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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
Fundamentals of Safety Safety Management System Components of SMS Legislation Summary
Safety Stereotype Management Dilemma Need for Safety Management Strategies for Safety Management Imperative of Change Building Blocks – SMS Responsibilities of Managing Safety
Outline
Fundamentals of Safety Safety Management System Components of SMS Legislation Summary
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
TOD
AY
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
People, Context & Safety
Understanding Human Performance
People, Context & Safety
Understanding Human Performance
People, Context & Safety
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 Amplification
Normal 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
Viol
atio
n Sp
ace
Exce
ptio
nal
viol
atio
n Sp
ace
Regulations
Technology
Training System’s production objectives
IncidentAccident
Understanding Violations
Minimum Maximum
High
Low
RISK
SYSTEM OUTPUT
Organizational Culture
National
Organizational
Professional
Organizational Culture
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.
Organizational Culture
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
Organizational Culture
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
Fundamentals of Safety Safety Management System Components of SMS Legislation Summary
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
Need for Safety Management
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
Need for Safety Management
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
Strategies for Safety Management
Strategies for Safety Management
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
Strategies for Safety Management
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).
Imperative of Change
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).
Imperative of Change
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