Safety Management

Systems: Reflecting
on performance
challenges
Second in a series of perspectives on SMS for the aviation industry
May 2025

A business of Marsh McLennan

 Safety Management Systems: Reflecting on Performance Challenges

I. Introduction
In our first paper, “the Evolution of Safety Management Systems,” we explored the motivations
and reasoning that drove the introduction of safety management systems (SMS) in high-risk
operating environments. In some transportation industries, regulated organizations were
required to adopt an SMS due to prescribed safety requirements. In many cases, this adoption
occurred without a full understanding of the intent and purpose of the SMS and the wide-
ranging benefits that effective implementation could provide.
The decision to mandate an SMS is primarily influenced by the potential consequences of
failure, the regulatory environment, and the scale of the operation. Industries such as
chemicals, nuclear, oil & gas, and transportation have adopted these systems due to their
inherent risks. The implementation process is crucial, as systems designed internally often seek
to fit with legacy requirements, which can lead to duplication of effort and resistance to
change.
Many aviation operators have adopted and established SMS, but questions remain. In his 2012
article, “SMS Reconsidered,” Flight Safety Foundation President William Voss challenged
operators to ask the following four questions to determine if they have an effective SMS: 1
1. What is most likely to be the cause of your next accident or serious incident?
2. How do you know that?
3. What are you doing about it?
4. Is it working?
We would add another question to this list: How is your business benefiting as a result of SMS
adoption?
This paper highlights the challenges industry can face in SMS implementation and sustainment.
It also discusses SMS expectations, including developing a common and agreed upon purpose
for an SMS that truly encompasses the organization’s safety performance requirements.
Defining the purpose of the SMS and how it will relate to existing operational management
systems, enterprise risk management, and Board oversight are essential, as this sets the
foundation for successful rollout and sustainability. Organizations must clearly articulate the
system's value and objectives beyond paper-based compliance with regulations, ensuring that
all stakeholders understand its significance and relevance. This clarity helps align the
organization around a common goal, facilitating smoother integration with other existing
management frameworks.

1 “SMS Reconsidered,” Flight Safety Foundation, William Voss, May 17, 2012.

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II. Management Systems Implementation

To date, “safety management system” is the broadly accepted term for what has been
established across the aviation industry. But could the naming of this framework also be a part
of the problem? Should aviation organizations be moving beyond just considering “safety” in
isolation, to focus on management systems that can more fully meet their needs?
Effective implementation of any management system requires organizations to have a full
understanding of the system’s purpose and objectives, with clear expectations regarding the
significant changes this will bring. The International Civil Aviation Organization’s (ICAO) intent
has always been that SMS should be fully integrated with other, existing management systems
to provide an accurate picture of an organization’s overall safety risk, such that effective risk-
based decision-making could be adopted. 2 SMS was never intended as a “bolt-on” addition to
existing management systems or safety programs.
The introduction of SMS to the industry has been the culmination of an evolving set of
initiatives, including quality management and human factors (Exhibit 1). It could be argued that
this has not aided integration and possibly hindered the intent, by creating the perception that
each initiative was an additional element, rather than an interdependent component of a larger
composite “management system.”

Exhibit 1: The evolution of safety management in aviation

Origins of aviation SMS

The ICAO introduced SMS to the industry through Annex 19 and the Safety Management
Manual (Doc 9859) in 2013. These documents detailed much of the intent of SMS, but it was
down to the regulators of ICAO member states to ensure effective implementation and
oversight. Naturally, this has led to variances in the introduction of SMS from country to
country in terms of timing of implementation, the domains that are included, and oversight
stance.

2 IACO Doc 9859, 4th edition.

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Consequently, the integration and adoption of SMS globally has been inconsistent. Exacerbating
this (and an unintended consequence of having a standalone Annex for Safety) is that SMS is
seen in many organizations as a standalone system. This continues despite clear ICAO guidance
describing how SMS should be integrated with other management systems at the service
provider level.
As a result, industry implementation of SMS has not always realized the ICAO’s intent. When
the key question of “how well are you managing safety, and how do you know?” is posed to
organizations, few can explicitly articulate how they demonstrate effective control and
management of safety risk to the degree envisaged by the ICAO. This situation, and continual
references to “the SMS” as though it were a standalone solution to all ills, serves to highlight
the gap in the effective integration of ICAO SMS requirements into cohesive management
systems to date.

The intent of management systems

As discussed in our first paper, other industries, such as oil & gas, chose to create much broader
operating management systems that included safety and risk management as a core function.
They spent considerable time and effort in establishing a vision and purpose, building a guiding
coalition of senior leaders, and planning how the system would be designed, integrated,
implemented, and sustained.
This opportunity was not afforded to aviation, which had to focus on the building blocks
defined by regulatory mandates as these were released. There was a rush to assess
performance gaps and implement mandated aspects of the management system before
operational leaders or employees had had the opportunity to fully understand the intent of the
requirements. This left scant time to build sufficiently robust governance, management review,
and continuous improvement processes that would ensure sustainability and provide
anticipated benefits. And thus we have the situation we see today, where SMS is commonly
viewed as “bolt-on” requirement and activity, as opposed to being integrated with existing
management systems.
The descriptions on the next page are excerpts from various regulatory bodies and, when
considered collectively, address the main components required to deliver an effective
management system. The challenge lies in determining how all these components can be
integrated and applied in a cohesive manner – in the context of a busy commercial organization
like an airline – to achieve the desired benefits.

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 Safety Management Systems: Reflecting on Performance Challenges

Regulatory body Excerpt

The ICAO SMS description hints at “A proactive way to pursue the mitigation of safety risks and improve
going beyond the traditional view of safety performance. Safety management, effectively implemented, can
binary compliance and introduces lead to a documented, process-based approach to safety, as well as a
elements of safety performance and better understanding of safety-related interdependencies and
management system integration relationships” 3
The European Aviation Safety “Safety management seeks to proactively identify hazards and to
Agency (EASA) description breaks mitigate the related safety risks before they result in aviation accidents
the management system down and incidents. Safety management enables an organization to manage
further by bringing in prioritization, its activities in a more systematic and focused manner. When an
resource allocation, and achieving organization has a clear understanding of its role and contribution to
optimal outputs aviation safety, it can prioritize safety risks and more effectively manage
its resources and obtain optimal results” 4
The Federal Aviation Administration “SMS is the formal, top-down, organization-wide approach to managing
(FAA) description brings in further safety risk and assuring the effectiveness of safety risk controls. It
components such as assurance and includes systematic procedures, practices, and policies for the
ensuring that controls take into management of safety risk… SMS provides a means for a structured,
consideration the operating context repeatable, systematic approach to proactively identify hazards and
of the organization manage safety risk. By incorporating SMS, aviation organizations are
better able to proactively develop and implement mitigations that are
appropriate to their specific environment and operations” 5
The International Organization for ‘ISO management system standards (MSS) help organizations improve
Standardization (ISO) provides a their performance by specifying repeatable steps that organizations
more holistic view. Its definition of a consciously implement to achieve their goals and objectives, and to
management system introduces create an organizational culture that reflexively engages in a continuous
continuous improvement, cycle of self-evaluation, correction, and improvement of operations and
management commitment and processes through heightened employee awareness and management
leadership, and culture leadership and commitment” 6

The above excerpts outline the various components required for management systems. EASA
even defines and promotes an integrated management system approach in its regulations and
guidance, not even using SMS as a term. We believe that all the above miss one key ingredient,
however: the ability to visualize the intent of an integrated management system in simple
visual terms. An example of such a model, which we developed based on SMS assessment work
across a variety of aviation domains, is shown in Exhibit 2.
This holistic, ICAO-compliant model reflects the key foundations and enablers of an effective
management system. It comprises three main components: foundations, enablers, and culture.
Collectively, these generate an accurate risk picture to enable timely, risk-based decision-
making. Our experience has repeatedly shown us that “foundations” are pivotal to ensuring
that “enablers” can function effectively. Organizations that strive to ensure that these facets
are robust at the outset are likely to see more sustainable and beneficial outcomes.

3 What is safety management, Chapter 1.1 of Safety Management Implementation, International Civil Aviation Organization.
4 Safety Management System and Management System — the integrated approach, European Aviation Safety Agency.
5 What is a Safety Management System (SMS)? US Federal Aviation Administration.

6 The ISO model: agreed by experts, International Organization for Standardization.

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Furthermore, a high-performance organization can only be realized when a “culture” that

promotes accountability, transparency, and trust has been instilled. In so doing, each person
becomes empowered to take the sorts of small actions at scale that reduce deviations from
compliance and arrest practical drift. As a result, the workforce directly contributes to the
reduction of operational risk and improvements in business efficiencies and bottom-line profit.

Exhibit 2 : Overview of a holistic approach to SMS 7

7 Oliver Wyman Vector.

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III. SMS implementation challenges

Organizations intend the best outcomes in building their management systems, but as
described above, the aviation industry has been challenged in targeting what “good” really
looks like in terms of effective management systems that fully deliver the benefits envisaged by
the ICAO. Organizations typically follow a well-trodden path of producing the observable
artifacts required for acceptance by regulators, but this can lead to an approach to safety
performance that is “content-driven” as opposed to value-adding and “intent-driven.”
A holistic SMS, as shown above in Exhibit 2, will not only take into consideration practical
implementation requirements but also highlight key areas that, if developed correctly, can
improve an organization’s safety performance. Core components of such a model and how they
avoid or respond to key SMS challenges are shown in Exhibit 3.

Exhibit 3: Key components of a holistic SMS and avoided implementation challenges

Component Definition Avoids challenge of
Safety strategy • A safety strategy establishes an • Absence of a guiding safety strategy and goals, resulting
organization’s medium/long-term in a reactive approach
plan, articulating aspirations and • Limited commitment from management to implement
performance goals and defining a strategies that align safety with operational priorities
proactive approach to safety
• Misaligned, non-contextual safety objectives
management
Governance • Governance and organizational • Undisciplined and rudderless safety governance and
and structure structures are interconnected committee meetings and reporting
components that enable escalation, • Lack of explicit discussions on acceptable risk/risk
open dialogue, and decision-making tolerance
on key risks
• Meetings that are forums for sharing outcomes rather
• Collectively they create a system than discussing and challenging levels of exposure
that ensures operational resilience
• No measurable responsibilities for safety within
and a safety-centric culture
management roles
Leadership and • Establishing and sustaining core • Leadership attributes, actions, and decisions negatively
ownership management system functions influence safety culture
• Taking a stand, owning (not • Observable behaviors diverge from safety policy
delegating) safety performance and • Inconsistent or counterintuitive communications on
being deliberate about creating the safety issues
culture
• Unclear or overlapping roles for safety ownership
decision-making
Compliance • Integrated and systematic approach • Low employee competence and engagement with
control and ensuring operational activities compliance
assurance adhere to and meet the intent of • Compliance viewed as a series of unnecessary steps to
regulations, standards, and best be followed, with pathways sought to bypass
practices procedures
• Robust monitoring and review to • Overreliance on quality audit and assurance function to
provide assurance that the system is “demonstrate compliance”
working as intended
• Audit and assurance inputs and outputs that are not
integrated into broader organizational management
system activities

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Component Definition Avoids challenge of

Appropriate • The necessary human, financial, • Lack of clarity on adequate resources required to
resources physical, technological, and support safe operations
informational assets allocated to • Inability to justify or connect resource constraints to
effectively support a safe operation potential safety hazards
and continuously improve safety
• Mismatches in recruitment, retention, and optimization
performance
of human resources to meet operational demands
• Known equipment resource challenges go unaddressed
Competent and • The combination of knowledge, • Competence development programs not focused on
engaged skills, and attitudes to perform a management system approach and expectations or
employees role effectively human and organizational performance
• Engaged employees understand the • Limited or absent workplace engagement and coaching
expectations associated with their and mentoring programs
roles and are motivated to work • Low levels of communication and safety promotion
safely for themselves and others
Effective • Simple, accessible, intuitive system • Onerous reporting systems with poor user interfaces
reporting facilitating timely, accurate, and • Inconsistent feedback provided to employees
system responsive reporting of safety
• Absence of a common taxonomy and quality analytic
incidents, hazards, and concerns by
tools
all stakeholders
• Multiple locally stored and/or uncaptured verbal reports
Risk • Disciplined and structured approach • Fear of raising concerns and potential risks that may
management to identify, critically analyze, and impact/decrease on-time performance/production
integrity control risk, ensuring data created is • Reactive and subjective risk management approaches
accurate, reliable, and that rely on highly simplistic analytical tools
comprehensive
• Limited management of change and interface risk
• Operational risk management is management
integrated into ERM, and supported
• Known operational hazards not included in data, giving a
by corporate planning/budgeting
false sense of security
processes
Insightful data • Comprehensive and reliable data • Large volumes of data with limited ability to cleanse and
analytics analysis that delivers high-integrity filter to demonstrate an accurate risk picture
information, driving insight and • Inconsistent/missing taxonomies and tools for hazard
supporting risk-based decisions classification
• Absence of safety data strategy
• Lack of internal capability to utilize AI for data analysis
to support safety decisions
Culture • Culture is the product of the • Proactive promotion of culture that is not an
interactions and behaviors among intentional, standardized, or consistent process
individuals and groups based on • On-time performance that trumps safety, leading to
beliefs, assumptions, values, daily conflicts, fear of questioning practices/decisions
attitudes, and perceptions
• Employees who are not confident of fair treatment;
• Reflects the commitment to safety managers who mistake blame for accountability and
at all levels and is shaped by leaders, challenge the principles of just culture
policies, practices, and the shared
• Operational deviations that go unchallenged, leading to
beliefs of its people
procedural drift
• Lack of clear communication and demonstration of
safety values from leaders

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The common challenges we have observed during client engagements, involvement in

regulatory working groups, and across the wider industry indicate a need for evolution in the
practical application of management systems. Enhancements should focus on strengthening
foundations such as strategic intent, governance and leadership commitment, augmenting risk
management capabilities and tools, and ensuring adequate resources and competence are
provided to foster a proactive safety culture. Addressing these themes at scale would reflect an
industry-wide shift toward integrated, data-driven, and risk-based safety management
practices.
The transformation now needed in aviation involves moving from traditional, binary,
compliance-focused implementation and oversight to embracing a more strategic and holistic
approach. There has always been a commitment across the industry to conduct profitable
operations safely, recognizing their inherent risk. However, aviation safety programs are not
consistently connecting with leaders to demonstrate the day-to-day operational value of
management systems for safety in the absence of accidents or serious incidents. Equally, the
loop in providing an accurate and complete risk picture to decision-makers at all levels who
make planning and budgeting choices to support medium to long-term strategies is incomplete.
Recognizing the need to embrace transformational change, the industry’s goal should be to
change mindsets so that safety and risk management are viewed not simply as components of
regulatory compliance but as an opportunity to promote learning and enhance resilience across
operations. The reward for taking this route for aviation organizations is sustained safety
performance excellence and greater operational integrity and profitability.

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IV. What Comes Next?

We have seen a broad consensus that aviation safety management has become overly complex
and sight has been lost of its true purpose and benefits. There are numerous valuable academic
models and theories available, with practitioners using social media platforms to explore the
challenges and debate the issues. But this ongoing discussion risks becoming an echo chamber,
with insufficient emphasis on practical solutions and meaningful engagement with operational
stakeholders.
There is a pressing need to simplify the management system approach to safety and highlight
what a high-performing management system can actually do for organizations. In addition to
promoting enterprise risk management, there is the need for effective and efficient controls
that not only support safe outcomes but demonstrably improve operational efficiency – to the
good of the bottom line.
If the aviation industry fails to achieve this, the outlook for improvements in aviation system
safety remains uncertain at best. As Steve Jobs has said: “Simple can be harder than complex:
You have to work hard to get your thinking clean to make it simple. But it’s worth it in the end,
because once you get there, you can move mountains.”
Lastly, although we have highlighted here the important challenges aviation faces in
implementing and sustaining management systems, we can’t fail to mention that there are
notable bright spots where organizations have excelled. Our third paper in this series will look
at organizational best practices around SMS, together with a deeper dive into the key
components of a holistic management system model.

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AUTHORS
Jeff Fieldhouse Chris Drew Susie Scott
Senior Manager Director Director
[email protected] [email protected] [email protected]

Managing editor: Rebekah E. Bartlett

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