1. 1 Fourth Meeting Flight operations and Air traffic management Component of the North Asia Regional Aviation Safety Team (NARAST) Bangkok, Thailand 31 st August,1,2 September 2005 ICAO Developments in Safety Management Gustavo De León Technical Officer, ATM ICAO

2. 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)

3. 3 What is Safety Safety can be defined as a condition in which the risk of harm or damage is limited to an acceptable level Risk is inherent in all human activity The best we can do is manage it

4. 4 Risk 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. 5 ALARP As Low As Reasonable Probable Unacceptable region Acceptable region Tolerable region ALARP Negligible risk

6. 6 Risk Classification Scheme (Example)

7. 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

8. 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

9. 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. 10 The Concept of SMS Philosophy of Safety Management Safety Monitoring Safety Assessment Safety Auditing Safety Promotion Safety Policy Supporting organizational requirement Maintenance or Improvement of Safety Performance Safety Management Safety Culture

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

12. 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. 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. 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 Monitoring Safety Assessment Safety Auditing Safety Promotion

15. 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. 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. 17 Safety Auditing 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 Monitoring Safety Assessment Safety Auditing Safety Promotion

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

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

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

21. 21 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 Maintenance or Improvement of Safety Performance

22. 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. 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: a)the harmonization of provisions relating to safety assessment and safety management in relevant Annexes and Procedures for Air Navigation Services (PANS); and b)the harmonization of the approaches to safety assessment in the development of safety-related standards and recommended practices (SARPs)

24. 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

25. 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

26. 26 An integrated ATM System requires an integrated approach to safety PeopleSystems 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

27. 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

28. 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)

29. 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)

30. 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

31. 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

32. 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

33. 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. 34 ICAO Safety Management Manual (SMM) 1984ICAO Accident Prevention Manual (APM) 2004Draft SMS manual for ATM Draft SMS manual for Aerodromes Revised APM (second edition) 2005New ICAO Safety Management Manual

35. 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. 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. 37 SMM Outline Part 1 — Introduction Chapter 1- Overview Chapter 2 - Responsibility For Safety Management Chapter 3 – State Safety Programme

38. 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. 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. 40 SMM Outline Part 3 - Safety Management Systems (SMS) Chapter 12 – Establishing A Safety Management System Chapter 13 - Safety Assessments Chapter 14 - Safety Auditing Chapter 15 - Practical Considerations For Operating a Safety Management System

41. 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. 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. 43 Your Contribution to Safety Implement safety management systems Foster safety culture Enforce regulations Report safety occurrences

44. 44 THE END THANKS