ICAOSMSModuleN3Introductiontosafetymanagement2008-11E.pdf

    ICAO Safety Management Systems (SMS) CourseModule N° 3 – Introduction to safety management

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

    Module N° 3 – Introduction to safety management

    Module N° 3 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 3Introduction

    to safety management

    Module 4Hazards

    Module 5Risks

    Management

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

    Objective

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

    explain the need for, the strategies and the key features of

    safety management.

    Module N° 3 ICAO Safety Management Systems (SMS) Course 4

    Outline

    The safety stereotypeThe management dilemmaNeed for safety managementStrategies for safety managementThe imperative of changeSafety management – Eight building blocks Four responsibilities for managing safetyQuestions and answersPoints to rememberExercise Nº 03/01 – The Anyfield Airport accident (See Handout N° 2)

    ICAO Safety Management Systems (SMS) CourseModule N° 3 – Introduction to safety management

    Module N° 3 ICAO Safety Management Systems (SMS) Course 5

    The safety stereotype

    Module N° 3 ICAO Safety Management Systems (SMS) Course 6

    Is it?

    Module N° 3 ICAO Safety Management Systems (SMS) Course 7

    Really?

    Module N° 3 ICAO Safety Management Systems (SMS) Course 8

    What is the fundamental objective of a business organization?

    ICAO Safety Management Systems (SMS) CourseModule N° 3 – Introduction to safety management

    Module N° 3 ICAO Safety Management Systems (SMS) Course 9

    Safety management – Rationale

    In order to achieve its production objectives, the management of any aviation organization requires the management of many business processes.

    Managing safety is one such business process.

    Safety management is a core business function just as financial management, HR management, etc.

    This brings about a potential dilemma for management.

    Module N° 3 ICAO Safety Management Systems (SMS) Course 10

    The management dilemma

    Management levels

    Protection Production

    Module N° 3 ICAO Safety Management Systems (SMS) Course 11

    The management dilemma

    Management levels

    Protection

    Production

    CatastropheModule N° 3 ICAO Safety Management Systems (SMS) Course 12

    The management dilemma

    Protection

    Production

    Manage

    ment lev

    els

    Bankruptcy

    ICAO Safety Management Systems (SMS) CourseModule N° 3 – Introduction to safety management

    Module N° 3 ICAO Safety Management Systems (SMS) Course 13

    Safety

    space

    Bankruptcy

    Catastrophe

    Production

    Pro

    tect

    ion

    Safety space

    Financial management ?

    Safety management

    Module N° 3 ICAO Safety Management Systems (SMS) Course 14

    Safety management – The response to the dilemma

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

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

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

    Module N° 3 ICAO Safety Management Systems (SMS) Course 15

    Why SM ? – The first ultra-safe industrial system

    Fragile system (1920’s -1970’s)Individual risk management & intensive trainingAccident investigation

    Safe system (1970’s – mid 1990’s)Technology and regulationsIncident investigation

    Ultra-safe system (mid 1990’s onwards)Business management approach to safety (SMS)Routine collection and analysis of operational data Less than one catastrophic

    breakdown per million production cycles

    10-3

    10-5

    10-7

    Module N° 3 ICAO Safety Management Systems (SMS) Course 16

    Why SM? An imperfect system

    “Practical drift”

    Operationaldeployment

    System design

    Baseline performance

    Operational performance

    Baseline performance

    Operationaldeployment

    Baseline performance

    Operational performance

    “Practical drift”

    SMS

    ICAO Safety Management Systems (SMS) CourseModule N° 3 – Introduction to safety management

    Module N° 3 ICAO Safety Management Systems (SMS) Course 17

    The essential is invisible to the eyes

    Number of occurrences

    1 – 5 Accidents

    30 – 100 Serious incidents

    100 – 1000 Incidents

    1000 – 4000 Latent conditions

    Module N° 3 ICAO Safety Management Systems (SMS) Course 18

    Navigating the drift

    “Practical drift”Operational performance

    Baseline performance

    Organization

    Navigational aids

    Reactive Proactive Predictive

    Module N° 3 ICAO Safety Management Systems (SMS) Course 19

    Reactive safety management

    Investigation of accidents and serious incidents Based upon the notion of waiting until something breaks to fix it.Most appropriate for:

    situations involving failures in technology. unusual events.

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

    Module N° 3 ICAO Safety Management Systems (SMS) Course 20

    Proactive safety management

    Mandatory and voluntary reporting systems, safety audits and surveys.

    Based upon the notion that system failures can be minimized by:

    identifying safety risks within the system before it fails; and

    taking the necessary actions to reduce such safety risks.

    ICAO Safety Management Systems (SMS) CourseModule N° 3 – Introduction to safety management

    Module N° 3 ICAO Safety Management Systems (SMS) Course 21

    Predictive safety management

    Confidential reporting systems, flight data analysis, normal operations monitoring.

    Based upon the notion that safety management is best accomplished by looking for trouble, not waiting for it.

    Aggressively seek information from a variety of sources which may be indicative of emerging safety risks.

    Module N° 3 ICAO Safety Management Systems (SMS) Course 22

    Strategies – Summary

    Reactive methodReactive method

    The reactive method The reactive method responds to theresponds to the

    events that already events that already happened, such ashappened, such as

    incidents and incidents and accidentsaccidents

    Proactive methodProactive method

    The proactive The proactive method method

    looks actively for the looks actively for the identification ofidentification of

    safety risks safety risks through the analysis through the analysis of the organizationof the organization’’s s

    activitiesactivities

    Predictive methodPredictive method

    The predictiveThe predictivemethod captures method captures

    systemsystemperformance as performance as

    it happens in it happens in realreal–time time

    normal operationsnormal operations

    Module N° 3 ICAO Safety Management Systems (SMS) Course 23

    Strategies – Levels of intervention and tools

    “Practical drift”Operational performance

    Baseline performance

    Organization

    Predictive

    Highly efficient

    FDADirect

    observationsystem

    Proactive

    Very efficient

    ASRSurveysAudits

    Reactive

    ASRMOR

    Efficient Insufficient

    Accidentand incident

    reports

    ReactivePredictive

    Highly efficient

    FDADirect

    observationsystem

    Proactive

    Very efficient

    ASRSurveysAudits

    Reactive

    ASRMOR

    Efficient

    Desirable management levels

    Module N° 3 ICAO Safety Management Systems (SMS) Course 24

    The imperative of change

    As global aviation activity and complexity continues to

    grow, traditional methods for managing safety risks to an

    acceptable level become less effective and inefficient.

    Evolving methods for understanding and managing safety

    risks are necessary.

    ICAO Safety Management Systems (SMS) CourseModule N° 3 – Introduction to safety management

    Module N° 3 ICAO Safety Management Systems (SMS) Course 25

    The changing of the guard

    Traditional – Accident/serious incident investigationAviation system performs most of the time as per design specifications (base line performance).Compliance based.Outcome oriented.

    Evolving – Safety managementAviation system does not perform most of the time as per design specifications (practical drift).Performance based. Process oriented.

    Module N° 3 ICAO Safety Management Systems (SMS) Course 26

    Safety management – Eight building blocks

    Senior management’s commitment to the management

    of safety.

    Effective safety reporting.

    Continuous monitoring through systems to collect,

    analyse, and share safety-related data arising from

    normal operations.

    Module N° 3 ICAO Safety Management Systems (SMS) Course 27

    Safety management – Eight building blocks

    Investigation of safety occurrences with the objective of

    identifying systemic safety deficiencies rather than

    assigning blame.

    Sharing safety lessons learned and best practices

    through the active exchange of safety information.

    Integration of safety training for operational personnel.

    Module N° 3 ICAO Safety Management Systems (SMS) Course 28

    Safety management – Eight building blocks

    Effective implementation of Standard Operating Procedures (SOPs), including the use of checklists and briefings.

    Continuous improvement of the overall level of safety.

    The result of implementing the eight building blocks: An organizational culture that fosters safe practices,

    encourages effective safety communication, and actively manages safety with the same attention to

    results as financial management.

    ICAO Safety Management Systems (SMS) CourseModule N° 3 – Introduction to safety management

    Module N° 3 ICAO Safety Management Systems (SMS) Course 29

    Responsibilities for managing safety

    These responsibilities fall into four basic areas:

    Definition of policies and procedures regarding safety.

    Allocation of resources for safety management

    activities.

    Adoption of best industry practices.

    Incorporating regulations governing civil aviation

    safety.Module N° 3 ICAO Safety Management Systems (SMS) Course 30

    The safety management process at a glance

    Safety management

    process

    Identifyhazards

    Assessrisks

    Prioritizerisks

    Developelimination/ mitigationstrategies

    Approvecontrol

    strategiesAssign

    responsibilities

    Implementcontrol

    strategies

    Re-evaluatecontrol

    strategies

    Collectadditional

    hazarddata

    Module N° 3 ICAO Safety Management Systems (SMS) Course 31

    In summary

    Managing safety requires resources.

    Allocation of resources is a managerial function.

    Management has the authority and the responsibility to

    manage safety risks in the organization.

    Management thus is accountable for safety outcome.

    Module N° 3 ICAO Safety Management Systems (SMS) Course 32

    In summary

    Safety managementIncludes the entire operation Focus on processes (Clear difference between processes and outcomes)Data-driven (constant monitoring) Strictly documentedGradual improvement as opposed to dramatic changeStrategic planning as opposed to piecemeal initiatives

    ICAO Safety Management Systems (SMS) CourseModule N° 3 – Introduction to safety management

    Module N° 3 ICAO Safety Management Systems (SMS) Course 33

    A balanced perspective

    …The pilot-in-command must bear responsibility for the

    decision to land and take-off in Dryden… However, it is

    equally clear that the air transportation system failed

    him by allowing him to be placed in a situation where he

    did not have all the necessary tools that should have

    supported him in making the proper decision …

    Module N° 3 ICAO Safety Management Systems (SMS) Course 34

    Question and answersIntroduction to safety management

    Module N° 3 ICAO Safety Management Systems (SMS) Course 35

    Questions and answers

    Q: Explain the management dilemma regarding safety management. A:

    Management levels

    Protection Production

    Slide number: 10

    Module N° 3 ICAO Safety Management Systems (SMS) Course 36

    Questions and answers

    Q: Explain the difference between reactive, proactive and predictive safety strategies.A:

    Slide number: 22

    Reactive methodReactive method

    The reactive method The reactive method responds to theresponds to the

    events that already events that already happened, such ashappened, such as

    incidents and incidents and accidentsaccidents

    Proactive methodProactive method

    The proactive The proactive method method

    looks actively for the looks actively for the identification ofidentification of

    safety risks safety risks through the analysis through the analysis of the organizationof the organization’’s s

    activitiesactivities

    Predictive methodPredictive method

    The predictiveThe predictivemethod captures method captures

    systemsystemperformance as performance as

    it happens in it happens in realreal–time time

    normal operationsnormal operations

    ICAO Safety Management Systems (SMS) CourseModule N° 3 – Introduction to safety management

    Module N° 3 ICAO Safety Management Systems (SMS) Course 37

    Questions and answersQ: Explain the difference between the traditional and the evolving approach to safety management.A:

    Traditional – Accident/serious incident investigationAviation system performs most of the time as per design specifications (base line performance).Compliance based.Outcome oriented.

    Evolving – Safety managementAviation system does not perform most of the time as per design specifications (practical drift).Performance based. Process oriented.

    Slide number: 25

    Module N° 3 ICAO Safety Management Systems (SMS) Course 38

    Questions and answersQ: Enumerate at least four building blocks of safety management.A:

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

    2. Effective safety reporting. 3. Continuous monitoring through systems to collect,

    analyse, and share safety-related data arising from normal operations.

    4. Investigation of safety occurrences with the objective of identifying systemic safety deficiencies rather than assigning blame.

    Slide number: 26

    Module N° 3 ICAO Safety Management Systems (SMS) Course 39

    Questions and answers

    Q: Enumerate the four basic responsibilities for managing safety.A:

    1. Definition of policies and procedures regarding safety.2. Allocation of resources for safety management

    activities.3. Adoption of best industry practices.4. Incorporating regulations governing civil aviation

    safety.

    Slide number: 29

    Module N° 3 ICAO Safety Management Systems (SMS) Course 40

    Points to remember

    1. The dilemma of the two P’s.2. The safety space3. Why SM? An ultra-safe, yet imperfect system.4. Safety management methods and their effectiveness.5. The changing of the guard.6. The eight building blocks and the four basic

    responsibilities for the management of safety.

    ICAO Safety Management Systems (SMS) CourseModule N° 3 – Introduction to safety management

    Module N° 3 ICAO Safety Management Systems (SMS) Course 41

    Introduction to safety management

    Exercise 03/01 – The Anyfield Airport accident (Handout N° 2)

    Module N° 3 ICAO Safety Management Systems (SMS) Course 42

    The Anyfield Airport accident

    In the early hours of a Monday-morning, a twin-engined jet transport with 5 crew-members and 63 passengers on board while in its take-off run at Anyfield Airport collided with a small twin-engined propeller-driven aircraft, with only a single crew-member that had intruded the departure-runway. Both aircraft were severely damaged as a result of the collision. Most passengers and all crew members were killed.

    Module N° 3 ICAO Safety Management Systems (SMS) Course 43

    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 Anyfield Airport. …

    Module N° 3 ICAO Safety Management Systems (SMS) Course 44

    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; …

    ICAO Safety Management Systems (SMS) CourseModule N° 3 – Introduction to safety management

    Module N° 3 ICAO Safety Management Systems (SMS) Course 45

    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 03/01 – Analysis (Handout N° 2)classifying your findings in accordance with the organizational accident model.

    Module N° 3 ICAO Safety Management Systems (SMS) Course 46

    The organizational accident

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

    Module N° 3 – Introduction to safety management

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