How to Find Underlying Causes in Your Aviation SMS

What Are Underlying Causes in Aviation SMS

Underlying causes in aviation safety management systems (SMS) are the bridge between reactive and proactive risk management.

Underlying causes are the “input” for safety issues because they reinforce the actions and behaviors that cause incidents to happen.

When you make a concerted effort to uncover underlying causes in your aviation SMS program, you:

• Can start to manage the problem (underlying causes) rather than just the symptoms (incidents);
• Control risk at its earliest stages;
• Gain a thorough understanding of what makes your SMS program “tick”; and
• Practice high quality proactive risk management.

But SMS programs in aviation are often complex. There are hundreds or even thousands of variables at play when it comes to safety outcomes. Where do you start?

You should start by focusing on five areas of your safety program in which to look:

1. Executive management support;
2. Bureaucratic weaknesses;
3. Safety management efficiency and commitment;
4. Aviation safety culture; and
5. Safety data.

We will explore each area in more detail as you learn how to find underlying causes in your aviation safety management system.

1 – Top Down: Are Underlying Causes Coming From Executive Management?

A common misconception about safety management systems in aviation is that the safety manager is ultimately responsible for the safety program. It is actually an executive manager, such as the CEO, who is responsible for the safety program.

When this fact is not understood in safety programs it leads to some extremely common underlying causes, such as:

• Confusion about responsibilities can lead to important tasks not being done;
• It can quickly lead to strife between safety managers and executive management;
• The safety officer becomes tasked with too many responsibilities; and
• The safety officer’s responsibilities are not appropriate (or are downright impossible for them to control) because of their role in the company.

Safety officers and executive management need to have an open dialogue about this issue and set clear boundaries as to their responsibilities. Other common underlying causes to be vigilant for with executive management are:

• Getting the budget needed for quality risk management tools and adequate aviation SMS training courses;
• Resistance or apathy about the SMS program; and
• That executive management values a balance between performance and preparedness in terms of quality management and safety management integration.

2 – Underlying Causes in SMS Bureaucracy

Dated, inadequate, and missing safety policies/procedures can expose your organization to considerable risk. When a policy or procedure is associated with issues, it’s pretty obvious what the underlying cause is.

However, it usually won’t be obvious that a policy/procedure is the underlying cause. When evaluating the adequacy of policies and procedures, here are some questions to base an internal investigation on:

• What percent of jobs have checklists?
• Are reported safety issues constantly associated with a particular location, task, or role?
• When was each procedure last updated?
• Are policies and procedures based on behavior or just compliance requirements?

On this last note, I have always strongly advocated behavior based policies and procedures. This means that your organization develops policies and procedures that address the safety behavior specific to your company.

When policies and procedures only address compliance requirements but aren’t curtailed to the individual safety program, then they are not functional. A great way to avoid purely prescriptive policymaking is to:

• Adopt many checklists for different tasks; and
• Regularly make small updates to policies and procedures that address the behavior in your company.

3 – Safety Management Efficiency and Commitment

This can be a sensitive subject for safety managers. It takes a dedicated aviation safety manager to honestly assess their own safety performance and admit their negative contributions to the safety program. Yet it’s essential that safety managers do this.

Safety performance happens on the front lines of a company, such as “in the field.” However, an aviation safety management system is implemented top-down. The ramifications of top-down implementation cannot be underestimated, because they entail that:

• Changes and improvements are manufactured at the management level; and
• Oversight, mismanagement, and inefficiency result in exposure and stunted safety performance on the front-line.

When safety managers are evaluating their own efficiency and commitment, some things they need to be vigilant for are:

1. That they are consistently and frequently having safety meetings;
2. That many hazard reports are receiving direct feedback, such as praise, questions, recognition, etc.;
3. The average closure times for CPAs and issues based on the issues’ initial risk levels;
4. The % of on time closures for CPAs and issues based on the issues’ initial risk level; and
5. The number of reported low, medium, and high risk issues over time (best is a steady increase in low risk and steady decrease in medium/high risk).

All of the above areas reflect management’s commitment to safety and efficiency in quickly fixing issues, implementing changes, and creating adequate controls (point #5).

4 – Safety Culture Underlying Causes

The real significance of safety culture in aviation safety management systems is that safety culture is the means of realizing safety success.

• The SMS program provides the structure, guidelines, and road map for success;
• Safety culture is the vehicle for achieving it; and
• The quality of SMS and safety culture together is the competency to achieve safety.

If you have closely evaluated your SMS bureaucracy and found it to be adequate, and yet are still struggling with safety performance, the underlying cause very well may be rooted in safety culture. Some extremely effective ways to assess safety culture's underlying causes are:

• Monitor individual employee’s safety performance (learn how to do this with our free safety performance monitoring workflow guide);
• Use safety culture surveys with specific questions regarding employees opinions about various aspects of the safety program; and
• Evaluate how much company safety data an employee has access to.

All points will help you establish whether or not employees are actively engaged in the program, both with their attitude and their actions.

Related Aviation SMS Safety Culture Articles

• Why Transparency Promotes Safety Culture in Aviation SMS
• What Should Your Aviation Safety Culture Look Like [Free Checklists]
• Six Ways to Improve Safety Culture in Aviation SMS

5 – Safety Data Monitoring as an Underlying Cause

A final probable culprit of underlying causes is that your safety data monitoring is insufficient. The most common underlying cause scenarios are one of these three – do they look familiar?

• You are still using spreadsheets to track safety data;
• You are using point solutions (different software applications for different tasks); and/or
• You have been tracking the same safety metric data for a long time.

The safety data metrics you collect will need to grow as your aviation safety program matures. Organizations should continually be updating the metrics they track. Updates should focus on generating either more complex data metrics or adding new metrics to meet changing safety needs.

At some point, this will require having an aviation safety database to automatically monitor complex metrics (such as leading indicators), and an integrated safety management software to ensure that data is reliable.

Another critical underlying cause culprit is that employees are not being introduced to your safety program. Download our free, industry-tested induction training templates and ensure that your employees are formally inducted into your safety program.

Last updated Feb 2025.