ALPA at 90: Safety Management Systems
By Christopher Freeze, Senior Aviation Technical Writer
Editor’s note: This year marks the 90th anniversary of ALPA’s founding. As “the conscience of the airline industry,” the Association has been at the forefront of advocating for safety and security advancements to protect pilots and their passengers and cargo. In each issue of Air Line Pilot, a technology or topic that the union has championed will be highlighted.
While the jet age vastly improved the reliability and safety of airline travel, there was still room for significant improvement, especially as the phrase “fly-fix-fly” characterized safety management. As aircraft broke down and builders identified the failure, changes were made in an attempt to prevent a recurrence.
Since most companies at the time were small in size, safety fixes could be developed quickly. But there were limitations as an airline’s size increased. Recognizing this, as the U.S. Senate debated the Federal Aviation Act in the late 1950s, William Patterson, the president of United Airlines, testified on the importance and power of accurate safety trend information, remarking, “On the positive side, you take your statistics and your records and your exposures and you act before” an incident or accident can happen.
Processing all of the data to produce meaningful results, however, would have to wait until the development of computers and the shifting of the safety focus from pilots to the pilot/machine interface. In the mid-1970s, United developed an internal safety reporting program, the Flight Safety Awareness Program, to encourage crewmembers to report anonymously any incident they felt affected safety.
In October 1974, a United crew narrowly escaped hitting a ridgeline in northern Virginia on approach to Dulles International Airport near Washington, D.C. The pilots reported the occurrence to their internal safety reporting program, highlighting the ambiguous nature of the approach’s altitude restrictions.
Word of the potential problem spread throughout United, and the FAA was notified—but not everyone was made aware of the situation as, on Dec. 1, 1974, TWA Flight 514 crashed into Mount Weather, Va., killing all aboard. The investigation revealed that the TWA flight crew encountered the same ambiguity that nearly killed the United crew.
In its final report on the TWA accident, the NTSB commented that a national incident reporting system was needed. As a result, in May 1975, the FAA set up the Aviation Safety Reporting System (ASRS) as a confidential, nonpunitive incident reporting program run by NASA, deemed to be a neutral, yet governmental, third party.
During the initial years of the ASRS program, thousands of safety alerts were issued to the FAA, based on numerous reports submitted by pilots, mechanics, air traffic controllers, flight attendants, and others—yet there was a need to further refine safety management.
The Birth of SMS
Starting in the late 1980s, after the Challenger space shuttle disaster, attention shifted to the role organization and management influences played in accident causation. As accidents continued to occur, notwithstanding the attention paid to pilots, safety specialists and accident investigation agencies looked deeper into accident causation, studying the underlying factors that could contribute to potential incidents and accidents.
With that, the concept of the safety management system (SMS) was conceived. A decision-making system at its core, an SMS is both a defined structure and a “learning culture” within an organization that constantly gathers and analyzes information. SMS then turns that data into action that mitigates, or eliminates, safety risks before they become unwanted events.
According to Capt. Rick Clarke (United, Ret.), ALPA’s SMS Project Team director from 2003 to 2006, SMS made the “safety case” the “business case.”
Recognizing the potential of SMS, ALPA worked with Transport Canada and Air Transat to effectively implement SMS at the airline during 2002 and 2003. A key component was the company’s agreement with Air Transat’s Master Executive Council that the safety reporting system would be voluntary and nonpunitive.
In 2005 when Transport Canada introduced regulations requiring airlines to have an SMS, including nonpunitive reporting systems, ALPA was a strong advocate, providing its assistance to the Canadian Aviation Regulation Advisory Council.
While most countries were still developing and introducing the concept to their industries, in 2008 Canada became the first to implement SMS, starting with large CAR Part 705 airlines—five years before the International Civil Aviation Organization adopted Annex 19 to the Chicago Convention to implement SMS for airlines around the world.
“SMS programs ensure continuing safety by combining the appropriate levels of incentive for frontline employee reporting, internal auditing, and regulatory oversight,” said Capt. Dan Adamus, then president of ALPA’s Canada Board, in 2011. “Canada is a world leader in adopting SMS programs in its marine, rail, and aviation industries, and ALPA is proud to be part of that effort.”
A year after Canada required airlines to implement SMS, Canadian ALPA pilots lent their expertise to the Association when the FAA created an Aviation Rulemaking Committee (ARC) to develop regulations and guidelines for implementing SMS in the United States in the wake of the Colgan Flight 3409 crash.
Serving as one of three industry co-chairs of the ARC, Capt. Linda Orlady (United, Ret.) was ALPA’s representative. The committee’s work resulted in a notice of proposed rulemaking in 2010 for SMS for air carrier operators.
In addition, in 2010 the Airline Safety and Federal Aviation Administration Extension Act was signed into law, which mandated that the FAA develop a regulatory structure for employing SMS throughout airline operations.
“ALPA has collaborated with Transport Canada, the Transportation Safety Board of Canada, and our government and industry partners internationally to explore the most modern, effective ways of doing business,” said Capt. Lee Moak, then ALPA’s president, in 2011.
In early 2015, the FAA published the final rule requiring FAR Part 121 operators to develop and implement an SMS within three years of its effective date—early 2018.
Maintaining a “Just Culture”
Today, all FAR Part 121 air carriers in the U.S. have approved SMS programs. Central to them are voluntary safety reporting programs such as the Aviation Safety Action Program (ASAP) and Flight Operations Quality Assurance. These important collaborative tools enhance aviation safety through the analysis of voluntarily reported safety events and discrepancies, which leads to the prevention of accidents and incidents. A major tenet of SMS is the promotion of a nonpunitive and “just culture.”
A prime example of the potential of SMS and collaborative safety initiatives was the implementation of ASDE-X equipment, enhanced runway lighting, and changes to NOTAM systems to reduce the risk of wrong-runway departures.
When added to additional data sources, such as ground radar data, historical weather information, and others, SMS data—deidentified to protect the provider—becomes even more effective at preventing potential incidents and accidents.
While several air carriers had automatic acceptance protocols for safety reports in their SMS programs, there was no federal requirement to do so. ALPA successfully advocated for the autoacceptance of ASAP reports, pointing out that waiting for an Event Review Committee (ERC) to meet and review the reports delayed their safety benefit, sometimes by weeks or longer. If needed, a report could later be excluded when the ERC convened and determined whether the report met established exclusionary criteria.
Those efforts came to fruition when autoacceptance of reports was added to the FAA Reauthorization Act of 2018, requiring the FAA to act by 2019—which it failed to do. Due to ALPA’s efforts during the onset of the COVID-19 pandemic, on March 31, 2020, the agency finally issued updated Advisory Circular (AC) 120-66C, which not only included the autoacceptance provision but also enabled all ASAPs to be continuing programs without expiration and made the FAA’s attendance at an ERC meeting optional, depending on what types of reports the ERC is considering at a particular meeting.
In terms of safety, the industry has made great advancements since the days of fly-fix-fly to now collecting information that can proactively prevent incidents, accidents, and loss of life, thanks largely to the efforts of ALPA and its pilots.