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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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:

8. 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

9. 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

10. 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.

11. 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

12. 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

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

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

15. 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

16. 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

17. 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

18. 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

19. 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)

20. Types of Hazards
Natural
Technical
Economic

21. 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

22. 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

23. 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

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

25. 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

26. 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.

27. 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

28. 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.

29. 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

30. Safety risk assessment matrix (example)

31. Safety risk tolerability

32. 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

33. 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

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

35. 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

36. Basic safety management concepts
Questions and answers

37. 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:

38. 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:

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

40. 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

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