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An Introduction to Safety Management System (SMS) Safety Policy Safety Risk Management Safety Promotion Safety Assurance

An Introduction to Safety Management System (SMS)

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An Introduction to Safety Management System (SMS). Safety Policy. Safety Risk Management. Safety Assurance. Safety Promotion. Outline. Concept of Safety Evolution of Safe Thinking Accident Causation Organizational Accident People, Context & Safety – SHEL Errors & Violations - PowerPoint PPT Presentation

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Page 1: An Introduction to  Safety Management System  (SMS)

An Introduction to Safety Management System (SMS)

Safety PolicySafety Risk

Management

Safety Promotion

Safety Assurance

Page 2: An Introduction to  Safety Management System  (SMS)

Outline

Fundamentals of Safety Safety Management System Components of SMS Legislation Summary

Concept of Safety Evolution of Safe Thinking Accident Causation Organizational Accident People, Context & Safety – SHEL Errors & Violations Organizational Culture Safety Investigation

Page 3: An Introduction to  Safety Management System  (SMS)

Outline

Fundamentals of Safety Safety Management System Components of SMS Legislation Summary

Safety Stereotype Management Dilemma Need for Safety Management Strategies for Safety Management Imperative of Change Building Blocks – SMS Responsibilities of Managing Safety

Page 4: An Introduction to  Safety Management System  (SMS)

Outline

Fundamentals of Safety Safety Management System Components of SMS Legislation Summary

Safety Policy Safety Risk Management Safety Promotion Safety Assurance

Page 5: An Introduction to  Safety Management System  (SMS)

The Concept of Safety

Zero accidents or serious incidents — a view widely held by the travelling public;

Freedom from hazards, i.e. those factors which cause or are likely to cause harm;

Attitudes of employees of aviation organizations towards unsafe acts and conditions;

Error avoidance; and Regulatory compliance.

Page 6: An Introduction to  Safety Management System  (SMS)

What is Safety?

The state in which the possibility of harm to persons or of property damage is reduced to, and maintained at or below, an acceptable level through a continuing process of hazard identification and safety risk management.

Page 7: An Introduction to  Safety Management System  (SMS)

Evolution of Safety Thinking

Traditional Approach: Focus on outcomes (causes) Unsafe acts by operational personnel Assign blame/punish for failure to “perform safety” Address identified safety concern exclusively

Identifies:

WHAT? WHO? WHEN?

But not always disclose:

WHY? HOW?

Page 8: An Introduction to  Safety Management System  (SMS)

Evolution of Safety Thinking

TECHNICAL FACTORS

HUMAN FACTORS

ORGANIZATIONAL FACTORS

1950s 1970s 1990s 2000

TOD

AY

Page 9: An Introduction to  Safety Management System  (SMS)

Accident Causation

Management decision &

organizational processes

Working conditions

Errors & violations

Regulations

Training

Technology

Organization Workplace People Defences Accident

Page 10: An Introduction to  Safety Management System  (SMS)

Organizational Accident

Organizational processes

IdentifyImprove

Work place conditions

DefencesActive failures

Monitor

Cont

ain

ReinforceLatent conditions

Page 11: An Introduction to  Safety Management System  (SMS)

People, Context & Safety

People & Safety

Page 12: An Introduction to  Safety Management System  (SMS)

People, Context & Safety

Understanding Human Performance

Page 13: An Introduction to  Safety Management System  (SMS)

People, Context & Safety

Understanding Human Performance

Page 14: An Introduction to  Safety Management System  (SMS)

People, Context & Safety

Processes & Outcomes

Page 15: An Introduction to  Safety Management System  (SMS)

SHEL(L) Model

S

L

E

H L

S - Software

H - Hardware

E - Environment

L - Livewire

Page 16: An Introduction to  Safety Management System  (SMS)

SHEL(L) Model

Important factors affecting human performance:

a) Physical factors

b) Physiological factors

c) Psychological factors

d) Psycho-social factors

Page 17: An Introduction to  Safety Management System  (SMS)

SHEL(L) Model

Interfaces between different components of the aviation system:

a) Liveware-Hardware (L-H)

b) Liveware-Software (L-S)

c) Liveware-Liveware (L-L)

d) Liveware-Environment (L-E)

Page 18: An Introduction to  Safety Management System  (SMS)

Errors & Violations

Error Deviation AmplificationDegradation / Breakdown

Incident / Accident

Flaps omitted

Unheeded warning

Checklist failure

Operational Errors – Investigation of major breakdowns

Page 19: An Introduction to  Safety Management System  (SMS)

Errors & Violations

Error Deviation Amplification

Normal flight

Flaps omitted

Unheeded warning

Checklist failure

Safety Management – On almost every flight

Page 20: An Introduction to  Safety Management System  (SMS)

3 Strategies to Control Operational Errors

1. Reduction strategies

a) Human-centred design;b) Ergonomic factors; andc) Training.

2. Capturing strategies

d) Checklists;e) Task cards; andf) Flight strips.

3. Tolerance strategies

g) system redundancies; and

h) structural inspections.

Page 21: An Introduction to  Safety Management System  (SMS)

Errors vs. Violations

General types of violations:

1. Situational violations occur due to the particular factors that exist at the time, such as time pressure or high workload.

2. Routine violations are violations which have become “the normal way of doing business” within a workgroup.

3. Organization-induced violations, which can be viewed as an extension of routine violations. The full potential of the safety message that violations can convey can be understood only when considered against the demands imposed by the organization regarding the delivery of the services for which the organization was created.

Page 22: An Introduction to  Safety Management System  (SMS)

Errors vs. Violations

Safety Space

Viol

atio

n Sp

ace

Exce

ptio

nal

viol

atio

n Sp

ace

Regulations

Technology

Training System’s production objectives

IncidentAccident

Understanding Violations

Minimum Maximum

High

Low

RISK

SYSTEM OUTPUT

Page 23: An Introduction to  Safety Management System  (SMS)

Organizational Culture

National

Organizational

Professional

Page 24: An Introduction to  Safety Management System  (SMS)

Organizational Culture

Organizational literature proposes three characterizations of organizations, depending on how they respond to information on hazards and safety information management:

a) pathological — hide the information;b) bureaucratic — restrain the information; andc) generative — value the information.

Page 25: An Introduction to  Safety Management System  (SMS)

Organizational Culture

a) National culture differentiates the national characteristics and value systems of particular nations.

b) Professional culture differentiates the characteristics and value systems of particular professional groups

c) Organizational culture differentiates the characteristics and value systems of particular organizations

Page 26: An Introduction to  Safety Management System  (SMS)

Organizational Culture

Poor Bureaucratic Positive

Information Hidden Ignored Sought

Messenger Shouted Tolerated Trained

Responsibilities Shirked Boxed Shared

Reports Discouraged Allowed Rewarded

Failures Covered up Merciful Scrutinized

New Ideas Crushed Problematic Welcomed

Resulting organization

Conflicted organization

Red tape organization Reliable organization

Page 27: An Introduction to  Safety Management System  (SMS)

Effective Safety Reporting

Effective safety reporting builds upon certain basic attributes, such as:

a) Senior management places strong emphasis on hazard identification as part of the strategy for the management of safety;

b) Senior management and operational personnel hold a realistic view of the hazards faced by the organization’s service delivery activities;

c) Senior management defines the operational requirements needed to support active hazard reporting, ensures that key safety data are properly registered, demonstrates a receptive attitude to the reporting of hazards by operational personnel and implements measures to address the consequences of hazards;

Page 28: An Introduction to  Safety Management System  (SMS)

Effective Safety Reporting

d) Senior management ensures that key safety data are properly safeguarded and promotes a system of checks and);

e) Personnel are formally trained to recognize and report hazards and understand the incidence and consequences of hazards in the activities supporting delivery of services; and

f) There is a low incidence of hazardous behaviour, and a safety ethic which discourages such behaviour.

Page 29: An Introduction to  Safety Management System  (SMS)

Effective Safety Reporting – 5 basic traitsInformation

People are knowledgeable about the human, technical and organizational factors that determine the safety of

the system as a whole

WillingnessPeople are willing to report their errors and experiences

AccountabilityPeople are encouraged (and rewarded) for

providing essential safety-related information. However, there is a clear line

that differentiates between acceptable and unacceptable behaviour

FlexibilityPeople can adapt reporting when facing

unusual circumstances, shifting from the established mode to a direct mode

thus allowing information to quickly reach the appropriate decision-making

level

LearningPeople have the competence to draw conclusions from safety information systems and the will to implement

major reforms

Effective safety Reporting

Page 30: An Introduction to  Safety Management System  (SMS)

Safety Investigation

to put losses behind; to reassert trust and faith in the system; to resume normal activities; and to fulfil political purposes.

Page 31: An Introduction to  Safety Management System  (SMS)

Safety Investigation

Safety investigation for improved system reliability:

a) to learn about system vulnerability;b) to develop strategies for change; andc) to prioritize investment of safety resources.

Page 32: An Introduction to  Safety Management System  (SMS)

Outline

Fundamentals of Safety Safety Management System Components of SMS Legislation Summary

Safety Stereotype Management Dilemma Need for Safety Management Strategies for Safety Management Imperative of Change Building Blocks – SMS Responsibilities of Managing Safety

Page 33: An Introduction to  Safety Management System  (SMS)

Safety Stereotype

The safety stereotype:

safety first vs. safety is an organizational process Safety is not first priority in aviation safety is just organizational process

.

Page 34: An Introduction to  Safety Management System  (SMS)

Dilemma of 2 P’s:

Production Protection

Management Dilemma

Page 35: An Introduction to  Safety Management System  (SMS)

Management Dilemma

Protection Production

Management Levels

ResourcesResources

$$ PESO YEN

$$ PESO YEN

Page 36: An Introduction to  Safety Management System  (SMS)

Management Dilemma

Protection

Production

Management Levels

Resources

Resources

$$ PESO YEN

$$ PESO YEN

Catastrophe

Page 37: An Introduction to  Safety Management System  (SMS)

Management Dilemma

Protection

Production

Management Levels

Resources

Resources

$$ PESO YEN

$$ PESO YEN

Bankruptcy

Page 38: An Introduction to  Safety Management System  (SMS)

Minor-major accident

Need for Safety Management

Major air disaster are rare Incidents occur more frequently Ignoring the major could lead to an

increase number of more serious accidents

Page 39: An Introduction to  Safety Management System  (SMS)

Minor-major accident Economics of Safety

Need for Safety Management

Accidents cost money Insurance can help but not all There are many uninsured cost Lost of confidence of the travelling

public

Page 40: An Introduction to  Safety Management System  (SMS)

Minor-major accident Economics of Safety Publics perceived safety while traveling

Need for Safety Management

Prerequisite for a sustainable aviation business

Page 41: An Introduction to  Safety Management System  (SMS)

Strategies for Safety Management

System Design

Operational deployment Operational performance

Baseline performance

Regulations

TrainingTechnology

The practical drift

Source: Scott A. Snook

Page 42: An Introduction to  Safety Management System  (SMS)

Reactive Proactive Predictive

Strategies for Safety Management

Page 43: An Introduction to  Safety Management System  (SMS)

Strategies for Safety Management

Reactive method

The reactive method responds to events that have 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

Page 44: An Introduction to  Safety Management System  (SMS)

Strategies for Safety Management

Hazards Predictive Proactive Reactive Reactive

Strategies – Levels of intervention and tools

FDADirect

observation systems

ASRSurvey Audits

ASRMOR

Accident and incident reports

Highly efficient Very efficient Efficient Insufficient

Safety management levels

Desirable management levels

High

High Middle Low

Page 45: An Introduction to  Safety Management System  (SMS)

The management of change

Aircraft and Equipment are changing overtime Hazards that are by product of change Change can introduce new hazard Formal Process for the Management of change

Critically of system and activities Stability of systems and operational environment Past performance

Imperative of Change

Page 46: An Introduction to  Safety Management System  (SMS)

The traditional safety paradigm relied on the accident/serious incident investigation process as its main safety intervention and method, and it was built upon three basic assumptions:

a) The aviation system performs most of the time as per design specifications (i.e. baseline performance);

b) Regulatory compliance guarantees system baseline performance and therefore ensures safety (compliance-based); and

c) Because regulatory compliance guarantees system baseline performance, minor, largely inconsequential deviations during routine operations (i.e. processes) do not matter, only major deviations leading to bad consequences (i.e. outcomes) matter (outcome oriented).

Imperative of Change

Page 47: An Introduction to  Safety Management System  (SMS)

It is based on the notion of managing safety through process control, beyond the investigation of occurrences, and it builds upon three basic assumptions also:

a) The aviation system does not perform most of the time as per design specifications (i.e. operational performance leads to the practical drift);

b) Rather than relying on regulatory compliance exclusively, real-time performance of the system is constantly monitored (performance-based); and

c) Minor, inconsequential deviations during routine operations are constantly tracked and analysed (process oriented).

Imperative of Change

Page 48: An Introduction to  Safety Management System  (SMS)

1. Senior Management’s commitment to the management of safety2. Effective safety reporting3. Continuous monitoring4. Investigation of safety occurrences5. Sharing safety lessons learned and best practices6. Integration of safety training for operational personnel7. Effective implementation of standard operating procedures (SOP’s)8. Continuous improvement of the overall level of safety

8 Building Blocks - SMS

Page 49: An Introduction to  Safety Management System  (SMS)

The responsibilities for managing safety can be grouped into four generic and basic areas, as follows:

a) Definition of policies and procedures regarding safety. Policies and procedures are organizational mandates reflecting how senior management wants operations to be conducted.

b) Allocation of resources for safety management activities. Managing safety requires resources. The allocation of resources is a managerial function.

c) Adoption of best industry practices. The tradition of aviation regarding safety excellence has led to the continuous development of robust safety practices. Aviation has, in addition, a tradition regarding exchange of safety information through both institutional and informal channels.

4 Responsibilities of Managing Safety

Page 50: An Introduction to  Safety Management System  (SMS)

d) Incorporation of regulations governing civil aviation safety. There will always be a need for a regulatory framework as the bedrock for safety management endeavours. In fact, sensible safety management can develop only from sensible regulations.

4 Responsibilities of Managing Safety

Page 51: An Introduction to  Safety Management System  (SMS)

In summary, safety management:

a) includes the entire operation;b) focuses on processes, making a clear differentiation between

processes and outcomes;c) is data-driven;d) involves constant monitoring;e) is strictly documented;f) aims at gradual improvement as opposed to dramatic change; andg) is based on strategic planning as opposed to piecemeal initiatives.

Summary

Page 52: An Introduction to  Safety Management System  (SMS)

The End

Page 53: An Introduction to  Safety Management System  (SMS)

Questions & Answers