Get the Gouge: SMS Needs a Center of Excellence

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About 25 years ago the US Navy and in particular Naval Aviation established a Lessons Learned Center, which was essentially a database that could be accessed via a network and allowed participants to submit data and lessons that individual operational units collected from troubleshooting difficult technical problems, maintenance discrepancies and safety events. The Lessons Learned database was formulated to allow other operational users and organizations to gain immediate benefit from the lessons and experiences that other units gained from solving and addressing challenging problems. A typical entry would include a problem or technical issue, “symptoms” and analysis, what was done to troubleshoot the problem, and what was done to remedy the problem. As a result, the database enabled participants to resolve technical problems sooner, which lowered operating costs and helped maintain readiness levels.

The Federal Aviation Administration (FAA) developed the Aviation Safety Information Analysis and Sharing (ASIAS) system, which promotes the open exchange of safety information in order to continuously improve aviation safety. ASIAS system enables users to perform integrated queries across multiple databases, search an extensive warehouse of safety data, and display pertinent elements in an array of formats.

ASIAS contains Lessons Learned from the aviation accidents library representing some of the most major accidents and their related lessons. FAA, with support from many others, plans to continue adding to this material on an annual basis. The objective is to populate the material with many more of the most historically significant, policy shaping accidents, in order that the lessons that can be learned from their review may be available to all users of the library.

ASIAS data resources come from the FAA Accident/Incident Data System, Air Registry, ASRS, DOT, near mid-air collision data, runway incursions, and NTSB data system and accident reports. Organizations like the Commercial Aviation Safety Team can use this data to complete in-depth analysis of accidents and safety problems by category to help develop strategies and solutions to hopefully eliminate their reoccurrence.

ASIAS is a great resource and provides a wealth of knowledge, but it does not have the ability to provide immediate or near real-time feedback like the Naval Aviation Lessons Learned database provided.

If we are to improve the aviation safety performance record we have, we need to make information available that will help the community as soon as possible. In Naval Aviation parlance that was called, “Get the Gouge”—what happened, how did it happen, and tell me what to do so I don’t screw it up!

So here is a thought—create an SMS Center of Excellence (CoE) or Competency or Capability Center or Lessons Learned Center, but ‘Center of Excellence’ seems to be what resonates with the FAA and for that matter academia and businesses so we’ll go with it here.

Whatever it is called, at a most basic level, it should consist of a team of people and organizations that promote collaboration and using best practices around a specific focus area to drive results.

Responsibilities: the SMS Center of Excellence should provide six basic needs:

Support: offer support to the participants/”customer”
Guidance: standards, methodologies, tools and knowledge repositories
Lessons Learned: hazard analysis, risks assessments and mitigations
Learning: training resources such as on-demand courses and certifications, skill assessments, team building and formalized roles are all ways to encourage shared learning
Measurements: demonstrate valued results through the use of output metrics
Governance: coordination across all stakeholders to enable value

How an SMS CoE may work:

  1. Have it run by an organization like MITRE – no profit/not for profit.
  2. Implement reasonable but strong business and operating rules, such as data must be de-identified.
  3. Airports, repair stations, air carriers and general aviation (GA) with SMS programs submit hazard reports, resultant analyses, risk assessment and mitigation strategies to a hosted database/server.
  4. Categorize SMS reports by type of operation and type of hazard to allow cross reference. There would be a library of reports for commercial, GA, airports, and repair stations, etc., but each report should be accessible by all participants.
  5. Provide resource and training material.
  6. Convene annual user conference.
  7. Provide subject matter experts.

Every aspect of the aviation community would benefit and be able to “Get the Gouge.” Leave your comment about this article and specifically the notion of establishing an SMS CoE.

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