“To manage a system effectively, you might focus on the interactions of the parts rather than their behavior taken separately”.
Russell L. Ackoff
It was late that warm night of February at home. I was
about to get some sleep, which was a luxury during those days. The news on this
aviation accident was sharp and pretty cold for this season of the year. After
that, I called my boss, who confirmed the terrible event. It was our just-out-of-the-shop-visit
airplane. Then, I began recalling all the job cards we performed, all the
repair kits we managed, all the meetings to get staff and parts for this
airplane. We even had made a visual inspection on the horizontal stabilizer attachment
bolt holes for corrosion.
One month earlier, I was counting my defeated steps to receive my wage. The lady in charge was a good person. Her green eyes were giving us always a smile. But not this time. The Captain of the accident airplane was also waiting to get paid. I saluted him and he gave me a bitter smile, which was the opened curtain to the last time I saw him. Some moves of the airline were reflected in reduction of resources, and salaries not paid on time, but back in 1996 no one talked about a management system. No one was aware of the Swiss Cheese Model. No one told us about Human Factors. I was working for the Maintenance VP, specifically at the Inspections Department, and we were trying really hard to put the airplanes back to service. We were running a certified Repair Station and we made C inspections for DC8s of a foreign airline at that time. Ten C Checks for those DC8s within a year. Money was coming to the repair station. But this was not reflected in improvements for us in maintenance. The airline bought new cars for the managers and spend a lot of money in new offices for them. But little or no money for our training or the pilots’ or new (and better) tools or wages. We were four islands in that airline: Flight Operations, Maintenance, Administration, and Cargo. We perceived no connection between us. We were there to work as soldier ants, and that was it!
I heard plenty of times the statement “I wish I were that wise as I’m now, but twenty-five years younger.” Haven’t you? Those were pre-SMS times. Though I feel it is still happening the same things like twenty-five years ago. We are facing yet aviation service providers that run SMS services with four islands (components) with restricted, little or no connection whatsoever.
Thus, I will describe my perspective of how to achieve the interaction within the Safety Management System (SMS). As a backbone principle, we must recognize these four components must result in the systematic approach mentioned by ICAO Annex 19 when the SMS is defined.
To analyze the Four Components of the SMS, bear in mind this risk management principle: We deal first with hazards that possess consequences, which are activated by a trigger.
The first one is Safety Policy and Objectives. For the benefit of this analysis, let’s say this component deals with the Strategic Management of the Activities to be performed along with setting out the defenses to achieve the objectives. What’s the trigger to begin the interaction with the next component? The possibility of failures (deviations, omissions and procedural violations) when accomplishing the activities (uncertainty).
Now that we have the link (trigger), we are able to go to the Second Component or Risk Management. What needs to be addressed here? The uncertainty abatement through the process of risk management. The trigger to be considered for the next component is that the (safety) management system detects hazards and their consequences and evaluates them into risks taking into account existing/current defenses (controls) along with new ones (for mitigation purposes) and statistical data.
So, we are ready for the next destination: The third Component of the SMS or Safety Assurance. What’s addressed in this process? Safety Assurance checks for the effectiveness of the controls taken into account by the Second Component of the SMS. How to connect this with the last component of the SMS? It’s very simple: Ensuring the proper checking of the (safety) management system controls depends upon training.
Now that we are at the last component of the SMS or Safety Promotion, we must state this component aims at training personnel to possess required competencies to be able to accomplish the activities as documented. To assure the interaction and warrant the loop of this (safety) management system, we must recognize a trigger between this last component and the first one, so the equipment is continuously moving on a synchronized basis: The design of the planning activities requires information from all previous interactions to train in accordance with the organizational needs.
Back to that awful night again, it must be said that a few months after this accident, the airline entered into bankruptcy. Ancient times of aviation or current times are the same when the organizations are not interacting within a management system that fails good enough for the accident.