What is Aviation Risk Management Slippage
Aviation risk management slippage is an extremely important concept in aviation SMS programs.
Safety managers need to be aware of what this concept is, and what it looks like in the operational environment. In short, risk management slippage is a subtle, passive hazardous situation whereby:
- Risk management controls are meeting safety needs by all appearances; but
- Operational practice of the risk control is not in-line with how the control should function.
Here is a great example that shows slippage in action:
- There is a procedure for daily security check;
- The procedure specifically outlines how/where safety officers should perform their daily security checks;
- Security officers carry out this check every day and are used to the routine; and
- This routine leads to complacency and less than 100% vigilance in security checks.
As you can see, what slippage looks like is a control that should meet 100% of relevant safety needs, but (usually do to Human Factors) does not function at 100% for various reasons.
Types of Slippage
There are three different types of slippage that should account for most slippage:
- Unsecured controls: slippage due to Human Factors;
- Dated controls: slippage due to drift, lack of review, etc.; and
- Overambitious controls; slippage due to scope creep.
Unsecured safety control measures are controls that need multiple checks to maintain balance and work how they are supposed to. For example, in the previous scenario of a security check procedure, a way to further secure this control is to:
- Accompany the procedure with a checklist; and
- Test the checklist with a drill.
Now there would be three safety control measures to help maximize the effectiveness of the procedure.
Dated controls are controls that cannot function at 100% due to conditions changing since the time the control measure was created. For example:
- The security procedure may not account for a particular element of operations because it was implemented after the security checklist was created; and
- When a new employee is trained on that checklist, they will end up practicing a security check on less than 100% of operations.
Overambitious controls are control measures that attempt to do too much. For example:
- The security procedure may be more than in reasonable for a single person to complete;
- The security check procedure may involve too much time/walking that it is not reasonable to maintain alertness and energy for the entire procedure; or
- The procedure involves so many steps that it is not reasonable to maintain consistent performance.
The key word with overambitious controls is “reasonable.” Unreasonable controls are usually overambitious controls.
How to Combat Risk Management Slippage
Slippage does not always result in a hazard occurrence, which makes it hard to detect. Usually, new hazards are identified as a part of reactive risk management:
- Controls do not account for an unidentified hazard;
- A hazard occurrence emerges in operations and is reported; and
- Hazard analysis identifies the new hazard.
Ideally however, this hazard would be identified before it occurs. But how do you attempt to know what you “don’t know that you don’t know?” Fortunately, knowing where to look allows you to attempt to actively seek out slippage:
- Ensure that controls are not “one-offs” – ideally each control measure should have a complimentary control (i.e., procedures have checklists, policies have review intervals, etc.);
- Regularly review and test risk controls to ensure that they account for everything they were initially designed to; and
- Create controls that are smaller in scope and more easily manageable – if controls are ambitious, make a practice of breaking them into several smaller controls.
On the last point for example, a security check procedure for an airport might be broken into several security check procedures, one for each section of the airport.
Actively “backing-up” controls, testing controls, and segmenting controls is a proactive way to detect areas of likely slippage in aviation risk management.
Relationship Between Risk Management Slippage and Drift
Let’s not confuse risk management slippage with the concept of drift. Drift in aviation risk management is where, over time, certain control measures become less and less effective until they no longer perform their intended function.
Now, drift can be an element of slippage. However, drift would only be one type of situation where controls are not working at 100% of the intended purpose. They are most definitely not equivalent, they merely can be related depending on the situation.
Risk management slippage is controls that should be functioning at 100% but aren’t for a particular reason.
Final Thought: Who Is Susceptible to Slippage and How to Prevent
Slippage is generally most applicable to well implemented, larger aviation SMS programs. This is because as the number of control measures grows, so too does the workload to manage those controls.
Unless the safety program receives increased resources to manage these controls, they will not receive the upkeep needed to prevent slippage. Such resources are things like:
- Increased members of the safety team;
- Better aviation SMS software; and
- More aviation risk management resources.
A great tool to monitor slippage is SMS Shortfall Analysis, where you can identify why failures happen during safety incidents. This will help you establish whether or not these failures are due to slippage: