Asm 803 2

ASM 809 Air Safety Management
Dirk Maclean PhD MBA

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Acknowledged
This problem is acknowledged in the SMS

literature and widely discussed
We obviously can’t leave things at that, we
need a solution. Are there any ?
Yes, but…
As we shall see, they bring with them a
whole set of new problems and challenges.
They take us in a direction which is not
necessarily what was intended

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Is there a better option ?
One of the solutions to this problem is to

broaden out the data collection to include
near misses and incidents
Is this a good idea ?

Yes
But…
It is a concession, a half way step, towards
an even better solution, one we will
examine here in a lot of detail

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So if there is something better, why

don’t we use it ?
Because…
Decades ago we moved towards our
current understanding of safety and safety
management
This was a shift in thinking at the time
If we adopt the better solution now it is an
admission that we made a mistake, went
down the wrong path
It also means the whole approach behind
the SMS is thrown into question
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Do we want to go there ?

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What’s your beef ? Aviation is safe
Aviation still has the most impressive

safety record of any industry or sector. The
accident rate is infinitesimally small
Our approach is working, what’s your
problem ?
But is it ?

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Past our peak
Aviation is still extremely safe, but what is

the trend, is it going in the right direction ?
The evidence is not very clear, but there
are worrying signs that we hit a peak in
safety performance around 2016
2024 has got off to a terrible start
Is this significant ? We don’t yet know

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Accidents are not the correct metric
This follows from the focus on risk. So the

fact that accidents are very rare does not
help us to assess whether our current
approach is effective, or optimal
There is another issue too…

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A confounder
The problem with accident statistics is that

there is a confounding factor that prevents
us from evaluating our safety management
efforts
What is this confounder ?
Technology
There is strong evidence that the reliability
of our technical systems in aviation is the
main reason we have such a strong safety
record, and why it has improved so much
up until recently

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Haneda airport fire
The recent collision and fire that destroyed

an A-350 was survived by everybody on
board
A critical factor was the improvement in
fire resistance of the cabin seating and fit
out
These seats can also now protect from up
to 16G force of impact

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And human performance ?
This is harder to measure, for reasons we

will explore further. One is the
assumptions built into our current
approach
The evidence is mostly anecdotal, or based
on specific case studies, but…
Its not looking good

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We used to be good at this
One indicator we have is the performance

of organisations that used to excel in the
areas of safety and reliability, under
extreme conditions, like US Navy carrier
operations
These were once the model everyone tried
to emulate. But where are they now ?
There is no way to say this nicely, the
current record of the USN for safety in air
operations is…
appalling, its an absolute disaster

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Capability is declining
A review of cockpit emergencies, accidents,

and near misses across aviation suggests -
§ Basic flying skills are missing, for lack of
practice
§ The ability to deal with abnormal flying
conditions has declined drastically

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Capability is declining
A review of cockpit emergencies, accidents, and

near misses across aviation suggests –
At Haneda the evacuation took 18 minutes

after the collision to complete
In fairness, this includes 11 minutes of the
CPT completing a final walk through, which
shouldn’t be rushed
Still, 7 minutes. We could also take off the 3
minutes it took to start the evacuation
The accepted standard that cabin crew
train towards is 90 seconds

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UAL Flight 1722

conditions has declined drastically.
In this case we are simply talking bad

weather, there were no technical
malfunctions, and yet…
The pilots lost complete control over the
aircraft, almost plunging into the ocean
Several of the factors in this incident will
make up major themes in this subject

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Technology doesn’t help in this

respect
Technological advances do make routine

flying easier, but, from a human
perspective…
They get ever more complex, pilots have to
spend more and more time just trying to
keep up, to understand what computer
systems are doing and the logic behind
them
There is a stage where this becomes both
impossible, and redundant. We are close
to this point

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Qatar Airways QR 161
They get ever more complex, pilots have to

spend more and more time just trying to keep up,
to understand what computer systems are doing
and the logic behind them
In this case, the pilots did not pick up that

the aircraft was rapidly descending and
about to hit the sea, until the last moment

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Air Algerie Flight B738

conditions has declined drastically.
§ They get ever more complex, pilots have to
spend more and more time just trying to keep
up, to understand what computer systems
are doing and the logic behind them
In this incident, all of these factors were

present. The aircraft dropped to just 72’
above the ground before recovering
Chaos on the flightdeck continued, with
another dangerous drop in altitude
seconds later. The crew corrected this,
but… oversped the aircraft

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A ‘black box’
This logic behind automated systems

becomes less and less visible, they are
more and more of a ‘black box’, so when
something goes wrong an appropriate
response is hard to work out
The 737 Max debacle is one example, but
there are many
One of the best is this one involving flight
training students, from Mentour Pilot
https://www.youtube.com/watch?v=04M63B1sv_Y

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We know what the problem is
The reasons for this decline in human

performance is quite widely recognised
Ironically, it is the improvement of technical
systems and automation that has much to
do with it
Pilots and others in air operations just
don’t build up a depth of experience to
cope well when things go wrong, because it
happens so rarely
This is true in other sectors too,
emergency services for one

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Meanwhile, technology is advancing
Cockpit automation and other systems in

aviation, ATC for example, are constantly
improving
We now have the arrival of Artificial
Intelligence (AI), which promises a genuine
revolution

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The equation is shifting
So, we have a position where technologies

are making strides ahead…
while human performance is going
backwards
It is not hard to see where this is going

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Where does Safety Management fit

in with this picture ?
Our current understanding of safety and

our present approach focuses exclusively
on the human element as a source of
error
Pilots make mistakes, they are human. This
is a problem to be managed, a risk to be
reduced

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Reduced, or eliminated ?
Risks can be reduced, but better still, they

can be eliminated
The entire logic of our current approach
fits with this conception. We will see this in
ICAO’s SMS, the aim is to get to a point
where…
Human beings behave like technology as
much as possible. They are reliable,
predictable, compliant

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But do we need such pilots ?
No, we don’t, not if we have technical

systems, automation, AI, that can behave
technologically much more reliably
This applies to all personnel across air
operations, the push to replace the human
element is everywhere and accelerating
Baggage handling is one example, there
are many

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Will we keep pilots in the cockpit ?
Maybe, as window dressing, to keep

passengers happy
But they won’t be needed to fly the aircraft,
we have computers for that
Under no circumstances will they be
allowed to touch anything

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Not even in an emergency ?
But here is the problem – our entire

present approach is what is preventing
pilots from developing the skills to
intervene in an emergency
This is in fact where their current
performance is weakest
Just when we need them the most, they
perform the worst

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Are we happy with this trajectory ?
Some are, they welcome the adoption of

automation and AI, the elimination of the
human element
If it improves safety, then why not ?
Others are not so comfortable with this
Others still are just in denial, ‘it will never
happen’
But it is already happening, and in fact has
been for several decades. ICAO’s SMS is a
product of this process

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Where are we now ?
Right now we are at a half way house

We are applying a technologically driven
method that defines the human element
as a negative, and attempts to manage it
as such
But we are not quite ready to remove
humans altogether, we still need them for
situations where technology is either
inadequate or is malfunctioning

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Is ICAO’s SMS fit for purpose ?
The current method is technological in

essence. It seeks to remove everything
from air operations that is –
§ unreliable
§ unpredictable
§ inconsistent
§ non-compliant
§ out of control
These are the risks

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This makes sense in relation to humans, if

these are understood purely in such terms,
as in fact they are at present
§ unreliable
§ unpredictable
§ inconsistent
§ non-compliant
§ out of control
In this conception, these are the risks

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But what about technology ? Technical

systems that fail or malfunction ?
Does a technological approach work in
such cases ?
Or is something else needed ? Something
only humans can provide, precisely
because they are
§ unreliable
§ unpredictable
§ inconsistent
§ non-compliant
§ out of control

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Air operations today
In reality, air operations today consist of

both imperfect humans, and imperfect
technology
So if we want to evaluate our SMS and the
methodology it rests on, then we need to
consider its suitability for this reality
So, how does it do ?
Let’s find out

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ASM 809 Air Safety Management

Dirk Maclean PhD MBA

This problem is acknowledged in the SMS

Dirk Maclean PhD MBA

Is there a better option ?

One of the solutions to this problem is to

Is this a good idea ?

Dirk Maclean PhD MBA

So if there is something better, why

Dirk Maclean PhD MBA

What’s your beef ? Aviation is safe

Aviation still has the most impressive

Dirk Maclean PhD MBA

Past our peak

Aviation is still extremely safe, but what is

Dirk Maclean PhD MBA

Accidents are not the correct metric

This follows from the focus on risk. So the

Dirk Maclean PhD MBA

The problem with accident statistics is that

Dirk Maclean PhD MBA

Haneda airport fire

The recent collision and fire that destroyed

Dirk Maclean PhD MBA

And human performance ?

This is harder to measure, for reasons we

Dirk Maclean PhD MBA

We used to be good at this

One indicator we have is the performance

Dirk Maclean PhD MBA

A review of cockpit emergencies, accidents,

Dirk Maclean PhD MBA

A review of cockpit emergencies, accidents, and

At Haneda the evacuation took 18 minutes

Dirk Maclean PhD MBA

UAL Flight 1722

§ The ability to deal with abnormal flying

In this case we are simply talking bad

Dirk Maclean PhD MBA

Technology doesn’t help in this

Technological advances do make routine

Dirk Maclean PhD MBA

Qatar Airways QR 161

They get ever more complex, pilots have to

In this case, the pilots did not pick up that

Dirk Maclean PhD MBA

Air Algerie Flight B738

§ The ability to deal with abnormal flying

In this incident, all of these factors were

Dirk Maclean PhD MBA

This logic behind automated systems

Dirk Maclean PhD MBA

We know what the problem is

The reasons for this decline in human

Dirk Maclean PhD MBA

Meanwhile, technology is advancing

Cockpit automation and other systems in

Dirk Maclean PhD MBA

The equation is shifting

So, we have a position where technologies

Dirk Maclean PhD MBA

Where does Safety Management fit

Our current understanding of safety and