OT Safety Bulletin

Systems - Why have many when you can have one?

It is rare that anything really sits completely within its own world and it doesn’t have any effect or interaction with anything else. In aviation many people and organisations come together on a daily basis to orchestrate a truly amazing ballet of flights, where people and goods make it to their destinations safely. To improve and grow, it is important that all these continue to work together.

Looking at individual organisations, there are also many functions that come together to meet the aims of that organisation – these form the organisation’s management system. So when an organisation is examined, it is not unusual to find many differently named management systems coming together, sharing and interacting and that these are very much part of the day job. This is usually a good sign when these are embedded and all interact. The lines of what is part of the safety, quality, security and finance system, (to name a few) are blurred, if they exist at all in some cases?

ICAO Annex 19 requires many service providers to have a Safety Management System and other Annexes require many service providers to have a Quality Management System. It is not, and should not really be too surprising that these two should share functions and interact closely with each other.

Some organisations with truly functional Safety Management Systems actually run nearly all the components of a Quality Management System. I visited one such organisation recently who, in creating their Safety Management System, then decided to create a Quality Management System, only to find they had done it already in support of their SMS.

Where QMS looks to assure the quality of a service or product, SMS looks to identify safety related hazards, assess the risks and implement effective controls.

Both must be planned and managed, measured for performance and involve all those of the organisation who are involved in the delivery of products and services and strive for continuous improvement.

Here’s a real example of where they both come together:

An aerodrome’s wildlife management system identified that twice a day, large numbers of a certain bird species transited right across their runway threshold. The bird observation records had shown that the on and off aerodrome actions were having little affect, and there had been a couple of birdstrikes. The Aerodrome’s Management reviewed the risk and decided to act. A policy was communicated that, following training based on the new procedure, the wildlife hazard patrol could request that ATC suspend operations whilst the birds transited. This was all planned with everyone involved, including the airlines, via their change management process. The birdstrikes of that species then ceased.

So, here a policy (see the Spring 2014 Safety Bulletin article “Safety policy – what is it?” to understand the importance of communicating policies and how they can empower staff) was created and communicated to relevant staff and empowered certain staff to take action with the Aerodrome Management’s full support. A process defined how this was to work so not to create any other safety issues and allowed all those affected to plan ahead with their own processes. The effectiveness of this action was then measured.

The QMS facilitates the planning of the process and creation of the policy. Document control ensures the correct procedure is communicated and available to be used by all involved with the training provided for that version of the procedure.

Note, it is very easy to quickly get in a muddle with an evolving SMS if the area of document control has not been sorted out early on from the outset. The QMS audits the procedure and training to ensure it all works. The performance of the action is monitored and this improves both the safety (fewer birdstrikes) and quality of the aerodrome service (reduced total cancelled flights and aircraft damage).

Thinking back to the “Simply showing how you manage your hazards” article in the Winter 2013 Safety Bulletin, the number of outstanding risk mitigations could be a performance indicator within the QMS performance report, alongside on-time departures, non-conformities, passenger complaints and number of safety reports filed. QMS audits are a good opportunity to check the mitigations within the hazard log, particularly those high risks with few mitigating barriers. The Summer 2014 Safety Bulletin “Man versus machine” article highlighted the variable performance of people. So if there was a risk mitigation connected with a human repeating a process or action, the QMS could be focused to audit that process and function to validate the mitigation’s performance or seek something better.

Where processes do breakdown, reporting and investigation should follow. Often investigations only provide a temporary fix, but the underlying issue is still very much there and remains unaddressed.

Root cause analysis can be applied to explore near misses and incidents to ensure resource goes to the real causes and successful ongoing prevention. One method to assist the root cause analysis process is the “5 whys”, whereby one keeps asking the question “why” to drill down to what went wrong.

• Why did the aircraft’s wing hit the truck? The pilot could not see the correct centreline.

• Why couldn’t the pilot see the centreline? The taxi lane was covered with water.

• Why was the centreline covered with water? The drainage runs were overflowing.

• Why were the drainage runs overflowing? The drain clearing was not carried out.

• Why was the drain clearing not carried out? The contractor was changed and this was missed off the list of duties.

Now, as you can see, this can go beyond just 5 questions once it gets going but it highlights a number of weaknesses in a number of processes that should be addressed.

Many times the investigation and analysis stops at the first why and all the other learning points are missed. Also a typical response is to retrain, in this case the pilot; in many cases this is expensive and doesn’t actually address the real issue. Quite a bit of effort, time and money is wasted on a solution with a poor return.

Through QMS auditing, regulatory compliance can be checked and monitored. Some things may only require an initial check as they do not change, but other things such as flight time limitations, for example, may need constant monitoring.

So both SMS and QMS actively support each other, as well as many other management systems, within an organisation. You may identify parts of each system, but once embedded you usually cannot totally separate them.  Just as with all the flights operating throughout the world, they all come together to make your management system work for you, and that’s the day job.