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SAFETY MANAGEMENT EDGARS GINDRA 20. 09. 2007 LV CAA AOD 20. 09. 2007 SMS SAFETY MANAGEMENT EDGARS GINDRA 20. 09. 2007 LV CAA AOD 20. 09. 2007 SMS LV CAA AOD

SMS regulation Operation of aircraft u Maintenance of aircraft u Air traffic services u SMS regulation Operation of aircraft u Maintenance of aircraft u Air traffic services u Aerodromes u – Two audience groups u States u Service providers – Three distinct requirements u Safety programme u SMS u Management accountability 20. 09. 2007 SMS LV CAA AOD 2

The amendment 30 to ICAO Annex 6 Part I 3. 2. 1 States shall The amendment 30 to ICAO Annex 6 Part I 3. 2. 1 States shall establish a safety programme in order to achieve an acceptable level of safety in the operation of aircraft. u 3. 2. 4 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 that, as a minimum: u 20. 09. 2007 SMS LV CAA AOD 3

The amendment 30 to ICAO Annex 6 Part I a) b) c) d) Identifies The amendment 30 to ICAO Annex 6 Part I a) b) c) d) Identifies safety hazards; Ensures that remedial action necessary to maintain an acceptable level of safety is implemented; Provides for continuous monitoring and regular assessment of the safety level achieved; and Aims to make continuous improvement to the overall level of safety. 20. 09. 2007 SMS LV CAA AOD 4

The amendment 30 to ICAO Annex 6 Part I 3. 2. 5 A safety The amendment 30 to ICAO Annex 6 Part I 3. 2. 5 A safety management system shall clearly define lines of safety accountability throughout the operator’s organization, including a direct accountability for safety on the part of senior management. u 3. 2. 9 An operator shall establish a flight safety documents system, for the use and guidance of operational personnel, as part of its safety management system. u 20. 09. 2007 SMS LV CAA AOD 5

What is a safety programme? An integrated set of regulations and activities aimed at What is a safety programme? An integrated set of regulations and activities aimed at improving safety. u States are responsible for establishing a safety programme: u – Safety regulation – Safety oversight – Accident/incident investigation – Mandatory/voluntary reporting systems – Safety data analysis – Safety promotion 20. 09. 2007 SMS LV CAA AOD 6

Clarifying the use of terms u Safety oversight – Is what the CAA performs Clarifying the use of terms u Safety oversight – Is what the CAA performs with regard to the operators/service providers SMS. u Safety assurance – Is what the operators/service providers do with regard to safety performance monitoring and measurement u Safety audit – Is what the CAA performs with regard to its safety programme and the operators/service providers perform with regard to the SMS. 20. 09. 2007 SMS LV CAA AOD 7

Acceptable level of safety – a concept u High level safety management goals of Acceptable level of safety – a concept u High level safety management goals of an oversight authority (or a service provider) u Minimum safety performance that service providers should achieve while conducting their core business functions u A reference against which one can measure safety performance 20. 09. 2007 SMS LV CAA AOD 8

What is an SMS? A systematic approach to managing safety, including the necessary organizational What is an SMS? A systematic approach to managing safety, including the necessary organizational structures, accountabilities, policies and procedures. u Providers are responsible for establishing an SMS. u States are responsible of the acceptance and oversight for providers’ SMS. u 20. 09. 2007 SMS LV CAA AOD 9

In summary u Safety – The state in which the risk of harm to In summary u Safety – 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. u Management – Allocation of resources. u System – Organized set of processes and procedures. 20. 09. 2007 SMS LV CAA AOD 10

Safety programme – SMS relationships Protection Production Objective: Public safety State safety programme Oversight Safety programme – SMS relationships Protection Production Objective: Public safety State safety programme Oversight Acceptance Oversight Organization’s Objective: safety Manage and control management safety risk system (SMS) Objective: Organization’s Achieve commercial production goals and customer processes Risk management satisfaction Safety assurance 20. 09. 2007 SMS LV CAA AOD 11

ESARR ADVISORY MATERIAL u Annex 14 establishes that, as of 24 November 2005, certified ESARR ADVISORY MATERIAL u Annex 14 establishes that, as of 24 November 2005, certified aerodromes shall have in operation a safety management system. u ESARR 3 can be used by aerodrome operators to implement the SMS required in the SARPs contained in ICAO Annex 14. 20. 09. 2007 SMS LV CAA AOD 12

ESARR ADVISORY MATERIAL u As a result, Safety Management Systems (SMS) will have to ESARR ADVISORY MATERIAL u As a result, Safety Management Systems (SMS) will have to be implemented, not only in the provision of ATM service associated to aerodromes but also as regards the complete operation of the certified aerodromes at which those services are provided. 20. 09. 2007 SMS LV CAA AOD 13

ESARR ADVISORY MATERIAL u ESARR 3 addresses the management of safety in any ATM ESARR ADVISORY MATERIAL u ESARR 3 addresses the management of safety in any ATM service provided without confining the SMS scope to ATS as Annex 11 wherever it appears necessary. 20. 09. 2007 SMS LV CAA AOD 14

INTER-RELATIONSHIP BETWEEN SMS IN ATM AND AERODROMES u. A - single organization is involved. INTER-RELATIONSHIP BETWEEN SMS IN ATM AND AERODROMES u. A - single organization is involved. That means that the organization will have to implement: SMS compliant with ESARR 3 (and ICAO Annex 11) in its ATM services; SMS compliant with ICAO Annex 14 in its aerodrome operations. 20. 09. 2007 SMS LV CAA AOD 15

INTER-RELATIONSHIP BETWEEN SMS IN ATM AND AERODROMES u Two - different organizations are involved. INTER-RELATIONSHIP BETWEEN SMS IN ATM AND AERODROMES u Two - different organizations are involved. Two basic alternatives may be considered: Two separate SMS. Each organization implements its own SMS (one according to ESARR 3 to cover the ATM services, and one according to ICAO Annex 14 and specific national regulations. 20. 09. 2007 SMS LV CAA AOD 16

INTER-RELATIONSHIP BETWEEN SMS IN ATM AND AERODROMES - A common SMS. The ATM and INTER-RELATIONSHIP BETWEEN SMS IN ATM AND AERODROMES - A common SMS. The ATM and aerodrome safety regulator (s) could accept a set of arrangements proposed by both organizations to establish a “common SMS”. 20. 09. 2007 SMS LV CAA AOD 17

Regulation (EC) 2096/2005 laying down common requirements for the provision of air navigation services Regulation (EC) 2096/2005 laying down common requirements for the provision of air navigation services Article 3 Granting of certificates Shall comply with the specific additional requirements set in Annex II 3. Safety of services u Safety management system u Safety requirements for risk assessment and mitigation with regard to changes u Safety requirements for engineering and technical personnel undertaking operational safety related tasks 20. 09. 2007 SMS LV CAA AOD 18

SMS – Introductory concepts The scope of SMS encompasses most of the activities of SMS – Introductory concepts The scope of SMS encompasses most of the activities of the organization. u SMS must start from senior management, and safety must be considered at all levels of the organization. u SMS aims to make continuous improvement to the overall level of safety. u All aviation stakeholders have a role to play in SMS. u 20. 09. 2007 SMS LV CAA AOD 19

Identifying aviation system stakeholders u It is important to identify aviation system stakeholders to Identifying aviation system stakeholders u It is important to identify aviation system stakeholders to ensure that stakeholders relevant to risk decision are taken into consideration and contribute with their knowledge before the decision is taken. 20. 09. 2007 SMS LV CAA AOD 20

Aviation system stakeholders Aviation professionals u Aircraft owners and operators u Manufactures u Aviation Aviation system stakeholders Aviation professionals u Aircraft owners and operators u Manufactures u Aviation regulatory authorities u Industry trade associations u Regional air traffic service providers u Professional associations and federations u International aviation organizations u Investigative agencies u The flying public u 20. 09. 2007 SMS LV CAA AOD 21

First fundamental – System description u Most hazards are generated by operational interactions among First fundamental – System description u Most hazards are generated by operational interactions among different system components. It is therefore essential to describe the system in terms of its components as one of the first activities when planning an SMS. 20. 09. 2007 SMS LV CAA AOD 22

System description u u u u The system interactions with other systems in the System description u u u u The system interactions with other systems in the air transportation system. The system functions. Required Human Factors considerations of the system operation. Hardware components of the system. Software components of the system. Related procedures that define guidance for the operation and use of the system. Operational environment. Contracted and purchased products and services. 20. 09. 2007 SMS LV CAA AOD 23

Second fundamental – Gap analysis u u u An analysis of safety arrangements existing Second fundamental – Gap analysis u u u An analysis of safety arrangements existing within the organization. The organizational structures necessary for an SMS may be found throughout an organization. Various activities of an SMS are probably already in place and are working. SMS development should build upon existing organizational structures. Conduct the gap analysis against the components and elements of the SMS. Once completed and documented the gap analysis forms the basis of the implementation plan. 20. 09. 2007 SMS LV CAA AOD 24

Third fundamental – SMS and QMS SMS differs from quality systems in that: SMS Third fundamental – SMS and QMS SMS differs from quality systems in that: SMS focuses on the safety, human and organizational aspects of an operation (i. e. , safety satisfaction) QMS focus the product (s) of an operation (i. e. , customer satisfaction) u SMS results in the design and implementation of organizational processes and procedures to identify hazards and control/mitigate risks in aviation operation. u QMS techniques provide a structured process for ensuring that these processes and procedures achieve their intended objectives and, where they fall short, to improve them. u SMS builds partly upon QMS principles. u SMS should include both safety and quality policies. u The coverage of quality policies should be limited to quality in support of safety. u Safety objectives should receive primacy where conflicts are identified. u 20. 09. 2007 SMS LV CAA AOD 25

SMS planning The components of SMS u u Safety policy and objectives risk management SMS planning The components of SMS u u Safety policy and objectives risk management assurance promotion 20. 09. 2007 SMS LV CAA AOD 26

The elements of SMS 1. Safety policy and objectives 1. 1 Management commitment and The elements of SMS 1. Safety policy and objectives 1. 1 Management commitment and responsibility 1. 2 Safety accountabilities of managers 1. 3 Appointment of key safety personnel 1. 4 SMS implementation plan 1. 5 Coordination of the emergency response plan 1. 6 Documentation 20. 09. 2007 SMS LV CAA AOD 27

The elements of SMS 2. Safety risk management 2. 1 Hazard identification process 2. The elements of SMS 2. Safety risk management 2. 1 Hazard identification process 2. 2 Risk assessment and mitigation processes 2. 3 Internal safety investigations 20. 09. 2007 SMS LV CAA AOD 28

The elements of SMS 3. Safety assurance 3. 1 Safety performance monitoring and measurement The elements of SMS 3. Safety assurance 3. 1 Safety performance monitoring and measurement 3. 2 The management of change 3. 3 Continuous improvement of the safety system 20. 09. 2007 SMS LV CAA AOD 29

The elements of SMS 4. Safety promotion 4. 1 Training and education 4. 2 The elements of SMS 4. Safety promotion 4. 1 Training and education 4. 2 Safety communication 20. 09. 2007 SMS LV CAA AOD 30

Safety responsibilities Accountable executive Safety Review Board (SRB) Director of operations Director of maintenance Safety responsibilities Accountable executive Safety Review Board (SRB) Director of operations Director of maintenance Other directorates Safety services office Flight safety officer Maintenance safety officer Safety Action Group (s) (SAG) 20. 09. 2007 SMS LV CAA AOD 31

Appointment of key safety personnel The safety office – Corporate functions Advising senior management Appointment of key safety personnel The safety office – Corporate functions Advising senior management on safety matters Assisting line managers Overseeing hazard identification systems u The safety manager – Responsibilities Responsible individual and focal point for the development and maintenance of an effective safety management system u 20. 09. 2007 SMS LV CAA AOD 32

Appointment of key safety personnel u The safety manager – Functions Manages the SMS Appointment of key safety personnel u The safety manager – Functions Manages the SMS implementation plan on behalf of the accountable executive Facilitates hazard identification and risk analysis and management Monitors corrective actions to ensure their accomplishment Provides periodic reports on safety performance Maintains safety documentation Plans and organizes staff safety training Provides independent advice on safety matters 20. 09. 2007 SMS LV CAA AOD 33

Appointment of key safety personnel u The Safety Review Board (SRB) High level committee Appointment of key safety personnel u The Safety Review Board (SRB) High level committee Strategic safety functions Chaired by the accountable executive u It may include the Board of Directors u Composed of heads of functional areas u u SRB monitors: Safety performance against the safety policy and objectives Effectiveness of the SMS implementation plan Effectiveness of the safety supervision of subcontracted operations 20. 09. 2007 SMS LV CAA AOD 34

Appointment of key safety personnel SRB ensures that appropriate resources are allocated to achieve Appointment of key safety personnel SRB ensures that appropriate resources are allocated to achieve the established safety performance u SRB gives strategic direction to the SAG u Safety Action Group (SAG): Reports to SRB and takes strategic direction from SRB Members: u u Managers and supervisors from functional areas u Front-line personnel 20. 09. 2007 SMS LV CAA AOD 35

Appointment of key safety personnel u SAG: Oversees operational safety within the functional area Appointment of key safety personnel u SAG: Oversees operational safety within the functional area Resolves identified risks Assesses the impact on safety of operational changes Implements corrective action plans Ensures that corrective action is taken in a timely manner Review the effectiveness of previous safety recommendations Safety promotion 20. 09. 2007 SMS LV CAA AOD 36

SMS implementation plan u Contents 1. Safety policy Safety planning, objectives and goals System SMS implementation plan u Contents 1. Safety policy Safety planning, objectives and goals System description Gap analysis SMS components Safety roles and responsibilities Safety reporting policy Means of employee involvement Safety communication Safety performance measurement Management review (of safety performance) 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 20. 09. 2007 SMS LV CAA AOD 37

PHASED APPROACH TO SMS IMPLEMENTATION u Phase 1 - Provides a blueprint on how PHASED APPROACH TO SMS IMPLEMENTATION u Phase 1 - Provides a blueprint on how the SMS requirements will be met and integrated to the organization’s work activities - Provides an accountability framework for the implementation of the SMS = 1) Identify the accountable executive and the safety accountabilities of managers Elements 1. 1 and 1. 2 2) Identify the person or planning group within the organization responsible for implementing the SMS Element 1. 3 3) Describe the system (Air operator, ATC services provider, approved maintenance organization, certified aerodrome operator) Element 1. 4 20. 09. 2007 SMS LV CAA AOD 38

PHASED APPROACH TO SMS IMPLEMENTATION u Phase 2 - Puts into practice those elements PHASED APPROACH TO SMS IMPLEMENTATION u Phase 2 - Puts into practice those elements of the SMS implementation plan that refer to: 1) Safety risk management component u u u Reactive processes Investigation and analysis Hazard identification and risk management Elements 2. 1, 2. 2 and 2. 3 2) Training relevant to: u u The SMS implementation plan components The safety risk management component (Reactive processes) Element 4. 1 3) Documentation relevant to: u u The SMS implementation plan components The safety risk management component (Reactive processes) Elements 1. 4 and 1. 6 20. 09. 2007 SMS LV CAA AOD 39

PHASED APPROACH TO SMS IMPLEMENTATION u Phase 3 - Puts into practice those elements PHASED APPROACH TO SMS IMPLEMENTATION u Phase 3 - Puts into practice those elements of the SMS implementation plan that refer to: 1) Safety risk management component Proactive and predictive processes u Investigation and analysis u Hazard identification and risk management u Elements 2. 1, 2. 2 and 2. 3 2) Training relevant to proactive and predictive processes Element 4. 1 3) Documentation relevant to proactive and predictive processes Elements 1. 4 and 1. 6 20. 09. 2007 SMS LV CAA AOD 40

PHASED APPROACH TO SMS IMPLEMENTATION u Phase 4 1) Operational safety assurance Development of PHASED APPROACH TO SMS IMPLEMENTATION u Phase 4 1) Operational safety assurance Development of acceptable level (s) of safety Development of safety indicators and targets SMS continuous improvement Elements 3. 1, 3. 2 and 3. 3 2) Training relevant to operational safety assurance Element 4. 1 3) Documentation relevant to operational safety assurance Element 1. 6 20. 09. 2007 SMS LV CAA AOD 41

CAA - Four steps for SMS implementation u Step 1 State’s safety programme Conduct CAA - Four steps for SMS implementation u Step 1 State’s safety programme Conduct a gap analysis vis-à-vis the current status in the State of the following: Safety regulation u Safety oversight (capabilities and planning) u Accident/incident investigation u Mandatory/voluntary/confidential reporting systems u Safety data analysis u Safety promotion u Develop the State safety programme around four components of the ICAO SMS framework 20. 09. 2007 SMS LV CAA AOD 42

Safety analysis and safety studies u Analytical methods and tools: – Statistical analysis (to Safety analysis and safety studies u Analytical methods and tools: – Statistical analysis (to quantify situations); – Trend analysis (predictions may be made, and to trigger “alarms”); – Normative comparisons (to sample real world experience under similar operating conditions); 20. 09. 2007 SMS LV CAA AOD 43

Safety analysis and safety studies – Simulation and testing (simulation in the field under Safety analysis and safety studies – Simulation and testing (simulation in the field under actual operating conditions); – Expert panel ( to evaluate evidence of an unsafe condition and evaluating the best course for corrective action); – Cost-benefit analysis (the costs of implementing the proposed measures are weighed against the expected benefits over time). 20. 09. 2007 SMS LV CAA AOD 44

Safety analysis and safety studies Safety studies require data, appropriate analysis and effective communication. Safety analysis and safety studies Safety studies require data, appropriate analysis and effective communication. u Safety studies conducted by State authorities, airlines, manufactures, and professional and industry associations. u Safety recommendations may arise from the investigation of accidents and serious incidents and also from safety studies. u Safety studies have application to hazard identification and analysis in flight operations, maintenance, cabin safety, air traffic control, airport operations, etc. u 20. 09. 2007 SMS LV CAA AOD 45

Safety analysis and safety studies u Selecting study issues – Significant safety issues lists Safety analysis and safety studies u Selecting study issues – Significant safety issues lists (SIL) based on the accident and incident record in such areas as runway incursions, ground proximity warnings, TCAS, and prioritized in terms of the risks to the organization or the industry; – Support among participants and contributors. 20. 09. 2007 SMS LV CAA AOD 46

Safety analysis and safety studies u SIL should be reviewed and updated annually, adding Safety analysis and safety studies u SIL should be reviewed and updated annually, adding new high-risk issues and deleting lesser-risk issues: – Frequency of GPWS warnings; – Frequency of TCAS advisories; – Runway incursions; – Altitude deviations (busts); – Call sign confusion; – Un-stabilised approaches; and – Air proximities (near misses) at selected aerodromes. 20. 09. 2007 SMS LV CAA AOD 47

CAA - Four steps for SMS implementation u Step 2 Implementation SMS SARPs Develop CAA - Four steps for SMS implementation u Step 2 Implementation SMS SARPs Develop SMS regulations for operators/service providers u Refer to the SMS components and elements u Refer to ICAO Doc 9859 Prepare guidance material for the implementation of SMS Operators/service providers may need to use third party assistance to implement their SMS 20. 09. 2007 SMS LV CAA AOD 48

CAA - Four steps for SMS implementation u Step 3 CAA training programme Develop CAA - Four steps for SMS implementation u Step 3 CAA training programme Develop a training programme for CAA officers to: u Provide knowledge of safety management concepts and ICAO SARPs on safety management in Annexes 6, 11 and 14, and related guidance material; and u Develop knowledge to certify and oversee the implementation of key components of an SMS, in compliance with the national regulations and relevant ICAO SARPs 20. 09. 2007 SMS LV CAA AOD 49

CAA - Four steps for SMS implementation u Step 4 CAA enforcement policy Revision CAA - Four steps for SMS implementation u Step 4 CAA enforcement policy Revision of enforcement policy u Operators/service providers allowed to deal with deviations/minor violations internally, within the context of the SMS, to the satisfaction of the authority u Gross negligence, willful deviation and so forth to be dealt through established enforcement procedures 20. 09. 2007 SMS LV CAA AOD 50

State safety programme – SMS harmonization u State’s safety programme components – Safety policy State safety programme – SMS harmonization u State’s safety programme components – Safety policy and objectives risk management assurance promotion 20. 09. 2007 SMS LV CAA AOD 51

Safety policy and objectives How the CAA will oversee the management of safety in Safety policy and objectives How the CAA will oversee the management of safety in the State u. A definition of CAA requirements, responsibilities and accountabilities regarding the State safety programme u Similar to the equivalent SMS component 20. 09. 2007 SMS LV CAA AOD 52

Safety risk management Establishment of controls which govern how service providers SMS will operate Safety risk management Establishment of controls which govern how service providers SMS will operate u Standards/requirements u Same for service providers SMS processes as SMS Hazard identification and risk management u Different outputs New/modified rules and/or regulations (i. e. , controls) which govern how service providers SMS operate 20. 09. 2007 SMS LV CAA AOD 53

Hazard identification processes u Concept of safety Consider - The elimination of accidents (and Hazard identification processes u Concept of safety Consider - 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 error is acceptable in an inherently safe system. Safety is 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. 20. 09. 2007 SMS LV CAA AOD 54

Hazard identification processes u The organizational accident From the Investigation Report identify: a) Organizational Hazard identification processes u The organizational accident From the Investigation Report identify: a) Organizational processes that influenced the operation and which felt under the responsibility of senior management (i. e. those accountable for the allocation of resources): - Policy-making - Planning - Communication - Allocation of resources - Supervision 20. 09. 2007 SMS LV CAA AOD 55

The organizational accident Organizational processes Ø Ø Ø Policy-making Planning Communication Allocation of resources The organizational accident Organizational processes Ø Ø Ø Policy-making Planning Communication Allocation of resources Supervision … Activities over which any organization has a reasonable degree of direct control 20. 09. 2007 SMS LV CAA AOD 56

The organizational accident Organizational processes Ø Inadequate Latent conditions hazard identification and risk management The organizational accident Organizational processes Ø Inadequate Latent conditions hazard identification and risk management Ø Normalization of deviance Conditions present in the system before the accident, made evident by triggering factors. 20. 09. 2007 SMS LV CAA AOD 57

Hazard identification processes b) Latent conditions in the system safety which became precursors of Hazard identification processes b) Latent conditions in the system safety which became precursors of active failures: - Inadequate hazard identification and risk management - Normalization of deviance c) Defences which fail to perform due to weaknesses, inadequacies or plain absence: - Technology - Regulations - Training and checking 20. 09. 2007 SMS LV CAA AOD 58

The organizational accident Organizational processes Latent conditions ØTechnology ØRegulations Defences ØTraining and checking Resources The organizational accident Organizational processes Latent conditions ØTechnology ØRegulations Defences ØTraining and checking Resources to protect against the risks that organizations involved in production activities must confront. 20. 09. 2007 SMS LV CAA AOD 59

Hazard identification processes d) Workplace conditions which may have influenced operational personnel actions: - Hazard identification processes d) Workplace conditions which may have influenced operational personnel actions: - Workforce stability - Qualifications and experience - Morale - Credibility - Ergonomics e) Active failures, including errors and violations. 20. 09. 2007 SMS LV CAA AOD 60

The organizational accident Organizational processes Workplace conditions Ø Workforce stability Ø Qualifications and experience The organizational accident Organizational processes Workplace conditions Ø Workforce stability Ø Qualifications and experience Ø Morale Ø Credibility Ø Ergonomics Ø… Factors that directly influence the efficiency of people in aviation workplaces. 20. 09. 2007 SMS LV CAA AOD 61

The organizational accident Organizational processes Workplace conditions Active failures Ø Errors Ø Violations Actions The organizational accident Organizational processes Workplace conditions Active failures Ø Errors Ø Violations Actions or inactions by people (pilots, controllers, maintenance engineers, aerodrome staff, etc. ) that have an immediate adverse effect. 20. 09. 2007 SMS LV CAA AOD 62

The organizational accident Organizational processes Improve Monitor Latent conditions Reinforce Contain Workplace conditions Active The organizational accident Organizational processes Improve Monitor Latent conditions Reinforce Contain Workplace conditions Active failures Identify 20. 09. 2007 SMS LV CAA AOD Defences 63

Hazard identification processes u Two definitions Hazard – Condition, object or activity with the Hazard identification processes u Two definitions 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. Risk – The chance of a loss or injury, measured in terms of severity and probability. The chance that something is going to happen, and the consequences if it does. Example A wind of 15 knots blowing directly across the runway is a hazard. The possibility that the pilot may not be able to control the aircraft during take-off or landing, resulting in an accident, is one risk. 20. 09. 2007 SMS LV CAA AOD 64

Hazard identification processes u First fundamental – Understanding hazards - Natural tendency to describe Hazard identification processes u First fundamental – Understanding hazards - Natural tendency to describe the hazards as an outcome (“Runway incursion” vs. “Unclear aerodrome signage” - Stating hazards as outcomes disguises their nature and interferes with identifying other important outcomes - However, well-named hazards allows to infer the sources or mechanisms and loss outcome (s) 20. 09. 2007 SMS LV CAA AOD 65

Hazard identification processes u Examples of hazards For Operator (Flight crew): - Unfamiliar phraseology Hazard identification processes u Examples of hazards For Operator (Flight crew): - Unfamiliar phraseology - ATC procedures - Similar call signs - Terrain - Flight diversions - System malfunctions - Unfamiliar airports - Heavy traffic - Missed approaches - Weather - Automation events 20. 09. 2007 SMS LV CAA AOD 66

Hazard identification processes u Second fundamental – Hazard identification The scope for hazards in Hazard identification processes u Second fundamental – Hazard identification The scope for hazards in aviation is wide, and may be related to: - Design factors, including equipment and task design. - Procedures and operating practices, including documentation and checklists. - Communications, including means, terminology and language. - Organizational factors, such as company policies for recruitment, training, remuneration and allocation of resources. - Work environment factors, such as ambient noise and vibration, temperature, lighting and protective equipment and clothing. - Regulatory factors, including the applicability and enforceability of regulations; certification of equipment, personnel and procedures; and the adequacy of oversight. - Defences, including detection and warning systems and the extent to which the equipment is resilient against errors and failures. - Human performance, including medical conditions and physical limitations. 20. 09. 2007 SMS LV CAA AOD 67

Hazard identification processes u Third fundamental – Hazard analysis ABC of hazard analysis A Hazard identification processes u Third fundamental – Hazard analysis ABC of hazard analysis A – State the generic hazard (hazard statement) Airport construction B – Identify specific components of the hazard Construction equipment Closed taxiways C – Naturally leading to specific risk (s) Aircraft colliding with construction equipment Aircraft taking wrong taxiway 20. 09. 2007 SMS LV CAA AOD 68

Hazard identification processes u At the intersection of protection and production u Direct costs Hazard identification processes u At the intersection of protection and production u Direct costs u Indirect costs – The acronym ALARP is used to describe a safety risk which has been reduced to a level that is as low as reasonably practicable. – In determining what is reasonably practicable consideration is given to both the technical feasibility and the cost of further reducing the safety risk. – This includes a cost/benefit study – The obvious costs, which are easily determined. The high costs of exposure of hazards can be reduced by insurance coverage. – The uninsured costs. An understanding of these uninsured costs (or indirect costs) is fundamental to understanding the economics of safety 20. 09. 2007 SMS LV CAA AOD 69

The management dilemma Resources Management levels Resources Production Protection 20. 09. 2007 SMS LV The management dilemma Resources Management levels Resources Production Protection 20. 09. 2007 SMS LV CAA AOD 70

The management dilemma Res ourc es Man age leve ment ls Res our c The management dilemma Res ourc es Man age leve ment ls Res our c es Protection Production Catastrophe 20. 09. 2007 SMS LV CAA AOD 71

The management dilemma es rc sou R ent gem ana els es M urc The management dilemma es rc sou R ent gem ana els es M urc lev so e Re Production Protection Bankruptcy 20. 09. 2007 SMS LV CAA AOD 72

Safety space Protection Bankruptcy Source: James Reason um xim Ma ce pa es nc Safety space Protection Bankruptcy Source: James Reason um xim Ma ce pa es nc sta si re Catastrophe Production 20. 09. 2007 SMS LV CAA AOD 73

Safety management – The response to the dilemma u Safety issues are a byproduct Safety management – The response to the dilemma u Safety issues are a byproduct of activities related to production/services delivery. u 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. u The product/service provided by any aviation organization must be delivered safely (i. e. protecting users and stakeholders). 20. 09. 2007 SMS LV CAA AOD 74

Hazard identification processes u Fourth fundamental – Documentation of hazards Appropriate documentation management: – Hazard identification processes u Fourth fundamental – Documentation of hazards Appropriate documentation management: – A formal procedure to translate operational safety data into hazard-related information. – The “safety library” of an organization. – The need for standardization – facilitating tracking and analysis of hazards by common: Definitions Understanding Validation Reporting Measurement Management 20. 09. 2007 SMS LV CAA AOD 75

Risk management u First fundamental – Risk management The identification, analysis and elimination (and/or Risk management u First fundamental – Risk management The identification, analysis and elimination (and/or mitigation 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 mitigation. Risk management is an integral component of safety management. It involves a logical process of objective analysis, particularly in the evaluation of the risks. 20. 09. 2007 SMS LV CAA AOD 76

Hazard information management at a glance METHOD HAZARDS Reactive method ASR MOR Incident reports Hazard information management at a glance METHOD HAZARDS Reactive method ASR MOR Incident reports Accident reports Proactive method HAZARDS ASR Surveys Audits Predictive method FDA Direct observation systems IDENTIFICATION Assess and prioritize risks Develop control and mitigation strategies Inform person(s) responsible for implementin g strategies MANAGEMENT Assign responsibiliti es Implement strategies Re-evaluate strategies and processes DOCUMENTATION INFORMATION Safety management information S A F E T Y L I B R A R Y Trend analysis Safety bulletins Report distribution Seminars and workshops Feedback 20. 09. 2007 SMS LV CAA AOD 77

Risk management u Second fundamental – Risk probability Definition (s) Probability – The chance Risk management u Second fundamental – Risk probability Definition (s) Probability – The chance that a situation of danger might occur. Questions for assessing the probability of an occurrence: Is there a history of occurrences like the one being assessed, or is the occurrence an isolated event? What other equipment, or similar type components, might have similar defects? What number of operating or maintenance personnel must follow the procedure (s) in question? How frequently is the equipment or procedure under assessment used? 20. 09. 2007 SMS LV CAA AOD 78

Second fundamental – Risk probability Probability of occurrence Qualitative definition Frequent Meaning Likely to Second fundamental – Risk probability Probability of occurrence Qualitative definition Frequent Meaning Likely to occur many times (has occurred frequently) Occasional Likely to occur some times (has occurred infrequently) Value 5 4 Unlikely, but possible to occur (has occurred rarely) 3 Improbable Very unlikely to occur (not known to have occurred) 2 Extremely Almost inconceivable that the event will occur improbable 1 Remote 20. 09. 2007 SMS LV CAA AOD 79

Risk management u Third fundamental – Risk severity Definition (s) Severity – The possible Risk management u Third fundamental – Risk severity Definition (s) Severity – The possible consequences of a situation of danger, taking as reference the worst foreseeable situation. Define the severity in terms of: Property Health Finance Liability People Environment Image Public confidence 20. 09. 2007 SMS LV CAA AOD 80

Risk management Questions for assessing the severity of an occurrence : How many lives Risk management Questions for assessing the severity of an occurrence : How many lives are at risk? – – Employees Passengers Bystanders General public What is the environmental impact? – Spill of fuel or other hazardous product – Physical disruption of natural habitat What is the severity of the property of financial damage? – – Direct operator property loss Damage to aviation infrastructure Third party damage Financial impact and economic impact for the State Are there organizational, management or regulatory implications that might generate larger threats to public safety? What are the likely political implications and/or media interest? 20. 09. 2007 SMS LV CAA AOD 81

Third fundamental – Risk severity Severity of occurrences Aviation definition Meaning Value Hazardous Equipment Third fundamental – Risk severity Severity of occurrences Aviation definition Meaning Value Hazardous Equipment destroyed Multiple deaths A Catastrophic A large reduction in safety margins, physical distress or a workload such that the operators cannot be relied upon to perform their tasks accurately or completely. Serious injury or death to a number of people. Major equipment damage B A significant reduction in safety margins, a reduction in the ability of the operators to cope with adverse operating conditions as a result of increase in workload, or as a result of conditions impairing their efficiency. Serious incident. Injury to persons. Nuisance. Operating limitations. Use of emergency procedures. Minor incident. D Little consequences E Major Minor Negligible 20. 09. 2007 SMS LV CAA AOD C 82

Fourth fundamental – Risk assessment Risk severity Catastrophic Hazardous Major Minor Negligible A B Fourth fundamental – Risk assessment Risk severity Catastrophic Hazardous Major Minor Negligible A B C D E 5 – Frequent 5 A 5 B 5 C 5 D 5 E 4 – Occasional 4 A 4 B 4 C 4 D 4 E 3 – Remote 3 A 3 B 3 C 3 D 3 E 2 – Improbable 2 A 2 B 2 C 2 D 2 E 1 – Extremely improbable 1 A 1 B 1 C 1 D 1 E Risk probability 20. 09. 2007 SMS LV CAA AOD 83

Fourth fundamental – Risk tolerability Assessment risk index Suggested criteria 5 A, 5 B, Fourth fundamental – Risk tolerability Assessment risk index Suggested criteria 5 A, 5 B, 5 C, 4 A, 4 B, 3 A Unacceptable under the existing circumstances 5 D, 5 E, 4 C, 3 B, 3 C, 2 A, 2 B Risk control/mitigation requires management decision 4 D, 4 E, 3 D, 2 C, 1 A, 1 B Acceptable after review of the operation 3 E, 2 D, 2 E, 1 C, 1 D, 1 E Acceptable 20. 09. 2007 SMS LV CAA AOD 84

Risk assessment at a glance Identify the hazards to equipment roperty , personnel or Risk assessment at a glance Identify the hazards to equipment roperty , personnel or the organization. HAZARD IDENTIFICATION Identify the risk(s) and assess the chances of it (them) occurring? RISK ASSESSMENT Probability Evaluate the seriousness of the risk(s) occurring RISK ASSESSMENT Severity Is (are) the consequent risk(s) acceptable and within the organization’s safety performance criteria? RISK ASSESSMENT Tolerability YES Accept the risk(s) NO Take action to reduce the risk(s) to an acceptable level 20. 09. 2007 SMS LV CAA AOD RISK CONTROL/MITIGATION 85

Risk management u Fifth fundamental- Risk control/mitigation Definition (s) Mitigation – Measures to eliminate Risk management u Fifth fundamental- Risk control/mitigation Definition (s) Mitigation – Measures to eliminate the potential hazard or to reduce the risk probability or severity. – Risk mitigation = Risk control Strategies Avoidance – The operation or activity is cancelled because risks exceed the benefits of continuing the operation or activity. (Operations into an aerodrome surrounded by complex geography and without the necessary aids are cancelled. ) 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. (Operations into an aerodrome surrounded by complex geography and without the necessary aids are continued based upon the availability of specific aids and application of specific procedures. ) Segregation of exposure – Action is taken to isolate the effects of risks or buildin redundancy to protect against it, i. e. , reduce the severity of risk. (Operations into an aerodrome surrounded by complex geography are limited to daytime, visual conditions. ) (Non RVSM equipped aircraft not allowed to operate into RVSM airspace. 20. 09. 2007 SMS LV CAA AOD 86

Risk management u Risk mitigation – Defences (Technology, Training, Regulations) As part of the Risk management u Risk mitigation – Defences (Technology, Training, Regulations) As part of the risk mitigation, determine: Do defences to protect against such risk (s) exist? Do defences function as intended? Are the defences practical for use under actual working conditions? Is staff involved aware of the risks and the defences in place? Are additional risk mitigation measures required? 20. 09. 2007 SMS LV CAA AOD 87

Risk mitigation at a glance Hazard identification and risk management Assessment of the defences Risk mitigation at a glance Hazard identification and risk management Assessment of the defences within the safety system Control and mitigation of the risk (s) H H Ø Does the mitigation Regulations EACH HAZARD Accepting the mitigation of the risk Training Technology R R EACH RISK address the hazard? Ø Does it address the risk (s)? Ø Is it effective? Ø Is it appropriate? Ø Is additional or differe mitigation warrante nt Ø Do the mitigation strategies generate additional risk (s) 20. 09. 2007 SMS LV CAA AOD 88

Risk management process at a glance A safety concern is perceived Feedback and record Risk management process at a glance A safety concern is perceived Feedback and record the hazard identification and assessment and/or risk mitigation Identify hazards and assess risks Define the level of severity Define the level of probability Define the level of risk No Is the risk level acceptable? Take action and continue the operation Yes Can the risk be eliminated? Yes Take action and continue the operation No Can the risk be mitigated? Yes Can the residual risk be accepted (If any)? 20. 09. 2007 SMS LV CAA AOD No Cancel the operation 89

Risk control/mitigation log Current measures Risk reduce Generic hazard Risk(s) descriptionreduce risk(s) and Further Risk control/mitigation log Current measures Risk reduce Generic hazard Risk(s) descriptionreduce risk(s) and Further actions to risk index Responsibility to reference risk(s) and resulting risk index Risk index: Risk tolerability: 20. 09. 2007 SMS LV CAA AOD 90

Risk management considerations for State Administrations u Policy development through to the “go/no-go” decisions: Risk management considerations for State Administrations u Policy development through to the “go/no-go” decisions: – Policy. To what extent should a State accept the certification paperwork of another State? – Regulatory change. From the many (often-conflicting) recommendations made for regulatory change, how are decisions made? 20. 09. 2007 SMS LV CAA AOD 91

Risk management considerations for State Administrations u Situations when risk management should be applied: Risk management considerations for State Administrations u Situations when risk management should be applied: – Start-up or rapidly expanding companies; – Corporate mergers; – Companies facing bankruptcy or other financial difficulties; – companies facing serious labourmanagement difficulties; 20. 09. 2007 SMS LV CAA AOD 92

Risk management considerations for State Administrations – Introduction of major new equipment by an Risk management considerations for State Administrations – Introduction of major new equipment by an operator; – Certification of a new aircraft type, new airport, etc. ; – Introduction of new communication, navigation or surveillance equipment and procedures; and – Significant change to air regulations or other laws potentially impacting on aviation safety. 20. 09. 2007 SMS LV CAA AOD 93

Risk management considerations for State Administrations – Priority setting. How are decisions made for Risk management considerations for State Administrations – Priority setting. How are decisions made for determining those areas of safety warranting emphasis during safety oversight audits? – Operational management. How are decisions made when insufficient resources are available to carry out all planned activities? – Operational inspections. At the front line, how are decisions made when critical errors are discovered of normal working hours? 20. 09. 2007 SMS LV CAA AOD 94

Risk management considerations for State Administrations u Risk management by State administrations will be Risk management considerations for State Administrations u Risk management by State administrations will be affected by such factors as: – Time available to make the decision (grounding an aircraft, revoking a certificate, etc. ); – Resources available to effect the necessary actions; – Number of people affected by required actions (company-wide, fleet-wide, regional, national, international, etc. ); 20. 09. 2007 SMS LV CAA AOD 95

Risk management considerations for State Administrations – Potential impact of the State’s decision for Risk management considerations for State Administrations – Potential impact of the State’s decision for action (or inaction); and – Cultural and political will to take the action required. 20. 09. 2007 SMS LV CAA AOD 96

Risk management considerations for State Administrations u Benefits of risk management for State administrations: Risk management considerations for State Administrations u Benefits of risk management for State administrations: – Avoiding costly mistakes during the decision-making process; – Ensuring that all aspects of the risk are identified and considered ehen making decisions; – Ensuring that the legitimate interests of affected stakeholders are considered; 20. 09. 2007 SMS LV CAA AOD 97

Risk management considerations for State Administrations – Providing decision-makers with a solid defence in Risk management considerations for State Administrations – Providing decision-makers with a solid defence in support of decisions; – Making decisions easier to explain to stakeholders and the general public; and – Providing significant savings in time and money. 20. 09. 2007 SMS LV CAA AOD 98

Safety assurance Ensuring that the operation of service providers SMS follows established controls (standards)/requirements) Safety assurance Ensuring that the operation of service providers SMS follows established controls (standards)/requirements) u Oversight, inspections and audits u Data tracking and analysis Data driven targeting of oversight on areas of greater concern/need 20. 09. 2007 SMS LV CAA AOD 99

The essential is invisible to the eyes Number of occurrences 1– 5 Accidents 30 The essential is invisible to the eyes Number of occurrences 1– 5 Accidents 30 – 100 Serious incidents 100 – 1000 Incidents 1000 – 4000 Latent conditions 20. 09. 2007 SMS LV CAA AOD 100

Safety promotion Support the integration of the State safety programme with the operation of Safety promotion Support the integration of the State safety programme with the operation of service providers SMS u Training, communication and dissemination of safety information u Dual-track promotion Within the CAA Among service providers it oversees 20. 09. 2007 SMS LV CAA AOD 101

The final objective – Integration Safety programme + SMS = State integrated safety management The final objective – Integration Safety programme + SMS = State integrated safety management system Protection Production Objective: Public safety State safety programme Oversigh t Acceptance Oversight Organization’s Objective: Manage and safety management control safety risk system (SMS) Objective: Organization’s Achieve production commercial goals and processes customer Risk management Safety assurance 20. 09. 2007 SMS LV CAA AOD satisfaction 102