Error Chains and SMS
Introduction
In aviation, a safety management system is necessary as it ensures a systemic approach to managing safety. It encompasses organizational structures, accountabilities, policies, and processes. The purpose is to continually strive in the identification of safety hazards and provide assurance on associated safety risks in aviation. Despite the emphasis on safety management protocols and systems, the history of aviation accidents highlights a lack of adherence to the safety management systems. The following paper addresses two aviation accidents that occurred in 2009 and 2013. The paper discusses the common denominators of the two error chains and provides the influence of safety management systems in averting these accidents if the system was followed.
Similarities in Error Chains
A similarity between the two accidents is the evidence of the lack of any background training risk management training. Risk management training encompasses aeronautical decision-making, single-pilot resource management, and risk management. All these pieces of training ensure that pilots are aware of situational analysis and what measures to undertake during aviation processes. Firstly, a common feature in both accidents is the lack of single-pilot resource management in training. The 2013 accident involving Eurocopter AS350 B3, N911AA, the pilot’s history of training lacked a background in instrument flight simulation training. The accident report further stated that the pilot was required to attend a commercial initial NVG course to update training in NVG (night vision goggles) environment quoted in 2009. The pilot is reported to have a history of aviation accidents involving vision-based evaluations, but no concrete evidence suggests that this may not be a recurrent problem. Similarly, the Agusta S.p.A. A-190E helicopter, N606SP, the accident report indicates that the pilot lacked sufficient training in mountain flying, and there were concerns about the pilot’s training in instrument flying skills in particular to the scan and situational awareness. Interestingly, the pilot had no history of aviation incidences and had successfully passed his NVG training according to NTSB requirements.
Another common feature in the two accidents is the lack of proper aeronautical decision-making skills. Aeronautical decision-making skills are a set of thought-process that pilots need to make during abnormal circumstances. It includes background training in controlled flight into terrain, including weather, unfamiliar environment, and non-standard procedures. The Agusta S.p.A. A-190E helicopter, N606SP pilot, showed limited decision making regarding the rescue mission. According to the report, colleagues laud the pilot as a ‘hero-type,’ and he never turned down missions regardless of the weather conditions. The lack of proper judgment on his end shows improper training in judgment calls regarding bad weather terrain. Eye-witness report indicates that on the night of the rescue, there were strong gusty winds with heavy rains shortly after the helicopter crashed. Similarly, Eurocopter AS350 B3, N911AA weather report, highlighted a strong change in weather conditions to snow showers, which was forecasted to mix with rain. The pilot for this accident lacked a proper simulation and actual training regarding flying using NVG in rough terrain as it was reported. In other words, the two pilots did not have satisfactory training regarding rescue missions in rough terrain.
Dynamics of Safety Management Systems
The safety management systems provide elaborate management processes that are both reactive and proactive in safety management. Among them is the focus on safety requirements for personnel and aircraft. The pilots and personnel on both accidents should have implemented an extensive team-based decisional capacity in the search and recuse missions. According to the safety management manual, reactive safety management mandates personnel to provide a thorough examination of the failures in missions, determine safety trends, and regard any causal or contributory event during a mission. If there are exhaustive factors that contribute negatively to a mission, then it is considered unsafe for the mission.
The two accidents show little regard for reactive analysis for the take up of the missions. For the Agusta S.p.A. A-190E helicopter, N606SP, there was a clear indication of a lack of proper management skills and decision-making the search and rescue mission. According to the report, the Agusta S.p.A. A-190E helicopter, N606SP, was not equipped to handle search and rescue operations due to the instrument meteorological conditions constraints. Additionally, there was no proper risk assessment policy for the pilots and personnel regarding search and rescue missions. The Eurocopter AS350 B3, N911AA, only required pilots to have flight planning, risk analysis, and decision-making capabilities, which goes against NTSB and FAA requirement for risk assessment policy. These explain why the accidents happen given the rough terrain weather and lack of proper risk training for personnel in rescue missions.
The other concept is hazard identification and risk assessment. Safety management systems explain the necessity to conduct a state-of-the-art risk assessment, including operational safety and mission safety issues. Another common similarity between the two accidents is the lack of proper risk management regarding weather updates and management, lack of proper equipment and facilities, and lack of proper training for the Air Traffic Control and pilots on severe weather risk management. If the pilots and personnel incorporated the hazard risk identification and risk assessment protocols, then there would not have been incident reports. For the Eurocopter AS350 B3, N911AA, the forecast for the weather was not promptly provided to the pilot during the departure. It is required that prior to the departure of any flight, it is mandatory for the ATC staff, and the pilot determines the current weather forecast. However, pertaining to this accident, the provision of such information was limited. The time-lapse between the update was more than four hours. As for the Agusta S.p.A. A-190E helicopter, N606SP, there was a lack of weather information given that the airport lacked proper weather maintenance and reporting equipment. However, the report suggests that real-time information regarding the weather could be accessed through personal computers at home, which the pilot did not.
Conclusion
The obvious lack of proper adherence to safety management systems in both accidents highlights the lack of compliance with safety and risk assessment guidelines. Pilot error, poor decision making, lack of proper training, insufficient safety management protocols, and lack of risk assessment policies are among the variables that increased the occurrence of the two accidents. As such, the use of safety management systems may have averted the accidents if they were used.