SMS v-1

Pakistan International Corp.
Introduction to Safety
Management Systems Seminar
Presented by
William L. (Bill) Rankin, Ph.D.

Technical Fellow
Lead, Maintenance Human Factors
Boeing Commercial Aviation Services
Basis of the Training

The following training is based on a 5-day
International Civil Aviation Organization (ICAO)
course.
The original ICAO training was aimed at National
Aviation Authorities and included materials relevant
to: airlines (Flight Ops and Maintenance), Air
Traffic Control (ATC), and Aerodromes.
This course is a shortened version of the ICAO
training leaving out most references to ATC and
Aerodromes.
2
Outline
1. What is an SMS?
2. Basic Safety Concepts
3. Safety Management
4. Hazards
5. Risks
6. Regulations
7. Introduction to SMS
8. Planning
9. Operations
10. Implementation
3
Introduction to
Safety Management Systems
1. What is an SMS?
Outline
ICAO intent for SMS
What is an SMS
Characteristics of an SMS
Functional elements of an SMS
ICAO Intent for SMS

ICAO has proposed SMS implementation in:
Aerodromes (airports)
Air Traffic System
Airlines (fixed wing and helicopter operations)
Flight Operations
Maintenance and Engineering
Secretariat proposes that the SMS provisions be

Recommended practices from 23 November 2006
and
Standards from 1 January 2009
ICAO Annex 6 Requirements

a safety management system acceptable to the State of
the Operator that, as a minimum:
identifies safety hazards; (Note: These are safety of flight hazards)
ensures that remedial action necessary to maintain an acceptable
level of safety is implemented; and
provides for continuous monitoring and regular assessment of
the safety level achieved.
and, aims to make continuous improvement to the overall level of
safety (proposed amendment)
An accepted safety management system shall clearly

define lines of safety accountability throughout the
operators organization, including a direct accountability for
safety on the part of senior management.
7
What is a Safety Management

System?
A Safety Management System (SMS) is an set of
integrated tools, policies and processes used by
corporate management to fulfill their responsibility
to manage the safety risks associated with their
organizations operations as a part of its overall
business.
Flight operations/cabin crew
Maintenance and engineering
Ground operations
Customer services
Airport operations
Air Traffic control
8
Characteristics of an SMS
An SMS is different from other safety programs
because of
Corporate management ownership,
A risk based approach and
It is integrated into the business system.
Risk based
Corporate Management
Ownership
Integrated
SMS Characteristics
Corporate Management Ownership
Risk based
Ownership
Integrated
As a corporate management process, an SMS is implemented

and managed at the corporate level. This type of corporate
management ownership is characterized by the fact that:
Corporate management
Understands and accepts the business case for safety
Accepts the direct responsibility for the implementation and
management of the SMS
Establishes levels of acceptable risk
Sets performance management metrics and expectations for the
entire corporation.
10
SMS Characteristics
Risk Based Approach
Risk based
Ownership
Integrated
Risk = Probability of Event Occurring X Severity of its Outcome

Addressing safety issues in terms of risk provides management
with a measurable picture of how SAFE its operations currently
are and how best to achieve its safety goals
Defines safety in measurable terms
Provide means to set measurable objectives
Provides short term measure of effectiveness
Provides means to evaluate safety strategies in terms of
Performance
Cost
11
SMS Characteristics
Integrated System
Risk based
Ownership
Integrated
SMS integrates safety activities into the organizations operations

On two levels:
Organization Level
SMS policies and procedures are vertically integrated throughout
the organization from corporate management down through every
level of the organization
Operational Requirement Level
Operational safety requirements are horizontally integrated into
all operational practices and procedures
12
SMS Functional Elements

Regardless of how an SMS is structured
and organized, an SMS requires that
five functions be carried out.
Planning
Training/Safety
Promotion
Surveillance
& Control
Documentation
Risk
Management
13

Planning
The planning function of an SMS starts with clear statement of
what top managements objectives are
with regard to safety.
SMS implementation plan
Organizational structure
Policies
Performance measures
Safety
Management
System Plan
Emergency response
System components
Roles & Responsibilities
Training
Strategic Safety Planning
14

Documentation
SMS information and activity must be documented. New
documentation will have to be written. All applicable
documentation must be maintained and kept current.
Plans
Audit reports
Policies & Procedures
Assessment findings
Regulatory requirements
Industry information
Job descriptions
Incident investigations
15

Risk Management
The Risk Management component of an
SMS is designed to identify safety of flight
hazards, evaluate them for risk, and
manage those risks.
Hazard identification process
Reactive
Proactive
Predictive
Risk assessment process

Corrective action/risk management process.
16
Risk Assessment Matrix

Severity
1
Negligible
2
Minor
3
Major
5
Frequent
10
15
20
25
4
Occasional
12
16
20
3
Remote
12
15
2
Improbable
10
1
Extremely
Improbable
Likelihood
4
5
Hazardous Catastrophic
Unacceptable
Acceptable with Monitoring
Acceptable
17

Program Surveillance and Control
Purpose of this functional element is to make sure
that the SMS is working.
Internal audits of the SMS components
External audits
Internal system assessments of how well the SMS
components are working
Employee reporting and feedback
Top management reviews.
18

Training/Safety Promotion
Purpose of this functional element is to make sure
that:
Staff in major safety-related positions have adequate
knowledge/skills to do their job
All other staff are knowledgeable about the SMS
components and their role in the SMS
Top management promotes safety and the SMS in order
to move the organization into a Safety Culture.
Informed culture
Reporting culture
Learning culture
Just culture
Flexible culture
19
Summary
ICAO has proposed that SMS be a Standard by
January 1, 2009
SMS is different from other safety programs
Top management ownership,
A risk based approach and
It is integrated into the business system.
20
Introduction to
2. Basic Safety Concepts
Objective
At the end of this module, participants will be able
to describe the limitations of traditional methods to
manage safety and describe new perspectives and
methods for managing safety.
22
Outline
Concept of safety
The evolution of safety thinking
A concept of accident causation Reason model
The organizational accident
People and safety
Errors and violations
Organizational culture
Safety investigation
Questions and answers
Points to remember
23
Concept of safety
What is safety
Zero accidents (or serious incidents)?
Freedom from danger or risks?
Error avoidance
Regulatory compliance?
24
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.
25
Concept of safety
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.
26
Safety
Traditional approach Accident prevention
Traditional approach Accident prevention

Focus on outcomes (causes)
Unsafe acts by operational personnel
Attach blame/punish for failures to perform safely
Address identified safety concern exclusively
Identifies:
WHAT?
WHEN?
WHO?
But not always discloses:

WHY?
HOW?
27
The evolution of safety thinking

TECHNICAL FACTORS
TODAY
HUMAN FACTORS
ORGANIZATIONAL
FACTORS
1950s
1970s
1990s
2000s
28
Reasons Model of Accident

Causation
Defenses
Functional Tests
Checklists
A maintenance organization has

Productive Activities
many barriers to error.
Repairs, Servicing
Fault Isolation
Errors can happen

at any level.
Pre-Conditions
Off work activities
Physical size
Facilities
Schedule
Line Management
Delegation
Prioritization
Planning
Active And
Latent Failures
Active Failures
Decision Makers
Policies, procedures,
corporate culture
Latent Failures
Latent Failures
Latent Failures
Latent Failures
29

Causation
Defenses
Functional Tests
Checklists
In most cases, errors are

caught before an
Repairs, Servicing
Fault Isolation
accident occurs.
Pre-Conditions
Off work activities
Physical size
Facilities
Schedule
Line Management
Delegation
Prioritization
Planning
Active And
Latent Failures
Decision Makers
corporate culture
Active Failures
Latent Failures
Latent Failures
Latent Failures
Latent Failures
30

Causation
Defenses
Functional Tests
Checklists
An accident only occurs

when a failure occurs Repairs, Servicing
Fault Isolation
in all of the
Pre-Conditions
Off work activities
barriers.
Physical size
Accident
Facilities
Schedule
Line Management
Delegation
Prioritization
Planning
Active And
Latent Failures
Decision Makers
corporate culture
Active Failures
Latent Failures
Latent Failures
Latent Failures
Latent Failures
31

Organizational processes
Policy-making
Planning
Communication
Allocation of resources
Supervision
Activities over which any organization has a

reasonable degree of direct control
32

Inadequate hazard
identification and risk
management
Normalization of
deviance
Latent
conditions
Conditions present in the system before the accident,

made evident by triggering factors.
33

Latent
conditions
Technology
Regulations
Training and checking
Defences
Resources to protect against the risks that

organizations involved in production activities
must confront.
34

Workplace
conditions
Workforce stability
Qualifications and
experience
Morale
Credibility
Ergonomics design
Factors that directly influence the efficiency of

people in aviation workplaces.
35

Workplace
conditions
Active
failures
Errors
Violations
Actions or inactions by people (pilots,

controllers, maintenance engineers,
aerodrome staff, etc.) that have an immediate
adverse effect.
36

Improve
Monitor
Latent
conditions
Reinforce
Contain
Workplace
conditions
Active
failures
Identify
Defences
37
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.
38
Understanding human performance

A
Understand human
performance within the
operational context
where it takes place
B
39
Definitions of Error and Violation

An error is a human action (behavior) that
unintentionally departs from the expected action
(behavior).
A violation is a human action (behavior) that
intentionally departs from the expected action
(behavior).
40
Errors and Violations

Errors have been the focus of research, so we have
more theories of why errors occur than theories of why
violations occur.
However, errors and violations often occur together to
produce an unwanted outcome. Data from the U.S.
Navy suggest that
~20% of the events are caused by a violation only
~20% of the events are caused by an error and a violation,
and
~60% of the events are caused by an error only.
We will collectively call errors and violations a

maintenance system failure.
41
Types of Maintenance System Failures

Maintenance System Failure = System
failure caused by a mechanic/engineer/inspector
that leads to problems on the aircraft.
Installation failure
Servicing failure
Repair failure
Fault isolation/inspection/testing failure
Foreign object damage (FOD)
Equipment damage
Personal injury
42
Human Error in Aircraft

Maintenance: UK CAA 1992
1.
2.
3.
4.
5.
6.
Incorrect installation of components

Fitting of wrong parts
Electrical wiring discrepancies
Loose objects left in aircraft
Inadequate lubrication
Access panels/fairings/cowlings not
secured
7. Fuel/oil caps and fuel panels not secured
8. Gear pins not removed before departure
43
UK Flight Safety Committee 2004

Top 10 Causes of Maintenance Mishaps
1.
2.
3.
Failure to follow published technical data or local instructions

Using unauthorized procedure not referenced in technical data
Supervisors accepting non-use of technical data or failure to follow
maintenance instructions
4. Failure to document maintenance properly in maintenance records,
work package
5. Inattention to detail/complacency
6. Incorrectly installed hardware on an aircraft/engine
7. Performing an unauthorized modification to the aircraft
8. Failure to conduct a tool inventory after completion of the task
9. Personnel not trained or certified to perform the task
10. Ground support equipment improperly positioned for the task
44
Processes and outcomes
Error:
causes and
consequences
are not linear in
their magnitude
45
Operational performance and

technology
In production-intensive
industries like aviation,
technology is essential.
The operational
consequences of the
interactions between
people and technology
are often overlooked,
leading to human error.
46
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.
47
Errors and safety A non

linear relationship
Statistically, millions of
operational errors are
made before a major
safety breakdown occurs
Accident investigation Once

in a million flights
Flaps
omitted
Error
Checklist
failure
Deviation
Unheeded
warning
Amplification
Degradation/
breakdown
Safety management On
almost every flight
Flaps
omitted
Error
Checklist
works
Effective
warning
Deviation Amplification
Normal
operation
50
Errors and consequences

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.
Redesign using Human-centred design
principles
Ergonomic factors
Training
51

Three strategies for the control
of human error
Error capturing strategies intervene
once the error has already been
made, capturing the error before it
generates adverse consequences.
QC inspections
Operational checks
Functional checks
52

Three strategies for the control of
human error
Error tolerance strategies intervene to
increase the ability of a system to
accept errors without serious
consequence.
System redundancies
Structural inspections
ETOPS maintenance rules
53
Understanding violations Are we ready?

Production objective(s)
High
Incident Accident
Violations
Technology
People
Risk
Safety
space
Training
Low
Procedures
Minimum
System Output
Maximum
54
Violations
What can be violated?
Company policies
Company processes
Company procedures
Violations are often made by well-intentioned

staff trying to finish a job, not staff who are trying
to increase comfort or reduce their work load.
55
Types of Violations
There are three types of violations that we
are interested in
Routine
Situational
Exceptional.
56
Violation Definitions
RoutineThese are common practice.
Often occur with such regularity that they
are automatic. Violating this rule has
become a group norm. Routine violations
are condoned by management.
57
Violation Definitions (contd.)

SituationalMechanic/inspector strays from
accepted practices, bending a rule. Occur as a
result of factors dictated by the employees
immediate work area or environment. Due to
such things as
Time pressure
Lack of supervision
Unavailability of equipment, tools, or parts
Insufficient staff.
58
Violation Definitions (contd.)

ExceptionalMechanic/inspector willfully
breaks standing rules while disregarding the
consequences.
59
Definition of Culture
Culture = Customary beliefs, behavior
patterns, and material traits of a racial,
religious, or social group
Any organization has a culture of its own
Management style
Morale
Acceptable behaviors
Norms
60
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.
61
Three cultures
National
Organizational
Professional
62
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
63
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.
here
64
Safety culture
A construct
An outcome, not a process
The introduction of safety management
concepts lays the foundation upon which to
build a safety culture
Safety culture cannot be mandated or
designed, it evolves.
It is generated top-down
65
Definition of Safety Culture

What is a safety culture as it applies to an
aircraft maintenance organization?
A safety culture is a (maintenance
organization) culture in which safety plays a
major role.
66
Importance of a Good Safety Culture

Safety, as it applies to maintenance, has
four components
1.
2.
3.
4.
Safety of flight
Personal safety
Equipment damage
Environmental damage
A good safety culture will reduce the

instances of all three of these events,
reducing the accident rate and, thus,
saving lives and money.
67
Safety culture
Informed culture
People are knowledgeable about the human, technical,
organizational and environmental factors that determine the
safety of the system as a whole.
Reporting culture
People are prepared to
report their errors and
experiences
Safety
culture
Just culture
People are encouraged (even rewarded) for providing
essential safety-related information. However, there is a
clear line that differentiates between acceptable and
unacceptable behaviour.
Flexible culture
People can adapt
organizational processes
when facing high
temporary operations or
certain kinds of danger,
shifting from the
conventional hierarchical
mode to a flatter mode.
Learning culture
People have the willingness
and the competence to
draw conclusions from
safety information systems
and the will to implement
major reforms.
68
Safety culture
Safety Culture
Component
Definition
Safety Values
The organization regards safety as being of prime

importance.
Safety Beliefs
The organization believes that:
Safety makes commercial sense
Individuals are not the sole causes of incidents
The next accident is waiting to happen.
Common Problem-Solving Risk assessment
Methods
Cost-benefit analyses
Accident investigation AND accident analysis
Search for problems in advance of incidents.
Safety integral to design and operations practice
Common Working
Practices
Safety #1 on meeting agendas up to Board level
Chronic unease about safety.
Taken from Safety Culture The Way ahead?: Theory and Practical Principles,
Patrick Hudson, Centre for Safety Science, Leiden University, 1999.
69
Three organizational types

Organizations and the management of
information
Pathological Hide the information
Bureaucratic Restrain the information
Generative Value the information
Source: Ron Westrum
70
Three possible organizational

cultures
Source: Ron Westrum
Pathological Bureaucratic
Generative
Information
Hidden
Ignored
Sought
Messengers
Shouted
Tolerated
Trained
Responsibilities
Shirked
Boxed
Shared
Reports
Discouraged
Allowed
Rewarded
Failures
Covered up
Merciful
Scrutinized
Crushed
Problematic
Welcomed
New ideas
Resulting
organization
Conflicted
Red tape
organization organization
Reliable
organization
71
Safety investigation
For funereal purposes
To put losses behind
To reassert trust and faith in the system
To resume normal activities
To fulfill political purposes
Like a police investigation
For improved system reliability

To learn about system vulnerability
To develop strategies for change
To prioritize investment of resources
72
Errors ...
are like mosquitoes

73
To fight them
... drain their breeding swamps.

74
Points to remember
1. The organizational accident.
2. Operational contexts and human performance
3. Errors and violations.
4. Organizational culture and safety.
5. The management of safety information and
safety culture.
75
Introduction to
3. Safety Management
Objective
At the end of this section, participants will be able
to explain the need for, the strategies and the key
features of safety management.
77
Outline
The safety stereotype
The management dilemma
Need for safety management
Strategies for safety management
The imperative of change
Safety management Nine building blocks
Four responsibilities for managing safety
Points to remember
78
The safety stereotype
79
What is the fundamental objective

of a business organization?
To make money in order

to stay in business!!
80
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.
81

Management levels
Resources
Resources
Protection
Production
82

Res
ourc
es
Man
agem
leve ent
ls
Res
ou
rces
Protection
Production
Catastrophe
83
rce
u
o
s
Re
t
n
e
m
e
g
a
Man vels
le
es
c
r
u
o
Res
Production
Protection
Bankruptcy
84
Safety space
Protection
Bankruptcy
e
c
n
ta
s
i
es
r
m
u
m
i
x
Ma
Production
e
c
spa
Catastrophe
85
Safety management The

response to the dilemma
Safety issues are a byproduct 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).
86
Safety management The response to

the dilemma Alternate view
Safety is viewed as a requirement for profitability and is
managed as an aspect of product quality and integrated into
the core business process
Bankruptcy
Zone
Bang
Zone
SAFETY
19
Conflicting Requirements
Profitability
Air
wo
rth
i
PERFORMANCE
s
Co
ft y
a
t
r
rc bili
i
A ila
va
AM
Safe
Zone
nes
s
et y
f
Sa
Safety as a Requirement for

Profitability
87
Why SMS? The First Ultra-Safe

Industrial System
Fragile system (1920s -1970s)
1/1000
Fly-Fix-Fly
Individual risk management & intensive training
Accident investigation
Safe system (1970s mid 1990s)
1/100,000
System Safety
Quality Management Systems
Technology & regulations
Incident investigation
Ultra-safe system (mid 1990s onwards)
1/10,000,000
Business management approach (SMS)

to safety
Routine collection and analysis
of operational data
88
Why SM? An imperfect system

System
design
Operational
deployment
Baseline performance
Op
era
tio
na
lp
erf
orm
an
ce
Practical
drift
89
The essential is invisible to the

eyes
Number of occurrences
1 5
Accidents
30 100
Serious incidents
100 1000
Incidents
1000 4000
Latent conditions
90
Navigating the drift

Baseline performance
Op
era
tio
na
lp
erf
orm
an
ce
organization
Practical
drift
Navigational aids
Reactive
Proactive
Predictive
91
Reactive safety management

Investigation of accidents and serious incidents
Based upon the notion of waiting until something breaks
to fix it. Also based on the belief that we should learn
from our mistakes, which provide valuable information.
Most appropriate for:
Events caused by errors and violations
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 contributing factors and findings as to risks.
92
Predictive safety management

Risk analysis, cost vs. benefit analysis and
engineering trade studies.
Based upon the notion that any proposed change in a
system should first be assessed to determine whether the
change imposes any new or additional risks.
Use risk data as a selection criteria for new equipment,
aircraft or processes.
Develop and implement risk management strategies
before system change takes place.
93
Strategies Summary
Reactive method
Proactive method
The reactive method

responds to the
events that already
happened, such as
incidents and
accidents
The proactive method

looks actively for the
identification of
safety risks
through the analysis
of the organizations
activities.
Predictive method
Change
Management
The predictive
method identifies
potential risks
associated with
system changes.
94
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 efficient.
Evolving methods for understanding and managing
safety risks are necessary.
95
The changing of the guard

Traditional Accident/serious incident investigation
Aviation system as pre-specified is perfect.
Compliance based.
Outcome oriented.
Evolving Safety management

Aviation system as pre-specified is imperfect.
Performance based.
Process oriented.
96
Safety management Nine

building blocks
Executive managements commitment to the

management of safety.
reporting
Effective safety reporting.
Continuous monitoring through systems to
collect, analyse, and share safety-related
data arising from normal operations.
97
Safety management Nine

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 (including Human

Factors) for operational personnel.
98
Evolving methods Nine building

blocks
Effective implementation of Standard
Operating Procedures (SOPs), including the

use of checklists and briefings.
Continuous improvement of the overall level

of safety.
An organizational culture that fosters safe

practices, encourages safety communications
and actively manages safety with the same
attention to results as financial management.
99
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.
100
The safety management process

at a glance
Identify
hazards
Re-evaluate
control
strategies
Collect
additional
hazard
data
Assess
risks
Implement
control
strategies
Safety
management
process
Prioritize
risks
Assign
responsibilities
Approve
control
strategies
Develop
elimination/
mitigation
strategies
101
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.
102
In summary
Safety management
Includes the entire operation.
Focuses on processes (Clear difference between
processes and outcomes).
Data-driven (constant monitoring).
Strictly documented.
Gradual improvement as opposed to dramatic change.
Strategic planning as opposed to piecemeal initiatives.
103
Points to remember
1. The dilemma of the two Ps.
2. Why SM? An ultra-safe, yet imperfect system.
3. Safety management methods and their
effectiveness.
4. The changing of the guard.
5. The fundamental contribution of senior
management to safety.
104
Introduction to
4. Hazards
Objective
to apply the fundamentals of hazard identification.
106
Outline
Two definitions
Understanding hazards
Hazard identification
Documentation of hazards
Points to remember
107
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 likelihood of injury to personnel, damage to
equipment or structures, loss of material, or reduction of
the ability to perform a prescribed function, measured in
terms of probability and severity.
Loss
Risk ( UnitExpected
Time or Activity ) = Severity (
Loss
Loss Event
) X Prob.(
Loss Event
Unit Time or Activity
A wind of 15 knots blowing directly across the runway is a

hazard.
The possibility that a pilot may not be able to control the aircraft
during take off or landing, resulting in an accident, is one risk .
108
Examples of hazards
Automation events
Unfamiliar phraseology
ATC procedures
Weather
Similar call signs

Missed approaches
Terrain
Heavy traffic
Flight diversions
Unfamiliar airports
Non-airworthy
aircraft
System
malfunctions
109
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).
110
Significant MaintenanceRelated Events

Kahului, Hawaii, U.S.A. 1988
Upper fuselage separation 737-200
111
Kahului 737 Event

Post incident inspection revealed that there were at
least 240 cracks present at the last inspection prior
to incident.
Among the contributing factors to the error of not
seeing the cracks
Lack of resourcesNo proper platform or inspection lights.
FatigueInspection carried out late at night.
Lack of technical knowledgeNot enough inspection
training.
ComplacencyDone other aircraft and had not find any
cracks.
112
Primary Causes of All Hull Loss Accidents

Worldwide Commercial Large Jet Fleet
Primary factor
Flight crew
Airplane
Maintenance & Inspection
Weather
Number of accidents
1959--1994 1995--2004
338
75
20
5
17
21
Total
4%
4%
4%
17
Miscellaneous/other
73%
11%
23
16
Unknown or awaiting reports
56%
53
Airport/ATC
Total with known causes
Percentage of total accidents with known causes

20
30
40
50
60
70
10
5
8
465
133
77
44
542
177
17%
.
13%
3%
4%
5%
6%
Excludes::
Sabotage
Military action
Legend:
1959 through 1994
1995 through 2004
113
Significant Maintenance
Human Factors Events
Lima, Peru 1996
Tape left on static ports757-200
114
Lima 757 Event

The aircraft's three static ports on the left side were
obstructed by masking tape. The tape had been
applied before washing and polishing of the aircraft
the day before the accident flight
Work was begun on one shift and handed over to
next mornings shift
Poor shift handover log was a contributing factor
Mechanics and pilots both missed tape during walk
around
115
IATA Safety Report 2003

92 accidents world wide in 2003
42 Western-built jets
32 Western-built turboprops
7 Eastern-built jets
11 Eastern-built turboprops
Maintenance failures were involved in 24

(26%) of all accidents
Sometimes the primary cause.
However, the accident scenario is often a combination
of the maintenance failure and the (incorrect) handling
of the failure by the flight crew.
116
Understanding HazardsThe Dilemma

Which One is the Hazard??
Maintenance
Contributing
Factors
Maintenance
Error/
Violation
A/C Event:
In-flight
engine
shutdown
Pilot head
down: Loss
of aircraft
control
CFIT
accident
Inadequate lighting
Hard-to-understand AMM
No training on the task
Fatigue
Forgot
117
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.
118
for example:
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.
119
Sources of hazard identification

Predictive
Proactive
Reactive
Internal
Company voluntary reporting
system
Audits and surveys
External
Accident reports
State mandatory occurrence
system
120
By whom?
By anybody
By designated personnel
How?
Through formal processes
Depends on the organization
When?
Anytime
Under specific conditions
121
Specific conditions
Unexplained increase in
safety-related events or
infractions.
Major operational changes are
foreseen.
Periods of significant
organizational change.
122
Hazard analysis
Efficient and safe operations or provision of service
require a constant balance between production
goals (maintaining regular flight operations during a
runway construction project) and safety goals
(maintaining existing margins of safety in flight
operations during runway construction project).
Aviation workplaces contain hazardous conditions
which may not be cost-effective to eliminate even
when operations must continue.
123
Third fundamental Hazard analysis

Method 1 ICAO
ABCs 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 potential risk(s)

Aircraft colliding with construction equipment
Aircraft taking wrong taxiway

124
Hazard analysis
Method 2 Southern California Safety Institute
Redefine: A hazard is anything that successfully
attacks an asset and causes damage.
Anything that can attack an asset is a threat to attack
that asset.
A successful attack causes damage to an asset.
We are interested in any threats that can successfully
attack and damage an asset.
A threat that is of vital concern in one situation may be a
threat of no interest in another situation.
The threat is the same, it is the situation that makes it
interesting or not interesting.
125
Hazard analysis
Associated with each threat (hazard) is

1. A likelihood that the threat will
2. cause damages to an
3. asset during some period of time.
Look at threat (hazard)/asset pairs
Rocks/propellers
Berm/aircraft
Wrench/jet engine
Mis-installation/system failure
126
Hazard analysis
How do you find the threat (hazard)/asset pairs in
your org?
Look at safety-related repair/doctor bills.
Look at every safety-related legal bill.
Ask employees what threat/asset pairs are going to cost
you money sooner or later.
Name some threat/asset pairs relevant to your

operation
127
Documentation of hazards
The fundamental importance of
appropriate documentation
management:
A formal procedure to translate
operational safety data into
hazard-related information.
The safety library of an
organization.
128
Points to remember
1. Hazard, risk and consequence.
2. ABCs of hazard identification.
3. Hazard documentation: the safety library of
an organization.
129
Introduction to
5. Risks
Objective
to apply the fundamentals of risk management.
131
Outline
Risk management
Risk probability
Risk severity
Risk assessment and tolerability
Risk control/mitigation
Risk management warm-up exercises
Points to remember
132
Risk management
What is it?
The identification, analysis and elimination, and/or
mitigation to an acceptable level of risks that threaten
the capabilities of an organization.
What is the objective?

Aims at a directed and effective allocation of resources
to address all significant risks and viable risk control
and mitigation.
Why is it important?
A key component of a Safety Management System.
Data-driven approach to safety resources allocation,
thus defensible and easier to explain.
133
What is Risk?
The expectation of loss.
An expression of the combined severity and
probability of loss.
Loss
Risk ( UnitExpected
Time or Activity ) = Severity (
Loss
Loss Event
) X Prob.(
Loss Event
Unit Time or Activity
134
Risk Probability/Likelihood
Definition(s)
Likelihood The chance that a situation might
occur expressed in qualitative terms.
Frequent
Seldom
Probability The result of a statistical analysis of a

system conducted to predict the chances that an
event might occur.
Expressed quantitatively
0 > probability < 1
Probability and likelihood are often used interchangeably

135
Probability or Likelihood When to

use them
Probability
Most accurate
Provides most detailed results
Requires more and better data
More difficult and time consuming to calculate
Generally used for risk assessments involved in certification and
reliability.
Likelihood
Less accurate and detailed
Potential variability between analysts
Less time consuming
Generally used in most aviation SMS models
136
Risk Likelihood
Questions for assessing the likelihood of an
occurrence:
Is there a history of occurrences like the one being
assessed, or is the occurrence an isolated event?
Is there a change in a process or procedure?
What number of operating or maintenance
personnel must follow the procedure (s) in
question?
How frequently is the equipment or procedure
under assessment used?
137
Risk likelihood
Likelihood of occurrence
Qualitative
definition
Meaning
Value
Likely to occur many times (has occurred frequently)
Likely to occur some times (has occurred infrequently)
Remote
Unlikely, but possible to occur (has occurred rarely)
Improbable
Very unlikely to occur (not known to have occurred)
Extremely
improbable
Almost inconceivable that the event will occur
Frequent
Occasional
138
Risk severity
Definition(s)
Severity The possible consequences of a situation of
danger, taking as reference the worst foreseeable
situation that can be reasonably expected under
existing or proposed operational conditions.
139
Risks
Define the severity in terms of:
Property
Health
Finance
Liability
People
Environment
Image
Public confidence
140
Risk severity
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
141
Risk severity
questions:
What is the severity of the property or 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?
142
Risk severity
Aviation
definition
Catastrophic
Hazardous
Major
Minor
Negligible
Meaning
Equipment destroyed
Multiple deaths
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
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.
Little consequences
Value
E/5
D/4
C/3
B/2
A/1
143
Risk assessment (ICAO)

Risk severity
Negligible
Minor
Major
Hazardous
Catastrophic
5 Frequent
5A
5B
5C
5D
5E
4 Occasional
4A
4B
4C
4D
4E
3 Remote
3A
3B
3C
3D
3E
2 Improbable
2A
2B
2C
2D
2E
1 Extremely
improbable
1A
1B
1C
1D
1E
Risk
probability
144
Risk tolerability (ICAO)

Assessment risk index
Suggested criteria
3E, 4D, 4E, 5C, 5D, 5E
Unacceptable under the existing

circumstances
2D, 2E, 3C, 3D, 4C, 5A, 5B
Risk control/mitigation requires

management decision
1D, 1E, 2C, 3B, 4A, 4B
Acceptable after
review of the operation
1A, 1B, 1C, 2A, 2B, 3A
Acceptable
145
Safety Risk Assessment Matrix

(Alternate)
Severity
1
Negligible
2
Minor
3
Major
5
Frequent
10
15
20
25
4
Occasional
12
16
20
3
Remote
12
15
2
Improbable
10
1
Extremely
Improbable
Likelihood
4
5
Hazardous Catastrophic
146
Risk Level Definitions (alternate)

Assessment Risk
Level
20, 25
10, 12, 15, 16
Criteria
Unacceptable, requiring immediate cessation of
operation until risk is mitigated to acceptable
level.
Unacceptable, requiring that the
likelihood of the hazard or the severity of
hazard be reduced to an acceptable level,
while continuing the operation.
5, 6, 8, 9
Acceptable, but requires active monitoring to

insure risk remains at acceptable levels.
1, 2, 3, 4,
Acceptable
147
Risk matrix 4 X4
Likelihood
Severity
12
16
12
148
Risk matrix 8X8
Likelihood
Acceptable risk in a 4x4 matrix
8
7
6
5
4
3
2
1
16
24
32
40
48
56
64
14
21
28
35
42
49
56
12
18
24
30
36
42
48
10
15
20
25
30
35
40
12
16
20
24
28
32
12
15
18
21
24
10
12
14
16
Outcome
Acceptable risk in
A 4X4 matrix
149
What is at Risks ?
Most undesirable conditions can be analyzed
in terms of risk.
Economic
Safety
Maintenance error
Pilot error
Public relations
Strategic operations
Equipment failure
150
Risks and Hazards, which is which?

There can be risks associated with risks. In these cases
what was once considered a risk becomes a hazard.
Maintenance
Contributing
Factors
Maintenance
Error/
Violation
Inadequate lighting
Hard-to-understand AMM
No training on the task
Fatigue
Risks associated
Forgot
A/C Event:
System
Failure
Loss of A/C
Control
Accident
with maintenance contributing factors are errors and
violations
Risks associated with errors and violations are aircraft system failures
Risks associated with aircraft system failures are loss of aircraft control
Risks associated with loss of aircraft control are accidents
151
Risk mitigation/management
Definition(s)
Risk Mitigation Measures to eliminate the
hazard, reduce the severity of the hazard, or
reduce the probability of the hazard.
(Mitigate To make milder, less severe or less
harsh)
Risk Monitoring Measures to ensure that a
risk is reliably maintained at an acceptable level.
152
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.
153
Strategies
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.
complex geography and without the necessary aids
are continued based upon the availability of specific
aids and application of specific procedures.
154
Risk mitigation
Strategies
Segregation of exposure Action is taken to
isolate the effects of risks or build-in
redundancy to protect against it, i.e., reduce
the severity of risk.
complex geography are limited to day-time, visual
conditions.
Non RVSM equipped aircraft not allowed to operate
into RVSM airspace.
155
Risk mitigation Defences

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?
156
Risk mitigation Defences

Recall the three basic defences in aviation:
Technology
Training
Procedures
157
Risk Mitigation How Far?
How far do we need to reduce an

unacceptable risk?
As low as reasonability practicable ?
Reliably acceptable?
158
Risk Mitigation (ICAO)

At the intersection of protection and
production
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.
159
Risk mitigation at a glance using

ALARP (ICAO)
and
risk management
Assessment of the
defences within
the safety system
Control and
mitigation
of the risk (s)
H H H H
Does the mitigation

Regulations
EACH HAZARD
Training
Technology
R R R R
EACH RISK
Accepting the
mitigation of
the risk
different
address the hazard?

Does it address the
risk (s)?
Is it effective?
Is it appropriate?
Is additional or
mitigation warranted?
Do the mitigation
strategies generate
additional risk (s)
160
Risk Mitigation (Alternate)

The intent of a risk mitigation strategy is to
reduce a risk to a level where is can reliably
maintained (managed)
Control/mitigation strategies are evaluated on the
basis of achieved risk reduction (is the risk now
acceptable?).
When you reach a reliably acceptable level - stop
161
Risk mitigation (Alternate)

H
EACH HAZARD
procedures
Training
Unacceptable
Technology
R R R R
Management
Zone
Develop Risk Mitigation

strategy
Strategy
no
Is risk acceptable?
Acceptable
Develop Risk
Management
Strategy
yes
yes
no
Does risk require

active management
162
As a reminder
There is no such thing as absolute safety In aviation it is
not possible to eliminate risks.
Risks must be managed at a level that is acceptable to
Senior Management
Risks can be managed to a level as low as reasonably
practicable (ALARP)
Risks can also be managed to a level that can be reliably
maintained at an acceptable level
Risk mitigation must be balanced against:
Time
Cost
Difficulty of taking measures to reduce or eliminate the
risk (i.e. managed).
163
As a reminder
Effective risk management seeks to
maximize the benefits of accepting a
risk (a reduction in time and cost) while
maintaining the risk at an acceptable
level.
Communicate the rationale for risk
decisions to gain acceptance by
stakeholders affected by them.
164
165
Risk likelihood
Likelihood of occurrence
Qualitative
definition
Meaning
Value
Likely to occur many times (has occurred frequently)
Likely to occur some times (has occurred infrequently)
Remote
Unlikely, but possible to occur (has occurred rarely)
Improbable
Very unlikely to occur (not known to have occurred)
Extremely
improbable
Almost inconceivable that the event will occur
Frequent
Occasional
166
Risk severity
Aviation
definition
Catastrophic
Hazardous
Major
Minor
Negligible
Meaning
Equipment destroyed
Multiple deaths
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
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.
Little consequences
Value
E/5
D/4
C/3
B/2
A/1
167
Risk assessment (ICAO)

Risk severity
Negligible
Minor
Major
Hazardous
Catastrophic
5 Frequent
5A
5B
5C
5D
5E
4 Occasional
4A
4B
4C
4D
4E
3 Remote
3A
3B
3C
3D
3E
2 Improbable
2A
2B
2C
2D
2E
1 Extremely
improbable
1A
1B
1C
1D
1E
Risk
probability
168
Risk tolerability (ICAO)

Assessment risk index
Suggested criteria
3E, 4D, 4E, 5C, 5D, 5E
Unacceptable under the existing

circumstances
2D, 2E, 3C, 3D, 4C, 5A, 5B
Risk control/mitigation requires

management decision
1D, 1E, 2C, 3B, 4A, 4B
Acceptable after
review of the operation
1A, 1B, 1C, 2A, 2B, 3A
Acceptable
169
Hazard identification and risk

management Warm-up exercise
Scenario:
Fuel spill on the apron area surface of approximately 25
m (75 ft) length and 5 m (15 ft) width, produced by an
A310 ready to pushback and taxi for departure.
Report by the apron responsible person:

After the A310 pushback the spill was contained and the
apron area was decontaminated.
170

Hazard:
Risk probability
Risk severity
Risk(s):
Risk index
Risk tolerability
171

Scenario:
It was observed that airline baggage handling personnel
generates FO(D) on the aerodrome apron area.
Report by the apron responsible personnel:

It should be noted that airline baggage handling
personnel are not complying with safety standards as set
in the aerodrome operating manual. This is considered a
hazard that can produce incident or accident in the
movement area.
172

Hazard:
Risk probability
Risk severity
Risk(s):
Risk index
Risk tolerability
173

Scenario:
A parked aircraft shows damage in the left wing root
near the fuselage. Such damage was caused by a
maintenance stair hitting the aircraft as a
consequence of the wind, apparently because the stair
was not properly restrained.

In conditions of strong winds it is essential that all
equipment around aircraft is properly restrained and
locked, thus preventing the possibility of aircraft
damage.
174

Hazard:
Risk probability
Risk severity
Risk(s):
Risk index
Risk tolerability
175

Scenario:
The vehicle and ramp equipment parking area behind the
fingers shows a large amount of FO(D) (food, trays,
plastics, pillows, etc.) left behind by an airline.

The presence of decomposed food and others dangerous
material was informed to the airline, since in addition to
FO(D), this presents a bacteriological danger for people
who operate in this sector, also attracting animals to the
operative apron.
176

Hazard:
Risk probability
Risk severity
Risk(s):
Risk index
Risk tolerability
177

Scenario:
A loose wheel, apparently from a baggage cart, was
observed in the handling area. The driver apparently
did not notice what happened. The wheel rolled at high
speed through the area, hitting the fence accessing the
fuel zone.

This could have caused injuries to ramp personnel in
addition to material damage to equipment and/or
aerodrome facilities. We have insisted in the past on
the periodic verification of all equipment and vehicles
that operate in the aerodrome apron area.
178

Hazard:
Risk probability
Risk severity
Risk(s):
Risk index
Risk tolerability
179

Scenario:
The absence of airline personnel attending the stairs was
observed in three occasions, in flights from different
companies. The presence of airline personnel is
necessary to guide passengers when embarking and
disembarking.
Report by the apron responsible personnel:

This is a risk for passengers, since they should access
the apron to board aircraft in an orderly manner under the
guidance of airline personnel.
180

Hazard:
Risk probability
Risk severity
Risk(s):
Risk index
Risk tolerability
181
Points to remember
1. The risk assessment matrix.
2. The risk assessment criteria table.
3. Risk mitigation: avoid, reduce, segregate.
182
Introduction to
6. Regulations
Objective
At the end of this module participants will be able to
describe the safety management requirements
included in Annexes 6, 11 and 14, including the
relationship between a safety programme and an
SMS.
184
Outline
AGA, ATS and OPS/AMO safety management
What is a safety programme?
What is an SMS?
Acceptable level of safety
Acceptable level of safety Implementation,
scope and legal considerations
Protection of sources of safety information
Points to remember
185
The big picture

Operation of aircraft
Maintenance of aircraft
Air traffic services
Aerodromes
Two audience groups
States
Service providers
Three distinct requirements

Safety programme
SMS
Management accountability
186
As of 23 November 2006
States shall establish a safety programme, in order
to achieve an acceptable level of safety in:
The operation of aircraft
The maintenance of aircraft
The provision of air traffic services
Aerodrome operations
The acceptable level of safety to be achieved shall

be established by the State(s) concerned.
187
What is a safety programme?

An integrated set of regulations and activities
aimed at improving safety.
States are responsible for establishing a safety
programme:
Safety regulation
Safety oversight
Accident/incident investigation
Mandatory/voluntary reporting systems
Safety data analysis
Safety promotion
188
Definitions
Acceptable level of safety A concept
High level safety management goals of an
oversight authority [or a service provider]
Minimum safety performance that service
providers should achieve while conducting their
core business functions
A reference against which one can measure
safety performance
189
States shall require, as part of their safety programme,
that an [operator, maintenance organization, ATS provider,
certified aerodrome operator] implements a safety
management system accepted by the State that, as a
minimum:
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
Aims to make continuous improvement to the overall
level of safety
190
What is an SMS?
A systematic approach to
managing safety, including
the necessary organizational
structures, accountabilities,
risk management, policies
and procedures, and safety
promotion.
Providers are responsible for
establishing an SMS.
States are responsible of the
acceptance and oversight for
providers SMS.
191
Safety programme SMS

relationships
Protection
Objective:
Public
safety
Production
State
safety
programme
Oversight
Acceptance
Oversight
Objective:
Manage and
control
safety risk
Organizations
safety
management
system (SMS)
Risk management
Safety assurance
Organizations
production
processes
Objective:
Achieve
commercial
goals and
customer
satisfaction
192
An accepted safety management system shall
clearly define lines of safety accountability
throughout the [airline, maintenance, ATS
provider, certified aerodrome operator]
organization, including direct accountability
for safety on the part of senior management.
Note. Guidance on safety management
systems is contained in the ICAO Safety
Management Manual (Doc 9859).
(Accountability Obligation or willingness to
account for ones actions)
193

Implementation
The concept of acceptable level of safety is
expressed in practical terms by three measures:
Safety metrics
Safety performance indicators
Safety performance targets
It is delivered through various tools and means:

Safety requirements.
requirements
194

Safety metrics
Variables that are measured and are related to safety
Pilot examples
Rejected take-offs due to pilot skill
Unstabilized approaches
Go arounds
Runway incursions
Maintenance examples
Rejected take-offs due to mechanical failures
Maintenance write-ups for 10 days after D check
Average number of MEL items per aircraft per fleet.
195

Safety indicators
Short and medium term objectives of a State safety
programme, or an operator/services provider SMS.
Linked to major components of a State safety
programme, or an operator/services provider SMS.
The measure that the state considers safe or safe
enough
Expressed in numerical terms.
Example No more than 0.8 Cat A and B (most serious)
runway incursions per million operations through 2009.
196

Safety targets
Long-term objectives of a State safety programme,
or an operator/services provider SMS.
Determined weighing what is desirable and what is
realistic for an individual State/operator/services
provider.
Expressed in numerical terms.
Example - By 2010 reduce Cat A and B (most serious)
runway incursions to a rate of not more than 0.5 per
million operations.
197

Safety indicators and safety targets may be different
Example No more than 0.8 Cat A and B (most
serious) runway incursions per million operations
through 2009, and reduce Cat A and B (most serious)
runway incursions to a rate of not more than 0.5 per
million operations by 2010.
Safety indicators and safety targets may be the same
Example Maintain 0.8 Cat A and B (most serious)
runway incursions per million operations through 2010.
198

Implementation
The safety requirements should be
expressed in terms of operational procedures,
technology and systems, programmes, and
contingency arrangements.
Measures of reliability, availability and/or
accuracy may be added.
Example Install Airport Surface Detection
Equipment-Model X (ASDE-X) at (three busiest
airports) within the next 12 months, with 98%
annual availability.
199

Implementation
An acceptable level of safety will always be expressed
by a number of safety indicators and safety targets,
never by a single one.
200

Scope
There will seldom be a single or national
acceptable level of safety.
Most frequently, within each State, different
acceptable levels of safety will be separately
agreed between the oversight authority and
individual operators/services providers.
201

Scope
Each agreed acceptable level of safety
should be commensurate to the:
complexity of individual operator/services
provider specific operational contexts
availability of operator/services provider
resources to address them.
202

Legal considerations States
Establishing acceptable level(s) of safety does
not replace legal, regulatory, or other already
established requirements, but it must support
compliance with them.
Establishing acceptable level(s) of safety for their
safety programme leaves unaffected the
obligations of States, and does not relieve States
from compliance with SARPs.
203

Legal considerations Operators and service
providers
Establishing acceptable level(s) of safety for their
safety management system leaves unaffected
the obligations of operators or services providers
and other related parties, and it does not relieve
the operator, services providers and other related
parties from compliance with SARPs and/or
national regulations, as applicable.
204
Protecting sources of safety

information
Assembly Resolution A35/17
Legal guidance in Annex 13, Attachment E
Safety information must not be used for
purposes other than the purposes for which it
was collected.
Introduction and definitions
General principles
Principles of protection
Principles of exceptions
Responsibilities of the custodian of safety information
Protection of recorded information
205
Why ICAO safety management

provisions?
A move from prescription to performance
Prescriptive regulations Prescribe what the
safety requirements are and how they are to be
met.
Performance based regulations Specify the
safety requirements to be met, but provide
flexibility in terms of how safety requirements are
met.
206
FAA SMS Applicability

AC 120-92 Introduction to Safety Management
Systems for Air Operators
Developing AC 145-XXX Introduction to Safety
Management Systems for Maintenance
Organizations
ATOSAdding an Element 8 Safety Management
Systems
207
FAA Four Pillars

Safety Management System
Policy
Procedures
Process
Controls
Planning
Safety
Risk
Management
Safety
Assurance
System
Descrip
Data
Hazard
Ident
Analysis
Risk
Analysis
Risk
Assmt
Risk
Control
Safety
Promotion
Audits
Invest.
Reports
Comm
Training
Assmt
Prev/Corr
Action
208
Points to remember
1. Standardised SMS provisions Prescription vs.
performance.
2. Safety programme.
3. SMS.
4. Acceptable of level of safety.
a) Safety performance indicators.
b) Safety performance targets.
c) Safety requirements.
5. The need to protect the source of information
References: Annexes 6, 11, 13 and14, and Doc 9859, Chapter 3
209
Introduction to
7. Introduction to SMS
Objective
to describe the features of an SMS, explain the
importance of system description and gap analysis,
and the relationship between SMS and QMS.
211
Outline
ICAO requirements
SMS Introductory concepts
SMS features
System description
Gap analysis
SMS and QMS
Clarifying terms
Points to remember
212
ICAO requirements
Compliance with all relevant
regulations and ICAO
standards, in addition to those
SMS-related, is a key
component of an SMS.
Many of these regulations and
standards, including the
operational provisions, will
form part of the SMS.
213
SMS Introductory concepts

A toolkit
The scope of SMS encompasses most of the
activities of the organization.
SMS must start from senior management,
management and safety
must be considered at all levels of the organization.
organization
SMS aims to make continuous improvement to the
overall level of safety.
All aviation stakeholders have a role to play in SMS.
214
Identifying aviation system

stakeholders
Aviation professionals
Aircraft owners and operators
Manufacturers
Aviation regulatory authorities
Industry trade associations
Regional air traffic service providers
Professional associations and federations
International aviation organizations
Investigative agencies
The flying public
215
Identifying aviation system

stakeholders
Why is it important to identify aviation system
stakeholders?
To ensure that stake holders relevant to risk
decision are taken into consideration and
contribute with their knowledge before the
decision is taken.
216
SMS features
Systematic Safety management activities are
in accordance with a pre-determined plan, and
applied in a consistent manner throughout the
organization.
Proactive An approach that emphasizes
hazard identification and risk control and
mitigation, before events that affect safety occur.
Explicit All safety management activities are
documented and visible.
217
Operational System description

Operational system description
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.
218
Operational system description

1. The system interactions with other systems in
the air transportation system.
2. The system functions.
3. Required Human Factors considerations of the
system operation.
4. Hardware components of the system.
5. Software components of the system.
6. Related procedures that define guidance for the
operation and use of the system.
7. Operational environment
8. Contracted and purchased products and
services.
219
Gap analysis
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.
220
Gap analysis
Conduct the gap analysis against the
components and elements of the SMS
Once completed and documented the
gap analysis forms the basis of the
SMS implementation plan.
221
SMS and QMS (ICAO)

SMS results in the design and implementation of
organizational processes and procedures to identify
hazards and control/mitigate risks in aviation
operation.
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.
222
SMS and QMS (ICAO)

SMS builds partly upon QMS principles.
SMS should include both safety and quality
policies.
The coverage of quality policies should be
limited to quality in support of safety.
Safety objectives should receive primacy
where conflicts are identified.
223
SMS and QMS (Alternate)

In commercial aviation safety is an aspect of
product quality
Aircraft
Passenger service
Maintenance
An SMS is that part of a QMS that addresses

safety
224
SMS and QMS (Alternate)

Safety and quality policies should be integrated
The coverage of quality policies should include
safety risk management requirements
Safety requirements should receive primacy where
conflicts are identified.
225
Systems integration
There is a tendency in civil aviation to integrate
the different systems of management:
Quality management system (QMS).
Environment management system (EMS).
Occupational health and safety management system
(OHSMS).
Safety management system (SMS).
Security management system
IATA supports this and has just developed a

program to integrate these different functions.
226
Systems integration benefits

Reduce duplication and therefore costs.
Reduce risks and increase profitability.
Balance potentially conflicting objectives.
Eliminate potentially conflicting responsibilities
and relationships.
227
Systems integration
considerations (ICAO)
There are different ways to integrate a safety
management system in the operation of the
organization.
Aviation organizations should be encouraged to
integrate their management system for quality,
safety, security, occupational health and safety, and
environmental protection management.
This integration, however, is presently beyond the
scope of the harmonized ICAO safety management
requirements.
228
Clarifying the use of terms

Safety oversight Is what the CAA performs
with regard to the operators/service providers
SMS.
Safety assurance Is what the operators/service
providers do with regard to safety performance
monitoring and measurement
Safety audit Is what the CAA performs with
regard to its safety programme and the
operators/service providers perform with regard
to the SMS.
229
SMS Nothing new?

Rounding up the usual suspects.
In aviation, safety is first.
Safety is everybodys responsibility.
If aint broke, why fix it?
If you believe safety is expensive, try an accident.
70% accidents are due to human error.
SMS sets forth to destroy all these

misperceptions.
230
In summary
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.
Management Allocation of resources.

System Organized set of processes and
procedures.
231
Points to remember
1.
2.
3.
4.
SMS main features

The importance of system description
The importance of gap analysis
The relationship between SMS and QMS
232
Introduction to
8. Planning
Objective
When completing the module the participants will
be able to describe the requirements associated to
the planning of an SMS, and explain the structure
of an SMS implementation plan.
234
Outline
The components of SMS
The elements of SMS
Safety policy and objectives
Points to remember
235

Safety risk management
SMS (program) surveillance and control
Safety promotion
236

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
2.1 Hazard identification processes
2.2 Risk assessment and mitigation processes
237
SMS (program) Surveillance and Control

3.1 Safety performance monitoring and measurement
3.2 The management of change
3.3 Continuous improvement of the safety system
Safety promotion
4.1 Training and education
4.2 Safety communication
238

1.6 Documentation
239

1.1 Management commitment and
responsibility
Executive management must:
Develop the safety policy, signed by the senior management,
in accordance to national and international standards and
organizational priorities.
Communicate, with visible endorsement, the safety policy to all
staff.
Provide necessary human and financial resources.
240

responsibility
Executive management must:
Establish safety objectives and performance standards
standard for
the SMS.
The safety objectives and performance standards should be
linked to the safety performance indicators,
indicators safety
performance targets and safety requirements of the SMS.
SMS
241

responsibility
Executive management
Single, identifiable person
Has responsibility for the organizations safety performance
CEO/Chairman Board of Directors
President
The proprietor
242

responsibility
Executive management must have:
Final responsibility for determining level of acceptable risk for
safety
Full authority for human resources issues.
Authority for major financial issues.
Direct responsibility for the conduct of the organizations
affairs.
Final authority over operations under certificate.
Final responsibility for all safety issues.
243

1.6 Documentation
244

SMS organization
Safety responsibilities of key personnel
245
Safety responsibilities An
example
Safety Review
Board (SRB)
Executive Management
Director of
operations
Director of
maintenance
Other directorates
Safety services
office
Safety Action
Group (s)
(SAG)
Flight
safety officer
Maintenance
safety officer
246

1.6 Documentation
247

The safety office Corporate functions
Advising executive
management on safety matters.
Assisting line managers.

Overseeing hazard identification systems.
248

The safety manager Responsibilities
Responsible individual and focal point for the development
and maintenance of an effective safety management system
The safety manager is NOT responsible for the

safety performance of the organization
249

The safety manager Functions
Manages the SMS implementation plan on behalf of
the executive manager.
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.
250

The safety manager Selection criteria
Operational management experience and technical
background to understand the systems that support
operations.
People skills.
Analytical and problem-solving skills.
Project management skills.
Oral and written communications skills.
251
Safety responsibilities
Safety Review
Board (SRB)
Director of
operations
Director of
maintenance
Other directorates
Safety services
office
Safety Action
Group (s)
(SAG)
Flight
safety officer
Maintenance
safety officer
252

The Safety Review Board (SRB):
High level committee
Strategic safety functions
Chaired by executive management
It may include the Board of Directors.
Composed of heads of functional areas.
253

SRB monitors :
Safety performance against the safety policy and objectives.
Effectiveness of the SMS implementation plan.
Effectiveness of the safety supervision of sub-contracted
operations.
SRB ensures that appropriate resources are allocated

to achieve the established safety performance.
SRB gives strategic direction to the SAG
254
Safety responsibilities
Safety Review
Board (SRB)
Director of
operations
Director of
maintenance
Other directorates
Safety services
office
Safety Action
Group (s)
(SAG)
Flight
safety officer
Maintenance
safety officer
255

Safety Action Group(s) (SAG):
Reports to SRB and directors takes strategic direction
from SRB.
Members:
Managers and supervisors from functional areas.
Front-line personnel.
256

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.
257

1.6 Documentation
258

Developed by a planning group, which:
Comprises an appropriate experience base.

Meets regularly with executive management.
Receives resources (including time for meetings).
A realistic strategy for the implementation of an

SMS that will meet the organizations safety
needs.
A definition of the approach the organization will
adopt for managing safety.
259

1.4 SMS implementation plan Contents
1)
Reference to the safety policy
2)
Safety planning, objectives and goals
3)
System description
4)
Gap analysis
5)
SMS components
6)
Safety roles and responsibilities
7)
Safety reporting policy
8)
Means of employee involvement
9)
Safety communication
10)
Safety performance measurement
11)
Management review (of safety performance)
260

Executive management approves the plan.
Typical implementation time frame will be one to
four years ahead (Phased approach).
261

1.6 Documentation
262

An emergency response plan
(ERP) outlines in writing what
should be done after an
accident, and who is responsible
for each action.
Plans should address several
types of emergencies such as:
Aircraft accidents
Facility fires
Natural disasters
263

1.5 Coordination of the ERP
The purpose of an ERP is to ensure that there is:
Orderly and efficient transition from normal to emergency
operations.
Designation of emergency authority.
Assignment of emergency responsibilities.
Authorization by key personnel for actions contained in the
plan.
Coordination of efforts to cope with the emergency.
Safe continuation of operations, or return to normal operations
as soon as possible.
264

1.5 Coordination of the ERP
Plan contents:
Governing policies.
Organization.
Notifications.
Initial response.
Additional assistance.
Crisis Management Centre
(CMC).
Plan contents:
Records.
Accident site.
News media.
Formal investigations.
Family assistance.
Post critical incident stress
counselling.
Post occurrence review.
265

1.6 Documentation
266

1.6 Documentation
Applicable regulations
SMS records and documentation
Records management
The Safety Management System Manual (SMSM)
267

1.6 Documentation Safety policy and objectives
Defines executive managements commitment and vision
for safety
Safety policy must include a commitment to:
Achieve the highest safety standards.
Observe all applicable legal requirements and
international standards, and best effective practices.
Provide appropriate resources.
Enforce safety as one primary responsibility of all
managers.
Ensure that the policy is understood, implemented
and maintained at all levels.
268

1.6 Documentation Safety management
system manual (SMSM)
Key instrument for communicating the organizations
approach to safety to the whole organization.
Documents all aspects of the SMS, including the safety
policy, objectives, procedures and individual safety
accountabilities.
269

1.6 Documentation SMSM contents
1. Scope of the safety
7.
management system.
2. The safety policy and
8.
objectives.
3. Safety accountabilities.
9.
4. Key safety personnel.
10.
5. Documentation control
11.
procedures.
6. Hazard identification and 12.
risk management schemes
Safety performance
monitoring.
Emergency response
planning.
Management of change.
Safety auditing.
Safety promotion.
Contracted activities
270
Conclusion
The successful management of safety is a
functional responsibility that requires the
participation of all operational personnel and the
supervision of the organization (Systematic).
This principle must be reflected in the structure of
the organization (Explicit).
271
Conclusion
The organization must define, document and
communicate individual lines of responsibility and
authority in regard to the management of
operational safety (Explicit).
The means to manage safety within the
organization include hazard identification, risk
management, safety assurance and safety
promotion (Proactive).
272
Points to remember
1.
2.
3.
The four components of an SMS.

The SMS implementation plan.
The importance of documenting safety
responsibilities.
4. The SMSM.
5. SRB, SAG and the safety manager.
6. Safety responsibilities.
273
Introduction to
9. Operations
Objective
When completing the module the
participants will be able to describe the
requirements associated to the operation of
an SMS.
275
Outline
SMS (Program) surveillance and control
Safety promotion
Points to remember
276

3. Program surveillance and control
3.1 Performance monitoring and analysis
Safety promotion
277

A formal means of collecting, recording, acting
on and generating feedback about hazards and
risks in operations.
Three methods:
Reactive
Proactive
Predictive
278

Reporting systems A special paragraph

Nobody knows better actual system
performance than operational personnel.
Mandatory reporting system.
Voluntary reporting systems.
Confidential reporting systems.
279

Reporting systems
People are reluctant to report.
Why?
Retaliation.
Self-incrimination.
Embarrassment.
280

Typical qualities of successful confidential

reporting systems:
Reports easy to make.
No disciplinary actions as result of reports.
Reports are confidential.
Feedback is rapid, accessible and informative.
281

Four steps for action:
1. Reporting hazards, events or safety concerns.
2. Collecting and storing the data.
3. Analyzing reports.
4. Distributing the information distilled from the
analysis.
282

Program surveillance and control


Safety promotion
283

The risk assessment, the mitigation of a risk to an
acceptable level, and reliably maintaining it at that
level.
284


2.2 Risk assessment, mitigation and processes

Safety promotion
285

3.1 Safety performance monitoring and analysis
Performance monitoring and analysis is conducted for
two reasons
Verify safety performance of the organization in comparison to the
approved safety policies and objectives.
Provide data to support the quality improvement program of the
SMS
286
SMS Functional Element

This function provides quality assurance for the SMS. It is
divided into:
Compliance Monitoring
Compliance monitoring
Process control
Compliance monitoring provides management with information
concerning
whether SMS policies, practices and procedures
Audits
have
been
incorporated into the organizations operations and
Incident
reports
business practices and whether they are being correctly
followed.
Process Control
Process control provides management with information
concerning the effectiveness of SMS policies, practices and
Procedures.
Performance
Cost
287

3.1 Safety system performance monitoring
and analysis
Safety audits are used to ensure that the structure of
the SMS is sound in terms of:
levels of staff;
compliance with approved procedures and instructions;
level of competency and training to:
operate equipment and facilities; and
maintain their levels of performance.
288
Program Surveillance and

Control

and analysis
Safety surveys examine particular elements or
processes of a specific operation.
Problem areas or bottlenecks in daily operations.
Perceptions and opinions of operational personnel.
Areas of dissent or confusion.
289

Control

and analysis
Safety surveys may involve the use of:
Checklists
Questionnaires.
Informal confidential interviews.
Since surveys information is subjective, verification

may be needed before corrective action.
Surveys may provide an inexpensive source of
significant safety information.
290
SMS performance metrics

Lagging indicators
Relatively small sample sizes.
Will generally take a long time (years) to acquire enough
data to establish statistical significance.
Accident and injury data are most common lagging
indicators.
Difficult to use for quality management and process
improvement.
Leading indicators
Large sample sizes.
Shorter time to develop statistical significance.
Used commonly for quality management and process
improvement.
291



Safety promotion
292

Control

Aviation organizations experience permanent
change due to expansion, introduction of new
equipment or procedures.
Changes can:
Introduce new hazards.
Impact the appropriateness of risk mitigation.
Impact the effectiveness of risk mitigation.
293

Control

External changes
Change of regulatory requirements.
Security.
Reorganization of air traffic control.
Internal changes
Management changes
New equipment.
New procedures.
294

Control

A formal management of change process should:
Identify changes within the organization which may
affect established processes and services.
Conduct a predictive hazard assessment and risk
analysis to identify risks associated with the change
Prior to implementing changes describe the
arrangements to ensure safety performance.
295


3.1 Performance monitoring and measurement

Safety promotion
296

Control
3.3 Continuous improvement of the safety

Continuing improvement aims at:
Determining the immediate the causes of performance
under the standard and the implications of this
performance in the operation of the SMS.
Rectifying situations involving situations under the
standard identified through other safety assurance
activities.
297

Control
Continuing improvement is achieved through:

Reactive evaluations in order to determine why the
risks were not under control, for example:
investigations of minor and major incidents and
accidents.
Proactive evaluation of facilities, equipment, and
documentation and procedures through audits and
surveys.
Proactive evaluation of the individuals performance,
to verify the fulfillment of their safety responsibilities.
Predictive change management.
298



Safety promotion
299
Safety promotion
The safety manager should, in conjunction with the
personnel department, review the job descriptions of all
staff, and identify those positions that have safety
responsibilities.
300
Safety promotion
Who?
Operational personnel
Managers and supervisors
Senior managers
Accountable executive
Why?
To ensure that personnel are trained and competent
to perform the SMS duties.
How much?
Appropriate to the individuals involvement in the
SMS.
301
Safety promotion
A building block approach
Operational personnel
Organization safety policy
SMS fundamentals and overview
Manager and supervisors

The safety process
Hazard identification and risk management
The management of change
Senior managers
Organizational safety standards and national regulations
Safety assurance
302
Safety promotion
Accountable executive A special paragraph
Awareness of:
SMS roles and responsibilities
Safety policy
SMS Standards
Safety assurance
303


3.1 Safety performance monitoring and analysis

Safety promotion
304
Safety promotion
Safety communication aims to:
Ensure that all staff are fully aware of the SMS.
Convey safety critical information.
Explain why particular actions are taken.
Explain why safety procedures are introduced or
changed.
Convey nice-to-know information.
305
Safety promotion
The means to communicate may include:
Safety policies and procedures
News letters.
Bulletins.
Safety communication is an essential

foundation for the development and
maintenance of a safety culture.
306
SMS at a glance
Safety
Safety risk
management
Safety policy
and objectives
Safety
promotion
Effectiveness
Management
commitment
Aviation
community
stakeholders
Surveillance
and
control
Efficiency
307
Points to remember
1. Key ingredients for successful reporting
2. The importance of a formal management of
change
3. Safety training Who, why and how much
308
Introduction to
10. Implementation
Objective
At the end of this module participants will be able to
develop a proposal for an SMS standard, based
upon a phased implementation.
310
Outline
Why a phased approach to SMS?
The four phases
CAAs Four steps for SMS implementation
Points to remember
311
Why a phased approach to SMS?

To provide a manageable series of steps to follow in
implementing an SMS.
To effectively manage the workload associated with
SMS implementation.
To pre-empt a ticking boxes exercise.
Four implementation phases are proposed.
Each phase is based upon the introduction of
specific SMS elements.

312
Phase 1
Provides a blueprint on how the SMS
requirements will be met and integrated to the
organizations work activities.
Provides an accountability framework for the
implementation of the SMS.
313
Phase 1
1. Identify the accountable executive and the
safety accountabilities of managers.
2. Identify the person (or planning group) within
the organization responsible for implementing
the SMS.
3. Describe the system (Air operator or
approved maintenance organization)
314
Phase 1
4. Conduct a gap analysis of the organizations existing
resources compared with the national requirements
for establishing a SMS.
5. Develop an SMS implementation plan that explains
how the organization will implement the SMS on the
basis of national requirements and the results of the
gap analysis.
6. Develop documentation relevant to safety policy and
objectives.
7. Develop and establish means for safety
communication.
315
Phase 2
Puts into practice those elements of the
SMS implementation plan that refer to:
1. Safety risk management component.

Reactive processes
Investigation and analysis
2. Training relevant to:
The SMS implementation plan components.
The safety risk management component (Reactive
processes).
3. Documentation relevant to:
The SMS implementation plan components.
The safety risk management component (Reactive
processes).
316
Phase 3
Puts into practice those elements of the SMS
implementation plan that refer to:
1. Safety risk management component.
Proactive and predictive processes
Investigation and analysis
2. Training relevant to proactive and predictive
processes.
3. Documentation relevant to proactive and predictive
processes.
317
Phase 4
1. Program Surveillance and Control
Development of acceptable level (s) of safety.
safety
Develop SMS program metrics

Leading indicators
Lagging indicators
2. Training relevant to SMS program surveillance and

control.
3. Documentation relevant to SMS program surveillance
and control.
318
The final objective Integration

Safety programme + SMS = State integrated safety
management system
Protection
Objective:
Public
safety
Production
State
safety
programme
Oversight
Acceptance
Oversight
Organizations
Objective:
safety
Manage and
management
control
safety risk
system (SMS)
Organizations
production
processes
Risk management
Safety assurance
Objective:
Achieve
commercial
goals and
customer
satisfaction
319
Points to remember
1. Reduce a complex task to series of manageable
steps.
2. Avoid a bureaucratic exercise (Ticking boxes).
3. Element allocation under a particular phase may
slightly vary depending upon the specific Annex.
4. The CAAs four steps for SMS implementation.
320
321

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Pakistan International Corp.

William L. (Bill) Rankin, Ph.D.

Basis of the Training

ICAO Intent for SMS

Secretariat proposes that the SMS provisions be

ICAO Annex 6 Requirements

An accepted safety management system shall clearly

What is a Safety Management

As a corporate management process, an SMS is implemented

Risk = Probability of Event Occurring X Severity of its Outcome

SMS integrates safety activities into the organizations operations

SMS Functional Elements

SMS Functional Elements

Roles & Responsibilities

SMS Functional Elements

Policies & Procedures

SMS Functional Elements

Risk assessment process

Risk Assessment Matrix

SMS Functional Elements

SMS Functional Elements

Zero accidents (or serious incidents)?

Freedom from danger or risks?

The elimination of accidents (and serious incidents) is

Traditional approach Accident prevention

But not always discloses:

The evolution of safety thinking

Reasons Model of Accident

A maintenance organization has

Errors can happen

Reasons Model of Accident

In most cases, errors are

Reasons Model of Accident

An accident only occurs

The organizational accident

Activities over which any organization has a

The organizational accident

Conditions present in the system before the accident,

The organizational accident

Resources to protect against the risks that

The organizational accident

Factors that directly influence the efficiency of

The organizational accident

Actions or inactions by people (pilots,

The organizational accident

People and safety

Understanding human performance

Definitions of Error and Violation

Errors and Violations

We will collectively call errors and violations a

Types of Maintenance System Failures

Human Error in Aircraft

Incorrect installation of components

UK Flight Safety Committee 2004

Failure to follow published technical data or local instructions

Processes and outcomes

Operational performance and

Understanding operational errors

Errors and safety A non

Accident investigation Once