“SMS” A COMMON SENSE APPROACH TO REDUCING HAZARDS AND RISKS
Have you ever met a graduate of a correspondence school for pilots? I haven’t. In fact I believe it would be a safe bet to say that one does not exists, at least not in Canada.
We have all acquired our knowledge and skill through the efforts of other pilots and instructors who cared enough to take the time to share their knowledge and experiences. As pilots or flight instructors, regardless of our roles, it is our responsibility, just as it was the responsibility of pilots that came before us, to provide the next generation of pilots with all the best practices we possess to help keep them safe throughout their aviation journey.
It’s been said that, “If we care, we act, if not, we observe.”
The minute we commence our aviation journey and acquire the knowledge necessary to empower to us, “to take to the air” we abdicate our defence of being, “just a passenger.” For those of us who have embarked on our aviation journey, regardless of the distance we have traveled, the days of dazing at the scenery below while flying or staring vacantly upon apron operations oblivious of any hazards that may exist, should be just a memory. As pilots we have a duty to keep each other safe. We can only accomplish this obligation if we, “speak up” and/or, “act.”
To assess your ability to exercise due diligence in the face of witnessing a hazardous situation consider the following scenarios and answer the question at the end.
Scenario: “It’s a cold frosty morning and you are standing inside Langley Flying School, holding a hot beverage in your hand and watching the activity on the apron and taxiway. You observe a Cherokee aircraft taxiing passed towards the run-up bay and notice that it is missing its portside gas cap.
Your immediate reaction is to:
A. Attempt to personally intervene
B. Locate and inform a flight instructor
C. Do nothing.
D. A or B
If you care about your fellow pilots the answer is clearly, “D”. The only incorrect answer above would be, “C”. For if you chose, “C” then there is a significant probability that you will be contributing to, and possibly observing, an aviation accident, the affects of which could have life altering consequences for yourself, for those on board, their families and anyone else observing the event.
As you may now be aware, LFS is in the process of developing and implementing a Safety Management System, ahead of the Transport Canada initiative to be imposed on CARS 403 Operators next fall. Airlines and Commuter Operators are just some of the aviation operations that have already created and implemented such a system. Flight Schools are amongst the last operators to be required to develop and implement SMS.
The essence of SMS is the management of hazards and risks. For the purpose of clarity it is important that these two terms be defined. The following definitions are from the Transport Canada publication, “Safety Management System for Small Aviation Operations, A Practical Guide to Implementation” (TC-1001017)
“Hazard: a condition with the potential of causing loss or injury
Risk: the chance of a loss or injury, measured in terms of severity and probability.”
In the above scenario the hazard identified was significant and the risk of an impending accident, without immediate intervention, highly probable.
Unfortunately the detection of hazards contributing to an aviation incident or accident are not always as simplistic and obvious as that identified in the above scenario. Many hazards are insidious in nature and over time progress in their severity of risk, e.g. A pilot’s diminishing performance in clearing checks before turning aircraft in flight, or diminishing fuel management awareness or increasing inattention to density altitude and its effect on take-off and climb performance, etc.
A cursory review of the many incidents and accidents published within the Aviation Safety Newsletters, quickly reveals that, for the most part, there appears to be a limited number of incidents and accidents and their causes which seem to be re-occurring with regularity, e.g. Controlled Flight into Terrain (CFIT), landing accidents, high density departure stalls, VFR into poor weather, hazardous night VFR operations, fuel mismanagement, and runway incursions as a result of such causes as Gethomeitis and impulsivity, just to name a few. What is conspicuously absent from the majority of the published articles is the frequency of the pilot’s previous performance or behavior in similar situations where an incident or accident had been consciously or unconsciously avoided.
It is no surprise that the number of general and commercial aviation flights each year is increasing worldwide. Notwithstanding the low percentage of accidents that occur each year in Canada, it is critical that all those in the aviation industry do their part to introduce best practices, policies and procedures that will assisting in actually lowering the number of incidents and accidents that are occurring. For you see, based on the burgeoning growth of the aviation industry, we simply cannot afford to maintain the status quo in the current accident percentage.
The current perception in Canada by those not exposed to the aviation industry is that flying is generally a safe mode of transportation. However, as the number of flights occurring in Canada each year continues to escalate, simply maintaining the same annual percentage of incidents and accidents will actually expose more people to risk and unjustifiably create the illusion that flying is becoming unacceptably dangerous. Therefore, to reduce the likelihood of an incident or accident based on statistical probably and to maintain the confidence of our instructors, students, and customers it is critical that we create, develop and incorporate into the daily operating procedures of Langley Flying School, a safety management system that continuously examines the way we fly, conduct our operation and instruct our students.
The first step toward the development of such a system is to create a pro-active approach to accident prevention. The obvious question then becomes, “How do we best create a pro-active atmosphere of accident prevention within Langley Flying School? The answer is easier than you think and has actually been provided for us. The safety environment we are trying to create and institute within Langley Flying School is what Transport Canada refers to as a, “Safety Culture.”
The following exert is from Transport Canada’s publication, Safety Management System for Small Aviation Operations, A Practical Guide to Implementation that refers to and describes a, “safety culture."
CHANGING THE SAFETY CULTURE
. . . Traditionally, when something broke, it was fixed; if there was an accident, a change was made to prevent the accident from reoccurring. This reactive approach depended on a “command and control” style of management in order to achieve a safe environment. Lack of Standard Operating Procedures (SOPs) required close supervision to ensure safety. With the advent of company safety programs in the 1980s the aviation industry moved to a more team driven approach to safety. This approach continued to reduce the accident rate by creating safety awareness through programs such as Crew Resource Management (CRM) and Human Factors training. Documented SOPs allowed the training of consistent, repeatable procedures with the emphasis on individuals acting as a team. However, safety programs were still mostly re-active in nature.
The goal of a systems approach to safety is to further reduce the incident rate by making safety “behavior driven”. In other words, if everyone is trained to do their job in a safe manner and proactively look for hazards, then a company can improve their defences and build an organization more resistant to human error.”
As you can see the genesis of the safety management system concept is from the realization that even with aviation operators providing formal training to personnel in such concepts as, Human Factors and Crew Resource Management, the introduction of a best practice associated to safety is still very much a reactionary approach to an incident or accident. For a small aviation operation to realize the benefits of accident prevention this paradigm simply must change. We must shift our practices from implementing change based on an incident or accident to proactively using our life experiences, aviation knowledge and aviation experience to identify an area of risk before it becomes problematic. It’s easier and more responsible to introduce a small change in operations based on the identification of a hazard and its associated risk than to ignore a potential problem and suffer its ultimate consequence.
Similar to the introduction of any system to an organization, where the need for same has not be identified and requested by its personnel, the success of a safety management system within Langley Flying School is contingent on the belief by staff and students that the adoption of the ideals and principles of SMS and participation in advocated SMS practices will be a positive experience. The goal of the LFS/SMS system is to create a safer aviation environment for our staff and students through enhanced vigilance respecting unsafe practices, open communications and a non-punitive approach to guidance. This goal can only be achieved and maintained if we believe that we will not be punished for simply making a mistake through omission or poor practices. Here is how Transport Canada envisions a non-punitive approach to safety, which will be adopted and practiced by Langley Flying School.
“.Non-Punitive or No Blame Reporting Policy
A policy describing under what circumstances an employee would be disciplined should be clearly laid out and communicated to all staff. Some operators communicate this policy to their staff by having it printed on the hazard reporting forms. In order to encourage a healthy reporting culture in a company there should really be only three reasons to discipline an employee. They are
1. Willful negligence
2. Criminal intent
3. Use of illicit substances”
The objective of LFS/SMS is to proactively identify hazards within our organization and apply appropriate corrective action so as to reduce or eliminate the risk. Such a foresighted approach obviously lacks the clarity of hindsight and requires a little more faith in the abilities, knowledge and experience of those participating in the process however, it is ultimately far less expensive than the latter.
In focusing our vision inwards, it is recognized that Langley Flying School has experienced unprecedented growth and development in the last 11 months. The fleet has grown and the size of the instructor cadre compliment has almost doubled! In addition, and as we expect to observe, many of our previous instructors have moved on in the aviation industry and we are proud to say they were once one of us! The strength of our instructor cadre is in their diversity of aviation training and experience. Such strength however can be an also be an Achilles’ heal if foreign practices and procedures are unwittingly introduced within the LFS environment without the knowledge of others. Therefore it is important that we care enough for each other to question any observed procedure that might deviate from the Standard Operating Procedures of Langley Flying School. Remembering that the objective in questioning is not to criticize but to acquire knowledge through exploration. If a new procedure has merit then it may be worth sharing and adoption. If the practice is in conflict with universal safe practices or LFS/SOP’s then it should be discarded. It is worthy to note that the introduction of a foreign procedure or practice is not unique to Langley Flying School. Talk to any pilot with diverse experience and you will quickly learn that one of the most difficult adjustments for them is to disregard the SOP’s of their previous employer within their new environment, especially in situations where they are flying a similar aircraft.
From an organizational safety risk perspective, there are times during an aviation organization's evolution, e.g. flying school, when it is more susceptible to the introduction of non-standard procedures and poor practices. The Transport Canada publication on SMS actually identifies some of these circumstances, which are, but not limited to, the following;
When major changes are made to the organization
During times of rapid growth
When there is significant staff change over
When many employees are inexperienced
Armed with the above knowledge and awareness of the changes that have occurred within Langley Flying School in 2007, it is only prudent and in the best interest of the operational health of Langley Flying school, that all staff and students exercise due diligence by identifying perceived hazards, be they, technical in nature, business related, associated to training, flight or ground procedures or even budgetary, so that corrective action can be implemented to reduce or eliminate the risk of an incident or accident.
To those who would ask, “Why is Langley Flying School creating and implementing a Safe Management System?” the answer is this “It is in the best safety interests of our staff, students and customers as well as an impending regulatory obligation.” and to those who would ask, “Why is Langley Flying School promoting and advocating the creation of a healthy “Safety Culture?” the answer is simple, “Because it’s a good idea.”
"To Err is Human"
Tom Larkin, Former Safety Managment Officer