Basic safety management concepts Module N° 2 Basic safety management concepts Revision N° 5 ICAO State Safety Programme (SSP) Implementation Course 25/02/10

SSP – A structured approach Module 2 Basic safety management concepts Module 3 ICAO SARPs related to safety management Module 4 ICAO SSP framework Module 5 ALoS related to an SSP Module 6 Prescription / Performance Module 8 SSP implementation plan Module 1 Introduction to the SSP implementation course Module 7 SSP training programme

Objective At the end of this module, participants will be able to explain the strengths and weaknesses of long-established approaches to manage safety and describe new perspectives and methods of managing safety by the State

Contents A concept of accident causation System performance in the real world Safety management strategies – Levels of intervention and tools Hazards and safety risks Safety risk assessment Questions and answers Points to remember

Concept of safety Consider (the weaknesses in the notion of perfection) The elimination of accidents (and serious incidents) is unachievable Failures will occur, in spite of the most accomplished prevention efforts No human activity or human-made system can be guaranteed to be absolutely free from hazard and operational errors Controlled safety risk and controlled error are acceptable in an inherently safe system

Concept of safety (Doc 9859) Safety is the state in which the possibility 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 Traditional approach – Preventing accidents Focus on outcomes (causes) Unsafe acts by operational personnel Attach blame/punish for failures to “perform safely” Address identified safety concern exclusively Regulatory compliance Identifies: WHAT? WHO? WHEN? WHY? HOW? But not always discloses:

A concept of accident causation Activities over which any organization has a reasonable degree of direct control Regulations Training Technology Defences Errors and violations People Working conditions Workplace Latent conditions trajectory Management decisions and organizational processes Organization

A concept of accident causation Factors that directly influence the efficiency of people in aviation workplaces. Regulations Training Technology Defences Errors and violations People Working conditions Workplace Latent conditions trajectory Management decisions and organizational processes Organization

A concept of accident causation Management decisions and organizational processes Organization Errors and violations People Regulations Training Technology Defences Working conditions Workplace Latent conditions trajectory Actions or inactions by people (pilots, controllers, maintenance engineers, aerodrome staff, etc.) that have an immediate adverse effect.

A concept of accident causation Resources to protect against the risks that organizations involved in production activities generate and must control. Regulations Training Technology Defences Errors and violations People Working conditions Workplace Latent conditions trajectory Management decisions and organizational processes Organization

A concept of accident causation Conditions present in the system before the accident, made evident by triggering factors Regulations Training Technology Defences Errors and violations People Working conditions Workplace Latent conditions trajectory Management decisions and organizational processes Organization

System performance in the real world design Baseline performance Practical drift Operational performance Operational deployment Regulations Training Technology Defences

Managing safety – “Navigating the drift” Baseline performance Operational performance Practical drift Organization Navigational aids Reactive Proactive Predictive

The predictive method captures Navigational aids Reactive method The reactive method responds to the events that 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

Strategies – Levels of intervention and tools HAZARDS Predictive Highly efficient Very efficient Efficient Insufficient High Proactive Middle Reactive Low FDA Direct observation system ASR Surveys Audits MOR Accident and incident reports Safety management levels

Three key definitions Hazard – Condition or object 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 Consequence – Potential outcome(s) of the hazard Safety Risk – The assessment, expressed in terms of predicted probability and severity, of the consequence(s) of a hazard taking as reference the worst foreseeable situation

Unclear aerodrome signage is a hazard Three key definitions Example Unclear aerodrome signage is a hazard A runway incursion is one of the consequences of the hazard The assessment (quantification) of the consequences of the potential runway incursion expressed in terms of probability and severity is the safety risk 18

Understanding hazards There is a natural tendency to describe hazards as their consequence(s) “Unclear aerodrome signage” vs. “runway incursion” Stating a hazard as consequence(s) disguises the nature of the hazard interferes with identifying other important consequences Well-named hazards allow to infer the sources or mechanisms of the hazard allow to evaluate the loss outcome(s)

Types of Hazards Natural Technical Economic

Examples of natural hazards Severe weather or climatic events: E.g.: hurricanes, major winter storms, drought, tornadoes, thunderstorms lightning, and wind shear Adverse weather conditions: E.g.: Icing, freezing precipitation, heavy rain, snow, winds, and restrictions to visibility 21

Examples of natural hazards Geophysical events E.g.: earthquakes, volcanic eruptions, tsunamis, floods and landslides Geographical conditions E.g.: adverse terrain or large bodies of water Environmental events E.g.: wildfires, wildlife activity, and insect or pest infestation Public health events E.g.: epidemics of influenza or other diseases 22

Examples of technical hazards Deficiencies regarding E.g.: aircraft and its components, systems, subsystems and related equipment E.g.: an organization’s facilities, tools, and related equipment E.g.: facilities, systems, sub-systems and related equipment that are external to the organization 23

Examples of economic hazards Major trends related to Growth Recession Cost of material or equipment Etc. 24

A B C Hazard analysis ABC of hazard analysis State the generic hazard (Hazard statement) Airport construction B Identify specific components of the hazard Construction equipment Closed taxiways … C Naturally leading to specific consequence(s) Aircraft colliding with construction equipment Aircraft taking wrong taxiway ABC of hazard analysis

Safety risk management What is it? The analysis and elimination, and/or mitigation to an acceptable level of the safety risks of the consequences of identified hazards What is the objective? A balanced allocation of resources to address all safety risks and viable safety risks control and mitigation Why is it important? It is a data-driven approach to safety resources allocation, thus defensible and easier to explain Definition standard Protective – Production Fundamental part of SMS When you establish the context in risk management, you must define the deepness and extension Of the project or activity that is going to be examined I t requires that you be familiar with all the elements or activity and decide under which criteria You are going to evaluate the risk. Example: operational needs, customers requirements or technical, financial or legal matters. When you establish the context you will limit the process towards something that can be managed As an activity , a project or a task. 1) Definición estándar 2) Protección– Producción 3) Es el parte fundamental del SMS. Establecer el contexto de la gestión del riesgo, se trata de definir la extensión y profundidad del proyecto o actividad que va a examinar. Requiere que usted esté familiarizado con todos los elementos del proyecto a actividad y decidir contra que criterio usted va a evaluar el riesgo. Por ejemplo: necesidades operacionales, requerimientos de los clientes o asuntos técnicos, financieros o legales. Al establecer el contexto le permitirá limitar su proceso hacia algo que pueda ser manejado, como una actividad o tarea.

Definitions Probability The likelihood that an unsafe event or condition might occur Severity The possible effects of an unsafe event or condition, taking as reference the worst foreseeable situation

Safety risk probability Probability of occurrence Meaning Qualitative definition Value Frequent Occasional Remote Improbable Extremely improbable Likely to occur many times (has occurred frequently) Likely to occur some times (has occurred infrequently) Unlikely, but possible to occur (has occurred rarely) Very unlikely to occur (not known to have occurred) Almost inconceivable that the event will occur 5 4 3 2 1 This is a particular method that has been made using some of the best practices, however, the States or suppliers of service could develop their own according to their special necessities This and the next matrixes come from the good practices of the industry using information from Australia, Canada, UK, New Zealand and the United States, we mixed them so that nobody got angry Also we tried to maintain the standardization with the language. We could not even if we want to change Modules 4 and 5 due to this standardization. (probability and severity) Australia, Canada, UK, New Zealand and the United States are strongly supporting this program. Try to be as realistic as possible, but not take always the possibilities to become a catastrophe again, inventing crazy possibilities. We encourage states and organizations to developed their own matrix, industry good practices. Este es un método particular que se ha hecho utilizando algunas de las mejores prácticas, sin embargo, los Estados o proveedores de servicio pueden desarrollar sus matrices de acuerdo a sus necesidades especiales Esta y las próximas matrices vienen de las buenas prácticas de la industria Australia, Canadá, UK, Nueva Zelandia y los Estados Unidos, las mezclamos para que nadie se enojar También se está tratando de mantener la estabilización. (con el lenguaje utilizado). Módulos 4 y 5 nuestro posibilidad de cambiar es próximo a 0 ya que estaríamos desestabilizando A Australia, Canadá, UK, Nueva Zelandia y los Estados Unidos quienes son los que mas están apoyando este programa. Traten de ser realistas pero no llevar esto al limite de que siempre se convierta en una catástrofe.

Safety risk severity Severity of occurrences Value 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 Major equipment damage Equipment destroyed Multiple deaths 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 Nuisance Operating limitations Use of emergency procedures Minor incident Little consequences Meaning Severity of occurrences Value Aviation definition Catastrophic Hazardous Major Minor Negligible A B C D E

Safety risk assessment matrix (example)

Safety risk tolerability

Warm-up exercise N° 02/01 Scenario Fuel spill on the apron area surface of approximately 25 m (75 ft) length and 5 m (15 ft) width, produced by an A310 ready to pushback and taxi for departure 32

Warm-up exercise N° 02/01 – results Identify the hazard(s) 2. Determine the hazard(s) consequence(s) 3. Assess the probability of the consequence: 4. Assess the severity of the consequence 5. Determine the resulting safety risk index 6. Establish the safety risk tolerability 33

Warm-up exercise N° 02/02 Scenario It was observed that airline baggage handling personnel generates FO(D) on the aerodrome apron area 34

Warm-up exercise N° 02/02 – results Identify the hazard(s) 2. Determine the hazard(s) consequence(s) 3. Assess the probability of the consequence: 4. Assess the severity of the consequence 5. Determine the resulting safety risk index 6. Establish the safety risk tolerability 35

Basic safety management concepts Questions and answers

Q: What is the ICAO definition for safety in Doc 9859? A: ? Questions and answers Q: What is the ICAO definition for safety in Doc 9859? A: ? Slide number:

Q: Explain the three different methods for “navigating the drift” A: Questions and answers Q: Explain the three different methods for “navigating the drift” A: Slide number:

Q: Define safety risk management A: ? Questions and answers Q: Define safety risk management A: ? Slide number:

Points to remember The concept of safety Systems and operational performance in the real world Levels of intervention and tools for managing safety Hazard identification Safety risk management

Basic safety management concepts Module N° 2 Basic safety management concepts