4.safety Management Fundamental

Safety Management Fundamentals
Company Aviation Safety Officer Training
Agus Nugraha Sardjani

1
Objective
To introduce the participants
of principles and concepts of
accident prevention
pw/issue-4-2022 2
Background
• Role of the Operators (Pelita Air) must meet
the regulatory requirements to obtain and
hold an Air Operator Certificate (AOC)
• Operators (Pelita Air) must maintain the
highest level of safety in the public interest.
• A Safety Management System (SMS) gives
the operators (Pelita Air) management a
structured system to meet their legal and
regulatory requirements
pw_v3-2021 Airline Safety Investigation Training 3
ICAO Annex 19
Safety Management System
Airline Safety Investigation Training

Sistem Manajemen Keselamatan – “Suatu pendekatan
sistematis untuk mengelola keselamatan termasuk struktur
organisasi yang diperlukan, kewajiban, kebijakan dan prosedur
Safety Management
ICAO Doc 9859
✓ Safety management seeks to proactively mitigate

safety risks before they result in aviation
accidents and incidents.
✓ Through the implementation of safety management
can manage their safety activities in a more
disciplined, integrative and focused manner.
✓ Possessing a clear understanding of its role and
contribution to safe operations, prioritize actions
to address safety risks and more effectively manage
its resources for the optimal benefit of aviation safety.
pw_v3-2021 Airline Safety Investigation Training 7
SMS Start Implementation Prgram:
Airlines, January 1st, 2009
Airports, January
Airline Safety Investigation Training
1 st, 2010
The Four Pillars SMS
9
Safety
Management as a
systematic
approach to
managing safety
10
Role of Safety Officer
Required by regulation
The advisor to senior management
Duty and responsibility to manage SMS
pw/issue-4-2022 Company Aviation Safety Officer Training - INACA 11

Elements in Accident prevention
Roles and
Incident Reporting
Responsibilities for Safety Basics Managing Safety Risk Management
System
accident prevention
Safety Analysis, Investigating for

Management of Safety Information Assessing Safety
Studies and Accident
Safety Information Exchange Performance
Surveys Prevention
12
Stakeholders in safety
• Aircraft owners and operators;
• Manufacturers, (especially airframe and engine
manufacturers);
• Aviation regulatory authorities (e.g. DGCA, FAA,
EASA);
• Industry trade associations (e.g. INACA, IATA, ATA);
• Professional associations and unions (e.g. IPI, IATCA,
IFALPA, IFATCA);
• International aviation organizations (e.g. ICAO);
• Investigative agencies (e.g. KNKT); and
• The flying public.
13
• Next of kin, victims, or
persons injured in the
accident;
Additional groups • Investors;
• Insurance companies; • Coroners and police;
with an interest in
• Travel industry; • Media;
accident
• Safety training and • General public;
prevention when educational institutions
• Lawyers and consultants;
there is a major (e.g. Flight Safety
and
Foundation);
accident • Other government • Diverse special interest
investigation departments and groups.
agencies;
• Elected government
officials (i.e. politicians);

Scope of accident prevention
• Flight operations;
• Airworthiness;
• Cabin safety;
• Air traffic services;
• Aerodrome
operations, including
ground handling and
aircraft servicing; etc
• The traditional approach which
responds to particular safety events:
• Reacts to undesirable events by
prescribing measures to prevent
Approaches recurrence. It called reactive safety.
to accident • Is based upon ensuring minimum

standards are met; focused on
prevention compliance with and enforcement of
increasingly complex regulatory
requirements
• Accidents continued to occur in spite
of all the rules and regulations.
• The contemporary approach which
actively seeks out those conditions
which might enable a safety event, and
takes appropriate action to reduce the
Approaches risks - before an accident confirms the
existence of a safety problem.
to accident • It shift from a reactive mode to a
prevention proactive mode.
• Keep accident numbers at an
acceptable level.
• Considered to be effective in
preventing accidents.
• Senior management’s commitment to the company
safety programme;
• A corporate safety culture that fosters safe
practices, encourages safety communications and
actively manages safety with the same attention to
Other factors results as financial management;
that are
considered to • Effective implementation of SOPs, including the use
be effective in of checklists and briefings;
preventing • A non-punitive environment to foster effective
accident incident and hazard reporting systems (both
company and national level);
• Systems to collect, analyse, and share safety-related
data arising from normal operation (through such
programmes as Flight Data Analysis (FDA) and Line
pw/issue-4-2022 Operations Safety Audits (LOSA); 18
Application of scientifically-based, risk management
methods;
Competent investigation of accidents and serious
incidents, identifying systemic safety deficiencies
(rather than just targets for blame);
Other factors
that are Integration of safety training (including Human Factors
considered to training) into training programmes for operations
be effective in personnel;
preventing Sharing safety lessons learned and best practices
accident through the active exchange of safety information
(among companies and States); and
Systematic safety oversight programmes aimed at
assessing safety performance and reducing or
eliminating emerging problem areas.
pw/issue-4-2022 19
Roles and Responsibilities for accident prevention
• The responsibility for preventing

accidents goes well beyond the cockpit.
• It is a shared responsibility involving a
wide spectrum of organizations and
institutions.
image:www.jdasolution.aero
• It is organizational responsibilities.

Organizational responsibilities in accident prevention
• Defining policies and standards affecting accident prevention;

• Allocating resources to sustain accident prevention initiatives and
activities;
• Providing expertise for the identification and evaluation of safety
hazards;
• Taking safety action to eliminate or reduce systemic hazards to what
has been decided is an acceptable level of risk;
• Incorporating technical advances in design and maintenance of
equipment;

Organizational responsibilities in accident prevention
• Conducting safety oversight and accident prevention programme

evaluation;
• Contributing to the investigation of accidents and serious
incidents;
• Keeping abreast of best industry practices, adopting these as
appropriate;
• Promoting aviation safety (including the exchange of safety-related
information); and
• Amending regulations governing civil aviation safety as required.

Management roles in accident prevention
• Management has the authority and the responsibility to manage safety
risks in the company.
• Management has the ability to introduce changes in the organization,
its structure, its staffing, its equipment, policies and procedures.
• Management sets the organizational climate for safety.
• Management ensures that safety is an integral part of the
management plan:
• Clear direction in the form of credible policies, objectives, goals,
standards, etc.;
• Time for meetings, setting and communicating policies and
standards, etc.;
• Adequate resources to fulfil assigned tasks safely and efficiently;
• Expertise in terms of access to experience through safety
literature, training, seminars, etc. 23
Safety Basics,
safety concepts, the meaning…
• Zero accidents?
• A freedom from danger or risks?
• An attitude towards unsafe acts
and conditions by employees?
• Compliance?
• Risks in aviation are ‘acceptable’?
image:www.blogspot.com
•…
Safety is increasingly viewed as
‘the management of risk’.
Safety is considered to be the state in

which the risk of harm to persons or
property damage is reduced to, and
maintained at or below, an acceptable
level through a continuing process of
hazard identification and risk
management
Accident
Causation
Safety Management Fundamentals

Accident and Incident
Causation
• Understanding accident and incident causation is a key

to accident prevention.
• Since accidents and incidents are so closely related, no
attempt is made to differentiate accident causation from
incident causation.
Traditional view of Accident
causation
• Focus on outcomes (causes)
• Unsafe acts by operational personnel
• Attach blame/punish for failures to “perform
safely”
• Address identified safety concern exclusively
• Identifies: WHAT, WHO, WHEN
• But not always disclose: HOW, WHY
pw/issue-4-2022 28
Background
Evolution in Safety Thinking – Factors in Accidents
Technical Era Mechanical Improvement for better technology
Human Era Human Performance

CRM, DRM, TRM, HF-AM
Organizational Era Organizational Performance

Safety Management System
Total Era
1950 1970 1990 2000 Training 2010
Airline Safety Investigation
Concept of safety
• The elimination of accidents (and serious incidents) is

unachievable.
• Failures will occur, in spite of the most accomplished prevention
efforts.
• No human endeavour or human-made system can be free from
risk and error.
• Controlled risk and controlled error is acceptable in an
inherently safe system.
pw/issue-4-2022 30
Incidents: Precursors of accidents
• Typically there would have been

precursors evident before the accident
• Latent unsafe conditions may have
existed at the time of the occurrence
• Identifying and validating these unsafe
conditions requires an objective, in-
depth risk analysis
• However,…using accident
investigations to identify hazards is
reactive!
H.W. Heinrich’s
classic safety pyramid
1
Major Accidents
• Number of errors is
relative to the severity of Significant Events 10
consequences.
• For every major accident
there are many errors. Near Misses
30
• Leads us to assume that
driving down errors will Nonconsequential
eliminate major Errors 600
accidents.
• It amplifies the ideology
of zero-accidents. 32
Alternative to the
Heinrich’s safety
pyramid
• The consequence of
error has no relationship
to the number of errors.
• It is related to the
number and integrity of
defences.
• Any error can lead to a
major accident if
defences fail.
Contemporary view of causation
Organization Workplace People Defences Accident
Latent conditions trajectory

Source: James Reason
Understanding the Accident/Incident context
Some of the principal factors shaping the
context for accidents and incidents include:
• equipment design,
• supporting infrastructure,
• human and cultural factors,
• corporate safety culture, and
• cost factors
Understanding the context in which accidents
occur is fundamental to accident prevention

Equipment design
• Does the equipment do what it is

supposed to do?
• Does the equipment interface well
with the operator? Is it “user-
friendly”?
• Does the equipment fit in the
allocated space? etc.
Supporting infrastructure
• Regulator’s perspective:
• Personnel licensing;
• Certification of aircraft, operators,
service providers and aerodromes;
• Ensuring the provision of required
services;
• Investigation of accidents and
incidents; and
• Providing operational safety oversight
Pilot’s perspective:
• Airworthy aircraft suitable for the type of operation;
• Adequate and reliable CNS services;
• Adequate and reliable aerodrome, ground
handling, and flight planning services; and
• Effective support from the parent organization with
respect to initial and recurrent training, scheduling,
flight dispatch or flight following system, etc.
Air traffic controller’s perspective:

• Availability of operable (CNS) equipment suitable
for the operational task;
• Effective procedures for the safe and expeditious
handling of aircraft; and
• Effective support from the parent organization
with respect to initial and recurrent training,
rostering and general working conditions
Human Factors
• The human element is the most flexible and adaptable

part of the aviation system, but it is also the most
vulnerable to influences that can adversely affect its
performance
• Understanding of the operating context in which
humans err

Cultural factors
• Culture influences the values, beliefs and behaviours that we share

with the other members of our various social groups.
• Culture serves to bind us together as members of groups and to
provide clues as to how to behave in both normal and unusual
situations.
• Culture provides a context in which things happen.
• For accident prevention, understanding this context is an important
determinant of human performance and its limitations.
Human error
• Errors are not some type of aberrant behaviour;

they are a natural bi-product of virtually all human
endeavour
• Error must be accepted as a normal component of
any system where humans and technology interact.

Control of Human Error
• Error Reduction strategies intervene directly at the source
of the error by reducing or eliminating the contributing
factors to the error. They aim at eliminating any adverse
conditions that increase the risk of error
• Error Capturing assumes the error has already been
made. The intent is to capture the error before any
adverse consequences of the error are felt
• Error Tolerance refers to the ability of a system to accept
an error without serious consequence.
Accident prevention cycle
Accident prevention begins
with an appreciation of the
operational context in
which accidents occur!!

Costs of accident prevention
If you think safety is expensive, try an accident

Managing Safety
• Effective risk minimization requires the management of all the factors
which can impact on safety.
• The management of safety is one of their core business functions -
just as financial management is.
• The application of contemporary risk management methods facilitates
the identification of weaknesses and guides management towards the
cost-effective resolution of unacceptable risks.
• Effective information management is required to support safety
analyses and for the sharing of safety lessons and best practices
across the industry.
• System of performance measurement is required to confirm the
effectiveness of the organization’s safety management system and to
test the validity of steps taken to reduce risks. 46
Strategies for safety management
• Reactive strategy: Investigate accidents and reportable

incidents.
• Management’s safety focus being on compliance with
minimum requirements;
• Safety measurement being based on reportable
accidents and incidents.
• Constant catching up is required to match human
inventiveness for new types of errors.
Strategies for safety management
• Proactive safety strategy: Prevent accidents by aggressively
seeking information from a variety of sources which may be
indicative of emerging safety problems.
• Hazard and incident reporting systems (preferably
confidential and non-punitive systems);
• Safety surveys to elicit feedback from front-line personnel;
• Flight data recorder analysis for identifying operational
exceedances and confirming normal operating procedures;
• Operational inspections or audits of all aspects of flight
operations,
• A policy for consideration and embodiment of manufacturers
service bulletins. 48
Effective Safety Management System (SMS)
3 defining cornerstones:
• A comprehensive corporate approach sets the tone for
the management of safety.
• Effective organizational tools are needed to deliver the
necessary activities and program to advance safety.
• A system for safety oversight to confirm the organization’s
continuing fulfilment of its corporate safety policy,
objectives, goals and standards.
Effective Safety Management System (SMS)
50
Risk Management
• Risk Management:
• the identification, analysis and elimination (and/or control to an
acceptable level) of those hazards, as well as the subsequent
risks that threaten the viability of an organization.
• Risk management facilitates the balancing act between assessed
risks and viable risk control.
• It is an integral component of safety management programmes.
• Risk management involves a logical process of objective analysis,
particularly in the evaluation of the risks.
• Risk management serves to focus safety efforts on those hazards
posing the greatest risks.
Risk
management
process

Risk Communication
• Risk communication includes any exchange of information about risks,
i.e. any public or private communication that informs others about the
existence, nature, form, severity or acceptability of risks.
• Effective communication of the risks, adds value to the Risk
Management process. The stakeholders can assist the decision-
maker(s) if the risks are communicated early in a fair, objective and
understandable way.
• Failure to communicate the safety lessons learned in a clear and timely
fashion will undermine management’s credibility in promoting a
positive safety culture
Incident Reporting System
The value of reporting system:

• The reporting system can facilitate an understanding of the causes of
hazards, help define intervention strategies, and the effectiveness of
interventions.
• The investigation can provide a unique means of obtaining first-hand
evidence on the factors associated with mishaps from the
participants themselves.
• Reporters can describe the relationships between stimuli and their
actions. They may provide their interpretation of the effects of various
factors affecting their performance, such as fatigue, interpersonal
interactions and distractions.
Incident Reporting System
The value of reporting system:

• Many reporters are able to offer valuable suggestions for
remedial action.
• Incident data have also been used to improve operating
procedures, display and control design, and provide a better
understanding of human performance associated with the
operation of aircraft and air traffic control.

• Facilitates the collection of
information that may not be
Incident captured by a mandatory incident
Reporting reporting system;
System • Is non-punitive; and
requirements • Affords protection to the sources of
the information.

• Mandatory incident reporting system
• Annex 13 requires States to establish a
mandatory incident reporting system to
facilitate the collection of information on
Types of actual or potential safety deficiencies.
incident • Voluntary incident reporting systems
• Annex 13 recommends that States introduce
reporting voluntary incident reporting systems to
system supplement the information obtained from
mandatory reporting systems.
• Confidential reporting systems
• Confidential reporting systems aim to protect
the identity of the reporter.
Principles for effective incident reporting systems
• Trust - Trust begins with the design and implementation of the
programme. employee input into the development of a reporting
system is vital.
• Non-punitive - They must receive a commitment from the regulatory
authority or from top management that reported information would
not be used punitively against them.
• Inclusive reporting base - Taking a systemic approach to accident
prevention requires that safety information be obtained from all parts
of the operation.
• Independence - Incident reporting systems are operated by an
organization separate from the aviation administration responsible for
the enforcement of aviation regulations.
Principles for effective incident reporting systems
• Ease of reporting - The task of submitting incident reports

should be as easy as possible for the reporter.
• Acknowledgment - The reporting of incidents requires time
and effort by the reporter and should be appropriately
acknowledged.
• Promotion - The (de-identified) information received from an
incident reporting system should be made available to the
aviation community in a timely manner.

Typical indicators that SMS was a factor in the
causation of an accident
• Control measures were absent or inadequate.
• Hazards had not been identified and/or the risk was not
understood.
• The organization had not recognized that its control
measures were deficient or had failed to detect non-
compliance with its safety systems.
• The organization had not learnt lessons from previous
experience or had not taken previous learning into account.
• The safety culture created the conditions that allowed the
accident to occur. 60

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Safety Management Fundamentals

Company Aviation Safety Officer Training

Agus Nugraha Sardjani

Airline Safety Investigation Training

✓ Safety management seeks to proactively mitigate

The advisor to senior management

Duty and responsibility to manage SMS

pw/issue-4-2022 Company Aviation Safety Officer Training - INACA 11

Safety Analysis, Investigating for

pw/issue-4-2022 Company Aviation Safety Officer Training - INACA 14

to accident • Is based upon ensuring minimum

• The responsibility for preventing

pw/issue-4-2022 Company Aviation Safety Officer Training - INACA 20

• Defining policies and standards affecting accident prevention;

pw/issue-4-2022 Company Aviation Safety Officer Training - INACA 21

• Conducting safety oversight and accident prevention programme

pw/issue-4-2022 Company Aviation Safety Officer Training - INACA 22

Safety is considered to be the state in

Safety Management Fundamentals

• Understanding accident and incident causation is a key

Technical Era Mechanical Improvement for better technology

Human Era Human Performance

Organizational Era Organizational Performance

• The elimination of accidents (and serious incidents) is

• Typically there would have been

Latent conditions trajectory

pw/issue-4-2022 Company Aviation Safety Officer Training - INACA 35

• Does the equipment do what it is

Air traffic controller’s perspective:

• The human element is the most flexible and adaptable

pw/issue-4-2022 Company Aviation Safety Officer Training - INACA 40

• Culture influences the values, beliefs and behaviours that we share

• Errors are not some type of aberrant behaviour;

pw/issue-4-2022 Company Aviation Safety Officer Training - INACA 42

pw/issue-4-2022 Company Aviation Safety Officer Training - INACA 44

pw/issue-4-2022 Company Aviation Safety Officer Training - INACA 45

• Reactive strategy: Investigate accidents and reportable

pw/issue-4-2022 Company Aviation Safety Officer Training - INACA 52

The value of reporting system:

The value of reporting system:

pw/issue-4-2022 Company Aviation Safety Officer Training - INACA 55

pw/issue-4-2022 Company Aviation Safety Officer Training - INACA 56

• Ease of reporting - The task of submitting incident reports

pw/issue-4-2022 Company Aviation Safety Officer Training - INACA 59

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