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

2. 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

3. 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

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

5. Two Ways to Look at Safety

6. 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.

7. 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

8. Regulatory safety is “Reactive”

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

10. 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

11. 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.

12. SMS comes from System Safety
“Cradle to Grave” Concept

13. Adapted to Ongoing Organizations

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

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

16. 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

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

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

19. 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

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

21. 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

22. 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

23. 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.

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

25. Focusing on “Events”

26. Focusing on “Processes”
Root Causes

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

28. “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.

29. 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

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

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

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

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

34. 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:

35. Access the Manual…

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