Unsafety is as Systemic as Safety!

Written by Sergio Romero

I was heading to the office in this weird summer. The call I received was way long before my shift begins. It knocked me not only at my ears, but shocked me like a surge. It was an event with the same engineer again. Over and over, we retrained him, we monitored him -bulky reports arouse, wherein I wrote my insights and advice based on hours-long interviews and references, and we gave him a special treatment. But something appears not to be working in this system. Then, I regain consciousness and get back to present time. I am at my new office, and in my way to the restaurant for a bite, a man touches my shoulder. His eyebrow covered by a patch, with a thin and insidious cue of blood reminds me what to expect with this guy. It’s the same man, who was involved in several personal accidents when he worked with us. He is working on-call mode for a small maintenance organization now. After he was speaking and making the story of how he was injured again, a hug was the outcome of the last time I saw him.

All my reports came to me. All figures, statistics and references became alive and were breathing next to me like a letany until a clue decided to show up. It is clear we had not all answers by just ticking the boxes, but reviewing my stuff I realized fundamentals are over- and underrated. When did this happen? When organizations are not able to work processes within a system.

What does this mean? Can you figure out how many publications talk us about the Safety Management System? What is to be done? The easiest way demands us just to follow or copy-and-paste publications. It could be like tailoring some cloth to fit the “organization’s” body, we are told to do that. How many of you, guys, have heard this statement of “tailored” SMS? But still, the required results do not fulfill the organization’s requirements. It seems the SMS is flawed since beginning. I remember a friend that was telling me how to understand, Sergio all these incidents during the pandemic with less operations and traffic? I agree, buddy, but are they reviewing and updating their hazard registers? Have they made the exercise of Change of Management? Why can someone think we are free of incidents with less operations and traffic? I would reply do you need only regular operations and traffic for the incidents to happen? What is to be done here? Yes, the management system concept again rings me even before the birds sing.

This is the answer to the circumstance of being defeated before beginning the battle with the SMS. We need to understand to make a business within this management-system-based approach; it means in a systemic-based context. So, before looking for the best safety publications, we have to build this management system culture for real. What does the International Organization for Standardization (ISO) state about this? ISO says the Management System is a “set of interrelated or interacting elements of an organization to establish policies and objectives and processes to achieve those objectives”. So, the first activity in the endeavor for an operational SMS is to achieve the organizations plan, build and budget interrelated or interacting elements. Have you done that? We have to take into account the SMS is a management system and it must be treated as such. Otherwise, it means failure, lack of operational nature, and loss of funds. It will be a flawed-and-good-intention activity, but it is not a management system.

Can you find key words in the definition ISO states above? I’d lean to Peter Drucker’s concept of being unable to know if something is working as planned without measuring the system you are running. That’s when policies and objectives and processes to achieve those objectives come into play. Some organizations change their blueprint actions only after an incident or an accident occurs, but never look back at the original objectives. All the management should be running based on policies and their relevant objectives, and organizations must accurately know if the ways the reality is drifting must be corrected and how. Should be only incidents and accidents the alarm cues for a change? What about monitoring actual performance with surveys, audits and studies? When did this idea arise of thinking Quality Assurance means just auditing? Why auditing only after an incident or accident?

Safety Management Systems constitute a key tool to preserve resources in aviation, no doubt about it. But let’s give a try to understand that these unsafe cues are eroding our organizations in a systemic manner. They become alive if we are running organizations, wherein a set of interrelated or interacting elements are operating not to plan, do, check or act against unsafe practices or activities way far or beyond our organizational objetives. We have to consider quality is a grade and safety is a state. That’s why the human behavior is to be understood and deemed into this equation. We, humans, make both the quality and safety in the organizations. We must first walk these management systems to be able then to run safe aviation organization services!

About the author

Sergio Romero