The Role of SMS in Aviation Accident Prevention

Kurt KleinerBLM Oregon/WashingtonState Aviation Manager

January, 2010

What is Safety Management Systems?

SMS is a formal, top-down, business-like approach to managing safety risk. It includes systematic procedures, practices, and policies for the management of safety.

FAA Advisory Circular AC 120-92

What is a “System?”

A “System” is an integrated set of elements combined in an operational or support environment to accomplish a defined objective. These elements include people, hardware, software, information, procedures, facilities, services, and other support facets.

Some integrated elements or components of an Agency or Interagency Aviation “SYSTEM”

Aircraft and TechnologyTraining programsSupervision (span of control)Aviation PolicySafety PlansCommunication proceduresVendor Pilot/Aircraft cardingLine Officers’ oversightDedicated Aviation ManagersPPE requirementsSAFECOM (hazard reporting)

ICS and organizational structureInteragency agreementsFinancial SystemsFAA Part 135, 137 stds., etc.Contract requirementsPilot and aircraft inspectorsFrequency management

What is “System Safety?”

Definition: The application of special technical and managerial skills applied over the lifetime of a project, program or activity in support of SMS.

Example: Our Interagency “System Safety” Plan is one of several tools available at the ground level that implements or applies to SMS as an umbrella “organizational foundation.”

What does SMS do for us?• SMS takes a proactive, “systemic” (big-picture) approach to

managing Aviation safety from all-angles within an organization…. SEEKS and IDENTIFIES“LATENT DEFECTS”

• Identifies hazards and control measures to reduce risks (ORM, JHA, etc. are SMS sub-components.)

• Provides for ongoing “quality assurance” to ensure that risk controls are effective.

• Aligns our Interagency Federal land management agencies’ aviation programs with global regulations and direction (ICAO, FAA, etc.) and with the general aviation and commercial aviation “Industry Standard.”

The “Ultimate Goal” of SMS

SMS provides an organizational framework or roadmap for developing and promoting a true HRO Safety Culture, which ultimately and inevitably reduces the accident rate within an organization. (It becomes a fair assumption to say that HRO and SMS are closely interrelated.)

SMS is based on the following premises:

• Every person in the organization accepts that safety is a conscious and ongoing mindset as opposed to simply “a box to be checked.” Solicits input, requires buy-in, and applies the involvement from ALL levels of an organization

If we continuously and proactively seek out and eliminate latent defects within our systems and culture, we eliminate potential causal factors that could lead to future accidents.

Four “Pillars” or Components of SMS

1. Safety Policy: FSM 5700, Organization and Position requirements, Red Book, NWCG position standards, taskbooks, Contract requirements, National/Regional/Zone Aviation Plans

2. Safety Risk Management: ORM process (IHOG), JHAs, Go-No Go checklists, SMS risk assessments, CRM “team decision-making,” assignment “turn-down” policy, etc.

3. Safety Assurance: Load Calculations, Briefings, Training, FAST Teams, Phase Limitations, Check rides/carding requirements, accident investigations, program reviews

4. Safety Promotion: Lessons Learned bulletins, Safety Alerts, Training, Briefings, SAFECOM reporting system, Airwards, effective Leadership, Safety Communication

Point – CounterpointCommon Question/Comment:

“SMS is just a new buzzword or name for what we’re already doing…. my crew is working safely. They haven’t had an accident in over 20 years. Why are they forcing this SMS stuff on us?”

• Our Accident statistics confirm that the way we are currently doing business is not working.

• We continue to fly perfectly good aircraft into the ground and people are dying unnecessarily.

FACT: Our System has unresolved “latent defects.”

What is an Organizational Culture

• Shared values (what is important) and beliefs (how things work) that interact with an organization’s structures and control systems to produce [positive] behavioral norms.”

“It’s how we do things around here.”

Source James Reason, “Managing the Risks of Organizational Accidents”, page 192

When is a safety culture “positive?”

• Organizations with a positive safety culture are characterized by communications founded on mutual trust, by shared perceptions of the importance of safety, and by confidence in the effect of preventative measures.

Source: Derived from the “Proceedings of British Health and Safety Spring Conference: Safety Culture and the Management of Risk”, April 1993

Sub-Cultures that lead to a Positive Safety Culture

Reporting Informed CultureLearningJust Flexible

Safety Culture

Reduction of Organizational Accidents

James Reason, Managing the risks of Organizational Accidents, pg 196

Organizational & Cultural Threats to SMS

• Improper use of SAFECOMs, failure to report unsafe acts, assumption others will report.

• Failure to understand or follow policy (or too much, confusing or conflicting policies, etc.)

• Fiscal/staffing constraints, management pressure, unreasonable policy barriers, policies with unintended consequences.

• Inappropriate actions driven by resource policies (i.e. heli-mopping)

• Overemphasis on mission accomplishment or a “can-do” attitude left unchecked.

Organizational & Cultural Threats to SMS(continued)

• Focusing blame on individuals instead of examining Systems as a whole for weaknesses.

• Hindsight/reactive vs. proactive approach.• Accepting/condoning taking unnecessary risk,

“normalization of deviance,” and allowing Hazardous Attitudes to go unchecked (macho, invulnerability, antiauthority, complacency, etc.)

• Possible inadequate pilot and aircraft inspection processes (by both the Govt. and Contractors.)

• Failure to reward good decisions and behavior

Accident Review

Note to Instructor/Presenter: Insert one or more recent Accident summaries (i.e. from

an IAT A-200 presentation). Review the accident of your choice, tie the conclusion back to SMS, and ask the audience the following questions:

1. “If individuals at all levels in the organization had the knowledge and understanding to effectively implement an SMS program, would this accident have been prevented? What latent defects in the System could have been detected and mitigated to prevent this accident?”

Accident Review (contd.)

2. What latent defects or failures possibly existed in the “System” which allowed the accident to occur?

3. What could you have done on the day the accident occurred (if you were the UAO) to prevent the accident from occurring?

How can I promote/implement SMS in my local organization or program?

1. Educate and share information. – Provide your crews/staff with a list of websites (i.e.

the Aviation Lessons Learned and FS, BLM, AMD Safety websites).

– Print off and post the SMS guide and other publications in a conspicuous location in the facility (i.e. on bulletin board next to Aviation Safety Alerts, Accident Prevention Bulletins, etc.

– Incorporate SMS as the overarching theme for many training sessions (i.e. B-3, M-3, SEAT Helicopter, and ATGS classes, refresher training, sand-table exercises)

Promoting and Implementing SMS in your local program (contd.)

2. Use SMS as the theme in daily Aircrew, Flight Crew, or Air Base briefings.

– Pick a different hazard each day from the SMS Guide to discuss as a group. Ask a different agency or Contractor employee to lead a discussion each day that answers, “What am I going to do today in my job to ensure this hazard does not cause or contribute to an accident?” Sharing the task of presenting the briefing with ALL members of the organization reinforces the concept that ALL individuals share in the responsibility and have an influence in accident prevention.

Promoting and Implementing SMS in your local program (contd.)

3. During slow periods of activity, build scenarios and sand table exercises around the SMS theme that tests the ability of participants to identify hazards and develop mitigation strategies. Discuss strategies for Safety Assurance and Safety Promotion within the group at the conclusion.

Promoting and Implementing SMS in your local program (contd.)

4. Use hazards from the SMS Guide to build the risk assessment worksheet to be included in a PASP. Aviation Manager/UAO should work with the designated Flight Manager and the Resource staff person who is planning the mission.– Find appropriate hazards in the Guide (group-effort).– Brainstorm any additional hazards not found in the

Guide and develop your own mitigation strategies.– Use the Risk Assessment as a pilot briefing tool to

ensure all hazards are identified, discussed, and the mitigations are viable from the pilot’s perspective.

Promoting and Implementing SMS in your local program (contd.)

5. A Line Officer’s approval signature is required on every PASP. Each UAO should strive to develop a good working relationship with the Unit/District Manager or Forest Supervisor.

– Personally brief the Line Officer on each proposed (non-fire) mission PASP with an emphasis on reviewing the documented risk assessment worksheet.

– Before they sign the PASP, conclude the briefing by asking if they concur that the identified level of risk and the planned mitigation strategies are acceptable when weighed against the benefits or need to fly the mission. (Discuss the risks and ask the question with sincerity and eye contact.)

– Ensure the LO is current with M2 or M3 training.