Introduction to the management of safety New ICAO Annex 19 Jean-Pierre ARNAUD R4.2 Rulemaking officer 27 June 2012

Introduction to the management of safety

New ICAO Annex 19

Jean-Pierre ARNAUD R4.2 Rulemaking officer27 June 2012

Introduction to safety management - 27 june 2012 2

ICAO definition of SMS

Safety Management System (SMS): a systematic approach to managing safety, including the necessary organizational structures, accountabilities, policies and procedures

It provides a systematic way to identify hazards and control risks while maintaining assurance that these risk controls are effective.

Did you understand?

..me neither!

Let’s try another way…


On the menu today…


Component n’2: Safety risk management


The Titanic case


14 April 1912

The largest steamer in the world…promoted as the “unsinkable”…sunk!

The court reported that the loss of the Titanic was due to collision with an iceberg, brought about by the excessive speed at which the ship was being navigated.

Weather and navigation conditionsCalm night, flat surface – no noise, no light reflect of wavesNo moonlight at all: no visibilityIn April icebergs remain a hazard when you navigate north and the probability to hit an iceberg is high.

1912 was reported to be a very cold year with numerous iceberg straying abnormally southerly.………………...role of observation, statistics and metrics...


Additional noticeable safety factors Applicability

Design: double bottom; built to remain afloat if as many of 4 of its watertight compartments were flooded; after the collision, 5 floodedManufacturing: One allegation is that, under great pressure, the shipyard resorted to using second-rate iron rivetsOperational rules: Titanic did not carry enough lifeboats to save all aboard

although it met British safety codes – out-dated, however the most advanced at that time

Certification and Operations + organizational factors:Inadequate emergency procedures:

Lifeboat n’1 departed with only 12 people instead of 40.Several lifeboats were unusable due to the configuration of the sinking

It was a maiden voyageNo real test of the ship in operations and no training in real conditionsNot enough experience (evacuation, size of the boat, configuration etc)

Navigation servicesTitanic received 6 messages on April 14 warning of the approaching ice field – all disregarded


Piling pressures…

The alleged root reasons why the captain persevered in his course, and maintained high speed, is probably to be found:

in competition with other transportation means The captain of the ship was allegedly invited to set a speed record for its landmark maiden journey between Southampton and NY in order to increase the profit of the investors;Therefore the ship navigated too northerly in order to save time.

in the desire of the public for quick passages rather than in the judgement of navigators (safety culture)

in the beliefs he had in the boat (« unsinkable » )Human factor - overconfidence


Titanic case

HazardCollision with iceberg

Probability and severityHigh if you navigate northerlyHigher with no moonlightVery high if you ignore the warning messages

Risk is the combination of hazard and probability of severity


Titanic case

How to mitigate the risk?Reduce speedIncrease vigilanceRe-enforce radio monitoringNavigate more southerly of CanadaTake timely effective management decision

This is called risk management:Identify hazard, evaluate the risk, assess whether it is acceptable, mitigate the risk if necessary, to reduce the risk to an acceptable levelThe Titanic case is clearly a failure in risk management as all information were available to avoid the accident.Risk management is a subset of safety management (component n’2)


This accident also highlights…

Just culture – (non) CriminalizationThe captain was cleared of blame

Safety cultureCaptain (retired for the night at 21h30 dispite the warning messages about icebergs)Crew team (no one questioned the captain’s decision)Senior management of the operator and manufacturer pushing for accelerating the assembling of the steamerShareholders (money, money, money…)

The need to have an effective decision-making management process in operations


What can we learn from this event?

This event is not out of date and the root causes are still of interests in the aviation domain:

Human factor, piling pressure from shareholders, safety culture, organizational and human factors…

Safety management applies to any domains:Nuclear, railways etc…even your private life…Rules, design, certification, manufacturing, operations, navigation services, infrastructure…

Safety management is not a novelty:Clinical approach started in the 90’sICAO started to adopt SARPs in 2003Accident investigation boards have been repeatedly highly recommended to implement it asap.


Safety risk management


Safety risk management

Key Words: Hazard, consequence, risk, mitigating factors, risk

management.

Challenges:Identify the relevant hazards

Reporting systems and all kinds of safety information will help;

Assess correctly the probability and severityCollection of data and sharing will help;

Address the appropriate mitigating factors;Effectively manage the safety of the operations;Exchange of information on safety data, safety hazards and risks between stakeholders.


Component n’3 is Safety Assurance


Paramount objective of the safety management

To reduce the accident rate per million flightsCurrently around 4 accident per million flights (next slide – source ICAO MTOW above 2250kg)


Which year would you prefer to travel?

First levelSecond level

Third levelFourth level

Fifth level

•…If you had this kind of indicators in your life….

•…you would start to manage your life differently…


Safety intelligence

With the advent of the computer, data serve as a comprehensive source of aviation safety information.

Technology explores all domains and brings us a huge amount of data for analysis

Equipment monitor and record everything, even satellites… Statistics is everywhere

Mandatory and voluntary incident and accident reporting system, helping in identifying hazards.

Predicting …the future… (proactive approach) by selecting the right metrics…. and then acting consequently…

19

Active failure versus latent failure

The accidents are just tips of the iceberg named “active failures”.

There is still a vast quantity of data from the bottom of the iceberg, called “latent failures” waiting for triggering factors in order to emerge.


Safety-related data intelligence and safety analysis highlights capabilities that assist organisations in:

•Identifying hazard and risks (systematically or using reporting systems, incidents, any safety-related events or reports, audits, safety studies, experience etc);•Collecting and analyzing all these data available;•Getting the trends and acting consequently…

Hamelre

the line of thoughts is not clear. Do you mean the proactive element?


Proactive approach

Each State or each service provider has to:Collect safety-related data and analyse them;Set up key safety indicators reflecting its activities;Define and target objectives;Monitor the system in place by evaluating the overall performance of the system;Improve or maintain its safety performance;Eventually allocate the most-effective resources to meet these objectives.

This is called the “proactive approach”.

In addition, the State will oversee the Safety Performance Indicators (SPIs) of the services providers and share data.

10/04/23 change via "view" > "header and footer" 21

High-level instances (main contributors in accident)

Runway safety related (incursions, excursion, ground collisions)

EX: reported accidents and serious incidents involving runway excursions has increased during the last decade

Loss of control in-flightControlled flight into terrainCollision in flight

Fatal Accidents per aircraft Category (2006-2010)

22%

19%

43%

1% 0%7%

8%

Balloon

Fixed w ing

Microlight

Glider

Other

Helicopter

Gyroplane

Fatal accidents by aircraft type (MTOM<2250kg)

0

10

20

30

40

50

60

70

80

Aeroplane Microlight Glider Motorglider Helicopter Gyroplane Balloon Other

a/c category

Fata

l acc

iden

ts

2006

2007

2008

2009

2010

Fatal accidents by aircraft type (MTOM<2250kg)

0

10

20

30

40

50

60

70

80

Aeroplane Microlight Glider Motorglider Helicopter Gyroplane Balloon Other

a/c category

Fata

l acc

iden

ts

2006

2007

2008

2009

2010


Instances of low-level safety metrics

StateDevelopment/absence of primary aviation legislation or operating regulationsLevel of regulatory compliance – Lack of Effective Implementation (LEI – USOAP ICAO indicator)Does the audit programme cover all activities?

State and organisationIncident rate or incidents reportedNumber of deviations to the SOPs (Standard Operating Procedures)

OrganisationMeasurement of safety culture in an organisation or open climate in an organisation for reportingMTBF for maintenance (Aircraft, ANS and Aerodrome)Dispatch or stabilized approaches (operations)…Deviations to the flight path or separation (Air Navigation Services)Bird strikes (Aerodrome)

The data will set you free….

“The goal is to transform data into information, and information into insight”

Ernest Greenwood

Introduction to safety management - 27 june 2012


Component n’3 is Safety Assurance


Challenges and key words for safety assuranceSafety assurance based on effective safety data-driven processes but not being entirely data-driven;Collecting information in an organized and standardized manner; sharing and protecting information;Setting the right Key Safety Indicators (moving from concept towards implementable / practical KSIs);Managing properly (safety trends and effective decision making);Collaboration between States and Service Providers (KSIs)Compliance with the rules remains a mustDevelop performance-based oversight and performance – based rulesEnhancement of regional agencies (RSOOs – oversight and RAIOs –Accident, incidents), eliminating duplication of efforts, fostering cooperation (sharing information - databases) and independency


Component n’4 is Safety Promotion


Safety promotion

Safety promotion based onInternal and external trainingCommunication and dissemination of safety information

•Train (initial and continuous) your staff, educate, inform, increase the level of safety awareness, promote your policy and your objective, communicate, instruct, share…

•Develop and maintain the level of “safety culture” among the States, the organisations or any stakeholders playing a role in safety•It includes senior management, front-line management, staff in the field, decision-makers etc

28

What is Safety culture?

• Safety culture is the set of enduring values and attitudes regarding safety issues, shared by every member at every level of an organization.

• Refers to the extent to which every individual of the organization is aware of the risks and unknown (?) hazards induced by their activities

•Objective: Raising and maintaining the level of awareness• In that sense, component n°4 of the safety management is the safety

awareness promotion

Introduction to safety management - 27 June 2012 28


Concorde and safety culture (1)

Concorde F-BTSC accident, 25 July 2000, France 109 casualties, a/c destroyed

Source: final investigation report, available at http://www.bea.aero/docspa/2000/f-sc000725a/htm/f-sc000725a.html

The French BEA concluded in 2002 that a wear strip of metal, fallen off from a DC-10 that took off 4 minutes earlier, had punctured a tire of the Concorde, sending shards of rubber into the fuel tanks, leading to flames pouring from its undercarriage and making the plane crashing into a hotel few kilometers away.

The strip was attached with rivets close to other previous existing holes (reverse of the engine) and was improperly attached

29

http://www.bea.aero/docspa/2000/f-sc000725a/htm/f-sc000725a.html



•Who could have thought that this 40cm long piece of metal was a killer?

•8 holes and rivets over 5 cm long

•Not even the mechanic

who did the repair…






DC10 reverse as found How it should be

•Holes too close•37 holes in total

•Correct spacing – 12 holes were only allowed



The engine cowl support was drilled with 37 holes whereas the installation of the strip required only 12.

Therefore the strip was attached with rivets close to other previous existing holes and was improperly attached, resulting in it falling onto the runway.

The mechanic (a metal sheet worker, not a certifying staff) used titanium, rather than aluminium (higher resistance), to construct a replacement piece (deviation to the maintenance repair as prescribed by the engine manufacturer).

The mechanic who did the repair and the certifying staff who released to service the aircraft were charged with negligence (just culture).

This part had been replaced during a C check 6 weeks before the accident took place.

3 weeks after the C check, the part detached again and was replaced by another part (the one fell off on 25 July 2000).

These signals should have alerted the maintenance organization that improper maintenance had been carried out and that the trouble shooting was poor. The organisation was charged with negligence.

34


Component n’4 is Safety Promotion


Component n’1 is:


Component n’1: Policies and ObjectivesResponsibilities, accountabilities and commitment, including identification of key safety personnelA legislative framework for the StateAn accident and incident investigation for the StateA mandatory and voluntary incident reporting system (State and service provider)Policies and resources to collect and analyse safety dataAn emergency response planning for the service providerA process to set-up objectives, policies, monitoring and maintaining…then train and communicate…Documentation (process, manual and procedures)The management of changesAn enforcement policy


About the reporting system…

It mustBe voluntary;Be anonymous;Identify the hazards and better understand the latent failuresShould not lead to any blaming except in the case of malicious act or gross negligence (this is called “just culture”)Be supported by a statement / commitment of the accountable manager (no blaming)

Just culture (definition): an atmosphere of trust in which people are encouraged for providing essential safety-related information, but in which they are also clear about where the line must be drawn between acceptable and unacceptable behavior.

•Report! And avoid the sinking…


Safety policies and objectives - component n’1

• Key words: Just culture

• Challenges:• Criminalization or lay off of staff• Protection of persons and data• Commitment of the personnel and effective implementation of

the policies• In particular middle and front-line management (leadership and

safety culture in the field play essential roles)• Safety vision

• Transparency and sharing• Effective implementation


Vocabulary

The safety management is called:

SSP (Sate Safety Programme) for the StateEASA has developed the EASPICAO has developed the GASP

SMS (Safety Management System) for the service provider.


Main objectives of the State Safety Programme

Ensure that a State has the minimum required regulatory framework in placeEnsure coordination and harmonization amongst the State‘s regulatory and administrative organizations in their respective safety risk management rolesFacilitate monitoring and measurement of the aggregate safety performance of the service providersCoordinate and continuously improve the State‘s safety management functionsProvides appropriate oversight functionsPromulgate and support effective implementation and interaction with service providers‘ SMSFacilitate data aggregationFacilitate information sharingPromote safety


What is ICAO Annex 19?

Safety Management


What is Annex 19 First Edition

Compilation of common existing safety management provisions from existing annexes into one single new annex:

Annex 1 — Personnel Licensing

Annex 6 — Operation of AircraftPart I — International Commercial Air Transport — AeroplanesPart II — International General Aviation — AeroplanesPart III — International Operations — Helicopters

Annex 8 — Airworthiness of Aircraft

Annex 11 — Air Traffic Services

Annex 13 — Aircraft Accident and Incident Investigation

Annex 14 — AerodromesVolume I — Aerodrome Design and Operations


Applicability (Service providers)

A) training services that are directly exposed to safety risks; B) operation and maintenance of aeroplanes and helicopters

involved in international commercial air transport; C) operation of aeroplanes and helicopters involved in international

general aviation, except aerial work; D) type design and manufacture of aircraft, engines, and

propellers; E) air navigation services; and F) operation of aerodromes.


Content of Annex 19

Five chapters, 2 appendices and 2 attachments:• Definitions• Applicability• State safety management responsibilities

• Appendix 1: State safety oversight system• Attachment A: Framework for a State Safety Programme (SSP)

• Safety Management System (Service providers)• Appendix 2: Framework for a safety management system (SMS)

• Safety data collection, analysis and exchange• Attachment B: Legal guidance for the protection of information from

safety data collection and processing systems


Status of Annex 19


Benefit of Annex 19

The consolidation of provisions from six different Annexes into a new draft Annex had been undertaken with the intent of improving implementation:

Enhancing the role of the State at a higher level (coordination between all domains and all stakeholders);Having a “legal” basis in one unique document;Developing harmonized standards that are applicable to several domains;Better identifying and developing the future needs;Having a dedicated ICAO panel, working on the next iterations (EC and EASA are members);Having a global vision through implementation.


Future needs or challenges

Better integration between the SSP and the oversight systemBetter and higher State policy –not only at CAA level (implementation, overall performance and coordination between all actors)

Collection, sharing and protection of data:Analysis and common formatting of safety data (standardisation)Identification of hazardJust culture (Criminalization)Better coordination between AIG and State, between States and Agencies

Development of an Emergency Response Plan by both the State and the service providerDevelopment of implementation guidance:

Effective and efficient safety indicatorsScalability

Training – safety cultureIndustry and State (ex: oversight inspectors)Communication between State and Service Providers

Moving from compliance towards performance


Benefit of integrated safety management

What’s being put forward is a vision of a community identifying hazard sharing data etc

The recent agreement signed off between EASA and Singapore illustrates this willingness.The role of Regional Agency and Regional investigation board is another example of cooperation and development.

EASA / EASP: common objectives – 27 States


This is not an all-cure system

It is not a revolution but an evolutionJust a clinical approach of better managing safetya kind of “modern” management of safety with the available technological tools

It is an additional layerTraditional compliance to the rules remains a must

Safety management builds on this fundamental because most of the incidents or accident are due to deviation to the SOPs

Make our processes and procedures more robustRaise our awareness – performance and safety culture

Develop an integrated safety system (complex environment – needed coordination).


How does it affect EASA?Establishment of an EASP (the global safety vision):

Identification of hazards and risks, safety performance indicators etcCoordination between all partners

Being more data-driven, collecting all safety info (E2, E6)Review of our processes and procedures, introducing the management of risks on top of “compliance to the rules”:

Certification of aircraft (C)Performance based oversight (Standardisation Inspection Annual Programme - SIAP) (S) – workshop next OctoberPerformance –based rules (R)Safety assurance (E)International cooperation and sharing (based on agreements) (E, R, C, S)Training and competence (EASA staff, States, stakeholders)Promotion of safety everywhere – safety cultureBetter managing our internal resources


Basic Safety Management Tool Kit

ICAO Annex 19Click here to access to the document

SMM edition 3 (ICAO doc 9859)Click here to access to the document

Rulemaking focal point within the Agency: [email protected]

A more detailed presentation on Annex 19 is here available (click here)

mailto:[email protected]

53

Advanced safety management tool kit

Noteworthy websites about Safety management in aviationhttp://flightsafety.org/current-safety-initiatives/corporate-flight-operational-quality-assurance-c-foqa.ICAO Flight Safety Information Exchange http://www.icao.int/fsix/ The Australian Civil Aviation Safety Authority web site at http://www.casa.gov.au/sms/index.htm including Advisory Circular 172-01(0) September 2005 Guidelines For Preparing A Safety Management System (SMS) at http://www.casa.gov.au/rules/1998casr/172/172c01.pdf, , The Transport Canada Civil Aviation web site at http://www.tc.gc.ca/civilaviation/systemsafety/pubs/menu.htm and The UK Civil Aviation Authority web site at http://www.caa.co.uk/default.aspx?catid=872&pagetype=90&pageid=9953 The Overseas Territories web site at http://www.airsafety.aero/safety_development/sms The IBAC web site at http://www.ibac.org. In addition, chapter 5 Evaluating the Operator’s SMS of the IS-BAO Internal Audit Manual may be helpful in the SMS development process.The NASA web site at http://www.nasa.gov.The FAA Safety Management System information pages at: http://www.faa.gov/about/initiatives/sms/specifics_by_aviation_industry_type/ and Risk Management Handbook at: www.faa.gov/library/manuals/aviation/media/FAA-H-8083-2.pdfThe International Helicopter Safety Team (IHST) SMS Toolkit at: http://ihst.rotor.com/Portals/54/2009_SMS_Toolkit_ed2_Final.pdf The European Strategic Safety Initiative (ESSI) at http://www.easa.europa.eu/essi/index.html FAA Advisory Circular 120-92 Introduction to Safety Management Systems for Air Operators at http://www.airweb.faa.gov/Regulatory_and_Guidance_Library/rgAdvisoryCircular.nsf/0/6485143d5ec81aae8625719b0055c9e5/$FILE/AC%20120-92.pdf, and FAA’s Flight Risk Assessment Tool at http://www.faa.gov/other_visit/aviation_industry/airline_operators/airline_safety/info/all_infos/media/2007/inFO07015.pdf. EASA website www.easa.europa.eu/sms/

Introduction to safety management - 27 june 2012

http://flightsafety.org/current-safety-initiatives/corporate-flight-operational-quality-assurance-c-foqa

http://www.icao.int/fsix/

http://www.casa.gov.au/sms/index.htm

http://www.casa.gov.au/rules/1998casr/172/172c01.pdf

Introduction to safety management - 27 June 2012 54

True or false?

Annex 19 is called “risk management”.SSP is created by Service ProvidersICAO facilitates safety management information sharing among Service Providers within the StateEASA oversees Service Providers’ Safety performanceRisk management means you can deviate to the rules if properly mitigating factors are in place All statements are false

Any comment or question, [email protected]

http://intranet/your-intranet-page

Documents

Introduction to the management of safety New ICAO Annex 19 Jean-Pierre ARNAUD R4.2 Rulemaking officer 27 June 2012