1. An Introduction to Safety Management System (SMS)
Safety Policy
Safety Risk Management
Safety Assurance
Safety Promotion

2. Outline Fundamentals of Safety Safety Management System
Concept of Safety
Evolution of Safe Thinking
Accident Causation
Organizational Accident
People, Context & Safety – SHEL
Errors & Violations
Organizational Culture
Safety Investigation
Fundamentals of Safety
Safety Management System
Components of SMS
Legislation
Summary

3. Outline Fundamentals of Safety Safety Management System
Components of SMS
Legislation
Summary
Safety Stereotype
Management Dilemma
Need for Safety Management
Strategies for Safety Management
Imperative of Change
Building Blocks – SMS
Responsibilities of Managing Safety

4. Outline Fundamentals of Safety Safety Management System
Components of SMS
Legislation
Summary
Safety Policy
Safety Risk Management
Safety Promotion
Safety Assurance

5. The Concept of Safety
Zero accidents or serious incidents — a view widely held by the travelling public;
Freedom from hazards, i.e. those factors which cause or are likely to cause harm;
Attitudes of employees of aviation organizations towards unsafe acts and conditions;
Error avoidance; and
Regulatory compliance.

6. What is Safety?
The state in which the possibility of harm to persons or of property damage is reduced to, and maintained at or below, an acceptable level through a continuing process of hazard identification and safety risk management.

7. Evolution of Safety Thinking
Traditional Approach:
Focus on outcomes (causes)
Unsafe acts by operational personnel
Assign blame/punish for failure to “perform safety”
Address identified safety concern exclusively
Identifies:
WHAT? WHO? WHEN?
But not always disclose:
WHY? HOW?

8. Evolution of Safety Thinking
TECHNICAL FACTORS
TODAY
HUMAN FACTORS
ORGANIZATIONAL FACTORS
1950s
1970s
1990s
2000

9. Management decision & organizational processes
Accident Causation
Organization
Workplace
People
Defences
Accident
Technology
Training
Regulations 
Management decision & organizational processes
Working conditions
Errors & violations

10. Organizational Accident
Organizational processes
Improve
Identify
Monitor
Work place conditions
Latent conditions
Contain
Reinforce
Active failures
Defences 

11. People, Context & Safety
People & Safety

12. People, Context & Safety
Understanding Human Performance

13. People, Context & Safety
Understanding Human Performance

14. People, Context & Safety
Processes & Outcomes

15. S H L L E SHEL(L) Model S - Software H - Hardware E - Environment
L - Livewire E

16. SHEL(L) Model Important factors affecting human performance:
Physical factors
Physiological factors
Psychological factors
Psycho-social factors

17. SHEL(L) Model
Interfaces between different components of the aviation system:
Liveware-Hardware (L-H)
Liveware-Software (L-S)
Liveware-Liveware (L-L)
Liveware-Environment (L-E)

18.  Errors & Violations Flaps omitted Checklist failure Unheeded warning
Incident / Accident
Unheeded warning 
Degradation / Breakdown
Error
Deviation
Amplification
Operational Errors – Investigation of major breakdowns

19. Safety Management – On almost every flight
Errors & Violations
Flaps omitted
Checklist failure
Unheeded warning 
Normal flight
Error
Deviation
Amplification
Safety Management – On almost every flight

20. 3 Strategies to Control Operational Errors
Reduction strategies
Human-centred design;
Ergonomic factors; and
Training.
2. Capturing strategies
Checklists;
Task cards; and
Flight strips.
3. Tolerance strategies
system redundancies; and
structural inspections.

21. Errors vs. Violations General types of violations:
Situational violations occur due to the particular factors that exist at the time, such as time pressure or high workload.
Routine violations are violations which have become “the normal way of doing business” within a workgroup.
Organization-induced violations, which can be viewed as an extension of routine violations. The full potential of the safety message that violations can convey can be understood only when considered against the demands imposed by the organization regarding the delivery of the services for which the organization was created.

22. Understanding Violations
Errors vs. Violations
Regulations
Accident
Technology
High
Incident
System’s production objectives
Training
Violation Space
Exceptional violation Space
RISK
Safety Space
Low
Minimum
SYSTEM OUTPUT
Maximum
Understanding Violations

23. Organizational Culture
National
Organizational
Professional

24. Organizational Culture
Organizational literature proposes three characterizations of organizations, depending on how they respond to information on hazards and safety information management: a) pathological — hide the information; b) bureaucratic — restrain the information; and c) generative — value the information.

25. Organizational Culture
National culture differentiates the national characteristics and value systems of particular nations.
Professional culture differentiates the characteristics and value systems of particular professional groups
Organizational culture differentiates the characteristics and value systems of particular organizations

26. Organizational Culture
Poor
Bureaucratic
Positive
Information
Hidden
Ignored
Sought
Messenger
Shouted
Tolerated
Trained
Responsibilities
Shirked
Boxed
Shared
Reports
Discouraged
Allowed
Rewarded
Failures
Covered up
Merciful
Scrutinized
New Ideas
Crushed
Problematic
Welcomed
Resulting organization
Conflicted organization
Red tape organization
Reliable organization

27. Effective Safety Reporting
Effective safety reporting builds upon certain basic attributes, such as: a) Senior management places strong emphasis on hazard identification as part of the strategy for the management of safety; b) Senior management and operational personnel hold a realistic view of the hazards faced by the organization’s service delivery activities; c) Senior management defines the operational requirements needed to support active hazard reporting, ensures that key safety data are properly registered, demonstrates a receptive attitude to the reporting of hazards by operational personnel and implements measures to address the consequences of hazards;

28. Effective Safety Reporting
d) Senior management ensures that key safety data are properly safeguarded and promotes a system of checks and); e) Personnel are formally trained to recognize and report hazards and understand the incidence and consequences of hazards in the activities supporting delivery of services; and f) There is a low incidence of hazardous behaviour, and a safety ethic which discourages such behaviour.

29. Effective Safety Reporting – 5 basic traits
Information
People are knowledgeable about the human, technical and organizational factors that determine the safety of the system as a whole
Flexibility
People can adapt reporting when facing unusual circumstances, shifting from the established mode to a direct mode thus allowing information to quickly reach the appropriate decision-making level
Willingness
People are willing to report their errors and experiences
Effective safety Reporting
Learning
People have the competence to draw conclusions from safety information systems and the will to implement major reforms
Accountability
People are encouraged (and rewarded) for providing essential safety-related information. However, there is a clear line that differentiates between acceptable and unacceptable behaviour

30. Safety Investigation to put losses behind;
to reassert trust and faith in the system;
to resume normal activities; and
to fulfil political purposes.

31. Safety Investigation
Safety investigation for improved system reliability:
to learn about system vulnerability;
to develop strategies for change; and
to prioritize investment of safety resources.

32. Outline Fundamentals of Safety Safety Management System
Components of SMS
Legislation
Summary
Safety Stereotype
Management Dilemma
Need for Safety Management
Strategies for Safety Management
Imperative of Change
Building Blocks – SMS
Responsibilities of Managing Safety

33. Safety Stereotype The safety stereotype:
safety first vs. safety is an organizational process
Safety is not first priority in aviation
safety is just organizational process .

34. Management Dilemma
Dilemma of 2 P’s:
Production
Protection

35. Management Dilemma Management Levels Resources Resources Protection
$$ PESO YEN
$$ PESO YEN
Protection
Production

36.  Management Dilemma Management Levels Resources Resources Catastrophe
$$ PESO YEN
Protection
$$ PESO YEN
Production
Catastrophe 

37.  Management Dilemma Management Levels Resources Resources Bankruptcy
$$ PESO YEN
Production
$$ PESO YEN
Protection
Bankruptcy 

38. Need for Safety Management
Major air disaster are rare
Incidents occur more frequently
Ignoring the major could lead to an increase number of more serious accidents
Minor-major accident

39. Need for Safety Management
Minor-major accident
Economics of Safety
Accidents cost money
Insurance can help but not all
There are many uninsured cost
Lost of confidence of the travelling public

40. Need for Safety Management
Minor-major accident
Economics of Safety
Publics perceived safety while traveling
Prerequisite for a sustainable aviation business

41. Strategies for Safety Management
Baseline performance
System Design
Training
Technology
Regulations 
Operational deployment
Operational performance
Source: Scott A. Snook
The practical drift

42. Strategies for Safety Management
Reactive
Proactive
Predictive

43. Strategies for Safety Management
Reactive method
The reactive method responds to events that have already happened, such as incidents and accidents
Proactive method
The proactive method looks actively for the identification of safety risks through the analysis of the organization’s activities
Predictive method
The predictive method captures system performance as it happens in real-time normal operations to identify potential future problems

44. Strategies for Safety Management
Safety management levels
High
Middle
Low 
Hazards
Predictive
Proactive
Reactive
Reactive
FDA
Direct observation systems
ASR
Survey Audits
ASR
MOR
Accident and incident reports
Highly efficient
Very efficient
Efficient
Insufficient
Desirable management levels
High
Strategies – Levels of intervention and tools

45. Imperative of Change The management of change
Aircraft and Equipment are changing overtime
Hazards that are by product of change
Change can introduce new hazard
Formal Process for the Management of change
Critically of system and activities
Stability of systems and operational environment
Past performance

46. Imperative of Change
The traditional safety paradigm relied on the accident/serious incident investigation process as its main safety intervention and method, and it was built upon three basic assumptions: a) The aviation system performs most of the time as per design specifications (i.e. baseline performance); b) Regulatory compliance guarantees system baseline performance and therefore ensures safety (compliance-based); and c) Because regulatory compliance guarantees system baseline performance, minor, largely inconsequential deviations during routine operations (i.e. processes) do not matter, only major deviations leading to bad consequences (i.e. outcomes) matter (outcome oriented).

47. Imperative of Change
It is based on the notion of managing safety through process control, beyond the investigation of occurrences, and it builds upon three basic assumptions also: a) The aviation system does not perform most of the time as per design specifications (i.e. operational performance leads to the practical drift); b) Rather than relying on regulatory compliance exclusively, real- time performance of the system is constantly monitored (performance-based); and c) Minor, inconsequential deviations during routine operations are constantly tracked and analysed (process oriented).

48. 8 Building Blocks - SMS
Senior Management’s commitment to the management of safety
Effective safety reporting
Continuous monitoring
Investigation of safety occurrences
Sharing safety lessons learned and best practices
Integration of safety training for operational personnel
Effective implementation of standard operating procedures (SOP’s)
Continuous improvement of the overall level of safety

49. 4 Responsibilities of Managing Safety
The responsibilities for managing safety can be grouped into four generic and basic areas, as follows:
Definition of policies and procedures regarding safety. Policies and procedures are organizational mandates reflecting how senior management wants operations to be conducted.
Allocation of resources for safety management activities. Managing safety requires resources. The allocation of resources is a managerial function.
Adoption of best industry practices. The tradition of aviation regarding safety excellence has led to the continuous development of robust safety practices. Aviation has, in addition, a tradition regarding exchange of safety information through both institutional and informal channels.

50. 4 Responsibilities of Managing Safety
d) Incorporation of regulations governing civil aviation safety. There will always be a need for a regulatory framework as the bedrock for safety management endeavours. In fact, sensible safety management can develop only from sensible regulations.

51. Summary
In summary, safety management: a) includes the entire operation; b) focuses on processes, making a clear differentiation between processes and outcomes; c) is data-driven; d) involves constant monitoring; e) is strictly documented; f) aims at gradual improvement as opposed to dramatic change; and g) is based on strategic planning as opposed to piecemeal initiatives.

52. The End

53. Questions & Answers