Safety Management System & Crew Resource Management

Day 1

Safety Management System

Basic Safety Concepts

Objective

At the end of this topic, you will be able to explain the strength and weaknesses of
traditional methods to manage safety, and describe new perspectives and methods for
managing safety.

Concepts of Safety

What is SAFETY?

Most people think of safety as:

 Zero Accidents (or serious incidents);

 Freedom from danger or risks;
 Error Avoidance; and
 Compliance to regulations

Consider that there is a weakness in the notion of perfection because:

 The elimination of accidents (and serious incidents) is unachievable;

 Failures will occur, in spite of the most accomplished prevention efforts; and
 No human endeavour or human-made system can be free from risk and error.

But, controlled risk and controlled error is acceptable in an inherently safe system.

People and Safety

Aviation workplaces involve complex interrelationships among its many components. To

understand operational performance, we must understand how it may be affected by the
interrelationship among the various components of the aviation work places.

SHEL(L) MODEL

Creates understanding in the relationship between people and operational contexts

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Fig. 1 - The SHEL(L) Model

Understanding Operational Errors

Human Error is considered a contributing factor in most aviation occurrences and even competent
personnel commit errors.

Error must be accepted as normal component of any system where humans and technology
interact.

The “Three Strategies to Control Human Error”

Reduction – This strategy intervene at the source of the error by reducing or eliminating the
contributing factors.

Capturing – This strategy intervene once the error has already been made, capturing the error
before it generates adverse consequences.

Tolerance – This strategy intervene to increase the ability of the system to accept errors without
serious consequences.

Culture

Culture binds people together as members of the group and provides clues as how to behave in
both normal and unusual situations.

Culture influences the values, beliefs and behaviours that people share with other members of
various groups.

The “Three Distinct Cultures”

National Culture – encompasses the value system of particular nations.

Organizational Culture – differentiates the values and behaviours of particular organizations.

Organizational/Corporate Culture sets the boundaries for acceptable behaviour in the

workplace by establishing norms and limits, and it also provides a frame work for
managerial and employee decision making. Most of the time this culture revolves around
– “This is how we do things here, and how we talk about the way we do things here”.

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This culture also shapes among many others, safety reporting procedure and practices by
operational personnel.

Professional Culture – differentiates the values and behaviours of particular professional groups.

Safety Culture

It is a trendy notion with a potential for misperceptions and misunderstanding. It is the outcome
of a series of organizational processes. This culture is not an end in itself, but a means to achieve
an essential safety management prerequisite which is “effective safety reporting”.

Fig. 2 - Elements of Safety Culture

Organization and the Management of Information

 Pathological – Hide the Information

 Bureaucratic – Restrain the information
 Generative – Value the information

Introduction to Safety Management

Objective

At the end of this module, participants will be able to explain the need for, the strategies and the
key features of safety management.

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Safety Management

In order to achieve its production objectives, the management of any aviation organization
requires the 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. This brings about a potential dilemma for management.

Safety issues are a by-product of activities related to production/service delivery.

An analysis of an organization’s resources and goals allows for a balanced and realistic allocation
of resources between protection and production goals, which supports the needs of the
organization

The product/service provided by any aviation organization must be delivered safely (i.e.
Protecting users and stakeholders).

Fig. 3 Protection/Production Chart

Types of Safety Management

Reactive Safety Management

Involves investigation of accident and serious incident, based upon the notion of waiting until
something breaks to fix it.

Most appropriate for:

 Situation involving failures in technology.

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 Unusual events.
The contribution of reactive approaches to safety management depends on the extent to which
the investigation goes beyond the triggering cause(s), and includes contributory factors and
findings as to risks.

Proactive Safety Management

Involves mandatory and voluntary reporting systems, safety audits and surveys and based upon
the notion that system failures can be minimized by identifying safety risks within the system
before it fails and taking the necessary actions to reduce such safety risks.

Predictive Safety Management

Involves confidential reporting systems, flight data analysis/test flights, normal operations
monitoring and based upon the notion that the safety management is best accomplished by
looking for trouble, not waiting for it.

This type of safety management aggressively seeks information from a variety of sources which
may be indicative of emerging safety risks.

The Imperative of Change

As global aviation activity and complexity continues to grow, traditional methods for managing
safety risks to an acceptable level become less efficient and effective

Evolving methods for understanding and managing safety risks are necessary.

Eight (8) Building Blocks of Safety Management

1. Senior management’s commitment to the management of safety.

2. Effective safety reporting.

3. Continuous monitoring through systems to collect, analyze and share safety – related data
arising from normal operations.

4. Investigation of safety occurrences with the objective of identifying systematic safety

deficiencies rather that assigning blame

5. Sharing safety lessons learned and best practices through the active exchange of safety
information.

6. Integration of safety training for operational personnel

7. Effective implementation of Standard Operating Procedures (SOP’s) , including the use of

checklists and briefing.

8. Continuous improvement of the overall level of safety.

Responsibilities of managing SAFETY

These responsibilities fall into four basic areas:

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1. Definition of policies and procedures regarding safety.

2. Allocation of resources for safety management activities.

3. Adoption of best industry practices.

4. Incorporating regulations governing civil aviation safety.

Hazards

Objective

At the end of this module, participants will be able to apply the fundamentals of hazard
identification and analysis through a case study.

Hazard

Condition, object or activity with the potential of causing injuries to personnel, damage to
equipment or structures, loss of material or reduction of ability to perform a prescribed function.

Consequence

Potential outcome(s) of the hazard

Four Fundamental of Hazards

1. Understanding Hazards

Types of Hazards – Natural, Technical and Economic

2. Hazard Identification

Sources of hazard identification – Internal and external

3. Hazard Analysis

This is the cost-effect analysis of the hazard’s outcome.

4. Hazard Documentation

It is a formal procedure to translate operational safety data into hazard-related

information.

The focus of Hazard Identification

Hazard identification is a wasted effort if restricted to the aftermath of rare occurrences where
there is serious injury, or significant damage.

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Day 2

Safety Risks

Objective

At the end of this module, participants will be able to apply the fundamentals of safety risk
management through a case study.

Safety Risk

The assessment, expressed in terms of predicted probability and severity, of the consequences of
a hazard taking as reference to the worst foreseeable situation.

Five Fundamentals of Safety Risks

1. Risk Management

It is the identification, analysis and elimination and/or mitigation to an acceptable level of

risks that threaten the capabilities of an organization. It also aims at a balanced allocation of
resources to address all risks and viable risk control and mitigation

It is a key component of safety management system and a data-driven approach to safety

resources allocation.

2. Risk Probability

The likelihood that an unsafe event or condition might occur.

Qualitative Meaning Value

definition

Frequent Likely to occur many times 5

(has occurred frequently)

Occasional Likely to occur some times 4

(has occurred infrequently)

Remote Unlikely, but possible to occur (has occurred rarely) 3

Improbable Very unlikely to occur 2

(not known to have occurred)

Extremely Almost inconceivable that the event will occur 1

Improbable

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3. Risk Severity

The possible consequences of an unsafe event or condition, talking as reference to the worst
foreseeable situation.

Qualitative definition Meaning Value

Frequent Likely to occur many times 5

(has occurred frequently)

Occasional Likely to occur some times 4

(has occurred infrequently)

Remote Unlikely, but possible to occur (has occurred rarely) 3

Improbable Very unlikely to occur 2

(not known to have occurred)

Extremely Improbable Almost inconceivable that the event will occur 1

4. Risk Assessment

This fundamental combines the values of risk probability and risk severity to create the risk
matrix that is used to identify the tolerability of the safety risk.

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5. Risk Mitigation

Mitigation – measures to address the potential hazard or to reduce the risk probability or
severity.

Three strategies for Risk Mitigation

 Avoidance – the operation or activity is cancelled because risks exceeds the

benefits of continuing the operation or activity;
 Reduction – the frequency of the operation or activity is reduced, or action is
taken to reduce the magnitude of the consequences of the accepted risks.
 Segregation of Exposure – Action is taken to isolate the effects of the
consequences of the hazard or build-in redundancy to protect against it.

Crew Resource Management

Airline industry has reduced errors by 80% over the past 20 years by identifying that there is a
need to focus on the human operating in/at the aircraft. Through constant research and
experience in root cause analysis, it is therefore stated that most errors are preventable.

Crew resource management provides strategies to enhance crew’s ability to proactively recognize
and react to error and abnormalities, as such, there has to be an opportunity to speak up to be
able to use all available resources around us may it be human, financial and/or technical resource.

Cause of Accidents

The causation probabilities of an accident tips between the balances of human or technical
influences. An organization’s management is trying to balance this anomaly to have a safe yet
efficient business model.

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Fig. 4 Accidents by Primary Cause – Human Factor: 64%

Why Accidents Happen

Human performance problems influences 60-80% of all accidents and incidents. Improving human
performance skills utilizing CRM is a highly effective method to bring the accident/incident rate
down.

Open-minded Approach to Safety

Some things are just hard to let go or change when we are used to do it every day but, that is not
the case in aviation. “Because we’ve always done it that way” This phrase has become the most
powerful answer to any proposal for change, or any inquiry into how things may be done better.

In a nutshell Crew Resource Management (CRM) is the ability to use all available resources to
make the best decision under existing circumstances. Many of us do not use all the available
resources due to possible corporate or cultural barriers or attitudes.

Crew Resource Management is not the following:

 A quick fix
 An attempt to change personalities
 A substitute for technical skills; and
 Behavior dictated by management.

Communications

“Exchanging information, thoughts and feelings in a clear and understandable manner.”

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Fig. 5 Effective Communication Process

Feedback

Feedback is the only thing that allows the sender to be confident that the receiver understood
the message in the same terms as intended by the sender. It is also classified as :

 Acknowledgement
 Affirmation
 Agreement
 Confirmation
 Reinforcement
 Understanding

How do we communicate?

Fig. 6 Elements of Personal Communication

Verbal Communication

This type of communication includes but not limited to the following:

Speeches, Face-to-Face conversations, Telephone Conversations, Voicemail, Television and

Radio.

To ensure that the communication process is effective and complete we should be clear, crisp
and concise on our conversations.

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Non-Verbal Communications

“Non-Verbal” refers only to communication without words. This includes but not limited to the
followings:

Body language, Symbols, Signals, Cues, and Emotions.

Non-Verbal communication can be ambiguous but are seen more reliable and is sometimes used
in some polygraph test. When in doubt trust the non-verbal messages, it may subtle but often
quite powerful and most of the time honest to what the sender really wants to verse out. Some
non-verbal communication are also culture-bound and differs from nation to nation.

Because of non-verbal communication, you cannot not communicate.

Communication Barriers and Road Blocks

A communication barrier is anything that prevents understanding of the message. Many physical
and psychological barrier exist like having a cleft palate. Reading, speaking and listening to fast
could also pose as a communication barrier.

A communication road blocks may muffle the message like noise and others. The way to
overcome these roadblocks are through active listening and effective feedback.

Conflict

Conflict is a normal occurrence in group dynamics, it is also the natural result of people thinking.
Everyone should expect that some point in time there will be conflict in a group setting.

Conflict in the workplace can be incredibly destructive to good team work. Managed the wrong
way, real and legitimate differences between people can quickly spiral out of control, resulting
in situations where cooperation breaks down and the team’s mission is threatened.

Conflict Resolution

Conflict exist when one person has a need of another, and that need is not met.

There are steps that we as a group or an individuals can take in order to have a healthy conflict
resolution process or skills.

First we should always express our need so that the other party would have a clear view on
where we are standing. After expressing our needs, ask the question “Can the need be met?” if
the need can be met by both parties then the conflict is resolved. If not, continue to negotiate or
if resolution is deemed almost impossible then, enter a management of conflict with a third
party mediator.

Once group members are prepared for the inevitable, resolving conflict becomes an easier
experience. Conflict resolution techniques are an integral part of CRM. The principal key to
conflict resolution revolves around “what’s right, not who is right”.

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Human Element

The SUGAR model shows three key sources of influence for our trade-off decisions. It is these
three sets of influences that give rise to the name of the model – SUGAR – as follows.

The model depicts how the interaction of the factors producing our state, understanding and
goals at any moment influences our action (or decision) at that moment, and this cycle then
repeats at the next moment.

State

Refers to the sum total of our current temporary state (emotions) together with our more
permanent state (character).

Understanding

Includes the technical, social and cultural knowledge that allows us to carry out our tasks – often
as team members – within the prevailing rules, regulations, procedures and social norms of our
operational settings.

Crucially, our knowledge and interpretation in these areas is governed by a large range of
perceptual and cognitive biases that exert huge influence on our ability to make sense of things
and to decide what is relevant.

Goals

The aims we have, including our personal goals, our operational targets, and our organisational
objectives.

What these are, how clear we are about them, how much we want to achieve them, how
conflicting they are and how we balance them will also affect our judgments of what is most
important or most relevant at any particular moment.

Putting SUGAR in our TEA

TEA, to suggest what can be done to increase our awareness of the constant influences on our
behavior. We can constantly recalibrate our sense of risk with the actual risk we are taking by
remembering to:

Test our assumptions

Examine the implications of those assumptions being wrong

Act accordingly

With TEA, we can help decide the right trade-off between efficiency and thoroughness as we
work through our operational lives.

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Teamwork

Teamwork is always a combined effort, without the effort of everyone either big or small it
would not be possible. Teamwork is synonymous to synergy on where a whole is greater than
the sum of its parts. As crew working together as team attains better results.

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