Aviation Safety Management Systems Tony Cramp Senior Advisor (Americas) 17th May 2005 Lafayette File Title 4/15/2017

Underlying 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 lowered The 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 safe Everyone can contribute to causing an accident, we can also contribute to preventing one A fundamental requirement for this is effective collaboration between line personnel and ‘management’ These are 3rd Generation Safety beliefs

Safety 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.

Safety Paradigms: 3rd Generation The finding of ‘human error’ should be the starting point of an investigation, not its conclusion

Safety Management Systems Defences in Depth If 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

Safety 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 safely To ensure and demonstrate that safety is being managed as formally as any other critical business function To 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?

SMS 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 resolution This engineering / astronautics approach then migrated into the Nuclear, Maritime, Rail, Oil/Chemical industries and has shown considerable benefits

SMS 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 effectiveness SMS 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 culture Have to get past the SMS language used by other disciplines, mainly the ‘speak’ of HSE and Quality Assurance BUT: 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

SMS Primary Components Accident cause ⌗ 1. Inadequate Procedural Baseline

SMS Primary Components Ops Manual, GMM/MPM, Ramp Procedures, Fuel Quality, OSHA Compliance ① Procedural baseline to assure safety in work

SMS 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 purposes ② SMS Manual SMS Manual can be written bottom- up, or preferably as a template ‘top-down’, gives the big-picture, highlights any major ‘holes’ in SMS Component ⌗1 Any holes? ① (Full spectrum of policies, procedures, methods, practices to assure safety in work)

SMS Primary Components X Cause ⌗ 1. Inadequate Procedural Baseline Cause ⌗ 2. Uncontrolled Hazards

SMS Primary Components ③ Safety Management Program ② SMS Manual ① Procedural baseline to assure safety in work

Systems are for People? “Even the most well-considered safety system can be wrecked by the idiosyncratic behaviour of a single individual”

SMS Component ⌗3: Safety Program Management Proactive Safety Management Encouraging and developing Management commitment Creation of a Safety Culture Safety structure and resources, committees and meetings Ongoing hazard identification and management (HEMP) Safety education (training, information dissemination) ‘ Watchdog’ function 2. Reactive Safety Management Occurrence investigation (‘occurrences’, incidents, accidents) Data analysis Continuous learning

SMS Primary Components ③ Safety Program Management ② SMS Manual ④ Safety Case ① Procedural baseline to assure safety in work

SMS 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 HEMP A safety case functions at Management, Supervisor and Line levels: a Living document.

SMS Primary Components X Cause ⌗ 1. Inadequate Procedural Baseline X Cause ⌗ 2. Uncontrolled Risk Factors / Hazards Cause ⌗ 3. Failures in Communication

SMS Primary Components ⑤ SIS ③ Safety Program Management ② SMS Manual ④ Safety Case ① Procedural baseline to assure safety in work

Safety 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 prevented A 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 forms Regular safety meetings, with minutes recorded and distributed. Company newsletters Effective, updated notice boards Intranet employee notices

SMS Primary Components X Cause ⌗ 1. Inadequate Procedural Baseline X Cause ⌗ 2. Uncontrolled Risk Factors / Hazards X Cause ⌗ 3. Failures in Communication

Next Challenge! How to integrate these components:

Integrating 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’

SMS Primary Components ⑥ Quality System ⑤ SIS ③ Safety Program Management ② SMS Manual ④ Safety Case ① Procedural baseline to assure safety

A Typical Safety-Orientated ‘Quality’ System Principles & Policy Management Review Objectives Strategy Targets & Plans Customer Satisfaction Standards Feedback Check Do Plan Remedial Action Accountability & Competence Culture Investigation & Follow-up Product Management COMMUNICATION Incident Reporting Risk Assessment Hazard Management Monitoring Audit Review

SHELL ‘Model’ HSSE-MS Elements

③ ① SMS Booklet ② SMS Summary See ‘Model Manual’ 33 Sub-Elements ④ ⑥ Quality System ⑤ SIS ③ Safety Program Management See ‘Model Manual’ 33 Sub-Elements ② SMS Manual ④ Safety Case ① Procedural baseline to assure safety SMS Booklet

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 HEMP A safety case functions at Management, Supervisor and Line levels: a Living document.

Hazards, Incidents, Accidents Byrd’s Triangle Eliminate hazards and you will eliminate accidents 1 Accident 10 Incidents 600 Hazards

Hazard Identification: Fundamental Requirements The fundamental requirements for effective hazard identification are: To get past perceptions and to quantify wherever possible To tap into the vast reservoir of knowledge that exists within Aviation and other complex industries To ‘think outside the box’ Be paranoid: believe everything and believe nothing: continually test for the truth

Which hazards? Type specific Hazards Major Aviation Safety Hazards Company Specific Hazards Aviation Safety Case Generic Aviation Safety Hazards + = Operation Specific Hazards Significant Workplace Hazards Workplace Safety Procedures (Defined in HSE-MS) Generic HSE Hazards The 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 procedures Location Specific Hazards

Primary Sources for Identifying Hazards Safety Critical Processes External Sources Internal Sources Formal Hazard Models Hazard Register

Hazard and Effects Register

Risk Analysis Process When 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 industry The 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 matrix In terms of the Shell model, all hazards ranked as ‘intolerable’ shall be subjected to a ‘bow-tie’ analysis.

The Risk Grading (Threat Analysis) Matrix

The ‘Bow-Tie’ Process

The Bow-Tie Process For those hazards assessed as being ‘Intolerable’, develop ‘controls in depth’ as follows: Identify the Threats that might release the hazard Identify Controls to contain the Threats Identify factors that could prevent the Controls from being effective: Escalation Factors Develop controls to contain the Escalation Factors: Escalation Controls The hazard is released, but it’s consequence has not yet occurred: what controls make detection and recovery possible: Recovery Measures Identify Escalation Factors hampering detection and recovery Identify a final layer of Escalation Controls Identify measures to mitigate the effects of the Consequence These 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.

T H E B O W - T I E Hazardous Event Slide 15 HAZARD THREAT CONTROL ESCALATION CONTROL T H E B O W - T I E Hazardous Event RECOVERY Tiger in the cage !! Hazard = Tiger in the cage Threats = Door unlocked, corroded bars Controls = double locking, corrosion protection Escalations = non competent staff, corrosive atmosphere, lack of maintenance. Escalation controls = training, maintenance programme Top event = Tiger out of the cage! Recovery = Shoot the tiger, or drive back into cage Escalations = miss the tiger, or tiger outwits keeper Escalation controls = marksman available, competent keepers Consequence = 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 15 ESCALATION CONTROL CONSEQUENCE MITIGATION MEASURES

Hazard Threat Control Escalation Tiger out of the Cage Cage Door Locking System Twin Locks & Warning Lights Unserviceable Warning System Records & Maintenance Tiger out of the Cage T H E B O W - T I E Recovery Escalation Control Consequence Mitigation Shoot Tiger, or drive back in cage If 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 16 Miss Tiger, or Tiger Evades Keeper Competent Keepers Tiger Bites Keeper Effective Emergency Response Plan

Human Error Inappropriate pilot control input Hazard Threat Control Escalation PEOPLE Errors, Mistakes, Violations Competence, Procedures, Systems Non Compliant Pactice Monitoring and Feedback T H E B O W - T I E Human Error Inappropriate pilot control input Recovery Escalation Control Consequence Mitigation Make corrective control selection If 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 17 Input can not be made it time Competence & Awareness Aircraft Crashes Effective Emergency Response

Percentage of Accidents Reported in NASA Study Preventable by Individual Mitigation Measures Seven Key Initiatives Requires development work

Hazard and Effects Register

So 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 security An SMS Manual should give the ‘big picture’ regarding safety management in the organization

Conclusion SMS 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’

QUESTIONS File Title 4/15/2017