Air Traffic Management / Air Navigation Service Providers (ATM/ANSPs) manage a dynamic, real-time system where an error has the potential to lead to severe consequences.
A Safety Management System (SMS) therefore allows service providers to move beyond compliance with regulations, providing a structured framework to improve their safety performance and manage risk within their organisation. This ensures they are an effective mitigation in an airline operators overall risk picture.
Human Factors and SMS
An effective SMS addresses both technical and human factors, including understanding cognitive workload, decision latency and situational awareness. Understanding how human performance, limitations, and decision-making impacts safety, allows the SMS to proactively manage risks associated with human behaviour.
Challenges and Future Outlooks
There are still challenges in implementing an SMS within ATM and ANSPs, particularly as organisations must also account for emerging risks that demand adaptive, forward-looking safety strategies.
| Challenges | Emerging risks |
|---|---|
| Resource allocation Cultural embedding System interoperability | Cyber threats AI-assisted decision Space traffic integration Cloud based assurance Novel airspace users |
Past ATM/ANSP accident – Uberlingen Mid-air collision
Two aircraft collided over Uberlingen, Germany. The investigation report by German Federal Bureau of Aircraft Accident Investigation (BFU) identified two crucial contributory factors in the accident:
- he lack of standardisation with TCAS protocols
- High workload on the air traffic controller who was operating multiple frequencies and sectors, while ATM system updates and maintenance were taking place.
Uberlingen mid-air collision and lack of SMS and safety culture as per BFU’s investigation report.
Hazard Identification and Risk Assessment
– No risk assessment was undertaken to ensure system safety during maintenance work on key systems.
– No procedures were in place to actively monitor or manage degraded modes of operation.
– No risk assessment was undertaken of overlapping maintenance and ATC solo shift operations.
Safety Assurance
– Insufficient safety performance indicators or mechanism in place to identify that the staffing and maintenance practices at the time created unacceptable risk in ATM.
– Pre-incident performance reviews and near-miss data had been ineffectively analysed or ignored.
– TCAS overrides were not formally trained or integrated as part of normal operational checks.
Safety Culture
– The ATCO as an individual was persecuted / blamed for the event, rather than the investigation considering the systemic organisational failings that enabled the ATCO to issue an instruction contrary to the TCAS-RA.
How SMS could have helped prevent the accident
A Risk Register (or alternative) where risks related to the delivery of the ATS were identified, assessed, mitigated and managed, help create a ‘known risk environment’ which is mitigated to an acceptable level. Hazard reports could have identified that solo shifts/ band-boxing sectors or maintenance during operations required additional mitigations to make the residual risk acceptable.
A just culture would have empowered staff to report and prevent unsafe scheduling or procedural deviations. Additionally, not blaming individuals for an event caused by systemic organisational failing further supports a positive safety culture as more employees would be willing to report hazards.
A mature SMS would have identified any possible trends through safety performance monitoring, incident reports and investigations, taking proactive steps to ensure risks were mitigated to an acceptable level. This could include activities such as simulation or scenario analysis of degraded mode operations, including how TCAS and ATC interactions are handled.
Ebeni’s Experience
Ebeni has a proven track record for supporting the development and implementation of SMS’s within the aviation, rail and defence sectors, in the UK and overseas. Our team have first-hand experience managing and continuously improving SMS’s and addressing safety culture challenges.
Partner with Ebeni
Ebeni stands ready to support you in your journey towards proactive safety management and a positive and engaged safety culture.