When we think about the risks associated with flight, pilots bear the heaviest burden. They and their passengers will immediately suffer the consequences of a mistake or lack of focus. We as maintainers also carry a heavy burden, for our actions can lead to horrifying outcomes, but not always right away. What can seem inconsequential at the time of occurrence could result in catastrophe. A momentary distraction that leads to a lapse in concentration, resulting in an incorrectly torqued fastener, for example, can go unnoticed. When the unthinkable happens due to your own mistake, the guilt that goes along with that type of error never really fades.
Aviation is most unforgiving and intolerant of error. However, as humans we make mistakes and errors in judgment. So how do we fight against nature? The key is to change how we think about risk and develop a systematic approach to identify and assess hazards. We can easily determine if something is out of our risk comfort zone — no bungee jumping for me, please. But as a group, you cannot have individuals determining risk acceptance on behalf of others without their consent. Even more dangerous is hiding a hazard from others due to ego, or fear of being fired. As a group, you need to have a common and agreed-upon approach to risk. This is the foundation of risk management, one of the pillars of Safety Management Systems (SMS).
SMS has been a popular acronym for the last decade or so, but few people really understand what it is all about. In most parts of the world, having an accepted safety program is just a part of doing business. Many European operators shake their heads when we discuss our reluctance to embrace what for them is just another mechanism to help stay out of trouble. Between the regulatory, environmental and workplace safety authorities, many maintenance managers fear all new alphabet programs, and for many, SMS just means “Some More . . . er . . . Stuff.” This comes from a lack of understanding of how it can help keep you safe.
SMS is not just a binder that you keep on the shelf, it is really about changing the way we identify and address hazards. The organization has to decide what is important and how it is addressed. At its most basic level, the group undergoes a change in culture, one where individual tolerance for risk is not the deciding factor. The organization must decide — from the top down and the bottom up — what is acceptable and how hazards are addressed. We spoke to experts and other managers to help shed some light on what SMS means for maintainers.
Hazards and Risk
For many years, safety management meant looking back at an accident and trying to determine the root cause in order to prevent recurrence. The accident investigation would lead to recommendations that may or may not have been adopted by regulation. In many ways we still use this model. During the 1980s, the Quality Management System (QMS) began to receive widespread acceptance. Based on Japanese automotive production techniques, it was a proactive approach to ensure products met specifications. Many of the QMS techniques were adapted for aviation. It was once thought that you could inspect your way to safety. “The difference between a QA Management System and SMS is that QA is geared toward production and not necessarily safety,” said Bob Gould, an aviation safety and management consultant for western Massachusetts-based Bravo Golf Aviation. Gould is an experienced aviation professional with over four decades of experience in maintenance, management and safety. “Some maintenance departments have been relying on quality systems and cannot differentiate between the two. Getting an aircraft out the door correctly is not the same as doing it safely. A technician at the top of a ladder without fall protection may adequately inspect the aircraft but puts himself at risk. The two systems have a small area of overlap, but SMS is about managing risk,” he added.
For most flight departments, SMS is not a mandatory program. Larger FAR Part 135 operators and those who frequently travel overseas need some minimum amount of compliance for the flight department, but SMS for maintainers is still in its early stages. However, some operators start with a mandate from on high, and it is often the maintenance manager who is left trying to develop a program. For maintainers, it can be difficult to think of safety in terms of managing it. We tend to think that we know what is safe and what is not. However, while safety is the goal, what we are really trying to do is manage risk.
The foundation of SMS is risk management. You decide as an organization to identify, classify and address the hazard by either accepting, mitigating (taking some type of action to either reduce severity or probability) or removing the hazard altogether. For example, you can MEL your deice boots, but since you can never really know if the aircraft will encounter icing, you decide as an organization that every flight has to have functioning boots. At its most basic level, this is what SMS is all about. “Many flight departments are reluctant to adopt a complete SMS program, but risk management is one of the four pillars of a good program and adopting this will go a long way to reducing accidents. Once you start to understand risk management, you will begin to change the culture, and the other aspects of SMS will begin to fall into place,” Gould added.
From the Top Down, and Bottom Up
Many programs that start as a good idea from the senior leadership team fail because they lack acceptance from those who need to implement it. The folks on the hangar floor already know what needs to be done but often lack the support from up high. The key to successful implementation of an SMS program comes from education, training and the resolve to make your operation safer through development of a safety culture. In a safety culture everyone recognizes that safety is the highest priority and that there are times when other goals will not be met if a reasonable, credible hazard exists. The process falls apart when exceptions are made at the expense of safety. Buy-in from all parties has to be complete.
For technicians, the most difficult part of the equation is identifying hazards that they may have a part in, or observe from others. “One of the areas that can prove troubling is reporting of mistakes,” said Bob Conyers, senior manager for safety management at Hilton Head, S.C.-based Baldwin Aviation Inc., a safety management and support services firm. “In an environment of punishment, no one will self-report mistakes or near misses because of fear of disciplinary action. Because if you are reticent to report your own mistakes, you may also be reluctant to report an observation [of what] somebody else is doing for the same reason,” he added. In a safety culture, observations and mistakes need to be treated as learning experiences that can be used to make improvements.
Changing the culture is an uphill climb. It could take years to get to that point. One way to speed up the process is to take all reports seriously and investigate and determine a root cause. Then develop a plan to address it. Over time, as people gain confidence in the process, you will see a change in attitudes. Trusting in the organization to use the data and make real change creates a snowball effect, which will stimulate more reporting and improvements. The more people see that the process is working, the more they will want to participate.
Another way to demonstrate commitment to the program is to build in participation in the safety process as part of the job description. “When I’m working with clients on their manuals . . . I make it a point that participation in the SMS is part of the job description. Hopefully people will be measured on their performance report, or go up for promotion based on how well they participate. This becomes an indicator of how professional they are,” Conyers added.
As a manager, you need to set the example. You need to show that the process is part of your normal routine and that all observations will be investigated and actions followed through. If you are just going through the motions, you cannot expect your team to fully embrace risk management practices. Conversely, this means that you will have to be forgiving of mistakes and only apply disciplinary action where willful non-compliance takes place. You will also be the one to break the bad news to senior management when a flight is missed due to a safety concern. However, in a safety culture, this should be accepted as a necessary action without repercussion.
Big or Small — SMS Can Fit All
While the airlines and some of the Part 135 operators have adopted SMS into their normal operations, many small to midsize operators are reluctant to take on any large projects because of limited resources. The good news about SMS is that it is scalable and adaptable to meet just about any need. “We have implemented a Safety Management System and risk assessment for our department. It not only covers inspections but also discrepancies and even has an involvement for human factors as they relate to the maintenance function. This was covered during our last Stage Two IS-BAO audit,” said Mark Jones, director of maintenance and pilot for a small, IS-BAO registered, Midwest-based flight department.
Maintainers often wonder how we can use risk assessment as part of our day-to-day operations. A good maintenance manual and MEL should be considered a starting point. You apply your own risk tolerance and then can identify if other hazards occur. “While the MEL gives us guidance, we also strive to have a discrepancy free operation. Any inoperative instrument or system results in an error that could develop into an error chain that could possibly cause an accident. Any discrepancy is a distraction and that can lead to starting an error chain and from that the result could be undesirable,” he added.
As a manager, you are pulled in many directions. Sometimes the amount of things that you need to comply with can be overwhelming. The last thing you need is to implement another “helpful” program, mandated from on high. However, you may or may not be able to implement a fully compliant SMS program; you can adopt the principles of risk management into your day-to-day operations. You want to develop a safety culture, based on trust and acceptance that observations are learning opportunities to prevent hazards in the future and avoid accidents. We as maintainers cannot afford to let mistakes or errors slip by and endanger our passengers, crew and fellow team members. The stakes are too high. Learn the principles, teach them to your team and implement them. Gaining acceptance by all is the hard part, but you need to be the catalyst that makes it happen. B&CA