The news that two maintenance engineers and their supervisor had been charged with manslaughter by the Spanish judge heading the judicial inquiry into the 20 August Spanair Boeing MD-82 take-off accident at Madrid Barajas airport sent shockwaves through the aircraft maintenance community.

In Spain, as in most countries, a judicial inquiry and action to prosecute individuals runs parallel to the technical inquiry, even though this contravenes the state's obligations under Chapter 13 of the International Civil Aviation Organisation's Chicago Convention, which sets global standards for aviation practice.

If the standard knee-jerk blame reflex is not sufficiently disturbing, the swift recourse to prosecution threatens at least to compromise the full thrust of ICAO's latest mandate to safeguard the flying public.

Spanair MD-82 crash
 © AP/PA photos

This general shift by the regulators from the prescriptive to a more performance-based approach - wielding the carrot rather than the stick - is enshrined in an imminent requirement for every aircraft maintenance business to have its own bespoke safety management system (SMS).


Work on establishing these systems will become mandatory in about six weeks' time, when all maintenance repair and overhaul organisations must have started drawing up plans to implement a comprehensive shopping list of requirements (see box P33). Despite the risk of overzealous prosecutions, best practitioners within the maintenance industry have welcomed the move, believing there are business benefits to be derived from a more systematised, comprehensive approach to safety management.

Martin Ambrose is chairman of the regulatory European Aviation Safety Agency safety standards committee and manager of air safety and maintenance at the European Regions Airline Association. He summarises SMS as an enhanced regulatory framework that applies a dynamic data-based approach to identify, prioritise and mitigate risks.

Incidents have long been known to be precursors to accidents, yet the traditional scope of occurrence reporting has been limited to fatal and serious accidents. That reporting environment is now set to be widened to include the reporting of all more minor mistakes.

"You may well have an SMS already," Ambrose told a recent ERA workshop. "All this means is that it must become framed within a more systematic approach: writing down incidents starting risk registers. Actually, encouraging an SMS mentality is not so difficult. And SMS doesn't mean having to spend £30,000 on a bespoke IT programme - you really just need to formalise what you've got."

Chris Holliday, chief operating officer at UK regional carrier Eastern Airways, also sees the upside, citing savings in indirect and direct costs, accident and incident reduction, higher reliability and productivity as well as potential insurance benefits: "Why have an SMS? Because it's a regulatory requirement? Our experience is a bit more than that. It really does make business sense."


Ambrose agrees: "At the end of the day if you value your people as an asset, value also the information they feed back to you equally as an asset. If you think safety is expensive, just wait till you have an accident. Even a relatively minor accident could cost you hundreds of millions of dollars."

Ian Herbert, managing director of IT solutions specialist Vistair, reckons that a realistic estimate would be about £50 ($75) per aircraft. System complexity, whether computerised or not, will inevitably vary for different sizes of maintenance, repair and overhaul operation and ICAO is well aware of this. An SMS should correspond to the MRO's size and nature so one size certainly will not fit all nor is there an off-the-shelf solution.

Even so, Herbert recommends minimising complexity in the reporting and monitoring regime: "Above all, it's got to be simple. It has to fall below the 'noise level' of the organisation." He also advises MROs to keep their SMS reporting system as anonymous as possible to ensure a high level of reporting: "After all, submitters are giving you something that could allow you to immediately identify trends... something that could actually be improving your business."

Milan Linate crash
 © PA/Luca Bruno

Eastern's Holliday adds that an MRO needs to look outside its business to ensure a whole-system approach. This would involve, for example, air traffic control, subcontractors such as ground handlers and de-icing operations, where objectives are shared within a holistic SMS environment - getting a better bang for your safety buck.


Henning Pfisterer is airport safety manager at Munich Airport where ICAO rules for airport SMS were introduced in 2005.

"Management decisions in the airport industry often involve trade-offs between safety and financial efficiency and increasing environmental protection," he says. "Often the trade-offs are not made in favour of safety. The safety argument is often based on uncertainty and ambiguity but what safety management systems do is put that argument on a much more measurable and rational basis.

"SMS allows whatever trade-offs have to be made between safety and other corporate objectives to take place in a controlled manner based on the careful definition of acceptable and unacceptable risk," Pfisterer adds.

The absence of such a system-wide approach was cited in the Taipei, Taiwan 2000 incident when a Singapore Airlines Boeing 747 took off on a closed runway and ploughed into construction equipment, killing 83 people. The subsequent inquiry found that the airport had no integrated SMS.

Similarly, the investigators of the Milan Linate 2001 runway incursion reported that "the absence of a functioning SMS is the main cause for most of the discrepancies found and should be considered as one of the main contributing factors of the accident".

Eastern's Holliday reckons MROs should avoid "sweating the small stuff" when starting out on their SMS odyssey. "An imperfect SMS system with a 100% buy-in is far better than the perfect SMS with a low level of buy-in," he says.

The tougher job, according to Holliday, involves producing results from data, identifying unacceptable risks and mitigation and, at the very heart of the system, developing a culture in which people are encouraged and even rewarded for providing safety-essential information, even it if self-incriminating. "Getting the trust for a just culture ethos takes time and depends on how individual businesses have been run before they attempt to enhance their own safety culture," he adds.

Even so, where even the smallest threat of prosecution exists, could a well-meaning attempt at boardroom level to encourage openness and information-sharing lead to a paper trail of ignominious discovery? Could the diligent documenting of a myriad of minor mistakes turn up as a prime exhibit in a criminal case? Is SMS simply masquerading as procedural jailbait?

One thing is for sure: by 8 April 2012, the quality of an SMS itself will be policed.

Munich Airport's Pfisterer has some salutary words of advice: "Senior managers cannot be held to be liable for not knowing about latent risk in the operation of the airport. But they must demonstrate that information on risks is actively sought and appropriate means for risk identification are in place."

Jerry Allen, US managing director of Baines Simmons, perhaps best summed up the principal challenge at the recent International Aviation Safety Seminar: "As we move into the brave world of SMS, the actions that an organisation takes for or against its people after an event occurs will continue to be the single biggest determiner of its success. We must continue to move toward an environment of shared accountability, regardless of the backdrop of criminalisation of accidents if we are to realise the safety gains envisioned through SMS."

Source: Flight International