SMS Pro Aviation Safety Software Blog 4 Airlines & Airports

How to Overcome Iceberg of Ignorance in Aviation SMS

Posted by Tyler Britton on Sep 26, 2018 5:06:00 AM

What Is the Iceberg of Ignorance

CRM iceberg analysis top management

The Iceberg of Ignorance was first developed in 1989 by a consultant named Sidney Yoshida. The Iceberg of Ignorance is a model that addressed concerns about safety awareness in large organizations. This model contends that of all problems:

  • Only 4% of problems are known to upper managers;
  • Only 9% of problems are known to middle managers;
  • 74% of problems are known to supervisors; and
  • 100% of problems are known to staff and front-line employees.

The idea is that management is only aware of the “tip of the iceberg.” This model has some rather obvious problems, namely that:

  • Top managers will be aware of problems that staff has no idea about.

However, this model does identify the important fact that:

  • Top managers are bound to be aware of high level problems; but
  • Not the many, many small problems that plague staff and eventually can lead to big problems.

Iceberg of Ignorance Reconstructed

In aviation SMS, this model is probably more useful when slightly reconstructed as being an awareness of quality vs quantity:

  • Top managers (decision makers) are aware of the few, high level problems, but are not aware of the many minor issues;
  • As we move down the latter, awareness of quality issues goes down, and awareness of quantify goes up; and
  • Staff are not necessarily aware of the high level, trending problems, but are pointedly aware of the many minor problems that cause them problems every day.

This idea seems rather obvious: top managers are much more concerns with the “serious” problems, and front-line employees are concerned with the minor issues that cause frustration every day.

But the other reality is that most organizations simply don’t have a meaningful way to for the “minor issues” to go all the away up the communication ladder for top mangaers to be aware of them.

These are important truths that leads to many preventable accidents and incidents every year.

Why Iceberg of Ignorance Matters in Risk Management

The reason the Iceberg of Ignorance (reconstructed) matters is because of one important point:

  • All serious problems are the result of many smaller problems that went unnoticed or un-managed.

One study found that for:

  • Every serious incident;
  • There were 59 smaller, “minor” incidents; and
  • 600 minor conditions.

As decision makers, if top manages can be more aware of the “minor” issues and conditions, they have the power to stop these issues/conditions before they lead to a serious incident. This is why the Iceberg of Ignorance matters to top managers and employees.

To overcome this issue:

  • Top managers need to make a concerted effort to be aware of minor issues and conditions.

Overcoming this issue happens primarily through changing your hazard reporting system requirements.

Overcome Iceberg of Ignorance Through Hazard Reporting

Overcome ignorance in your SMS requires:

  • Having decision makers be aware of minor problems;
  • Having staff and front-line employees see importance of minor problems; and
  • Ensuring that front-line employees report these minor problems.

In real world terms, it looks like this: all issues should be reported, even trivial concerns. Trivial concerns lead to bigger problems. Reporting all concerns requires a bit more work on the part of safety managers having to manage these issues, but it ensures safety managers are making decisions based on an awareness of all of the data, rather than just the ostensible problems.

Hazard/Issue Reporting Poster

Topics: Safety Culture

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