An Introduction to Safety Management System (SMS) Safety Policy Safety Risk Management Safety Promotion Safety Assurance

An Introduction to Safety Management System (SMS)

Safety PolicySafety Risk

Management

Safety Promotion

Safety Assurance

Outline

Fundamentals of Safety Safety Management System Components of SMS Legislation Summary

Concept of Safety Evolution of Safe Thinking Accident Causation Organizational Accident People, Context & Safety – SHEL Errors & Violations Organizational Culture Safety Investigation

Outline


Safety Stereotype Management Dilemma Need for Safety Management Strategies for Safety Management Imperative of Change Building Blocks – SMS Responsibilities of Managing Safety

Outline


Safety Policy Safety Risk Management Safety Promotion Safety Assurance

The Concept of Safety

Zero accidents or serious incidents — a view widely held by the travelling public;

Freedom from hazards, i.e. those factors which cause or are likely to cause harm;

Attitudes of employees of aviation organizations towards unsafe acts and conditions;

Error avoidance; and

Regulatory compliance.

What is Safety?

The state in which the possibility of harm to persons or of property damage is reduced to, and maintained at or below, an acceptable level through a continuing process of hazard identification and safety risk management.

Evolution of Safety Thinking

Traditional Approach:

Focus on outcomes (causes) Unsafe acts by operational personnel Assign blame/punish for failure to “perform safety” Address identified safety concern exclusively

Identifies:

WHAT? WHO? WHEN?

But not always disclose:

WHY? HOW?

Evolution of Safety Thinking

TECHNICAL FACTORS

HUMAN FACTORS

ORGANIZATIONAL FACTORS

1950s 1970s 1990s 2000

TO

DA

Y

Accident Causation

Management decision &

organizational

processes

Working conditions

Errors & violations

Regulations

Training

Technology

Organization Workplace People Defences Accident

Organizational Accident

Organizational processes

IdentifyImprove

Work place conditions

DefencesActive failures

Monitor

Cont

ain

ReinforceLatent conditions

People, Context & Safety

People & Safety


Understanding Human Performance


Understanding Human Performance


Processes & Outcomes

SHEL(L) Model

S

L

E

H L

S - Software

H - Hardware

E - Environment

L - Livewire

SHEL(L) Model

Important factors affecting human performance:

a) Physical factors

b) Physiological factors

c) Psychological factors

d) Psycho-social factors

SHEL(L) Model

Interfaces between different components of the aviation system:

a) Liveware-Hardware (L-H)

b) Liveware-Software (L-S)

c) Liveware-Liveware (L-L)

d) Liveware-Environment (L-E)

Errors & Violations

Error Deviation AmplificationDegradation / Breakdown

Incident / Accident

Flaps omitted

Unheeded warning

Checklist failure

Operational Errors – Investigation of major breakdowns

Errors & Violations

Error Deviation AmplificationNormal flight

Flaps omitted

Unheeded warning

Checklist failure

Safety Management – On almost every flight

3 Strategies to Control Operational Errors

1. Reduction strategies

a) Human-centred design;b) Ergonomic factors; andc) Training.

2. Capturing strategies

d) Checklists;e) Task cards; andf) Flight strips.

3. Tolerance strategies

g) system redundancies; and

h) structural inspections.

Errors vs. Violations

General types of violations:

1. Situational violations occur due to the particular factors that exist at the time, such as time pressure or high workload.

2. Routine violations are violations which have become “the normal way of doing business” within a workgroup.

3. Organization-induced violations, which can be viewed as an extension of routine violations. The full potential of the safety message that violations can convey can be understood only when considered against the demands imposed by the organization regarding the delivery of the services for which the organization was created.

Errors vs. Violations

Safety Space

Vio

lati

on

Sp

ace

Exc

epti

on

al

vio

lati

on

Sp

ace

Regulations

Technology

TrainingSystem’s production objectives

Incident

Accident

Understanding Violations

Minimum Maximum

High

Low

RISK

SYSTEM OUTPUT

Organizational Culture

National

Organizational

Professional


Organizational literature proposes three characterizations of organizations, depending on how they respond to information on hazards and safety information management:

a) pathological — hide the information;b) bureaucratic — restrain the information; andc) generative — value the information.


a) National culture differentiates the national characteristics and value systems of particular nations.

b) Professional culture differentiates the characteristics and value systems of particular professional groups

c) Organizational culture differentiates the characteristics and value systems of particular organizations


Poor Bureaucratic Positive

Information Hidden Ignored Sought

Messenger Shouted Tolerated Trained

Responsibilities Shirked Boxed Shared

Reports Discouraged Allowed Rewarded

Failures Covered up Merciful Scrutinized

New Ideas Crushed Problematic Welcomed

Resulting organization

Conflicted organization

Red tape organization Reliable organization

Effective Safety Reporting

Effective safety reporting builds upon certain basic attributes, such as:

a) Senior management places strong emphasis on hazard identification as part of the strategy for the management of safety;

b) Senior management and operational personnel hold a realistic view of the hazards faced by the organization’s service delivery activities;

c) Senior management defines the operational requirements needed to support active hazard reporting, ensures that key safety data are properly registered, demonstrates a receptive attitude to the reporting of hazards by operational personnel and implements measures to address the consequences of hazards;

Effective Safety Reporting

d) Senior management ensures that key safety data are properly safeguarded and promotes a system of checks and);

e) Personnel are formally trained to recognize and report hazards and understand the incidence and consequences of hazards in the activities supporting delivery of services; and

f) There is a low incidence of hazardous behaviour, and a safety ethic which discourages such behaviour.

Effective Safety Reporting – 5 basic traitsInformation

People are knowledgeable about the human, technical and organizational factors that determine the safety of

the system as a whole

WillingnessPeople are willing to report their errors and experiences

AccountabilityPeople are encouraged (and rewarded) for

providing essential safety-related information. However, there is a clear line

that differentiates between acceptable and unacceptable behaviour

FlexibilityPeople can adapt reporting when facing

unusual circumstances, shifting from the established mode to a direct mode

thus allowing information to quickly reach the appropriate decision-making

level

LearningPeople have the competence to draw conclusions from safety information systems and the will to implement

major reforms

Effective safety Reporting

Safety Investigation

to put losses behind; to reassert trust and faith in the system; to resume normal activities; and to fulfil political purposes.

Safety Investigation

Safety investigation for improved system reliability:

a) to learn about system vulnerability;b) to develop strategies for change; andc) to prioritize investment of safety resources.

Outline


Safety Stereotype Management Dilemma Need for Safety Management Strategies for Safety Management Imperative of Change Building Blocks – SMS Responsibilities of Managing Safety

Safety Stereotype

The safety stereotype:

safety first vs. safety is an organizational process Safety is not first priority in aviation safety is just organizational process

.

Dilemma of 2 P’s:

Production Protection

Management Dilemma

Management Dilemma

Protection Production

Management Levels

ResourcesResources

$$ PESO YEN

$$ PESO YEN

Management Dilemma

Protection

Production

Management Levels

Resources

Resources

$$ PESO YEN

$$ PESO YEN

Catastrophe

Management Dilemma

Protection

Production

Management Levels

Resources

Resources

$$ PESO YEN

$$ PESO YEN

Bankruptcy

Minor-major accident

Need for Safety Management

Major air disaster are rare Incidents occur more frequently Ignoring the major could lead to an

increase number of more serious accidents

Minor-major accident Economics of Safety


Accidents cost money Insurance can help but not all There are many uninsured cost Lost of confidence of the travelling

public

Minor-major accident Economics of Safety Publics perceived safety while traveling


Prerequisite for a sustainable aviation business

Strategies for Safety Management

System Design

Operational deployment Operational performance

Baseline performance

Regulations

TrainingTechnology

The practical drift

Source: Scott A. Snook

Reactive Proactive Predictive



Reactive method

The reactive method responds to events that have already happened,

such as incidents and accidents

Proactive method

The proactive method looks actively for the

identification of safety risks through the analysis of the

organization’s activities

Predictive method

The predictive method captures system

performance as it happens in real-time normal

operations to identify potential future problems


Hazards Predictive Proactive Reactive Reactive

Strategies – Levels of intervention and tools

FDADirect

observation systems

ASRSurvey Audits

ASRMOR

Accident and incident reports

Highly efficient Very efficient Efficient Insufficient

Safety management levels

Desirable management levels

High

High Middle Low

The management of change

Aircraft and Equipment are changing overtime Hazards that are by product of change Change can introduce new hazard Formal Process for the Management of change

Critically of system and activities Stability of systems and operational environment Past performance

Imperative of Change

The traditional safety paradigm relied on the accident/serious incident investigation process as its main safety intervention and method, and it was built upon three basic assumptions:

a) The aviation system performs most of the time as per design specifications (i.e. baseline performance);

b) Regulatory compliance guarantees system baseline performance and therefore ensures safety (compliance-based); and

c) Because regulatory compliance guarantees system baseline performance, minor, largely inconsequential deviations during routine operations (i.e. processes) do not matter, only major deviations leading to bad consequences (i.e. outcomes) matter (outcome oriented).


It is based on the notion of managing safety through process control, beyond the investigation of occurrences, and it builds upon three basic assumptions also:

a) The aviation system does not perform most of the time as per design specifications (i.e. operational performance leads to the practical drift);

b) Rather than relying on regulatory compliance exclusively, real-time performance of the system is constantly monitored (performance-based); and

c) Minor, inconsequential deviations during routine operations are constantly tracked and analysed (process oriented).


1. Senior Management’s commitment to the management of safety2. Effective safety reporting3. Continuous monitoring4. Investigation of safety occurrences5. Sharing safety lessons learned and best practices6. Integration of safety training for operational personnel7. Effective implementation of standard operating procedures (SOP’s)8. Continuous improvement of the overall level of safety

8 Building Blocks - SMS

The responsibilities for managing safety can be grouped into four generic and basic areas, as follows:

a) Definition of policies and procedures regarding safety. Policies and procedures are organizational mandates reflecting how senior management wants operations to be conducted.

b) Allocation of resources for safety management activities. Managing safety requires resources. The allocation of resources is a managerial function.

c) Adoption of best industry practices. The tradition of aviation regarding safety excellence has led to the continuous development of robust safety practices. Aviation has, in addition, a tradition regarding exchange of safety information through both institutional and informal channels.

4 Responsibilities of Managing Safety

d) Incorporation of regulations governing civil aviation safety. There will always be a need for a regulatory framework as the bedrock for safety management endeavours. In fact, sensible safety management can develop only from sensible regulations.

4 Responsibilities of Managing Safety

In summary, safety management:

a) includes the entire operation;b) focuses on processes, making a clear differentiation between

processes and outcomes;c) is data-driven;d) involves constant monitoring;e) is strictly documented;f) aims at gradual improvement as opposed to dramatic change; andg) is based on strategic planning as opposed to piecemeal initiatives.

Summary

The End

Questions & Answers

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An Introduction to Safety Management System (SMS) Safety Policy Safety Risk Management Safety Promotion Safety Assurance