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THE HUMAN ERROR


SMS — WHERE DO YOU START? BY GORDON DUPONT


Phase One Safety Management Systems (SMS) have been around for a good while now and are here to stay, as they are the next logical step in reducing human error and its often- costly outcomes. I called it “The Big Picture” in 1995 (for want of a better name). If you refer back to article #13 (D.O.M. April 2016) you can read about that model that is shown in the “Gap Analysis” cartoon. If your organization has a Safety Management System ask yourself, “Is it working as effi ciently as it should be?” If not, hopefully the following series of articles will help. The very fi rst thing that any successful SMS MUST have is commitment from the top management. They need to believe that the SMS will: 1) improve their bottom line, and 2) help create a true Safety culture within the organization. If you want to see where your Safety culture stands now just go back to article #11 – (D.O.M. Jan/Feb 2016) and #12 – (D.O.M. March 2016) and have the employees fi ll out the 20 questions developed by Jim Reason. Any company that says that Safety is their top priority is dreaming. Profi t has to come fi rst as without it there is no need for Safety, as the organization will cease to exist. I remember a meeting with a CEO who said, “We can no longer aff ord the Cadillac of maintenance as I am right now trying to fi gure out how to lay off 20% of our maintenance employees.” Sadly, this company no longer exists. The best one can hope for is that Safety is a close second. Figure 1 illustrates a typical company where profi t is a high priority. There are human error costs that occasionally cut into all of the profi t for a time when, for example,


24 DOMmagazine.com | apr 2020


a tug runs into the side of an aircraft or, as I’ve seen, the side of a 747 gets scraped bringing the aircraft into the maintenance dock in the hangar. It was considered just the price of doing business — fi re the guilty parties and move on. This worked in the past, but without a concerted Safety culture a singe fatal accident can result in “The Death of an Airline” (Safety video #1 on System-safety.com website). Figure 2, I investigated many accidents that, after talking to their management, I knew that there was a fatal accident coming in the future. When investigating a minor accident, I recall the manager/ owner saying in a loud voice when I came in, “Watch out. Here comes the Gestapo.” I mentally called them the “I’ll kill you” airline. They did kill fi ve people due to a simple maintenance error followed by a pilot error, and no longer existed shortly after. A Safety Management System is going to cost money as shown in Figure 3. The old saying “If you think Safety is expensive, try an accident” likely won’t cut it as an excuse for the expenditure. A regulation requiring it helps, but management wants to see just what the return on investment


(ROI) is going to be. ROI is simply the total cost of the setting up and running the SMS compared to the money saved in reduced costly errors. The diffi culty with that is one can not calculate the cost of an accident or accidents you never have. The reactive solution is to look at incidents that have occurred. Determine the true cost of the incident, for example: cost of the damaged part, cost to repair it, cost of aircraft down time, etc. Let’s say the damage cost totaled $100,000. Now


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