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An Introduction to Safety Management System (SMS). Safety Policy. Safety Risk Management. Safety Assurance. Safety Promotion. Outline. Concept of Safety Evolution of Safe Thinking Accident Causation Organizational Accident People, Context & Safety – SHEL Errors & Violations

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an introduction to safety management system sms
An Introduction to Safety Management System (SMS)

Safety Policy

Safety Risk Management

Safety Assurance

Safety Promotion

outline
Outline
  • Concept of Safety
  • Evolution of Safe Thinking
  • Accident Causation
  • Organizational Accident
  • People, Context & Safety – SHEL
  • Errors & Violations
  • Organizational Culture
  • Safety Investigation
  • Fundamentals of Safety
  • Safety Management System
  • Components of SMS
  • Legislation
  • Summary
outline1
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
outline2
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
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
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
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 thinking1
Evolution of Safety Thinking

TECHNICAL FACTORS

TODAY

HUMAN FACTORS

ORGANIZATIONAL FACTORS

1950s

1970s

1990s

2000

accident causation
Accident Causation

Organization

Workplace

People

Defences

Accident

Technology

Training

Regulations

Management decision & organizational processes

Working conditions

Errors & violations

organizational accident
Organizational Accident

Organizational processes

Improve

Identify

Monitor

Work place conditions

Latent conditions

Contain

Reinforce

Active failures

Defences

people context safety1
People, Context & Safety

Understanding Human Performance

people context safety2
People, Context & Safety

Understanding Human Performance

people context safety3
People, Context & Safety

Processes & Outcomes

shel l model
SHEL(L) Model

S

S - Software

H

L

L

H - Hardware

E - Environment

L - Livewire

E

shel l model1
SHEL(L) Model

Important factors affecting human performance:

  • Physical factors
  • Physiological factors
  • Psychological factors
  • Psycho-social factors
shel l model2
SHEL(L) Model

Interfaces between different components of the aviation system:

  • Liveware-Hardware (L-H)
  • Liveware-Software (L-S)
  • Liveware-Liveware (L-L)
  • Liveware-Environment (L-E)
errors violations
Errors & Violations

Checklist failure

Incident / Accident

Flaps omitted

Unheeded warning

Degradation / Breakdown

Error

Deviation

Amplification

Operational Errors – Investigation of major breakdowns

errors violations1
Errors & Violations

Checklist failure

Flaps omitted

Unheeded warning

Normal flight

Error

Deviation

Amplification

Safety Management – On almost every flight

3 strategies to control operational errors
3 Strategies to Control Operational Errors
  • Reduction strategies
      • Human-centred design;
      • Ergonomic factors; and
      • Training.

2. Capturing strategies

      • Checklists;
      • Task cards; and
      • Flight strips.

3. Tolerance strategies

      • system redundancies; and
      • structural inspections.
errors vs violations
Errors vs. Violations

General types of violations:

  • Situational violations occur due to the particular factors that exist at the time, such as time pressure or high workload.
  • Routine violations are violations which have become “the normal way of doing business” within a workgroup.
  • 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 violations1
Errors vs. Violations

Regulations

Accident

Technology

High

Incident

System’s production objectives

Training

Violation Space

Exceptional violation Space

RISK

Safety Space

Low

Minimum

SYSTEM OUTPUT

Maximum

Understanding Violations

organizational culture
Organizational Culture

National

Organizational

Professional

organizational culture1
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; and

c) generative — value the information.

organizational culture2
Organizational Culture
  • National culture differentiates the national characteristics and value systems of particular nations.
  • Professional culture differentiates the characteristics and value systems of particular professional groups
  • Organizational culture differentiates the characteristics and value systems of particular organizations
effective safety reporting
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 reporting1
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 traits
Effective Safety Reporting – 5 basic traits

Information

People are knowledgeable about the human, technical and organizational factors that determine the safety of the system as a whole

Flexibility

People 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

Willingness

People are willing to report their errors and experiences

Effective safety Reporting

Learning

People have the competence to draw conclusions from safety information systems and the will to implement major reforms

Accountability

People are encouraged (and rewarded) for providing essential safety-related information. However, there is a clear line that differentiates between acceptable and unacceptable behaviour

safety investigation
Safety Investigation
  • to put losses behind;
  • to reassert trust and faith in the system;
  • to resume normal activities; and
  • to fulfil political purposes.
safety investigation1
Safety Investigation

Safety investigation for improved system reliability:

  • to learn about system vulnerability;
  • to develop strategies for change; and
  • to prioritize investment of safety resources.
outline3
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
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

.

management dilemma
Management Dilemma

Dilemma of 2 P’s:

  • Production
  • Protection
management dilemma1
Management Dilemma

Management Levels

Resources

Resources

$$ PESO YEN

$$ PESO YEN

Protection

Production

management dilemma2
Management Dilemma

Management Levels

Resources

Resources

$$ PESO YEN

Protection

$$ PESO YEN

Production

Catastrophe

management dilemma3
Management Dilemma

Management Levels

Resources

Resources

$$ PESO YEN

Production

$$ PESO YEN

Protection

Bankruptcy

need for safety management
Need for Safety Management
  • Minor-major accident
  • Major air disaster are rare
  • Incidents occur more frequently
  • Ignoring the major could lead to an increase number of more serious accidents
need for safety management1
Need for Safety Management
  • Minor-major accident
  • Economics of Safety
  • Accidents cost money
  • Insurance can help but not all
  • There are many uninsured cost
  • Lost of confidence of the travelling public
need for safety management2
Need for Safety Management
  • Minor-major accident
  • Economics of Safety
  • Publics perceived safety while traveling
  • Prerequisite for a sustainable aviation business
strategies for safety management
Strategies for Safety Management

Baseline performance

System Design

Training

Technology

Regulations

Operational deployment

Operational performance

Source: Scott A. Snook

The practical drift

strategies for safety management1
Strategies for Safety Management
  • Reactive
  • Proactive
  • Predictive
strategies for safety management2
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 management3
Strategies for Safety Management

Safety management levels

High

Middle

Low

Hazards

Predictive

Proactive

Reactive

Reactive

FDA

Direct observation systems

ASR

Survey Audits

ASR

MOR

Accident and incident reports

Highly efficient

Very efficient

Efficient

Insufficient

Desirable management levels

High

Strategies – Levels of intervention and tools

imperative of change
Imperative of Change

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 change1
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 change2
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).

8 building blocks sms
8 Building Blocks - SMS
  • Senior Management’s commitment to the management of safety
  • Effective safety reporting
  • Continuous monitoring
  • Investigation of safety occurrences
  • Sharing safety lessons learned and best practices
  • Integration of safety training for operational personnel
  • Effective implementation of standard operating procedures (SOP’s)
  • Continuous improvement of the overall level of safety
4 responsibilities of managing safety
4 Responsibilities of Managing Safety

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

  • Definition of policies and procedures regarding safety.Policies and procedures are organizational mandates reflecting how senior management wants operations to be conducted.
  • Allocation of resources for safety management activities. Managing safety requires resources. The allocation of resources is a managerial function.
  • 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 safety1
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.

summary
Summary

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; and

g) is based on strategic planning as opposed to piecemeal initiatives.