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Safety Management Systems (SMS) An Introduction for Senior Management.

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1 Safety Management Systems (SMS) An Introduction for Senior Management

2 An Introduction to SMS An Introduction to SMS The objective of this presentation is to provide the Senior Management with : an overview of ICAO Standards and Recommended Practices (SARPs) on safety management in Annexes 6, 11 and 14, and their underlying concepts, and an overview of ICAO Standards and Recommended Practices (SARPs) on safety management in Annexes 6, 11 and 14, and their underlying concepts, and a structured process for the implementation of a safety programme and an SMS, as proposed by ICAO a structured process for the implementation of a safety programme and an SMS, as proposed by ICAO

3 Session No. 1 Basic Contemporary Safety Concepts

4 For Starters The total elimination of risk is unachievable The total elimination of risk is unachievable Errors will occur, in spite of the most accomplished prevention efforts Errors will occur, in spite of the most accomplished prevention efforts No human endeavour or human-made system can be free from risk and error No human endeavour or human-made system can be free from risk and error Controlled risk and error are acceptable in an inherently safe system Controlled risk and error are acceptable in an inherently safe system

5 Concept of safety (Doc 9859) 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 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 Safety Management System is an organized approach to managing safety, including the necessary organizational structure, accountabilities, policies and procedures Safety Management System is an organized approach to managing safety, including the necessary organizational structure, accountabilities, policies and procedures

6 Focus on the outcome (s) Focus on the outcome (s) Unsafe acts at the tip of the arrow Unsafe acts at the tip of the arrow Blame & punishment for failure to perform safely Blame & punishment for failure to perform safely Address specific safety concern exclusively Address specific safety concern exclusively Forensic Safety Management

7 The Underlying Paradigm Rule-based – The world as it should be Aviation system – as pre-specified – is perfect Aviation system – as pre-specified – is perfect Compliance based Compliance based Outcome oriented Outcome oriented Accident investigation Accident investigation

8 Inefficiency and Perversity The beatings will continue until morale improves 2. Punishment 3.Remedial Training 4.Add more procedures & regulations 1. Exhortations to professionalism and discipline

9 The evolution of safety thinking TECHNICAL FACTORS HUMAN FACTORS ORGANIZATIONAL FACTORS TODAY 1950s1970s1990s 2000s

10 A concept of accident causation Regulations Training TechnologyDefencesAccident Source: James Reason Latent conditions trajectory Errors and violationsPeopleWorking conditionsWorkplace Management decisions and organizational processesOrganization

11 Operational performance Operationaldeployment Systemdesign Baseline performance Operational drift System Performance in the Real World

12 Managing Safety–Navigating the Drift Baseline performance Practical drift Operational performance Organization Navigational aids ReactiveProactivePredictive

13 The Navigational Aids Reactive systems Reactive systems Accident investigation Accident investigation Incident investigation Incident investigation Predictive systems Predictive systems Electronic safety data acquisition systems Electronic safety data acquisition systems Direct observation safety data acquisition systems Direct observation safety data acquisition systems Proactive systems Proactive systems Mandatory reporting systems Mandatory reporting systems Confidential reporting systems Confidential reporting systems Voluntary self-reporting systems Voluntary self-reporting systems

14 Safety Data Systems and Levels of Intervention Baseline performance Practical drift Operational performance organization Predictive ProactiveReactiveHighly efficientVery efficient Efficient Safety management levels Reactive Desirable management level Inefficient ASR Surveys Audits ASRMOR Accident and incident reports H i g h M i d d l e L o w Hazards FDA Directobservationsystems

15 Operational performance Operationaldeployment Systemdesign Baseline performance Operational drift Managing Safety: Collapsing the Drift Operationaldeployment Systemdesign Operational drift Operational performance Baseline performance

16 Emerging Paradigm Performance-based – The world as it is Aviation system – as pre-specified – is imperfect Aviation system – as pre-specified – is imperfect Performance based Performance based Process oriented Process oriented Safety data captured from daily, normal operations Safety data captured from daily, normal operations Rule-based – The world as it should be Aviation system – as pre-specified – is perfect Aviation system – as pre-specified – is perfect Compliance based Compliance based Outcome oriented Outcome oriented Accident investigation Accident investigation

17 Organizational processes Latent conditions Workplace conditions Defences Active failures 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 Performance-based Safety

18 Organizational processes Latent conditions Workplace conditions Defences Active failures Performance-based Safety Organizational processes Latent conditions 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

19 Organizational processes Latent conditions Workplace conditions Defences Active failures Performance-based Safety Organizational processes Latent conditions Defences Technology Technology Training Training Regulations Regulations Resources to protect against the risks that organizations involved in production activities must confront

20 Organizational processes Latent conditions Workplace conditions Defences Active failures Performance-based Safety Organizational processes Workplace conditions Factors that directly influence the efficiency of people in aviation workplaces Workforce stability Workforce stability Qualifications and experience Qualifications and experience Morale Morale Credibility Credibility Ergonomics Ergonomics …

21 Organizational processes Latent conditions Workplace conditions Defences Active failures Performance-based Safety 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

22 Organizational processes Latent conditions Workplace conditions Defences Active failures Performance-based Safety Organizational processes Latent conditions Workplace conditions Defences Active failures ImproveIdentify Monitor Contain Reinforce

23 Performance-Based Safety: The ABC A. Senior managements commitment to the management of safety B. Initial analysis of system and establishment of risk controls (safety risk management) C. Continuous safety monitoring and analysis of safety data from normal operations (safety assurance)


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