When Parallel Paths Diverge

The global aviation industry has made considerable progress in the area of safety management with the introduction of the Safety Management System (SMS). From those early days of introducing this new concept, the path to an effective program for many operators has been challenging. Gaining employee buy-in for the active reporting of hazards and barriers to effective safety management has presented challenges, particularly due to skepticism and distrust regarding the non-punitive protections established in the safety policy. Many organizations honestly embraced SMS and the benefits it promised, while others saw it as another program to burden their staff.

We’ve come a long way. Today’s organizations that have implemented an SMS, either because of regulatory requirements or voluntarily, have benefited from embracing the program. Benefits are clearly visible, from breaking down siloed communications to raising awareness of everyday hazards to reducing or eliminating various negative behaviors and incidents or accidents. While an SMS is not a panacea, it is a valuable management tool that can raise institutional awareness when implemented properly.

An aviation SMS is a structured, organization-wide approach to managing safety risks and ensuring effective safety controls. Mandated globally by the International Civil Aviation Organization (ICAO) and regulated domestically by authorities such as the Federal Aviation Administration (FAA), an SMS shifts an organization’s approach from reactive incident response to proactive and predictive risk management.

Safety Reporting Categories

One of the most compelling aspects of safety management is, in its simplest form, the need to become aware—specifically aware of actual or potential hazards that may impact your operation, such as the safe transport of passengers and personnel via aircraft to a predetermined destination, on time and on budget. We become aware by embracing and encouraging the organization (management and non-management staff) to take reporting seriously.

Within Safety Risk Management (SRM), organizations generally classify safety reports into three categories, depending on applicable regulatory requirements and company policy: mandatory (required by regulation, such as FAA or OSHA requirements), voluntary (submitted in accordance with company policy) and confidential.

There are three types of reporting that follow the categories above: reactive, proactive and predictive. Each is fairly straightforward. Reactive is just that, reacting to an event. Proactive is taking action before a problem occurs to prevent it from happening based on goals, audits or root-cause identification. Predictive is using data, trends, statistical models and real-time monitoring to forecast when or how a specific failure or hazard will happen. This methodology helps to anticipate future exposure based on past performance data.

The common denominator among reactive, proactive and predictive reporting is safety data as the foundational input. Without the act of reporting—the identification of a data point—the ability to analyze and correct a condition is greatly diminished. So, reporting for reporting’s sake is critical to ensure the data-collection component of the SMS can function.

Where Design and Human Reality Diverge

From the operator’s perspective, a fully implemented SMS should function as designed once the organization establishes an effective reporting tool and provides employees with multiple reporting pathways. The system should generate meaningful safety data through employee reports. Safety professionals and functional subject matter experts (SMEs) can then analyze that information, identify hazards and develop effective corrective actions to mitigate or eliminate the associated operational risk. In the ideal world, this is also the corporate expectation aligned to the SMS model—once we put it in place, it will function as designed.

However, in our heightened state of cognizance, we are aware that human factors may come into play and, with long-held biases, prevent these expectations from being realized. This is where the parallel paths of SMS system design and corporate expectations diverge and spin off into eddies.

What was aligned to corporate expectations, such as organizational goals, objectives, expectations, policy and documented responsibilities, emerges as vortices of lost opportunities spinning off. Some of these lost opportunities may have become elements of undesired organizational culture, further degrading the SMS and the benefits we hoped to realize.

The Pitfall of the Informal Fix

As an illustration, an employee identifies a real or potential hazard and, guided by initial SMS training and the sage guidance found within the organization’s safety policy, reports it through the chain of command to their supervisor. The employee, like the corporation, maintains the expectation that this active engagement will result in a positive outcome.

The chain of command, however, decides otherwise. The supervisor, while providing positive feedback to the reporting individual, addresses the hazard on the spot and ends it. The identified hazard never reaches the SMS reporting portal and therefore remains outside of the data capture system. This very human act prevented the system from being informed of the hazard and working through the risk assessment, analysis and corrective action process.

A Culture of Active Reporting

I’ve often asked the question: What makes a trend? In the safety business, if we wait for a trend, we have already lost the war. A trend is composed of many indicators present throughout the operation on a daily basis. When those indicators line up, as aptly described by Dr. Reason’s Model of Causation (Swiss Cheese Model), the event has already occurred.

Prof. Malcolm Macdonald FRAeS, president of the Royal Aeronautical Society, recently shared a call to action to further advance safety theory but, more so, safety practice, with the phrase “Let’s shape what comes next.” It serves as a call to all of us within this global aviation system to actively work to shape the message to those coming up within the system and stress the importance of collecting all data points for the opportunity for well-intentioned factual analysis and solution sharing.

From the early days of SMS implementation, Dr. Reason opined, “I compare managing safety to fighting a guerrilla war in which there are no final victories. It is a never-ending struggle to identify and eliminate or control hazards.”

Building on the “guerrilla warfare” example, if you walked by it and didn’t report it, then it didn’t happen. Every opportunity to report has elements worthy of analysis. Let’s shape what comes next: An active reporting and data-sharing culture.