Module Six

Advanced Safety Assurance

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Module Objectives

• Review Safety Assurance

• Evaluate the link between Safety Assurance

and Operations Risk Management

• Assess the benefits of SMS

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Safety Assurance

Planned and systematic actions necessary to

afford adequate confidence that a product, a
service, an organization or a functional
system achieves acceptable or tolerable
safety

SMS process management functions that

systematically provide confidence that
organisational products/services meet or
exceed safety requirements

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Being in Control

• Examples of controlling a process:

– Driving a car
– Flying an aircraft
• Managing safety
– Process: vaguely known (HIRAM & SA)
– Goal: defined by exclusion (no risk)
– Controls: badly understood

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SA Components

• Safety performance monitoring and

measurement
• Safety records
• Management of change
– Risk assessment on organization’s changes
• Continuous improvement of SMS
– System assessment

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SA Purpose

• Assurance creates confidence as required by:

– Accountable Manager
– Regulators
– Staff
– Customers
– All stakeholders

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SA Processes

• Monitoring and feedback of the SMS

performance
• Safety audits
• Ensuring that, once controls are implemented the
organization assures that they continue to be in
place and that they work as intended

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On-going Process

• A process of permanent examination, analysis

and assessment of risk controls must continue
throughout the daily operation of the system
• Monitor residual risk level
• Monitor new hazards in operations
• Manage daily operational risk

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SA Elements

• Regulatory compliance remains important (QMS)

• Formal auditing and evaluation
• Investigations of safety-related events and
occurrences
• Continuous monitoring of day-to-day activities
• Assessments of sub-contractors
• Assessments of change

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SA Inputs

• Employee input into the following provides

feedback on effectiveness:
-Hazard reporting
-Safety studies
-Safety reviews
-Safety surveys
-Internal safety investigations

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SA Inputs

• Hazard analysis to identify hazardous conditions for

the purpose of their elimination or control
• Safety Analysis as a detailed demonstration of safety
• Safety studies to assess risks of accident
• Safety reviews to examine the level of safety
• Safety Survey to recommend improvements where
needed
• Internal Safety Investigation to study the facts and
circumstances surrounding an occurrence
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SA as part of RM

• Systems-based approach that focuses on the

identification of hazards involved in each aspect
of the operation
– Flight operations
– Cockpit procedures
– Aircraft maintenance
– Turn-around
– Ticketing
– Scheduling
– Baggage handling
– Etc..

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SA and ORM

• While SMS is a strategic approach to safety,

Operational Risk Management (ORM) is a tactical
application of SMS
• ORM is a continual cyclic process aiming at
controlling operational risks
• It is an integral and required part of a SMS
• A well functioning ORM becomes an integral part of
an SMS SA process

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Safety Control

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Safety Performance Monitoring

• Performance monitoring is one, not all, means of

measuring progress towards safety goals
• It is also used to monitor trends associated with
operations safety
• This is usually done defining a set of relevant and
meaningful safety indicators (SPI), or KPI like in
any other management area

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Setting SPIs

• By reviewing the safety controls in place, we must

ask ourselves:
– What can go wrong?
– What controls are in place to prevent
occurrences?
– What does each control deliver as outcome?
– How do we know they continue working as
intended?

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SPI Dimensions

PERSONAL PROCESS
SAFETY SAFETY

LEADING LAGGING

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Personal v/s Process Hazards

• These distinction comes from OHS distinguishing

personal risks and plant risks.
• In aviation personal refers to Human Factors
issues that could affect operational safety such
as:
– Crew conduct
– Engineer & technicians' actions
– Operational personnel behavior

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Lagging Indicators

• Lagging indicators are a form of reactive

monitoring requiring the reporting and
investigation of specific incidents and events to
discover weaknesses in that system
• They show when a desired safety outcome has
failed, or has not been achieved
• They provide historical information about safety
performance (what happened happened, we look
at preventing reoccurrence)
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Leading Indicators

• Leading indicators are a form of active

monitoring focused on a few critical risk control
systems to ensure their continued effectiveness

• They require a routine systematic check that key

actions or activities are undertaken as intended

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Leading Indicators

• Leading indicators of safety performance are

used as predictors of safety performance
• Leading indicators of safety performance are
numerous, but harder to determine
• This may be a factor as to why leading indicators
have not been widely used in the past
• In SMS, leading indicators are expected to
increase considerably

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Being Proactive

• The advantage of using leading indicators is that

actions can be taken to alter the course of safety
performance
• If an indicator predicts poor performance, it is
not necessary to wait to see if the prediction is
correct (this would not be managing safely)
• Changes can be implemented to increase the
probability of good safety performance

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Examples
• Quality of recurrent training
• Regular Audits of Safe Crew Behavior
• Results of Crew Observations
• Level of involvement of staff in the safety process
(reporting, surveys, etc..)
• Level of job satisfaction when working
• Skill level of the personnel
• Job Hazard Analysis (JHA) in planning operations
• Safety meetings (MRM, SAG, etc..)
• Safety tours and surveys
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Examples

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Indicators & Control

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Indicators in Context

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Safety Audits

• Used to ensure that the structure and processes

of the SMS is sound
• Implemented at all levels
• Complies with approved requirements,
procedures and instructions
• Staff are competent to:
– Operate equipment and facilities
– Maintain their levels of performance

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Safety Investigation

• All occurrences shall be investigated, like

– In-flight turbulence (flight operations)
– Frequency congestion (ATC)
– Material failure (Maintenance)
– Ramp vehicle operations (Aerodromes)

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activities. More often people are inclined to define smaller system boundaries than is required (such as

Depth of Investigation
Scenarios 1 and 2 presented in Section 2).

Four levels of thinking as a guide to deep thinking

There is another dimension of systems thinking which consists of four levels of thinking shown in
Figure 1.

Figure 1. Four levels of thinking (Adapted from: Maani and Cavana [5], p. 16, Figure 2.1).
Ease Effectiveness

Events

Patterns

Systemic structures

Mental models

The four levels of thinking shows the depth of thinking in a vertical way by focusing on events,
patterns, systemic structures and mental model levels [5]. The analogy of an iceberg is used to describe
the four levels of thinking where the only visible part is the events level which often requires immediate
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attention [5]. In most situations, managers prefer to address issues at the events level because they are 30
visible. However, the level of events thinking is the shallowest; actions based on events thinking are
ALoSP
• SPI: based on current data or best estimate of
current situation
• SPT: Medium or long-term objectives of a safety
programme or an SMS
- Reduce the number of un-stabilized approaches
by 10 % by December 2022
• Safety Action to achieve targets:
– Investigate root cause of un-stabilized approaches
– Act based on outcome of investigation (training,
awareness, briefings, etc..)
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Selection Sources

SPTs
ü Reporting
ü Investigations
ü Audits Alert Level
ü Monitoring
ü Studies
SPIs
ü Reviews
ü Surveys

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SPIs & SPTs
• Performance Monitoring is basic business
management (KPI/KPT for budget control,
personnel management, etc..)
• Therefore, organizations must:
– Develop action plans and set alert levels
– Verify the safety performance against targets
– Validate the effectiveness of safety risk controls
– Verify safety performance in relation to the SPIs
and SPTs of the SMS
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 Measurement

Lines -of-Defence Lines-of-Defence

s of ess of
u re aten s
re ess
s
a pri su
a iven
e
M pro e
M e ct
Ap Eff Decision
Measurement Measurement
+
1 2 resource
allocation
DATA

Safety Management
DATA INFORMATION Decision-Making
Measurement
3

Measures of Effective
Safety Management

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Safety Health

• The organizations safety health, also called

resilience, refers to its ability to defend itself
against the unknown and to adapt
• The intrinsic ability of a system to adjust its
functioning during changes and disturbances
• It is achieved by responding, learning, monitoring
and anticipating risks
• It is an indicator of an effective Safety Culture

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Evaluating the SMS

• Three principle measures:

– Is the SMS sound?
– Are safety activities appropriate?
– Are safety activities effective?

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Soundness

• Does the company have a policy that explicitly

states a safety performance goal?
• Does the company’s SMS provide the necessary
infrastructure to achieve that goal?
• Are the SMS tools being used:
– Tactically, in day-to-day management?
– Strategically, to enhance safety performance?

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Appropriateness

• Does the company know its key risks?

• Have the key risks been validated?
• Does it employ a process to proactively
identify hazards and mitigate risk?
• Does it have appropriate feedback
mechanisms? (Internal & external)

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Effectiveness

• Is safety feedback sought? Valued? Used?

• Are there “disconnects” in safety attitudes or
values (functionally or hierarchically) ?
• Is everyone knowledgeable, involved and
committed?
• Are corrective and mitigation action taken, as
planned?

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SMS Maturity

• SMS develops in 4 stages:

1. Program under development
2. Program documented, approved, resourced
and being implemented
3. Program functioning, results being
measured
4. Program sustained and supported by an
ongoing improvement process

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SSD

• At every stage we should be able to measure

the System Safety Deficiencies (SSD) in order
to remedy them
System Safety
Deficiency

Hazard H H H

R Mitigation
R
R
R

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Origins of SSDs

• New Hazard(s) = Unmitigated risk = Potential

SSD

• Old Hazard(s) = Inappropriate or ineffective

mitigation = Potential SSD

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PDCA Cycle

Dr. Edward Deming

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 PDCA

• Plan: establish the objectives and processes

necessary to deliver results in accordance with
customer requirements and the organization's
policies
• Do: implement the processes
• Check: monitor and measure processes and
product against policies, objectives and
requirements for the product and report the
results
• Act: take actions to continually improve process
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Continuous Improvement

• The implementation of the PDCA cycle in the

management system will result in continuous
improvement of that system
• The implementation of that cycle in SMS will
ensure that it will continuously improve and
make the safety system more resilient
• Abiding by the PDCA cycle becomes more critical
in times of economical and social challenges

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Trainee can now

• Review Safety Assurance

• Evaluate the link between Safety Assurance

and Operations Risk Management

• Assess the benefits of SMS

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Questions?

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