Transcript The Role of SMS in Aviation Accident Prevention

The Role of SMS in
Aviation Accident Prevention
Kurt Kleiner
BLM Oregon/Washington
State 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 Technology
Training programs
Supervision (span of control)
Aviation Policy
Safety Plans
Communication procedures
Vendor Pilot/Aircraft carding
Line Officers’ oversight
Dedicated Aviation Managers
PPE requirements
SAFECOM (hazard reporting)
ICS and organizational structure
Interagency agreements
Financial Systems
FAA Part 135, 137 stds., etc.
Contract requirements
Pilot and aircraft inspectors
Frequency 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 – Counterpoint
Common 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
Learning
Just
Flexible
Informed Culture
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 (nonfire) 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.