SAFETY MANAGEMENT EDGARS GINDRA 20.09.2007 LV CAA AOD

SAFETY SAFETY MANAGEMENTMANAGEMENT

EDGARS GINDRA EDGARS GINDRA 20.09.2007 LV CAA AOD20.09.2007 LV CAA AOD

20.09.2007 SMS LV CAA AOD20.09.2007 SMS LV CAA AOD 22

SMS SMS regulationregulation

Operation of aircraftOperation of aircraft Maintenance of aircraftMaintenance of aircraft Air traffic servicesAir traffic services AerodromesAerodromes

– Two audience groupsTwo audience groups StatesStates Service providersService providers

– Three distinct requirementsThree distinct requirements Safety Safety programmeprogramme SMSSMS Management accountabilityManagement accountability


The amendmentThe amendment 30 to ICAO 30 to ICAO Annex Annex 6 Part I6 Part I

3.2.1 States shall establish a safety 3.2.1 States shall establish a safety programmeprogramme in order to achieve an in order to achieve an acceptable level of safety in the operation acceptable level of safety in the operation of aircraftof aircraft..

3.2.4 3.2.4 From 1 January 2009, States shall From 1 January 2009, States shall require, as part of their safety programme, require, as part of their safety programme, that an operator implement a safety that an operator implement a safety management system acceptable to the management system acceptable to the State of the Operator that, as a minimum:State of the Operator that, as a minimum:



a)a) Identifies safety hazards;Identifies safety hazards;

b)b) Ensures that remedial action Ensures that remedial action necessarynecessary to maintain an acceptable level of safety to maintain an acceptable level of safety is implemented;is implemented;

c)c) Provides for continuous monitoring and Provides for continuous monitoring and regular assessment of the safety level regular assessment of the safety level achieved; andachieved; and

d)d) Aims to make continuousAims to make continuous improvement improvement to the overall level of safety. to the overall level of safety.



3.2.5 A safety management system shall 3.2.5 A safety management system shall clearly define lines of safety accountability clearly define lines of safety accountability throughout the operator’s organization, throughout the operator’s organization, including a direct accountability for safety including a direct accountability for safety on the part of senior management.on the part of senior management.

3.2.9 3.2.9 An operator shall establish a flight An operator shall establish a flight safety documents system, for the use and safety documents system, for the use and guidance of operational personnel, as part guidance of operational personnel, as part of its safety management system.of its safety management system.


What is a safety What is a safety programme?programme?

An integrated set of regulations and An integrated set of regulations and activities aimed at improving safety.activities aimed at improving safety.

States are responsible for establishing a States are responsible for establishing a safety programme:safety programme:– Safety regulationSafety regulation– Safety oversightSafety oversight– Accident/incident investigationAccident/incident investigation– Mandatory/voluntary reporting systemsMandatory/voluntary reporting systems– Safety data analysisSafety data analysis– Safety promotionSafety promotion


Clarifying the use of termsClarifying the use of terms Safety Safety oversightoversight – Is what the CAA performs – Is what the CAA performs

with regard to the operators/service providers with regard to the operators/service providers SMS.SMS.

Safety Safety assuranceassurance – Is what the – Is what the operators/service providers do with regard to operators/service providers do with regard to safety performance monitoring and safety performance monitoring and measurementmeasurement

Safety Safety auditaudit – Is what the CAA performs with – Is what the CAA performs with regard to its safety programme and the regard to its safety programme and the operators/service providers perform with regard operators/service providers perform with regard to the SMS.to the SMS.


Acceptable level of safety – Acceptable level of safety – a concepta concept

High level safety management goals High level safety management goals of an oversight authority (or a of an oversight authority (or a service provider)service provider)

Minimum safety performance that Minimum safety performance that service providers should achieve service providers should achieve while conducting their core business while conducting their core business functionsfunctions

A reference against which one can A reference against which one can measure safety performancemeasure safety performance


What is an SMS?What is an SMS?

A systematic approach to managing A systematic approach to managing safety, including the necessary safety, including the necessary organizational structures, accountabilities, organizational structures, accountabilities, policies and procedures.policies and procedures.

Providers are responsible for establishing Providers are responsible for establishing an SMS.an SMS.

States are responsible of the acceptance States are responsible of the acceptance and oversight for providers’ SMS.and oversight for providers’ SMS.


In summaryIn summary SSafety – afety – The state in which the risk of The state in which the risk of

harm to persons or property damage is harm to persons or property damage is

reduced to, and maintained at or below, reduced to, and maintained at or below,

an acceptable level through a continuing an acceptable level through a continuing

process of hazard identification and risk process of hazard identification and risk

management.management.

MManagementanagement – Allocation of resources. – Allocation of resources.

SSystemystem – Organized set of processes – Organized set of processes

and procedures.and procedures.


Safety programme – SMS Safety programme – SMS relationshipsrelationships

Statesafety

programme

Organization’ssafety

management system (SMS)

Organization’sproductionprocesses

Objective:Publicsafety

Objective:Manage and controlsafety risk

AcceptanceOversight

Objective:Achieve commercialgoals andcustomer satisfactionRisk management

Safety assurance

Protection Production

Oversight


ESARR ADVISORY MATERIALESARR ADVISORY MATERIAL

Annex 14 establishes that, as of 24 Annex 14 establishes that, as of 24 November 2005, certified November 2005, certified aerodromes shall have in operation a aerodromes shall have in operation a safety management system.safety management system.

ESARR 3 can be used by aerodrome ESARR 3 can be used by aerodrome operators to implement the SMS operators to implement the SMS required in the SARPs contained in required in the SARPs contained in ICAO Annex 14.ICAO Annex 14.



As a result, Safety Management As a result, Safety Management Systems (SMS) will have to be Systems (SMS) will have to be implemented, not only in the implemented, not only in the provision of ATM service associated provision of ATM service associated to aerodromes but also as regards to aerodromes but also as regards the complete operation of the the complete operation of the certified aerodromes at which those certified aerodromes at which those services are provided.services are provided.



ESARR 3 addresses the management ESARR 3 addresses the management of safety in any ATM service provided of safety in any ATM service provided without confining the SMS scope to without confining the SMS scope to ATS as Annex 11 wherever it appears ATS as Annex 11 wherever it appears necessary.necessary.


INTER-RELATIONSHIP BETWEEN INTER-RELATIONSHIP BETWEEN SMS IN ATM AND AERODROMESSMS IN ATM AND AERODROMES

A single organization is involved. A single organization is involved. That means that the organization will That means that the organization will have to implement: have to implement:

- SMS compliant with ESARR 3 (and SMS compliant with ESARR 3 (and ICAO Annex 11) in its ATM services;ICAO Annex 11) in its ATM services;

- SMS compliant with ICAO Annex 14 in SMS compliant with ICAO Annex 14 in its aerodrome operations.its aerodrome operations.



Two different organizations are Two different organizations are involved. Two basic alternatives may involved. Two basic alternatives may be considered:be considered:

- Two separate SMS. Each organization Two separate SMS. Each organization implements its own SMS (one implements its own SMS (one according to ESARR 3 to cover the according to ESARR 3 to cover the ATM services, and one according to ATM services, and one according to ICAO Annex 14 and specific national ICAO Annex 14 and specific national regulations.regulations.



- A - A common SMS. The ATM and common SMS. The ATM and aerodrome safety regulatoraerodrome safety regulator (s) could (s) could accept a set of arrangements accept a set of arrangements proposed by both organizations to proposed by both organizations to establish a “common SMS”.establish a “common SMS”.


Regulation (EC) 2096/2005Regulation (EC) 2096/2005laying down common requirements for the provision of air laying down common requirements for the provision of air

navigation servicesnavigation services

Article 3 Granting of certificatesArticle 3 Granting of certificatesShall comply with the specific additional Shall comply with the specific additional requirements set in Annex II 3. Safety of requirements set in Annex II 3. Safety of servicesservicesSafety management systemSafety management systemSafety requirements for risk assessment and Safety requirements for risk assessment and

mitigation with regard to changesmitigation with regard to changesSafety requirements for engineering and Safety requirements for engineering and

technical personnel undertaking operational technical personnel undertaking operational safety related tasks safety related tasks


SMS – Introductory conceptsSMS – Introductory concepts

The scope of SMS encompasses most of The scope of SMS encompasses most of the activities of the organization.the activities of the organization.

SMS must start from senior management, SMS must start from senior management, and safety must be considered at all levels and safety must be considered at all levels of the organization.of the organization.

SMS aims to make continuous SMS aims to make continuous improvement to the overall level of safety.improvement to the overall level of safety.

All aviation stakeholders have a role to All aviation stakeholders have a role to play in SMS.play in SMS.


Identifying aviation system Identifying aviation system stakeholdersstakeholders

It is important to identify aviation It is important to identify aviation system stakeholders to ensure that system stakeholders to ensure that stakeholders relevant to risk decision stakeholders relevant to risk decision are taken into consideration and are taken into consideration and contribute with their knowledge contribute with their knowledge before the decision is taken.before the decision is taken.


Aviation system stakeholdersAviation system stakeholders Aviation professionalsAviation professionals Aircraft owners and operatorsAircraft owners and operators ManufacturesManufactures Aviation regulatory authoritiesAviation regulatory authorities Industry trade associationsIndustry trade associations Regional air traffic service providersRegional air traffic service providers Professional associations and federationsProfessional associations and federations International aviation organizationsInternational aviation organizations Investigative agenciesInvestigative agencies The flying publicThe flying public


First fundamental – System First fundamental – System descriptiondescription

Most hazards are generated by Most hazards are generated by operational interactions among operational interactions among different system components. It is different system components. It is therefore essential to describe the therefore essential to describe the system in terms of its components as system in terms of its components as one of the first activities when one of the first activities when planning an SMS.planning an SMS.


System descriptionSystem description The system interactions with other systems in The system interactions with other systems in

the air transportation system.the air transportation system. The system functions.The system functions. Required Human Factors considerations of the Required Human Factors considerations of the

system operation.system operation. Hardware components of the system.Hardware components of the system. Software components of the system.Software components of the system. Related procedures that define guidance for the Related procedures that define guidance for the

operation and use of the system.operation and use of the system. Operational environment.Operational environment. Contracted and purchased products and Contracted and purchased products and

services.services.


Second fundamental – Gap Second fundamental – Gap analysisanalysis

An analysis of safety arrangements existing An analysis of safety arrangements existing within the organization.within the organization.

The organizational structures necessary for an The organizational structures necessary for an SMS may be found throughout an organization.SMS may be found throughout an organization.

Various activities of an SMS are probably already Various activities of an SMS are probably already in place and are working.in place and are working.

SMS development should build upon existing SMS development should build upon existing organizational structures.organizational structures.

Conduct the gap analysis against the components Conduct the gap analysis against the components and elements of the SMS.and elements of the SMS.

Once completed and documented the gap Once completed and documented the gap analysis forms the basis of the implementation analysis forms the basis of the implementation plan.plan.


Third fundamental – SMS and Third fundamental – SMS and QMSQMS

SMS differs from quality systems in that:SMS differs from quality systems in that: SMS focuses on the safety, human and organizational aspects of an SMS focuses on the safety, human and organizational aspects of an

operation (i.e., operation (i.e., safety satisfactionsafety satisfaction)) QMS focus the product (s) of an operation (i.e., QMS focus the product (s) of an operation (i.e., customer customer

satisfactionsatisfaction)) SMS results in the design and implementation of organizational SMS results in the design and implementation of organizational

processes and procedures to identify hazards and control/mitigate processes and procedures to identify hazards and control/mitigate risks in aviation operation.risks in aviation operation.

QMS techniques provide a structured process for ensuring that QMS techniques provide a structured process for ensuring that these processes and procedures achieve their intended objectives these processes and procedures achieve their intended objectives and, where they fall short, to improve them.and, where they fall short, to improve them.

SMS builds partly upon QMS principles.SMS builds partly upon QMS principles. SMS should include both safety and quality policies.SMS should include both safety and quality policies. The coverage of quality policies should be limited to quality in The coverage of quality policies should be limited to quality in

support of safety.support of safety. Safety objectives should receive primacy where conflicts are Safety objectives should receive primacy where conflicts are

identified.identified.


SMS SMS planningplanning

The components of SMSThe components of SMS Safety policy and objectivesSafety policy and objectives Safety risk managementSafety risk management Safety assuranceSafety assurance Safety promotionSafety promotion


The elements of SMSThe elements of SMS

1. 1. Safety policy and objectivesSafety policy and objectives1.1 1.1 Management commitment and Management commitment and responsibilityresponsibility1.2 1.2 Safety accountabilities of managersSafety accountabilities of managers1.3 1.3 Appointment of key safety personnelAppointment of key safety personnel1.4 1.4 SMS implementation planSMS implementation plan1.5 1.5 Coordination of the emergencyCoordination of the emergency response planresponse plan1.6 1.6 DocumentationDocumentation



2. 2. Safety risk managementSafety risk management

2.1 2.1 Hazard identification processHazard identification process

2.2 2.2 Risk assessment and mitigation Risk assessment and mitigation

processesprocesses

2.3 2.3 Internal safety investigationsInternal safety investigations



3. 3. Safety assuranceSafety assurance

3.1 3.1 Safety performance monitoringSafety performance monitoring

and measurementand measurement

3.2 3.2 The management of changeThe management of change

3.3 3.3 Continuous improvement of theContinuous improvement of the

safety systemsafety system



4. 4. Safety promotionSafety promotion

4.1 4.1 Training and educationTraining and education

4.2 4.2 Safety communicationSafety communication


Accountable executive

Flight safety officer

Maintenance safety officer

Safety Action Group (s)

(SAG)

Safety Review Board (SRB)

Director of operations

Director of maintenance

Other directorates

Safety services office

Safety responsibilitiesSafety responsibilities


Appointment of key safety Appointment of key safety personnelpersonnel

The safety office – Corporate functionsThe safety office – Corporate functions Advising senior management on safety Advising senior management on safety mattersmatters Assisting line managersAssisting line managers Overseeing hazard identification Overseeing hazard identification systemssystems

The safety manager – ResponsibilitiesThe safety manager – Responsibilities Responsible individual and focal point Responsible individual and focal point for the development and maintenance of for the development and maintenance of an effective safety management system an effective safety management system



The safety manager – FunctionsThe safety manager – Functions Manages the SMS implementation plan on Manages the SMS implementation plan on behalf of the accountable executivebehalf of the accountable executive Facilitates hazard identification and risk Facilitates hazard identification and risk analysis and managementanalysis and management Monitors corrective actions to ensure their Monitors corrective actions to ensure their accomplishmentaccomplishment Provides periodic reports on safety Provides periodic reports on safety performanceperformance Maintains safety documentationMaintains safety documentation Plans and organizes staff safety trainingPlans and organizes staff safety training Provides independent advice on safety matters Provides independent advice on safety matters



The Safety Review Board (SRB)The Safety Review Board (SRB) High level committee High level committee Strategic safety functionsStrategic safety functions

Chaired by the accountable executiveChaired by the accountable executive It may include the Board of DirectorsIt may include the Board of Directors Composed of heads of functional areasComposed of heads of functional areas

SRB monitors:SRB monitors: Safety performance against the safety policy Safety performance against the safety policy and objectivesand objectives Effectiveness of the SMS implementation planEffectiveness of the SMS implementation plan Effectiveness of the safety supervision of Effectiveness of the safety supervision of subcontracted operationssubcontracted operations



SRB ensures that appropriate resources SRB ensures that appropriate resources are allocated to achieve the established are allocated to achieve the established safety performancesafety performance

SRB gives strategic direction to the SAGSRB gives strategic direction to the SAG Safety Action Group (SAG):Safety Action Group (SAG):

Reports to SRB and takes Reports to SRB and takes strategic strategic direction from SRBdirection from SRB Members:Members:

Managers and supervisors from functional areasManagers and supervisors from functional areas Front-line personnelFront-line personnel



SAG:SAG: Oversees operational safety within the Oversees operational safety within the functional areafunctional area Resolves identified risksResolves identified risks Assesses the impact on safety of operational Assesses the impact on safety of operational changeschanges Implements corrective action plansImplements corrective action plans Ensures that corrective action is taken in a Ensures that corrective action is taken in a timely mannertimely manner Review the effectiveness of previous safety Review the effectiveness of previous safety recommendationsrecommendations Safety promotionSafety promotion


SMS implementation planSMS implementation plan ContentsContents

1.1. Safety policySafety policy2.2. Safety planning, objectives and goalsSafety planning, objectives and goals3.3. System descriptionSystem description4.4. Gap analysisGap analysis5.5. SMS componentsSMS components6.6. Safety roles and responsibilitiesSafety roles and responsibilities7.7. Safety reporting policySafety reporting policy8.8. Means of employee involvementMeans of employee involvement9.9. Safety communicationSafety communication10.10. Safety performance measurementSafety performance measurement11.11. Management review (of safety performance)Management review (of safety performance)


PHASED APPROACH TO SMS PHASED APPROACH TO SMS IMPLEMENTATIONIMPLEMENTATION

Phase 1 Phase 1 - - Provides a blueprint on how the SMS Provides a blueprint on how the SMS requirements requirements will will be met and be met and integrated integrated to the organization’s work activitiesto the organization’s work activities- - Provides an accountability framework for the Provides an accountability framework for the implementation of the SMS =implementation of the SMS =1) 1) Identify the accountable executive and the safety Identify the accountable executive and the safety accountabilities of managersaccountabilities of managers Elements 1.1 and 1.2Elements 1.1 and 1.22) 2) Identify the person or planning group within the Identify the person or planning group within the organization responsible for implementing the SMS organization responsible for implementing the SMS Element 1.3Element 1.33) 3) Describe the system (Air operator, ATC services provider, Describe the system (Air operator, ATC services provider, approved maintenance organization, certified aerodrome approved maintenance organization, certified aerodrome operator)operator)Element 1.4Element 1.4



Phase 2Phase 2 - - Puts into practice those elements of the SMS Puts into practice those elements of the SMS implementation plan that refer to:implementation plan that refer to:1) 1) Safety risk management componentSafety risk management component

Reactive processesReactive processes Investigation and analysisInvestigation and analysis Hazard identification and risk managementHazard identification and risk management

Elements 2.1, 2.2 and 2.3Elements 2.1, 2.2 and 2.32) 2) Training relevant to:Training relevant to:

The SMS implementation plan componentsThe SMS implementation plan components The safety risk management component (Reactive processes)The safety risk management component (Reactive processes)

Element 4.1 Element 4.1 3) 3) Documentation relevant to:Documentation relevant to:

The SMS implementation plan componentsThe SMS implementation plan components The safety risk management component (Reactive processes)The safety risk management component (Reactive processes)

Elements 1.4 and 1.6Elements 1.4 and 1.6



Phase 3Phase 3 - - Puts into practice those elements of the SMSPuts into practice those elements of the SMSimplementation plan that refer to:implementation plan that refer to:

1) 1) Safety risk management componentSafety risk management component Proactive and predictive processesProactive and predictive processes Investigation and analysisInvestigation and analysis Hazard identification and risk managementHazard identification and risk management

Elements 2.1, 2.2 and 2.3Elements 2.1, 2.2 and 2.32) 2) Training relevant to proactive and predictive Training relevant to proactive and predictive processesprocesses

Element 4.1Element 4.13) 3) Documentation relevant to proactive and predictive Documentation relevant to proactive and predictive processesprocesses

Elements 1.4 and 1.6Elements 1.4 and 1.6



Phase 4Phase 4 1) 1) Operational safety assuranceOperational safety assuranceDevelopment of Development of acceptable level (s) of safetyacceptable level (s) of safetyDevelopment of Development of safety indicators and targetssafety indicators and targetsSMS SMS continuous improvementcontinuous improvementElements 3.1, 3.2 and 3.3Elements 3.1, 3.2 and 3.32) 2) Training relevant to operational safety assuranceTraining relevant to operational safety assuranceElement 4.1Element 4.13) 3) Documentation relevant to operational safety Documentation relevant to operational safety assuranceassuranceElement 1.6Element 1.6


CAA - Four steps for SMS CAA - Four steps for SMS implementationimplementation

Step 1Step 1 State’s safety programmeState’s safety programme Conduct a gap analysis vis-à-vis the current Conduct a gap analysis vis-à-vis the current status in the State of the following:status in the State of the following:

Safety regulationSafety regulation Safety oversight (capabilities and planning)Safety oversight (capabilities and planning) Accident/incident investigationAccident/incident investigation Mandatory/voluntary/confidential reporting systemsMandatory/voluntary/confidential reporting systems Safety data analysisSafety data analysis Safety promotionSafety promotion

Develop the State safety programme around Develop the State safety programme around four components of the ICAO SMS frameworkfour components of the ICAO SMS framework


Safety analysis and safety studiesSafety analysis and safety studies

Analytical methods and tools:Analytical methods and tools:– Statistical analysis (to quantify Statistical analysis (to quantify

situations);situations);– Trend analysis (predictions may be Trend analysis (predictions may be

made, and to trigger “alarms”);made, and to trigger “alarms”);– Normative comparisons (to sample real Normative comparisons (to sample real

world experience under similar world experience under similar operating conditions);operating conditions);



– Simulation and testing (simulation in the Simulation and testing (simulation in the field under actual operating conditions);field under actual operating conditions);

– Expert panel ( to evaluate evidence of Expert panel ( to evaluate evidence of an unsafe condition and evaluating the an unsafe condition and evaluating the best course for corrective action);best course for corrective action);

– Cost-benefit analysis (the costs of Cost-benefit analysis (the costs of implementing the proposed measures implementing the proposed measures are weighed against the expected are weighed against the expected benefits over time). benefits over time).



Safety studies require data, appropriate Safety studies require data, appropriate analysis and effective communication.analysis and effective communication.

Safety studies conducted by State Safety studies conducted by State authorities, airlines, manufactures, and authorities, airlines, manufactures, and professional and industry associations.professional and industry associations.

Safety recommendations may arise from Safety recommendations may arise from the investigation of accidents and serious the investigation of accidents and serious incidents and also from safety studies.incidents and also from safety studies.

Safety studies have application to hazard Safety studies have application to hazard identification and analysis in flight identification and analysis in flight operations, maintenance, cabin safety, air operations, maintenance, cabin safety, air traffic control, airport operations, etc. traffic control, airport operations, etc.



Selecting study issuesSelecting study issues– Significant safety issues lists (SIL) based Significant safety issues lists (SIL) based

on the accident and incident record in on the accident and incident record in such areas as runway incursions, ground such areas as runway incursions, ground proximity warnings, TCAS, and proximity warnings, TCAS, and prioritized in terms of the risks to the prioritized in terms of the risks to the organization or the industry;organization or the industry;

– Support among participants and Support among participants and contributors.contributors.



SIL should be reviewed and updated SIL should be reviewed and updated annually, adding new high-risk issues and annually, adding new high-risk issues and deleting lesser-risk issues:deleting lesser-risk issues:– Frequency of GPWS warnings;Frequency of GPWS warnings;– Frequency of TCAS advisories;Frequency of TCAS advisories;– Runway incursions;Runway incursions;– Altitude deviations (busts);Altitude deviations (busts);– Call sign confusion;Call sign confusion;– UnUn--stabilised stabilised approaches; andapproaches; and– Air proximities (near misses) at selected Air proximities (near misses) at selected

aerodromes.aerodromes.



Step 2Step 2 Implementation SMS SARPsImplementation SMS SARPs Develop SMS regulations for Develop SMS regulations for operators/service providersoperators/service providers

Refer to the SMS components and elementsRefer to the SMS components and elements

Prepare guidance material for the Prepare guidance material for the implementation of SMSimplementation of SMS

Refer to ICAO Doc 9859Refer to ICAO Doc 9859

Operators/service providers may need Operators/service providers may need to use third party assistance to implement to use third party assistance to implement their SMStheir SMS



Step 3Step 3

CAA training programmeCAA training programme

Develop a training programme for Develop a training programme for CAA officers to:CAA officers to:

Provide knowledge of safety management Provide knowledge of safety management concepts and ICAO SARPs on safety concepts and ICAO SARPs on safety management in Annexes 6, 11 and 14, and management in Annexes 6, 11 and 14, and related guidance material; and related guidance material; and

Develop knowledge to certify and oversee the Develop knowledge to certify and oversee the implementation of key components of an SMS, implementation of key components of an SMS, in compliance with the national regulations and in compliance with the national regulations and relevant ICAO SARPsrelevant ICAO SARPs



Step 4Step 4

CAA enforcement policyCAA enforcement policy

Revision of enforcement policyRevision of enforcement policyOperators/service providers allowed to Operators/service providers allowed to

deal with deviations/minor violations deal with deviations/minor violations internally, within the context of the internally, within the context of the SMS, to the satisfaction of the authoritySMS, to the satisfaction of the authority

Gross negligence, willful deviation and Gross negligence, willful deviation and so forth to be dealt through established so forth to be dealt through established enforcement proceduresenforcement procedures


State safety programme – State safety programme – SMS harmonizationSMS harmonization

State’s safety programme State’s safety programme componentscomponents– Safety policy and objectivesSafety policy and objectives– Safety risk managementSafety risk management– Safety assuranceSafety assurance– Safety promotionSafety promotion


Safety policy and objectivesSafety policy and objectives

How the CAA will oversee the How the CAA will oversee the management of safety in the Statemanagement of safety in the State

A definition of CAA requirements, A definition of CAA requirements, responsibilities and accountabilities responsibilities and accountabilities regarding the State safety programme regarding the State safety programme

Similar to the equivalent SMS componentSimilar to the equivalent SMS component


Safety risk managementSafety risk management

Establishment of controls which govern Establishment of controls which govern how service providers SMS will operatehow service providers SMS will operate

Standards/requirements for service providers SMSStandards/requirements for service providers SMS Same processes as SMS Same processes as SMS

Hazard identification and risk Hazard identification and risk management management

Different outputsDifferent outputs

New/modified rules and/or New/modified rules and/or regulations (i.e., controls) which regulations (i.e., controls) which govern how service providers govern how service providers

SMS SMS operateoperate


Hazard identification processesHazard identification processes

Concept of safetyConcept of safety ConsiderConsider- - The elimination of accidents (and serious incidents) is The elimination of accidents (and serious incidents) is unachievable.unachievable.- - Failures will occur, in spite of the most accomplished Failures will occur, in spite of the most accomplished prevention efforts.prevention efforts.- - No human endeavour or human-made system can be free No human endeavour or human-made system can be free from risk and error.from risk and error.- - Controlled risk and error is acceptable in an inherently Controlled risk and error is acceptable in an inherently safe system.safe system.Safety Safety is the state in which the risk of harm to persons or is the state in which the risk of harm to persons or property damage is reduced to, and maintained at or property damage is reduced to, and maintained at or below, an below, an acceptable level acceptable level through a continuing process through a continuing process of of hazard identification hazard identification and and risk management.risk management.



The organizational accidentThe organizational accident From the Investigation Report identify:From the Investigation Report identify:a) a) Organizational processes Organizational processes that influenced that influenced the operation and which felt under the the operation and which felt under the responsibility of senior management (i.e. those responsibility of senior management (i.e. those accountable for the allocation of resources):accountable for the allocation of resources):- - Policy-making Policy-making - - PlanningPlanning- - CommunicationCommunication- - Allocation of resourcesAllocation of resources- - SupervisionSupervision


Organizational processes

Policy-makingPolicy-making PlanningPlanning Communication Communication Allocation of resourcesAllocation of resources SupervisionSupervision ……

Activities over which any organization has a Activities over which any organization has a reasonable degree of direct controlreasonable degree of direct control

Activities over which any organization has a Activities over which any organization has a reasonable degree of direct controlreasonable degree of direct control

The organizational accident


The organizational accidentThe organizational accidentOrganizational processes

Latentconditions

Inadequate hazard Inadequate hazard identification and risk identification and risk managementmanagement

Normalization of Normalization of deviancedeviance

Inadequate hazard Inadequate hazard identification and risk identification and risk managementmanagement

Normalization of Normalization of deviancedeviance

Conditions present in the system before the accident, Conditions present in the system before the accident, made evident by triggering factors. made evident by triggering factors.



b) b) Latent conditions Latent conditions in the system safety in the system safety which became precursors of active failures:which became precursors of active failures:- - Inadequate hazard identification and risk Inadequate hazard identification and risk managementmanagement- - Normalization of devianceNormalization of deviancec) c) Defences Defences which fail to perform due to which fail to perform due to weaknesses, inadequacies or plain absence:weaknesses, inadequacies or plain absence:- - TechnologyTechnology- - RegulationsRegulations- - Training and checkingTraining and checking



Latentconditions

Defences

Technology Technology RegulationsRegulationsTraining and checkingTraining and checking

Technology Technology RegulationsRegulationsTraining and checkingTraining and checking

Resources to protect against the risks that organizations Resources to protect against the risks that organizations involved in production activities must confront. involved in production activities must confront.



d) d) Workplace conditions Workplace conditions which may which may have influenced operational personnel have influenced operational personnel actions: actions: - - Workforce stabilityWorkforce stability- - Qualifications and experienceQualifications and experience- - MoraleMorale- - CredibilityCredibility- - ErgonomicsErgonomicse) e) Active failures, Active failures, including errors and including errors and violations.violations.



Workplaceconditions

Factors that directly influence the efficiency of people in Factors that directly influence the efficiency of people in aviation workplaces.aviation workplaces.

Workforce stabilityWorkforce stabilityQualifications and Qualifications and

experienceMoraleMoraleCredibilityCredibilityErgonomicsErgonomics……

Workforce stabilityWorkforce stabilityQualifications and Qualifications and

experienceMoraleMoraleCredibilityCredibilityErgonomicsErgonomics……



Workplaceconditions

Activefailures

Actions or inactions by people (pilots, controllers, Actions or inactions by people (pilots, controllers, maintenance engineers, aerodrome staff, etc.) that maintenance engineers, aerodrome staff, etc.) that have an immediate adverse effect. have an immediate adverse effect.

ErrorsErrors ViolationsViolations ErrorsErrors ViolationsViolations



Latentconditions

Workplaceconditions

DefencesActive

failures

Organizational processes

Latentconditions

Workplaceconditions

DefencesActive

failures

ImproveImprove IdentifyIdentifyMonitorMonitor

Con

tain

Con

tain

Reinforce

Reinforce



Two definitionsTwo definitionsHazard – Condition, object or activity Hazard – Condition, object or activity with the potential with the potential of causing injuries to personnel, damage to equipment or of causing injuries to personnel, damage to equipment or structures, loss of material, or reduction of ability to structures, loss of material, or reduction of ability to perform a prescribed function.perform a prescribed function.Risk – The chance of a loss or injury, Risk – The chance of a loss or injury, measured in measured in terms of severity and probability. The chance that terms of severity and probability. The chance that something is going to happen, and the consequences if it something is going to happen, and the consequences if it does.does. Example Example A wind of 15 knots blowing directly across the runway is a A wind of 15 knots blowing directly across the runway is a hazard. hazard. The possibility that the pilot may not be able to control the The possibility that the pilot may not be able to control the aircraft during take-off or landing, resulting in an accident, aircraft during take-off or landing, resulting in an accident, is one is one risk.risk.



First fundamental – Understanding hazardsFirst fundamental – Understanding hazards - - Natural tendency to describe the hazards Natural tendency to describe the hazards as an outcome (“Runway incursion” vs. as an outcome (“Runway incursion” vs. “Unclear aerodrome signage” “Unclear aerodrome signage” - - Stating hazards as outcomes disguises Stating hazards as outcomes disguises their nature and interferes with identifying their nature and interferes with identifying other important outcomesother important outcomes- - However, well-named hazards allows to However, well-named hazards allows to infer the sources or mechanisms and loss infer the sources or mechanisms and loss outcomeoutcome (s)(s)



Examples of hazardsExamples of hazards For Operator (Flight crew):For Operator (Flight crew):- Unfamiliar phraseology- Unfamiliar phraseology- ATC procedures- ATC procedures- Similar call signs- Similar call signs- Terrain- Terrain- Flight diversions- Flight diversions- System malfunctions- System malfunctions- Unfamiliar airports- Unfamiliar airports- Heavy traffic- Heavy traffic- Missed approaches- Missed approaches- Weather - Weather - Automation events- Automation events


Hazard identification processesHazard identification processes Second fundamental – Hazard identificationSecond fundamental – Hazard identification

The scope for hazards in aviation is wide, and may be related to:The scope for hazards in aviation is wide, and may be related to:

- - Design factors, including equipment and task design.Design factors, including equipment and task design.- - Procedures and operating practices, including documentation and Procedures and operating practices, including documentation and checklists.checklists.- - Communications, including means, terminology and language.Communications, including means, terminology and language.- - Organizational factors, such as company policies for recruitment, training, Organizational factors, such as company policies for recruitment, training, remuneration and allocation of resources.remuneration and allocation of resources.- - Work environment factors, such as ambient noise and vibration, Work environment factors, such as ambient noise and vibration, temperature, lighting and protective equipment and clothing.temperature, lighting and protective equipment and clothing.- - Regulatory factors, including the applicability and enforceability of Regulatory factors, including the applicability and enforceability of regulations; certification of equipment, personnel and procedures; and the regulations; certification of equipment, personnel and procedures; and the adequacy of oversight.adequacy of oversight.- - Defences, including detection and warning systems and the extent to Defences, including detection and warning systems and the extent to which the equipment is resilient against errors and failures.which the equipment is resilient against errors and failures.- - Human performance, including medical conditions and physical Human performance, including medical conditions and physical limitations.limitations.



Third fundamental – Hazard analysisThird fundamental – Hazard analysis

ABCABC of hazard analysis of hazard analysis

AA – State the generic hazard (hazard statement)– State the generic hazard (hazard statement) Airport constructionAirport construction

B – Identify specific components of the hazardB – Identify specific components of the hazard Construction equipmentConstruction equipment Closed taxiwaysClosed taxiways

C – Naturally leading to specific riskC – Naturally leading to specific risk (s)(s) Aircraft colliding with construction Aircraft colliding with construction

equipmentequipment Aircraft taking wrong taxiwayAircraft taking wrong taxiway



At the intersection of protection and productionAt the intersection of protection and production– The acronym The acronym ALARP ALARP is used to describe a safety risk which is used to describe a safety risk which

has been reduced to a level that is has been reduced to a level that is as low as reasonably as low as reasonably practicable.practicable.

– In determining what is In determining what is reasonably practicable reasonably practicable consideration consideration is given to both the technical feasibility and the cost of further is given to both the technical feasibility and the cost of further reducing the safety risk.reducing the safety risk.

– This includes a This includes a cost/benefit studycost/benefit study Direct costsDirect costs

– The obvious costs, which are easily determined. The high costs The obvious costs, which are easily determined. The high costs of exposure of hazards can be reduced by insurance coverage.of exposure of hazards can be reduced by insurance coverage.

Indirect costsIndirect costs– The uninsured costs. An understanding of these uninsured The uninsured costs. An understanding of these uninsured

costs (or indirect costs) is fundamental to understanding the costs (or indirect costs) is fundamental to understanding the economics of safetyeconomics of safety


The management dilemmaThe management dilemma

ProductionProtectionProtection

ResourcesResourcesManagement levels



Management levels

Production

ProtectionProtection

Resources

Resources

Catastrophe



Management levels

Production

ProtectionProtection

Bankruptcy

Resources

Resources


Safety spaceSafety space

ProductionProduction

Prot

ectio

nPr

otec

tion

BankruptcyBankruptcy

CatastropheCatastropheMaximum resistance space

Maximum resistance space

Source: James Reason


Safety management – The response to Safety management – The response to the dilemmathe dilemma

Safety issues are a byproduct of activities Safety issues are a byproduct of activities related to related to production/services deliveryproduction/services delivery. .

An analysis of an organization's resources and An analysis of an organization's resources and goals allows for a balanced and realistic goals allows for a balanced and realistic allocation of resources between allocation of resources between protection protection and production goaland production goalss, which supports the , which supports the needs of the organization.needs of the organization.

The product/service provided by any aviation The product/service provided by any aviation organization must be delivered safely (i.e. organization must be delivered safely (i.e.

protecting users and stakeholders).protecting users and stakeholders).



Fourth fundamental – Documentation of hazardsFourth fundamental – Documentation of hazards

Appropriate documentation management:Appropriate documentation management:

– A formal procedure to translate operational safety data A formal procedure to translate operational safety data into hazard-related information.into hazard-related information.

– The “safety library” of an organization.The “safety library” of an organization.– The need for standardization – facilitating tracking and The need for standardization – facilitating tracking and

analysis of hazards by common:analysis of hazards by common: DefinitionsDefinitions UnderstandingUnderstanding ValidationValidation ReportingReporting MeasurementMeasurement ManagementManagement


Risk managementRisk management

First fundamental – Risk managementFirst fundamental – Risk management

The identification, analysis and elimination The identification, analysis and elimination (and/or mitigation to an acceptable level) of those (and/or mitigation to an acceptable level) of those hazards, as well as the subsequent risks that hazards, as well as the subsequent risks that threaten the viability of an organization.threaten the viability of an organization.

Risk management facilitates the balancing act Risk management facilitates the balancing act between assessed risks and viable risk mitigation. between assessed risks and viable risk mitigation. Risk management is an integral component of Risk management is an integral component of safety managementsafety management. . It involves a logical process It involves a logical process of objective analysis, particularly in the of objective analysis, particularly in the evaluation of the risks.evaluation of the risks.


Assess and prioritize risks

Develop control and mitigation strategies

Inform person(s)

responsible for implementing

strategies

Reactive method

ASRMORIncident reportsAccident reports

Proactive method

ASRSurveysAudits

Predictive method

FDADirect observation systems

Assignresponsibilities

Implement strategies

Re-evaluate strategies

and processes

HA

ZAR

DS

HA

ZAR

DS

HA

ZAR

DS S

AFETY

LIBRARY

Safety managementinformation

Trend analysis

Safety bulletins

Report distribution

Seminars and workshops

METHOD IDENTIFICATION MANAGEMENT INFORMATIONDOCUMENTATION

Feedback

Hazard information management at a Hazard information management at a glanceglance


Risk managementRisk management

Second fundamental – Risk probabilitySecond fundamental – Risk probability

DefinitionDefinition (s)(s) Probability – Probability – The chance that a situation of danger The chance that a situation of danger might occur.might occur.

Questions Questions for assessing the probability of an occurrence:for assessing the probability of an occurrence: Is there a history of occurrences like the one being Is there a history of occurrences like the one being assessed, or is the occurrence an isolated event?assessed, or is the occurrence an isolated event? What other equipment, or similar type components, What other equipment, or similar type components, might have similar defects?might have similar defects? What number of operating or maintenance personnel What number of operating or maintenance personnel must follow the proceduremust follow the procedure (s) in question?(s) in question? How frequently is the equipment or procedure under How frequently is the equipment or procedure under assessment used?assessment used?


Second fundamental – Risk probabilitySecond fundamental – Risk probabilityProbability of occurrenceProbability of occurrence

Qualitative Qualitative definitiondefinition MeaningMeaning ValueValue

FrequentFrequent Likely to occur many times (has occurred frequently)Likely to occur many times (has occurred frequently) 55

OccasionalOccasional Likely to occur some times (has occurred infrequently)Likely to occur some times (has occurred infrequently) 44

RemoteRemote Unlikely, but possible to occur (has occurred rarely)Unlikely, but possible to occur (has occurred rarely) 33

ImprobableImprobable Very unlikely to occur (not known to have occurred)Very unlikely to occur (not known to have occurred) 22

ExtremelyExtremely improbableimprobable Almost inconceivable that the event will occurAlmost inconceivable that the event will occur 11


Risk managementRisk management Third fundamental – Risk severityThird fundamental – Risk severity

DefinitionDefinition (s)(s) Severity – Severity – The possible consequencesThe possible consequences of a situation of danger, of a situation of danger, taking as reference the taking as reference the worst foreseeable situation.worst foreseeable situation.

Define the severity in terms of:Define the severity in terms of:

PropertyProperty HealthHealth FinanceFinance LiabilityLiability PeoplePeople EnvironmentEnvironment ImageImage Public confidence Public confidence


Risk managementRisk managementQuestions Questions for assessing the severity of an occurrencefor assessing the severity of an occurrence::

How many How many lives are at risk?lives are at risk?– EmployeesEmployees– PassengersPassengers– BystandersBystanders– General publicGeneral public

What is the What is the environmental impact? environmental impact? – Spill of fuel or other hazardous productSpill of fuel or other hazardous product– Physical disruption of natural habitatPhysical disruption of natural habitat

What is the severity of the What is the severity of the property of financial damage?property of financial damage?– Direct operator property lossDirect operator property loss– Damage to aviation infrastructureDamage to aviation infrastructure– Third party damageThird party damage– Financial impact and economic impact for the StateFinancial impact and economic impact for the State

Are there Are there organizational, management or regulatory implications organizational, management or regulatory implications that might generate larger threats to public safety?that might generate larger threats to public safety? What are the likely What are the likely political implications political implications and/or and/or media interest?media interest?


Third fundamental – Risk severityThird fundamental – Risk severitySeverity of occurrencesSeverity of occurrences

Aviation Aviation definitiondefinition MeaningMeaning ValueValue

CatastrophicCatastrophic Equipment destroyedEquipment destroyed Multiple deathsMultiple deaths AA

HazardousHazardous

A large reduction in safety margins, physical distress or a A large reduction in safety margins, physical distress or a workload such that the operators cannot be relied upon to workload such that the operators cannot be relied upon to perform their tasks accurately or completely. perform their tasks accurately or completely.

Serious injury or death to a number of people. Serious injury or death to a number of people. Major equipment damageMajor equipment damage

BB

MajorMajor

A significant reduction in safety margins, a reduction in the ability A significant reduction in safety margins, a reduction in the ability of the operators to cope with adverse operating conditions as a of the operators to cope with adverse operating conditions as a result of increase in workload, or as a result of conditions result of increase in workload, or as a result of conditions impairing their efficiency. impairing their efficiency.

Serious incident. Serious incident. Injury to persons.Injury to persons.

CC

MinorMinor

Nuisance. Nuisance. Operating limitations. Operating limitations. Use of emergency procedures. Use of emergency procedures. Minor incident.Minor incident.

DD

NegligibleNegligible Little consequencesLittle consequences EE


Fourth fundamental – Risk assessmentFourth fundamental – Risk assessment

Risk probabilityRisk probability

Risk severityRisk severity

CatastrophicCatastrophic

AA

HazardousHazardous

BB

MajorMajor

CC

MinorMinor

DD

NegligibleNegligible

EE

5 – Frequent 5 – Frequent 5A5A 5B5B 5C5C 5D5D 5E5E

4 – Occasional4 – Occasional 4A4A 4B4B 4C4C 4D4D 4E4E

3 – Remote3 – Remote 3A3A 3B3B 3C3C 3D3D 3E3E

2 – Improbable2 – Improbable 2A2A 2B2B 2C2C 2D2D 2E2E

1 – Extremely 1 – Extremely improbableimprobable

1A1A 1B1B 1C1C 1D1D 1E1E


Fourth fundamental – Risk tolerabilityFourth fundamental – Risk tolerability

Assessment risk indexAssessment risk index Suggested criteriaSuggested criteria

5A, 5B, 5C, 4A, 4B, 3A5A, 5B, 5C, 4A, 4B, 3A Unacceptable under the existing Unacceptable under the existing circumstancescircumstances

5D5D,5E, ,5E, 4C,4C, 3B, 3C, 2A, 3B, 3C, 2A, 2B2B

Risk control/mitigation requires Risk control/mitigation requires management decisionmanagement decision

4D,4D, 4E, 3D, 2C, 1A, 1B4E, 3D, 2C, 1A, 1B Acceptable afterAcceptable afterreview of the operationreview of the operation

3E, 2D, 2E, 1C, 1D, 1E3E, 2D, 2E, 1C, 1D, 1E AcceptableAcceptable


Risk assessment at a glanceRisk assessment at a glance

Evaluate the seriousness of the risk(s) occurring

YESAccept the risk(s)

NOTake action to reduce the risk(s) to an

acceptable level

Identify the hazards to equipment, property, personnel or the organization.

HAZARD HAZARD IDENTIFICATIONIDENTIFICATION

RISK ASSESSMENTRISK ASSESSMENTProbabilityProbability

RISK ASSESSMENTRISK ASSESSMENTSeveritySeverity

RISK ASSESSMENTRISK ASSESSMENTTolerabilityTolerability

RISK CONTROL/MITIGATIONRISK CONTROL/MITIGATION

Identify the risk(s) and assess the chances of it (them) occurring?

Is (are) the consequent risk(s) acceptable and withinthe organization’s safety performance criteria?


Risk managementRisk management Fifth fundamental- Risk control/mitigationFifth fundamental- Risk control/mitigation

DefinitionDefinition (s)(s) Mitigation – Mitigation – Measures to eliminate the potential hazard or to reduce the risk Measures to eliminate the potential hazard or to reduce the risk probability or severity.probability or severity.

– Risk mitigation = Risk controlRisk mitigation = Risk control

StrategiesStrategies Avoidance – Avoidance – The operation or activity is cancelled because risks exceed the The operation or activity is cancelled because risks exceed the benefits of continuing the operation or activity.benefits of continuing the operation or activity.((Operations into an aerodrome surrounded by complex geography and without the Operations into an aerodrome surrounded by complex geography and without the necessary aids are cancelled.)necessary aids are cancelled.) Reduction – Reduction – The frequency of the operation or activity is reduced, or action is The frequency of the operation or activity is reduced, or action is taken to reduce the magnitude of the consequences of the accepted risks.taken to reduce the magnitude of the consequences of the accepted risks.((Operations into an aerodrome surrounded by complex geography and without the Operations into an aerodrome surrounded by complex geography and without the necessary aids are continued based upon the availability of specific aids and necessary aids are continued based upon the availability of specific aids and application of specific procedures.)application of specific procedures.) Segregation of exposure – Segregation of exposure – Action is taken to isolate the effects of risks or build-Action is taken to isolate the effects of risks or build-in redundancy to protect against it, i.e., reduce the severity of risk.in redundancy to protect against it, i.e., reduce the severity of risk.((Operations into an aerodrome surrounded by complex geography are limited to day-Operations into an aerodrome surrounded by complex geography are limited to day-time, visual conditions.)time, visual conditions.)(Non RVSM equipped aircraft not allowed to operate into RVSM airspace.(Non RVSM equipped aircraft not allowed to operate into RVSM airspace.


Risk managementRisk management Risk mitigation – Defences Risk mitigation – Defences (Technology, (Technology,

Training, Regulations)Training, Regulations)

As part of the risk mitigation, determine:As part of the risk mitigation, determine: Do defences to protect against such riskDo defences to protect against such risk (s) (s) exist?exist? Do defences function as intended?Do defences function as intended? Are the defences practical for use under actual Are the defences practical for use under actual working conditions?working conditions? Is staff involved aware of the risks and the Is staff involved aware of the risks and the defences in place?defences in place? Are additional risk mitigation measures Are additional risk mitigation measures required?required?


Risk mitigation at a glanceRisk mitigation at a glance

Does the mitigation address the hazard?

Does it address the risk (s)?

Is it appropriate? Is it effective?

Assessment of the defences within

the safety system

R RR R

Accepting the mitigation of

the risk

H H H H

Hazard identificationand

risk management

Control and mitigation

of the risk (s)

Is additional or

mitigation warranted?different

EACH HAZARD

Regulations

Training

Technology

Do the mitigationstrategies generateadditional risk (s)

EACH RISK

ALARP

Intolerable region

Acceptable region

Tolerable region


Risk management process at a glance

Feedback andrecord the

hazardidentification

and assessmentand/or riskmitigation

Identify hazards and assess risks

Define the level ofprobability

Is the risk level acceptable?

Define the level ofseverity

A safety concern is perceived

Define the levelof risk

No

Yes

Yes

Can the risk be mitigated?

Take action andcontinue the

operation


operation

No


operationYes

Can the residual riskbe accepted (If any)?

Can the risk be eliminated?

Yes

Cancel theoperationNo


Risk control/mitigation logRisk control/mitigation logRisk

reference Generic hazard Risk(s) description Current measures

to reduce risk(s) and risk index

Further actions to reduce risk(s) and resulting risk index Responsibility

Risk index:Risk tolerability:

Risk index:Risk tolerability:


Risk management considerations Risk management considerations for State Administrationsfor State Administrations

Policy development through to the Policy development through to the “go/no-go”“go/no-go” decisions:decisions:– PolicyPolicy. To what extent should a State . To what extent should a State

accept the certification paperwork of accept the certification paperwork of another State?another State?

– Regulatory changeRegulatory change. From the many . From the many (often-conflicting) recommendations (often-conflicting) recommendations made for regulatory change, how are made for regulatory change, how are decisions made?decisions made?



Situations when risk management Situations when risk management should be applied:should be applied:– Start-up or rapidly expanding Start-up or rapidly expanding

companies;companies;– Corporate mergers;Corporate mergers;– Companies facing bankruptcy or other Companies facing bankruptcy or other

financial difficulties;financial difficulties;– companies facing serious companies facing serious labour-labour-

management difficulties;management difficulties;



– Introduction of major new equipment by Introduction of major new equipment by an operator;an operator;

– Certification of a new aircraft type, new Certification of a new aircraft type, new airport, etc.;airport, etc.;

– Introduction of new communication, Introduction of new communication, navigation or surveillance equipmentnavigation or surveillance equipment and procedures; andand procedures; and

– Significant change to air regulations or Significant change to air regulations or other laws potentially impacting on other laws potentially impacting on aviation safety.aviation safety.



– Priority settingPriority setting. How are decisions made for . How are decisions made for determining those areas of safety warranting determining those areas of safety warranting emphasis during safety oversight audits?emphasis during safety oversight audits?

– Operational managementOperational management. How are decisions . How are decisions made when insufficient resources are available made when insufficient resources are available to carry out all planned activities?to carry out all planned activities?

– Operational inspectionsOperational inspections. At the front line, how . At the front line, how are decisions made when critical errors are are decisions made when critical errors are discovered of normal working hours?discovered of normal working hours?



Risk management by State Risk management by State administrations will be affected by such administrations will be affected by such factors as:factors as:– Time available to make the decision Time available to make the decision

(grounding an aircraft, revoking a certificate, (grounding an aircraft, revoking a certificate, etc.);etc.);

– Resources available to effect the necessary Resources available to effect the necessary actions;actions;

– Number of people affected by required actions Number of people affected by required actions (company-wide, fleet-wide, regional, national, (company-wide, fleet-wide, regional, national, international, etc.);international, etc.);



– Potential impact of the State’s decision Potential impact of the State’s decision for action (or inaction); andfor action (or inaction); and

– Cultural and political will to take the Cultural and political will to take the action requiredaction required..



Benefits of risk management for Benefits of risk management for State administrationsState administrations::– Avoiding costly mistakes during the Avoiding costly mistakes during the

decision-making process;decision-making process;– Ensuring that all aspects of the risk are Ensuring that all aspects of the risk are

identified and considered ehen making identified and considered ehen making decisions;decisions;

– Ensuring that the legitimate interests of Ensuring that the legitimate interests of affected stakeholders are consideredaffected stakeholders are considered;;



– Providing decision-makers with a solid Providing decision-makers with a solid defencedefence in support of decisions; in support of decisions;

– Making decisions easier to explain to Making decisions easier to explain to stakeholders and the general public; and stakeholders and the general public; and

– Providing significant savings in time and Providing significant savings in time and money.money.


Safety assuranceSafety assurance

Ensuring that the operation of Ensuring that the operation of service providers SMS follows service providers SMS follows established controls established controls (standards)/requirements)(standards)/requirements)

Oversight, inspections and auditsOversight, inspections and auditsData tracking and analysisData tracking and analysis

Data driven targeting of Data driven targeting of oversight on areas of greater oversight on areas of greater concern/needconcern/need


The essential is invisible to the eyesThe essential is invisible to the eyesNumber of occurrences

1 – 5 AccidentsAccidents

30 – 100 Serious incidentsSerious incidents

100 – 1000 IncidentsIncidents

1000 – 4000 Latent conditionsLatent conditions


Safety promotionSafety promotion

Support the integration of the Support the integration of the State safety programme with the State safety programme with the operation of service providers SMSoperation of service providers SMS

Training, communication and dissemination Training, communication and dissemination of safety informationof safety information

Dual-track promotionDual-track promotion

Within the CAA Within the CAA Among service providers Among service providers

itit overseesoversees


Statesafety

programme

Organization’ssafety

management system (SMS)

Organization’sproductionprocesses

Objective:Publicsafety

Objective:Manage and controlsafety risk

AcceptanceOversight

Objective:Achieve commercialgoals andcustomer satisfaction

Risk managementSafety assurance

Protection Production

Oversight

The final objective – The final objective – Integration Integration

Safety programme + SMS = Safety programme + SMS = State integrated safety State integrated safety management systemmanagement system

Documents

SAFETY MANAGEMENT EDGARS GINDRA 20.09.2007 LV CAA AOD