The “Why” and “What” of Safety Management Systems Presented by Captain Rick Clarke Director, SMS Project Air Line Pilots Association

The Issue of Safety What do we understand? The record is a good one Air transportation will continue to grow The Air Transportation System is outgrowing the capabilities of the current aviation safety system

Safety Efforts are Changing What is Driving this? Financial stress for Air Carriers and Regulators A Tangle of Regulations, Standards, Annexes, Policies and Procedures Lessons Learned

The Issue of Focus What does ALPA want for the Industry? Safe and Efficient Air Carrier Service Effective and Strong Air Carriers

Two Ways to Look at Safety

The Traditional Way – “Regulatory Safety” A foundation of rules aimed to improve the standards of … behavior, practice and of operating…the level of which is governed by societal, cultural, philosophical factors, legal systems, technological progress and experience.

Regulatory Safety Has Limits Design, manufacture and operations of aircraft must comply with regulations… …but you can’t write a regulation to address every potential hazard… …so, the goal becomes compliance with existing rules … ignoring other hazards

Regulatory safety is “Reactive”

What is the Regulator’s Duty? It is NOT safety achievement It IS safety oversight

What is the Airline’s Duty? Safety achievement is the responsibility of the airline Regulators’ diminishing resources are best applied in assisting / enabling airline safety management

Safety via the Proactive Way “Safety Management Systems” A systematic and continuous Management process based on proactive identification of Hazards, and analyses of their Risk.

SMS comes from System Safety “Cradle to Grave” Concept

Adapted to Ongoing Organizations

SMS ….. Is an Operator based system Integrates Employee expertise Interfaces with Regulators’ oversight systems Operator Employee Regulator

SMS is the toolbox Management tools System Safety tools Safety Information tools

Three “Hallmarks” of SMS The CEO establishes the policy and sets the SMS into motion The airline uses and maintains a robust Risk Management system The airline has a non-punitive safety reporting system for all the employees

SMS is… … a top-down program starting with the “Accountable Executive”

SMS…emphasizes Risk Management …It integrates safety with Line Management

Parallel Approaches in Business and SMS The Business Approach SMS is the link between the two similar approaches to “business” The Safety Approach Mission - Vision - Corporate Goals - Safety Goals - Policies - Requirements - Business Processes: SRA Processes: Identify Non-Compliance Identify Hazards / Non-Compliance Implement Solutions Implement Hazard Controls Measure Performance Lessons Learned Lessons Learned – Improve Process Repeat the Process

A SMS Company… Organizes: Policy, Procedure, and Practice Management Systems and Communications

Adopts Risk Management Practices to: A SMS Company… Adopts Risk Management Practices to: Adapt to Change Manage Resource Application Understand the pitfalls of the operating environment

A SMS Company… Develops a “Just Culture” or “Safety Culture” to: Capture the operational knowledge and experience of the employees Involve the employees in the safety achievement process

What’s in a “Just Culture?” The immediate response is to find “what happened,” not “who to blame and punish” Acceptance that more can be learned through full reporting and detailed investigation Partnership in identifying hazards and root causes Professor Reason does not like this term and prefers Just Culture because he sees “no blame” as having no exceptions While we talk about “no blame” culture, that does not mean that we recommend that an organization totally drop the idea of punishment or discipline. There are some actions which clearly should result in discipline such as negligence, willful disregard for rules or a criminal act. However, there are a number of other actions which traditionally have resulted in punishment and we would benefit more by providing a level of impunity to obtain better information on possible hazards and deficiencies. The idea of a “no blame” culture as used here is more relative to the first bullet. The first reaction is not to punish and punishment only arises if the facts of the case warrant such punishment. This fundamental approach to blame should result in a “Just Culture” being developed.

SMS is about… “Process” instead of “Events”

Focusing on “Events”

Focusing on “Processes” Root Causes

“Risk” manageable, but what is it? In Business and SMS “Risk” manageable, but what is it?

“Risk” The consequence of a hazard, measured in terms of Probability and Severity The consequence is merely what eventually could occur - mid-air collision, runway overrun etc. Until we assess the probability of the consequence occurring and measure the severity if it does occur, we do not know the risk. Severity and probability are necessary elements before we say we have defined a risk. Risk analysis includes and assessment and evaluation of severity and probability of the identified consequence. The measurement of risk may be subjective, if the data is not available, and you may have to rely on “expert opinion”. Experts may also modify the data sets based on their experience You or a team must decide to what extent you can or are able to accomplish risk determination.

Risk Assessment Matrix PROBABILITY 5 4 3 2 1 10 8 6 15 12 9 20 16 25 S E V R I T Y This comes from Transport Canada guidance material and presents a 5x5 matrix which offers the most flexibility in assigning risk categories. For each classification you would clearly identify corporate action would be necessary to take to minimize the risk. The reaction must be identified and agreed on before the assessment process begins to ensure objective application of findings and controls. During the Vancouver and Key West risk assessments we used a 4x5 matrix but found it too limiting in selecting degrees of risk

Risk Management is…. SMS ….a continuous process New Info? Tracking? ….a continuous process ….a closed loop process ….cross discipline SMS

SMS is a “System” that Integrates … Organization Risk Management Safety Information

Keep This In Mind… SMS is the toolbox for… Management tools Risk Management tools Safety Information tools

The Issue of Safety Current safety approaches can’t keep up with aviation growth We need a new approach to the problem

SMS The Industry’s Answer Launching a common idea and a new approach: ALPA, Regulators, Air Carriers, ICAO, IATA, IBAC SMS Launching a common idea and a new approach:

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A product from the ALPA Safety Management System (SMS) Project The End A product from the ALPA Safety Management System (SMS) Project