What Actions You Should Take on Each Reported Safety Issue
Through the course of daily work in an aviation safety management system, you will discover safety issues – this is called “discovery.” When you make discoveries, such as through hazard reporting or SMS audits, you need to formally process them through your SMS Safety Assurance Process. In short, you need to document and manage the safety issues you discover.
While different issues require some different actions, there are certain actions you need to take on every issue. These actions are:
- Understand the issue in great detail;
- Understand how the issue fits in to your overall operations;
- Initial/closing risk assessments;
- Root cause analysis;
- Issue classifications; and
- Corrective actions.
At a minimum, auditors will most likely look for these items when spot-checking safety issues during an SMS audit. Secondly, performing due diligence with these actions will give you the means to improve your SMS in the future.
Thoroughly Understand the Safety Issue
Good hazard reporting forms make reviewing safety issues easy. If you discovered a safety issue by some other mechanism, such as an SMS audit, make sure you document as much as you can about the discovery.
Purpose: When reviewing report details, the big concerns are that you answer the following questions:
- What was the order of events that led to this report, i.e. the “narrative;”
- What are the basic facts that are relevant to the issue, such as time of day, people involved, etc.; and
- What is your immediate impression about how severe this problem is?
The first two bullet points are related to data gathering. The last point is important because it will dictate how quickly you act on managing this issue, as there may be more pressing concerns.
Why this step is needed: Obviously, if you don’t thoroughly understand the safety issue you are likely to not appropriately mitigate the threat/risk the issue poses!
Understand Context of the Safety Issue in Your SMS
Purpose: Before you perform an initial risk assessment, it’s extremely important to understand the context of the safety issue in your operational environment. By context, we are attempting to answer the following questions:
- Has this problem happened before in our company?
- Is this problem a part of a recent or long term trend?
- Do we have safety risk controls that address this issue?
To understand the context of an issue, you need to investigate whether there are other, similar issues that have been reported recently.
Why this step is needed: If you don’t understand the context of the issue you might:
- Underestimate the actual risk the issue poses;
- Misidentify the root causes/threat; or
- Fail to prevent reoccurrence.
For example, the issue might appear to be one problem, but after understanding the context of the problem you might discover a trend that indicates a deeper underlying problem.
Related Aviation SMS Safety Issue Articles
- Safety Chart: How to Discover Most Common Safety Issue in Aviation SMS
- How to Review Safety Issues in SMS Programs
- How to Audit Previously Managed Safety Issues in Aviation SMS
Perform an Initial/Closing Risk Assessment
Purpose: An initial and closing risk assessment rank the issue based on issue details and analyzed context. This ranking will provide some more guidance on what to do next:
- (Initial) How quickly should this issue be corrected?
- (Initial) What are our next steps for managing this issue?
- (Initial/Closing) Does the issue fall within your defined Acceptable Level of Safety (ALoS)?
- (Initial/Closing) Will this issue enter our review schedule?
You will perform your initial risk assessment with a risk matrix. Based on this risk assessment, you will set a target closure date. The more severe the assessment, the sooner the target closure date should be, as more severe issues need to be corrected sooner.
Why this step is needed: Initial risk assessments help you evaluate whether additional risk controls are needed or not. Closing risk assessments are your way of documenting that the issue is being closed and is acceptable.
If you implement corrective actions and/or additional controls, you should consider doing a risk reassessment after each control is implemented in order to understand the impact of each risk control.
Perform Root Cause Analysis
Purpose: Root cause analysis is an important step in the risk analysis process. The goals of root cause analysis are to answer the following questions:
- Why did this safety issue happen? and
- What are the underlying causes of this issue?
Why this step is needed: Performing root causes analysis is intimately tied to corrective actions. Many corrective actions you implement should be tied to a root cause. Without performing root causes analysis, you cannot know which underlying threats you need to mitigate to prevent reoccurrence.
Classify the Safety Issue
Purpose: Classifications are a taxonomy scheme you create to organize your data. Organizing issues with classifications provide a powerful way in the future for:
- Data mining;
- Establishing trends;
- Reviewing similar issues; and
- Organizing issues.
Why this step is needed: You should classify issues based on several criteria to thoroughly organize the issue. It also allows you to document that you have done due diligence to understand the issue. For example, you might classify an issue with:
- The identified hazard in the current issue;
- The identified root causes in the current issue;
- Relevant Human Factors in the current issue;
- Relevant policies and procedures; and
- Other relevant classifications as you see fit.
Implement Corrective Actions/ Additional Risk Controls If Not ALoS
Purpose: After performing all of the above steps, you should have all of the information you need to know how to correct the issue. Only issues that are not within your defined criteria for Acceptable Level of Safety will need corrective actions. If an issue poses an unacceptable level of threat, you need to mitigate it to an acceptable level.
Why this step is needed: As we say in a different article, “Correcting the issue means using corrective preventative actions to update your SMS back within an ALoS for the given circumstance. These CPAs should be assigned to relevant users who will facilitate the CPAs. Many aviation safety programs also have a practice of assigning relevant department heads or other subject-matter experts the task of managing assigned CPAs.”
Last updated in June 2022.