Modelo de Indicadores
Modelo de Indicadores
Modelo de Indicadores
any reference to the term 'service provider' is intended to cover providers of aviation products
and services;
any reference to 'operations' is intended to mean your core activities being regulated through
aviation safety regulations; and
any reference to 'regulator' is used in the broad sense, to cover all State functions and
responsibilities as relevant for the management of aviation safety.
Terms and definitions used throughout this document consider definitions contained in International
Civil Aviation Organization (ICAO) Annex 19 Edition 1 and the Safety Management International
Collaboration Group (SM ICG) Safety Management Terminology paper.
Table of Contents
1. The concept....................................................................................................2
1.1.
1.2.
1.3
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1. The concept
1.1.
ICAO Annex 19 defines safety as the state in which risks associated with aviation activities,
related to, or in direct support of the operation of aircraft, are reduced and controlled to an
acceptable level and safety performance as a service providers safety achievement as
defined by its safety performance targets and safety performance indicators. These
definitions provide a good indication of the complexity related to measuring safety
performance. In many areas safety metrics tend to focus on serious incidents and
accidents, as these are easy to measure and often receive more attention. In terms of
safety management, the focus on such negative events should be considered with some
caution, because:
-
counting final outcomes will not reveal any of the systemic factors, hazards or latent
conditions that have a potential to result in high consequence negative outcomes,
under the same conditions; and
where the resilience of a system has been undermined, such outcomes are more
likely to occur by chance and therefore these outcomes may draw unwarranted
attention and use scarce resources when they are not predictive of later events.
The issue is further complicated because the aviation system is a highly dynamic, complex
system with many different players, interactions, dependencies and parameters that may
have a bearing on final safety outcomes. Therefore, in most cases it is impossible to
establish a linear relationship between specific parameters or safety actions and the final,
aggregate safety outcome.
Hence, the absolute measurement of safety is itself
unachievable. Whilst there are many models of what makes up the level of safety (and
conversely the level of exposure to risk), indicators will always constitute imperfect markers
of these levels.
Safety is more than the absence of risk; it requires specific systemic enablers of safety to be
maintained at all times to cope with the known risks, to be well prepared to cope with those
risks that are not yet known, and to address the natural erosion of risk controls over time.
Thus, from the perspective of your company there cannot be any direct measures of safety.
Measures should in particular focus on those features of your system that are intended to
ensure safe outcomes those elements that will constitute organizational enablers of safe
outcomes and specific safety controls and barriers for any risks identified. Measures also
need to address how external factors may influence these enabling elements, risk controls
and barriers or how these controls and barriers influence each other. This approach is
aligned with current industry practice in the area of quality management as promoted for
example by International Organization for Standardization (ISO) 9000 series standards;
when the resulting output cannot be directly measured, the underlying systems and
processes need to be validated instead.
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The principles above are valid both from a regulators perspective and from the perspective
of an individual service provider; in all cases the dynamic nature of the systemic,
operational and external components of safety performance should be considered.
1.2.
ICAO Safety Management System (SMS) standards and recommended practices promote
the development and maintenance of means to verify the safety performance of your
organization and to validate the effectiveness of safety risk controls.
The analysis and assessment of how your company functions to deliver its activities should
form the basis for defining your safety policy, the related safety objectives and the
corresponding safety performance indicators and targets.
SMS requires a systemic approach as with any other element of business management
(e.g., quality, finance), and in this respect safety performance measurement provides an
element that is essential for management and effective control: 'feedback.'
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Feedback will allow management to validate the analysis and assessment of how well
your organization functions in terms of safety and to make adjustments as required
(Plan-Do-Check-Act).
Feedback to all staff will ensure that everyone is informed on your companys safety
achievements. This will help to create commitment and contribute to fostering your
companys safety culture.
Effective safety performance measurement will support the identification of opportunities for
improvement not only related to safety, but also to efficiency and capacity.
The management of safety relies on the capabilities of your organization to systematically
anticipate, monitor, and further develop your organizational performance to ensure safe
outcomes of your activities.
Effective safety management requires a thorough
understanding and sound management of your system and processes. This cannot be
achieved without some form of measurement. Rather than randomly selecting outcomes
that are easy to measure, you should select safety performance indicators that consider the
type of feedback needed to ensure your companys capabilities for safety management can
be properly evaluated and improved.
This implies that you will need to measure
performance at all levels of your organization by adopting a broad set of indicators involving
key aspects of your system, and operations and allowing to measure those key aspects in
different ways.
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1.3
ICAO defines safety performance indicator as a data-based safety parameter used for
monitoring and assessing performance and safety performance target as the planned or
intended objective for safety performance indicator(s) over a given period.
Safety performance indicators (SPIs) can be classified in accordance with specific features;
and different classifications are commonly used in different areas. The types of indicators
described in this document have been defined following a review of such commonly used
classifications and definitions to identify commonalities. An explanation is provided where
relevant on the use of each. You may adopt any terms for your specific safety performance
indicators as you see fit; the information below is provided to complement the conceptual
information required for effective safety performance measurement.
Lagging indicator
Metrics that measure safety events that have already occurred including those
unwanted safety events you are trying to prevent (SM ICG).
Lagging indicators are measures of safety occurrences, in particular the negative
outcomes that the organization is aiming to prevent. Lagging indicators are mainly
used for aggregate, long-term trending, either at a high level or for specific
occurrence types or locations. Because they measure safety outcomes, they can be
used to assess the effectiveness of safety measures, actions, or initiatives and are a
way of validating the safety performance of the system. Also, trends in these
indicators can be analyzed to determine if latent conditions exist in present systems
that should be addressed.
Two types of lagging indicators are generally defined as:
1. Indicators for high severity negative outcomes, such as accidents or serious
incidents.
The low frequency of high severity negative outcomes means that aggregation
(e.g., at industry segment level or regional level) may produce more meaningful
analyzes.
Example: number of runway excursions/1000 landings.
2. Indicators for lower level system failures and safety events that did not manifest
themselves in serious incidents or accidents (including system failures and
procedural deviations); however, safety analysis indicates there is the potential
for them to lead to a serious incident or accident when combined with other
safety events or conditions. Such indicators are sometimes referred to as
precursor event indicators 1 .
This term should be used with caution: Before defining one event or condition as a precursor to a more serious
event or condition (e.g., incidents as precursors to accidents), it must be ensured that there is a demonstrable
correlation between the two. Such correlation underlies the concept of measurement validity. The factors that
cause the incidents defined as 'precursors' must be common between those incidents and the probability of
accidents they are assumed to predict.
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Indicators for lower level system failures and safety events are primarily used to
monitor specific safety issues and measure the effectiveness of safety controls or
barriers put in place for mitigating the risk associated with these hazards.
Example: number of unstabilized approaches/1000 landings
Leading indicator
Metrics that provide information on the current situation that may affect future
performance (SM ICG).
Leading indicators should measure both: things that have the potential to become or
contribute to a negative outcome in the future (negative indicators), and things that
contribute to safety (positive indicators). From a safety management perspective,
it is important to provide sufficient focus on monitoring positive indicators to enable
strengthening of those positive factors that make up your companys safety
management capability.
Leading indicators, which are particularly relevant from a management perspective,
may be used to influence safety management priorities and the determination of
actions for safety improvement. You may use this type of indicator to proactively
develop (drive) your companys safety management capabilities, in particular during
initial implementation of SMS. This may entail the setting of performance targets.
Example: The percentage of changes to Standard Operating Procedures that
have been subject to hazard identification and safety risk management
Leading indicators may also be used to inform your management about the dynamics
of your system and how it copes with any changes, including changes in its operating
environment. The focus will be either: on anticipating emerging weaknesses and
vulnerabilities to determine the need for action, or on monitoring the extent to which
certain activities required for safety are being performed. For these monitoring
indicators, alert levels can be defined.
Example: The extent to which work is carried out in accordance with Standard
Operating Procedures
The concept of leading and lagging indicators has existed in domains outside of aviation for
a number of years. In particular, economists use them as a means to measure the health
of an economy.
Safety performance measurement should ideally consider a combination of leading and
lagging indicators. The main focus should be to measure and to act upon the presence of
those systemic and operational attributes that enable effective safety management within
your company and meanwhile, use lagging indicators to ensure that this safety
management is effective. Lagging indicators, particularly indicators for lower level system
failures, are useful to validate the effectiveness of specific safety actions and risk barriers or
to support the analysis of information derived from your leading indicators.
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http://www.faa.gov/about/initiatives/sms/pilot_projects/guidance/media/DM_SMS_PilotProjectGuide.pdf
http://www.skybrary.aero/index.php/SM_ICG_SMS_Evaluation_Tool
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This will form the basis for reviewing the adequacy of your safety policy, defining or
adapting your safety objectives, and deriving your safety performance indicators.
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and knowledge of safety and/or quality management principles and data analysis. They
should also have experience applying this knowledge and these skills in the context of your
policies, programs, operational procedures and practices. Process owners must be directly
involved even if specialists are used to supply measurement expertise or to
support/facilitate the SPI development process. Also, it is essential that process owners take
ownership of safety performance measurement for their processes. The SPI team (or
individual with designated responsibilities, depending on the size and complexity of your
organization) must clearly be shown to be in either a support or advisory role to
management and process owners.
Management should be kept informed of progress on a regular basis and should take an
active role in steering the process of implementing SPIs. For larger organizations it may be
useful to develop an analysis of the costs and benefits of the SPI development project, with
particular focus on the positive effects on your companys management information system
that will lead to improved resource allocation.
Finally the SPI team should set a reasonable timetable, including milestones, to ensure
adequate progress in developing the SPIs.
Step 2: Review safety policy and objectives identify key issues and main focus
At this step, the SPI team should identify the scope and focus of measurement considering
the results of the system analysis (cf. 2.1), paying particular attention to the
completeness and adequacy of your SMS.
To define indicators for specific operational safety issues, the bow-tie methodology 5
similar tools can be used to determine the safety actions and risk barriers that would
most suitable for the definition of operational SPIs. A thorough hazard identification will
required as part of your system analysis to provide a good understanding of threats
safety in your operations.
or
be
be
to
The SPI team may also review typical indicators used within your industry segment and
assess them to determine whether they are pertinent to your organization. For example,
measuring the number of internal reports may not be meaningful if your system analysis
reveals that there are no easily accessible means to report or there are concerns about
confidentiality.
Step 3: Determine data needs
To be meaningful, measures of performance must be based on reliable and valid data, both
qualitative and quantitative. Therefore the SPI team should identify all pertinent data and
information that is available within your company and determine what additional
information is needed. It should also consider information available through the internal
audit/compliance monitoring system.
Regardless of the type of data, quality is one of the most important elements in ensuring
that the data can be integrated and used properly for analysis purposes. Data quality
principles and practices should be applied throughout the processes from data capture and
integration to analysis. Guidance about required data attributes and data management can
be found in the SM ICG Risk Based Decision Making Principles document 6 .
5
6
http://www.skybrary.aero/index.php/Bow_Tie_Risk_Management_Methodology
http://www.skybrary.aero/index.php/Risk_Based_Decision_Making_Principles
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You may be tempted to identify things that lend themselves to being measured instead of
identifying what you should measure. This is likely to result in identifying SPIs that are
most obvious and easy to measure rather than SPIs that are most valuable for effective
safety management. Therefore, at this step of the process, it is important to focus on what
changes your organization wants to drive and what aspects it needs to monitor. You
should also consider that, to be effective at assessing system safety, a broad set of
indicators involving key aspects of your system and operations should be developed; this
will reduce the possibility of having a narrow and therefore potentially flawed view of your
companys safety performance.
Also, it may be necessary to measure the same system in several ways in order to gain a
more precise idea of the actual level of safety performance. For example, only assessing
your companys safety culture without measuring operational parameters will merely
provide a very partial indication of safety performance.
In the area of hazard identification and risk management in operations (core processes),
availability of data will depend in part on the maturity of your internal safety reporting
schemes. Aggregate data for your industry segment may also be considered, particularly
when your SMS has not yet generated sufficient data. Other information, such as number
of flights, fleet size, and financial turnover, may contribute to a better understanding of the
context of operations. Continuous availability of data should be ensured to generate
relevant and timely indicators. Delays in compiling data for the generation of indicators are
likely to delay any safety actions that may be required.
Step 4: Define indicator specifications
Once the scope and focus of your SPIs have been determined and available
data/information reviewed, the specifics need to be defined.
Each SPI should be
accompanied by sufficient information (or metadata) which enables any user to determine
both the source and quality of the information, and place this indicator in the context
necessary to interpret and manage it effectively. 7
Whenever possible, indicators should be quantitative, as this facilitates comparison and
detecting trends. Quantitative metrics should be precise enough to allow highlighting trends
in safety performance over time or deviations from expected safety outcomes or targets.
For qualitative SPIs, it is important to minimize subjectivity. This may be achieved through
an evaluation by members of staff not directly involved in the definition of SPIs.
Depending on the size of your company and the complexity of your activities, a hierarchical
framework for your SPIs could be defined to reflect the different processes and sub-systems
within your organizational structure. While some indicators for assessing systemic issues
may be common to different processes and subsystems, indicators for assessing operational
issues will need to be specific. This underlines the importance of having performed an
accurate system analysis identifying all system components and sub-systems as a
prerequisite for implementing SMS (cf. 2.1).
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Indicators of safety culture selection and utilization of leading safety performance indicators, Reiman and
Pietikainen. VTT Technical Research Centre of Finland 2010:07
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opportunity for learning and for adjusting not only the SPIs (see Step 7) but your SMS
itself.
Indicators should not be simply seen as a metric, with actions being taken to get a good
score rather than to improve safety performance. It is important that results obtained
through the collection, analysis and interpretation of SPIs are conveyed to your
management for decision and action. Ideally, these results should be presented at regular
meetings (e.g., management reviews, safety review board meetings) to determine what
actions are required to address deficiencies or to further improve the system. It is
important that such actions do not focus on certain indicators in isolation, but on optimizing
your organizations overall safety performance.
As part of your safety communication and promotion, all staff should be informed of the
results obtained through the collection, analysis, and interpretation of SPIs.
Step 7: Evaluate SPIs and make changes as appropriate
The systems analysis of your organization, along with the set of SPIs and their
specifications, including the metrics and any defined targets, should be periodically reviewed
and evaluated to consider:
-
The frequency of the review cycle should be defined. Periodic reviews will help to ensure
that the indicators are well defined and that they provide the information needed to drive
and monitor safety performance. Periodic reviews will also help identify when specific drive
indicators are no longer needed (e.g., if the intended positive changes have been achieved)
and allow adjustment of SPIs so that they always focus on the most important issues in
terms of safety. Nevertheless, too frequent reviews should be avoided, as they may not
allow establishing a stable system.
After the first two to three cycles, you should have collected enough data and gained
sufficient experience to be able to determine which are your key SPIs - those that are most
valuable and most effective to monitor and to drive safety performance. At this stage you
may be able to derive targets for these key SPIs by extrapolating the data collected during
previous cycles.
Any such extrapolation needs to consider the dynamics of your
organization.
You might also compare your SPIs with those implemented by other
organizations within your industry segment, but you should never simply copy another
organizations SPIs without checking that they are meaningful for your organization.
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3. SPI examples
Below is a non-exhaustive list with examples of indicators intended to assist your
organization with selecting your own set of safety performance indicators, following the
process described in 2.2. Before adopting any of these as your own SPIs, you should
determine if the particular indicator is relevant to your specific organization, considering the
maturity of your SMS and the specific features you would like to improve or that need
attention.
Focus of measurement
Compliance
SMS
effectiveness
Metrics
strategic management
length of term
management commitment
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Area
Focus of measurement
Metrics
supervision
reporting
% of reports followed by an
independent safety review
number of accident/serious
incident scenarios analyzed to
support Safety Risk Management
(SRM) per month/quarter/year
hazard identification
risk controls
management of change
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Area
Focus of measurement
Metrics
per month/quarter/year & trend
management of contractors
safety promotion
% of changes
(organizational/SOP/technical
etc.) that have been subject to
risk assessment
(per month/quarter/year)
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Area
Focus of measurement
safety culture
Metrics
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Metrics
traffic collision
Air Traffic
management/
Air Navigation
Services
runway excursion
ground collision
for additional
indicators
number of unstabilized
approaches per 1000 landings
number of runway incursions per
1000 take-offs
number of Ground Proximity
Warning System (GPWS) and
Enhanced Ground Proximity
Warning System (EGPWS)
warnings per 100 take-offs
number of cases where flight
preparation had to be done in less
than the normally allocated time
number of short fuel events per
100 flights
See also
Maintenance
organizations
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Area
Air Traffic
management/
Air Navigation
Services
traffic collision
Metrics
maintenance engineer fatigue /
maintenance error:
% of work orders with a
difference > 10% between the
expected lead time and the actual
processing time
% of work orders with a
difference > 10% between the
estimated work force and the
actual needs
maintenance error:
% of work orders that required
re-work
number of duplicate inspections
that identified a maintenance
error
number of safety reports related
to ambiguous maintenance data
number of investigations
performed following components
removed from service
significantly before expected life
limit was reached
number of level busts/exposure
number of TCAS required action
(RA) (with and without loss of
separation) /exposure
number of minimum separation
infringement/exposure
number of inappropriate
separation (airspace in which
separation minima is not
applicable) /exposure
number of aircraft deviation from
air traffic control (ATC)
clearance/exposure
number of airspace
infringements/exposures
runway excursion
runway incursion
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Area
Airports
Flight training
organizations
Design
organizations
Metrics
post-accident/incident fire
runway incursion
runway incursion
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Area
Metrics
processing time
Manufacturing
organizations
Post certification:
number of service
difficulty/safety reports due to
design errors per program and
per period
number of service
difficulty/safety reports due to
manufacturing errors per
program and per period
number of investigations
performed following work orders
that required re-work
number of investigations
performed following delayed
delivery
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Monitoring focus
Regulations
new regulations
amendments to regulations
staff turnover
market opportunities
Technology
Competition
Metrics
competitors
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Reference documents
1.
Leading indicators of system safety Monitoring and driving the organizational safety potential,
Teemu Reiman, Elina Pietikinen, Safety Science Journal 50 (2012)
2.
Leading Performance Indicators Guidance for effective use 'Step Change in Safety'
http://www.stepchangeinsafety.net/knowledgecentre/publications/publication.cfm/publicationid/
26
3.
ICAO Document 9859 Safety Management Manual, Third edition - unedited advance version
http://www2.icao.int/en/ism/Guidance%20Materials/SMM_3rd_Ed_Advance_R4_19Oct12_clean.
pdf
4.
5.
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This paper was prepared by the Safety Management International Collaboration Group (SM ICG). The
purpose of the SM ICG is to promote a common understanding of Safety Management System
(SMS)/State Safety Program (SSP) principles and requirements, facilitating their application across the
international aviation community.
The current core membership of the SM ICG includes the Aviation Safety and Security Agency (AESA)
of Spain, the National Civil Aviation Agency (ANAC) of Brazil, the Civil Aviation Authority of the
Netherlands (CAA NL), the Civil Aviation Authority of New Zealand, the Civil Aviation Safety Authority
(CASA) of Australia, the Direction Gnrale de l'Aviation Civile (DGAC) in France, the European
Aviation Safety Agency (EASA), the Federal Office of Civil Aviation (FOCA) of Switzerland, Japan Civil
Aviation Bureau (JCAB), the United States Federal Aviation Administration (FAA) Aviation Safety
Organization, Transport Canada Civil Aviation (TCCA) and the Civil Aviation Authority of United
Kingdom (UK CAA). Additionally, the International Civil Aviation Organization (ICAO) is an observer to
this group.
Members of the SM ICG:
Collaborate with international organizations such as ICAO and civil aviation authorities that
have implemented or are implementing SMS
For further information regarding the SM ICG please contact:
Regine Hamelijnck
EASA
+49 221 8999 1000
Jacqueline Booth
TCCA
(613) 952-7974
Amer M. Younossi
FAA, Aviation Safety
(202) 267-5164
regine.hamelijnck@easa.europa.eu
jacqueline.booth@tc.gc.ca
Amer.M.Younossi@faa.gov
Ian Banks
CASA
+61 2 6217 1513
ian.banks@casa.gov.au