Category: Incident Investigation

The cargo ship Dali after it ran into and collapsed the Francis Scott Key Bridge in Baltimore on Tuesday. Tasos Katopodis / Getty Images

Safety in Transportation: Exploring Safety Management Systems in Transportation

Transportation and Safety Management

Transportation is a vast industry that involves moving people and goods throughout the world. It encompasses air, land, and sea movement. Many times, we see news stories that encompass transportation, and usually they are telling us about negative occurrences. Many of these contain safety failures. Let’s look at some safety positives and see how they can be used in all transportation industries.

Lessons from Aviation

Aviation has had and will have its portion of the news that deals with safety escapes. American Airlines, Hawaiian Airlines, Southwest and others have made the headlines recently. Even Boeing, a manufacturer of aircraft used by most airlines has had safety escapes recently. When we look closer at these escapes, there is one underlying item that can help prevent these escapes. Aviation has done a lot of work developing a process called Safety Management Systems (SMS), which are means to ensure that safety is taken seriously in all operations. The Federal Aviation Administration, part of the Department of Transportation has required part 121 Airlines to develop and maintain an SMS for their operations. With the recent events (incidents and accidents) the requirement for SMS is expanding to include Charter Airlines, Commuter Airlines, Air Tour operators, Part 135 operators and certain manufacturers. These organizations will be required to establish an SMS and maintain it to the proper standard.
To learn more about the SMS standard, visit the FAA’s SMS page.

Other Groups That May Benefit from Implementing Safety Management Systems (SMS)

There are many other organizations that could benefit from a system such as the Safety Management Systems found in Aviation SMS. The other transportation organizations such as land transportation, including rail and roadway, as well as sea transportation including passenger cruise lines, and freight ship organizations.

Case Studies

Case Study 1: The Francis Scott Key Bridge Incident
In recent news we saw the Francis Scott Key bridge in Baltimore come crashing into the Patapsco River after a cargo ship struck one of the support piers, causing the bridge to fail.

U.S. Army Corps of Engineers staff onboard Hydrographic Survey Vessel CATLETT observe the damage resulting from the collapse of the Francis Scott Key Bridge in Baltimore, March 26, 2024. In accordance with USACE’s federal authorities, USACE will lead the effort to clear the channel as part of the larger interagency recovery effort to restore operations at the Port of Baltimore.
U.S. Army Corps of Engineers staff onboard Hydrographic Survey Vessel CATLETT observe the damage resulting from the collapse of the Francis Scott Key Bridge in Baltimore, March 26, 2024. In accordance with USACE’s federal authorities, USACE will lead the effort to clear the channel as part of the larger interagency recovery effort to restore operations at the Port of Baltimore.

Could the collapse have been prevented? To understand this, we need to look at the accident sequence, and analyze why things occurred leading to the collision between the ship and the bridge pier. We need to look at the details of the event, and where failures occurred that allowed the collision. The trip originated at the Seagirt Marine Terminal and was piloted by two ‘Harbor Pilots’ aboard the ship. Approximately 30 minutes later the ship hit the pier. The ship apparently had an electrical failure, which prevented the pilots from steering. The ship was being pushed through the water by the wind and current at about 8 Knots. Without the ability to steer, the wind pushed the ship into the pier. Smoke from the boat prior to the collision seems to indicate the ship was trying to reverse its engines to move back from the bridge, a maneuver that ultimately failed. Moments prior to the collision the ship’s crew issued a Mayday call to the Coast Guard which allowed other ships in the area to stop.
The ship was the DALI and was owned and operated by Singapore’s Synergy Marine Group. The ship underwent routine engine maintenance in the port at Baltimore. There were also reports that the DALI had experienced power outages while in the Baltimore port. This was reportedly caused by refrigerated containers causing circuit breakers to trip. This apparently went on for two days prior to leaving Baltimore. Some other striking events were the loss of the voyage data recorder for a period of two minutes.
Had a properly administrated SMS been in place, would the ship have left port prior to ensuring everything was working properly for the voyage? That is a question that will likely never be answered. Could it have helped? Absolutely.

55 people were injured after a Los Angeles Metro train collided with a USC bus, on April 30, 2024, in Los Angeles. KABC
Case Study 2: Train and Bus Collision
We have seen incidents and accidents in the news recently pertaining to trains. One of the latest occurred on April 30th. An E Line train in Los Angeles, California hit a USC bus and injured 50 people. What went wrong? While we don’t know the exact cause of this accident yet, can we offer a preventative solution? With a robust SMS in place, the bus and the operator would be tasked to ensure they were safe to operate on this trip. If the A-line trains had an SMS they too would require the train and operator was safe to operate.

Case Study 3: CSX Train Collision
On April 15th two trains from CSX collided. The crash was caused by an improperly aligned switch during maintenance work. A CSX intermodal train collided with a stationary loaded rock train on a Jesup Subdivision main track. The intermodal train was traveling to Florence, South Carolina, on a different main track when it was inadvertently diverted onto the Jesup Subdivision main track and collided head-on with the stationary train. As a result of the accident, CSX published a safety alert that reviews operating requirements for a dual-controlled power-operated switch in a hand position. Special emphasis was placed on reaffirming that “all trains must approach all switches within the limits of the signal suspension at restricted speed until it is known they are lined for the authorized and intended route.” Having an SMS in place would have potentially prevented this crash. For more information, visit this report.

On April 15, two CSX trains collided in Folkston, Georgia. Photo – National Transportation Safety Board
On April 15, two CSX trains collided in Folkston, Georgia.
Photo – National Transportation Safety Board

Benefits of SMS

What are the benefits of SMS? An SMS is an overarching systematic way of looking at various elements of a job and analyses the information about the job. The most crucial benefit of an SMS is development of a culture of safety, which allows organizations to put safety first in all operations.

  • In Case Study 1, it would look at the sea worthiness of the ship, the sea worthiness of the crew, the load of the ship, and all documentation prior to authorizing the ship to depart. Had the ship been experiencing electrical problems those would have been required to be repaired prior to sailing. Any other maintenance problems would need to be analyzed prior to departure and decisions made whether to continue prior to repair. Crucial items would require repair while luxury items may not have been utilized, allowing the ship to depart. There may have been additional requirements placed on the ship to depart the port, such as using non required tugboats as an added safety measure. These items are being looked at now as hindsight, but the purpose of the SMS is to look at them from a future perspective. The crew would be required to be well rested and ready for duty prior to departure. Other things that may be analyzed would be weather, including wind speed and direction, as well as other phenomena that may impact the ships’ operations.
  • In Case Study 2, an SMS would ensure the driver of the bus was rested and well trained to conduct the transport for the day. It would also ensure the bus was in operational condition prior to use, which would eliminate things such as brake failure when the brakes were required.
  • In Case Study 3, an SMS would have developed and engaged a lock out tag out program which would not have allowed the switch to be changed when the track was not clear for operations. It would also train the maintenance personnel to use the appropriate systems when completing maintenance. It would also have alerted the conductor of the train about the maintenance on the tracks and raised his awareness to possible problems. Other items such as limiting the speed of the train in an area that has ongoing or has had maintenance completed, allowing better reaction time to action and prevent collisions of this type.

Culture of Safety

A major aspect of a properly developed and managed SMS is the proliferation of a ‘Culture of Safety’ within the organization. The culture of safety empowers everyone in the organization to make safety a priority. It enables them to question things that don’t appear to be safe without fear. Their concern for the organization and anyone impacted by the organization is embraced. If there was a properly developed SMS in place for the DALI would the personnel on the ship feel they could wait for the repair of the ship prior to setting sail? Would that have prevented the accident? These questions are unknowns; however, they are possibilities as well.

Building an SMS

Building and implementing an SMS may seem like a daunting task. Learning from the aviation industry can help make that task easier. There is an abundance of places to seek information to model SMS for other industries. Aviation has helped other industries with the development of SMS previously. Medicine has used aviation SMS models to help develop a program to enhance safety in surgeries as well as other areas. I think it is easy to see the benefits gleamed from these efforts as well. If you are interested in seeing if an SMS will help your organization excel in safety, reach out to sources that can help you get the information you need. Those who have an SMS are usually glad to share information.

Here at TCASS, we have experience with Safety Management Systems and will be glad to help you develop an SMS for your organization. Contact us today to set up a conference to see what your needs are.
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Visit www.tcas2.com/blog to read more blog posts pertaining to safety, and Safety Management Systems.

Aviation Safety in the News: Challenges, Solutions, and the Role of Safety Management Systems (SMS)

Aviation Safety in the News: Challenges, Solutions, and the Role of Safety Management Systems (SMS)

Once again, we find Aviation Safety in the news. There are multiple stories that pertain to aviation safety from several aspects of the industry. The largest story involves Boeing, and the lack of safety the organization reportedly has. Of the gravest concerns, is that Boeing sees itself as an organization with an impeccable safety stance and program. While Boeing may have a safety culture, how good is it? Boeing does not have the elements that support a Safety Management System. Is this a problem manifested only by Boeing? Only in the manufacturing sector? NO of course not. FAA part 121 Airlines also have SMS challenges, even though they are required to meet the FAA SMS regulations. We also read about American Airlines and the problems they seem to be having that rival those of Boeing. They also report they have a safety program that is top notch. Much like Boeing, all the outward signs of a safety program are visible. But are they meaningful? American Airlines is not the only part 121 Airline that is experiencing problems.

Watch the 96-minute long testimony given at the Senate Panel in April, 2024.

The Challenge of “Culture of Safety”

What we really need to know is how the culture at these organizations and many more organizations like them around the world feel about safety. As we investigate cultures, one thing we look at is relics. Relics are those things that tell us a story about those in the culture. These organizations usually have the relics we look for to see a safety culture. Those are the posters and such that may show their interest or may just be for show in case they get a visit from the FAA or regulator. The true test is the development of a culture of safety, rather than a safety culture.

Relics of Safety Culture

The Evolution of Safety Management Systems

Looking back, SMS was introduced by the International Civil Aviation Organization (ICAO) in the 1980 – 1990s. This occurred due to a series of high-profile aviation accidents which underscored the necessity to take safety to the next level. That level was a systematic approach. During the 2000s SMS gained widespread acceptance, and regulators began to require the program.

In the 1980s and 1990s, there was a lot of effort put into developing what has become the aviation SMS today. It was a collaborative effort between many organizations and regulators. There are opportunities to get help today as well. If you feel your organization needs help with the development of or improving your SMS, ask for help. Building an organization with a culture of safety will probably be the most satisfying activity you can engage in.

There are many documents provided by regulators that outline what an SMS requires, and organizations still fail in these areas. SMS regulations started with FAA part 121 airlines. The large passenger carrying airlines were the first to be required to have an SMS. The new group in the push for SMS goes to FAA part 135 air carriers and FAA part 21 carriers. The new rules will also include FAA part 145 Maintenance organizations.

The latest news is about Safety Management Systems (SMS), and regulation changes requiring SMS in more areas of aviation. At face value this is a good thing. However, if companies such as Boeing and American Airlines are having problems, how can this work for those in the new group? Saying I have an SMS is not proof enough that a ‘true’ SMS exists.

Evaluating Safety Management Systems Effectiveness

Recently the National Transportation Safety Board has cited weakness or lack of an SMS as a causal factor in accidents and incidents. Many of the current incidents or accidents show a lack of safety as a part of the problem. Boeing has shown many areas where there is no SMS, even though they have relics that show they have a safety culture. The events with American Airlines and Southwest also show their SMS efforts are falling short of the mark to ensure safety is paramount to the organizations. These highlight the difference between a safety culture and a culture of safety.

All organizations should take a top to bottom look at their SMS on a regular basis. Is the accountable executive active in the SMS process as they should be, or is it delegated down to employees that don’t have the proper level of leadership to accomplish what needs to be accomplished? Is the safety policy just words that the organization can recite without meaning, or is it truly the “Way we do business here” within the organization?

If things are going well, why is there a need to evaluate the SMS on a regular basis?
Drift is a naturally occurring process in organizations. As time passes, people drift towards ways of doing things that are not within the ‘Culture of Safety’ way of doing business, for many reasons. Shortcuts occur, and we can start to see failures in the SMS. Time constraints are always an issue as well. From top to bottom, time must be devoted to the SMS. Another crucial aspect of culture is trust. If the workforce trusts the management, they are more likely to follow the SMS. If they don’t trust, they likely won’t. Every aspect of SMS must fit together like a well-designed and maintained puzzle.

The Future of Safety Management

If we are going to make aviation safer, we must take steps to build a safe organization, and keep safety top of mind for every employee in the organization, as well as every organization that supports it. SMS is that umbrella that pulls everything and everyone together in the name of safety. Regulators play a role in this as well. If SMS is required by regulation, see that it is done correctly. If SMS is needed, develop the regulation to require it, and then ensure it is done correctly.

Visit www.tcas2.com to read more blog posts pertaining to aviation and aviation safety.

Image showing a Southwest Airlines Boeing plane with its engine cover detached during takeoff.

Southwest Airlines 737-800 Makes Emergency Landing in Denver

Breaking Aviation News & Videos
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Southwest Airlines 737-800 makes emergency landing in Denver after its engine cowling detached on departure.

Everyone seems to have an opinion about Southwest and Boeing, however, like most people know, everybody disagrees with everyone else’s opinion.

At this point, we need to wait until an investigation is completed to determine what the cause of this event was. It may have been maintenance error, and we need to investigate the reasons for that maintenance error which allowed this to occur, and then treat that symptom in an appropriate way.

That doesn’t mean condemning the airline, manufacturer, or the maintenance technician without understanding what occurred.

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Ensuring Aviation Safety: A Perspective from a 40-Year Aviation Veteran Pilot

Ensuring Aviation Safety: A Perspective from a 40-Year Veteran Helicopter Pilot

As news of the recent emergency landing of a Southwest Airlines 737-800 in Denver due to engine cowling detachment spreads, opinions are abundant but understanding remains scarce. As a 40-year veteran helicopter pilot with Treasure Coast Aviation and Safety Services (TCASS), it is imperative to approach such incidents with a balanced perspective and await the findings of thorough investigations.

Firstly, it’s crucial to acknowledge that incidents like these warrant serious attention and swift action. The safety of passengers and crew should always be the top priority in aviation. However, knee-jerk reactions and baseless accusations serve no one. Instead, it’s paramount to let the investigative process unfold before drawing conclusions.

Speculation often leads to finger-pointing, whether it’s directed at the airline, the aircraft manufacturer, or maintenance personnel. Yet, true progress in enhancing safety comes from a comprehensive understanding of the root causes of such incidents. Was it a maintenance error? Was there a flaw in the design or manufacturing process? These are questions that demand answers, and only a thorough investigation can provide them.

At TCASS, we understand the complexity of aviation safety. Our decades of experience have taught us that safety is not achieved through blame but through collaboration, transparency, and continuous improvement. It’s about identifying weaknesses in the system and addressing them proactively to prevent future occurrences.

In the case of the Southwest Airlines incident, it’s essential to refrain from rushing to judgment. Instead, let’s focus on supporting the investigative authorities as they meticulously analyze every aspect of the event. Only through this diligent process can we gain the insights needed to bolster safety measures across the industry.

As a company deeply committed to aviation safety, TCASS emphasizes the importance of learning from every incident, no matter how rare or isolated it may seem. Our dedication to this principle is evident in the services we provide, as an aviation safety consulting organization.

TCASS stands by its testament to unwavering commitment to advancing safety in aviation. By harnessing the power of data analysis, TCASS empowers airlines, maintenance crews, and regulatory bodies to identify potential risks and take proactive measures to mitigate them.

In conclusion, while the recent incident involving a Southwest Airlines 737-800 is undoubtedly concerning, it’s crucial to approach it with a level head and a steadfast commitment to safety. Let’s allow the investigative process to run its course and use the findings to drive meaningful change. Together, we can ensure that incidents like these become increasingly rare as we continue to prioritize safety above all else.

Keywords: Aviation Safety, Boeing 737-800, Southwest Airlines Incident, TCASS, TCAS2, Maintenance Error, Safety Investigation, Collaborative Safety Efforts.

For more details, visit ABC News.


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