EDGARS GINDRA 20.09.2007 LV CAA AOD SAFETY MANAGEMENT EDGARS GINDRA 20.09.2007 LV CAA AOD

SMS regulation Operation of aircraft Maintenance of aircraft Air traffic services Aerodromes Two audience groups States Service providers Three distinct requirements Safety programme SMS Management accountability 20.09.2007 SMS LV CAA AOD

The amendment 30 to ICAO Annex 6 Part I 3.2.1 States shall establish a safety programme in order to achieve an acceptable level of safety in the operation of aircraft. 3.2.4 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: 20.09.2007 SMS LV CAA AOD

The amendment 30 to ICAO Annex 6 Part I Identifies safety hazards; Ensures that remedial action necessary to maintain an acceptable level of safety is implemented; Provides for continuous monitoring and regular assessment of the safety level achieved; and Aims to make continuous improvement to the overall level of safety. 20.09.2007 SMS LV CAA AOD

The amendment 30 to ICAO Annex 6 Part I 3.2.5 A safety management system shall clearly define lines of safety accountability throughout the operator’s organization, including a direct accountability for safety on the part of senior management. 3.2.9 An operator shall establish a flight safety documents system, for the use and guidance of operational personnel, as part of its safety management system. 20.09.2007 SMS LV CAA AOD

What is a safety programme? An integrated set of regulations and activities aimed at improving safety. States are responsible for establishing a safety programme: Safety regulation Safety oversight Accident/incident investigation Mandatory/voluntary reporting systems Safety data analysis Safety promotion 20.09.2007 SMS LV CAA AOD

Clarifying the use of terms 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 audit – Is what the CAA performs with regard to its safety programme and the operators/service providers perform with regard to the SMS. 20.09.2007 SMS LV CAA AOD

Acceptable level of safety – a concept 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 A reference against which one can measure safety performance 20.09.2007 SMS LV CAA AOD

What is an SMS? A systematic approach to managing safety, including the necessary organizational structures, accountabilities, policies and procedures. Providers are responsible for establishing an SMS. States are responsible of the acceptance and oversight for providers’ SMS. 20.09.2007 SMS LV CAA AOD

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. Management – Allocation of resources. System – Organized set of processes and procedures. 20.09.2007 SMS LV CAA AOD

Safety programme – SMS relationships State safety programme Organization’s management system (SMS) production processes Objective: Public Manage and control safety risk Acceptance Oversight Achieve commercial goals and customer satisfaction Risk management Safety assurance Protection Production 20.09.2007 SMS LV CAA AOD

ESARR ADVISORY MATERIAL 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. 20.09.2007 SMS LV CAA AOD

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. 20.09.2007 SMS LV CAA AOD

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. 20.09.2007 SMS LV CAA AOD

INTER-RELATIONSHIP BETWEEN SMS IN ATM AND AERODROMES 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. 20.09.2007 SMS LV CAA AOD

INTER-RELATIONSHIP BETWEEN SMS IN ATM AND AERODROMES 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. 20.09.2007 SMS LV CAA AOD

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”. 20.09.2007 SMS LV CAA AOD

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 requirements for risk assessment and mitigation with regard to changes Safety requirements for engineering and technical personnel undertaking operational safety related tasks 20.09.2007 SMS LV CAA AOD

SMS – Introductory concepts 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 aims to make continuous improvement to the overall level of safety. All aviation stakeholders have a role to play in SMS. 20.09.2007 SMS LV CAA AOD

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. 20.09.2007 SMS LV CAA AOD

Aviation system stakeholders Aviation professionals Aircraft owners and operators Manufactures Aviation regulatory authorities Industry trade associations Regional air traffic service providers Professional associations and federations International aviation organizations Investigative agencies The flying public 20.09.2007 SMS LV CAA AOD

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. 20.09.2007 SMS LV CAA AOD

System description The system interactions with other systems in the air transportation system. The system functions. Required Human Factors considerations of the system operation. Hardware components of the system. Software components of the system. Related procedures that define guidance for the operation and use of the system. Operational environment. Contracted and purchased products and services. 20.09.2007 SMS LV CAA AOD

Second fundamental – Gap analysis An analysis of safety arrangements existing within the 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. SMS development should build upon existing organizational structures. 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. 20.09.2007 SMS LV CAA AOD

Third fundamental – SMS and QMS SMS differs from quality systems in that:  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) 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. SMS builds partly upon QMS principles. SMS should include both safety and quality policies. The coverage of quality policies should be limited to quality in support of safety. Safety objectives should receive primacy where conflicts are identified. 20.09.2007 SMS LV CAA AOD

SMS planning The components of SMS Safety policy and objectives Safety risk management Safety assurance Safety promotion 20.09.2007 SMS LV CAA AOD

The elements of SMS 1. Safety policy and objectives 1.1 Management commitment and 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 1.6 Documentation 20.09.2007 SMS LV CAA AOD

The elements of SMS 2. Safety risk management 2.1 Hazard identification process 2.2 Risk assessment and mitigation processes 2.3 Internal safety investigations 20.09.2007 SMS LV CAA AOD

The elements of SMS 3. Safety assurance 3.1 Safety performance monitoring and measurement 3.2 The management of change 3.3 Continuous improvement of the safety system 20.09.2007 SMS LV CAA AOD

The elements of SMS 4. Safety promotion 4.1 Training and education 4.2 Safety communication 20.09.2007 SMS LV CAA AOD

Safety responsibilities Accountable executive Flight safety officer Maintenance Safety Action Group (s) (SAG) Safety Review Board (SRB) Director of operations maintenance Other directorates Safety services office 20.09.2007 SMS LV CAA AOD

Appointment of key safety personnel The safety office – Corporate functions  Advising senior management on safety matters  Assisting line managers  Overseeing hazard identification systems The safety manager – Responsibilities  Responsible individual and focal point for the development and maintenance of an effective safety management system 20.09.2007 SMS LV CAA AOD

Appointment of key safety personnel The safety manager – Functions  Manages the SMS implementation plan on behalf of the accountable executive  Facilitates hazard identification and risk analysis and management  Monitors corrective actions to ensure their accomplishment  Provides periodic reports on safety performance  Maintains safety documentation  Plans and organizes staff safety training  Provides independent advice on safety matters 20.09.2007 SMS LV CAA AOD

Appointment of key safety personnel The Safety Review Board (SRB)  High level committee  Strategic safety functions Chaired by the accountable executive It may include the Board of Directors Composed of heads of functional areas SRB monitors:  Safety performance against the safety policy and objectives  Effectiveness of the SMS implementation plan  Effectiveness of the safety supervision of subcontracted operations 20.09.2007 SMS LV CAA AOD

Appointment of key safety personnel SRB ensures that appropriate resources are allocated to achieve the established safety performance SRB gives strategic direction to the SAG Safety Action Group (SAG):  Reports to SRB and takes strategic direction from SRB  Members: Managers and supervisors from functional areas Front-line personnel 20.09.2007 SMS LV CAA AOD

Appointment of key safety personnel SAG:  Oversees operational safety within the functional area  Resolves identified risks  Assesses the impact on safety of operational changes  Implements corrective action plans  Ensures that corrective action is taken in a timely manner  Review the effectiveness of previous safety recommendations  Safety promotion 20.09.2007 SMS LV CAA AOD

SMS implementation plan Contents Safety policy Safety planning, objectives and goals System description Gap analysis SMS components Safety roles and responsibilities Safety reporting policy Means of employee involvement Safety communication Safety performance measurement Management review (of safety performance) 20.09.2007 SMS LV CAA AOD

PHASED APPROACH TO SMS IMPLEMENTATION - Provides a blueprint on how the SMS requirements will be met and integrated to the organization’s 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 20.09.2007 SMS LV CAA AOD

PHASED APPROACH TO SMS IMPLEMENTATION - Puts into practice those elements of the SMS implementation plan that refer to: 1) Safety risk management component Reactive processes Investigation and analysis Hazard identification and risk management Elements 2.1, 2.2 and 2.3 2) Training relevant to: The SMS implementation plan components The safety risk management component (Reactive processes) Element 4.1 3) Documentation relevant to: Elements 1.4 and 1.6 20.09.2007 SMS LV CAA AOD

PHASED APPROACH TO SMS IMPLEMENTATION - Puts into practice those elements of the SMS implementation plan that refer to: 1) Safety risk management component Proactive and predictive processes Investigation and analysis 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 20.09.2007 SMS LV CAA AOD

PHASED APPROACH TO SMS IMPLEMENTATION 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 20.09.2007 SMS LV CAA AOD

CAA - Four steps for SMS implementation State’s safety programme  Conduct a gap analysis vis-à-vis the current status in the State of the following: Safety regulation Safety oversight (capabilities and planning) Accident/incident investigation Mandatory/voluntary/confidential reporting systems Safety data analysis Safety promotion  Develop the State safety programme around four components of the ICAO SMS framework 20.09.2007 SMS LV CAA AOD

Safety analysis and safety studies 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); 20.09.2007 SMS LV CAA AOD

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). 20.09.2007 SMS LV CAA AOD

Safety analysis and safety studies Safety studies require data, appropriate analysis and effective communication. 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 studies have application to hazard identification and analysis in flight operations, maintenance, cabin safety, air traffic control, airport operations, etc. 20.09.2007 SMS LV CAA AOD

Safety analysis and safety studies 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. 20.09.2007 SMS LV CAA AOD

Safety analysis and safety studies 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. 20.09.2007 SMS LV CAA AOD

CAA - Four steps for SMS implementation Implementation SMS SARPs  Develop SMS regulations for operators/service providers Refer to the SMS components and elements  Prepare guidance material for the implementation of SMS Refer to ICAO Doc 9859  Operators/service providers may need to use third party assistance to implement their SMS 20.09.2007 SMS LV CAA AOD

CAA - Four steps for SMS implementation CAA training programme  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 Develop knowledge to certify and oversee the implementation of key components of an SMS, in compliance with the national regulations and relevant ICAO SARPs 20.09.2007 SMS LV CAA AOD

CAA - Four steps for SMS implementation CAA 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 Gross negligence, willful deviation and so forth to be dealt through established enforcement procedures 20.09.2007 SMS LV CAA AOD

State safety programme – SMS harmonization State’s safety programme components Safety policy and objectives Safety risk management Safety assurance Safety promotion 20.09.2007 SMS LV CAA AOD

Safety policy and objectives  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 Similar to the equivalent SMS component 20.09.2007 SMS LV CAA AOD

Safety risk management  Establishment of controls which govern how service providers SMS will operate Standards/requirements for service providers SMS Same processes as SMS  Hazard identification and risk management Different outputs  New/modified rules and/or regulations (i.e., controls) which govern how service providers SMS operate 20.09.2007 SMS LV CAA AOD

Hazard identification processes Concept of safety Consider - 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. 20.09.2007 SMS LV CAA AOD

Hazard identification processes 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 20.09.2007 SMS LV CAA AOD

Organizational processes The organizational accident Organizational processes Policy-making Planning Communication Allocation of resources Supervision … Activities over which any organization has a reasonable degree of direct control 20.09.2007 SMS LV CAA AOD

The organizational accident Organizational processes Latent conditions Inadequate hazard identification and risk management Normalization of deviance Conditions present in the system before the accident, made evident by triggering factors. 20.09.2007 SMS LV CAA AOD

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 20.09.2007 SMS LV CAA AOD

The organizational accident Organizational processes Latent conditions Defences Technology Regulations Training and checking Resources to protect against the risks that organizations involved in production activities must confront. 20.09.2007 SMS LV CAA AOD

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. 20.09.2007 SMS LV CAA AOD

The organizational accident Organizational processes Workplace conditions Factors that directly influence the efficiency of people in aviation workplaces. Workforce stability Qualifications and experience Morale Credibility Ergonomics … 20.09.2007 SMS LV CAA AOD

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 Violations 20.09.2007 SMS LV CAA AOD

The organizational accident Organizational processes Latent conditions Workplace Defences Active failures Improve Identify Monitor Contain Reinforce 20.09.2007 SMS LV CAA AOD

Hazard identification processes 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. 20.09.2007 SMS LV CAA AOD

Hazard identification processes 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) 20.09.2007 SMS LV CAA AOD

Hazard identification processes 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 20.09.2007 SMS LV CAA AOD

Hazard identification processes 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. 20.09.2007 SMS LV CAA AOD

Hazard identification processes Third fundamental – Hazard analysis ABC of hazard analysis A – State the generic hazard (hazard statement)  Airport construction B – Identify specific components of the hazard  Construction equipment  Closed taxiways C – Naturally leading to specific risk (s)  Aircraft colliding with construction equipment  Aircraft taking wrong taxiway 20.09.2007 SMS LV CAA AOD

Hazard identification processes 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 The obvious costs, which are easily determined. The high costs of exposure of hazards can be reduced by insurance coverage. Indirect costs The uninsured costs. An understanding of these uninsured costs (or indirect costs) is fundamental to understanding the economics of safety 20.09.2007 SMS LV CAA AOD

The management dilemma Production Protection Resources Management levels 20.09.2007 SMS LV CAA AOD

The management dilemma Management levels Production Protection Resources Catastrophe 20.09.2007 SMS LV CAA AOD

The management dilemma Management levels Production Protection Bankruptcy Resources 20.09.2007 SMS LV CAA AOD

Maximum resistance space Safety space Production Protection Bankruptcy Catastrophe Maximum resistance space Source: James Reason 20.09.2007 SMS LV CAA AOD

Safety management – The response to the dilemma 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. The product/service provided by any aviation organization must be delivered safely (i.e. protecting users and stakeholders). 20.09.2007 SMS LV CAA AOD

Hazard identification processes 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  Understanding  Validation  Reporting  Measurement  Management 20.09.2007 SMS LV CAA AOD

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. 20.09.2007 SMS LV CAA AOD

Hazard information management at a glance 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 Surveys Audits Predictive method FDA Direct observation systems Assign responsibilities Implement strategies Re-evaluate strategies and processes HAZARDS S A F E T Y L I B R Safety management information Trend analysis Safety bulletins Report distribution Seminars and workshops METHOD IDENTIFICATION MANAGEMENT INFORMATION DOCUMENTATION Feedback 20.09.2007 SMS LV CAA AOD

Risk management Second fundamental – Risk probability Definition (s)  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?  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?  How frequently is the equipment or procedure under assessment used? 20.09.2007 SMS LV CAA AOD

Second fundamental – Risk probability Probability of occurrence Qualitative definition Meaning Value 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 20.09.2007 SMS LV CAA AOD

Risk management Third fundamental – Risk severity Definition (s)  Severity – The possible consequences of a situation of danger, taking as reference the worst foreseeable situation. Define the severity in terms of:  Property  Health  Finance  Liability  People  Environment  Image  Public confidence 20.09.2007 SMS LV CAA AOD

Risk management Questions for assessing the severity of an occurrence:  How many lives are at risk? Employees Passengers Bystanders General public  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? 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?  What are the likely political implications and/or media interest? 20.09.2007 SMS LV CAA AOD

Third fundamental – Risk severity Severity of occurrences Aviation definition Meaning Value Catastrophic Equipment destroyed Multiple deaths A 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. Serious injury or death to a number of people. 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. Serious incident. Injury to persons. C Minor Nuisance. Operating limitations. Use of emergency procedures. Minor incident. D Negligible Little consequences E 20.09.2007 SMS LV CAA AOD

Fourth fundamental – Risk assessment Risk probability Risk severity Catastrophic A Hazardous B Major C Minor D Negligible E 5 – Frequent 5A 5B 5C 5D 5E 4 – Occasional 4A 4B 4C 4D 4E 3 – Remote 3A 3B 3C 3D 3E 2 – Improbable 2A 2B 2C 2D 2E 1 – Extremely improbable 1A 1B 1C 1D 1E 20.09.2007 SMS LV CAA AOD

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 20.09.2007 SMS LV CAA AOD

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 organization’s safety performance criteria? 20.09.2007 SMS LV CAA AOD

Risk management Fifth fundamental- Risk control/mitigation Definition (s)  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. (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. (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. (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. 20.09.2007 SMS LV CAA AOD

Risk management Risk mitigation – Defences (Technology, Training, Regulations) As part of the risk mitigation, determine:  Do defences to protect against such risk (s) exist?  Do defences function as intended?  Are the defences practical for use under actual working conditions?  Is staff involved aware of the risks and the defences in place?  Are additional risk mitigation measures required? 20.09.2007 SMS LV CAA AOD

Risk mitigation at a glance Ø 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 R Accepting the mitigation of the risk H 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 20.09.2007 SMS LV CAA AOD

A safety concern is perceived 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? severity A safety concern is perceived Define the level of risk No Yes Can the risk be mitigated? Take action and continue the operation Can the residual risk be accepted (If any)? Can the risk be eliminated? Cancel the 20.09.2007 SMS LV CAA AOD

Risk control/mitigation log 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: 20.09.2007 SMS LV CAA AOD

Risk management considerations for State Administrations 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? 20.09.2007 SMS LV CAA AOD

Risk management considerations for State Administrations 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; 20.09.2007 SMS LV CAA AOD

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. 20.09.2007 SMS LV CAA AOD

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? 20.09.2007 SMS LV CAA AOD

Risk management considerations for State Administrations 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.); 20.09.2007 SMS LV CAA AOD

Risk management considerations for State Administrations Potential impact of the State’s decision for action (or inaction); and Cultural and political will to take the action required. 20.09.2007 SMS LV CAA AOD

Risk management considerations 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; 20.09.2007 SMS LV CAA AOD

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. 20.09.2007 SMS LV CAA AOD

Safety assurance  Ensuring that the operation of service providers SMS follows established controls (standards)/requirements) Oversight, inspections and audits Data tracking and analysis  Data driven targeting of oversight on areas of greater concern/need 20.09.2007 SMS LV CAA AOD

The essential is invisible to the eyes Number of occurrences 1 – 5 Accidents 30 – 100 Serious incidents 100 – 1000 Incidents 1000 – 4000 Latent conditions 20.09.2007 SMS LV CAA AOD

Safety promotion  Support the integration of the State safety programme with the operation of service providers SMS Training, communication and dissemination of safety information Dual-track promotion  Within the CAA  Among service providers it oversees 20.09.2007 SMS LV CAA AOD

The final objective – Integration Safety programme + SMS = State integrated safety management system State safety programme Organization’s management system (SMS) production processes Objective: Public Manage and control safety risk Acceptance Oversight Achieve commercial goals and customer satisfaction Risk management Safety assurance Protection Production 20.09.2007 SMS LV CAA AOD