Slide 1

Report
Introduction to
Safety Management
System (SMS)
Federal Aviation
Administration
Flight Standards and
Industry Roles
Presented By: Flight Standards Service
Federal Aviation
Administration
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SL-1
Agenda
•Overview
•Safety Fundamentals & Case for SMS
•SMS Fundamentals - Overview
•Policy Component
•Safety Risk Management Component
•Safety Assurance Component
•Safety Promotion Component
•Standards, Tools and Implementation
Federal Aviation
Administration
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SL-2
Federal Aviation
Administration
Overview
Federal Aviation
Administration
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SL-3
What SMS is not and what it is…
What it isn’t:
What it is:
A substitute for
compliance
Compliance is integral
to safety management
A substitute for
oversight
An effective interface for
safety management
A replacement for
system safety
SMS completes the
systems approach
A requirement for a
new department
A set of decision making
processes for senior and
line management
Federal Aviation
Administration
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SL-4
What is safety?
• Freedom from harm (Dictionary def’n.)
• Safety is not equivalent to risk free (U.S.
Supreme Court, 1980)
• “Risk management” is a more practical term
than “safety.” (Jerome Lederer ~1928)
• Carelessness and overconfidence are more
dangerous than deliberately accepted risk
(Wilbur Wright, 1901)
• Practical safety is risk management
Federal Aviation
Administration
SL-5
Definition of Safety
“Safety is the state in which the risk of harm
to persons or property is reduced to, and
maintained at or below, an acceptable level
through a continuing process of hazard
identification and risk management”
ICAO Doc 9859
Federal Aviation
Administration
SL-6
3- Minute SMS Introduction Video
Example Safety Promotion Video
Federal Aviation
Administration
SL-7
Safety Management Systems
“SMS”
A systemic approach to managing safety,
including the necessary organizational
structures, accountabilities, policies and
procedures.
ICAO Doc. 9859
Federal Aviation
Administration
SL-8
SMS Purpose and Methods
• Safety management systems provide a
systematic way to control risk and to
provide assurance that those risk controls
are effective
• The SMS gives the certificate holder a
formal means of meeting statutory safety
requirements (title 49) and the FAA a means
of evaluating management capability
Federal Aviation
Administration
SL-9
System Safety
• "The application of special technical and
managerial skills in a systematic, forward
looking manner to identify and control hazards
throughout the life cycle of a project, program,
or activity" (Roland & Moriarty, 1990)
• Traditional approach concentrates on technical
• SMS adds emphasis on management elements
Federal Aviation
Administration
SL-10
SMS, ATOS, SAS, and QMS
Does SMS =ATOS=SAS?
• SMS
– Management system
– Only service provider can
manage
• ATOS
– Oversight system
– Used to meet regulator
responsibilities
Does SMS = QMS?
• Same principles but
different objectives
• QMS Objective
– Customer satisfaction
• SMS Objective
– Aviation safety
• SAS
– Safety Assurance System
– FAA-Future-State system
safety oversight across
14CFR parts (121, 135, 145)
Federal Aviation
Administration
SL-11
ICAO Annex 6
• “From 1 January, 2009,
States shall require, as part
of their safety programme,
that an operator implement
a safety management
system acceptable to the
State of the Operator…”
• The U.S. has filed a
difference with ICAO
• Currently, there are no FAA
authorized procedures to
accept of approve Service
Providers’ SMS’s
Federal Aviation
Administration
SL-12
ICAO: State’s “safety
programme”
• Definition:
– An integrated set of regulations and activities aimed
at improving safety.
– Includes SMS requirements for aviation service
providers
• The AVSSMS is the U.S. safety program
– FAA Oversight
• Regulations, Standards & Policy
• Assurance (ex; Certification, Surveillance, etc.)
– Service Provider SMS Requirements
Federal Aviation
Administration
SL-13
ICAO
State Safety
Programme (SSP)
SSP Framework
•Annex 6
•ICAO Doc 9859: Safety
Management Manual (SMM)
SMS Framework
FAA Aviation Safety
(AVS) Safety
Program=AVS SMS
Internal
(FAA SMS)
•Order 8000.369; FAA SMS Guidance
•VS8000.367; Requirements Doc
External
(Service Provider SMS)
Flight Standards
AVS LOB’s
SSP & FAA
Oversight
•AC 120-92; SMS Standard
•Developmental Guidance
Air Operators’/
Service
Providers’ SMS
Federal Aviation
Administration
SL-14
Clarifying the “3 R’s”:
FAA’s Safety
Management
(Oversight)
(SAS)
Operator’s Safety
Management
System
(External SMS)
Roles, Responsibilities
and Relationships:
•FAA
•Service Providers
Operational
Process
Federal Aviation
Administration
SL-15
Federal Aviation
Administration
Safety
Fundamentals
&
Case for SMS
Federal Aviation
Administration
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SL-16
What is the Fundamental Objective of
a Business Organization?
To achieve its
production objectives!
Federal Aviation
Administration
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SL-17
The Business Case
• Aviation organization management requires
managing many business processes.
• Safety management is a core business
function just as financial management, HR
management, etc.
• This constitutes a management challenge.
Federal Aviation
Administration
SL-18
Protection and Production
• Safety Requirements
– Title 49 USC…44702 “…the duty of an air
carrier to provide service at the highest level
of safety in the public interest”
• Economic Requirements
– [Proposed operation must be] “…consistent
with public convenience and necessity”
– [Company must be] “…fit, willing and able to
provide the service proposed”
Federal Aviation
Administration
SL-19
Safety Space
Protection
Financial
Management
Bankruptcy
Unrocked Boat
Safety
Management
Catastrophe
Production
Life of the system
Federal Aviation
Administration
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SL-20
Safety Management System
• Infuses safety into all parts of the system
–
–
–
–
–
–
People
Tools
Procedures
Materials
Equipment
Software
Management levels
Protection
Production
• To maintain the balance of production and
protection
Federal Aviation
Administration
SL-21
Accidents and Incidents Cost!
Direct costs
• Loss of aircraft
• Injuries to or death of
flight crewmembers,
passengers
• Insurance deductibles
• Costs not covered by
insurance
Indirect costs
• Loss of use of equipment
• Loss of staff
– Involved in accident issues
– Lower productivity
•
•
•
•
Investigation & clean-up
Legal claims
Fines
Misplaced/stranded
passengers
• Negative media exposure
Federal Aviation
Administration
SL-22
Ramp Damage Has Big Price
Tag For Airlines
Aileron & Tab Assembly $183,545
Outboard Flap Assembly
$255,845
Parts prices only
Elevator
Assembly
$264,708
Inboard Flap
Assembly $224,872
Cargo Door $58,327
Main Entry Door
$171,220
L.E. Slat Assembly
$52,863
Radome $19,712
Wingtip Assembly $28,872
TAT Probe
$6,583
AOA Vane
$4,300
Pitot Static Probe
$5,157
Side cowl
$161,407
Inlet Cowl $329,203
Inlet Cowl Segment $5,151
8
Federal Aviation
Administration
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SL-23
Income lost
Event
Direct
Indirect
Catering truck hits airplane
$17,000
$230,000
Jetway hits airplane
$50,000
$600,000
$1,900,000
$4,800,000
Landing event
Source: USAir/America West Airlines
Federal Aviation
Administration
SL-24
Accidents Cost Small Operators, Too
Claim
Flight Training Fixed Wing Air
Operation Taxi Operation
Helicopter
Air Taxi
Forced landing
(aircraft destroyed)
$150,000
$300,000
$900,000
Propeller makes
contact with object
on ground
$20,000
$30,000
$150,000
$5,000
$10,000
$35,000
$500-1,400
$3-5,000
$8-10,000
Hangar Rash
Flight cancellation
per day
Federal Aviation
Administration
SL-25
…
Technical Factors
Human Factors1949 British Comet
Organizational Factors
1954 Boeing
Federal Aviation
Administration
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SL-26
Traditional approach – Preventing accidents
•
•
•
•
Focus on outcomes (causes)
Unsafe acts by operational personnel
Attach blame/punish for failures to “perform safely”
Address identified safety concern exclusively
Identifies:
WHAT?
WHEN?
WHO?
But not always discloses:
WHY?
HOW?
Federal Aviation
Administration
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SL-27
Human Error and Operations
• Human error: a contributing
factor in most aviation
occurrences.
• Even competent personnel
commit errors.
• Errors are a normal
component of any system
where humans and
technology interact.
Federal Aviation
Administration
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SL-28
Context and outcomes
Causes and
consequences
of operational
errors are not
linear in their
magnitude
Source: ICAO SMM
Federal Aviation
Administration
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SL-29
Types of Errors (Active Failures)
• Perception Errors
– “I didn’t see it,” or “I didn’t notice the difference…”
• Memory Lapses
– “I forgot to do it…”
• Slips
– “I didn’t mean to do that…”
• Wrong Assumption
– “I assumed that the situation was different…”
Alan Hobbs, ATSB (2008)
Federal Aviation
Administration
SL-30
Errors (cont.)
• Technical Misunderstandings
– “I tried to do it right but I didn’t understand
what I had to do…”
• Procedure Violations
– “Nobody follows that procedure here….”
– “We can’t get the job done if we do all that…”
Alan Hobbs, ATSB (2008)
Federal Aviation
Administration
SL-31
Organizational Accidents
Organizational processes
Workplace
conditions
Latent
conditions
Active
failures
Defenses
Federal Aviation
Administration
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Organizational Culture
Values
Professional Norms
National Culture
Psychological
•Laws/Regulations
•Industry Standards
System/
Environment
•Industry Norms
•Business Relations
•Markets
Behavioral
Outcomes
Practices
Federal Aviation
Administration
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SL-33
Safety Management Strategies
Reactive
(Past)
Proactive
(Present)
Predictive
(Future)
Responds to
events that have
already
happened, such as
incidents and
accidents
Actively seeks the
identification of
hazardous
conditions
through the analysis
of the organization’s
processes
Analyzes
system
processes and
environment to
identify potential
future problems
Federal Aviation
Administration
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SL-34
Federal Aviation
Administration
SMS
Fundamentals
Federal Aviation
Administration
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SL-35
SMS Concepts
• Applying Risk Management
• Assuring Safety Risk
Controls
• Oversight of Design and
Performance of Systems
– Design Assurance
• Using Assessment tools
– Performance Assurance
• Using Assessment tools
Federal Aviation
Administration
SL-36
SMS Concepts: Risk Management
• Understanding the
system and environment
• Identifying hazardous
conditions
• Assessing risk
• Applying risk controls
Federal Aviation
Administration
SL-37
SMS Concepts: Assurance
• Assurance: “something
that gives confidence”1
• Quality assurance: “...
focused on providing
confidence that quality
requirements are being
met”2
• Likewise, Safety
Assurance relates to
safety requirements
1
Black’s Law Dictionary
2
ISO 9000-2000
Federal Aviation
Administration
SL-38
SMS Components (“Pillars”)
Policy:
(Structure)
Risk
Mgmt.
Safety
Assurance
Safety Promotion:
(Culture)
Federal Aviation
Administration
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SL-39
The 4 SMS Components
Policy
(Structure)
Risk
Management
Safety
Assurance
Safety
Promotion
1. Policy
• All management systems must define
policies, procedures, and organizational
structures to accomplish their goals.
• Policy establishes the structure of the SMS.
Federal Aviation
Administration
SL-40
The 4 SMS Components
Policy
(Structure)
Risk
Management
Safety
Assurance
Safety
Promotion
2. Safety Risk Management.
• A formal system of hazard identification,
analysis and risk management is essential
in controlling risk to acceptable levels.
Federal Aviation
Administration
SL-41
The 4 SMS Components
Policy
(Structure)
Risk
Management
Safety
Assurance
Safety
Promotion
3. Safety Assurance.
• Once controls are identified, the SMS must
assure they are continuously practiced and
continue to be effective in a changing
environment.
Federal Aviation
Administration
SL-42
The 4 SMS Components
Policy
(Structure)
Risk
Management
Safety
Assurance
Safety
Promotion
4. Safety Promotion.
• The organization must promote safety as a
core value with practices that support a
positive safety culture.
Federal Aviation
Administration
SL-43
Safety Risk Management (SRM) and Safety Assurance (SA) Workflow
SRM
SA
System
Description
System
Operation
Hazard
Ident
Data
Acquisition
& Process
Specific
Information
Risk
Analysis
Analysis
(RCA)
Analysis
Risk
Assmt
System
Assmt
Assessment
Risk
Control
Corrective
Action
Design
Performance
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Description
& Context
Action:
Problem
Resolution
Federal Aviation
Administration
SL-44
Oversight and SMS
FAA
Oversight Program
Management
DA
PA
Protection
FAA’s Safety
Management
(Oversight)
(SAS)
Production
Technical Program Requirements
•Systems
•Subsystems
•Elements
Surveillance
S
R
M
Cert
S
A
Operator’s Safety
Management
System
Operational
Process
Public:
Users
C.O.S.
Federal Aviation
Administration
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SL-45
1
National Aviation System Level
2
Service Provider/Organizational Level
3
Individual (Airman/Aircraft) Level
Federal Aviation
Administration
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SL-46
Policy: QMS
Regs./Policy
1
FAA
SRM(S)
FAA
SA(S)
Strategic
Analysis
2
DA
FAA
SA
S
R
M
CH
SRM
PA
S
A
3
FAA
SA
Designee
System
SAS
Public
Users
SMS
Education & Awareness
of Risk (GA)
FAA
SP
Airmen & Aircraft
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Federal Aviation
Administration
SL-47
AVS SMS = FAA Safety Programme
FAA Internal SMS
(SSP & Oversight)
External SMS
Flight Standards
Air Operators/
Service Providers
Policy
Policy
Safety Risk
Management
Safety
Assurance
Safety
Promotion
FAA Act 44702
CFR’s (aka FAR’s)
Field Divisions (Oversight)
Safety Risk
Management
Safety
Assurance
Design Assurance (Certification,
SAS
Prgrm. Apprvl./Accept., Cert. Mgt)
Safety
Promotion
Performance Assurance (Surveil., Plus)
Federal Aviation
Administration
SL-48
Safety Management System
Provides a systematic way to:
1. Identify hazards and control risk
2. Provide assurance that risk controls are effective
Policy
(Structure)
Safety Risk
Managemen
t
Safety
Assurance
Safety Promotion
(Culture)
Federal Aviation
Administration
SL-49
Federal Aviation
Administration
SMS Details:
Policy
Component
Federal Aviation
Administration
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SL-50
SMS Policy
• Establishes management commitment and
objectives – what the management wants
• Sets up framework of organizational
structures, accountabilities, plans,
procedures, and controls to meet objectives
Federal Aviation
Administration
SL-51
Management Responsibility
• Managers should manage safety in the same
way that they manage other areas of the
business
• Safety management involves judgment,
assessing priorities, and making decisions –
like all management decision making
Federal Aviation
Administration
SL-52
Top Management Involvement
Top management stimulates a healthy safety
environment
• Visible, personal involvement of top
management
• Setting safety goals and objectives as
policy
• Allocation of resources to meet safety goals
• Clear communication
AC 120-92, App. 1
Federal Aviation
Administration
SL-53
Objectives of the Policy Component
Top Management will:
• Implement an integrated, comprehensive
SMS for entire organization
• Define a safety policy and set safety
objectives
• Define roles, responsibilities, and authorities
throughout the organization
• Appoint a member of management to
implement and maintain the SMS
Federal Aviation
Administration
SL-54
Policy: Other Responsibilities
• Emergency response
– Develop and implement procedures
to respond to accidents and incidents
• Control of Documents and Records:
– Have a clearly defined document maintenance
process
– Implement and maintain a safety management plan
Federal Aviation
Administration
SL-55
Safety Policy Requirements:
• Commitment to:
–
–
–
–
Implement an SMS
Continually improve safety
Manage safety risk
Comply with statutory & regulatory requirements
• Establish clear standards of acceptable
behavior
• Documented
• Communicated
• Periodically reviewed
Federal Aviation
Administration
SL-56
Organizational Structure
• Top management with ultimate authority and
responsibility
• Top management requirement to provide
resources
• Defined lines of supervision and control
• Defined safety responsibilities for all employees
• Designated management official to ensure
effectiveness of SMS (e.g. DOS)
Federal Aviation
Administration
SL-57
Accountability Defined
Accountability = Obligation or willingness
to account for one’s actions
A SMS shall clearly define lines of safety
accountability throughout the provider
organization, including direct accountability
for safety on the part of senior management.
ICAO Doc. 9859
Federal Aviation
Administration
SL-58
Accountability vs. Liability
• SMS promotes an environment that stimulates
open reporting
• This includes and active involvement of all
personnel, starting with top management in
safety problem-solving
• Barring negligence or deliberate disregard for
safety, SMS does not promote blame for error
Federal Aviation
Administration
SL-59
Management Functions
Managers must be actively and personally
involved in:
• Planning: Setting clear goals, guidelines,
standards, and timelines for safety
• Organizing: Providing clear lines of
management and supervisory
responsibility, control and communication
• Directing: Allocation of resources needed
for accomplishment of safety goals
• Controlling: Personal involvement in
assurance of safety goals and objectives
Federal Aviation
Administration
SL-60
System Attributes
Processes must have safety requirements built
into their design.
a) Responsibility: accountable for quality of
activities
b) Authority: power to accomplish required activities
c) Procedures: clear instructions for members of the
organization
d) Controls: supervisory controls on processes to
ensure activities produce the correct outputs
Federal Aviation
Administration
SL-61
System Attributes
In addition, there are process measures and
interfaces.
e) Process Measures: measurement of both
processes & their products
f)
Interfaces: Recognizing interrelationships
between individuals and organizations within the
company as well as with contractors, vendors,
customers, and other organizations
Federal Aviation
Administration
SL-62
System Attributes in Management
• The six attributes are the essence
of management:
– Planning: Procedures
– Organizing: Procedures, Responsibilities & Interfaces
– Directing: Responsibilities & Authority
– Controlling: Process Measures & Controls
• Now also documented in the ICAO SMM
Federal Aviation
Administration
SL-63
SMS Documentation
• System documentation conveys
management expectations and work
instructions to employees
• May be a stand-alone manual or
integrated into existing documentation
systems
Federal Aviation
Administration
SL-64
Federal Aviation
Administration
SMS Details:
Data
Quality
Federal Aviation
Administration
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SL-65
Decision Making:
Data, Analysis, and Assessment
• Reports (Facts): what exists or is happening
now
• Inferences (Interpretations)
– What’s likely to happen in the future, based on
what’s happening now
– Conclusions based on facts
• Judgments: value, quality assessments
(e.g. good, bad, acceptable, unacceptable)
of what is or will exist or happen
Federal Aviation
Administration
SL-66
Example:
• Facts (Conditions):
–
–
–
–
Duty day is 14 hours
Flight schedule is 8 hours
Flights have 10 legs, 10 IFR approaches
Flights are legal (within regs.)
• Inference (Hazard):
– Crew fatigue will probably result
• Inference (Risk analysis):
– Likelihood of crew errors will increase
• Judgment (Risk Assessment):
– Unacceptable risk
Federal Aviation
Administration
SL-67
Attributes of Data and Measures
• Validity:
– Does the data/measure address the subject
desired?
– Does it only address the subject desired?
– How completely does it cover the subject desired?
• Reliability:
– Are data points about the same thing comparable?
– Are data points collected by different observers
comparable?
Data and measures must be reliable to be
valid but reliable data is not always valid
Training and careful
preparation of tools can
increase reliability of data
Federal Aviation
Administration
SL-68
Federal Aviation
Administration
SMS Details:
Safety Risk
Management
Component
Federal Aviation
Administration
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SL-69
Definitions
Safety management systems provide a
systematic way to control risk and to provide
assurance that those risk controls are effective.
Safety Risk Management is a formal system of
hazard identification, analysis and risk management
essential in controlling risk to acceptable levels.
Federal Aviation
Administration
SL-70
Levels of Risk Management
• Process Risk Management
– Policy (What)
– Procedure (How)
– Controls
• Operational Risk Management
– Operational Control (Flight/Task/Mission)
– Crew/Team (Real time decision making)
Federal Aviation
Administration
SL-71
System Description
System
Description
Hazard
Identification
What is System & Task Analysis?
• It is a system design function.
• It is a predictive method of hazard identification.
• It is the foundation for sound safety analysis.
Risk
Analysis
Risk
Assmt
When is it used?
Risk
Control
• Used during implementation phases of SMS.
• Used in conjunction with all operational changes.
Who uses System & Task Analysis?:
• Personnel within the organization who form an appropriately
diverse team:
– Stakeholders
ICAO Doc. 9859
– Subject Matter Experts
Federal Aviation
Administration
SL-72
SRM
System
Description
System Description
Facts
Processes
Hazard
Identification
Activities
Workplace Conditions:
e.g.
System
Factors &
Attributes
Risk
Analysis
Risk
Assmt
Variable
Human
Performance
• Equipment
• Information (Procedures)
• Facilities
• Phys. Envir.
• Other Proc. (Interfaces)
• Training
• Supv./Mgmt. (Controls)
• ….
Risk
Control
Federal Aviation
Administration
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SL-73
Typical Workplace Conditions
• Equipment: Human-Machine Interface,
Facilities
• Operators: Individual performance
• Crew/team performance
• Organizational culture
• Company/regulator factors
Strauch, Barry (2004). Investigating Human Error
Federal Aviation
Administration
SL-74
Process (System) Attributes
• Responsibility
• Authority
• Procedures
• Controls
• Process
Measures
• Interfaces
Federal Aviation
Administration
SL-75
Conditions Related to Error
• Time pressure
• Procedures and documentation
• Teamwork/documentation
• Shift turnovers/crew briefings
• Group norms
• Fatigue management (shifts/circadian
problems)
Alan Hobbs, ATSB (2008)
Federal Aviation
Administration
SL-76
Conditions Related to Error (cont.)
• Lack of System Knowledge
• Equipment/facilities
• Human-machine interface (e.g. design for
maintainability)
Federal Aviation
Administration
SL-77
Activities and Conditions: Deicing
Activities/Tasks and Actors
Workplace Conditions
What and Who
System and Environment
Select type of fluid
(Check holdover time)
Day/Night
Precipitation/cold
Position at Aircraft
Employee demographics
Communicate with crew
Apply Fluid
Depart Ramp Area
Federal Aviation
Administration
SL-78
Hazard Identification
System
Description
Hazard
Identification
A hazard is any real or potential
condition…
Risk
Analysis
that can result in injury, illness, or death
to people; damage to, or loss of, a
system (hardware or software),
equipment, or property;
and/or damage to the
operating environment.
Risk
Assmt
Risk
Control
ICAO Doc. 9859
Federal Aviation
Administration
SL-79
SRM
Hazard Identification
from Workplace Conditions
System
Description
Hazard
Identification
Processes
Activities
Workplace Conditions:
e.g.
System
Factors &
Attributes
Risk
Analysis
Risk
Assmt
• Equipment
• Information (Procedures)
• Facilities
• Phys. Envir.
• Other Proc. (Interfaces)
• Training
• Supv./Mgmt. (Controls)
• ….
Deficient Conditions
impacting activities =
Risk
Control
Inference
Variable
Performance
Causing…
Active Failures
Hazards
Resulting in…
Consequences
Federal Aviation
Administration
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SL-80
Risk Analysis
System
Description
 Important to distinguish between:
Hazard
Identification
Risk
Analysis
 Hazard – a condition
Risk
Assmt
 Consequence – result
Risk
Control
 Risk – likelihood & severity of the
consequence
 Analyzing risk involves the consideration
of both the likelihood and the severity of
any adverse consequences.
ICAO Doc. 9859
Federal Aviation
Administration
SL-81
SRM
From Hazard to Risk
System
Description
Hazard
Identification
Deficient Conditions
impacting activities =
Variable
Performance
Hazards
Causing…
Risk
Analysis
Risk
Assmt
Risk
Control
Resulting in…
Active Failures
Consequences
L ikelihood
S everity
Risk
Judgment
Risk
Federal Aviation
Administration
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SL-82
Failures and Consequences
Active failures
Potential Consequences
Direct results of conditions
(e.g. accident/incident severity)
Incorrect Fluid Type
Take-off accidents due to
ice
Hold-over time too long
Incomplete deicing
Federal Aviation
Administration
SL-83
Risk Analysis
Risk is the composite of the predicted likelihood or
probability and the severity of each possible
consequence of each identified hazard.
Hazard
Intolerable
Active Failure
Tolerable
Consequence
Acceptable
Probability
Severity
Risk Level
Adapted from ICAO Doc. 9859
Federal Aviation
Administration
SL-84
Risk Assessment
Risk assessment determines the level of risk to use in
making a bottom line decision.
System
Description
Hazard
Identification
Risk
Analysis
Risk
Assmt
Risk
Control
Risk
Likelihood
Risk Severity
Catastrophi
c
Hazardo
us
A
B
Major
Minor
Negligible
C
D
E
Frequent
5
5A
5B
5C
5D
5E
Occasional
4
4A
4B
4C
4D
4E
Remote
3
3A
3B
3C
3D
3E
Improbable
2
2A
2B
2C
2D
2E
Extremely
improbable
1
1A
1B
1C
1D
1E
A risk matrix is a tool used for risk assessment. It can vary in
form yet it accomplishes the same purpose.
Federal Aviation
Administration
SL-85
Risk Control = Risk Mitigation
System
Description
Hazard
Identification
A major component of any safety system
is the defenses (controls) put in place to
protect people, property or the
environment.
Risk
Analysis
Risk
Assmt
Risk
Control
These defenses are used to reduce the
likelihood or severity of the
consequences associated with any
given hazard or condition.
ICAO Doc. 9859
Federal Aviation
Administration
SL-86
SRM
Risk Control/Mitigation
System
Description
Hazard
Identification
Processes
Activities
e.g.
System
Factors &
Attributes
Risk
Analysis
Risk
Assmt
Risk
Control
Workplace Conditions:
Variable
Human
Performance
• Equipment
• Information (Procedures)
• Facilities
• Phys. Envir.
• Other Proc. (Interfaces)
• Training
• Supv./Mgmt. (Controls)
• ….
Risk Controls
Federal Aviation
Administration
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SL-87
Risk Control
Order of Precedence:
System
Description
Hazard
Identification
1. Modify the system (design hazard out)
2. Physical guards or barriers
Risk
Analysis
Risk
Assmt
3. Warnings or alert signal
Risk
Control
4. Administrative controls
• Procedures
• Training
Federal Aviation
Administration
SL-88
Federal Aviation
Administration
SMS Details:
Safety Assurance
Component
Federal Aviation
Administration
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SL-91
SMS Concepts: Assurance
• Assurance: “something
that gives confidence”1
• Quality assurance: “...
focused on providing
confidence that quality
requirements are being
met”2
• Likewise, Safety
Assurance relates to
safety requirements
1
Black’s Law Dictionary
2
ISO 9000-2000
Federal Aviation
Administration
SL-92
SM Strategies – Intervention Levels & Tools
Safety management levels
Baseline performance
Predictive
System
Analysis
Design
Assessment
Highly efficient
Proactive
Reactive
Surveys
Audits
Performance
Assessment
Very efficient
“Practical drift”
Reactive
Organization
ASRS
SDR
Efficient
Accident
and incident
reports
Insufficient
Desirable management
levels
Federal Aviation
Administration
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SL-93
Safety Assurance Functions:
• Collect and analyze information to
determine that process requirements are
continuously being met.
• Assess performance and effectiveness
of risk controls.
• Works in partnership with Risk
Management.
AC 120-92
Federal Aviation
Administration
SL-94
S.A. is similar to Q.A.
• QA focuses on product conformity & customer
satisfaction on a continuous basis.
• SA ensures that risk controls, once designed and
put to place, perform in a way that continue to
meet their safety objectives.
• Integration of management systems may be
beneficial.
AC 120-92
Federal Aviation
Administration
SL-95
S.A. & Q.A.:
“Once controls are in place, quality
management techniques can be used to
provide a structured process for ensuring that
they achieve their intended objectives and,
where they fall short, to improve them.”
AC 120-92
Federal Aviation
Administration
SL-96
System
Operation
System Operation
Data
Acquisition
& Process
Written documentation to describe:
Analysis
System
Assmt
Who, What, When, Where, Why, How
Preventive/
Corrective
Action
The system operation includes:
1) Monitoring of risk controls during operations;
2) System description, including risk controls
added during SRM which form the basis for
SA functions such as audits and analysis.
AC 120-92
Federal Aviation
Administration
SL-97
System
Operation
Data Acquisition & Process
Data
Acquisition
& Process
Information Sources
Analysis
1. Continuous Monitoring
2. Internal Audits
System
Assmt
Preventive/
Corrective
Action
3. Internal Evaluation
4. External Audits
5. Investigations
6. Employee Reporting Systems
AC 120-92
Federal Aviation
Administration
SL-98
Continuous Monitoring
System
Operation
Where SRM and SA interface - risk controls
Data
Acquisition
& Process
Analysis
Line managers of operational departments:
• Accomplish continuous monitoring of
day-to-day activities & processes
System
Assmt
Preventive/
Corrective
Action
• Have direct responsibility for process
control
• Must ensure that processes in their
areas function as designed.
Federal Aviation
Administration
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SL-99
Continuous Monitoring
- Operational Data Sources
• Flight dispatch records
• Flight schedules
• Financial data
• Crew schedules and records
• Warranty return reports
• Aircraft discrepancy reports
• Flight cancellation and delay
reports
Federal Aviation
Administration
SL-100
Internal Audits
System
Operation
The day-to-day responsibility for safety
management rests with those who “own” the
technical processes.
Data
Acquisition
& Process
Analysis
System
Assmt
Preventive/
Corrective
Action
This is where:
• deficiencies in processes contribute to
risk
• audits provide feedback to process
owners
• direct supervisory control and resource
allocation can help to maintain
effectiveness of risk controls
Federal Aviation
Administration
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SL-101
Internal Audits Continued
System
Operation
Data
Acquisition
& Process
• Performed by each department.
• Department Director/Manager is responsible.
Analysis
System
Assmt
• Regularly scheduled
Preventive/
Corrective
Action
• Include contractors & vendors
• Determine:
– Conformity with safety risk controls
– Performance of safety risk controls
– Performance to meet business objectives
• Deficiencies always get action!
AC 120-92
Federal Aviation
Administration
SL-102
Internal Evaluation
System
Operation
• Performed by a functionally independent
person or organization (e.g. QA, Safety)
Data
Acquisition
& Process
Analysis
System
Assmt
• A process-oriented control function
Preventive/
Corrective
Action
• Backs up the internal audit function
• Uses sampling to validate SA processes
Federal Aviation
Administration
SL-103
External Audits
System
Operation
Data
Acquisition
& Process
Analysis
Conducted by:
System
Assmt
• Code-share partners
• Industry organizations (e.g. C.A.S.E.)
Preventive/
Corrective
Action
• Third parties: consultants
• The regulator (FAA) = “Safety Oversight”
Federal Aviation
Administration
SL-104
System
Operation
Safety investigations
• For continuity – put the event behind us
Data
Acquisition
& Process
Analysis
– To put losses behind
– To reassert trust and faith in the system
System
Assmt
Preventive/
Corrective
Action
– To resume normal activities
– To fulfil political purposes
• For improved system reliability
– To learn about system vulnerability
– To develop strategies for change
– To prioritize investment of resources
Federal Aviation
Administration
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SL-105
Employee Reporting
System
Operation
• Employee safety reporting & feedback
system is required.
Data
Acquisition
& Process
Analysis
System
Assmt
• Must provide confidentiality.
• Employees must be encouraged to use
the system.
Preventive/
Corrective
Action
• Data may identify emerging hazards.
• Data must be included in analysis.
AC 120-92, App. 1
Federal Aviation
Administration
SL-106
Analysis
System
Operation
Data
Acquisition
& Process
• To be useful, information must be
made understandable.
Analysis
System
Assmt
• Analysis is used to determine
effectiveness of:
Preventive/
Corrective
Action
1. Risk controls in the organization’s
operational processes, and
2. the SMS.
AC 120-92
Federal Aviation
Administration
SL-107
Types of analysis
System
Operation
Data
Acquisition
& Process
• Against criteria/objectives
Analysis
• Compared to norms
System
Assmt
• Patterns from multiple data points
Preventive/
Corrective
Action
• Trends over time
– “Trends” is one of the most misused term in
analysis
– Must have stable, reliable measures at each
time sample for a valid trend
Federal Aviation
Administration
SL-109
Attributes of Data and Measures
• Validity:
– Does the data/measure address the subject
desired?
– Does it only address the subject desired?
– How completely does it cover the subject desired?
• Reliability:
– Are data points about the same thing comparable?
– Are data points collected by different observers
comparable?
Data and measures must be reliable to be
valid but reliable data is not always valid
Training and careful
preparation of tools can
increase reliability of data
Federal Aviation
Administration
SL-110
System Assessment
System
Operation
• Are objectives being met? (“Happy loop”)
• Risk controls failing due to:
–
–
–
–
Lack of supervision
Lack of resources
Lack of training
Poor job aids
Data
Acquisition
& Process
Analysis
System
Assmt
Preventive/
Corrective
Action
• New Hazard/failed Risk Controls
(redesign - back to SRM)
• Prioritize according to safety criticality
(triage)
Federal Aviation
Administration
SL-111
Preventive/Corrective Actions
System
Operation
• Revised policies
Data
Acquisition
& Process
• New procedures
Analysis
• Equipment changes
System
Assmt
Preventive/
Corrective
Action
• Enhanced training
• Schedule changes
• Assignment of responsible persons
Federal Aviation
Administration
SL-112
Management Review
Top management will conduct regular
reviews of the SMS, including:
• The outputs of SRM & SA
• Lessons learned
• Need for changes
Federal Aviation
Administration
SL-113
Continuous Improvement
The organization shall continuously improve
the effectiveness of the SMS through:
• Safety and Quality Policies
• Safety Objectives
• Audit & Evaluations
• Analysis of Data
• Corrective and Preventive Actions
• Management Reviews
AC 120-92
Federal Aviation
Administration
SL-114
Federal Aviation
Administration
SMS Details:
Safety
Promotion
Component
Federal Aviation
Administration
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SL-115
Promotion: Definition
Safety promotion = a combination of:
• Safety Culture,
• Training and
• Knowledge Sharing
activities that support the implementation and
operation of SMS in an organization
Organizations must promote safety as a
core value with practices that support a
positive safety culture. AC 120-92, App. 1
Federal Aviation
Administration
SL-116
Culture
Management
Employees
Communication
Informed:
People understand the hazards & risks
Learning:
The company learns from mistakes. Staff are
updated on safety issues by management.
Just:
Employees know what is acceptable
& unacceptable behavior.
Reporting:
All personnel freely share critical safety
information.
AC 120-92
Federal Aviation
Administration
SL-117
What gets communicated upward?
4%
Problems known to
top management
9%
Problems known to
middle management
74%
Problems known to
supervisors
100%
Problems known to rank
and file MX personnel
Source: Yoshida, Shuichi, 2nd
Intl Quality Symposium, 1989
Federal Aviation
Administration
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SL-118
To Support a Sound Safety Culture:
1. Senior management commitment
2. Senior management visibility
3. Safety accountability framework
4. Safety policy, goals, objectives, standards,
and performance
5. Effective employee safety reporting system
6. Safety information system
7. Resource commitment
Federal Aviation
Administration
SL-119
Training and Communication!
• Employees must understand the SMS
• Employees benefit from safety lessons learned
• Explain why particular actions are taken
• Develop awareness of hazards
• Foster open reporting of safety concerns
• Initial and ongoing training
Example Safety Promotion Video
Federal Aviation
Administration
SL-120
Personnel Competencies and SMS
Training
• Identification of competency requirements
• Selection and hiring criteria and standards
• Training
• Skill competency
– Initial training
– Recurrent training
– Continuous communication
Federal Aviation
Administration
SL-121
ISD Processes
SMS Processes
Analyze
SRM: System/ Task
Description & Analysis
Design
Develop
•Safety Critical Job Tasks
•Competencies (KSA’s, etc)
•Target audience characteristics
•Training Tasks
•Qualification Standards (SRM risk Control)
•Courseware
•Medium
•Lessons, Exercises, Activities
•Tests, Evaluations
SA: Monitoring
Implement
Evaluate
•Training Delivery
•Records
•Testing/Qualifying
SA: Assessment
•Student Evaluation/critique
•Instructor Critique
•OJT & performance observations
Federal Aviation
Administration
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SL-122
Commitment to SMS
•Documents alone will not
guarantee development of
a positive safety culture.
•Employees must see evidence of
management commitment to SMS.
Management Attitudes & Actions =
the most important factor.
ICAO Doc. 9859
Federal Aviation
Administration
SL-123
Federal Aviation
Administration
SMS Guidance,
Tools and
Implementation
Federal Aviation
Administration
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SL-124
SMS Guidance and Tools
•
•
•
•
•
ICAO Doc 9859: Safety Management Manual (SMM)
FAA Order 8000.369: FAA SMS Guidance
Order VS 8000.367: AVS Requirements Document
SMS Standard: AC 120-92 Appendix 1
Voluntary Implementation Guidance (Multiple Docs)
Federal Aviation
Administration
SL-125
ICAO and FAA SMS Framework
Policy
(Structure)
Safety Risk
Managemen
t
Safety
Assurance
Elements:
3.1 Safety Performance Monitoring & Measurement
•Elements:
Process 3.1.1 Continuous monitoring
•2.1
Process
Internal audits
operational depts.
Hazard3.1.2
identification
andby
analysis
Elements:
• 1.1Process
3.1.3
Internal
evaluation
Process
2.1.1
System
and task analysis
Safety
Policy
•
Process 3.1.4 External auditing of the SMS
Process 2.1.2
Hazard identification
1.2
Management
Commitment
& Accountabilities
Elements:
•
Process 3.1.5 Investigation
2.2
assessment
and Training
control
1.3Risk
Key
Safety Personnel
Competencies
and
• 4.1
Process
3.1.6 Employee
reporting and feedback syst.
Process
Analyze
risk
Emergency
Preparedness
and
Response
Process
4.1.1
Personnel
requirements
• 1.4Process
3.1.72.2.1
Analysis
of datasafety
Process
Assess
safety
risk
SMS
Documentation
and
Records
• 1.5Process
3.1.82.2.2
System
assessment
Process
4.1.2
Training
• 4.2
Process
3.1.92.2.3
Preventive/corrective
Process
Control
safety action
risk
Communication
and Awareness
•
Safety Promotion
(Culture)
Process 3.1.10 Management review
3.2 Management of Change
3.3 Continual Improvement
Federal Aviation
Administration
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SL-126
Federal Aviation
Administration
SL-127
Start
SRM
System
Analysis
(Design)
Hazard
Ident
Risk
Analysis
Inputs: 2.0(B)(2)(a),(b) & (d)
•New System
•System Change
•New Operational Procedure
2.1.1
2.1 Hazard
Identification
& Analysis
2.1.2
Inputs: 2.0(B)(2)(c)
From SA: 3.1.8(B)(3)
2.2.1
2.2 Risk
Assessment
& Control
2.2.2
Risk
Assmt
Evaluate
Controls
2.2.3(B)
(2) & (3)
Risk
Control
Outputs: To SA 3.0(B)(1)(b)
2.2.3
Federal Aviation
Administration
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SL-128
SA
Inputs:
From SRM 2.2.2(B)
& 2.2.3 (B)(2)(b)
To SA:
3.0(B)(1)(b)
System
Operation
Data
Acquisition
& Process
Analysis
Outputs: 3.1.8(B)(3)
To SRM 2.0(B)(2)(c)
System
Assmt
Preventive/
Corrective
Action
Per 2.1.1 including
Risk Controls per 3.1.3
*
3.1 Safety
Performance
Monitoring
and Measurement
3.1.1 Continuous Monitoring
3.1.2 Internal Audits
3.1.3 Internal Evaluation
3.1.4 External Evaluation
3.1.5 Investigations
3.1.6 Employee Reporting
How is this going to be
analyzed? By whom?
3.1.7 Analysis of Data
3.1.8 System Assessment
3.1.10 Management Review
3.1.9
*
Note: Each data source should be traceable
through analysis (3.1.7(B)(1)), assessment and
Corrective Action (3.1.9(B)(1) where necessary.
Federal Aviation
Administration
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SL-129
External
Internal
Decision by
Organization
Inputs
Previous Process
Interface – (I)
Process
Controls (C)
•Procedural
•Supervision
•Assurance
Processes
Responsibility (R)
Activities
•Accountable for
process output
Authority (A)
Procedures (P)
Empowered to:
•Make key
decisions
•Alter process
Outputs
•Deliverable – Performance Measures (PM)
•Destination – Interface (I)
Federal Aviation
Administration
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SL-130
Each Element/Process has a
Performance Objective that
defines the expected outcome
of
the process.
Design
expectations are then
defined that outline characteristics
of a well
designed
process.
Inputs
tell us
where the
process
These are organized in terms of the
starts:
Management
tells us:
six
•Aattributes.
decision Responsibility
on the part of the
•Who is accountable for process
company
completion
(Responsibility)
Each
process
has
a
number
of
•The
output
of
a previous
Finally,
the
“Bottom
Line
Assessment”
takes
us
Every
process
has
an
output.
There
are
two
activities
–objective
theis“things
peopleto:
do”
•Who
empowered
process
(Interface)
back
to
the
–
will/does
the process
aspects
to
outputs:
(Procedures)
Make key
decisions
in the
achieve
its intended
outcome?
(Affirmation)
•Evidence
of accomplishment
(Process
process
(Authority)
Measures)
Alter or deviate from the
process
•Destination
of (Authority)
the output (Interfaces)
Some critical processes also
have
Controls
Federal
Aviation
SL-131
Administration
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SMS Implementation
• Should follow a Phased
Approach
• The processes underlying the
four components will be
modularized
• “Growth” or “increasing
maturity” will then be
emphasized for each process
and the system as a whole
Federal Aviation
Administration
SL-132
SMS Voluntary Implementation: Pilot
Projects
• Pilot Project activities commenced in 2007
• Voluntary SMS development
• AFS combined effort
• Objectives are to Develop:
– Implementation strategies,
– Oversight interfaces, and
– Gain experience for FAA and Service Providers
Federal Aviation
Administration
SL-134
SMS Implementation Process
4
3
2
1
0
Continuous
Improvement
Proactive
Processes
Reactive
Processes
Planning &
Organization
Orientation &
Commitment
Federal Aviation
Administration
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SL-135
Who’s Involved in Implementation?
• The Operator/Service Provider
• The Certificate Management
Organization (CMO, FSDO, CHDO)
• The SMS Standardization and Assistance
Team (STAT)
Federal Aviation
Administration
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SL-136
SMS Transition Assistance Team (STAT)
• Provides Standardization and Assistance to
operators and CMT’s in voluntary SMS projects
• Under direction of AFS SMS Program Office (PO)
– Team members currently from:
• SMS PO
• FAASTeam
• HQ Policy Divisions
• All activities coordinated with appropriate certificate
oversight offices
Federal Aviation
Administration
SL-137
Safety Management System
Focus Group (SMSFG)
Voluntary implementation user’s group
• Provides a two-way communications
mechanism between SMS PO and
participants in voluntary implementation
• Provides a forum for knowledge sharing
among participants
Federal Aviation
Administration
SL-138
Level 1: Planning & Organization
Charting the Course
• Preliminary Gap Analysis: Evaluating
existing processes, programs, and
practices for safety management
• Develop Safety Policy
• Develop Implementation Plan
• Organizing for Implementation
Federal Aviation
Administration
SL-140
Level 1 - Meetings
Session 1 is a 2-day event
•
Day 1- STAT Briefing:
–
–
–
–
•
SMS Tutorial – 4-Hr. In-Depth Overview
In-depth walk-through of the Framework & Assurance Guide
Preliminary Audit/Gap Analysis Tool
Detailed Audit/Gap Analysis Tools
Day 2 - Service Provider & CMT jointly Perform
Preliminary Gap Analysis
–
–
Schedule Operator’s Detailed Gap Analysis
The operator may require 4 to 6 months to complete the
detailed gap analysis. STAT and CMT will be available on call
while the operator is performing this task.
Federal Aviation
Administration
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SL-142
Level 1 - Expectations
• Service Provider/Certificate Holder
–
Sessions 1
•
–
Session 2
•
•
•
•
–
Complete preliminary gap analysis
Completed detailed gap analysis utilizing the detailed audit/gap
analysis tools
Brief gap analysis results
Brief gaps and how they will be addressed
Provide evidence of conformity
Session 3
•
•
•
•
Present implementation plan
Complete the required documents
Meet the requirements of the exit criteria for this phase
Provide process inputs to the STAT
Federal Aviation
Administration
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SL-146
Level 1 - Expectations
Oversight Organization
– Review and utilize audit/gap analysis tools
– Attend audit/gap analysis meetings with the operator
– Participate in meetings with the STAT and operator
– Review the operator’s implementation plan and other
documents
– Discuss the requirements of the exit criteria for this
phase with the operator and STAT
– Provide input to the STAT regarding the SMS
implementation, documents and audit tools
Federal Aviation
Administration
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SL-147
Level 2: Reactive Processes
Basic Risk Management
• Setting up the information infrastructure and processes
• Going after known problems: Reactive Hazard
Identification
• Designing and implementing risk controls
• Non-punitive voluntary employee reporting system
• Documentation
• Training
– Training commensurate with this level of
implementation phase maturity
Federal Aviation
Administration
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SL-149
Level 3: Proactive Processes
Looking Ahead
• System and task analysis of the
operational (production) systems
• Proactive Hazard identification
• Updating:
– Risk controls
– Documentation
• Additional specialist training
Federal Aviation
Administration
SL-151
Level 4: Continuous Improvement
Continued Assurance
• Mature safety assurance process
– Analysis of data
– System performance assessment
– Corrective/Preventive action: Maintaining the
controls
– Identifying new and emerging hazards
• Management Reviews: Formal involvement
• Documentation & Training as required
Federal Aviation
Administration
SL-153
SMS Studies and Analysis
4
Phase 2:
2
1
0
Proactive
Processes
3
Experience
Continuous
Improvement
Reactive
Processes
Planning &
Organization
Orientation &
Commitment
Phase 1:
Readiness
Federal Aviation
Administration
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SL-155
Organizations
Federal Aviation
Administration
SL-156
AFS SMS Program Office (PO)
Authorized by Order FS1100.1A:
– AFS SMS Policy
– Focal point for SMS rulemaking
– Oversight and coordination of voluntary SMS
implementation and testing
– Integration with oversight systems
– Policy, guidance, and tool development
– Training and outreach development and coordination
Federal Aviation
Administration
SL-157
FAASTeam (FAA Safety Team)
• Participate in STAT team efforts
• Conduct outreach sessions for CMTs and
service providers
• Assist SMS PO in development of:
–
–
–
–
Guidance material
Promotional Material
Development and Delivery of Training
Promotional web presence for SMS
Federal Aviation
Administration
SL-158
SMS Transition Assistance Team (STAT)
• Provides Standardization and Assistance to
operators and CMT’s in voluntary SMS projects
• Under direction of AFS SMS Program Office (PO)
– Team members currently from:
• SMS PO
• FAASTeam
• HQ Policy Divisions
• All activities coordinated with appropriate certificate
oversight offices
Federal Aviation
Administration
SL-159
MITRE Corporation Involvement
• MITRE is a Federally-Funded Research and
Development Corporation (FFRDC)
• MITRE assists the AFS SMS PO in:
– SMS Pilot Project (SMSPP) activities
– Studies and analysis to support development of
SMS implementation and oversight strategies
Federal Aviation
Administration
SL-161
Federal Aviation
Administration
Summary
Federal Aviation
Administration
Downloaded from www.avhf.com
SL-163
Safety Management System
Provides a systematic way to:
1. Identify hazards and control risk
2. Provide assurance that risk controls are effective
Policy
(Structure)
Safety Risk
Managemen
t
Safety
Assurance
Safety Promotion
(Culture)
Federal Aviation
Administration
SL-164
Roles, Responsibilities & Relationships
AVS SMS = FAA Safety Programme (SSP)
FAA Internal SMS
(SSP & Oversight)
External SMS
Flight Standards
Air Operators/
Service Providers
Safety Policy
Safety Policy
Safety Risk
Management
Safety
Assurance
Safety
Promotion
FAA Act 44702
CFR’s (aka FAR’s)
Field Divisions (Oversight)
Safety Risk
Management
Safety
Assurance
Design Assurance (Certification,
SAS
Prgrm. Apprvl./Accept., Cert. Mgt)
Safety
Promotion
Performance Assurance (Surveil., Plus)
Federal Aviation
Administration
SL-165
Safety Management System
Provides
1. Increased Safety
2. International Harmonization
3. Improved Organizational
Effectiveness
Federal Aviation
Administration
SL-166
“Carelessness and overconfidence are more
dangerous than deliberately accepted risk”
Wilbur Wright, 1901
Contact:
SMS Program Office Manager
Don Arendt, Ph.D.
(703) 661-0516
[email protected]
Wilbur Wright gliding, 1901
Photographs: Library of Congress
Federal Aviation
Administration
SL-167

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