Remarks of Robert Sumwalt, Vice Chairman
National Transportation Safety Board
27th Annual Conference of the
Aviation Law Association of Australia and New Zealand
May 8, 2008
“Safety Management Systems (SMS): Building a Wall of Safety”
Thank you. It is wonderful to be in Sydney. I thank you for including me on this discussion of Safety Management Systems (SMS).
Think about the various safety programs that are out there – programs like Internal Evaluation programs, Standards, Line Operations Safety Audits, Employee Feedback, Audits, Quality Assurance, Aviation Safety Action Programs, Flight Operations Quality Assurance, Procedures and Training, etc.
I envision these safety programs as vital components of an imaginary wall that we are trying to build to protect companies from bad things. When I say “bad things,” in this context, I am thinking of accidents, incidents and events with undesired outcomes.
SMS figuratively fills-in the gaps in the wall and ties together these vital safety programs. By filling in the gaps, it ensures that things don’t fall through the cracks – because the cracks are few and far between.
Safety Board Recommends SMS
The Safety Board recently deliberated an accident involving a nighttime repositioning flight in a regional jet. The crew evidently decided that since it was just the two of them, they would, as they told ATC before things went sour, “… have a little fun…” Post accident analysis reveals that the crew performed a number of unauthorized actions, including intentionally causing the stall warning system to activate on three occasions, imposing dangerous sideloads on the aircraft’s tail structure by intentionally mishandling the rudder, allowing the first officer to occupy the captain’s seat while the captain sat in the first officer’s seat, along with a series of other serious errors.
The crew elected to climb to the airplane’s maximum authorized altitude of 41,000 (FL 410), despite the fact that they were flight planned for 33,000 (FL 330). The aircraft was only climbing a few hundred feet per minute, so to increase the climb rate, the crew selected a 500 foot per minute climb. As they did this, airspeed began to bleed off from the recommended climb profile speed. When the aircraft leveled at FL410, the aircraft was about 40 knots below the recommended climb speed. Because the aircraft was behind the power curve, despite climb power being applied, it began decelerating, leading to a high altitude stall and loss of control. The high altitude upset disrupted airflow through the engines and both flamed out. Unfortunately, the crew was unable to restart either engine and they paid for this behavior with their lives.
A question that emerged early in the investigation was “why was the crew at 41,000 in the first place?” After all, they were only flight planned to be at FL 330.
What NTSB investigators learned was that there was an unofficial “410 Club” at this airline. On repositioning flights such as this one, pilots would climb to 41,000 just so they could say they had done so. The Safety Board was curious if the airline knew of this “410 Club,” and how did the airline monitor and keep track of potential safety issues? In fact, the investigation revealed that the airlines did not have effective safety programs, effectively putting holes in the “wall of safety.”
The Safety Board concluded: “All air carriers would benefit from Safety Management System programs because they would require the carriers to incorporate formal system safety methods into the carriers’ internal oversight programs.” The Board issued recommendation A-07-10 to the FAA to “Require that all [air carriers] establish Safety Management System programs.”
So, what is SMS, anyway?
There is a lot of talk about SMS, but really what is it? According to ICAO Doc 9859, “A SMS is an organized approach to managing safety, including the necessary organizational structures, accountabilities, policies, and procedures.”
When a company has SMS, it systematically attends to those things it believes are important. It manages and values safety, just as they manage other vital business functions. For example, each company values finances. To ensure that finances are properly managed they typically appoint a Chief Financial Officer, they manage their financial books in accordance with General Accepted Accounting Practices (GAAP), and they have financial procedures, controls, audits and accountability. All of this is to ensure that the company finances receive adequate attention and care.
By a similar note, through SMS, the company puts in place formalized, comprehensive procedures and controls to ensure that safety is properly managed, valued and receives proper attention.
In simple terms, SMS is when you have:
Written policies, procedures, guidelines
There are a few questions to be asked about written policies, procedures and guidelines. First, does the organization have written policies, procedures and guidelines? And, if they do, are they actually following them?
An example of inadequate written policies, procedures and guidelines was an October 2002 accident involving a chartered King Air. This accident claimed eight lives, including that of a US Senator. The Safety Board’s investigation determined that the King Air pilots flew a non-standard approach profile, leading to low altitude stall and loss of control from which they were unable to recover.
Investigators were interested at what documentation, if any, that the charter company used to train pilots for instrument approaches. One company pilot told investigators that she had never seen any standardized callouts documented in any company manual, and to compensate, she used callouts she used at another company
Further, key procedures for briefing and conducting instrument approaches were contained in the company “Maneuvers Guide.” Pilots were expected to adhere to procedures in Maneuvers Guide, but oddly, the Maneuvers Guide was only issued to the chief pilot and instructors.
Further, for those procedures that were documented, company check airman rated company’s standardization as “six” on a one to ten scale. The lead ground instructor estimated standardization was “fair,” and he suspected that some pilots were following Standard Operating Procedures (SOPs) while others were not.
Key questions here are 1) how does the organization keep their finger on the pulse of the operations, and 2) do they have multiple data sources?
In the previously referenced accident involving the regional jet being flown to FL 410, at the time of the accident, the accident airline had no effective programs to collect and analyze safety data. They did not have a FOQA or ASAP program and they had never conducted a LOSA.
Remarkably, when asked how they ensured that crews were operating according to standard operating procedures during repositioning flights, the company’s chief pilot stated: “Same way I do any flight being conducted to SOP. We look at the reports. We look at the numbers, you know, did they leave on time, did they not leave on time, and if anyone is on the jump seat doing a check. That’s the only way I know if any flight I have is being conducted per SOP.”
Investigators learned that the company did have a safety hotline where crewmembers could call to report safety concerns. However, investigators uncovered that no one used the hotline.
In totality, the airline had no effective means of monitoring and keeping in touch with what was going on.
Quite simply, you know you have safety culture when employees do the right things, even when no one is watching. Corporate culture starts at the top of the organization and permeates the entire organization.
My special assistant, Dr. Katherine Lemos says: “If management values safety, they will devote appropriate resources to it.” “If they don’t truly value safety, employees will know.” “How? Because they watch you.”
SMS is an important part of ensuring safety. The NTSB not only thinks it is a good idea, but we have issued a safety recommendation for the FAA to require it for air carriers.
I very much appreciate the opportunity to present on behalf of the Safety Board. Thank you for your attention.