In the previous articles covering Safety Management Systems, we have addressed why SMS is important and how, at the very basic level, SMS works.
At this point, most readers are probably saying to themselves, “Who cares and how does it affect me?” This is actually one of the best questions that could be asked because one of the reasons SMS seems so mysterious is because the vast majority of it is never seen, making it difficult to understand what it is really accomplishing. However, there are some distinct and important ways that even the most entry-level line employees, trainees and contractors may interact with an SMS at an airline, even if they don’t realize they are interfacing with a much bigger system that exists behind the scenes.
A question that might be asked by such an employee is, “What does SMS look like to me?” Luckily, the answer is actually quite simple. To a normal line employee, SMS probably looks a lot like it did before SMS was implemented, which was probably most commonly in the form of employee filed reports. Some of these may have been routine operational reports, some may have been routine surveys or hazard reports, and some may have reported issues to management in an attempt to fix a problem. In the vast majority of operations, none of this changes. Simply, what changes is a matter of where the report goes and what happens behind the scenes. With SMS, rather than being handled in a decentralized manner, any perceived, reported or identified hazard will follow a formal process, beginning with the employee who perceived, reported or identified it. When the employee takes action to identify the hazard, (usually through the same operational reports that previously existed) the report will make its way through the SMS process (as discussed in the preceding article). This way, rather than hoping the issue might be fixed if it is reported, or having multiple people report the same issue at different times system-wide, the SMS will actively seek to resolve the issue. More importantly, once the issue is resolved, SMS will provide follow-through to ensure the risk has successfully been mitigated. Further, it will monitor and verify that reducing the previous risk hasn’t created other risks. The good part is that the way employees have operated within their job function is changed very little. The day-to-day routine for most people will be very similar to what it looked like prior to SMS.
It should be pretty obvious that in order for this all to work, reporting and identification of hazards is paramount. Per Heinrich’s Pyramid, for every actual incident that occurs, there are dozens, hundreds, or even thousands of previously reportable events that could have prevented that specific accident or incident. This is really where SMS earns its keep; as long as the hazards are being correctly reported by employees, they should be properly mitigated by SMS. Consider this scenario: Every employee has worked in a job where there were just certain tasks, pieces of equipment, or other routine functions that were obviously not very well thought-out and executed. Perhaps employees were working with equipment that wasn’t properly maintained, were using tools that weren’t suitable to the job, or didn’t have basic safety gear which would have greatly reduced the risk of injury. Most line employees would have been very familiar with this prior to any accident occurring because they likely would have almost had a close-call or could have identified that an accident was likely. Rather than adopting the “Well, I could say something, but nobody will fix it anyway” mentality, SMS seeks to ensure that if that hazard is reported, it goes through the right channels, managers and other personnel to ensure that it is properly handled and resolved.
The single most important thing an employee can do for SMS is to report those hazards, because if not reported, there is never an opportunity to prevent the accident. Since the entire purpose of SMS is prevention, it is critical for line level employees to report any hazard they may see. The law of probability suggests that it is likely this is not the first time this has happened and it won’t be the last. The end goal is to reduce that hazard before it has a chance to cause an accident rather than reacting to the hazard after it has caused an accident.
One of the most enlightening and fascinating aspects of safety is the reality that everything that happens is related to probability and is affected by sequence. A study of any major disaster will reveal a sequence of events, each of which occurred in an order that resulted in the accident. The fascinating part is that any one of those specific events, if eliminated, likely may have prevented the accident altogether. This is why there is such an intense focus in aviation on eliminating each specific threat and why the majority of each job function is layered with various processes, procedures and training requirements. Essentially, the safety systems are providing multiple redundant layers of protection so that if any one layer fails to eliminate a risk, the hope is that the subsequent layer will be effective enough to break that accident sequence or “chain.” When all layers are functioning as intended, the possibility of an accident becomes very remote because most risks are being successfully mitigated. This is evidenced by the remarkable rise in aviation safety.
A well organized and run Safety Management System has the potential to prevent accidents from occurring by proactively identifying and addressing operational risks before they have an opportunity to cause an acci dent or injury. It goes without saying that direct employee participation and reporting is not only important, but paramount in preventing operational accidents in an SMS environment.