ICAO SMS Module #3 - Introduction To Safety Management 2008-11 (E) PDF

Building an SMS
Safety Module 10
Phased approach to
Management SMS Implementation
System
Module N° 3 – Introduction Module 8 Module 9
SMS planning SMS operation
to safety management
Module 5 Module 6 Module 7
Risks SMS regulation Introduction to SMS
Module 1 Module 2 Module 3

Introduction Module 4
SMS course Basic safety to safety
introduction concepts Hazards
management
Revision N° 11 ICAO Safety Management Systems (SMS) Course 29/09/08 Module N° 3 ICAO Safety Management Systems (SMS) Course 2
Objective Outline
The safety stereotype
At the end of this module, participants will be able to The management dilemma
Need for safety management
explain the need for, the strategies and the key features of Strategies for safety management
The imperative of change
safety management. Safety management – Eight building blocks
Four responsibilities for managing safety
Questions and answers
Points to remember
Exercise Nº 03/01 – The Anyfield Airport accident (See
Handout N° 2)
Module N° 3 ICAO Safety Management Systems (SMS) Course 3 Module N° 3 ICAO Safety Management Systems (SMS) Course 4
ICAO Safety Management Systems (SMS) Course

Module N° 3 – Introduction to safety management
The safety stereotype Is it?
What is the fundamental objective of a

Really?
business organization?

Safety management – Rationale The management dilemma
In order to achieve its production objectives, the

management of any aviation organization requires the Management levels
management of many business processes.
Managing safety is one such business process.
Safety management is a core business function just as

financial management, HR management, etc.
Protection Production
This brings about a potential dilemma for management.
The management dilemma The management dilemma
Man s
age le vel
me ent
nt leve em
ls nag
Ma
Protection Production
Production Protection
Catastrophe Bankruptcy

Safety management – The response to the
Safety space dilemma
Financial
management ? Safety issues are a by-product of activities related to
production/services delivery.
Bankruptcy
An analysis of an organization's resources and goals allows
for a balanced and realistic allocation of resources between
e
Protection
pa c protection and production goals, which supports the

t ys
Sa
f e needs of the organization.
The product/service provided by any aviation organization
Catastrophe
must be delivered safely (i.e. protecting users and
stakeholders).
Safety
Production
management
Why SM ? – The first ultra-safe industrial

system Why SM? An imperfect system
Fragile system (1920’s -1970’s)

SMS
Individual risk management & intensive training Baseline performance
Accident investigation System
10-3 design
“Practical drift”
Safe system (1970’s – mid 1990’s) Operati
Technology and regulations Operational onal pe
rf ormance
Incident investigation deployment
Op
10-5 era
tio
Ultra-safe system (mid 1990’s onwards) n al p
Business management approach to erf
o rm
safety (SMS) an
ce
Routine collection and analysis of
Less than one catastrophic operational data
10-7 breakdown per million
production cycles

The essential is invisible to the eyes Navigating the drift
Number of occurrences Baseline performance

Op “Practical drift”
1–5 Accidents era
tio
n al p
erf
o rm
an Organization
30 – 100 Serious incidents ce
100 – 1000 Incidents

Navigational aids
Latent conditions
1000 – 4000 Reactive Proactive Predictive
Reactive safety management Proactive safety management

Investigation of accidents and serious incidents Mandatory and voluntary reporting systems, safety
¾Based upon the notion of waiting until something breaks audits and surveys.
to fix it.
¾Based upon the notion that system failures can be
¾Most appropriate for:
minimized by:
situations involving failures in technology.
unusual events. identifying safety risks within the system before it
¾The contribution of reactive approaches to safety fails; and
management depends on the extent to which the
taking the necessary actions to reduce such safety
investigation goes beyond the triggering cause(s), and
risks.
includes contributory factors and findings as to risks.

Predictive safety management Strategies – Summary
Confidential reporting systems, flight data analysis,
normal operations monitoring. Reactive method Proactive method Predictive method
¾Based upon the notion that safety management is best

The proactive
accomplished by looking for trouble, not waiting for it. The reactive method method
The predictive
method captures
¾Aggressively seek information from a variety of sources responds to the looks actively for the
system
events that already identification of
which may be indicative of emerging safety risks. happened, such as safety risks
performance as
it happens in
incidents and through the analysis
real-
real-time
accidents of the organization’
organization’s
normal operations
activities
Strategies – Levels of intervention and tools The imperative of change
As global aviation activity and complexity continues to

Baseline performance
grow, traditional methods for managing safety risks to an
Predictive Proactive “PracticalReactive
Reactive drift”
Op
era acceptable level become less effective and inefficient.
tiFDA
ona ASR ASR Accident
Directl pe r Surveys Organization
MOR and incident
observation forma Audits reports Evolving methods for understanding and managing safety
system nce
Highly efficient Very efficient Efficient Insufficient risks are necessary.
Desirable management
levels

The changing of the guard Safety management – Eight building blocks
Traditional – Accident/serious incident investigation n Senior management’s commitment to the management
¾Aviation system performs most of the time as per design
specifications (base line performance). of safety.
¾Compliance based. o Effective safety reporting.
¾Outcome oriented.
Evolving – Safety management
p Continuous monitoring through systems to collect,
¾Aviation system does not perform most of the time as analyse, and share safety-related data arising from
per design specifications (practical drift). normal operations.
¾Performance based.
¾Process oriented.
Safety management – Eight building blocks Safety management – Eight building blocks
q Investigation of safety occurrences with the objective of tEffective implementation of Standard Operating
Procedures (SOPs), including the use of checklists and
identifying systemic safety deficiencies rather than briefings.
assigning blame. uContinuous improvement of the overall level of safety.
r Sharing safety lessons learned and best practices The result of implementing the eight building blocks:
through the active exchange of safety information. An organizational culture that fosters safe practices,
encourages effective safety communication, and
s Integration of safety training for operational personnel. actively manages safety with the same attention to
results as financial management.

Responsibilities for managing safety The safety management process at a glance
These responsibilities fall into four basic areas: Identify

hazards
n Definition of policies and procedures regarding safety. Collect

Re-evaluate
additional Assess
o Allocation of resources for safety management control
strategies hazard
data
risks
activities.
Implement Safety Prioritize
p Adoption of best industry practices. control
strategies
management
process
risks
q Incorporating regulations governing civil aviation Approve Develop

Assign elimination/
control mitigation
safety. responsibilities
strategies strategies
In summary In summary
Managing safety requires resources. Safety management

¾Includes the entire operation
Allocation of resources is a managerial function.
¾Focus on processes (Clear difference between
Management has the authority and the responsibility to processes and outcomes)
manage safety risks in the organization. ¾Data-driven (constant monitoring)

¾Strictly documented
Management thus is accountable for safety outcome.
¾Gradual improvement as opposed to dramatic change
¾Strategic planning as opposed to piecemeal initiatives

A balanced perspective
…The pilot-in-command must bear responsibility for the

decision to land and take-off in Dryden… However, it is
equally clear that the air transportation system failed
him by allowing him to be placed in a situation where he
Introduction to safety management
did not have all the necessary tools that should have
supported him in making the proper decision … Question and answers
Questions and answers Questions and answers

Q: Explain the management dilemma regarding safety Q: Explain the difference between reactive, proactive and
management. predictive safety strategies.
A: A: Reactive method Proactive method Predictive method
Management levels
The proactive
The predictive
The reactive method method
method captures
responds to the looks actively for the
system
events that already identification of
performance as
happened, such as safety risks
it happens in
incidents and through the analysis
real-
real-time
accidents of the organization’
organization’s
normal operations
Protection Production activities
Slide number: 10 Slide number: 22


Questions and answers Questions and answers
Q: Explain the difference between the traditional and the evolving Q: Enumerate at least four building blocks of safety
approach to safety management. management.
A: A:
¾ Traditional – Accident/serious incident investigation 1. Senior management’s commitment to the
Aviation system performs most of the time as per design management of safety.
specifications (base line performance). 2. Effective safety reporting.
Compliance based. 3. Continuous monitoring through systems to collect,
Outcome oriented. analyse, and share safety-related data arising from
¾ Evolving – Safety management normal operations.
Aviation system does not perform most of the time as per 4. Investigation of safety occurrences with the objective
design specifications (practical drift). of identifying systemic safety deficiencies rather than
Performance based. assigning blame.
Process oriented.
Slide number: 25 Slide number: 26
Questions and answers Points to remember

Q: Enumerate the four basic responsibilities for managing 1. The dilemma of the two P’s.
safety.
2. The safety space
A:
1. Definition of policies and procedures regarding safety. 3. Why SM? An ultra-safe, yet imperfect system.
2. Allocation of resources for safety management 4. Safety management methods and their effectiveness.
activities.
3. Adoption of best industry practices. 5. The changing of the guard.
4. Incorporating regulations governing civil aviation 6. The eight building blocks and the four basic
safety. responsibilities for the management of safety.
Slide number: 29

The Anyfield Airport accident
In the early hours of a Monday-morning, a twin-engined jet
transport with 5 crew-members and 63 passengers on
board while in its take-off run at Anyfield Airport collided
with a small twin-engined propeller-driven aircraft, with only
a single crew-member that had intruded the departure-
runway.
Introduction to safety management Both aircraft were severely damaged as a result of the
Exercise 03/01 – The Anyfield Airport collision.
Most passengers and all crew members were killed.
accident (Handout N° 2)
The Anytown City Airport accident The Anytown City Airport accident
Group activity: … required task:
¾A facilitator will be appointed, who will coordinate the ¾ From the investigation report of the above accident,
discussion. you should identify:
¾A summary of the discussion will be written on flip 1. Organizational processes that influenced the
operation and which felt under the responsibility of
charts, and a member of the group will brief on their
senior management (i.e. those accountable for the
findings in a plenary session.
allocation of resources);
Required task: 2. Latent conditions in the system safety which
¾Read the text related to the accident of the twin-engined became precursors of active failures;
jet transport at Anyfield Airport. 3. Defences which failed to perform due to
¾… weaknesses, inadequacies or plain absence; …

The Anytown City Airport accident The organizational accident
… required task:
4. Workplace conditions, which may have influenced

operational personnel actions; and
5. Active failures, including errors and violations
When you have concluded the above, your task is to

complete the Table 03/01 – Analysis (Handout N° 2)
classifying your findings in accordance with the
organizational accident model.
Module N° 3 – Introduction
to safety management
Revision N° 11 ICAO Safety Management Systems (SMS) Course 29/09/08


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Building an SMS

Module 1 Module 2 Module 3

ICAO Safety Management Systems (SMS) Course

What is the fundamental objective of a

ICAO Safety Management Systems (SMS) Course

In order to achieve its production objectives, the

Managing safety is one such business process.

Safety management is a core business function just as

The management dilemma The management dilemma

ICAO Safety Management Systems (SMS) Course

pa c protection and production goals, which supports the

Why SM ? – The first ultra-safe industrial

Fragile system (1920’s -1970’s)

ICAO Safety Management Systems (SMS) Course

Number of occurrences Baseline performance

100 – 1000 Incidents

Reactive safety management Proactive safety management

ICAO Safety Management Systems (SMS) Course

¾Based upon the notion that safety management is best

Strategies – Levels of intervention and tools The imperative of change

As global aviation activity and complexity continues to

ICAO Safety Management Systems (SMS) Course

ICAO Safety Management Systems (SMS) Course

These responsibilities fall into four basic areas: Identify

n Definition of policies and procedures regarding safety. Collect

q Incorporating regulations governing civil aviation Approve Develop

Managing safety requires resources. Safety management

manage safety risks in the organization. ¾Data-driven (constant monitoring)

ICAO Safety Management Systems (SMS) Course

…The pilot-in-command must bear responsibility for the

Questions and answers Questions and answers

Slide number: 10 Slide number: 22

ICAO Safety Management Systems (SMS) Course

Questions and answers Points to remember

ICAO Safety Management Systems (SMS) Course

ICAO Safety Management Systems (SMS) Course

4. Workplace conditions, which may have influenced

5. Active failures, including errors and violations

 When you have concluded the above, your task is to

Revision N° 11 ICAO Safety Management Systems (SMS) Course 29/09/08

ICAO Safety Management Systems (SMS) Course

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In order to achieve its production objectives, the

Managing safety is one such business process.

Safety management is a core business function just as

As global aviation activity and complexity continues to

These responsibilities fall into four basic areas: Identify

Managing safety requires resources. Safety management

…The pilot-in-command must bear responsibility for the

When you have concluded the above, your task is to