Historical Research and the case for a Fifth Component of SMS

<p><strong>Abstract</strong></p> <p>Three tragic events from aviation history were examined using a Historical Research and Case Study Method. The events explored were the disasters of the Airship R101 (1930), the Space Shuttle Challenger (1986) and the Boeing 737 Max 8 (2018). From the research, several closely related commonalities, or themes, were discovered across the three events. In each case, fatal decisions were made by upper-level managers, who allowed non-safety related motivations to influence their decision making. Each case also involved employees who discovered safety concerns and reported those concerns within their organizations, only to have those alerts be ignored, downplayed, rationalized or overruled. Analysis of these themes lead to recommendations that are aimed at preventing the circumstances that surrounded these three events from ever evolving again. Specifically, a recommendation is made to add a fifth component to the FAA’s current Safety Management System.</p>