Beyond Paper SMS: What Boeing’s Journey Teaches Gas Utilities

Some say Curiosity Kills the Cat. I say Overconfidence Kills People.

Safety Management Systems (SMS) are essential frameworks designed to ensure safety by managing risks, promoting a safety culture, and facilitating continuous improvement. My personal take on the experience of Boeing, particularly highlighted in the FAA's expert panel review, is simple: a paper SMS is insufficient to prevent disasters. For gas utilities implementing PSMS, this lesson is paramount. Implementing a robust, actionable PSMS can prevent incidents and ensure operational safety. This article explores Boeing's challenges with SMS, drawing lessons applicable to the gas utilities sector.

Lessons from Boeing

Boeing had an SMS program on paper, but the lack of integration and proper implementation allowed critical issues with the 737 Max to go unresolved until tragedy struck. The FAA report highlights several deficiencies in Boeing's SMS that probably contributed to the 737 Max disasters. These include a failure to fully implement a robust safety culture, inadequate feedback mechanisms, and a lack of accountability.

The disconnect between senior management and employees regarding safety priorities was stark. Despite having an SMS, the FAA determined key safety consideration were not deeply embedded into Boeing’s organizational culture. This disconnect meant that safety concerns were not adequately addressed before leading to catastrophic consequences occurred. For gas utilities, this serves as a cautionary tale: safety culture must be a top-down, pervasive commitment, not just a checkbox exercise.

 The complexity and ineffectiveness of SMS procedures were significant issues.  Procedures were not only complex but also poorly understood by employees, leading to confusion and ineffectiveness. Gas utilities must learn from this by ensuring that PSMS procedures are clear, consistent, and simplified. Employees at all levels should understand their roles within the SMS framework to enhance its effectiveness.

Another critical lesson is the lack of direct input from pilots in high-level decisions. This absence led to significant oversights. In the gas utilities sector, involving frontline workers—those who operate and maintain gas systems—in safety decision-making processes is crucial. Their insights are invaluable for identifying practical risks and developing effective safety measures.

The FAA questioned whether there was a non-punitive safety reporting culture. Employees feared retaliation, which hindered open communication about safety concerns. Gas utilities must create an environment where employees feel safe to report issues without fear of reprisal. Encouraging transparent and honest reporting is essential for identifying and mitigating risks before they escalate into major incidents.

 The FAA report further highlighted a lack of accountability and confusing SMS procedures within Boeing. Clear roles, responsibilities, and accountability are essential for a successful SMS. Gas utilities should define these elements explicitly to ensure everyone understands their part in maintaining safety. Simplified and well-documented procedures help in achieving this clarity.

There were significant challenges in overseeing Boeing's SMS, particularly due to the company's complex and ever-changing procedures. Gas utilities should ensure effective oversight and compliance. Regular audits and feedback mechanisms can help in maintaining a robust SMS.

Severe Consequences

The tragic accidents involving the 737 Max resulted in the loss of hundreds of lives, highlighting the critical importance of a functional and integrated SMS. Beyond the immediate safety impact, Boeing faced significant financial repercussions, including significant financial losses from grounded planes, legal settlements, and compensation to airlines. The company's reputation suffered tremendously, leading to a loss of trust from customers, regulators, and the public. Furthermore, Boeing faced potential criminal charges, underscoring the legal and ethical responsibilities tied to safety management.

 Application to Gas Utilities

Engagement with corrective actions programs is often low among operations personnel and contractors in gas utilities. To address this, utilities should foster a culture of ownership and responsibility. Training programs, incentives, and clear communication can enhance engagement and ensure that corrective actions are effectively implemented.

A partial or incomplete rollout of PSMS and Corrective Action Programs (CAP) can undermine safety efforts. Gas utilities must ensure a comprehensive rollout of these programs, with regular reviews and updates. Successful implementation requires commitment from all levels of the organization.

Timely feedback from incident reports and education on lessons learned from industry events are crucial for improving safety culture. Employees need to see that their reports lead to tangible actions and improvements. When feedback is provided promptly, it reinforces the importance of reporting and shows that management takes safety concerns seriously. Additionally, educating employees on lessons learned from past industry events helps in building a knowledgeable workforce that can anticipate and mitigate similar risks. Gas utilities should establish robust feedback mechanisms and incorporate regular training sessions on industry lessons to ensure continuous learning and improvement.

Conclusion

The experience of Boeing underscores that a mere roll out of SMS is not enough. For gas utilities, the lessons are clear: a robust, actionable, and well-implemented PSMS is crucial for ensuring safety and preventing disasters. By learning from Boeing's challenges and applying these lessons, gas utilities can enhance their safety management efforts, fostering a culture that prioritizes safety at every level.

 The call to action is clear: Assess your PSMS program to ensure the roll out goes deeper than the paper it is written on. Identify and address areas that suggest weaknesses in the key principles of PSMS. Do not wait until the weaknesses become self revealing.