ensure that these safety roles and responsibilities are clearly documented, (Auditable) understood, (Measurable) and practiced throughout the organization (Visible and Evidence based).

Our goal should be for individuals to both understand their own responsibilities together with an appreciation of how their individual activities may impact the safety, performance and behaviour of our colleagues within the organization as a whole.
Each business area within the organization must assume both responsibility and accountability for safety of the key elements of personal safety and organisational safety and financial safety.

Best Practice Behaviour to support our SMS

All employees should have a clear understanding of their individual safety roles and responsibilities. (This information should also appear in each job description.)

Who is best placed to answer this question? In fact the starting point should be – "What do we want our SMS to do for us?"

We often talk about the management of change and here we do not need to look any further than the implementation of an SMS as our first challenge.

As either a perfect opportunity to develop and optimize the organisation or alternatively as an organizational burden which requires specific actions to ensure compliance.

So in reality this question should be answered by the Accountable Manager and the Management Team. In fact once we answer the question then other decisions become easier and we can start to develop the structure of the SMS.

Please note it is a significant step backwards to jump into SMS implementation without really appreciating what your real goals are. So assume we have decided that we see the SMS as a real business opportunity to develop and optimize the organization.What should we do next?

To consider the differences and the advantages of bringing together the elements associated with MEDA and the analytical capacity which is available within the SMS system.

Maintenance Error Management System (MEMS) which is typically represented by “Maintenance Error Decision Aid” (MEDA) as developed by Boeing is an effective way of analyzing events (initially MEDA was developed to facilitate the analysis of incidents and accidents – At the inception its use was employed where there was an adverse outcome; however it was subsequently extended and it is now typically found to be also be employed for the investigation of events.