SMS works when people are empowered to act on safety.
I once asked one of our veteran aviation investigators what the toughest part of his job was. His response: seeing in accident investigations the same safety deficiencies over and over again that, for some reason, haven’t been addressed.
I can relate. In an effort to prevent crashes and injuries and save lives, the US National Transportation Safety Board (NTSB) has repeatedly urged operators across all modes of transportation to develop and implement a safety management system (SMS) and called on federal regulators to mandate SMS in operations. A key component of the most basic SMS is fostering a positive safety culture. Without a healthy safety culture, there’s no way an operator can actively manage and improve safety consistent with an SMS.
This past May, the NTSB held a public meeting to consider the tragic Jan. 29, 2019, Zaleski, Ohio, crash of a helicopter air ambulance operated by Survival Flight that killed three heroes: the pilot and two medical personnel. Our investigation revealed numerous safety deficiencies at Survival Flight—including their failure to perform comprehensive preflight risk assessments, which would have identified prior flight refusals or required obtaining forecasts of en route weather information. In fact, one pilot said he expected the accident pilot to complete the so-called preflight risk assessments after the flight.
Other deficiencies we identified at Survival Flight included noncompliance with regulations and procedures, pressure from management to complete flights in poor weather, and a safety culture described to investigators as so “damaging” and “toxic” that employees were afraid to report unsafe conditions. In fact, current and former employees reported negative consequences for speaking up, verbal abuse from management when flights were declined, and a complete lack of concern by management to learn about, much less address, pervasive safety problems.
I don’t think this is the norm; I think most commercial helicopter operators, including helicopter air ambulance operations, are safe. However, what the NTSB has learned about both the Zaleski accident and another accident, in New York, give me a great deal of pause.
In December 2019, we held a public meeting on the Mar. 11, 2018, crash of a doors-off flight in New York’s East River that tragically killed five passengers. The crash was preventable; in fact, aspects of it were predicted by Liberty pilots, who repeatedly raised safety concerns that were disregarded by the NYONair CEO and management. Pilots raised concerns about the difficulties passengers would have in accessing the carabiners on their harness/tether systems in an emergency and the inadequacy of the passengers’ cutting tools to quickly sever their tethers. Some pilots were also aware of the potential for entangling the harness/tether system with the helicopter’s floor-mounted controls and the possibility that the emergency flotation system would only partially inflate. All of these issues played a part in this crash and the loss of life.
Had these safety issues been addressed by management, tour operations could have continued with safer equipment and procedures, likely preventing the crash or loss of life. That’s why the NTSB continually focuses on safety culture as part of a comprehensive SMS program. In a healthy safety culture, employees aren’t just casually encouraged to “be safe”; they’re empowered to report unsafe conditions without fear of reprisal. Their concerns are taken seriously by management, thoroughly evaluated (and then constantly reevaluated), and resolved before an accident chain has the chance to form. In our Zaleski report, the NTSB reiterated our recommendation to the FAA that all Part 135 operators implement an SMS program. But don’t wait for federal action: operators should implement this recommendation now to save lives.