Safety isn’t something that just happens – it’s something we do. When we look before crossing the road or complete a pre-take-off checklist, we are doing safety. A safety management system (SMS) is a way to make sure we do safety well.

The simple definition of SMS is an organised approach to managing safety. ‘Organised common sense’ is an often-quoted informal definition. This is good news if you operate in aviation and have some common sense; you’re probably enacting several of the components of an SMS without knowing it.

SMS has been traditionally associated with the big end of town, the ‘heavy metal’ of air transport, but aspects of SMS can be even more effective in smaller organisations.

Smaller organisations can move quickly. A policy change that might take an international carrier with thousands of employees several months to implement can be done by the afternoon in a small, non-complex organisation.

And while SMS might sound a daunting and bureaucratic concept, many of its elements are already in place under other names in workplace health and safety and quality assurance programs. The lack of steps in a small organisation can be a real advantage. If you mention an issue in a small organisation, you are often within earshot of the CEO. Messages move fast.

Conversely, small organisations have no place to hide and an open reporting culture in these requires a solid and constantly demonstrated foundation of trust.

And while unconscious bias can exist among staff members of any size organisation, it can be a roadblock to improvement in small organisations. It can be difficult when you’re investigating and analysing in a small organisation. You may not realise that you’re not considering or not weighting some factors. Advice or mentorship from an outsider can help with this.

The rigor and rhythm of keeping an SMS rolling can bring an advantage in general business management.

The structure of SMS

Australia uses the International Civil Aviation Organization (ICAO) SMS framework, which consists of 4 components:

1. safety policy and objectives
2. safety risk management
3. safety assurance
4. safety promotion.

In other words: you think about how safe you want to be (point 1 above), analyse your hazards and risks (point 2), take action to make sure you keep on managing those risks (point 3) and keep everyone motivated to be safe every shift (point 4). Precisely how you do this will depend on the size of your organisation.

Safety policy and objectives

The first component of an SMS explicitly sets out senior management’s commitment to safety, how this will be striven for, and the organisational structure required to support safety.

Safety policy

This is the outline of what your organisation will do to manage safety.

Safety policy statements typically include:

• the overall safety objectives of the organisation
• the commitment of senior management to provide the resources necessary for effective safety management
• a statement regarding responsibility and accountability for safety at all levels of the organisation
• management’s explicit support of a ‘positive safety culture’, as part of the overall safety culture of the organisation.

Safety objectives

The safety objectives should state an intended safety outcome, that is, what you are going to achieve.

These objectives may be expressed in terms of short-, medium- and long-term safety goals.

To be able to measure the effectiveness of operational safety objectives, they should be SMART:

• specific
• measurable
• achievable
• relevant
• have specified timeframe within which they are to be achieved.

Safety risk management

Risk management is a key component of an SMS and involves 2 fundamental safety activities:

• identifying hazards
• assessing risks and mitigating their potential to cause harm.

To determine what controls you use to mitigate risk, you apply the ‘as low as reasonably practicable’ (ALARP) principle. Risk management is simply a careful examination of what could cause harm, so that you can weigh up whether you have taken enough precautions or should do more to prevent harm.

Safety assurance

Safety assurance means establishing a systematic process for assessing and recording an organisation’s safety performance. It’s an organised way to answer the question, ‘What are we doing to create safety?’ A related and important question is, ‘How well are we doing those things?’

Safety assurance includes activities such as internal audits, safety investigations, management of change, monitoring, analysis, and continuous improvement.

Safety promotion

Under the ICAO SMS structure, safety promotion is divided into 2 elements:

• safety communication
• safety training and education.

Effective safety promotion fosters awareness and understanding of an SMS throughout the organisation, helping to create a positive safety culture.

• Safety communication sets the tone for individual behaviour, giving a sense of purpose to safety efforts. You need strong lines of communication at all stages of your SMS implementation. Maintaining your SMS requires ongoing communication, from reporting to raising awareness of safety issues.
• Safety training provides skills and knowledge, as well as raising awareness of risk issues.

There are also 2 factors that are fundamental to the success of an SMS for all organisations regardless of size or complexity, these are:

• management commitment and responsibility for safety
• a positive safety culture or ‘Just Culture’.

Scale and commitment

Implementing an SMS may initially appear to be a daunting and costly task; however, it is likely your organisation is already doing some, perhaps many of the activities that make an SMS. It’s possible all you have to do for an SMS is formalise or clearly document these.

The SMS should also consider the complexity of the activities undertaken and the interfaces with external organisations (including contractors and third parties), such as ground handlers, refuelling providers, maintenance providers, data service providers and aerodrome operators.

Some factors to consider include but are not limited to:

• number of employees, particularly number of operational safety-critical personnel
• length of runways
• number of aircraft movements
• number and complexity of aircraft types operated or maintained
• number of bases
• number of approvals and ratings held
• instrument arrival or departure procedures
• environmental factors.

The CASA website has some useful resources. Alternatively, talk with us.

The habits and tricks your brain uses to get you through everyday life become a problem when they run riot in the cockpit.

We do no end of feeling and we mistake it for thinking.

Mark Twain

The Nobel Memorial Prize for economics had an unusual winner in 2002. Daniel Kahneman became the first psychologist to win the world-renowned award, with a version of an idea he had first developed 30 years earlier with Amos Tversky – cognitive bias.

If his life’s work can be summed up in a proverb, it would be that we are not as smart as we like to think we are. As well as changing economic thought, Kahneman and Tversky’s insights have unsettling ramifications for aviation safety.

In 2 minds

A widely quoted but unsourced statistic says the average person makes 35,000 decisions a day. Whether you agree or disagree with this extraordinary number – which works out to a decision about every 2 seconds – is not the point. Each of us makes a huge number of decisions every day, starting when we get out of bed.

Most of these decisions are automatic. The unconscious mind has been known of and accepted since the time of Sigmund Freud in nineteenth century Vienna. Kahneman and Tversky’s contribution was to show, by experiment, how the unconscious mind could influence conscious decision-making in ways that were irrational – and potentially dangerous if they happen in a cockpit.

Kahneman proposes our brain has 2 operating systems, which he calls System 1 and System 2.

System 1 is the fast-thinking mind:

• unconscious, automatic, effortless
• no self-awareness or control
• assesses the situation, delivers updates
• does 98% of thought.

System 2 is the slow but thorough part of our thinking:

• is deliberate and conscious, effortful, controlled and rational
• has self-awareness/control, logical and scepticism
• seeks new/missing information, makes decisions
• does 2% of thought.

The automatic System 1 lightens the load on the deliberate System 2, in 2 ways:

• takes care of our more familiar tasks by turning them into automatic routines, also known as habits
• rapidly and unconsciously sifts through information and ideas by prioritising whatever seems relevant and filtering out the rest by taking shortcuts, called heuristics.

Expectation bias occurs when a pilot hears or sees something they expect to hear or see, rather than what actually may be occurring.

Your first few flights as a pilot use System 2 as you struggle with the effects of controls, radio procedures, engine management and your instructor’s helpful suggestions. Remember how exhausted you used to be after an hour of circuits But, as you learn, the task of flying becomes transferred to System 1 – and gets easier. The problem for safety is that System 1’s network of decision- making shortcuts can ‘leak’ into our System 2 thinking. These leaks are biases.

The number and scope of all our cognitive biases is a matter of discovery and debate, but there are at least 7 that are potentially troublesome for aeronautical decision-making:

1. confirmation bias
2. continuation/sunk cost bias
3. outcome bias
4. anchoring bias
5. expectation bias
6. framing bias
7. ambiguity effect.

1. Confirmation bias

Just as I’ve always thought.

Confirmation bias is the tendency for a person to seek out information that is consistent with an individual’s existing beliefs or expectations when confronted with unusual situational factors. In the setting of VFR flight into IMC, confirmation bias might result in a pilot subconsciously searching for environmental cues that the weather conditions are slightly above the minimum required, steady or improving, when the opposite is true.

2. Continuation/sunk cost bias

Stepped in so far, that, should I wade no more / Returning were as tedious as go o’er

Macbeth, William Shakespeare

Continuation/sunk cost bias is the tendency to continue a decision, endeavour or effort to preserve an investment of money, effort or time. As the goal – such as arrival at the destination – becomes closer, people may tend to change their decision-making. The mid-point of a flight can be a significant psychological turning point for pilots when faced with adverse weather decisions, regardless of the distance flown. An analysis of 77 general aviation cross-country accidents in New Zealand between 1988 and 2000 found weather-related accidents occurred further away from the departure aerodrome and closer to the destination than other types of accidents.

3. Outcome bias

No harm no foul.

Chick Hearne

Outcome bias is the tendency to judge a decision based on its outcome rather than on an assessment of the quality of the decision at the time it was made. Outcome bias can arise when a decision is based on the outcome of previous events, without taking into account how the past events developed. Outcome bias can contribute to the organisational phenomenon of normalisation of deviance, where obvious hazards are ignored or downplayed because they have not so far contributed to an accident.

4. Anchoring bias

I can see clearly now the rain is gone. 

Johnny Nash

Anchoring bias is the tendency for a person to rely substantially on the first piece of information (the anchor) that is received and make estimates or judgements based on the anchor. This first piece of information becomes an arbitrary benchmark for all other information. A pilot may perceive a ceiling of 500 feet as good after many days of 200-foot ceilings, or bad after many days of CAVOK. A more relevant reference point for decision-making would be fixed minimums, whether personal, operator or regulatory.

5. Expectation Bias

Believing is seeing.

Karl Weick

For the second time that afternoon, the first officer ran the pre-take-off checklist. The first departure had been abandoned after an anomalous reading in an engine temperature probe. Now, with the problem fixed, they were going again, not a minute too soon. But 3 seconds after take-off, the MD-82 began rolling and yawing. Spanair flight 5022 crashed near the boundary of Madrid Airport on 20 August 2008, killing 154 people.

Expectation bias occurs when a pilot hears or sees something they expect to hear or see, rather than what actually may be occurring. This bias likely played a role when the MD-82 first officer called out a flap setting of 11 degrees while conducting both the take-off briefing and the final check before take-off.

‘There is a natural tendency for the brain to “see” what it is used to seeing (look without seeing),’ the final accident report said. ‘In this case, the first officer, accustomed to doing the final checks almost automatically, was highly vulnerable to this type of error. … The captain, for his part, should have been monitoring to ensure that the answers being read aloud by the first officer corresponded to the actual state of the controls.’

6. Framing Bias

Good advice is one thing, but smart gambling is quite another.

Hunter S. Thompson

Framing bias is the tendency for a person to respond differently to the same information and choices, depending on how the information is presented to, or received (framed) by, the decision-maker. A decision can be framed as a gain or loss. Kahneman and Tversky showed when a decision is framed positively, as a gain, a person is likely to be more risk adverse. When the same decision is framed as a loss, people tend to exhibit more risk-seeking behaviours. They called this prospect theory.

Adherence to checklists, written personal minimums and standard operating procedures are the best tools for keeping biases at bay.

In the setting of VFR flight into IMC, the framing effect plays a role when pilots are considering whether to divert or continue, when faced with adverse weather. If a pilot perceives a diversion as a gain (safety is assured), they are more likely to adopt a risk-averse decision and divert.

7. Ambiguity effect

Better the devil you know.

Kylie Minogue

The ambiguity effect is a cognitive bias that describes how we tend to avoid options that we consider to be ambiguous or to be missing information. We dislike uncertainty and are, therefore, more inclined to select an option for which the probability of achieving a certain favourable outcome is known.

An example of the ambiguity effect is when a pilot decides to fly an approach in questionable weather, rather than diverting to an alternate airport which may have better weather but may have other unknown issues.

Battling your biases

CASA Sport and Recreation Aviation Branch Manager Tony Stanton, who wrote a PhD on the hazards of biases in general aviation, says the first safety step is to understand biases are real. ‘They are natural responses to the environment and the volume of information we receive,’ he says.

Biases also apply on an organisational level and Stanton is inspired by the success of a select group of high-reliability organisations. Individually, we can steal some of these concepts and steel ourselves with them, he says.

In aviation, it’s sometimes good to be like Spock. Ask yourself, ‘What would Spock do?’

Stanton nominates 3 of Kathleen Sutcliffe and Karl Weick’s high-reliability principles as particularly apt:

• Preoccupation with failure rather than success. ‘Think, “everything is going well, so what do I need to examine,”’ he says.
• Reluctance to simplify. ‘Realise not everything is a simple as it seems, and you bring your own perspective to what you are looking at or thinking about.’
• Deference to expertise. ‘Ask someone else whose biases are different.’

A trekkie solution

As a doctor, CASA Deputy Principal Medical Officer Tony Hochberg sees cognitive biases as a result of the interplay between the brain’s subsystems: the prefrontal cortex which is the seat of rational thought, and the limbic system of hippocampus and amygdala which are the centres of emotion and sensation/reward.

Like Stanton, Hochberg has no doubt biases are real, and deep seated. Controlling their influence over your thinking is analogous to the struggle of instrument flight, where pilots are taught to believe their instruments instead of their vestibular systems.

Adherence to checklists, written personal minimums and standard operating procedures are the best tools for keeping biases at bay, Hochberg says.

He agrees with the usefulness of seeking a second opinion and cross-checking. And he has a novel mental shortcut to help identify and counter biased thinking. As an easily recalled example, he invokes the extraterrestrial, emotionless and implacably logical intelligence of Star Trek’s Mr. Spock, who was never afraid to contradict the mercurial Captain Kirk.

In aviation, it’s sometimes good to be like Spock. Ask yourself, “What would Spock do?”

Rightly so, people ask ‘why’, closely followed by ‘how much will this cost to implement’ And then you (attempt) to decipher the legalese of the reg, the accompanying MOS and the plain English guide. It’s all in vain; all too difficult and so you ignore it. Now you’re non-compliant and at risk of enforcement action. But….as the saying goes, it’s easier to beg forgiveness right.

What is regulation Regulate (verb): to control or restrict, to cause to conform to a standard condition. For centuries have rebelled against anything that controls or restricts. Aviation regulation is no different.

So how did we go from this….

To this….

More importantly, does more regulation equal improved safety After all, that’s what regulation is all about right?

Supposedly regulations are written in blood, meaning each was introduced following an accident or serious incident to prevent recurrence. That’s true….to an extent. Semantically, you cannot directly regulate safety. In fact, the administration of aviation safety is about regulating the activities of people. Because people in general unwittingly act in unsafe ways (people don’t appreciate the dangers of their actions – take speeding as an example) the job of regulations is to make sure people in aviation have the knowledge and incentive to act safely. They are a functional attempt to express functional requirements. But regulations are not holy writ.

Nor are they wholly read.

Anyone relying on regulating people through statutory Regulations will soon be disappointed.

But it’s not because we are recalcitrant. It’s true, regulations can provide the knowledge and incentive to act safely…..if written appropriately.

Apart from being notoriously difficult to read, regulations don’t describe the hazard they are intending to mitigate. This is important when coupled with cognitive dissonance (the response to being confronted with two contradictory pieces of knowledge). When experiencing cognitive dissonance people will modify perceptions, so that there is no longer a contradiction.

This is best illustrated by an example. (Cognition) I am about to install unproved parts because it is cheaper. (Dissonant Cognition) The regulations prohibit the installation of unapproved parts. (Modification of Cognition) The regulations don’t say it’s dangerous or explain what could result from this practice. The unapproved part is made by the same company in the same factory, so they are likely acceptable just not approved. I’ll install the part.

Three other factors influence regulation:

• The recreant regulator. When the regulator is alleged to have caused or contributed to an accident, protective mechanisms kick in. The regulator, rather than arguing the toss, succumbs and introduces more regulation.
• Diminishing standards. Regulators are not immune from cognitive dissonance. Unfortunately, in the absence of standards and skills within the Authority, the modification of cognition is the perception that additional regulation is required. 
• Perceived hazards. It is impractical and unacceptable to use the absence of an event over time as justification for removing or introducing a regulation protecting against that event.

So why am I musing about regulations and whether they help or hinder Recently, I’ve been seconded to assist with developing regulation (yes, I’ve gone to the dark side). I wanted to understand the ‘other side’ (the Regulator’s side) of regulating having spent the best part of three-decades on the receiving end. I’ve read, pondered, discussed, scribbled and charted and its come to this…..

Education!

1. The Regulator needs educated SMEs; on the impacts of their administrative decisions to industry and on ways to better regulation.
2. The regulated community needs education on why regulations exist. More importantly, they need to understand the hazards that regulations are mitigating against.

Its use is synonymous with any unmanned aircraft or aerospace system (UAS). Regardless of size or whether the application is military, industry, hobby or other, we tend to dub any and all pilotless systems as a drone. In the last five years, the taxonomy of drones has become overwhelming, yet the volume has not bred a new, more appropriate collective name for these vehicles.

The etymology of the term ‘drone’, which is now widely used by the public, was coined in the 1920s in reference to the early remotely-flown target aircraft used for practice firing of a battleship’s guns.

The etymology of the term ‘drone’, which is now widely used by the public, was coined in the 1920s in reference to the early remotely-flown target aircraft used for practice firing of a battleship’s guns.

It wasn’t until the mid-2000s when the alternate term UAS was partially adopted by the US Department of Defense and the Federal Aviation Administration. Other administrations have followed, however many industry players have not. Perhaps the largest manufacturer, DJI, continues to refer to many of their products as drones. As do many of the other large players.

What’s most surprising—and exciting—about the advent of the drone age is that there’s so much room left to grow. There’s a whole flood of enterprises out there that haven’t even come through the door yet. One challenge to these ventures are the laws—or rather the lack of laws—which govern drone usage. Nevertheless, companies are charging ahead, under the assumption that the laws will work themselves out. That is of course a big assumption.

Here’s where it gets interesting though. Drone laws are working themselves out; predominantly through public discourse. Not really what the industry wants. Not surprising though. Why In part, it’s the drone. There are complex questions over the torts (legal wrongs) of trespass and nuisance. Several legal challenges against drone operations based on the right to quiet enjoyment are beginning to emerge. 

You see, drones are still (perhaps wrongfully) synonymous with three ugly facets; they are seen as loud (noise concerns), obtrusive (privacy and security concerns) and poorly regulated (safety concerns). If the industry itself continues to refer to remotely operated aircraft systems as drones, we do little to dispel the first concern. The terminology we use to describe the technology very much influences public perception. We are not doing ourselves any favours. The term is also burdened by years of association with death and destruction—drone wars, drone strike, drone surveillance.

Drone is a dirty word, implying lack of sophistication, and that these systems are ‘stupid’. This contrasts with the distributed and artificial intelligence, the complexity of the control systems, and the automative technology that these systems incorporate.

Further, drone is, in my opinion, unprofessional. Operators are aviators; we are professionals. Flying these systems takes skill and certification. And drones are an aerial vehicle, often operated in a complex environment or in support of a complex mission.

As an industry we must start thinking and referring to ourselves and our operations as such. That starts by referencing in the positive and losing the term ‘drone’. So how do we change that culture, and what should we refer to them as?

The Australian regulator—the Civil Aviation Safety Authority (CASA)—and the European Aviation Safety Agency (EASA) use the term Remote Piloted Aircraft (RPA) in respect to civilian usage. The Unmanned Aerial Vehicle (UAV) or RPA together with the datalink and ground control units are collectively referred to as Unmanned Aircraft Systems or UAS. This is also the term used by the Federal Aviation Administration (FAA). These are the terms I think we as pilots/operators, should adopt.

Remove the term drone from your own lingo, from your websites, presentations and company names. Use a technically accurate term as it will open the door to a more intelligent conversation about the technology. Focus on the positives of these systems and redirect when someone mentions the word ‘drone’. Consider educating instead. Acknowledge societies concerns and then move quickly to talk of the benefit to society, the advancements in technology and comparable (or lesser) risk to that of current manned aviation.

If we do this, then over time, it’s more than possible that drones will shed much of the current stigma surrounding them.