Sometimes organisations just added “implement SMS” to a long to-do list.
Once the implementation is considered “done” they forget to look back and ask themselves “What is SMS supposed to do again?”.
The basic assumption of an SMS is to move from ad-hoc, reactive management of safety to a more systematic and pro-active approach whereby it identifies weaknesses in the system and these safety problems are addressed in a structural and sustainable manner.
For that purpose the SMS is designed to gather data, the more the better, with the hope we can spot trends and identify those weaknesses. The mantra in safety circles has been for a long time “the data will set you free”.
To do that, there is a very long list of things that you have to comply with describes in ICAO doc 9859 and different regulations.
All these things are meant to equip your system with a capability to gather that data (e.g. reporting systems, just culture so that people feel free report, safety policies so that they know the just culture is supported by management, etc. etc.).
Of course these capabilities are important but they are only a means to an end.
More than that, they are only the first step towards actions that improve safety.
The danger Dekker points out is that SMS can become a “self-referential system”; i.e. a system that just exists for itself; while more and more data goes in (the good and bad kind of data) nothing useful comes out of the SMS.
In other words, despite that data gathering activity, the real nuggets of information are hidden because:
- there is so much quantity of data the “good stuff” gets buried
- the data we are pursueing and asking people to report is not necessarily of a high quality or relevant to our highest risks
- we are not creative in the way we correlate the data to identify previously undetected issues
In order to improve safety, the organisation obviously needs to take some kind of action. Once this “actionable intelligence” is presented to management, some kind of action will follow to improve safety. Right?
In my experience, even if the SMS does generate actionable intelligence, it is no guarantee that the management of the organisation will take effective action.
This is not because these managers are necessarily bad people but, like the Challenger accident showed, even the best technical information is sometimes not enough to influence the decisions positively.
The ability of “actionable intelligence” to positively influence the safety decision-making process depends on many factors:
- the general awareness of risk and mental biases of individuals in management
- the “language” of the communication and the presention of this information
- the personal credibility of the safety professional or department
- the framing of the decision to be made
- mental obstacles and group dynamics of the moment (information overload, analysis paralysis,
One of the risks Dekker highlights, is a dangerous bastardisation of the philosophy and intent of SMS when showing the paperwork of the SMS activity becomes more important than the actual actions taken to improve safety in the operation.
What is coming out of your SMS?
Does your SMS generate “actionable” intelligence? You might have a nice database full of reports, but how many substantial safety recommendations have all these reports generated?
If it does generate actionable intelligence and safety recommendations, do actions actually happen?
Are those actions actually improving the safety performance of your operation?
How often is there a disconnect, i.e. a safety issue identified but the recommendations are not accepted?
If this happens, have you investigated the reasons ? (Perception of cost or complexity, no awareness of risk, misunderstanding, no cooperation, … )
There are many reasons why valid safety recommendations are rejected by the management team. Sometimes it is a misunderstanding based on language used to explain the issue to non-technical people.
Sometimes it is a motivation issue and the recommendation was not created in collaboration with the involved managers and they lack autonomy, purpose and a sense of mastery (or all three)
Sometimes it is a presentation issue, due to the design of the safety meeting which generates a negative personal dynamic. Sometimes there is simply no mental space for the managers to comprehend the complex issue.
The timing and context of the discussion around the problem might be the issue.
The best way to find out is to observe the dynamic and see what happens if the presentation or framing of the problem is different.
About the Author
Jan is an experienced Safety practitioner who is always on the lookout to improve SMS and the management of safety. He coaches organisations and individuals in Safety Management.
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