THE EVOLUTION OF

SAFETY MANAGEMENT SYSTEMS IN AVIATION:

A DECADAL ANALYSIS

AVIA 540 WEB

YORK COLLEGE

DR. TRIANT FLOURIS

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 EXECUTIVE SUMMARY

The rising number of aircraft accidents, mishaps, and environmental hazards brought the topic of
safety in aviation to the spotlight. The primary rationale was that passenger confidence, an
airline's brand, and its worldwide standing are all directly tied to its commitment to aviation
safety. How well hazards associated with aviation operations related to or indirectly supporting
aircraft operations are mitigated and managed is what we mean when we talk about aviation
safety. The current study was based on the topic of “The Evolution of Safety Management
Systems in Aviation: A Decadal Analysis”. A quantitative content analysis study was conducted
to explore the evolution of SMS over the last decade. Two ICAO reports published in 2013 and
2023 were analyzed, and results showed that regardless of the evolution of safety management
systems over the last decade the number of fatal accidents has significantly increased. These
findings calls for new policies at global level and aviation sector around the globe should
cooperate to determine the human errors, technological faults and environmental threats and new
SMS policy measures to eliminate these threats.

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Table of Contents
1. Introduction..............................................................................................................................1

1. 1 Research Purpose..............................................................................................................2

1. 2 Research Question.............................................................................................................2

1. 3 Research Hypothesis.........................................................................................................2

1. Literature Review.....................................................................................................................2

2. Theoretical Framework: Human Reliability Analysis (HRA)..................................................4

3. Research Design.......................................................................................................................4

3.1 Data Collection.................................................................................................................4

3.2 Data analysis.....................................................................................................................5

3.3 Findings and Results.........................................................................................................5

3.3.1 Report of ICAO 2013.....................................................................................................5

3.3.2 Report Analysis of 2023.................................................................................................7

3.4 Discussing Key Changes and Improvements over the Last Decade.................................8

3.5 Study Limitations and Future Recommendations.............................................................9

3.6 Policy Implications.........................................................................................................10

4. Conclusion..............................................................................................................................10

References......................................................................................................................................12

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 1. Introduction

The global COVID pandemic stopped a rising trend toward reliance on air travel in 2020. The
International Air Transport Association, also known as IATA (2020), did a hypothetical study
and found that the possible increase in air travel over the following twenty years may be from
3.2% to 5.3% (Kešeľová et al., 2021). The International Civil Aviation Organization (ICAO,
2006) proposed that contracting states set up a safety program to approve and regulate the safety
management systems of safety service providers. As aviation safety has matured, an additional
phase of the 'Total Aircraft System Approach' has emerged, emphasizing the need to understand
and manage all aircraft stakeholders and their interactions to optimize safety performance. When
seen from the most basic perspective, safety management's goal is to ensure that occurrences and
accidents are reduced to an acceptable minimum. From another angle, safety management aims
to ensure that regular tasks end up where they are supposed to. SMSs, or Safety Management
Systems, are the result of years of improvements in the aviation industry. Safety regulations,
experience, and technical know-how needed to be improved for the early flying pioneers.
Regulation of aviation operations, operating expertise, and technological advancements has all
helped to make great strides in aviation safety throughout the years. Focusing on human
performance, sometimes known as "human factors," was the next big step in improving safety,
leading to even fewer incidents (Kešeľová et al., 2021).

Each method has resulted in substantial safety improvements. Analyzing what led up to an
accident might identify many points when the sequence of events could have been disrupted. The
organization's commitment to safety is reflected in these openings. The term "company accident"
was used to characterize mishaps whereby organizational choices and mindsets played a role in
their development.

The Safety Management System (SMS) is a strategy for enhancing workplace safety (FAA,
2023). In order to implement SMS, a company must first conduct an internal review of its
processes and related choices. Organizations may use SMS to adjust to new circumstances, more
complexity, and constrained resources. In addition, SMS will encourage the ongoing
enhancement of safety by using targeted strategies for foreseeing risks based on reports and data
gathered from workers. This data will subsequently be used for risk assessment and

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organizational management. Controls and the structure will be monitored as part of this
procedure to ensure they function as intended. Using SMS, businesses may stay in compliance
with current rules and regulations while anticipating further action. Finally, SMS comprises
standards that will improve an organization's safety attitudes by influencing leaders, managers,
and workers to adopt a new, more cautious mindset. These adjustments are meant to facilitate the
organization's adoption of all three modes of reasoning (reactive, assertive, and anticipatory)
(Tirpáková et al., 2021).

1. 1 Research Purpose

In only a few years, the aviation sector has advanced quite a ways, with technological
improvements playing a crucial part in changing how we think about and deal with the dangers
of flying. Modern technology and fresh perspectives on aviation risk management have led to
substantial developments in the sector, improving safety and productivity (Stroeve et al., 2022).
The purpose of current research study is therefore to explore the evolution of safety management
systems in aviation sector in the recent past decade.

1. 2 Research Question

i. What are the new safety management systems in aviation sector?

1. 3 Research Hypothesis

H1: Safety management systems in aviation sector have developed in the past decade

1. Literature Review

SMS has gained widespread acceptance in the aviation industry as a technique that has been
shown to improve safety and save costs. Safety management is just as crucial for businesses as
any other management area, and safety management systems (SMSs) emphasize this by
combining cutting-edge safety principles with standardized, proactive procedures. Organizations
may better understand their operating environment thanks to SMS's framework, which leads to
streamlined procedures and reduced expenses. Even in the first ad hoc deployment phases, some
participants have reported seeing positive results. More and more aviation companies are doing
this as they learn to integrate all three stages of process development (reactive, proactive, and
predictive) (FAA, 2023).

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A decade of formalized SMS in the US as well as around the globe will come to a close in 2016,
yet many of the key ideas of current aviation SMS have roots far deeper in the past. Racing the
roots of such a gigantic safety framework is tricky because of so many distinct influences such as
varying perceptions and varied dates in different nations. There is no one moment that can be
pinpointed as the birth of aviation SMS; rather, it has developed over time via a variety of
fusions and inspirations from various forms of management, including ISO 9000's quality
assurance systems. Nonetheless, there are significant turning points throughout SMS's 50 years,
beginning with the many factors that led to the development of what we now call aviation SMS
(Burling, 2021).

Safety system principles from the 1960s and 1970s, and more broadly from different types of
management systems (such as the quality management strategies (9000 series) and the systems
for environmental management (14000 series)), provide the foundation for a few of the present
ideas of safety in flight SMS. QMS and SMS share a lot of structural elements. Modern SMS
ideas emphasize a systematic, documented procedure to achieve the same results as ISO-9000
(Castagna, 2023).

The European Joint Aviation Authority (now EASA) and New Zealand's Internal Quality
Assurance (now EQA) both mandated crash avoidance program supervision as part of their
quality management processes in the 1980s. Similarly speedy was the response from the Federal
Aviation Administration. The previous norm for enhancing safety only included reactive
measures. The notion in QMS of *preparing* for developing a quality system was the primary
motivation for SMS' idea of hazard detection and risk management procedures. Proof from
EASA, the Federal Aviation Administration, and various additional agencies, as well as the
common system theory between SMS and QMS, makes it clear that aviation SMS developed
from QMS ideas. Naturally, aircraft SMS would rapidly alter significantly to differentiate itself
from QMS. The aviation SMS framework is developed from ISO 9000 when one analyzes the
QMS requirements in an ISO 9001 certified organization.

After a decade or so, several aviation authorities have begun to seriously consider integrating
safety supervision into their QMS initiatives. 950 people from airline companies, unions,
authorities, and other types of aviation organizations met in 1995 for a conference on aviation
safety. The year 1995 was a watershed moment when aviation SMS emerged as its own field. To

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begin with, FAA Administrator David Hinson coordinated efforts toward the aim of zero
accidents. To our knowledge, this had been the first worldwide gathering of its kind to take a
"proactive" approach to safety by setting shared long-term objectives. The following conclusions
came out of the two-day meeting:

 The delegates have identified 540 separate "issues"

 The Federal Aviation Administration's Office of Systems Safety has been established by
the FAA.

Once more, as previously stated, "plan" or "initiative" are just synonyms for "proactive." In stark
contrast to the past, this time around we are basing our standards not on previous incidents but on
what we want to achieve in the future. This method has shown to be the natural progression from
the present SMS emphasis, which is less on the actual accident and more on the conditions that
might lead to one. Preventive and predictive SMS rely on precursors to detect potential threats
before they arise (Moorkamp et al., 2014).

2. Theoretical Framework: Human Reliability Analysis (HRA)

While there are other Human Factors approaches that may help ensure System Safety, HRA is
particularly well-suited for this purpose because of its emphasis on risk assessment and
mitigation. The study of how people interact with the rest of a system is known as "human
factors," as defined by the scientific literature (Lowe, 2008). To investigate SMS in the Aviation
sector in the USA, the present research used 'Human Reliability Analysis' (HRA).

According to Curt Castagna, A “combination of factors is contributing to an increased number of

aircraft accidents, mishaps and near-misses – causing federal regulators to place a heightened
emphasis on aviation safety. Due to a shortage of qualified, trained pilots and air traffic
controllers, there are less experienced personnel in both the tower and the cockpit.” (Castagna,
C.,2023)

3. Research Design

In this study the researcher has applied quantitative research design to collect the official reports
of FAA published in 2013 and 2023.

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3.1 Data Collection

The data was collected from the official website of Federal Aviation Administration. The
collected reports are as follows:

1. 2013 Safety Report of International Civil Aviation Organization; accessible at:

https://www.icao.int/safety/documents/icao_2013-safety-report_final.pdf
2. 2023 Safety Report of International Civil Aviation Organization; accessible at:
https://www.icao.int/safety/Documents/ICAO_SR_2023_20230823.pdf

3.2 Data analysis

A quantitative content analysis technique was applied in the current research study as the
researcher aimed to analyze the reports of ICAO published in 2013 and 2023 respectively.

3.3 Findings and Results

3.3.1 Report of ICAO 2013

The daily commercial flight accident data was divided into United Nations regions according to
the location of each incident. Despite having the largest regional accident rate, Africa only makes
up around 3% of all scheduled commercial traffic worldwide. However, it should be emphasized
that no geographical accident rate was more significant than double the worldwide rate for the
second year in a row.

Figure 1 Global accident rate until 2013

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In the table above, we can see how many accidents, fatal accidents, and deaths there were in each
location. Although African countries were responsible for just 5% of all accidents, they were
responsible for 45% of all deaths. In 2012, there were no incidents at all in Oceania or anywhere
else in the Northern Hemisphere.

In 2013, the Council of the ICAO approved a new Safety Management Annex to the Chicago
Agreement on International Civil Aviation. The highest-level safety conference in Montréal in
2010 made a suggestion that led to the development of Annex 19. Existing laws on government
safety initiatives and safety systems for management were merged into this new Annex. Over
three years, ICAO, its member states, and other international organizations worked closely
together to produce this new Annex. Annex 19's creation bolsters the development of a
preventative approach to safety. Implementing a State Safety Program (SSP), which
progressively tackles safety concerns, is the basis of this preventative approach to safety
management. How long it takes to make an SSP depends on how complicated the air travel
system is and how well the state can oversee aviation security.

Since the aviation industry has many potential hazards, including accidents and security
breaches, preparation planning is nothing new. Although emergency medical services are often
engaged in aviation incidents like accidents, public health emergencies necessitate a distinct
approach to emergency preparation. Because of the potential negative influence on aviation
reliability, effectiveness, and the economics of states and businesses, anyone working in the
aviation industry should be familiar with how public health incidents might affect the industry.
When a significant portion of the workforce is out of commission owing to sickness and the
attendant effects of epidemics, safety, security, operations, and efficiency are all at risk. The
ICAO also places high importance on ensuring the terminal and cabin are safe spaces for

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passengers, employees, and crew. When airline employees contact sick passengers, their health is
at stake. The International Civil Aviation Organization (ICAO) has been cooperating with the
World Health Organization (WHO), the International Air Transportation Association (IATA), the
Airports Council International (ACI), and others to create a unified strategy for addressing public
health concerns in the aviation industry.

When flying for an airline that operates internationally and requires a minimum of two pilots, the
maximum age a pilot may be is currently 65. Pilots in Command (PICs) and Co-Pilots (CPs) are
both subject to this restriction; it is a Regulation for PICs and a Preferred Practice for CPs. The
"one over one under" rule states that if a pilot is 60 or older, the other one must be lower than 60.

3.3.2 Report Analysis of 2023

According to the International Civil Aviation Organization (ICAO), the number of passengers
carried globally increased to 3.2 billion in 2022, compared to 2.3 billion in 2021. While
passenger traffic is still down 29% from pre-pandemic (2019) levels (4.5 billion have been
carried globally), it is up 78% since the first year of the global pandemic (2020), when just 1.8
billion people went to the skies. According to analyses of historical data, the number and
frequency of accidents throughout the world are expected to rise in 2022. According to reports
the overall number of accidents increased by 33.3% between 2021 and 2022. Nonetheless, it's
significant that 2022 saw a rise in both worldwide airfares and the quantity of airline departures
once pandemic limitations were relaxed and air travel began to recover. The worldwide accident
rate in 2022 was 2.05 per million departures, a 6.3% rise from 2021's rate of 1.93 per million.
During this time, there was a 25-percent rise in flight departures, it should be noted.

Figure 2 accidents from 2018 to 2023

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In 2022, there were 160 deaths as a consequence of scheduled international air transport
accidents, up from 104 in 2021, and the mortality rate increased to roughly 50 per billion
passengers, above 45 per billion in 2021. There were four fatal incidents in 2020, but seven in
2022. In Figure 3, we see the breakdown of ICAO-accredited regions by the quantity of fatal
crashes and overall deaths.

Figure 3 Accidents by region

Strategic choices favoring the future effectiveness, security, and ecological viability of air travel
were made during the 41st Meeting of the ICAO Assembly, which took place from September
27th to October 7th, 2022, in Montréal, Canada. As a worldwide strategic plan for aviation
safety, the Assembly has approved the Global Flight Safety Plan (GASP) for 2023–2025. ICAO
helps the world's aviation community adapt to current and future trends by supporting
standardization, deployment, and monitoring. It also makes safety improvements for the future,
intending to improve safety performance and lower operational safety risk. Statistics and
assessments of accidents between 2018 and 2022 are included in the twenty-third year of the
Safety Report, together with an up-to-date set of GASP indicators connected to Objective 1 and
its associated objective. The main goals of GASP are as follows:

1. “to achieve a continuous reduction of operational safety risks”

2. “calls for all States to strengthen their safety oversight capabilities”
3. “calls for the implementation of effective State safety program”
4. “calls for States to increase collaboration at the regional level to enhance safety”
5. “aims to expand the use of industry programs and safety information sharing networks”

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 6. “focuses on the appropriate infrastructure needed to support safe operations”

(GASP, 2023).

3.4 Discussing Key Changes and Improvements over the Last Decade

According to the 2013 safety report of ICAO the global air aviation industry transported roughly
2.9 billion travelers in 2012, up 5 per cent over 2011. The number of scheduled passengers in
2012 increased by 5.5% compared to 2011 in terms of revenue passenger-kilometers. There was
a 21% drop in total accidents in 2012, and the worldwide accident rate for scheduled commercial
operations dropped to 3.2% per million takeoffs. The number of deaths fell by 10% from 2011 to
2012, making 2012 the year with the fewest fatalities since 2004 (Reveley et al., 2011).

Annual accident figures show a rise in both the overall number of accidents and the worldwide
accident rate in 2022, according to a study from 2023. According to reports the number of
accidents increased by 33.3% between 2021 and 2022. Nonetheless, it's significant that 2022 saw
a rise in both worldwide passengers and the amount of airline departures once pandemic
limitations were relaxed and air travel began to recover. The worldwide accident rate in 2022
was 2.05 per million departures, a 6.3% rise from 2021's rate of 1.93 per million (Britton, 2022).

The comparative analysis of decade apart reports indicated that till 2013 the number of fatal
accidents decreased as the focus of safety management systems was on the human and
technological factors. The results shown in the report of 2023 has indicated that the rate of fatal
accidents has increased since 2015. We can say that the reason for such increase in rate of fatal
accidents is human negligence during COVID 19 pandemic, because the global attention was
diverted towards health factors. To eliminate these safety management issues, GASP had
proposed 6 sustainable developments goals to be achieved by 2030 including the implementation
of a successful national safety program, the enhancement of safety through more cooperation at
the regional level, a continual decrease of operational safety risks, the strengthening of safety
supervision capabilities, the expansion of industrial programs and safety knowledge sharing
networks, and so forth.

The study refutes the hypothesis (H1) proposing advancements in safety management systems
(SMS) within the aviation sector over the past decade. Instead, it is asserted that although SMS

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has evolved due to technological progress, the increased rate of fatal accidents is linked to
human, environmental, and technological factors.

3.5 Study Limitations and Future Recommendations

The current research study has some limitations which includes the research methodology and
sample size for the study. The future researchers are suggested to accumulate mixed research
method to triangulate the results so that the researchers can get deeper insights to Safety
management systems globally. The researchers can also conduct empirical research study and
collect data from actual respondents to explore how SMS have evolved overtime how this
evolution is contributing to the aviation industry.

3.6 Policy Implications

 Save lives using measures that are both standardized and adaptable. To ensure the safety
of travelers, crew, and other personnel at all times, it is imperative that governments and
businesses collaborate to implement risk-based procedures that are either standardized or
generally recognized.
 Demonstrate aviation team unity by working together cohesively. There should be
synergy between the programs of ICAO, States, regional and international bodies, and the
business sector. States should try to synchronize their responses in accordance with
ICAO's standards, plans, and policies, while this may not always be achievable due to
differences in national and regional demands.
 It is particularly important for states and businesses to ensure that distant areas, isolated
islands, and additional susceptible states retain crucial connections and global supply
chains.
 Hazards to operational safety, security, and health throughout the restart and recuperation
stages need states and industry to apply data-driven systematic methods to management.
 Health precautions must be carefully examined to prevent significantly influencing
aircraft safety and/or security.
 The need for direct and/or indirect assistance, in proportional and open methods, should
be considered by states and financial organizations commensurate with their mandates.
When doing so, policymakers should ensure that diversity and access are protected
without distorting markets.

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 4. Conclusion

In the current study a quantitative content analysis study of two ICAO reports was analyzed to
explore the evolution of safety management systems over the last decade. The content analysis
showed that number of fatal accidents which was decreasing in 2013 has increased in 2023
which was due to the human negligence during COVID 19.

The research hypothesis of the study was rejected on the basis of these results and it was
concluded that although SMS has evolved over the last decade but still implication of ICAO
policies is required with the cooperation of international aviation industry to eliminate the risks
of accidents. The aviation industry facilitates communication and is vital to the revival of
economies and communities. The aviation business relies heavily on a healthy economy and a
clean environment, both of which must be protected. As the globe heals, the lessons learnt have
to be applied to build the aviation system better.

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