When an organization is asked whether it is safe, the answer is almost always yes; the question of this episode is how that is known. The structure built to close the gap between believing you are safe and being able to show that you are safe is called a safety management system. The episode first examines why the issue is organizational rather than personal. Reason (1990) states that the primary origins of system breakdowns in complex, high-risk technologies lie in latent human failures that formed long before the situation was noticed, and that the outcome arises from the combination of many causal factors, each necessary but none sufficient on its own. According to the same study, front-line operators are rarely the main instigators of a system breakdown; their role is usually to provide the local triggering conditions that expose systemic weaknesses created by flawed decisions made earlier in the organizational and managerial domain. The study distinguishes between active and latent human failures and argues that new methods of risk assessment and risk management are needed. It should be noted that this source is not specific to aviation; it refers to complex, high-risk technologies. In international aviation regulation, the safety management system framework consists of four components and twelve elements. In the safety policy and objectives component, management commitment and safety leadership are key; safety risk management covers hazard identification, safety risk assessment and safety risk mitigation; safety assurance consists of processes and activities aimed at determining whether the system is working as expected; and safety promotion fosters a positive safety culture. Lee (2006) develops a quantitative model to improve the effectiveness of the safety risk management system by integrating the fuzzy linguistic scale method, the principle of failure mode, effects and criticality analysis, and the as low as reasonably practicable approach; the model evaluates factors by the criteria of severity, degree of hazard, detectability, probability, criticality and frequency. Chen and Chen (2012), noting that the degree to which the system is implemented varies in practice and that a comprehensive scale measuring its core dimensions is still lacking, develop a five-factor scale of twenty-three items: documentation and instructions, safety promotion and training, top management commitment, emergency preparedness and response plan, and safety management policy; since the study does not claim that these five factors map one-to-one onto the four components, no such link is drawn here. Hsu, Li and Chen (2010) state that, with the global regulatory trend towards a performance-based system, developing and implementing such a system has become the most important goal, yet there are some inconsistencies in how the system is explained and taught; they conclude that the most important dimension is organization, which begins with policies through which senior managers communicate the safety vision to all staff. At the end of the episode, you will clearly see a four-zone safety management review built on two axes, how well defined the system is and how measurable its functioning is, and how to close the gap between what is written and what is lived.

📌 Playlist for the full series: https://www.youtube.com/playlist?list=PL6s4Uhec9cFBZNpSWXeuaybOuyCsHS71K

Sources Used

International Civil Aviation Organization. Safety Management Manual (Doc 9859), 4th edition, Chapter 9; and Annex 19, Safety Management.

Reason, J. (1990). The contribution of latent human failures to the breakdown of complex systems. Philosophical Transactions of the Royal Society of London, Series B, 327(1241), 475-484.

Lee, W.-K. (2006). Risk assessment modeling in aviation safety management. Journal of Air Transport Management, 12(5), 267-273.

Chen, C.-F., & Chen, S.-C. (2012). Scale development of safety management system evaluation for the airline industry. Accident Analysis and Prevention, 47, 177-181.

Hsu, Y.-L., Li, W.-C., & Chen, K.-W. (2010). Structuring critical success factors of airline safety management system using a hybrid model. Transportation Research Part E, 46(2), 222-235.

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