SMS Fundamentals of Safety

Report
An Introduction to
Safety Management System (SMS)
Safety Policy
Safety Risk
Management
Safety
Assurance
Safety
Promotion
Outline
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Fundamentals of Safety
Safety Management System
Components of SMS
Legislation
Summary
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Concept of Safety
Evolution of Safe Thinking
Accident Causation
Organizational Accident
People, Context & Safety – SHEL
Errors & Violations
Organizational Culture
Safety Investigation
Outline
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Fundamentals of Safety
Safety Management System
Components of SMS
Legislation
Summary
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Safety Stereotype
Management Dilemma
Need for Safety Management
Strategies for Safety Management
Imperative of Change
Building Blocks – SMS
Responsibilities of Managing Safety
Outline
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Fundamentals of Safety
Safety Management System
Components of SMS
Legislation
Summary
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Safety Policy
Safety Risk Management
Safety Promotion
Safety Assurance
The Concept of Safety
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Zero accidents or serious incidents — a view widely held by the travelling
public;
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Freedom from hazards, i.e. those factors which cause or are likely to cause
harm;
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Attitudes of employees of aviation organizations towards unsafe acts and
conditions;
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Error avoidance; and
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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:
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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
TODAY
TECHNICAL FACTORS
HUMAN FACTORS
ORGANIZATIONAL FACTORS
1950s
1970s
1990s
2000
Accident Causation
Organization
Workplace
People
Defences
Accident

Organizational Accident
Organizational processes
Improve
Identify
Monitor
Reinforce
Active failures
Latent conditions
Contain
Work place conditions
Defences
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
S - Software
H
L
L
H - Hardware
E - Environment
L - Livewire
E
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
Incident /
Accident
Error
Deviation
Amplification
Operational Errors – Investigation of major
breakdowns
Degradation /
Breakdown
Errors & Violations

Error
Deviation
Amplification
Safety Management – On almost every flight
Normal flight
3 Strategies to Control Operational Errors
1.
Reduction strategies
a) Human-centred design;
b) Ergonomic factors; and
c) Training.
2. Capturing strategies
a) Checklists;
b) Task cards; and
c) Flight strips.
3. Tolerance strategies
a)
system redundancies; and
b) structural inspections.
Errors vs. Violations
General types of violations:
1.
2.
3.
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. Violations
Accident
Incident
RISK
Safety Space
Low
Minimum
SYSTEM OUTPUT
Understanding Violations
Exceptional
violation Space
System’s
production
objectives
Violation Space
High
Maximum
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; and
c) 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 traits
Information
People are knowledgeable about the human, technical
and organizational factors that determine the safety of
the system as a whole
Willingness
People are willing to report
their errors and experiences
Effective safety
Reporting
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
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 decisionmaking level
Learning
People have the competence to draw
conclusions from safety information
systems and the will to implement
major reforms
Safety Investigation
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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; and
c) to prioritize investment of safety resources.
Outline
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


Fundamentals of Safety
Safety Management System
Components of SMS
Legislation
Summary






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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:
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safety first vs. safety is an organizational process
Safety is not first priority in aviation
safety is just organizational process
Management Dilemma
Dilemma of 2 P’s:
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Production
Protection
Management Dilemma
Management Levels
Resources
Resources
$$ PESO
YEN
$$ PESO
YEN
Management Dilemma
Resources
Resources
$$ PESO
YEN
$$ PESO
YEN
Catastrophe
Management Dilemma
Resources
Resources
$$ PESO
YEN
$$ PESO
YEN
Bankruptcy
Need for Safety Management
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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 Management
Minor-major accident
 Economics of Safety
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Accidents cost money
Insurance can help but not all
There are many uninsured cost
Lost of confidence of the travelling
public
Need for Safety Management
Minor-major accident
 Economics of Safety
 Publics perceived safety while traveling
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 Prerequisite for a sustainable
aviation business
Strategies for Safety Management
Baseline performance
System
Design
Operational
deployment
Source: Scott A. Snook
The practical drift
Strategies for Safety Management
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Reactive
Proactive
Predictive
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
Safety management levels
High
Hazards
Predictive
FDA
Direct
observation
systems
Highly efficient
Middle
Low
Proactive
Reactive
ASR
Survey
Audits
ASR
MOR
Very efficient
Reactive
Accident and
incident
reports
Efficient
Desirable management
levels
High
Strategies – Levels of intervention and tools
Insufficient
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
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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, realtime 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
1.
2.
3.
4.
5.
6.
7.
8.
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
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.
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.
The End
Questions & Answers

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