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2024-02-21

Sky-High Negligence: Near-Collision Due to SMS Issues

The Management Mistakes Behind a Near-Collision

Two aircraft pass each other at a minimum separation of 665 ft vertically and 1.5 NM laterally over France.
In a revealing report, the French BEA sheds light on this critical incident, emphasizing the crucial role of effective Safety Management Systems (SMS). It underscores how missed signals and overlooked or unreported occurrences can escalate into serious airborne encounters. It further reveals systemic managerial problems in oversight, addressing technical malfunctions and the necessity for robust reporting mechanisms.

Summary:
The investigation found that during the climb, the Citation crew observed erratic speeds on the airspeed indicator of system 1. Despite manual control to mitigate the issue, a discrepancy in altitude readings between the aircraft’s two altimeters was later identified. This discrepancy led to an erroneous climb to an incorrect en-route level. Upon noticing differing altimeter readings, the crew informed air traffic control, which then highlighted conflicting traffic information involving an Embraer 170. The situation escalated due to the transponder transmitting incorrect altitude data based on the faulty air data system 1, culminating in a near-collision incident with the Embraer 170. The incident was part of a pattern of similar occurrences on the same aircraft in 2017, 2019, and 2021, which had not been adequately addressed or rectified, underscoring systemic issues in the reporting and management of technical faults within the operational and maintenance frameworks.

Findings:
The investigation underscored the increasing focus of accident investigation authorities on the systemic details of management systems. The scrutiny revealed that the SMS’s inefficiencies were not isolated but indicative of broader management and operational deficiencies. This insight into systemic failures showcases the accountability that lies with executive and safety managers, stressing the importance of a robust SMS.

The report serves as a stark reminder to executive and safety managers of the critical importance of maintaining robust safety management systems. It demonstrates that authorities today are not just looking at the immediate causes of incidents but are delving deeper into organizational and management practices and their contributions to the occurrences. The management’s responsibility for ensuring these systems are effective cannot be overstated, as failures in these areas can lead to serious safety incidents, highlighting the interconnectedness of operational safety and organizational management practices.