- Email: [email protected]
Error Prevention as Developed in Airlines
Int. J. Radiation Oncology Biol. Phys., Vol. 71, No. 1, Supplement, pp. S178–S181, 2008 Copyright Ó 2008 Elsevier Inc. Printed in the USA. All rights reserved 0360-3016/08/$–see front matter
doi:10.1016/j.ijrobp.2007.09.040
QA FOR RT SUPPLEMENT
ERROR PREVENTION AS DEVELOPED IN AIRLINES TIMOTHY J. LOGAN, B.S.A.A.E., M.B.A. Operational Safety, Southwest Airlines, Dallas, TX The airline industry is a high-risk endeavor. Tens of thousands of flights depart each day carrying millions of passengers with the potential for catastrophic consequences. To manage and mitigate this risk, airline operators, labor unions, and the Federal Aviation Administration have developed a partnership approach to improving safety. This partnership includes cooperative programs such as the Aviation Safety Action Partnership and the Flight Operational Quality Assurance. It also involves concentrating on the key aspects of aircraft maintenance reliability and employee training. This report discusses recent enhancements within the airline industry in the areas of proactive safety programs and the move toward safety management systems that will drive improvements in the future. Ó 2008 Elsevier Inc. Safety, Prevention, Voluntary, Aviation Safety Action Partnership, Flight Operational Quality Assurance, ASAP, FOQA.
INTRODUCTION
improved industry safety brought about by these programs is also reviewed. This discussion has emphasized the key aspects of these programs that make them successful and the pitfalls resulting the correct safety culture is not established.
Airline safety has evolved to a level at which a hull loss accident (an aircraft damaged to the extent that it is not economically feasible to repair it, including aircraft destroyed or missing) is now a random event. Airline safety offices and the air transport industry have evolved from concentrating on reactive safety initiatives to a proactive process that concentrates on the identification of hazards before they result in accidents. Through collaboration with the Federal Aviation Administration (FAA) and employee labor organizations, the airlines have implemented voluntary safety programs based on a voluntary employee self-reporting philosophy. These programs are the Aviation Safety Action Partnership (ASAP), Flight Operations Quality Assurance (FOQA), and voluntary self-disclosure programs. In addition, systemic aircraft maintenance programs, including comprehensive quality assurance and reliability programs, have enhanced the safety of the aircraft. All these programs have resulted from a concerted effort by the industry to implement systematic methods for the identification and mitigation of safety hazards before they result in accidents. To accomplish this, voluntary safety programs were developed that provided incentives to both line employees and operators to report their own errors or safety events. These incentives usually involve a waiver of enforcement by the regulator or a waiver of disciplinary action taken by the operator. This report describes these voluntary programs and how they work. The operational environment changes and
AIRLINE SAFETY PROGRAMS Before 1995, safety in the airline industry was reactive. An accident or accidents would occur, and, eventually, a mitigation strategy would be developed, implemented, and, in most cases, mandated, resulting in an incremental overall improvement in safety. As Fig. 1 shows, this has resulted in dramatic reductions in the airline accidents to the point at which an accident currently is a random event that results from a breakdown in multiple layers of safety barriers. However, accidents had to happen for the industry to identify and fix the problems. An airline accident that results in multiple fatalities is an unacceptable occurrence in our society. Although commercial airline travel is the safest form of transportation by any safety measure, the publicity following even a single accident reverberates throughout the industry as additional safety enhancements are proposed by government regulators or politicians. The industry realized that to further improve the safety performance, a new direction must be taken. The industry could no longer rely on reactive methods to improve airline safety. A proactive approach was needed to identify potential hazards before they resulted in an accident and to implement Conflict of interest: none. Received Feb 5, 2007, and in revised form Sept 11, 2007. Accepted for publication Sept 12, 2007.
Reprint requests to: Timothy J. Logan, B.S.A.A.E., M.B.A., Operational Safety, Southwest Airlines, 2702 Love Field Dr., HDQ-1SE, Dallas, TX 75235. Tel: (214) 792-3536; Fax: (214) 792-4700; E-mail: [email protected] S178
Error prevention in airlines d T. J. LOGAN
S179
Fig. 1. Accident rates and fatalities by year for the worldwide commercial jet fleet.
corrective actions in an efficient and cost-effective manner. This resulted in the development of the voluntary safety programs. PARTNERSHIP PROGRAMS Airline operators, regulators, and organized labor developed the partnership safety programs with the intent of moving toward a proactive safety approach. This was motivated by the realization that enforcement or discipline was not having the desired effect in improving safety. In addition, it was recognized that enforcement or discipline actually impeded the reporting of safety issues by line employees and the identification of safety hazards. This was the genesis of the voluntary safety programs, ASAP, FOQA, and voluntary disclosure. Airline operations are very complex, involving significant capital expenditures, facilities, and highly skilled employees. The major component in this operation is humans. Humans make mistakes. It was realized that enforcement and disciplinary actions were not preventing human errors but were motivating employees to conceal errors when they did not result in an accident or significant incident. The ASAP programs were developed to provide a vehicle for line employees to report hazards or inadvertent errors that did not result in an accident without fear of retaliation or disciplinary action. In addition, as aircraft systems and personal computers became more powerful, the ability to systematically review large sets of airline flight data to measure aircraft performance, piloting procedures, and techniques became practical. The industry realized a benefit would ensue from reviewing this information from everyday operations to identify hazards
rather than waiting for an accident or serious incident and then reviewing the flight data recorder. Currently, >200 ASAP programs are in place within U.S. air carriers industry, involving pilots, mechanics, dispatchers, and flight attendants. In addition, >14 airlines have implemented FOQA programs, and >2,000 aircraft are monitored on a daily basis, providing terabytes of data for safety analysis. The FAA also realized that they needed a method to enable the operators to report safety deficiencies. The result of this was the Voluntary Disclosure Program. The Voluntary Disclosure Program allows a carrier to report to the FAA instances in which Federal Aviation Regulations or company procedures approved by the FAA have been violated during the course of daily operations. Systemic safety issues that were usually only uncovered after an accident or a comprehensive audit could now be identified during the investigation of minor events and reported to the FAA. The incentive for the carrier is that the FAA would waive the finding of a violation and the usual stiff monetary fines associated with such violations. The FAA benefited by learning of system breakdowns before they resulted in an accident and could work with the operator to ensure the hazard or hazards were mitigated sufficiently. VOLUNTARY SAFETY PROGRAM CONCERNS The development of these programs was not without controversy. All three partnership organizations were initially concerned that these programs, especially the access to, and control of, the collected information, would be abused. These concerns were abated as the industry evolved from a governance system activity based on enforcement, discipline,
S180
I. J. Radiation Oncology d Biology d Physics
penalty avoidance, and, in some instances, brute force to one based on cooperation and trust among its constituent entities. In the ASAP and FOQA, airline employees were concerned that the information would be used against individual crew members inappropriately. Airlines were worried that the FAA would misuse the information against the carriers and that the information would be made available to the press through the Freedom of Information Act (FOIA) provisions. The FAA was concerned that the operators and line employees would use these programs to protect themselves against supervisory control or penalties even for intentional or criminal acts. To overcome these concerns, the three partners developed guidance documents that addressed how the programs would operate, what information was allowed within the program, what sanctions could result, and to what extent corrective action would be administered. The development of these guidelines took many years to develop, and each of the three partners had to compromise to get a program that would meet the objectives of providing improved safety information. ADVISORY CIRCULARS The results of the industry collaboration were three documents called Advisory Circulars (ACs) (AC120-66B Aviation Safety Action Partnership; AC120-82 Flight Operational Quality Assurance; and AC00-58A Voluntary Disclosure Reporting Program; all can be found at www. faa.gov). These ACs provide the guidance to all participants on how to develop and operate ASAP and FOQA programs and, in the case of Voluntary Disclosures, the procedures and protocols carriers are to use for reporting events to the FAA under the Voluntary Disclosures program. VOLUNTARY SAFETY PROGRAM COMPONENTS Reporting The programs were set up with some basic premises. The first and most important was that the program intent was to promote hazard reporting and identification. To accomplish this, priority was placed on protecting those reports dealing with issues that can only be discovered by line employees, such as the air and ground crews. These reports, called ‘‘sole source’’ reports, are the baseline of the programs and provide the most benefit to the overall system safety. These are reports that normally would go undocumented if not for the reporting incentives provided for in the programs. In the same manner, the ability of the airline to download and review its FOQA data from day-to-day operations uncovers events, that until the program was in place, were known only to the crews operating the aircraft. Therefore, when sole source reports are submitted, they cannot be used for policy enforcement, disciplinary action, or other personnel actions. Exceptions to this rule include events involving ‘‘intentional disregard for safety’’ or criminal activities. To ensure prompt reporting, the maximal inter-
Volume 71, Number 1, Supplement, 2008
val between the event occurrence and ASAP or FOQA report filing is limited. With regard to the FOQA data, the airline, usually through agreements with the pilot union, only reviews deidentified flight data that cannot be tied to a specific pilot. In no case can the FOQA data be used in any disciplinary process against a pilot. Consensus In ASAP, whether an event report qualifies for inclusion in the program is decided by an Event Review Committee (ERC) consisting of members from each of the three partnership groups. This group has sole responsibility to make the determination of whether a report is included and also to decide the appropriate corrective action. As outlined in the ACs, an important aspect of the ERC and ASAP processes is that the ERC must reach a consensus for the program to avoid suspension. Thus, it lends itself, although not without some angst by the ERC members, to each member having to compromise a little for the benefit of the program. Because ASAP is a safety program, ERC corrective actions are directed at skill enhancement and do not result in disciplinary action. The FAA cannot take enforcement action against any individual employee or the airline operator using the information they have gained from their participation in the program. All three partners gain equal knowledge of the reports filed and can therefore work collectively to mitigate safety hazards in a cooperative and proactive manner. In the case of FOQA, the identification of individual incidents is not shared with the FAA and the airline. In most programs, only the labor and/or employee members of the team are provided the means of identifying fellow employees. These labor representatives contact the employees involved, request information about the event, and then discuss with the employee the consequences of the event and what steps could be taken to prevent future events. The identity of the employee is maintained, but the error or hazard uncovered through investigation of the event is reviewed by all the members of the partnership. In addition, FOQA data provide information on day-to-day normal operations that can be compared with the abnormal cases to identify areas for mitigation. In the case of voluntary disclosures, the concept and process are very similar to those of ASAP. Airlines can report to the FAA areas of inadvertent noncompliance and work with the FAA to develop procedures or policies to prevent recurrence. The FAA approves the airline’s plan for correcting the problem and can institute monitoring of future operations to ensure the hazard has been resolved. The FAA gains access to airline operation hazards information, never before available to it, and the airline has an opportunity to address safety issues proactively without fear of FAA enforcement or monetary penalties. Freedom of Information Act A major concern of all parties was the disclosure requirements mandated by the FOIA. The FAA desired to include
Error prevention in airlines d T. J. LOGAN
safety information reporting by the carriers in the safety program. However, under the FOIA, the FAA was subject to the public disclosure of the information reported to it. The three partners believed that the possibility of public disclosure would be a barrier to reporting by both individual line employees and the carriers and would be in direct conflict with the intent of the programs. To maintain the confidentiality of the voluntary reporting programs, Title 14 CFR Part 193 exempts certain aspects of approved FOQA and ASAP programs, including voluntary disclosure filing, from FOIA public disclosure requirements. This designation enables the FAA Administrator, in the best interest of safety, to exempt voluntarily reported safety data from disclosure under the provisions of the FOIA. Without this provision, it would have been very difficult for the airline carriers to agree to share safety information derived from the ASAP and FOQA programs for fear of the information being used inappropriately. This designation was another important milestone in the development of the voluntary safety programs sought by both the airlines and the employee labor unions. SAFETY MANAGEMENT SYSTEMS As the voluntary safety programs have matured, the industry has realized that it must proactively manage the collected information. To meet this challenge, the development of Safety Management Systems (SMSs) (AC120-92 Introduction to Safety Management Systems for Operators), both within the government and the regulated community, has begun. The SMS has been described as a business-like approach to safety. An SMS is a systematic, explicit, and comprehen-
S181
sive process for managing safety risks. The SMS outlines how the safety program will be organized, managed, and measured. It also outlines the roles and responsibilities of all participants in managing and participating in the safety program. The SMS cannot exist in a vacuum. It must be a part of, and integral to, the company business plan. The SMS must have a commitment from the highest levels of the organization and be communicated to all participants. Although not mandatory, a strong consensus has been reached within the industry that SMS programs will enable it to advance its safety programs, and most airlines have either implemented an SMS or are in the process of developing an SMS. The airlines are developing their programs using Advisory Circular guidance but are also adapting the programs to their company’s management style.
CONCLUSION Airline safety programs have evolved from reactive to proactive programs in an attempt to improve an already excellent safety record. Zero accidents are the goal that the industry strives for. Without the detailed information on hazards, processes, and precursor events needed to support realistic risk assessments and useful hazard mitigation actions, little progress toward this goal would have been made. The voluntary safety programs that have been implemented and the comprehensive SMS plans currently under development for managing the volumes of data generated will enable the industry to methodically and proactively work toward a zero-accident goal.
doi:10.1016/j.ijrobp.2007.09.040
QA FOR RT SUPPLEMENT
ERROR PREVENTION AS DEVELOPED IN AIRLINES TIMOTHY J. LOGAN, B.S.A.A.E., M.B.A. Operational Safety, Southwest Airlines, Dallas, TX The airline industry is a high-risk endeavor. Tens of thousands of flights depart each day carrying millions of passengers with the potential for catastrophic consequences. To manage and mitigate this risk, airline operators, labor unions, and the Federal Aviation Administration have developed a partnership approach to improving safety. This partnership includes cooperative programs such as the Aviation Safety Action Partnership and the Flight Operational Quality Assurance. It also involves concentrating on the key aspects of aircraft maintenance reliability and employee training. This report discusses recent enhancements within the airline industry in the areas of proactive safety programs and the move toward safety management systems that will drive improvements in the future. Ó 2008 Elsevier Inc. Safety, Prevention, Voluntary, Aviation Safety Action Partnership, Flight Operational Quality Assurance, ASAP, FOQA.
INTRODUCTION
improved industry safety brought about by these programs is also reviewed. This discussion has emphasized the key aspects of these programs that make them successful and the pitfalls resulting the correct safety culture is not established.
Airline safety has evolved to a level at which a hull loss accident (an aircraft damaged to the extent that it is not economically feasible to repair it, including aircraft destroyed or missing) is now a random event. Airline safety offices and the air transport industry have evolved from concentrating on reactive safety initiatives to a proactive process that concentrates on the identification of hazards before they result in accidents. Through collaboration with the Federal Aviation Administration (FAA) and employee labor organizations, the airlines have implemented voluntary safety programs based on a voluntary employee self-reporting philosophy. These programs are the Aviation Safety Action Partnership (ASAP), Flight Operations Quality Assurance (FOQA), and voluntary self-disclosure programs. In addition, systemic aircraft maintenance programs, including comprehensive quality assurance and reliability programs, have enhanced the safety of the aircraft. All these programs have resulted from a concerted effort by the industry to implement systematic methods for the identification and mitigation of safety hazards before they result in accidents. To accomplish this, voluntary safety programs were developed that provided incentives to both line employees and operators to report their own errors or safety events. These incentives usually involve a waiver of enforcement by the regulator or a waiver of disciplinary action taken by the operator. This report describes these voluntary programs and how they work. The operational environment changes and
AIRLINE SAFETY PROGRAMS Before 1995, safety in the airline industry was reactive. An accident or accidents would occur, and, eventually, a mitigation strategy would be developed, implemented, and, in most cases, mandated, resulting in an incremental overall improvement in safety. As Fig. 1 shows, this has resulted in dramatic reductions in the airline accidents to the point at which an accident currently is a random event that results from a breakdown in multiple layers of safety barriers. However, accidents had to happen for the industry to identify and fix the problems. An airline accident that results in multiple fatalities is an unacceptable occurrence in our society. Although commercial airline travel is the safest form of transportation by any safety measure, the publicity following even a single accident reverberates throughout the industry as additional safety enhancements are proposed by government regulators or politicians. The industry realized that to further improve the safety performance, a new direction must be taken. The industry could no longer rely on reactive methods to improve airline safety. A proactive approach was needed to identify potential hazards before they resulted in an accident and to implement Conflict of interest: none. Received Feb 5, 2007, and in revised form Sept 11, 2007. Accepted for publication Sept 12, 2007.
Reprint requests to: Timothy J. Logan, B.S.A.A.E., M.B.A., Operational Safety, Southwest Airlines, 2702 Love Field Dr., HDQ-1SE, Dallas, TX 75235. Tel: (214) 792-3536; Fax: (214) 792-4700; E-mail: [email protected] S178
Error prevention in airlines d T. J. LOGAN
S179
Fig. 1. Accident rates and fatalities by year for the worldwide commercial jet fleet.
corrective actions in an efficient and cost-effective manner. This resulted in the development of the voluntary safety programs. PARTNERSHIP PROGRAMS Airline operators, regulators, and organized labor developed the partnership safety programs with the intent of moving toward a proactive safety approach. This was motivated by the realization that enforcement or discipline was not having the desired effect in improving safety. In addition, it was recognized that enforcement or discipline actually impeded the reporting of safety issues by line employees and the identification of safety hazards. This was the genesis of the voluntary safety programs, ASAP, FOQA, and voluntary disclosure. Airline operations are very complex, involving significant capital expenditures, facilities, and highly skilled employees. The major component in this operation is humans. Humans make mistakes. It was realized that enforcement and disciplinary actions were not preventing human errors but were motivating employees to conceal errors when they did not result in an accident or significant incident. The ASAP programs were developed to provide a vehicle for line employees to report hazards or inadvertent errors that did not result in an accident without fear of retaliation or disciplinary action. In addition, as aircraft systems and personal computers became more powerful, the ability to systematically review large sets of airline flight data to measure aircraft performance, piloting procedures, and techniques became practical. The industry realized a benefit would ensue from reviewing this information from everyday operations to identify hazards
rather than waiting for an accident or serious incident and then reviewing the flight data recorder. Currently, >200 ASAP programs are in place within U.S. air carriers industry, involving pilots, mechanics, dispatchers, and flight attendants. In addition, >14 airlines have implemented FOQA programs, and >2,000 aircraft are monitored on a daily basis, providing terabytes of data for safety analysis. The FAA also realized that they needed a method to enable the operators to report safety deficiencies. The result of this was the Voluntary Disclosure Program. The Voluntary Disclosure Program allows a carrier to report to the FAA instances in which Federal Aviation Regulations or company procedures approved by the FAA have been violated during the course of daily operations. Systemic safety issues that were usually only uncovered after an accident or a comprehensive audit could now be identified during the investigation of minor events and reported to the FAA. The incentive for the carrier is that the FAA would waive the finding of a violation and the usual stiff monetary fines associated with such violations. The FAA benefited by learning of system breakdowns before they resulted in an accident and could work with the operator to ensure the hazard or hazards were mitigated sufficiently. VOLUNTARY SAFETY PROGRAM CONCERNS The development of these programs was not without controversy. All three partnership organizations were initially concerned that these programs, especially the access to, and control of, the collected information, would be abused. These concerns were abated as the industry evolved from a governance system activity based on enforcement, discipline,
S180
I. J. Radiation Oncology d Biology d Physics
penalty avoidance, and, in some instances, brute force to one based on cooperation and trust among its constituent entities. In the ASAP and FOQA, airline employees were concerned that the information would be used against individual crew members inappropriately. Airlines were worried that the FAA would misuse the information against the carriers and that the information would be made available to the press through the Freedom of Information Act (FOIA) provisions. The FAA was concerned that the operators and line employees would use these programs to protect themselves against supervisory control or penalties even for intentional or criminal acts. To overcome these concerns, the three partners developed guidance documents that addressed how the programs would operate, what information was allowed within the program, what sanctions could result, and to what extent corrective action would be administered. The development of these guidelines took many years to develop, and each of the three partners had to compromise to get a program that would meet the objectives of providing improved safety information. ADVISORY CIRCULARS The results of the industry collaboration were three documents called Advisory Circulars (ACs) (AC120-66B Aviation Safety Action Partnership; AC120-82 Flight Operational Quality Assurance; and AC00-58A Voluntary Disclosure Reporting Program; all can be found at www. faa.gov). These ACs provide the guidance to all participants on how to develop and operate ASAP and FOQA programs and, in the case of Voluntary Disclosures, the procedures and protocols carriers are to use for reporting events to the FAA under the Voluntary Disclosures program. VOLUNTARY SAFETY PROGRAM COMPONENTS Reporting The programs were set up with some basic premises. The first and most important was that the program intent was to promote hazard reporting and identification. To accomplish this, priority was placed on protecting those reports dealing with issues that can only be discovered by line employees, such as the air and ground crews. These reports, called ‘‘sole source’’ reports, are the baseline of the programs and provide the most benefit to the overall system safety. These are reports that normally would go undocumented if not for the reporting incentives provided for in the programs. In the same manner, the ability of the airline to download and review its FOQA data from day-to-day operations uncovers events, that until the program was in place, were known only to the crews operating the aircraft. Therefore, when sole source reports are submitted, they cannot be used for policy enforcement, disciplinary action, or other personnel actions. Exceptions to this rule include events involving ‘‘intentional disregard for safety’’ or criminal activities. To ensure prompt reporting, the maximal inter-
Volume 71, Number 1, Supplement, 2008
val between the event occurrence and ASAP or FOQA report filing is limited. With regard to the FOQA data, the airline, usually through agreements with the pilot union, only reviews deidentified flight data that cannot be tied to a specific pilot. In no case can the FOQA data be used in any disciplinary process against a pilot. Consensus In ASAP, whether an event report qualifies for inclusion in the program is decided by an Event Review Committee (ERC) consisting of members from each of the three partnership groups. This group has sole responsibility to make the determination of whether a report is included and also to decide the appropriate corrective action. As outlined in the ACs, an important aspect of the ERC and ASAP processes is that the ERC must reach a consensus for the program to avoid suspension. Thus, it lends itself, although not without some angst by the ERC members, to each member having to compromise a little for the benefit of the program. Because ASAP is a safety program, ERC corrective actions are directed at skill enhancement and do not result in disciplinary action. The FAA cannot take enforcement action against any individual employee or the airline operator using the information they have gained from their participation in the program. All three partners gain equal knowledge of the reports filed and can therefore work collectively to mitigate safety hazards in a cooperative and proactive manner. In the case of FOQA, the identification of individual incidents is not shared with the FAA and the airline. In most programs, only the labor and/or employee members of the team are provided the means of identifying fellow employees. These labor representatives contact the employees involved, request information about the event, and then discuss with the employee the consequences of the event and what steps could be taken to prevent future events. The identity of the employee is maintained, but the error or hazard uncovered through investigation of the event is reviewed by all the members of the partnership. In addition, FOQA data provide information on day-to-day normal operations that can be compared with the abnormal cases to identify areas for mitigation. In the case of voluntary disclosures, the concept and process are very similar to those of ASAP. Airlines can report to the FAA areas of inadvertent noncompliance and work with the FAA to develop procedures or policies to prevent recurrence. The FAA approves the airline’s plan for correcting the problem and can institute monitoring of future operations to ensure the hazard has been resolved. The FAA gains access to airline operation hazards information, never before available to it, and the airline has an opportunity to address safety issues proactively without fear of FAA enforcement or monetary penalties. Freedom of Information Act A major concern of all parties was the disclosure requirements mandated by the FOIA. The FAA desired to include
Error prevention in airlines d T. J. LOGAN
safety information reporting by the carriers in the safety program. However, under the FOIA, the FAA was subject to the public disclosure of the information reported to it. The three partners believed that the possibility of public disclosure would be a barrier to reporting by both individual line employees and the carriers and would be in direct conflict with the intent of the programs. To maintain the confidentiality of the voluntary reporting programs, Title 14 CFR Part 193 exempts certain aspects of approved FOQA and ASAP programs, including voluntary disclosure filing, from FOIA public disclosure requirements. This designation enables the FAA Administrator, in the best interest of safety, to exempt voluntarily reported safety data from disclosure under the provisions of the FOIA. Without this provision, it would have been very difficult for the airline carriers to agree to share safety information derived from the ASAP and FOQA programs for fear of the information being used inappropriately. This designation was another important milestone in the development of the voluntary safety programs sought by both the airlines and the employee labor unions. SAFETY MANAGEMENT SYSTEMS As the voluntary safety programs have matured, the industry has realized that it must proactively manage the collected information. To meet this challenge, the development of Safety Management Systems (SMSs) (AC120-92 Introduction to Safety Management Systems for Operators), both within the government and the regulated community, has begun. The SMS has been described as a business-like approach to safety. An SMS is a systematic, explicit, and comprehen-
S181
sive process for managing safety risks. The SMS outlines how the safety program will be organized, managed, and measured. It also outlines the roles and responsibilities of all participants in managing and participating in the safety program. The SMS cannot exist in a vacuum. It must be a part of, and integral to, the company business plan. The SMS must have a commitment from the highest levels of the organization and be communicated to all participants. Although not mandatory, a strong consensus has been reached within the industry that SMS programs will enable it to advance its safety programs, and most airlines have either implemented an SMS or are in the process of developing an SMS. The airlines are developing their programs using Advisory Circular guidance but are also adapting the programs to their company’s management style.
CONCLUSION Airline safety programs have evolved from reactive to proactive programs in an attempt to improve an already excellent safety record. Zero accidents are the goal that the industry strives for. Without the detailed information on hazards, processes, and precursor events needed to support realistic risk assessments and useful hazard mitigation actions, little progress toward this goal would have been made. The voluntary safety programs that have been implemented and the comprehensive SMS plans currently under development for managing the volumes of data generated will enable the industry to methodically and proactively work toward a zero-accident goal.