ICAOSMSModuleN2Basicsafetyconcepts2008-11E.pdf

    ICAO Safety Management Systems (SMS) CourseModule N° 2 – Basic safety concepts

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

    Module N° 2 – Basic safety concepts

    Module N° 2 ICAO Safety Management Systems (SMS) Course 2

    Building an SMS

    Module 1SMS course introduction

    Module 2Basic safety

    concepts

    Module 3Introduction

    to safety management

    Module 4Hazards

    Module 5Risks

    Module 6SMS regulation

    Module 7Introduction to SMS

    Module 8SMS planning

    Module 9SMS operation

    Module 10Phased approach to SMS Implementation

    SafetyManagementSystem

    Module 2Basic safety

    concepts

    Safety

    Module N° 2 ICAO Safety Management Systems (SMS) Course 3

    Objective

    At the end of this module, participants will be able to

    explain the strengths and weaknesses of traditional

    methods to manage safety, and describe new perspectives

    and methods for managing safety.

    Module N° 2 ICAO Safety Management Systems (SMS) Course 4

    Outline

    Concept of safetyThe evolution of safety thinkingA concept of accident causation – Reason modelThe organizational accidentPeople, context and safety – SHEL(L) modelErrors and violationsOrganizational cultureSafety investigationQuestions and answersPoints to rememberExercise Nº 02/01 – The Anytown City Airport accident (See Handout N° 1)

    ICAO Safety Management Systems (SMS) CourseModule N° 2 – Basic safety concepts

    Module N° 2 ICAO Safety Management Systems (SMS) Course 5

    Concept of safety

    What is safetyZero accidents (or serious incidents)?Freedom from danger or risks?Error avoidanceRegulatory compliance?… ?

    Module N° 2 ICAO Safety Management Systems (SMS) Course 6

    Concept of safety

    Consider (the weaknesses in the notion of perfection)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.

    Module N° 2 ICAO Safety Management Systems (SMS) Course 7

    Concept of safety (Doc 9859)

    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.

    Module N° 2 ICAO Safety Management Systems (SMS) Course 8

    SafetyTraditional approach – Preventing accidents

    Focus on outcomes (causes)Unsafe acts by operational personnelAttach blame/punish for failures to “perform safely”Address identified safety concern exclusivelyIdentifies:

    WHAT? WHO? WHEN?

    WHY? HOW?

    But not always discloses:

    ICAO Safety Management Systems (SMS) CourseModule N° 2 – Basic safety concepts

    Module N° 2 ICAO Safety Management Systems (SMS) Course 9

    The evolution of safety thinking

    HUMAN FACTORS

    TODA

    Y1950s 1970s 1990s 2000s

    Module N° 2 ICAO Safety Management Systems (SMS) Course 10

    Latent conditions trajectory

    TechnologyTrainingRegulations

    Defences

    Errorsandviolations

    People

    A concept of accident causation

    Accident

    Working conditions

    WorkplaceOrganization

    Management decisions and

    organizational processes

    Source: James Reason

    Module N° 2 ICAO Safety Management Systems (SMS) Course 11

    The organizational accident

    Organizational processes

    Activities over which any organization has a reasonable degree of direct control

    Policy-makingPlanningCommunication Allocation of resourcesSupervision…

    Module N° 2 ICAO Safety Management Systems (SMS) Course 12

    The organizational accident

    Conditions present in the system before the accident, made evident by triggering factors.

    Inadequate hazard identification and risk managementNormalization of deviance

    ICAO Safety Management Systems (SMS) CourseModule N° 2 – Basic safety concepts

    Module N° 2 ICAO Safety Management Systems (SMS) Course 13

    The organizational accident

    Resources to protect against the risks that organizations involved in production activities generate and must control.

    Technology TrainingRegulations Defences

    Organizational processes

    Latentconditions

    Module N° 2 ICAO Safety Management Systems (SMS) Course 14

    The organizational accident

    Factors that directly influence the efficiency of people in aviation workplaces.

    Workforce stabilityQualifications and experienceMoraleCredibilityErgonomics…

    Module N° 2 ICAO Safety Management Systems (SMS) Course 15

    The organizational accident

    Actions or inactions by people (pilots, controllers, maintenance engineers, aerodrome staff, etc.) that have an immediate adverse effect.

    ErrorsViolations

    Module N° 2 ICAO Safety Management Systems (SMS) Course 16

    The organizational accident

    Improve IdentifyMonitor

    Cont

    ain

    Reinforce

    ICAO Safety Management Systems (SMS) CourseModule N° 2 – Basic safety concepts

    Module N° 2 ICAO Safety Management Systems (SMS) Course 17

    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 interrelationships among the various components of the aviation work places.

    Module N° 2 ICAO Safety Management Systems (SMS) Course 18BB

    AA

    Understand Understand human performance human performance

    within the within the operational context operational context where it takes placewhere it takes place

    Module N° 2 ICAO Safety Management Systems (SMS) Course 19

    Processes and outcomes

    Causes andconsequences of operational errors are not linear in their magnitude

    Module N° 2 ICAO Safety Management Systems (SMS) Course 20

    The SHEL(L) model

    SH L

    E

    LS

    H L LE

    SH L L

    E

    SoftwareHardwareEnvironmentLivewareLiveware, other persons

    Understanding the relationship between people and operational contexts

    ICAO Safety Management Systems (SMS) CourseModule N° 2 – Basic safety concepts

    Module N° 2 ICAO Safety Management Systems (SMS) Course 21

    Operational performance and technology

    In production-intensive industries like contemporary aviation, technology is essential. As a result of the massive introduction of technology, the operational consequences of the interactions between people and technology are often overlooked, leading to human error.

    Module N° 2 ICAO Safety Management Systems (SMS) Course 22

    Understanding operational errors

    Human error is considered contributing factor in most aviation occurrences. Even competent personnel commit errors. Errors must be accepted as a normal component of any system where humans and technology interact.

    Module N° 2 ICAO Safety Management Systems (SMS) Course 23

    Errors and safety – A non linear relationship

    Statistically, millions of operational errors are made

    before a major safety breakdown occurs

    Module N° 2 ICAO Safety Management Systems (SMS) Course 24

    Accident investigation – Once in a million flights

    Flaps omittedFlaps omitted

    Error

    Checklist failure

    Checklist failure

    Deviation

    Unheeded warning

    Unheeded warning

    AmplificationDegradation/breakdown

    ICAO Safety Management Systems (SMS) CourseModule N° 2 – Basic safety concepts

    Module N° 2 ICAO Safety Management Systems (SMS) Course 25

    Safety management – On almost every flight

    Flaps omittedFlaps omitted

    Error

    Checklist works

    Checklist works

    Deviation

    Effective warning

    Effective warning

    AmplificationDegradation/breakdown

    Module N° 2 ICAO Safety Management Systems (SMS) Course 26

    Three strategies for the control of human error

    Error reduction strategies intervene at the source of the error by reducing or eliminating the contributing factors.

    Human-centred design Ergonomic factorsTraining…

    Module N° 2 ICAO Safety Management Systems (SMS) Course 27

    Error capturing strategies intervene once the error has already been made, capturing the error before it generates adverse consequences.

    ChecklistsTask cardsFlight strips…

    Three strategies for the control of human error

    Module N° 2 ICAO Safety Management Systems (SMS) Course 28

    Error tolerance strategies intervene to increase the ability of a system to accept errors without serious consequence.

    System redundancies

    Structural inspections

    Three strategies for the control of human error

    ICAO Safety Management Systems (SMS) CourseModule N° 2 – Basic safety concepts

    Module N° 2 ICAO Safety Management Systems (SMS) Course 29

    Understanding violations – Are we ready?

    System output MaximumMinimum

    Risk

    High

    Low

    Technolo

    gy

    Training

    Regulat

    ions

    Safety space

    Viol

    atio

    n sp

    ace

    Exce

    ptio

    nal v

    iola

    tion

    spac

    e

    IncidentAccident

    System’s production objective(s)

    Module N° 2 ICAO Safety Management Systems (SMS) Course 30

    Culture

    Culture binds people together as members of groups and

    provides clues as to how to behave in both normal and

    unusual situations.

    Culture influences the values, beliefs and behaviours that

    people share with other members of various social groups.

    Module N° 2 ICAO Safety Management Systems (SMS) Course 31

    National

    Three cultures

    Organizational

    Professional

    National

    Module N° 2 ICAO Safety Management Systems (SMS) Course 32

    Three distinct cultures

    National culture encompasses the value system of particular nations.Organizational/corporate culture differentiates the values and behaviours of particular organizations (e.g. government vs. private organizations). Professional culture differentiates the values and behaviours of particular professional groups (e.g. pilots, air traffic controllers, maintenance engineers, aerodrome staff, etc.).No human endeavour is culture-free

    ICAO Safety Management Systems (SMS) CourseModule N° 2 – Basic safety concepts

    Module N° 2 ICAO Safety Management Systems (SMS) Course 33

    Organizational/corporate culture

    Sets the boundaries for acceptable behaviour in the workplace by establishing norms and limits. Provides a frame work for managerial and employee decision-making

    “This is how we do things here, and how we talk about the way we do things here”.

    Organizational/corporate culture shapes – among many others – safety reporting procedures and practices by operational personnel.

    Module N° 2 ICAO Safety Management Systems (SMS) Course 34

    Safety culture

    A trendy notion with potential for misperceptions and misunderstandings

    A construct, an abstractionIt is the consequence of a series of organizational processes (i.e., an outcome)

    Safety culture is not an end in itself, but a means to achieve an essential safety management prerequisite:

    Effective safety reporting

    Module N° 2 ICAO Safety Management Systems (SMS) Course 35

    Effective safety reporting – Five basic traitsInformation

    People are knowledgeable about the human, technical and organizational factors that determine the safety of the system

    as a whole.

    FlexibilityPeople can adapt reporting

    when facing unusual circumstances, shifting from the established mode to a direct mode thus allowing

    information to quickly reach the appropriate decision-

    making level.

    Learning

    People have the competence to draw conclusions from

    safety information systems and the will to implement

    major reforms.

    Willingness

    People are willing to report their errors and

    experiences.

    Accountability

    People are encouraged (and rewarded) for providing essential safety-related information. However, there is a clear line that

    differentiates between acceptable and unacceptable behaviour.

    Effective safety reporting

    Module N° 2 ICAO Safety Management Systems (SMS) Course 36

    Three options

    Organizations and the management of information

    Pathological – Hide the information

    Bureaucratic – Restrain the information

    Generative – Value the information

    Source: Ron Westrum

    ICAO Safety Management Systems (SMS) CourseModule N° 2 – Basic safety concepts

    Module N° 2 ICAO Safety Management Systems (SMS) Course 37

    Three possible organizational cultures

    Hidden

    Shouted

    Shirked

    Discouraged

    Covered up

    CrushedConflicted

    organization

    Ignored

    Tolerated

    Boxed

    Allowed

    Merciful

    Problematic“Red tape”

    organization

    Sought

    Trained

    Shared

    Rewarded

    Scrutinized

    WelcomedReliable

    organization

    PathologicalPathological BureaucraticBureaucratic GenerativeGenerative

    InformationInformation

    MessengersMessengers

    ResponsibilitiesResponsibilities

    ReportsReports

    FailuresFailures

    New ideasNew ideasResulting Resulting organizationorganization

    Source: Ron Westrum

    Module N° 2 ICAO Safety Management Systems (SMS) Course 38

    Safety investigation

    For “funereal” purposesTo put losses behindTo reassert trust and faith in the systemTo resume normal activitiesTo fulfil political purposes

    For improved system reliabilityTo learn about system vulnerabilityTo develop strategies for changeTo prioritize investment of resources

    Module N° 2 ICAO Safety Management Systems (SMS) Course 39

    Investigation

    The facts An old generation four engine turboprop freighter flies into severe icing conditions. Engines 2 and 3 flameout as consequence of ice accretion, and seven minutes later engine 4 fails. The flight crew manages to re-start engine number 2. Electrical load shedding is not possible, and the electrical system reverts to battery power. …

    Module N° 2 ICAO Safety Management Systems (SMS) Course 40

    Investigation

    … The facts While attempting to conduct an emergency landing, all electrical power is lost. All that is left to the flight crew is the self-powered standby gyro, a flashlight and the self-powered engine instruments. The flight crew is unable to maintain controlled flight, and the aircraft crashes out of control.

    ICAO Safety Management Systems (SMS) CourseModule N° 2 – Basic safety concepts

    Module N° 2 ICAO Safety Management Systems (SMS) Course 41

    Investigation

    FindingsCrew did not use the weather radar.Crew did not consult the emergency check-list.Demanding situation requiring decisive thinking and clear action.Conditions exceeded certification condition for the engines.Did not request diversion to a closer aerodrome….

    Module N° 2 ICAO Safety Management Systems (SMS) Course 42

    Investigation

    … FindingsCrew did not use correct phraseology to declare emergency.Poor crew resource management (CRM).Mismanagement of aircraft systems.Emergency checklist – presentation and visual information.Flight operations internal quality assurance procedures.

    Module N° 2 ICAO Safety Management Systems (SMS) Course 43

    Investigation

    CausesMultiple engine failuresIncomplete performance of emergency drillsCrew actions in securing and re-starting enginesDrag from unfeathered propellersWeight of icePoor CRMLack of contingency plansLoss of situational awareness

    Module N° 2 ICAO Safety Management Systems (SMS) Course 44

    Investigation

    Safety recommendations

    Authority should remind pilots to use correct

    phraseology.

    Authority should research into most effective form of

    presentation of emergency reference material.

    ICAO Safety Management Systems (SMS) CourseModule N° 2 – Basic safety concepts

    Module N° 2 ICAO Safety Management Systems (SMS) Course 45

    Investigation

    The factsAn old generation two engine turboprop commuter aircraft engaged in a regular passenger transport operation is conducting a non-precision approach in marginal weather conditions in an uncontrolled, non-radar, remote airfield. The flight crew conducts a straight-in approach, not following the published approach procedure. …

    Module N° 2 ICAO Safety Management Systems (SMS) Course 46

    Investigation

    … The facts

    Upon reaching MDA, the flight crew does not acquire

    visual references.

    The flight crew abandons MDA without having acquired

    visual references to pursue the landing.

    The aircraft crashes into terrain short of the runway.

    Module N° 2 ICAO Safety Management Systems (SMS) Course 47

    Investigation

    Findings

    The crew made numerous mistakes.

    ButCrew composition legal but unfavourable in view of demanding flight conditions.

    According to company practice, pilot made a direct approach, which was against regulations.

    …Module N° 2 ICAO Safety Management Systems (SMS) Course 48

    Investigation

    … ButThe company had consistently misinterpreted regulations. Level of safety was not commensurate with the requirements of a scheduled passenger operation.Aerodrome operator had neither the staff nor the resources to ensure regularity of operations.

    ICAO Safety Management Systems (SMS) CourseModule N° 2 – Basic safety concepts

    Module N° 2 ICAO Safety Management Systems (SMS) Course 49

    Investigation

    … But

    Lack of standards for commuter operations.

    Lack of supervision of air traffic facilities.

    Authorities’ disregard of previous safety violations.

    Legislation out of date.

    Module N° 2 ICAO Safety Management Systems (SMS) Course 50

    Investigation

    … But

    Conflicting goals within the authority.

    Lack of resources within the authority.

    Lack of aviation policy to support the authority.

    Deficiencies in the training system.

    Module N° 2 ICAO Safety Management Systems (SMS) Course 51

    Investigation

    Causes

    Decision to continue approach below MDA without

    visual contact.

    Performance pressures.

    Airline’s poor safety culture.

    Module N° 2 ICAO Safety Management Systems (SMS) Course 52

    Investigation

    Safety recommendations“Tip-of-the-arrow” recommendations.

    ButReview the process of granting AOC.Review the training system.Define an aviation policy which provides support to the task of the aviation administration. …

    ICAO Safety Management Systems (SMS) CourseModule N° 2 – Basic safety concepts

    Module N° 2 ICAO Safety Management Systems (SMS) Course 53

    Investigation

    … But

    Reform aviation legislation.

    Reinforce existing legislation as interim measure.

    Improve both accident investigation and aircraft and

    airways inspection processes.

    Module N° 2 ICAO Safety Management Systems (SMS) Course 54

    Errors …

    … are like mosquitoes …

    Module N° 2 ICAO Safety Management Systems (SMS) Course 55

    To fight them …

    … drain their breeding swamps…. drain their breeding swamps.Module N° 2 ICAO Safety Management Systems (SMS) Course 56

    Questions and answersBasic safety concepts

    ICAO Safety Management Systems (SMS) CourseModule N° 2 – Basic safety concepts

    Module N° 2 ICAO Safety Management Systems (SMS) Course 57

    Questions and answers

    Q: How is safety defined in document 9859? A:

    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.

    Slide number: 7

    Module N° 2 ICAO Safety Management Systems (SMS) Course 58

    Questions and answers

    Q: Enumerate the five building blocks of the organizational accident. A:

    Slide number: 16

    Module N° 2 ICAO Safety Management Systems (SMS) Course 59

    Questions and answers

    Q: Explain the components of the SHEL(L) Model. A:

    Slide number: 20

    SoftwareHardwareEnvironmentLivewareLiveware, other persons

    S

    H L LE

    Module N° 2 ICAO Safety Management Systems (SMS) Course 60

    Questions and answersQ: Enumerate three basic traits underlying effective safety reporting. A:

    Slide number: 35

    InformationPeople are knowledgeable about the human, technical and

    organizational factors that determine the safety of the system as a whole.

    FlexibilityPeople can adapt reporting

    when facing unusual circumstances, shifting from the

    established mode to a direct mode thus allowing information to quickly reach the appropriate

    decision-making level .

    Learning

    People have the competence to draw conclusions from safety

    information systems and the will to implement major reforms.

    Willingness

    People are willing to report their errors and

    experiences.

    Accountability

    People are encouraged (and rewarded) for providing essential safety-related information. However, there is a clear line that differentiates

    between acceptable and unacceptable behaviour.

    Effective safety reporting

    ICAO Safety Management Systems (SMS) CourseModule N° 2 – Basic safety concepts

    Module N° 2 ICAO Safety Management Systems (SMS) Course 61

    Questions and answers

    Q: How can organizations be characterized, depending upon their management of safety information?

    A:

    Pathological – Hide the informationBureaucratic – Restrain the informationGenerative – Value the information

    Slide number: 36

    Module N° 2 ICAO Safety Management Systems (SMS) Course 62

    Points to remember

    1. The organizational accident.

    2. Operational contexts and human performance

    3. Errors and violations.

    4. Organizational culture and effective safety reporting.

    5. The management of safety information.

    Module N° 2 ICAO Safety Management Systems (SMS) Course 63

    Basic safety concepts

    Exercise 02/01 – The Anytown City Airport accident (Handout Nº 1)

    Module N° 2 ICAO Safety Management Systems (SMS) Course 64

    The Anytown City Airport accident

    In the late hours of a summer Friday evening, while landing on a runway heavily contaminated with water, a twin-engine jet transport aircraft with four crew members and 65 passengers on board overran the westerly end of the runway at Anytown City airport. The aircraft came to rest in the mud a short distance beyond the end of the runway. There were no injuries to crew or passengers, and there was no apparent damage to the aircraft as a consequence of the overrun. However, a fire started and subsequently destroyed the aircraft.

    ICAO Safety Management Systems (SMS) CourseModule N° 2 – Basic safety concepts

    Module N° 2 ICAO Safety Management Systems (SMS) Course 65

    The Anytown City Airport accident

    Group activity:A facilitator will be appointed, who will coordinate the discussion. A summary of the discussion will be written on flip charts, and a member of the group will brief on their findings in a plenary session.

    Required task:Read the text related to the accident of the twin-engined jet transport at Anytown City Airport. …

    Module N° 2 ICAO Safety Management Systems (SMS) Course 66

    The Anytown City Airport accident

    … required task:From the investigation report of the above accident, you should identify:

    1. Organizational processes that influenced the operation and which felt under the responsibility of senior management (i.e. those accountable for the allocation of resources);

    2. Latent conditions in the system safety which became precursors of active failures;

    3. Defences which failed to perform due to weaknesses, inadequacies or plain absence; …

    Module N° 2 ICAO Safety Management Systems (SMS) Course 67

    The Anytown City Airport accident

    … required task:

    4. Workplace conditions, which may have influenced operational personnel actions; and

    5. Active failures, including errors and violations

    When you have concluded the above, your task is to complete the Table 02/01 – Analysis (Handout N° 1)classifying your findings in accordance with the organizational accident model.

    Module N° 2 ICAO Safety Management Systems (SMS) Course 68

    The organizational accident

    ICAO Safety Management Systems (SMS) CourseModule N° 2 – Basic safety concepts

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

    Module N° 2 – Basic safety concepts

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