Human Factor

When Safety Management Systems fail

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Pillars of SMS

Safety Management System was expected to perform like a magic pill, when it was introduced in 2006. The subject was introduced in the form of the International Civil Aviation Organisation (ICAO) Doc 9859

The manual was intended to provide States with guidance to develop the regulatory framework and the supporting guidance material for the implementation of safety management systems (SMS) by service providers. It also provides guidance for the development of a State safety programme (SSP), in accordance with the International Standards and Recommended Practices (SARPs).

Small cost for safety

Reasons for failure

Top management training and limited buyin

Can you imagine the CEO of an airline sitting on a 5 day SMS course? Yes, there have been examples like the CEO of Emirates. However in a setup where the top guys are ceremonial appointees, bureaucrats etc, there is little that can be done to educate the top management. Most heads are happy so long there are no accidents, their definition of safety is a limited one. What they need to realize is that anyone who is a policy maker needs to have a background in safety management system so that every time they take a decision, safety is always considered.

Safety culture

Airlines where there is no tradition or practice of asking the users how safe do they feel, often demonstrate poor safety culture. Airlines are so busy telling others what faults they did and how well the airline is managed that they miss out the key input of feedback.

Report handling

Does you airline promote reporting and how are the reports handled? Airlines make the right noise. They want safety but do not want to invest time & money into it. Therefore, they do say that they welcome feedback and open reporting but the feedback is seen as corporate critisism and reporting as complaining. The end result is that the reporting culture seizes to exist.

Safety performance indicator and matrix

Safety is normally prioritized by novices. In the true sense safety is engrained in every process and activity therefore it cannot be first or last. Since safety is perceptional, everyone has their views and risk tolerability. It then depends on whether you are from the production side or safety side. The critical balance of protection and production always tilts towards production.

Risk matrix of many organisations is skewed to paint a rosy picture. A catastrophic yet improbable accident is acceptable to a few airlines just to colour the events green.

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5X5 risk matrix


When safety becomes a chore and the organisation has to go through the motions, instead of getting oneself up to speed, parameters are adjusted to meet the goals. Easy targets are set, actions deferred, meetings postponed etc are signs that SMS is a necessity but not important. The ICAO USOAP audit report shows that a number of nations are still stuck in trying to establish the foundation of SMS, even years after introduction of ICAO Annex 19. It is not about governance but attitude of the organisations towards safety. High reliability organisations get on overdrive mode when this are normal trying to get as much data to sift and identify new trends.


A state which itself is struggling to implement safety within the regulator does not have the ethical or moral ground for auditing the airlines and point out deficiencies. There is a need to understand that it is a collective responsibility and the total performance will reflect on the states ability to manage safety. Therefore it is vital that the regulator who audits the SMS of operators must have sufficiently trained and standardised personnel on SMS.

The magic pill

SMS is often considered as action done and let the magic work. If the total is not the sum of its parts then any effort is going to fail. Just because SMS has been implemented on paper does not mean that it is functional and effective. Operations & Commercial interests in any organisation has a greater weightage as compared safety simply because the impact of safety or the consequences are not visualised at that instant and by the people who are not sensitised to it. Time and money are easily calculated as immediate losses where as safety and quality are not revenue generators but cost savers. They pay back in the long run.

The long term vision unfortunately is missing in the current day top management who are looking for immediate gains to secure better perks and promotions. Who suffers in the meanwhile, the organisation and safety.

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