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
