Personal Discipline and SMS
An established and respected commercial operator underwent a voluntary safety audit and the reviewer had the following comments:
- “The Safety Management System (SMS) of this operator is well-developed;”
- “Best practices are consistently employed in all facets of the program;”
- “Continuous SMS improvement is actively pursued;”
- “The flight operations manual is remarkably well-written and comprehensive;”
- “Safety culture within the department is shared among all team members;”
- “Open reporting of hazards is consistently encouraged by management;”
- “Solid safety program, maturing nicely.”
We should heap a round of congratulations to the management and staff of this company! Alas, these comments were made about the operator of N121JM, a Gulfstream G-IV, prior to its crash on takeoff from Bedford, MA on May 31st, 2014. The crash claimed the lives of all 7 occupants of the aircraft. The NTSB's investigation found that the crew habitually ignored standard operating procedures requiring preflight system checks and checklist usage to verify their completion.
Member Robert L. Sumwalt comments,
"There is a saying: 'You can fool the auditors, but never fool yourself.' These crewmembers made the critical mistake of attempting to fool both – a mistake that was costly, unfortunate, and tragic."
And that's just it. You can fool yourself and you can fool the SMS. How unfortunate that the NTSB report doesn't make any recommendations for improving SMS so that it can't be fooled! Maybe they know that any improvements in SMS will always hinge on the professionalism of the people who use it.
At the end of the day, you can stand on the shifting sand of checked boxes on paper, or you can stand on the bedrock of personal discipline. Which do you put your faith in? Is your SMS backed up by reality or is it a "Smoke Mirror System"?