alf5071h;
Thank you for your thoughtful response which takes the dialogue even further along an important road of understanding.
Re,
There are many values in the concept and processes of SMS when used by an organization or individuals.
I couldn't agree more. I think SMS, as conceived, is a far better system than "blame/enforcement". But I do not believe (and have seen evidence for this) that it is being done, "as conceived. Assumptions such as the efficacy of a two-day course on SMS for all managers, and having all the "right" documentation in place, (the importance of documentation vice taking actual action is a very big issue in aviation management today - documents are cheap - action can be very expensive).
Where regulators forgo active checks of operations and enable operators to ‘self-monitor’, then there is reason for concern.
The issues in the United States with Southwest and United indicated that this concern was a reality. I believe the same conditions exist in Canada but have yet to be discovered.
Whilst as yet, there is no evidence of weaknesses in regulatory oversight or operator SMS in this accident, there are signs of failure in continued airworthiness - a world wide process led by the prime certificating agency and the aircraft manufacturer.
There had been previous accidents and incidents involving configuration warnings and operational error. What were the recommendations from the investigations into these events? Were the recommendations implemented, and then reconsidered after further accidents/incidents – have all incidents been reported, have those reported been investigated?
Where additional system checks were required, was their effectiveness reviewed. Do all operators know of the checks and if so, are they implemented in the same way? If not how is this determined – who does the checking?
All excellent questions which demand responses. Coordinating same such that effective changes may be brought about is, as we know, much more difficult. Some questions have ready, and good answers. Others, such as those dealing with certification, may not.
This takes us back to devolved regulation; all that the regulator might see is a statement from the operator that checks are done, without confirming that this is the case. Operators are supposedly to follow SMS principles and audit daily operations, but failure to action this is another opportunity to miss a deviation from the norm and thus open opportunity for additional error or malfunction to contribute to an accident.
I have seen this first-hand and know that this circumstance exists even today and it causes great concern. When something is discovered in the data, conveyed to the appropriate internal airline departments and then is dismissed for "reasons", can occur even under SMS when there is little or no oversight and the documenation isn't followed and the audit processes do not reveal, or worse, tolerate such a weakness.
The non-use of FOQA/FDA data for example, by dismissing it when "inconvenient", (commercially), or worse, that the data is somehow not to be believed and is "wrong", is a real factor which governs operational decisions even now. Either the regulatory authority takes steps to protect safety information under SMS, and further, states that data from QARs used in FOQA/FDA programs is "the exact same" data as from the DFDR or such programs may as well stop and the money saved.
So I hear what you are saying and I agree that we view both SMS and the problems associated, in roughly the same way. For me, the term "devolution" may not reach far enough to describe some of what is happening, but be that as it may, the key is, the regulator is, in some countries anyway, beginning to examine what SMS means and, more to the point, what is being missed.
The risk in a non-robust SMS environment is, when no one is watching and there is little "danger" of discovery, commerical decisions can, depending on many factors, take priority over operationally safe decisions, which, because of such "success", can further result in the "normalization of deviance" and a continuance of the practice beyond the perview of the regulator. While that was/is always a possibility, under SMS, trust and integrity are absolutely fundamental keys that must be first demonstrated and then continuously proven to the regulator by the carrier. That is the only way SMS can work. The regulator who only "audits the audits" and not the air carrier's actions (which may or may not have been followed through on), may not discover a systemic weakness until an accident occurs, caused by quite different circumstances/pathways than the industry has experienced thus far.