I saw this question on Quora.com. Good question! Complex answer 🙂 I started writing and it became pretty long so might as well make an article out of it 🙂

So why do Safety Management Systems fail?

As usual there are a few ways to do something right and many more to mess it up.

In my experience, it starts with the motivation to get a Safety Management System in the first place.
An SMS can be a great tool to learn about safety issues in the organisation, investigate them and come up with solutions to resolve them.
If however the reason to implement an SMS is basically, “the regulator is on my back” or “because we have to”, most organisations in that camp start off on the wrong foot.
They tend to grab the nearest template manual, start implementing required procedures for policies, reporting, meetings etc. set up some databases “et voilá” something that looks like an SMS.

The regulators, who also were mainly complying too and have not necessarily fully understood the “why” of an SMS, come by with a checklist…
“Visible Policy?”
“Safety reports?”
“Doing plenty of safety meetings?”
“Check, look got minutes and everything!”

Of course it was established that the organsation had the attributes of an SMS but that only means your organisation has a tool at its disposal.
Not necessarily a working tool at that.
It did not necessarily mean that they were using the SMS for anything meaningful other than generate paper work about safety.

The previous dialogue with the regulator is becoming outdated, (or should be soon), now the regulator is going to ask (or should ask) different questions:
“So you have a safety policy, yes see it there above the head of the receptionist, nice and visible… Let´s ask that guy on the hangar floor if he knows it exists, and what it means to him roughly!”
“So you have had 10 safety meetings this year? Yes, minutes and everything… What is your company doing differently as a result of those meetings, and does it work?”
“What are the top risks your SMS has identified in your organisation and what are you doing to control them?”

If find the best summation of what an SMS should do a short article by William Voss from the Flight Safety Foundation.
Basically he says your SMS needs to be able to answer 4 fundamental questions:

  1. What is most likely to be the cause of your next accident or serious incident?
  2. How do you know that?
  3. What are you doing about it?
  4. Is it working?

Most organisations who claim to have an SMS have difficulty answering these 4 deceptively simple questions in a convincing manner.


  • they are not getting the data from their people, because despite the talk about Just Culture, it is not backed up with competent investigations, and people are still blamed rather than organisational factors found and fixed. The stats tend to portray “no problem” while in fact most people know there are serious issues, but they are not discussed nor addressed.
  • the mindset of investigations; most are still trying to find “the root cause” rather than considering the complexities of failure and the many factors that contribute to failure in complex organisations. A competent investigation looks at the many performance influencing factors, and looks at a large enough number of investigations to identify which contributing factors should be addressed to reduce the future likelihood of similar events.
    Safety problem solving tends to focus too close to the front line, and rarely are the fundamental organisational factors successfully identified and addressed.
  • there tends to be a misunderstanding on who manages safety. The title Safety Manager is misleading, the SM only has authorithy over the SMS. “Safety” is a condition that is maintained by every manager through day-to-day decision making. If the SMS works, the operational management team gets good information which helps them to improve the safety condition through better decision making, thus “managing Safety”. If it does not work, there is a lot of SMS bureaucracy but it does not help to improve the quality of the day-to-day decision making in the organisation
  • Risk assessments have not enough or the wrong people around the table discussing risk. Many assessments are done by the safety manager or quality manager alone, becuase nobody has the time. They might be very knowledgeable but do not know the intricate details of the day-to-day job, so risk assessments become filled with a lot of assumptions and end up an intricate fantasy which does not connect with the operational reality
  • Safety meetings are clogged up with useless detail discussions rather than decision making discussions, often the meeting ends with out constructive decisions on how to control risk and who is responsible for doing it.
    Also related to the above, the relationship between the Safety Manager and the operational management team can become adversarial and totally non-productive if there is an unconstructive mode of blame-shifting, and people refuse to take responsibility for deficiencies in their area of responsibility.
    Just Culture should apply to managers too but often does not… Note that this is not necessarily an SMS problem, it can be an organisational culture issue that has this effect in general.
  • little to no follow up of decisions that are made, “paper” implementations. Because many managers are super busy, when they are forced to address an issue it is tacked on at the end of a looong to -do list. Sometimes they write an e-mail and consider it “fixed”
  • Little to no follow up from the senior manager on how the management team is keeping on top of these 4 questions. the discusions tend to get buried in too much technical detail that does not interest the CEO , and they quickly disengage from the discussion
  • Poor communication skills to feedback success stories of when the SMS is used appropriately, often there is a dry technical bulletin, which is ill suited to most of the audience it reaches. So few people have an interest in the SMS success stories

There are many more failure modes, but the above are a few of the most common ones.

What to do about it?

It starts at the top!

This is easy to say…and often misunderstood, I don’t mean that the CEO needs to fix everything !

But s/he needs to take an active interest and demand from the management team and the SMS a digestible answer on what is being done about these 4 questions.
If there is confusion through information overload, or worse, blame shifting, it should cause the CEO to become worried that the management team is not very on top of the safety management, which should raise questions on other areas of the operation. Safety management in the end is a subset of overall operational management.
It would be improbable that operational management goes smooth and safety management does not or vice versa.

There is a saying, “What interests my boss, fascinates me” and I think this is true as well in Safety Management.
The CEO or senior leader in the organisation just by asking safety related questions (even simple high level ones like the above) helps everyone to discuss safety, rather than continously focus on the hot button issues.
How to get the boss interested ?
There are no magic bullets here, but a potentially useful frame for the discussion is that safety performance is an integral part of operational performance.
The SMS is a great tool to look into the organisation with an objective view and take a more systemic look at the operation.
Often CEO’s take it for granted that Safety is being managed, due to the abscence of accidents.
It is the job of the SMS to make safety as visible and quantifiable as finance to the CEO so they can make informed decisions. There are many opportunities for improvement that benefit both the operational efficiency and safety when looked at in a systemic view.

Designing safety decision making and follow up

Transforming decision making in any organisation is a very difficult task and will take time and purposeful development.
A successful safety decision making culture will not “just happen” because you have some policies, procedures and information.
Most organisations have not considered how to design their safety meetings for the purpose of Safety decision making. throwing 5-8 professionals in a room with unclear guidelines is going to default to technical discussions which are too detailed and don’t tend to address the organisational issues which are more nebulous and difficult to address.
Result is unfortunately that most safety meetings are perceived as a waste of time.


About the Author
Jan Peeters

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.