Presentation on theme: "Aviation Safety Management Systems"— Presentation transcript:
1Aviation Safety Management Systems Tony CrampSenior Advisor (Americas)17th May 2005LafayetteFile Title4/15/2017
2Underlying Safety Beliefs How many factors need to be removed to prevent the accident? Theoretically only one, but with each factor removed the probability for an accident is loweredThe fundamental requirements for accident prevention are thus (i) the ruthless hunting out and elimination (the identification and management) of risk factors and (ii) using systems of work that are inherently safeEveryone can contribute to causing an accident, we can also contribute to preventing oneA fundamental requirement for this is effective collaboration between line personnel and ‘management’These are 3rd Generation Safety beliefs
3Safety Paradigms: 3rd Generation Safety is a corporate value. Safety practices consider the organizations particular “way of doing business” as well as corporate’s possibilities and constraints. What works well for one airline does not necessarily work equally well for others.Accidents are caused by systems flaws. The failures observed at the “front end” of aviation operations are considered symptoms of deficiencies in the architecture of the aviation system.Human error as a symptom. Error is accepted as normal component of human performance, unavoidable but manageable. Human error is a clue, which indicates where the safety investigation process must begin rather than end.Proaction. Attention is focused on the processes incurred by the aviation system, regardless of the outcome of these processes.
4Safety Paradigms: 3rd Generation The finding of ‘human error’ should be the starting point of an investigation, not its conclusion
5Safety Management Systems Defences in DepthIf we have these beliefs then the foundation of a strategy for preventing accidents would be to introduce controls at Organizational (Systemic), Team and Personal levels so as to achieve Organizational defenses in depth:A Systemic approach to the management of safety:Safety Management Systems
6Safety Management Systems The formal goals of an SMS are as follows:To produce fully airworthy aircraft, in a safe working environment, that are subsequently operated safelyTo ensure and demonstrate that safety is being managed as formally as any other critical business functionTo ensure and demonstrate that the Organization is ‘responsible’ and exercising ‘due care’ (the counter to offence of ‘Corporate Killing’)But what is the bottom line?
7SMS is Not New!The concept and practice of ‘System Safety’ was first introduced consequent to the Apollo 204 pad fire in 1967 and has been embedded in engineering ever since.The Basic Principles of ‘System Safety in Engineering’ are:The assurance of safety is gained through the competence and safety-orientated procedures used by each individual engineer, however:In complex systems it is easy to ‘overlook the wood for the trees’: there must be an autonomous, safety oversight process that has the ‘big picture’ and a ‘watchdog’ function, and:There must be a system enforcing the effective communication of safety-critical information, and:There must be a ‘Facilitative function’ that ensures hazard identification and resolutionThis engineering / astronautics approach then migrated into the Nuclear, Maritime, Rail, Oil/Chemical industries and has shown considerable benefits
8SMS in Aviation: The Challenge Aviation is lagging some 15 years in implementing formal SMS: flight operations already heavily regulated and traditional Flight Safety methods have a high degree of effectivenessSMS has been developed primarily outside of aviation: past experience e.g.CRM and QA, shows that systems from outside are not always introduced correctly or tailored correctly to aviation cultureHave to get past the SMS language used by other disciplines, mainly the ‘speak’ of HSE and Quality AssuranceBUT: SMS is rapidly becoming a Regulatory requirement (UK CAA, Transport Canada, FAA moving in this direction etc) as well as a Customer requirement (Shell, ExxonMobil)The challenge is to take the benefits of SMS distilled to date and adapt and apply them to aviation in such a way that SMS is accepted and is demonstrated to add value
9SMS Primary Components Accident cause ⌗ 1.Inadequate Procedural Baseline
10SMS Primary Components Ops Manual, GMM/MPM,Ramp Procedures, Fuel Quality,OSHA Compliance①Procedural baseline to assure safety in work
11SMS Primary Components The manual forms a ‘road map’, has an integrative function and if the SMS Manual consists of a template of the ‘ideal’ system, then it can be used for both assessment and development purposes②SMS ManualSMS Manual can be written bottom- up, or preferably as a template ‘top-down’, gives the big-picture, highlights any major ‘holes’ in SMS Component ⌗1Any holes?①(Full spectrum of policies, procedures, methods, practices to assure safety in work)
13SMS Primary Components ③Safety Management Program②SMS Manual①Procedural baseline to assure safety in work
14Systems are for People?“Even the most well-considered safety system can be wrecked by the idiosyncratic behaviour of a single individual”
15SMS Component ⌗3: Safety Program Management Proactive Safety ManagementEncouraging and developing Management commitmentCreation of a Safety CultureSafety structure and resources, committees and meetingsOngoing hazard identification and management (HEMP)Safety education (training, information dissemination)‘ Watchdog’ function2. Reactive Safety ManagementOccurrence investigation (‘occurrences’, incidents, accidents)Data analysisContinuous learning
16SMS Primary Components ③Safety Program Management②SMS Manual④Safety Case①Procedural baseline to assure safety in work
17SMS Component ⌗ 4: The Safety Case A Safety Case is a formal, organizational risk management exercise conducted proactively (e.g. prior to contract launch), or reactively (e.g. to gain control over the risks in current operations)An aviation ‘Safety Case’ is defined as “The documented description of the major hazards that the aircraft operator faces and the means employed to control these hazards”As opposed to the SMS Manual, which gives ‘big picture’ inputs, a Safety Case gives detailed inputs into the procedural baseline. It identifies individual controls required.A Safety Case is a specific application of the HEMPA safety case functions at Management, Supervisor and Line levels: a Living document.
19SMS Primary Components ⑤ SIS③Safety Program Management②SMS Manual④Safety Case①Procedural baseline to assure safety in work
20Safety Information System The fifth primary element is the Organization’s ‘Safety Information System’ (SIS)Several studies have shown that in the vast majority of (aircraft) accidents there was always a piece of information available somewhere that had it been in the right place at the right time, the accident might well have been preventedA SIS may take a variety of forms, from the basic verbal / written communication of safety information across the organization to sophisticated company ‘intranets’.Examples:Hazard report formsRegular safety meetings, with minutes recorded and distributed.Company newslettersEffective, updated notice boardsIntranet employee notices
22Next Challenge!How to integrate these components:
23Integrating Principles After 200 years of industry and 100 years of flight surely there must be a package of elements or principles that if applied will give a high level of assurance of safety?Currently, there is agreement that these elements and principles are best described in systems developed by the science of ‘Quality Assurance’The most current definition of an SMS is thus:‘A system for the proactive management of safety that is appropriate to the Operator’s size and complexity and integrates operations, maintenance, human resources and finance and draws upon quality principles’
24SMS Primary Components ⑥ Quality System⑤ SIS③Safety Program Management②SMS Manual④Safety Case①Procedural baseline to assure safety
27③ ① SMS Booklet ② SMS Summary See ‘Model Manual’ 33 Sub-Elements ④ ⑥ Quality System⑤ SIS③Safety Program ManagementSee ‘Model Manual’33 Sub-Elements②SMS Manual④Safety Case①Procedural baseline to assure safetySMS Booklet
28The Safety CaseA Safety Case is a formal, organizational risk management exercise conducted proactively (e.g. prior to contract launch), or reactively (e.g. to gain control over the risks in current operations)An aviation ‘Safety Case’ is defined as “The documented description of the major hazards that the aircraft operator faces and the means employed to control these hazards”As opposed to the SMS Manual, which gives ‘big picture’ inputs, a Safety Case gives detailed inputs into the procedural baseline. It identifies individual controls required.A Safety Case is a specific application of the HEMPA safety case functions at Management, Supervisor and Line levels: a Living document.
29Hazards, Incidents, Accidents Byrd’s TriangleEliminate hazards and you will eliminate accidents1 Accident10 Incidents600 Hazards
30Hazard Identification: Fundamental Requirements The fundamental requirements for effective hazard identification are:To get past perceptions and to quantify wherever possibleTo tap into the vast reservoir of knowledge that exists within Aviation and other complex industriesTo ‘think outside the box’Be paranoid: believe everything and believe nothing: continually test for the truth
31Which hazards? Type specific Hazards Major Aviation Safety Hazards Company SpecificHazardsAviation Safety CaseGeneric Aviation Safety Hazards+=Operation SpecificHazardsSignificantWorkplaceHazardsWorkplaceSafetyProcedures(Defined inHSE-MS)Generic HSEHazardsThe important point to take from this model is that only major hazards should be included in a Safety Case. Significant workplace hazards are, as the process is developed, managed through the workplace safety proceduresLocation SpecificHazards
34Risk Analysis ProcessWhen identified and objectively analyzed, each hazard shall be subjected to a risk analysis. This shall accomplished by using a risk matrix of a format commonly found in the industryThe matrix is self-explanatory and even though some of the aspects may well be subjective, it at least allows the partial quantification of risk factors.The hazards are then ranked in terms of the rating obtained by use of the matrixIn terms of the Shell model, all hazards ranked as ‘intolerable’ shall be subjected to a ‘bow-tie’ analysis.
37The Bow-Tie ProcessFor those hazards assessed as being ‘Intolerable’, develop ‘controls in depth’ as follows:Identify the Threats that might release the hazardIdentify Controls to contain the ThreatsIdentify factors that could prevent the Controls from being effective: Escalation FactorsDevelop controls to contain the Escalation Factors: Escalation ControlsThe hazard is released, but it’s consequence has not yet occurred: what controls make detection and recovery possible: Recovery MeasuresIdentify Escalation Factors hampering detection and recoveryIdentify a final layer of Escalation ControlsIdentify measures to mitigate the effects of the ConsequenceThese are the basic steps of Hazard/Risk management.It identifies hazards and threats and evaluates the risk exposure. From this the means of control of the threats and in due course return the situation to normal safe operations. This whole process is documented in the SMS.
38T H E B O W - T I E Hazardous Event Slide 15 HAZARD THREAT CONTROL ESCALATIONCONTROLT H EB O W -T I EHazardousEventRECOVERYTiger in the cage !!Hazard = Tiger in the cageThreats = Door unlocked, corroded barsControls = double locking, corrosion protectionEscalations = non competent staff, corrosive atmosphere, lack of maintenance.Escalation controls = training, maintenance programmeTop event = Tiger out of the cage!Recovery = Shoot the tiger, or drive back into cageEscalations = miss the tiger, or tiger outwits keeperEscalation controls = marksman available, competent keepersConsequence = Tiger bites the keeper (death or serious injury)Mitigation's = First aid, emergency response, hospitalisation,letter of regret to the keepers widow, workers compensation programme.Slide 15ESCALATIONCONTROLCONSEQUENCEMITIGATION MEASURES
39Hazard Threat Control Escalation Tiger out of the Cage Cage Door Locking SystemTwin Locks & Warning LightsUnserviceable Warning SystemRecords & MaintenanceTiger out ofthe CageT H E B O W - T I ERecoveryEscalationControlConsequenceMitigationShoot Tiger, or drive back in cageIf a company knows what it is that it needs to manage then it now need a means of assuring that the controls are in place and embedded in the normal working systems within the company.That is what a safety management system is for assuring continuing application of safety in the completion of the day job (that what you normally do).So what is so different about a Safety Management System, is it something new?Slide 16Miss Tiger, or Tiger Evades KeeperCompetent KeepersTiger Bites KeeperEffective Emergency Response Plan
40Human Error Inappropriate pilot control input HazardThreatControlEscalationPEOPLEErrors, Mistakes, ViolationsCompetence, Procedures, SystemsNon Compliant PacticeMonitoring and FeedbackT H E B O W - T I EHuman ErrorInappropriate pilotcontrol inputRecoveryEscalationControlConsequenceMitigationMake corrective control selectionIf a company knows what it is that it needs to manage then it now need a means of assuring that the controls are in place and embedded in the normal working systems within the company.That is what a safety management system is for assuring continuing application of safety in the completion of the day job (that what you normally do).So what is so different about a Safety Management System, is it something new?Slide 17Input can not be made it timeCompetence & AwarenessAircraft CrashesEffective Emergency Response
41Percentage of Accidents Reported in NASA Study Preventable by Individual Mitigation Measures Seven KeyInitiativesRequires development work
43So What is an SMS?An SMS is a suite of standards, policies, procedures, practices etc that will assure the safe and effective execution of work (‘Quantitative’ Quality elements)An SMS contains a structure for dynamic and flexible identification and control of risk to ALARP (‘Quantitative’ procedures and methods for the proactive management of safety: safety cases). This includes the requirement for a Safety Information System.An SMS requires the application of Human Factors: communication, leadership and followership, conflict management, cultural aspects, motivation & commitment (‘Qualitative’ elements)An SMS should encompass flight safety, ramp and maintenance safety, industrial (workplace) safety, occupational health, environmental protection and securityAn SMS Manual should give the ‘big picture’ regarding safety management in the organization
44ConclusionSMS is not a magic bullet: it is a set of tools and guidelines that if tailored to the Organization and diligently applied so that the probability of an accident will be reduced to a level that is as low as is reasonably practicable (ALARP)Apply these tools and guidelines and you will have done all that can be reasonably expected of you as aviation professionals and as a ‘responsible operator’