Safety Management System indispensable for High Reliability Organizations today

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A Safety Management System would probably have prevented the two serious Boeing 737 MAX accidents...

In October 2018 and March 2019, 346 passengers and crew member died in crashes of two Boeing 737 MAX aircraft. As a result, aviation authorities around the world grounded the aircraft. They are still on the ground today, waiting for re-certification. Experts are still rubbing their eyes how it was possible that the renowned aircraft manufacturer acted in such an unprofessional manner.

As a result of these events, the American Federal Aviation Administration (FAA) submitted a bill to the US Senate in June 2020 that would oblige aircraft manufacturers to operate a Safety Management System (SMS). With this, the Federal Aviation Authority (FAA) will address the most glaring product certification deficiencies that have come to light as part of the Boeing 737 MAX certification.

Serious deficiencies and poor decisions

The accident investigations have shown that the FAA did not understand the technical issues surrounding the flight control system of the 737 MAX during the certification of the aircraft. Boeing had submitted a design that was irritating for experts. The control system was a key factor in both accidents. The authority did not recognize as well that Boeing had failed to provide adequate instructions on how pilots should react in emergency situations. These instructions were not sufficiently verified by human factor specialists. And last but not least, Boeing made questionable decisions regarding the required training concept for the pilots. The company prioritized the costs at the expense of adequate training for the crews. The FAA also accepted this.

In this context it is important to understand that since 2013 the International Civil Aviation Organization (ICAO) has required aircraft manufacturers to operate a Safety Management System (SMS) in their standards. For airlines, SMS are a matter of course for years.

Why a Safety Management System is so important

Safety Management Systems enable proactive safety management. They identify risks before they cause problems. SMS are operated by departments that are independent of line management so as not to be exposed to financial or management pressures.

Although complex processes must be mastered in an SMS, its structure is manageably simple. In a policy, the top management commits itself to safety. In risk management, risks are recorded and risk assurance ensures that they are actively managed. Employees are informed and trained about safety aspects through a special development program. Together with the policy, this program creates the framework that ensures that the entire organization is culturally involved and that a "Just Culture" based on trust can be lived. A culture that sees mistakes as learning opportunities and where they are openly discussed. Everyone involved agrees today that mistakes are important indicators of a complex system that does not work as it should. It is a culture in which employees and managers work together to continuously improve the system. In this way, they ensure that the organization is not unexpectedly confronted with system failures even though everyone has done everything right.  A fact that unfortunately is inherent in complex systems.


Boeing has suffered massive damage to its reputation as a result of the two serious accidents, which has also placed the company in great financial straits. The aircraft manufacturer is probably right to ask why it did not rely on a safety management system earlier. An SMS has become indispensable for a "High Reliability Organization". Anyone who wants to be safe and who is committed or feels committed to reliability, who operates critical infrastructure or offers system-relevant services, can no longer do without such a system today.