University Name

Executive Summary
Safety Management System aims at reducing the risk of hazards by identifying and addressing
the gaps properly. It is extremely important for an organisation to comply by the safety
standards and maintain comprehensive SMS as it is enforced by national and international
bodies for the entire aviation industry. An organisation can readily control long term risks by
nurturing the safety culture. The example of air crash in Paris shows how it could be easily
avoided by implementing SMS. Similarly, the incident of Zagreb was also an incident of
negligence and it could also be avoided as well. Lastly, there is need of creating and modifying
the existing regulations to make it easier for operators and other stakeholders to run smoothly.

Table of Contents
Executive Summary...................................................................................................................1
Introduction................................................................................................................................ 3
Need of System.......................................................................................................................... 3
Vitality of Corporate Culture.....................................................................................................4
Employee Empowerment Policy.................................................................................... 5
Main Failures in Accidents........................................................................................................5
Risk Reduction through SMS...................................................................................................7
New Regulatory Frameworks..................................................................................................11
Management Dilemma.............................................................................................. 11
Crew Training........................................................................................................... 11
Health and Safety..................................................................................................... 11
Compliance Cost...................................................................................................... 11
Subjective Drafting.................................................................................................... 11
One Size Fit for All.................................................................................................... 11
Conclusion............................................................................................................................... 12
References............................................................................................................................... 13

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Introduction
Safety Management System (SMS) is systematic mechanism that identifies vulnerabilities and
manages risks while assuring the effectiveness in risk control (Harms-Ringdahl, 2004). SMS is
defined as a corporate approach towards safety.

Figure 1: SMS Components (Source: mckechnie-aviation.eu)

This process is comprehensive, explicit and systematic for managing safety. Like other
management systems, SMS also provides setting up objectives, planning and evaluating
performance. Safety Management System becomes the part of organizational culture (Hvold,
2010). The three imperatives of safety management are financial, legal and ethical. SMS can be
created to suit any sector or industry. For aviation industry, safety management is concerned
with the risk control pertinent to aircrafts, other property and people. According to CAP 712 (UK
Civil Aviation), SMS is controlling risks related to aircraft maintenance, engineering activities,
flight operations or relevant ground operations.
The report endeavours to analyse regulatory frameworks, policies and contemporary issues in
context of SMS. The report also analyses and compares certain aviation incidents and how
SMS could avoid those incidents.
Need of System
Safety Management System has been thoroughly becoming a standard in the global aviation
industry. JDPO (Joint Planning and Development), CAA (Civil Aviation Authorities) and ICAO
(International Civil Aviation Organisation) has also recognised the importance of safety
management in aviation and opened the way for evolution of SMS (FAA, 2016). History reveals
that several aviation accidents could have been avoided if there had been safety management
system in practice and if personnel had ever been encouraged to report their concerns. An
aviation authority requires certain safety management systems so that the risks of hazards are
mitigated. Safety Engineering manager and Flight Safety manager have in place various safety
and analysis systems within their control that serve as process through which incidents are
processed and reported. However, these are only the means by which information is processed.

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An organisation needs proactive approach towards safety management that allows to recognise
potential hazards and to prepare for managing such incidents (Roberts et al. 2001). It should be
the highest priority of a company to develop and maintain the ERP (Emergency Response Plan)
system so that safety management team is facilitated to cope with the hazardous events and to
continue the normal operations in parallel. A company needs safety management mechanism so
that it may place ERP at all operational locations and to keep robust coordination procedures to
stay informed and effectively respond to the incidents. The organisation needs to assign
responsibilities to different staff members, brief them about emergency procedures, develop
communication channels for in-house information flow as well as with external agencies
(Harrald and Jefferson, 2007).

Figure 2: Safety Need (Source: www.aci.aero)

For all these set of activities, an organisation necessarily needs a well devised safety
management system to implement simultaneous multiple activities.
Vitality of Corporate Culture
The existence of effective safety culture in an organisation primarily strengthens its success.
Safety culture of an organisation is its way conducting business and managing the safety
concerns. It is initiated from the top management and is eventually communicated to the staff to
show safety ethics and standards within the boundaries of organisation. This can be measured
through formal or informal observations and surveys conducted at work areas (Dekker, 2012).
Safety is seen as an integral strategic dimension of the overall management and it needs to be
highly prioritised. For that purpose, there must be a board level committee in the organisation
that is formally responsible for managing safety management system. Effective SMS is a mean
to achieve high safety performance that is compliant with regulatory requisites of safety and
quality. Safety culture can help to gain optimal contribution from supervisor and lower level staff
in this context (Antonsen, 2012).
Proactive safety culture can only enhance the safety performance and it can be achieved
through devolved management with autonomous oversight of the safety. This is the
responsibility of CEO of the organisation and the board to implement and retain safety culture

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(Reiman and Pietikinen, 2012). The corporate approach towards safety management must
meet the given criteria:

Safety accountabilities of staff members and managers must be published

Requisites for safety managers
The ability to show a thorough creation of positive safety culture.
Documented practices, policies and principles where safety is inherent
Independent oversight process of safety and commitment of management
Continuous improvement in safety planning and management
Formal process of safety reviewing

Figure 3: Safety Culture (Source: quotesgram.com)

Employee Empowerment Policy
Organisational culture provides a framework to assess and understand the fit of personenvironment that is essential for empowering the employees in an organisation. The approach
considers attitudes and behaviour of individuals and the interconnected organisational practices
that affect organisational life (Kirst-Ashman and Hull, 2014). In the aviation industry, it is
important for the companies to empower employees in order to reduce fatigue and to assure
safety. For example, Ryanair demoted a pilot who refused to fly when he was extremely
fatigued. It is an example of absence of employee empowerment. The pilots of Ryanair have
several times warned that the airline forces them to fly even in unsafe conditions (UKC Forum).
Any empowerment requires to essentially including issues of power and control. Employees
need to seek and acquire control and power to influence particular domains. For this purpose,
the companies must be able to expand and change their structure of power and the individuals
must also desire to acquire such control (Drake et al. 2007).
Main Failures in Accidents
History shows that most of fatal losses, incidents and aviation accidents occurred due to human
errors. Such errors in the aviation industry have been primarily linked with operation personnel
like engineers, pilots, maintenance staff, controllers, dispatchers, etc. Thats why substantial

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difference as been observed in the last decade regarding human errors in the aviation sector so
that the preventive strategies and actions may be devised (Shappell and Wiegmann, 2012).
The analyses of very recent aviation accidents have revealed that there is another level of
human error beyond the errors of operation personnel. This suggests that human failure in
decision making is another important factor that occurs in managerial sectors of the industry.
Human failures are divided into two main categories i.e. active failures and latent failures. Active
failures are those errors that have sudden adverse effects while latent failures do not have
sudden bad impact rather their impacts are observed in the long term (Marais et al. 2012).
One such popular example of air accident was of DC 10 in Paris that resulted in the death of
345 passengers including men, women and children. The accident was caused by the cargo
door ejection of the flight. The passenger floor collapse all of a sudden due to depressurisation
that resulted in damaging engine number 2 and eventually the plane had become inoperative.
The defective closing of door had been caused by several factors that were found in the
investigative report. Those factors were:

The design of vent door could be defected that seemed apparently closed while it was not
actually closed and latched.
Maintenance service bulletin had not been complied with
There could be incorrect door modification or adjustment regarding locking process that had
disturbed the lock warning system. Hence, the door was not locked but no warning sign had
been seen.
There had been lack of visual inspection prior to the flight.
There was narrow space between passenger compartment and cargo compartment that
resulted in trapping the controls.

The summary of report had stated that such issues had already been observed but no
corrective measures had been taken to cope with the issues if they reoccur in the future. The
accident had somewhat active failure but mostly it was due to the latent failure as airline and the
manufacturer had not inspected this through safety management system. Otherwise the
accident could have been avoided if there had been in place a sound SMS. Safety management
is more cost effective and successful if latent failures are primarily discovered and corrected
rather than only working to demolish active failures. However, it is also important to eliminate or
at least minimise the active failures to keep the operations in smooth running (Virgin Atlantic,
2016).

Figure 4: Active vs. Latent Failures (Source: Shappell and Wiegmann, 2012)
The latent failure arises from policies, management, resources and organisational culture.
Hence, weak or no safety culture can lead to disaster that can be avoided with the long termed
low cost SMS.
Risk Reduction through SMS
Safety Management System embraces the rule that recognition of risks and managing them
increase the probability of attaining goals and objectives. The ICAO Document 9859 provides
manual for SMS and UK CAA also provides guidance for complex and non-complex
organisational guidance. These regulations form the basis of mitigating risk through a devised
safety mechanism (ICAO, 2016). Many incidents could have been avoided if there had been
proper practice of SMS. The risk must be identified with the level of tolerance and in case of
unacceptable risk; the mitigation mechanism must be placed to cope with the emergent
situation.

Figure 5: Risk Tolerance (Source: CASA.gov.au)

The two functions in SMS named Air Safety Review Board (ASRB) and Safety Action Group
(SAG) are responsible for reviewing policies and procedures for risk management and for
supporting risk assessment mechanism respectively. The negligence or absence of these two
functions may result in a bigger disaster (UK CAP 712).

Figure 6: Risk Tolerance Matrix (Source: CAA NZ)

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Like, British Airways had an accident in September 1976 of its flight 476 that had to fly from
London to Istanbul. The plane had collided with another flight 550 of Index-Aria at Zagreb,
Yugoslavia that was routing towards West Germany. The collision had occurred due to
procedural error and apparently air traffic controllers of Zagreb were responsible for the
accident. All of 176 passengers aboard had been killed in the accident and it had been
considered as the deadliest collision of its time. The controllers had been taken into the custody
for interrogation and later all had been released except Tasic who stayed in the custody until
trial was over (Jutarnji.hr, 2016).

At that time (mid 1970s), Zagreb had been one of the most hectic air traffic control in the Europe
despite the fact that it was poorly equipped and understaffed. The VOR of Zagreb was a
reporting point for various airways that were congested between Middle East, South Europe and
North Europe and beyond. The airspace had been divided into three categories i.e. 25000 feet
as lower sector, 25000 to 31000 feet as middle sector and 31000 and high and upper sector
(Stewart, 1986).

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The trial had opened in April 1977 in Zagreb Court and all of air controllers had been indicted
under Article 271-72 of Penal Code of Yugoslavia that states the persons to be guilty who
endanger sea, railway or air traffic. Tasic had been the only one who had been found guilty and
he was sentenced for 7 years of imprisonment. However, it was later determined after the
petition that Tasic had been used as scapegoat only and he was eventually released after 2
years and three months imprison (TIME.com, 2016).

The above incident reveals that there was sheer negligence at management level and the
incident could have been avoided through safety management system. The air traffic control of
Zagreb had latent failure as the management had not focused to maintain the required staff as
per workload. Also, the staff had not been adequately trained to manage critical circumstances.
1. Safety,
Concerns,
Hazards,
Occurrenc
es

2. Report

6. Not
Resolved

3. Analyse

4. Correct

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5. Evaluate

Problem
Resolved
Monitor

Document

Fig 7: Basic Safety Process (Source: Virgin Atlantic)

Moreover, the management had put liability on one person to free them while it was the sole
responsibility of management to provide required staff with adequate skills and expertise. The
incident could have been avoided easily if there had been the mechanism of safety
management as shown below:

Figure8: Risk Assessment (Source: CASA.gov.au)

It had already been in notice of the management that Zagreb was vulnerable and could cause
any big incident but no efficacious efforts had been put into practice to avoid it. However,
international bodies had also been blamed because they did not keep check over the noncomplying actions at Zagreb.
New Regulatory Frameworks
The current regulatory frameworks and policies of national and international bodies have been
performing at their best to assure safety and quality. UK CAA and ICAO have been practicing on
the principle of continuous improvement to make the aviation experience safer and reliable.

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However, there have been some of the issues that may arise and require reconsideration of few
regulations.
Management Dilemma
According to UK CAP 712, Safety Management is one of the core functions of organisations like
HR, Finance, Marketing, etc. The major objective of a business organisation is to make profit
while managing safety is merely a function. This results into a management dilemma as
resources are required for protection / safety and at times those resources may exceed the
resources required for production. By overemphasising the safety concerns, the business
purpose and profitability of an organisation may suffer.
Crew Training
The airline crews are mostly trained to perform their core functions while there may exist a skill
gap that can be converted into errors leading to disastrous accidents. The crew members are
not taken on board for safety measures and relevant training to cope with the emergent
situations. Hence, a regulation is required to make it compulsory for each crew member to
acquire safety training and necessary skills for emergency management to lessen the risk gaps.
Health and Safety
Although ICAO and UK CAA have provided detailed guideline and briefings about flight and
operational safety standards and certain regulations exist to overview and audit them, yet there
is no standard regulation seen pertaining to the health safety during operations. Like dealing
with the medical emergency in a flight needs to be regulated and maintain under standard
norms. Moreover, there is also a need to bring regulation for food safety during a flight. Though
airlines take care of food safety and hygiene but CAP 712 or ICAO regulations would further
enhance the food safety by providing a standard practice.
Compliance Cost
The cost for complying the safety standards in the industry has been raising which will curtail
the growth of aviation industry and will eventually push some operators out of the sector. Safety
compliance is heavily dependent over the trained human resource that adds to the cost of
operation. Thus, implementing such compliance standards need more expenses to incur without
any beneficial output in terms of business. A new safety regulation is demanded to ease the
process of safety compliance while at the same time operators may have enough room to
practice the safety standards.
Subjective Drafting
The language of legal drafting has been technically transformed after integrating criminal code
within the regulation. This has made it harder for the people to understand the regulations that
were used to of learning from plain language. Hence, there can be several subjective
interpretations of the regulations and as a result conflicts may occur and render the regulation
least effective. Therefore, it is required that the technical phrases must be re-phrased in plain
language to keep it simple and easy.
One Size Fit for All
The regulations are mostly tilted towards dealing with the commercial airlines while no provision
exists for the operations of non-airline passengers like of Cessna 172 that is also an aircraft like
others. Hence, safety standards must be generated for implementing the regulations and
policies for non-airline operations.

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Conclusion
Consequently, we have learnt that safety management system is extremely vital for an aviation
organisation and it not only saves the precious human lives rather it saves lot of losses and
hassles that may arise due to the accidents. Accidents are mostly caused by human errors
which mean that certain training and mechanism of safety management can safeguard from
potential recurring incidents.

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UKC Forums - Irish Aviation Authority investigate Ryan Air. (2016). [online] Ukclimbing.com.
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