1. EUR Runway safety and ATS safety management Seminar Moscow, Russian Federation September ICAO Safety management provisions and Manual on Safety management
Gustavo De León
Technical Officer, ATM
ICAO

2. Objectives Basic concepts related to Safety management systems;
Harmonization of ICAO Safety provisions through the consolidation of requirements related to Safety management systems contained in Annexes 11, 14 and introducing the concept in Annex 6; and
New ICAO Safety management manual (SMM)
ICAO stands for safety. That is primarily why we exist
So we always do a lot to improve safety
We are approaching this more aggressively lately in many ways
And importantly, we are doing a lot to clarify and harmonize our safety related work
And we are moving aggressively toward a more proactive approach to our safety related work
So there are two parts to our work that I want to establish clearly: our traditional regulatory work and our new proactive work. They are logically tied together
I’ll present our major programmes with respect to safety in a simplified way
But I’’ try to explain the ICAO provisions and where we are and where we’re going.

3. What is Safety
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.
Risk is inherent in all human activity
The best we can do is manage it
With that background, let’s look at what we are doing
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.
So what is safety
Almost all safety experts today accept that risk is inherent in all human activity and can never be totally eliminated.
The best we can do is manage it
But that means that management must be intricately involved, responsible and accountable
The days of investigating an accident so that we can find a few contributing and causal factors, make some recommendations for pilots and controllers to do a few things differently, and then close the books, are over.
Reasons for accidents are now being traced way back into the organization
There is even something called an organizational accident
So to fix the problems we need to involve management

4. Risk Risk As low as reasonable probable (ALARP)
The probable rate of occurrence of a hazard causing harm and the degree of severity of the harm
Risk = severity * probability
As low as reasonable probable (ALARP)

5. ALARP As Low As Reasonable Probable Unacceptable region Tolerable
Negligible
risk

6. Risk Classification Scheme (Example)

7. Safety Management System
Safety management system provides organizations with:
the capacity to anticipate and address safety issues before they lead to an incident or accident
the ability to deal effectively with accidents and incidents so that valuable lessons are applied to improve safety and efficiency
reduces costs through the proactive management of risks
Safety management requires effective safety action to be taken before accidents occur
Because successful safety management hinges on reporting of safety occurrences, a good reporting system is essential
But staff will not report of they feel threatened so a non threatening environment is essential
No reporting-no safety management system-its as simple as that
This environment can only come from management actions and commitment

8. Safety Management Systems
Management approach to human and organizational risks
Should be applied throughout the entire organization, including non-regulated areas
Mitigate latent conditions so that the holes in the Swiss cheese cannot line-up
This is where I begin talking about our proactive implementation efforts to improve safety
Avoiding accidents and incidents requires that we identify those safety conditions that lead to an accident or incident early on
This cannot be done by the operators alone, nor should they have this sole responsibility
Their responsibility is to report occurrences and risk factors that they come across.
But management must commit to implementation of a system that flushes out these conditions and then addresses them through mitigation
This is what safety management systems is all about
Management is also responsible for the safety culture, for providing resources and must be accountable
That is the only way safety management systems can work

9. Cautionary Notes
A Safety Management System in it self does not eliminate all risks…
It is a management tool which ensures a systematic and pro-active approach to safety throughout the whole organization of the ATS Service Provider

10. Philosophy of Safety Management
The Concept of SMS
Philosophy of Safety Management
Safety
Monitoring
Assessment
Auditing
Promotion
Policy
Supporting
organizational
requirement
Maintenance or
Improvement
of Safety
Performance
Safety Management
Safety Culture
I don’t need to spend any time on the mechanics of safety management systems here today but just to make sure we’re all talking about the same thing
Any good SMS addresses the question of philosophy, establishes a good culture, it audits and has a continuing monitoring programme
This is what we are selling to our Contracting States
Philosophy and culture are really management’s responsibility and are not a hard and fast set of rules (clouds)
Policy IS a hard and fast statement. It should be clear and brief. It translates management’s philosophy into action. It demonstrates management’s commitment and it lays the groundwork for a positive safety culture

11. Philosophy of Safety Management
Explicit
Systematic
Proactive
Philosophy of Safety Management

12. Safety Policy Overall safety objective of the organization
Commitment of senior management to meet safety performance targets
Commitment by the organization to a proactive and systematic approach to the management of safety
Commitment by the organization to making maintenance of safety its highest priority
The organization’s policy concerning responsibility and accountability for safety at all levels of the organization
Safety
Policy

13. Safety Culture
Managers in top positions foster a climate with a positive attitude towards criticism, comments and feedback from lower level of the organization
Awareness of the importance of communicating relevant safety information at all levels of the organization is present;
Low incidence of risk taking behavior and a safety ethic discouraging such behavior.
Safety Culture

14. Safety Monitoring Specify Safety Performance Indicators
Set Safety Performance Targets
Develop & implement appropriate data collection procedures
Safety Occurrence Reporting & Investigation System
Develop and implement monitoring processes
Safety
Assessment
Safety
Auditing
Safety
Promotion

15. Safety Monitoring Occurrence Reporting and Investigation System
Establishment of reporting culture
Mandatory/Voluntary
Non-punitive
Just culture
Safety
Monitoring
Safety
Assessment
Safety
Auditing
Safety
Promotion

16. Safety Assessment Seven step approach
Develop complete description of the system and of the environment in which the system is to be operated
Identification of hazards
Estimation of severity of potential consequences
Estimate of likelihood of hazard occurring
Evaluation of risk
Mitigation of risk
Development of safety assessment documentation
Safety
Monitoring
Safety
Assessment
Safety
Auditing
Safety
Promotion

17. Safety Auditing
Safety
Monitoring
Ensure that risks are identified and the potential for causing or contributing to an incident are recognized
Ensure that the “health” of the safety management system
Ensure that adequate arrangements exist to handle foreseeable emergencies
Ensure that equipment performance is adequate for the safety performance
Ensure that effective arrangements exist for promoting safety, monitoring safety performance and processing safety issues
Safety
Assessment
Safety
Auditing
Safety
Promotion

18. Safety Promotion Promulgation of Safety Management
Monitoring
Promulgation of Safety Management
Lesson Dissemination
Continuous awareness campaigns on safety management
Safety
Assessment
Safety
Auditing
Safety
Promotion

19. Supporting Organizational Requirements
Responsibility and accountability
Safety Manager / Safety Organization
Training and competency of personnel
Safety documentation
Supporting
organizational
requirement

20. Safety Organization ------ Chief Executive Safety Manager Training
Technical
Division
Operations
------

21. Safety Performance
Maintenance or
Improvement
of Safety
Performance
Identify actual and potential hazards and determine the need for remedial action
Ensure that remedial action necessary to maintain an acceptable level of safety is implemented
Provide for continuous monitoring and regular assessment of the safety level achieved

22. Summarizing SMS
Safety is a condition in which the risk of harm or damage is limited to an acceptable level
Safety Management System is a tool
Remember:
Implementation of Safety Management is not a desk job. It requires senior management commitment, senior management leadership and an organization willing to develop a safety culture

23. Eleventh Air Navigation Conference
Recommendation 2/1 — A framework for system safety
That ICAO investigate appropriate mechanisms for the development and implementation of a framework for a uniform and system-wide approach to safety, and the application of this framework to:
the harmonization of provisions relating to safety assessment and safety management in relevant Annexes and Procedures for Air Navigation Services (PANS); and
the harmonization of the approaches to safety assessment in the development of safety-related standards and recommended practices (SARPs)
The 11th Air Navigation Conference endorsed a new global ATM operational concept.
This was an important endorsement and will guide much of our work on the side of efficiency
I could talk about the concept for an hour but we are here to talk about safety
But the conference realized that with a new concept that envisions a highly integrated air navigation system, we also needed to address safety proactively, not as an add on as the system is developed but as part of the design of the system itself.
So the conference endorsed a recommendation encouraging us to look at safety of the air navigation system in new ways. In a systemic way

24. ICAO activities in support of systems safety
ATM operational concept considers safety from the start and throughout the life cycle
Systems approach to safety oversight
Unified strategy
Harmonization of ICAO Safety Management provisions
In fact, we were already moving in the system’s direction so the recommendation from the conference was logical and well received

25. Preparing for Global ATM
The emerging ATM system will allow maximum use to be made of enhanced capabilities and new technologies
Integrated system
Implementation requires adoption of a systems safety approach to safety
Eleventh Air Navigation Conference adopted a global ATM Operational Concept
But let me just focus on this new ATM system for a moment and lay the backdrop for why we really need to be addressing safety in new ways.
The emerging and future system will make maximum use of technologies and aircraft capabilities
Because of the integrated nature of the system, we need to look at safety in an integrated way
Not address safety in an ad hoc fashion as we often do today when designing systems and thinking about safety after implementation
Safety must be a part of the design of the system. Part of the DNA of the system

26. An integrated ATM System requires an integrated approach to safety
People
Systems
Procedures
Management
ATM
Service provider
Aircraft
operations
Maintenance
Engineering
Airspace
organization
and Management
ATM service delivery
management
Communications
Navigation
Surveillance
Information
Demand capacity
balancing
Airspace User
Aerodrome
Operator
Conflict Management
Information rich environment
Traffic synchronisation
A slide to illustrate the integrated nature of the global ATM system we are moving toward, no matter which operational concept you subscribe to
The people on the left side of the slide will make decisions collaboratively with respect to the procedures on the bottom of the slide as well as with respect to the systems and equipment on the right side
In a nutshell, the future will be an information rich environment where decisions will be made collaboratively.
Safety must be designed into that system

27. Inspiration for ATS safety management provisions
NATS introduced formal SM in 1991
ECAC adopted a common safety programme to implement SM
EUROCONTROL
Guidance material published in 1999
ESARR 3 published in 2000
Not meant to be a historical perspective. Just to describe how ICAO came upon SM programmes.
We have all always been involved in promoting safety.
The airline industry always had prescriptive and managed safety programmes, primarily because they were somewhat autonomous and their business plans required it.
We never really had a managed approach to safety for ATS because the providers were the governments and nobody was overseeing them. Safety was addressed in different ways.
In the UK, following a series of accidents in all kinds of industries, the notion of managing safety was born
That found its way to Eurocontrol
We picked up on it at the end of the 90s for application in ATM

28. Source of ATS Safety Management Requirements
Standards and Recommended Practices (SARPS) for Safety Management in ATS introduced in Amendment 40 to Annex 11
Complementary procedures introduced in Amendment 1 to the fourteenth edition of the PANS-ATM (Doc 4444)
This was ICAO’s first venture into safety management.
First placed in Annex 11 for ATS with an implementation date of November 2003.
With the expanded SOA programme coming along, this date became urgent for States
A good start and it probably caused States to get to work, however, in hind sight 2003 was probably a bit early
Especially considering that we didn’t have the guidance material available and it was a rather new concept

29. AN-Conf/11-Harmonization of safety provisions
Annex 6 – Operation of Aircraft, Parts I and III
Annex 11 – Air Traffic Services
Annex 14 – Aerodromes
Two basic concepts
Safety programme – An integrated set of regulations and activities aimed at improving safety
Safety management system – An organized approach to managing safety, including the necessary organizational structures, accountabilities, policies and procedures Two levels of responsibility for implementation
State
Operator (Airline, ATS provider, aerodrome operator)
In follow-up to the 11th Air Navigation Conference and the 35th Session of the ICAO Assembly, there was an urgency to harmonize our provisions and guidance material
We established a project team to address this and had several of the major players to Montreal for a day to ensure that we were not going off on a tangent
And this is what we came up with
Taking into account what we learned in our SOA programme we clearly identified the responsibilities of both the regulator and the provider of services
Safety programmes are directed at the regulator while safety management systems are directed at the organization provided a service

30. New harmonized provisions (Regulator)
Annexes 6, 11 and 14
States shall establish a safety programme, in order to achieve an acceptable level of safety in (Annex specific):
the operation of aircraft
the maintenance of aircraft
the provision of ATS
aerodrome operations
The acceptable level of safety to be achieved shall be established by the State(s) concerned
Annex specific

31. New harmonized provisions (Provider)
States shall require that the (operator/maintenance organization/air traffic services provider/certified aerodrome operator) implement a safety management system approved by the (State/State of the operator) that, inter alia:
identifies actual potential safety hazards
provides for continuous monitoring and regular assessment of the level of safety achieved.
ensures that remedial action necessary to maintain an acceptable level of safety is implemented; and
Annex specific

32. New harmonized provisions (Provider)
An approved safety management system shall clearly define lines of safety accountability throughout the (operator/maintenance organization/air traffic services provider/certified aerodrome operator), including a direct accountability for safety on the part of senior management
Strong emphasis on management accountability
This was urged by Eurocontrol, Australia and others who were already deeply involved in SMS

33. The State as a Service Provider
Where a State is also an ATM service provider:
It is important that there is a clear distinction between the regulatory functions and the service provision functions
The regulatory division must maintain effective safety oversight of the service provision divisions

34. ICAO Safety Management Manual (SMM)
1984 ICAO Accident Prevention Manual (APM)
2004 Draft SMS manual for ATM
Draft SMS manual for Aerodromes
Revised APM (second edition)
2005 New ICAO Safety Management Manual

35. Why an ICAO Safety Management Manual
Pressure on ICAO to publish appropriate guidance
(Annexes 6, 11, 13, 14)
Three large draft manuals produced around same time.
ICAO would have trouble producing the three manuals in a timely fashion.
All three dealt with SAFETY, albeit from different perspectives.
Combine into one manual (SMM)

36. The Safety Management Manual - Concept
No right (or single) way to address safety
No one size that fits all. (State, Operator, Individual)
Manual will take a more generic approach
Include both approaches to safety (SMS and traditional)
Users can take as much or as little as their circumstances permit
Make available on website;
More timely to produce
Cheaper; for ICAO and the user
Users can down-load as much as they want (cut and paste)
Can be easily updated by ICAO as new ideas/programmes are developed

37. SMM Outline Part 1 — Introduction
Chapter 1- Overview
Chapter 2 - Responsibility For Safety Management
Chapter 3 – State Safety Programme

38. SMM Outline Part 2 — The Management of Safety
Chapter 4 – Understanding Safety
Chapter 5 – Basic of Safety
Management
Chapter 6 – Risk Management
Chapter 7 – Hazard and Incident Reporting
Chapter 8 – Safety Investigations

39. SMM Outline Part 2 — The Management of Safety
Chapter 9 – Safety Analysis and Studies
Chapter 10 – Safety Performance Monitoring
Chapter 11 – Emergency Response Planning

40. SMM Outline Part 3 - Safety Management Systems (SMS)
Chapter 12 – Establishing A Safety Management System
Chapter Safety Assessments
Chapter Safety Auditing
Chapter Practical Considerations For Operating a Safety Management System

41. SMM Outline Part 4 — Applied Safety Management
Chapter 16 – Aircraft Operations
Chapter 17 – Air Traffic Services Operations
Chapter 18 – Aerodrome Operations
Chapter – 19 Aircraft Maintenance

42. Conclusions Safety, Risk and Safety management systems
Harmonization of ICAO Safety provisions in Annex 11, 14 and 6.
New ICAO Safety management manual

43. Your Contribution to Safety
Implement safety management systems
Foster safety culture
Enforce regulations
Report safety occurrences

44. THE END
THANKS