ASM 803 Air Safety Management

Dirk Maclean PhD MBA

3
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ASM 803 Air Safety Management

Its complicated

ICAO’s SMS sits as a half way house in that

it applies a technological mindset to a
context where both humans and technical
systems are flawed
It seeks to suppress the human element
even though this is precisely what is
required when technology fails
It also combines two separate and
contradictory approaches…

Dirk Maclean PhD MBA

3
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ASM 803 Air Safety Management

Its complicated

In both its documents and in practice,

ICAO’s SMS does at times embrace the
human element, and regard this as a
positive
This means the SMS does contain many
good ideas, and organisations
implementing it often emphasise these
rather than focusing solely on human error
as the problem
The picture can get very complicated,
messy, where the actual problems are hard
to see

Dirk Maclean PhD MBA

3
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ASM 803 Air Safety Management

Contradictions

Even at their most basic, the guiding

principles behind an SMS contain
contradictory ideas, generating a lot of
confusion as to what is intended
Lets pick out a few…

Dirk Maclean PhD MBA

3
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ASM 803 Air Safety Management

Risk – good or bad ?

In SRM, risk is defined as something bad.

But is it ?
Not in classical risk management, which it
also adopts. Risks can present an
opportunity, taking a risk can be precisely
what is needed in certain situations
Risk aversion can be a fatal flaw

Dirk Maclean PhD MBA

3
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ASM 803 Air Safety Management

The risk of missing an opportunity

Not only that, but opportunities

themselves present a risk, of being missed.
We have a name for this – opportunity
cost

Dirk Maclean PhD MBA

3
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ASM 803 Air Safety Management

Does it matter ?

Yes, the implications are enormous, they

shape entirely the way in which decision
making is evaluated.

Either –
§ Minimising risk as much as possible is
the goal, or in SMS language ‘preserving
the ‘safety margin’
Or
§ Accepting risks, seizing opportunities, is
expected, what is unforgiveable is to
take unnecessary or avoidable ones

Dirk Maclean PhD MBA

3
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ASM 803 Air Safety Management

Does it matter ?

Yes, the implications are enormous, they shape

entirely the way in which decision making is
evaluated.

The first leads to a risk averse and

compliance mindset, it promotes
indecision and timidity

It punishes decisions if they don’t turn out

well, it fails to reward them even if they do
This is in fact our dominant corporate
culture today, and this approach is why we
have got to this point

Dirk Maclean PhD MBA

3
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ASM 803 Air Safety Management

Does it matter ?

Yes, the implications are enormous, they shape

entirely the way in which decision making is
evaluated.

The second leads to an appreciation of

human judgment as the highest quality
Decisions may turn out badly, but the
question becomes –
Were the risks worth it ? Were they
properly taken into account ? Was this the
best course of action available ? What was
the risk from doing nothing ?

Dirk Maclean PhD MBA

3
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ASM 803 Air Safety Management

Dummy landing ?

One example is the decision whether to

practice landing while at altitude during an
emergency where control over the aircraft
is compromised
This is a risky manoeuvre
UA 232, QF 32, and QF 72 were all
confronted with this dilemma
Two went ahead, one didn’t
Two landed intact, one hull was lost
Who was right ? In truth, its open to
debate, the outcome doesn’t settle the
matter

Dirk Maclean PhD MBA

3
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ASM 803 Air Safety Management

Military pilots are better

This is one reason why military pilots are

generally regarded as better
Military aviation risk management does not
prioritise minimising risks, this would make
no sense
It is also because not taking risks can lead
to worse outcomes

Dirk Maclean PhD MBA

3
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ASM 803 Air Safety Management

Military pilots are better

Developing good judgment in relation to

avoidable and unavoidable risk is a key skill.
It requires practice, and it also requires
some tolerance towards ‘safety margins’
being compromised on occasion
This is the price to be paid for higher
performance over the longer term, above
all in an emergency
How far to take this notion is itself a
judgment call

Dirk Maclean PhD MBA

3
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ASM 803 Air Safety Management

Are mistakes a bad thing ?

The same logic applies to error. Is this

always a bad thing ?
But how do we learn if not from our
mistakes ?
Again, there is a judgment call to be made
here
The contrast between short and longer
term thinking is important here. Later we
will define this as an ‘operational
perspective’ and discuss it in detail

This is a core concept within this subject

Dirk Maclean PhD MBA

3
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ASM 803 Air Safety Management

Safety is everyone’s responsibility ?

And yet it is handled by specialists, in a

separate management function, using its
own data sources and performance
metrics
And everyone else ?
They have their own work to do, which
involves something else
Another contradiction with massive
implications

Dirk Maclean PhD MBA

3
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ASM 803 Air Safety Management

Senior management commitment

The SMS contains an entire chapter

stressing how important senior
management buy in and involvement is to
the safety function
Doesn’t this give the game away ?
Is the reason it needs stating so
prominently not the result of making
aviation a separate and specialist function,
divorced from every other aspect of flight
operations ?

Dirk Maclean PhD MBA

3
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ASM 803 Air Safety Management

Safety culture

The drive for an improved ‘safety culture’

stems from the same source
Safety is now extracted from all the normal
duties people perform, so that it has to be
artificially put back in

In practice, this takes up an enormous

effort, and often fails

Dirk Maclean PhD MBA

3
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ASM 803 Air Safety Management

Effect on operations

The effect on operations is the most

severe. All staff outside pilots to some
extent and ATC to another now have a set
of performance metrics that excludes
safety in all their essentials
Instead ‘safety’ is bolted on almost as an
afterthought
The chief outcome of this is pressure –
from line management to do their job, and
from safety professionals not to forget
about ’safety risks’

Dirk Maclean PhD MBA

3
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ASM 803 Air Safety Management

Operations Centre staff

Here is an example from a textbook for

Operations Control Centre (OCC) staff. It
states explicitly,
“Safety related decisions may be made by
pilots or air traffic controllers where the
well-being of an aircraft, persons, or the
aviation system is potentially or actually
compromised. However, while the
outcomes of such decision may be taken
into account in airline operations, OCC
decisions are not directly safety related”.
Bruce, Peter J.. Understanding Decision-Making Processes
in Airline Operations Control, Taylor & Francis Group,
2011, p.39

Dirk Maclean PhD MBA

3
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ASM 803 Air Safety Management

Operations Centre staff

In fact, OCC decisions outlined here

specifically ignore safety considerations,
which are solely the pilots’ responsibility
“If a decision by an OCC required a specific
direction to the Captain of an aircraft (eg to
to divert) the decision will not compromise
the responsibility that the captain has for
any safety matters pertaining to that
aircraft”.
Bruce, Peter J.. Understanding Decision-Making Processes
in Airline Operations Control, Taylor & Francis Group,
2011, p.40

Dirk Maclean PhD MBA

3
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ASM 803 Air Safety Management

Operations Centre staff

So, Ops do ops, and the pilots do safety

But safety is everyone’s responsibility ?

Dirk Maclean PhD MBA

3
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ASM 803 Air Safety Management

Risks versus reality

In practice pilots come under similar

pressures. Even air traffic controllers,
whose chief function is to maintain safety
are often pushed to compromise this for
the sake of other considerations
But safety is our number one priority. It
says so in our policy statement at the start
of the SMS
Well, if it says so then it must be

Dirk Maclean PhD MBA

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ASM 803 Air Safety Management

Cynicism ?

This sounds cynical. Many safety specialists

will argue it reflects a poor attitude,
precisely what a good ‘safety culture’ is
designed to overcome
But is it cynicism towards safety ?
Or towards endless management pressure
that pushes and pulls in two opposite
directions at the same time ?

Dirk Maclean PhD MBA

3
 ASM 803 Air Safety Management

Dirk Maclean PhD MBA

3