AVIATION SAFETY

Effective risk management depends on strong rules and not cutting corners

SMS promises lower loss rates, but safety culture is a prerequisite to success and key to achieving future goals.


A safety management system (SMS) integrates 8 functional building blocks. Safety culture is the overarching force enabling SMS to be moved from intent through investment to investiture.

Rob Lee, formerly director of the Australian Bureau of Air Safety Investigation, holds that a positive safety culture is vital to an effective integrated SMS. It is the essential ingredient for all the components of the SMS to work together.

Even if each SMS component is of high quality, he says, the system will fail without a positive safety culture. A first-class reporting system is of little use if people are afraid, or unwilling, to use it because of poor safety culture.

SMS is a behavior-based system. Safety culture has a direct impact on safe performance, and if safety is believed to be unimportant-even temporarily-then work_arounds, shortcuts or unsafe judgments will be the result.

This is especially true when the perceived risk is remote. In fact, safety culture is so important that the ICAO SMM 1st edition declares that before an organization can implement an effective SMS, it needs to possess an appropriate safety culture.

Yet the draft 2nd edition of the ICAO SMM dismisses this critical element as a trendy notion with the potential for misperceptions and misunderstandings. Why the unexpected change of heart? The answer may lie in a concept called "just culture."

Just culture, liability and management accountability

To reinforce the notion of safety management as a managerial process, ICAO requirements include provisions for an operator to establish lines of safety accountability throughout the organization, as well as at the senior management level.

Europe's EU-OPS 1 does not specifically require definition of lines of accountability throughout the operator's organization and the commitment of senior management.

It also permits a sharing of roles between various managers, which is not clearly in compliance with the ICAO standard.) A just culture-or nonpunitive environment-is widely suggested to encourage effective safety event and hazard reporting as well as willing acceptance of accountability.

The just culture concept was implemented to prevent criminalization and prosecutorial overreach whenever judicial inquiry enjoys primacy over technical investigation of an aircraft accident.

A regulator sets safety performance targets while the operator indicates achieved performance. Both evaluate effectiveness by monitoring and verifying the system performance trend.

Although the primary objective of any aviation event investigation is to prevent other occurrences, this cannot exclude liability, and judicial immunity from blame is not an option. Recent cases have attempted to establish negligence on the part of companies, managers and even corporate boards.

This trend has exposed the industry to criminal prosecution following aircraft accidents. For the first time in law, prosecutors are able to look at corporate culture, including previous convictions, and to see how far they fell short of approved codes of practice.

The UK even introduced a new corporate manslaughter and corporate homicide bill to determine if management conduct falls below reasonable expectation.

Both safety culture and SMS rely on appropriate open disclosure-a reporting environment in which people are encouraged to voice safety concerns and to analyze and take appropriate actions.

Just culture favors disclosure over self-incrimination. Over time, just culture was assumed-incorrectly-to be part of safety culture. (The former is a legal concept, while the latter is a concept of organizational behavior.)

The distinction between acceptable and unacceptable behavior is a matter of judgment ICAO insists is beyond its remit as an international organization, dramatically halting further discussion of the 2 constructs in the remainder of the draft SMM 2nd edition.

To avoid such cultural or political sensitivities, Europeans have coined the alternative term "justness" to reflect the extent to which safe behavior and reporting of safety issues are encouraged and unsafe behavior is discouraged.

Is it essential to have both SMS and safety culture?

It could easily-but mistakenly-be concluded that a well documented SMS will lead to a positive safety culture. An SMS reflects an operator's safety competence. Its importance-and that of a competent safety staff to execute it-cannot be overstated.

A positive safety culture must precede implementation of an SMS. This is because policies, rules and processes are not always followed, particularly in a broken safety culture in which standards are habitually relaxed to meet other goals having overriding priority, or in which risks are overshadowed by unwarranted optimism.

Ultimately, the reason why people behave in such ways comes down to peer influence, but to an even greater extent the behavior of superiors, including the CEO-especially those who repeatedly underestimate risks.

Organizational leaders must show that safety is their priority. Operators need both an SMS and a healthy safety culture to remain safe. Only safety culture will ensure that genuine executive commitment to safety survives a change in management.

Aviation is generally very safe, with rare accidents. Almost all organizations assume they are already safe, so complacency is a constant threat. There may be few incident reports and these may be of low severity.

Safety cases may be well developed for current operations and future changes. Since accidents are usually the result of multiple complex causes, it is not always easy to see their coming together to create unsafe conditions.

Even harder to see are influences which reduce an operator's safety foresight, eg, underreporting of incidents due to fears of recrimination or prosecution, running risks because people believe that is what is expected of them, or individuals or groups not sharing information owing to mutual mistrust.

How would a CEO-who is accountable for safety-know if such undermining factors were present in his/her organization? Alternatives include asking the directors, touring the facilities or asking the workforce.

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