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SAFETY MANAGEMENT EDGARS GINDRA 20.09.2007 LV CAA AOD.

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Presentation on theme: "SAFETY MANAGEMENT EDGARS GINDRA 20.09.2007 LV CAA AOD."— Presentation transcript:

1 SAFETY MANAGEMENT EDGARS GINDRA LV CAA AOD

2 SMS LV CAA AOD 2 SMS regulation Operation of aircraft Operation of aircraft Maintenance of aircraft Maintenance of aircraft Air traffic services Air traffic services Aerodromes Aerodromes –Two audience groups States States Service providers Service providers –Three distinct requirements Safety programme Safety programme SMS SMS Management accountability Management accountability

3 SMS LV CAA AOD 3 The amendment 30 to ICAO Annex 6 Part I States shall establish a safety programme in order to achieve an acceptable level of safety in the operation of aircraft States shall establish a safety programme in order to achieve an acceptable level of safety in the operation of aircraft From 1 January 2009, States shall require, as part of their safety programme, that an operator implement a safety management system acceptable to the State of the Operator that, as a minimum: From 1 January 2009, States shall require, as part of their safety programme, that an operator implement a safety management system acceptable to the State of the Operator that, as a minimum:

4 SMS LV CAA AOD 4 The amendment 30 to ICAO Annex 6 Part I a) Identifies safety hazards; b) Ensures that remedial action necessary to maintain an acceptable level of safety is implemented; c) Provides for continuous monitoring and regular assessment of the safety level achieved; and d) Aims to make continuous improvement to the overall level of safety.

5 SMS LV CAA AOD 5 The amendment 30 to ICAO Annex 6 Part I A 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 A 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 An operator shall establish a flight safety documents system, for the use and guidance of operational personnel, as part of its safety management system An operator shall establish a flight safety documents system, for the use and guidance of operational personnel, as part of its safety management system.

6 SMS LV CAA AOD 6 What is a safety programme? An integrated set of regulations and activities aimed at improving safety. An integrated set of regulations and activities aimed at improving safety. States are responsible for establishing a safety programme: States are responsible for establishing a safety programme: –Safety regulation –Safety oversight –Accident/incident investigation –Mandatory/voluntary reporting systems –Safety data analysis –Safety promotion

7 SMS LV CAA AOD 7 Clarifying the use of terms Safety oversight – Is what the CAA performs with regard to the operators/service providers SMS. 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 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. Safety audit – Is what the CAA performs with regard to its safety programme and the operators/service providers perform with regard to the SMS.

8 SMS LV CAA AOD 8 Acceptable level of safety – a concept High level safety management goals of an oversight authority (or a service provider) 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 Minimum safety performance that service providers should achieve while conducting their core business functions A reference against which one can measure safety performance A reference against which one can measure safety performance

9 SMS LV CAA AOD 9 What is an SMS? A systematic approach to managing safety, including the necessary organizational structures, accountabilities, policies and procedures. A systematic approach to managing safety, including the necessary organizational structures, accountabilities, policies and procedures. Providers are responsible for establishing an SMS. Providers are responsible for establishing an SMS. States are responsible of the acceptance and oversight for providers SMS. States are responsible of the acceptance and oversight for providers SMS.

10 SMS LV CAA AOD 10 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 through a continuing process of hazard identification and risk management. 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 through a continuing process of hazard identification and risk management. Management – Allocation of resources. Management – Allocation of resources. System – Organized set of processes and procedures. System – Organized set of processes and procedures.

11 SMS LV CAA AOD 11 Safety programme – SMS relationships State safety programme Organizations safety management system (SMS) Organizations production processes Objective: Public safety Objective: Manage and control safety risk Acceptance Oversight Objective: Achieve commercial goals and customer satisfaction Risk management Safety assurance Protection Production Oversight

12 SMS LV CAA AOD 12 ESARR ADVISORY MATERIAL Annex 14 establishes that, as of 24 November 2005, certified aerodromes shall have in operation a safety management system. Annex 14 establishes that, as of 24 November 2005, certified aerodromes shall have in operation a safety management system. ESARR 3 can be used by aerodrome operators to implement the SMS required in the SARPs contained in ICAO Annex 14. ESARR 3 can be used by aerodrome operators to implement the SMS required in the SARPs contained in ICAO Annex 14.

13 SMS LV CAA AOD 13 ESARR ADVISORY MATERIAL As a result, Safety Management Systems (SMS) will have to be implemented, not only in the provision of ATM service associated to aerodromes but also as regards the complete operation of the certified aerodromes at which those services are provided. As a result, Safety Management Systems (SMS) will have to be implemented, not only in the provision of ATM service associated to aerodromes but also as regards the complete operation of the certified aerodromes at which those services are provided.

14 SMS LV CAA AOD 14 ESARR ADVISORY MATERIAL ESARR 3 addresses the management of safety in any ATM service provided without confining the SMS scope to ATS as Annex 11 wherever it appears necessary. ESARR 3 addresses the management of safety in any ATM service provided without confining the SMS scope to ATS as Annex 11 wherever it appears necessary.

15 SMS LV CAA AOD 15 INTER-RELATIONSHIP BETWEEN SMS IN ATM AND AERODROMES A single organization is involved. That means that the organization will have to implement: A single organization is involved. That means that the organization will have to implement: - SMS compliant with ESARR 3 (and ICAO Annex 11) in its ATM services; - SMS compliant with ICAO Annex 14 in its aerodrome operations.

16 SMS LV CAA AOD 16 INTER-RELATIONSHIP BETWEEN SMS IN ATM AND AERODROMES Two different organizations are involved. Two basic alternatives may be considered: Two different organizations are involved. Two basic alternatives may be considered: - Two separate SMS. Each organization implements its own SMS (one according to ESARR 3 to cover the ATM services, and one according to ICAO Annex 14 and specific national regulations.

17 SMS LV CAA AOD 17 INTER-RELATIONSHIP BETWEEN SMS IN ATM AND AERODROMES - A common SMS. The ATM and aerodrome safety regulator (s) could accept a set of arrangements proposed by both organizations to establish a common SMS.

18 SMS LV CAA AOD 18 Regulation (EC) 2096/2005 laying down common requirements for the provision of air navigation services Article 3 Granting of certificates Shall comply with the specific additional requirements set in Annex II 3. Safety of services Safety management system Safety management system Safety requirements for risk assessment and mitigation with regard to changes Safety requirements for risk assessment and mitigation with regard to changes Safety requirements for engineering and technical personnel undertaking operational safety related tasks Safety requirements for engineering and technical personnel undertaking operational safety related tasks

19 SMS LV CAA AOD 19 SMS – Introductory concepts The scope of SMS encompasses most of the activities of the organization. The scope of SMS encompasses most of the activities of the organization. SMS must start from senior management, and safety must be considered at all levels of the organization. SMS must start from senior management, and safety must be considered at all levels of the organization. SMS aims to make continuous improvement to the overall level of safety. SMS aims to make continuous improvement to the overall level of safety. All aviation stakeholders have a role to play in SMS. All aviation stakeholders have a role to play in SMS.

20 SMS LV CAA AOD 20 Identifying aviation system stakeholders It is important to identify aviation system stakeholders to ensure that stakeholders relevant to risk decision are taken into consideration and contribute with their knowledge before the decision is taken. It is important to identify aviation system stakeholders to ensure that stakeholders relevant to risk decision are taken into consideration and contribute with their knowledge before the decision is taken.

21 SMS LV CAA AOD 21 Aviation system stakeholders Aviation professionals Aviation professionals Aircraft owners and operators Aircraft owners and operators Manufactures Manufactures Aviation regulatory authorities Aviation regulatory authorities Industry trade associations Industry trade associations Regional air traffic service providers Regional air traffic service providers Professional associations and federations Professional associations and federations International aviation organizations International aviation organizations Investigative agencies Investigative agencies The flying public The flying public

22 SMS LV CAA AOD 22 First fundamental – 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. 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.

23 SMS LV CAA AOD 23 System description The system interactions with other systems in the air transportation system. The system interactions with other systems in the air transportation system. The system functions. The system functions. Required Human Factors considerations of the system operation. Required Human Factors considerations of the system operation. Hardware components of the system. Hardware components of the system. Software components of the system. Software components of the system. Related procedures that define guidance for the operation and use of the system. Related procedures that define guidance for the operation and use of the system. Operational environment. Operational environment. Contracted and purchased products and services. Contracted and purchased products and services.

24 SMS LV CAA AOD 24 Second fundamental – Gap analysis An analysis of safety arrangements existing within the organization. An analysis of safety arrangements existing within the organization. The organizational structures necessary for an SMS may be found throughout an 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. Various activities of an SMS are probably already in place and are working. SMS development should build upon existing organizational structures. SMS development should build upon existing organizational structures. Conduct the gap analysis against the components and elements of the SMS. Conduct the gap analysis against the components and elements of the SMS. Once completed and documented the gap analysis forms the basis of the implementation plan. Once completed and documented the gap analysis forms the basis of the implementation plan.

25 SMS LV CAA AOD 25 Third fundamental – SMS and QMS SMS differs from quality systems in that: SMS differs from quality systems in that: SMS focuses on the safety, human and organizational aspects of an operation (i.e., safety satisfaction) SMS focuses on the safety, human and organizational aspects of an operation (i.e., safety satisfaction) QMS focus the product (s) of an operation (i.e., customer satisfaction) QMS focus the product (s) of an operation (i.e., customer satisfaction) SMS results in the design and implementation of organizational processes and procedures to identify hazards and control/mitigate risks in aviation operation. 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. 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. SMS builds partly upon QMS principles. SMS builds partly upon QMS principles. SMS should include both safety and quality policies. SMS should include both safety and quality policies. The coverage of quality policies should be limited to quality in support of safety. The coverage of quality policies should be limited to quality in support of safety. Safety objectives should receive primacy where conflicts are identified. Safety objectives should receive primacy where conflicts are identified.

26 SMS LV CAA AOD 26 SMS planning The components of SMS Safety policy and objectives Safety policy and objectives Safety risk management Safety risk management Safety assurance Safety assurance Safety promotion Safety promotion

27 SMS LV CAA AOD 27 The elements of SMS 1. Safety policy and objectives 1. Safety policy and objectives 1.1 Management commitment and responsibility 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 response plan 1.6 Documentation

28 SMS LV CAA AOD 28 The elements of SMS 2. Safety risk management 2.1 Hazard identification process 2.2 Risk assessment and mitigation processes processes 2.3 Internal safety investigations

29 SMS LV CAA AOD 29 The elements of SMS 3. Safety assurance 3. Safety assurance 3.1 Safety performance monitoring and measurement and measurement 3.2 The management of change 3.3 Continuous improvement of the safety system safety system

30 SMS LV CAA AOD 30 The elements of SMS 4. Safety promotion 4. Safety promotion 4.1 Training and education 4.2 Safety communication

31 SMS LV CAA AOD 31 Accountable executive Flight safety officer Maintenance safety officer Safety Action Group (s) (SAG) Safety Review Board (SRB) Director of operations Director of maintenance Other directorates Safety services office Safety responsibilities

32 SMS LV CAA AOD 32 Appointment of key safety personnel The safety office – Corporate functions The safety office – Corporate functions Advising senior management on safety Advising senior management on safetymatters Assisting line managers Assisting line managers Overseeing hazard identification Overseeing hazard identification systems systems The safety manager – Responsibilities The safety manager – Responsibilities Responsible individual and focal point for the development and maintenance of an effective safety management system Responsible individual and focal point for the development and maintenance of an effective safety management system

33 SMS LV CAA AOD 33 Appointment of key safety personnel The safety manager – Functions The safety manager – Functions Manages the SMS implementation plan on behalf of the accountable executive Manages the SMS implementation plan on behalf of the accountable executive Facilitates hazard identification and risk analysis and management Facilitates hazard identification and risk analysis and management Monitors corrective actions to ensure their accomplishment Monitors corrective actions to ensure their accomplishment Provides periodic reports on safety performance Provides periodic reports on safety performance Maintains safety documentation Maintains safety documentation Plans and organizes staff safety training Plans and organizes staff safety training Provides independent advice on safety matters Provides independent advice on safety matters

34 SMS LV CAA AOD 34 Appointment of key safety personnel The Safety Review Board (SRB) The Safety Review Board (SRB) High level committee High level committee Strategic safety functions Strategic safety functions Chaired by the accountable executive Chaired by the accountable executive It may include the Board of Directors It may include the Board of Directors Composed of heads of functional areas Composed of heads of functional areas SRB monitors: SRB monitors: Safety performance against the safety policy and objectives Safety performance against the safety policy and objectives Effectiveness of the SMS implementation plan Effectiveness of the SMS implementation plan Effectiveness of the safety supervision of subcontracted operations Effectiveness of the safety supervision of subcontracted operations

35 SMS LV CAA AOD 35 Appointment of key safety personnel SRB ensures that appropriate resources are allocated to achieve the established safety performance SRB ensures that appropriate resources are allocated to achieve the established safety performance SRB gives strategic direction to the SAG SRB gives strategic direction to the SAG Safety Action Group (SAG): Safety Action Group (SAG): Reports to SRB and takes strategic direction from SRB Reports to SRB and takes strategic direction from SRB Members: Members: Managers and supervisors from functional areas Managers and supervisors from functional areas Front-line personnel Front-line personnel

36 SMS LV CAA AOD 36 Appointment of key safety personnel SAG: SAG: Oversees operational safety within the functional area Oversees operational safety within the functional area Resolves identified risks Resolves identified risks Assesses the impact on safety of operational changes Assesses the impact on safety of operational changes Implements corrective action plans Implements corrective action plans Ensures that corrective action is taken in a timely manner Ensures that corrective action is taken in a timely manner Review the effectiveness of previous safety recommendations Review the effectiveness of previous safety recommendations Safety promotion Safety promotion

37 SMS LV CAA AOD 37 SMS implementation plan Contents Contents 1. 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)

38 SMS LV CAA AOD 38 PHASED APPROACH TO SMS IMPLEMENTATION Phase 1 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 = 1) Identify the accountable executive and the safety accountabilities of managers Elements 1.1 and 1.2 2) Identify the person or planning group within the organization responsible for implementing the SMS Element 1.3 3) Describe the system (Air operator, ATC services provider, approved maintenance organization, certified aerodrome operator) Element 1.4

39 SMS LV CAA AOD 39 PHASED APPROACH TO SMS IMPLEMENTATION Phase 2 Phase 2 - Puts into practice those elements of the SMS implementation plan that refer to: 1) Safety risk management component Reactive processes Reactive processes Investigation and analysis Investigation and analysis Hazard identification and risk management Hazard identification and risk management Elements 2.1, 2.2 and 2.3 2) Training relevant to: The SMS implementation plan components The SMS implementation plan components The safety risk management component (Reactive processes) The safety risk management component (Reactive processes) Element 4.1 3) Documentation relevant to: The SMS implementation plan components The SMS implementation plan components The safety risk management component (Reactive processes) The safety risk management component (Reactive processes) Elements 1.4 and 1.6

40 SMS LV CAA AOD 40 PHASED APPROACH TO SMS IMPLEMENTATION Phase 3 Phase 3 - Puts into practice those elements of the SMS implementation plan that refer to: 1) Safety risk management component Proactive and predictive processes Proactive and predictive processes Investigation and analysis Investigation and analysis Hazard identification and risk management Hazard identification and risk management Elements 2.1, 2.2 and 2.3 2) Training relevant to proactive and predictive processes Element 4.1 3) Documentation relevant to proactive and predictive processes Elements 1.4 and 1.6

41 SMS LV CAA AOD 41 PHASED APPROACH TO SMS IMPLEMENTATION Phase 4 Phase 4 1) Operational safety assurance Development of acceptable level (s) of safety Development of safety indicators and targets SMS continuous improvement Elements 3.1, 3.2 and 3.3 2) Training relevant to operational safety assurance Element 4.1 3) Documentation relevant to operational safety assurance Element 1.6

42 SMS LV CAA AOD 42 CAA - Four steps for SMS implementation Step 1 Step 1 States safety programme Conduct a gap analysis vis-à-vis the current status in the State of the following: Conduct a gap analysis vis-à-vis the current status in the State of the following: Safety regulation Safety regulation Safety oversight (capabilities and planning) Safety oversight (capabilities and planning) Accident/incident investigation Accident/incident investigation Mandatory/voluntary/confidential reporting systems Mandatory/voluntary/confidential reporting systems Safety data analysis Safety data analysis Safety promotion Safety promotion Develop the State safety programme around four components of the ICAO SMS framework Develop the State safety programme around four components of the ICAO SMS framework

43 SMS LV CAA AOD 43 Safety analysis and safety studies Analytical methods and tools: Analytical methods and tools: –Statistical analysis (to quantify situations); –Trend analysis (predictions may be made, and to trigger alarms); –Normative comparisons (to sample real world experience under similar operating conditions);

44 SMS LV CAA AOD 44 Safety analysis and safety studies –Simulation and testing (simulation in the field under actual operating conditions); –Expert panel ( to evaluate evidence of an unsafe condition and evaluating the best course for corrective action); –Cost-benefit analysis (the costs of implementing the proposed measures are weighed against the expected benefits over time).

45 SMS LV CAA AOD 45 Safety analysis and safety studies Safety studies require data, appropriate analysis and effective communication. Safety studies require data, appropriate analysis and effective communication. Safety studies conducted by State authorities, airlines, manufactures, and professional and industry associations. Safety studies conducted by State authorities, airlines, manufactures, and professional and industry associations. Safety recommendations may arise from the investigation of accidents and serious incidents and also from safety studies. Safety recommendations may arise from the investigation of accidents and serious incidents and also from safety studies. Safety studies have application to hazard identification and analysis in flight operations, maintenance, cabin safety, air traffic control, airport operations, etc. Safety studies have application to hazard identification and analysis in flight operations, maintenance, cabin safety, air traffic control, airport operations, etc.

46 SMS LV CAA AOD 46 Safety analysis and safety studies Selecting study issues Selecting study issues –Significant safety issues lists (SIL) based on the accident and incident record in such areas as runway incursions, ground proximity warnings, TCAS, and prioritized in terms of the risks to the organization or the industry; –Support among participants and contributors.

47 SMS LV CAA AOD 47 Safety analysis and safety studies SIL should be reviewed and updated annually, adding new high-risk issues and deleting lesser-risk issues: SIL should be reviewed and updated annually, adding new high-risk issues and deleting lesser-risk issues: –Frequency of GPWS warnings; –Frequency of TCAS advisories; –Runway incursions; –Altitude deviations (busts); –Call sign confusion; –Un-stabilised approaches; and –Air proximities (near misses) at selected aerodromes.

48 SMS LV CAA AOD 48 CAA - Four steps for SMS implementation Step 2 Step 2 Implementation SMS SARPs Develop SMS regulations for operators/service providers Develop SMS regulations for operators/service providers Refer to the SMS components and elements Refer to the SMS components and elements Prepare guidance material for the implementation of SMS Prepare guidance material for the implementation of SMS Refer to ICAO Doc 9859 Refer to ICAO Doc 9859 Operators/service providers may need to use third party assistance to implement their SMS Operators/service providers may need to use third party assistance to implement their SMS

49 SMS LV CAA AOD 49 CAA - Four steps for SMS implementation Step 3 Step 3 CAA training programme Develop a training programme for CAA officers to: Develop a training programme for CAA officers to: Provide knowledge of safety management concepts and ICAO SARPs on safety management in Annexes 6, 11 and 14, and related guidance material; and Provide knowledge of safety management concepts and ICAO SARPs on safety management in Annexes 6, 11 and 14, and related guidance material; and Develop knowledge to certify and oversee the implementation of key components of an SMS, in compliance with the national regulations and relevant ICAO SARPs Develop knowledge to certify and oversee the implementation of key components of an SMS, in compliance with the national regulations and relevant ICAO SARPs

50 SMS LV CAA AOD 50 CAA - Four steps for SMS implementation Step 4 Step 4 CAA enforcement policy Revision of enforcement policy Revision of enforcement policy Operators/service providers allowed to deal with deviations/minor violations internally, within the context of the SMS, to the satisfaction of the authority Operators/service providers allowed to deal with deviations/minor violations internally, within the context of the SMS, to the satisfaction of the authority Gross negligence, willful deviation and so forth to be dealt through established enforcement procedures Gross negligence, willful deviation and so forth to be dealt through established enforcement procedures

51 SMS LV CAA AOD 51 State safety programme – SMS harmonization States safety programme components States safety programme components –Safety policy and objectives –Safety risk management –Safety assurance –Safety promotion

52 SMS LV CAA AOD 52 Safety policy and objectives How the CAA will oversee the management of safety in the State How the CAA will oversee the management of safety in the State A definition of CAA requirements, responsibilities and accountabilities regarding the State safety programme A definition of CAA requirements, responsibilities and accountabilities regarding the State safety programme Similar to the equivalent SMS component Similar to the equivalent SMS component

53 SMS LV CAA AOD 53 Safety risk management Establishment of controls which govern how service providers SMS will operate Establishment of controls which govern how service providers SMS will operate Standards/requirements for service providers SMS Standards/requirements for service providers SMS Same processes as SMS Same processes as SMS Hazard identification and risk management Hazard identification and risk management Different outputs Different outputs New/modified rules and/or regulations (i.e., controls) which govern how service providers SMS operate New/modified rules and/or regulations (i.e., controls) which govern how service providers SMS operate

54 SMS LV CAA AOD 54 Hazard identification processes Concept of safety Concept of safetyConsider - 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. Safety is the state in which the risk of harm to persons or property damage is reduced to, and maintained at or below, an acceptable level through a continuing process of hazard identification and risk management.

55 SMS LV CAA AOD 55 Hazard identification processes The organizational accident The organizational accident From the Investigation Report identify: a) Organizational processes that influenced the operation and which felt under the responsibility of senior management (i.e. those accountable for the allocation of resources): - Policy-making - Planning - Communication - Allocation of resources - Supervision

56 SMS LV CAA AOD 56 Organizational processes Policy-making Policy-making Planning Planning Communication Communication Allocation of resources Allocation of resources Supervision Supervision … Activities over which any organization has a reasonable degree of direct control The organizational accident

57 SMS LV CAA AOD 57 The organizational accident Organizational processes Latent conditions Inadequate hazard identification and risk management Inadequate hazard identification and risk management Normalization of deviance Normalization of deviance Inadequate hazard identification and risk management Inadequate hazard identification and risk management Normalization of deviance Normalization of deviance Conditions present in the system before the accident, made evident by triggering factors.

58 SMS LV CAA AOD 58 Hazard identification processes b) Latent conditions in the system safety which became precursors of active failures: - Inadequate hazard identification and risk management - Normalization of deviance c) Defences which fail to perform due to weaknesses, inadequacies or plain absence: - Technology - Regulations - Training and checking

59 SMS LV CAA AOD 59 The organizational accident Organizational processes Latent conditions Defences Technology Technology Regulations Regulations Training and checking Training and checking Technology Technology Regulations Regulations Training and checking Training and checking Resources to protect against the risks that organizations involved in production activities must confront.

60 SMS LV CAA AOD 60 Hazard identification processes d) Workplace conditions which may have influenced operational personnel actions: - Workforce stability - Qualifications and experience - Morale - Credibility - Ergonomics e) Active failures, including errors and violations.

61 SMS LV CAA AOD 61 The organizational accident Organizational processes Workplace conditions Factors that directly influence the efficiency of people in aviation workplaces. Workforce stability Workforce stability Qualifications and Qualifications and experience Morale Morale Credibility Credibility Ergonomics Ergonomics … Workforce stability Workforce stability Qualifications and Qualifications and experience Morale Morale Credibility Credibility Ergonomics Ergonomics …

62 SMS LV CAA AOD 62 The organizational accident Organizational processes Workplace conditions Active failures Actions or inactions by people (pilots, controllers, maintenance engineers, aerodrome staff, etc.) that have an immediate adverse effect. Errors Errors Violations Violations Errors Errors Violations Violations

63 SMS LV CAA AOD 63 The organizational accident Organizational processes Latent conditions Workplace conditions Defences Active failures Organizational processes Latent conditions Workplace conditions Defences Active failures ImproveIdentify Monitor Contain Reinforce

64 SMS LV CAA AOD 64 Hazard identification processes Two definitions 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 chance of a loss or injury, measured in terms of severity and probability. The chance that something is going to happen, and the consequences if it does. Example A wind of 15 knots blowing directly across the runway is a hazard. The possibility that the pilot may not be able to control the aircraft during take-off or landing, resulting in an accident, is one risk.

65 SMS LV CAA AOD 65 Hazard identification processes First fundamental – Understanding hazards First fundamental – 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)

66 SMS LV CAA AOD 66 Hazard identification processes Examples of hazards Examples of hazards For Operator (Flight crew): - Unfamiliar phraseology - ATC procedures - Similar call signs - Terrain - Flight diversions - System malfunctions - Unfamiliar airports - Heavy traffic - Missed approaches - Weather - Automation events

67 SMS LV CAA AOD 67 Hazard identification processes Second fundamental – Hazard identification Second fundamental – Hazard identification 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. - 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.

68 SMS LV CAA AOD 68 Hazard identification processes Third fundamental – Hazard analysis Third fundamental – Hazard analysis ABC of hazard analysis A – State the generic hazard (hazard statement) Airport construction Airport construction B – Identify specific components of the hazard Construction equipment Construction equipment Closed taxiways Closed taxiways C – Naturally leading to specific risk (s) Aircraft colliding with construction equipment Aircraft colliding with construction equipment Aircraft taking wrong taxiway Aircraft taking wrong taxiway

69 SMS LV CAA AOD 69 Hazard identification processes At the intersection of protection and production 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 Direct costs Direct costs –The obvious costs, which are easily determined. The high costs of exposure of hazards can be reduced by insurance coverage. Indirect costs Indirect costs –The uninsured costs. An understanding of these uninsured costs (or indirect costs) is fundamental to understanding the economics of safety

70 SMS LV CAA AOD 70 The management dilemma Production Protection Resources Management levels

71 SMS LV CAA AOD 71 The management dilemma Management levels Production Protection Resources Catastrophe

72 SMS LV CAA AOD 72 The management dilemma Management levels Production Protection Bankruptcy Resources

73 SMS LV CAA AOD 73 Safety space Production Protection Bankruptcy Catastrophe Maximum resistance space Source: James Reason

74 SMS LV CAA AOD 74 Safety management – The response to the dilemma Safety issues are a byproduct of activities related to production/services delivery. 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. 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). The product/service provided by any aviation organization must be delivered safely (i.e. protecting users and stakeholders).

75 SMS LV CAA AOD 75 Hazard identification processes Fourth fundamental – Documentation of hazards Fourth fundamental – Documentation of hazards Appropriate documentation management: –A formal procedure to translate operational safety data into hazard-related information. –The safety library of an organization. –The need for standardization – facilitating tracking and analysis of hazards by common: Definitions Definitions Understanding Understanding Validation Validation Reporting Reporting Measurement Measurement Management Management

76 SMS LV CAA AOD 76 Risk management First fundamental – Risk management First fundamental – Risk management The identification, analysis and elimination (and/or mitigation to an acceptable level) of those hazards, as well as the subsequent risks that threaten the viability of an organization. Risk management facilitates the balancing act between assessed risks and viable risk mitigation. Risk management is an integral component of safety management. It involves a logical process of objective analysis, particularly in the evaluation of the risks.

77 SMS LV CAA AOD 77 Assess and prioritize risks Develop control and mitigation strategies Inform person(s) responsible for implementing strategies Reactive method ASR MOR Incident reports Accident reports Proactive method ASR Surveys Audits Predictive method FDA Direct observation systems Assign responsibilities Implement strategies Re-evaluate strategies and processes HAZARDS HAZARDS SAFETYLIBRARYSAFETYLIBRARY Safety management information Trend analysis Safety bulletins Report distribution Seminars and workshops METHOD IDENTIFICATION MANAGEMENTINFORMATION DOCUMENTATION Feedback Hazard information management at a glance

78 SMS LV CAA AOD 78 Risk management Second fundamental – Risk probability Second fundamental – Risk probability Definition (s) Probability – The chance that a situation of danger might occur. Probability – The chance that a situation of danger might occur. Questions for assessing the probability of an occurrence: Is there a history of occurrences like the one being assessed, or is the occurrence an isolated event? Is there a history of occurrences like the one being assessed, or is the occurrence an isolated event? What other equipment, or similar type components, might have similar defects? What other equipment, or similar type components, might have similar defects? What number of operating or maintenance personnel must follow the procedure (s) in question? What number of operating or maintenance personnel must follow the procedure (s) in question? How frequently is the equipment or procedure under assessment used? How frequently is the equipment or procedure under assessment used?

79 SMS LV CAA AOD 79 Second fundamental – Risk probability Probability of occurrence Qualitative definition MeaningValue Frequent Likely to occur many times (has occurred frequently) 5 Occasional Likely to occur some times (has occurred infrequently) 4 Remote Unlikely, but possible to occur (has occurred rarely) 3 Improbable Very unlikely to occur (not known to have occurred) 2 Extremely improbable Almost inconceivable that the event will occur 1

80 SMS LV CAA AOD 80 Risk management Third fundamental – Risk severity Third fundamental – Risk severity Definition (s) Severity – The possible consequences of a situation of danger, taking as reference the worst foreseeable situation. Severity – The possible consequences of a situation of danger, taking as reference the worst foreseeable situation. Define the severity in terms of: Property Property Health Health Finance Finance Liability Liability People People Environment Environment Image Image Public confidence Public confidence

81 SMS LV CAA AOD 81 Risk management Questions for assessing the severity of an occurrence: How many lives are at risk? How many lives are at risk? –Employees –Passengers –Bystanders –General public What is the environmental impact? What is the environmental impact? –Spill of fuel or other hazardous product –Physical disruption of natural habitat What is the severity of the property of financial damage? What is the severity of the property of 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? 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? What are the likely political implications and/or media interest?

82 SMS LV CAA AOD 82 Third fundamental – Risk severity Severity of occurrences AviationdefinitionMeaningValue Catastrophic Equipment destroyed Equipment destroyed Multiple deaths Multiple deathsA Hazardous 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. 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. Serious injury or death to a number of people. Major equipment damage Major equipment damage B Major 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. 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. Serious incident. Injury to persons. Injury to persons. C Minor Nuisance. Nuisance. Operating limitations. Operating limitations. Use of emergency procedures. Use of emergency procedures. Minor incident. Minor incident. D Negligible Little consequences Little consequences E

83 SMS LV CAA AOD 83 Fourth fundamental – Risk assessment Risk probability Risk severity CatastrophicAHazardousBMajorCMinorDNegligibleE 5 – Frequent 5A5B5C5D5E 4 – Occasional 4A4B4C4D4E 3 – Remote 3A3B3C3D3E 2 – Improbable 2A2B2C2D2E 1 – Extremely improbable 1A1B1C1D1E

84 SMS LV CAA AOD 84 Fourth fundamental – Risk tolerability Assessment risk index Suggested criteria 5A, 5B, 5C, 4A, 4B, 3A Unacceptable under the existing circumstances 5D,5E, 4C, 3B, 3C, 2A, 2B Risk control/mitigation requires management decision 4D, 4E, 3D, 2C, 1A, 1B Acceptable after review of the operation 3E, 2D, 2E, 1C, 1D, 1E Acceptable

85 SMS LV CAA AOD 85 Risk assessment at a glance Evaluate the seriousness of the risk(s) occurring YES Accept the risk(s) NO Take action to reduce the risk(s) to an acceptable level Identify the hazards to equipment,property, personnel or the organization. HAZARD IDENTIFICATION RISK ASSESSMENT Probability Severity Tolerability RISK CONTROL/MITIGATION Identify the risk(s) and assess the chances of it (them) occurring? Is (are) the consequent risk(s) acceptable and within the organizations safety performance criteria?

86 SMS LV CAA AOD 86 Risk management Fifth fundamental- Risk control/mitigation Fifth fundamental- Risk control/mitigation Definition (s) Mitigation – Measures to eliminate the potential hazard or to reduce the risk probability or severity. Mitigation – Measures to eliminate the potential hazard or to reduce the risk probability or severity. –Risk mitigation = Risk control Strategies Avoidance – The operation or activity is cancelled because risks exceed the benefits of continuing the operation or activity. 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.) 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. 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. (Operations into an aerodrome surrounded by complex geography and without the necessary aids are continued based upon the availability of specific aids and application of specific procedures.) 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. 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. (Operations into an aerodrome surrounded by complex geography are limited to day- time, visual conditions.) (Non RVSM equipped aircraft not allowed to operate into RVSM airspace.

87 SMS LV CAA AOD 87 Risk management Risk mitigation – Defences (Technology, Training, Regulations) Risk mitigation – Defences (Technology, Training, Regulations) As part of the risk mitigation, determine: Do defences to protect against such risk (s) exist? Do defences to protect against such risk (s) exist? Do defences function as intended? Do defences function as intended? Are the defences practical for use under actual working conditions? Are the defences practical for use under actual working conditions? Is staff involved aware of the risks and the defences in place? Is staff involved aware of the risks and the defences in place? Are additional risk mitigation measures required? Are additional risk mitigation measures required?

88 SMS LV CAA AOD 88 Risk mitigation at a glance Does the mitigation address the hazard? Does it address the risk (s)? Is it appropriate? Is it effective? Assessment of the defences within the safety system RRRR Accepting the mitigation of the risk HHHH Hazard identification and risk management Control and mitigation of the risk (s) Is additional or mitigation warranted? different EACH HAZARD Regulations Training Technology Do the mitigation strategies generate additional risk (s) EACH RISK

89 SMS LV CAA AOD 89 Risk management process at a glance Feedback and record the hazard identification and assessment and/or risk mitigation Identify hazards and assess risks Define the level of probability Is the risk level acceptable? Define the level of severity A safety concern is perceived Define the level of risk No Yes Can the risk be mitigated? Take action and continue the operation Take action and continue the operation No Take action and continue the operation Yes Can the residual risk be accepted (If any)? Can the risk be eliminated? Yes Cancel the operation No

90 SMS LV CAA AOD 90 Risk control/mitigation log Risk control/mitigation log Risk reference Generic hazard Risk(s) description Current measures to reduce risk(s) and risk index Further actions to reduce risk(s) and resulting risk index Responsibility Risk index: Risk tolerability: Risk index: Risk tolerability:

91 SMS LV CAA AOD 91 Risk management considerations for State Administrations Policy development through to the go/no-go decisions: Policy development through to the go/no-go decisions: –Policy. To what extent should a State accept the certification paperwork of another State? –Regulatory change. From the many (often-conflicting) recommendations made for regulatory change, how are decisions made?

92 SMS LV CAA AOD 92 Risk management considerations for State Administrations Situations when risk management should be applied: Situations when risk management should be applied: –Start-up or rapidly expanding companies; –Corporate mergers; –Companies facing bankruptcy or other financial difficulties; –companies facing serious labour- management difficulties;

93 SMS LV CAA AOD 93 Risk management considerations for State Administrations –Introduction of major new equipment by an operator; –Certification of a new aircraft type, new airport, etc.; –Introduction of new communication, navigation or surveillance equipment and procedures; and –Significant change to air regulations or other laws potentially impacting on aviation safety.

94 SMS LV CAA AOD 94 Risk management considerations for State Administrations –Priority setting. How are decisions made for determining those areas of safety warranting emphasis during safety oversight audits? –Operational management. How are decisions made when insufficient resources are available to carry out all planned activities? –Operational inspections. At the front line, how are decisions made when critical errors are discovered of normal working hours?

95 SMS LV CAA AOD 95 Risk management considerations for State Administrations Risk management by State administrations will be affected by such factors as: Risk management by State administrations will be affected by such factors as: –Time available to make the decision (grounding an aircraft, revoking a certificate, etc.); –Resources available to effect the necessary actions; –Number of people affected by required actions (company-wide, fleet-wide, regional, national, international, etc.);

96 SMS LV CAA AOD 96 Risk management considerations for State Administrations –Potential impact of the States decision for action (or inaction); and –Cultural and political will to take the action required.

97 SMS LV CAA AOD 97 Risk management considerations for State Administrations Benefits of risk management for State administrations: Benefits of risk management for State administrations: –Avoiding costly mistakes during the decision-making process; –Ensuring that all aspects of the risk are identified and considered ehen making decisions; –Ensuring that the legitimate interests of affected stakeholders are considered;

98 SMS LV CAA AOD 98 Risk management considerations for State Administrations –Providing decision-makers with a solid defence in support of decisions; –Making decisions easier to explain to stakeholders and the general public; and –Providing significant savings in time and money.

99 SMS LV CAA AOD 99 Safety assurance Ensuring that the operation of service providers SMS follows established controls (standards)/requirements) Ensuring that the operation of service providers SMS follows established controls (standards)/requirements) Oversight, inspections and audits Oversight, inspections and audits Data tracking and analysis Data tracking and analysis Data driven targeting of Data driven targeting of oversight on areas of greater concern/need

100 SMS LV CAA AOD 100 The essential is invisible to the eyes Number of occurrences 1 – 5 Accidents 30 – 100 Serious incidents 100 – 1000 Incidents 1000 – 4000 Latent conditions

101 SMS LV CAA AOD 101 Safety promotion Support the integration of the State safety programme with the operation of service providers SMS Support the integration of the State safety programme with the operation of service providers SMS Training, communication and dissemination of safety information Training, communication and dissemination of safety information Dual-track promotion Dual-track promotion Within the CAA Within the CAA Among service providers it Among service providers it oversees oversees

102 SMS LV CAA AOD 102 State safety programme Organizations safety management system (SMS) Organizations production processes Objective: Public safety Objective: Manage and control safety risk Acceptance Oversight Objective: Achieve commercial goals and customer satisfaction Risk management Safety assurance Protection Production Oversight The final objective – Integration Safety programme + SMS = State integrated safety management system


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