Safety Management System [SMS] Course presented by

SCANDINAVIAN AVIATION EDUCATION PROGRAM
Safety Management System [SMS] Course
presented by
for
Bodø 2014
Safety Management System Course
Introduction: The course is conducted by Scandinavian Aviation for Luftfartstilsynet.
Instructor: Morten Kjellesvig, MSc Air Safety Management
Pilot, Scandinavian Airlines, Manager ScandiAvia and Flyoperativt Forum
Morten Kjellesvig is an airline pilot with experience from both long haul, Airbus 330
and 340, and short haul MD-80 and B-737 in Scandinavian Airlines. He has attended
several courses in safety management and accident investigation and has extensive
experience in aviation Safety Management, Risk Management and Accident /
Incident investigation. In the Royal Norwegian Air Force he flew fighter aircraft and
held several management positions as safety manager, and held several courses for
safety employees. He also attended 10 accident investigations, three as chairman.
In Scandinavian Airlines Morten has held several management positions including
Head of Flight Safety and Quality Support administering SAS quality system and
been a part of SAS Company Investigation Team.
Morten is managing director of ScandiAvia and he has taught quality and safety
management in several Norwegian businesses and at different classes at SAS Flight
Academy, Oxford Aviation Academy, at the University of Southern California and at
City University around the world.
Morten finished his master project
in January 2008 on Risk
Management completing his Master
of Science, MSc in Air Safety
Management at City University in
London.
Course Introduction
Welcome to
Aviation Safety
Management Course
Morten Kjellesvig
Aviation Safety Management Course
Confidentiality Agreement
It is understood and agreed to that during this course
participants and lecturers may disclose or reveal own
companys ”confidential” information and that such information
must be kept confidential To ensure the protection of such
information, and to preserve any confidentiality necessary it is
agreed that:
Information in the interest of Safety shall be kept confidential
The participants agrees not to disclose the confidential
information obtained from the discloser to anyone
WHEREFORE, the parties acknowledge that they have read and
understand this Agreement and voluntarily accept the duties
and obligations set forth herein
Purpose
To give an overview of the SMS it’s elements
and organisational structures,
accountabilities, policies and procedures
1
SMS is a management system for safety and
claims for an active management of risks
equivalent to financial or personnel matters
SMS shall prevent aircraft accidents within the
next 20 years
INTRODUCTION
Safety Philosophy
Communicate for Safety!
Goal: To Achieve Zero Accident Record
First Airplane Crash, 17 SEP 1908
† Lt. Selfridge, Fort Meyr, VA
Severely injured, Orville Wright
The Flyer seconds before
the propeller breaks and
Orville loses control.
2
Airliner accident Fatalities 1989-2013
1800
1675
1600
1400
1380
1374
1200
1000
1061 1053
400
1306
1244
1101
973
730
800
600
1338
522
1095
1022
778
1050
863
702
466
757
831
597 583
507457
638 last
decade
265
200
0
1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013
2012 extremely safe year for aviation,
2013 even better
2013: 29 fatal airliner accidents, resulting in 265
fatalities
2012: 23 fatal airliner accidents, resulting in 475
fatalities
Since 1997 the average number of airliner
accidents has shown a steady and persistent
decline. Why do you think?
SHOULD YOU CRASH?
SHOULD YOU CRASH BECAUSE YOU
LOSE ONE RADAR ALTIMETER!
3
Dutch Safety Board statement 4 March 2009
CVR & FDM:
At 1950 feet the left radio altimeter
suddenly indicated a change in altitude –
from 1950 feet to - 8 feet - and passed this
on to the automatic pilot.
This change had a particular impact upon
the automatic throttle system
This radio altimeter is very significant for
providing the appropriate power for an
automatic landing.
The voice recorder has shown that the
crew were notified that the left radio
altimeter was not working correctly (via
voice “landing gear must go down”).
ICAO SMS documents
ICAO SMS Standards and
Recommended Practices
(SARPs) in Annex 1 to 19
ICAO Safety Management Manual
(SMM) Doc 9859 Ed. 3
Flight Safety Program vs SMS
A Flight Safety Program is primarily reactive
and typically focuses on only one part of the
system - the airline operation [EU-OPS]
A SMS is primarily proactive/predictive. It
considers Threats and risks that impact the
whole organization, and have a risk focus
4
Flight Safety Program vs SMS
Accident Prevention and Flight Safety program
Quality System
Safety Management System
Principles about the same
Safety across the whole organisation
More proactive / predictive
What is Safety
Within the context of
aviation, Safety is:
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.
(SMM Ed3 page 12)
Safety = no unacceptable risks
Concept of safety
The elimination of accidents through a risk
management approach
Failures will occur, in spite of the most
sophisticated prevention efforts
No human made system can be free from risk
Controlled risk are acceptable in an inherently
safe system
5
Concept of Safety (doc 9859)
Safety is the state which the risk or 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
Definitions - Safety Risk Management
“Safety risk management (SRM) - a formal
process within the SMS composed of
describing the system, identifying the
hazards, assessing the risk, analysing
the risk, and controlling the risk. The
SRM process is embedded in the processes
used to provide the product/service; it is not a
separate/distinct process.”
(FAA AC120-92, Introduction to SMS).
Quality
6
INTRODUCTION
Perceived Value
Expectation
>1 = Quality
Fitness for a Purpose
SMS definition SMM ed 3 – page 10
A systematic approach to managing safety,
including the necessary
organizational structures,
accountabilities,
policies and
procedures.
SMS – FAA – SMM
7
SMS – FAA – SMM
Safety
Training
Inspections
Man
Line check
(LOSA)
Evaluation
TEM
Audit
Safety
Assurance
Safety Policy
Management
Crisis
Management InvestiInvestigation
Safety
Promotion
Risk
Safety Culture
External
Info
CSM
FDM
PC
OPC
Safety
Magazine
Safety
reporting
SMS vs. Q
SMS focuses on the safety aspects in the
organization
Q focuses on the services and products of the
organization
Q focus on conformity, SMS focus on threats
Both systems enhance safety and are essential
and complimentary management tools
You cannot have an effective SMS without
applying quality management principles
SMS - orientation
Reac-ve → past oriented
accident investigation
Pro-ac-ve → present oriented
incidents, mandatory reports
Predic-ve → future oriented
threats, risks
8
AMC1 ORO.AOC.135 NOMINATED PERSONS
The operator shall appoint an accountable
manager [ORO.GEN.210]
Compliance monitoring manager
Safety Manager
Nominated Persons
Flight Operations
Crew training
Ground operations
Continuing airworthiness - [Maintenance system]
IMPORTANT
The Safety / Compliance Person is NOT,
Mr. FIX IT
but
Mr . FIND IT
?
Current code-share audit schedule
Audits
No audit sharing –
Multipel audits per airline
9
IOSA code-share audit schedule
Audits
IOSA
system
Audit sharing –
One audit pr airline
IOSA benefits
[IATA Operational Safety Audit]
First international operational standards
A model for operational safety/quality management
Quality oversight (standardization)
Fewer audits - replaces existing code-share audits
System for sharing audits
System for registration of Operators
A model to improve global operational safety
Benefits of Annex 19
Highlights the importance of SM at the State level;
Enhances safety by consolidating SM to multiple
aviation domains
Facilitates the evolution of SM provisions
An opportunity to further promote the
implementation of SMS and SSP provisions and
A process established to analyze feedback received
regarding Annex 19 and SM implementation.
10
ICAO SARP
ICAO Annex 19 SARPs address safety
management activities of:
approved training organizations
international aircraft operators
approved maintenance organisations
organizations responsible for type design and/or
manufacture of aircraft
air traffic service providers
certified aerodromes.
ICAO SMS SARPs Audience Groups
Two audience groups:
States
Service providers (providing aviation services)
Three distinct requirements:
SSP - the acceptable level of safety (ALoS) of a SSP
SMS incl. the Safety performance of an SMS
Management accountability in terms of managing
safety.
ALOS vs Safety Performance
Acceptable level of safety (ALoS) is an
objective measurable safety value used for
SSP
Safety performance is an objective
measurable safety value assessing outcomes
Safety performance indicators must be agreed
between the State and service provider
11
Safety Policy / Safety Culture
Safety Policy
Safety Culture
Safety Policy
The safety policy is the means whereby the
operator states its intention to maintain and,
where practicable, improve safety levels in all its
activities and to minimise its contribution to the
risk of an aircraft accident as far as is reasonably
practicable.
The safety policy should state that the purpose of
safety reporting and internal investigations is to
improve safety, not to apportion blame to
individuals.
AMC1 ORO.GEN.200(a)(2) Management system
Safety Policy
The safety policy should:
be endorsed by the accountable manager;
reflect organisational commitments regarding
safety and its proactive and systematic
management
be communicated, with visible endorsement,
throughout the operator; and
include safety reporting principles.
AMC1 ORO.GEN.200(a)(2) Management system
12
Safety Policy
The safety policy should include a commitment:
to improve towards the highest safety standards;
to comply with all applicable legislation, meet all
applicable standards and consider best practices;
to provide appropriate resources;
to enforce safety as one primary responsibility of all
managers; and
not to blame someone for reporting something which
would not have been otherwise detected
AMC1 ORO.GEN.200(a)(2) Management system
Safety Policy
Senior management should:
continually promote the safety policy to all
personnel and demonstrate their commitment to it;
provide necessary human and financial resources
for its implementation; and
establish safety objectives and performance
standards.
AMC1 ORO.GEN.200(a)(2) Management system
Can you state your company’s
policy?
Instruks for Luftfartstilsynet
Safety Policy
13
A Quality / Safety policy
Our flights shall be safe
Our flights shall be punctual
Our traveling customers shall find value for money
Our personnel shall be properly trained
Our performance shall be continuously improved
Following order of priorities shall always be applied:
Safety
Punctuality
All other services
Safety Era’s
Engineering
Accident
rate
Training
Human Factor
Present
Management's
culture
Time
Management Culture
“How we do things around here”
Influences everything the organization does
How safely employees behave and do their
jobs
Culture can be learned
14
What is Safety Culture?
Safety Culture progression
The World’s progression through safety
cultures can be summarised as:
1980’s a Blame Culture
1990’s a no Blame Culture
2000 building a Just Culture
2010 a Just Culture
Different from different parts of the world
What is a Safety Culture?
An Informed Culture
hazards/risks understood
continuous effort to ident/overcome threats
A Just Culture
errors understood, willful violations not accepted
acceptable behavior known/agreed
A Reporting Culture
people encouraged to voice safety concerns
reported concerns analyzed/action taken
A Learning Culture
everyone’s skill/knowledge used to enhance safety
leaders update on safety issues
everyone sees safety reports
15
Just culture
Attitude
(knowing what’s the right thing to do),
Behaviours
(doing the right thing)
It’s much
Consistency
about ME
(judging the right thing)
An Informed Culture
hazards/risks understood
continuous effort to ident/overcome threats
A Just Culture
errors understood, willful violations not accepted
acceptable behavior known/agreed
A Reporting Culture
people encouraged to voice safety concerns
reported concerns analyzed/action taken
A Learning Culture
everyone’s skill/knowledge used to enhance safety
leaders update on safety issues
everyone sees safety reports
Yes please, all of the above
How to encourage a ”Safety Culture”
All leaders practice what they preach
Leadership allocates adequate resources/
attention to safety
Leadership acknowledges safety concerns
provide feedback on decisions
decisions explained
timely, relevant, clear
“Organizational Alignment”
16
Principles for developing a ”Safety
Culture”
Identify & Communicate core values,
principles
Specify behavior’s that exemplify values
Feedback on people’s performance
Reward system (formal & informal) consistent
with values & principles
Assume personal responsibility for
championing desired culture
William Steere, CEO of Pfizer Inc
Qualities in Organizations with an Effective SMS
A top-down commitment from management and a
personal commitment from all employees to achieve
safety performance goals
A clear roadmap of what the SMS is and what it is
supposed to accomplish
An established practice of open communication
throughout the organization that is comprehensive and
transparent, and where necessary, non-punitive; and
An organizational culture that continuously strives to
improve.
17
Management by fear
Ruled by fear
Safety versus Operations
Safety people are spies
Accidents are cost of business
Management by fear
Managements wrong Focus
Lack of Communication or one way communication
Lack of personal participation
Lower management not involved
Inspection oriented
Safety meetings ineffective
“Do as I say, not as I do”
Unwritten rules
Visual and verbal communication
World class Culture
Clearly defined Safety Program
Everybody knows the elements in the Safety
Program
Supervisors are accountable for the safety
program
Superior management
Respond to feedback
Recognizes good performance
18
Proactive safety management
Mandatory and voluntary reporting systems,
safety audits and surveys.
Based upon the notion that system failures can be
minimized by:
identifying safety risks within the system before it fails;
and
taking the necessary actions to reduce such safety
risks.
Reactive safety management
Based upon: we wait until something breaks before
we fix it
Investigation of accidents and serious incidents
Most appropriate for:
situations involving failures in technology
unusual events
The contribution of reactive approaches to safety
depends on the quality of the investigation:
Did we look for and found all the DOMINOS?
Predictive safety management
Confidential reporting systems, flight data
analysis, normal operations monitoring
Based on the notion: safety management is best
accomplished by looking for trouble, not waiting
for it
Actively seek information from all sources which
may be indicative of reduced safety
19
INTRODUCTION
Basics of safety management
Reactive method
Proactive method
Predictive method
The reactive method
responds to the
events that already
happened, such as
incidents and
accidents
The proactive method
looks actively for the
identification of
safety risks
through the analysis
of the organization’s
activities.
The predictive
method captures
system
performance as
it happens in
real-time
normal operations
The imperative of change
As global aviation activity and complexity
continues to grow, traditional methods for
managing safety risks to an acceptable level
become less effective and efficient
Alternative methods for understanding and
managing safety risks are evolving
Accountable Manager
Has the final authority and responsibility for:
- the allocation of resources
- the acceptance of risks
Supports the SMS
Knows the safety policy
Hold persons accountable
€
20
Responsibilities of Senior Management
Establishing levels of acceptable risk
Establishing safety & quality policy
Establishing safety performance indicators
[SPI] goals
Allocating sufficient resources
Overseeing system performance
Modifying policies & goals, as necessary.
SMS Integration: Accountabilities
Safety management – Key features
Reactive, proactive and predictive schemes for
identifying safety risks throughout their organization
Active search of safety risks using such techniques as
trend monitoring and internal safety audits
Active safety promotion, sharing safety lessons
learned from reactive, proactive and predictive
schemes (internal and external)
Monitoring system in place to supervise safety
performance
Accidents or Incidents
Feedback from accidents
Can be useful but Reactive
Feedback from incidents
More useful / More data
Can be Proactive
Feedback from ‘normal’ operations
FDR, Audit
Break the Chain!
21
Is there a difference?
Should we
build a better fence at the top of the hill,
or
place an ambulance down in the valley?
When you make a mistake there is only three
things you should ever do about it:
Admit it,
Learn from it and
Don't repeat it.
Feedback creates
CULTURE!
Culture eats
STRATEGIES
for Breakfast.
22
Motivation
You can not only say it, you must LIVE it
Be a good listener (Communicator)
Share future plans
Involvement
Ask for ideas
Be a participant
Set tone for safety
In summary
Managing Safety requires resources
Allocation of resources is a management
function
Management has the authority and the
responsibility to manage safety risks in the
organization
Manuals are not
the essence of the process,
it is the people,
the organization
the culture and attitude.
23
Risk Management
Safety
Safety
Safety Policy
Risk
Assurance
Safety Culture
Promotion
Management
Definitions
Risk: The chance of Harm, in
terms of Probability and Severity
i.e. (how often x how bad)
considered with the element of
exposure to risk.
Hazard: Something that can
cause significant Harm
Threat: Cause the release of
Hazard
Acceptable risk?
ALARP – as low as reasonable practicable.
It should, however, be remembered that when
an individual, an organization or a society
”accepts” a risk, this does not mean that the
risk is eliminated.
24
Risk Based Approach
Problem solving or risk control for regulatory
agency needs the following capacities:
To Identify
To Analyze
To prioritize risk or problem areas in order:
To ascertain the justifiable intensity of regulatory safety
oversight
To fix and control the problem or risks
Risk Management
Define Risk
Identify Risk
involved
Assess
Risk factor
Make control
decisions
Action to
control Risk
Monitor &
Evaluate
Risk analysis
Risk assessment
Risk Management
Rationale for Risk Management
Every situation has Threats
No one knows all the Threats
Threats are not equally consequential
All situations require a balance (Risk vs.
Benefit)
Limited resources available to identify,
eliminate, and control Threats
All serious Threats should be eliminated or
controlled
25
Risk Management Rules
No unnecessary risk should ever be accepted
Risk decisions must be made at the
appropriate level
Advantages of Risk Management
Detect risk before loss
Quantify risk
Provide risk control alternatives
Greater integration of safety
Increased mission capability
Necessary Risk
..an organisation is safe enough when the
leaders seeks modern safety processes, and
makes the effort to identify every possible
hazard, and then strives to eliminate, control
or reduce the associated risks through
training, procedures and technology to the
point that operations do not accept
unnecessary risks.
Greg Alston 2003
26
Identify
Threats
Determine
Risk
Acceptable ?
Yes
NO
NO
Eliminate
Risk
Yes
Reduce
Risk
NO
Cancel !!!
Yes
Continue operation
Evaluate !
Safety Awareness
Over-reaction
Optimal
Awareness
X
Event
Under-reaction
Time
Change Probabilities
What is the Probability of getting:
2
3
4
5
6
7
8
9
10
11
12
27
Risk assessment
Severity (Consequences)
Probability (Frequency)
Low (1)
Low (2)
Medium (3)
High (4)
5
10
15
20
25
High (4)
4
8
12
16
20
Medium (3)
3
6
9
12
15
Low (2)
2
4
6
8
10
Lov (1)
1
2
3
4
5
High (5)
High (5)
Risk Acceptance Criteria
1-6
May be acceptable, however,
review task to see if risk can be
reduced further
7-14
Task should only proceed with appropriate
management authorisation. Where possible the
task should be redefined to take account of the
threats involved or the risk should be reduced
further prior to task commencement.
15-25
Task must not proceed. It should be redifined or
further control measures put in place to reduce
risk. The controls should be reassessed for
adequacy prior to task commencement.
Probability (of coming off the road) = High
Severity (half a meter
on to grass) = Low
Severity (big drop,
sudden stop) = High
Low Speed = Low Probability
High Speed =High Probability
Exposure = How many times do we pass by
28
Probability
Designation
Description
Low (1),
Improbable
Not credible or almost improbable, not heard of or seen before
and can be assumed that it never happens
Low (2),
Remote
Low probability and would require multiple failures but can
eventually happen
Medium (3), Probably that it happens sometimes and can lead to an accident
Occasional
High (4),
Probable
Could lead to an accident, and similar incident have occurred
before
High (5),
Frequent
Probably that it happens and likely to lead to an accident,
similar incidents have lead to accidents in the past
Severity
Personnel
Material Damage
Cost
Very low (1),
Insignificant
Negligible, no injury
Negligible or no
damage
Less than 10.000 $
Low (2), Marginal
Minor / Light injury
requiring first aid
treatment on site.
Damage requiring
minor repair
Up to 1 mill $
Medium (3),
Marginal to
Critical
Event leading to a
minor injury
where personnel
can no longer
continue duty.
Damage requiring
extensive repair
and or loss of
production /
function.
1 – 10 mill $
High (4), Critical
Involving severe
injury
Severe damage
requiring
extensive repair
and or loss of
production /
function
10 – 25 mill $
High (5),
Catastrophic
Involving death
Hull loss, material loss
More than 25 mill $
ICAO SMM page 5-8
29
An aircraft lands just after taking off due to fire/smoke in the cabin.
The investigation revealed that it was due to moist in the cables
and couplings and the air condition system had been operating
only partly for the last month.
How do we reduce the Probability?
How do we reduce the Severity?
Gnd towing collision
Report from Investigator
One qualified person in towcar and A/C
Catering truck stopped one meter past stop line
Tow car ”shortened” the turn
Person in TOW car: didn’t see the catering truck
Person in A/C occupied with ”trouble shooting”
Person in catering truck saw it happen but not
enough time to back off
Gnd towing collision
Conclusion from Investigator
21 incidents or ”hits” car / A/C last five
years
Painting of stop lines insufficient
Training for personnell
Attitude among ground personnell
30
Safety Assurance
Safety
Safety Culture
Safety
Assurance
Safety Policy
Risk
Promotion
Management
Acceptable level of safety [ALoS]
Implementation
An acceptable level of safety will always be
expressed by a number of safety performance
indicators [SPI] and safety targets, never by a
single one
What is a Safety Performance Indicator?
The management of change
The operator should manage safety risks
related to a change. The management of
change should be a documented process to
identify external and internal change that may
have an adverse effect on safety. It should
make use of the operator’s existing hazard
identification, risk assessment and mitigation
processes.
AMC1 ORO.GEN.200(a)(3) Management system
31
Safety review board
The safety review board should ensure that
appropriate resources are allocated to achieve
the established safety performance.
The safety manager or any other relevant
person may attend, as appropriate, safety
review board meetings. He/she may
communicate to the accountable manager all
information, as necessary, to allow decision
making based on safety data.
AMC1 ORO.GEN.200(a)(1) Management system
SMS components
Information
Collection
INTRODUCTION
Monitor
Document
Plan & Implement
Develop
Countermeasures
Action!
SMS components
Analysing
Data
Supporting Sub Systems
Safety reporting of
events and concerns
Incident Investigation
Audit
Risk Management
Cabin Safety Monitoring
Flight Data Monitoring
Safety and quality audits
Line check (LOSA)
External information
Proficiency check
Crisis management, Accident response
Safety orientation and training
32
INTRODUCTION
Three Domains For Collection
Flight Deck
Ground
Maintenance
Three steps
“You don’t know what you don’t know”
“If you don’t know, How can you fix it?”
“If you can’t fix it, you’ve got a real
problem!”
Multiple Causation Concept
Accidents have a many factors
Each factor can be looked upon as “threats”
Threats may stem from management, the system
or the individual
Controlling and/or eliminating threats at all
levels may prevent mishaps
A Safety Management program trains you to
manage or eliminate threats and their [causes]
influence
33
Accident Causation
Improper actions cause accidents
Actions are in three categories:
Planning – Missed checklist
Storage – Improper programming
Execution – Gear vs. flaps
Domino theory
Management introduces latent error into
system
Organization reacts and additional latent
errors are created
Individuals commit active errors
Domino theory
Underlying
Cause
Management
Basic
Cause
System
•Latent Conditions •Latent Conditions
Immediate
Cause
Individual
•Active Failures
34
INTRODUCTION
Domino
R
A
/
A
P
C
R
E
W
R
A
F
A
I
L
M
O
N
I
T
O
R
A
T
G
U
A
R
D
H
I
G
H
I
L
S
S
T
A
L
L
P
R
O
C
Domino
INTRODUCTION
Accident
Domino
INTRODUCTION
H
I
G
H
I
L
C
R
E
W
M
O
N
I
T
O
R
S
T
A
L
L
P
R
O
C
=
Normal &
safe operation
35
Domino theory
Underlying
Cause
Management
Basic
Cause
Immediate
Cause
System
•Latent Conditions •Latent Conditions
Safety
Defenses
Consequences
Individual
Safety Net
Result
•Active Failures
•Countermeasures
•Close Calls
•Incidents
•Accidents
Domino 1, underlying cause
Refers to Latent Conditions
created by management
Link between A/T
and idle not well
known to pilots
Underlying
Cause
Management
•Latent Conditions
Domino 2, basic cause
Refers to Latent Conditions
created by failure of system
Radio Altimeter fails – but
consequence not understood or
taken action to
Basic
Cause
System
•Latent Conditions
36
Domino 3, active failure
Refers to Immediate
Causes or Symptoms
and includes:
Substandard Practices
Substandard Conditions
Individual errors
Immediate
Cause
Individual
[Failure to crosscheck]
•Active Failures
Pay attention to paying attention!
Domino 4, safety defenses
Any action, procedure,
etc. that has the effect
of reducing hazards and
preventing accidents
Designed or has the effect of:
Trapping latent conditions
Trapping active failures
Safety
Defenses
Safety Net
•Countermeasures
37
Why was the Concorde grounded?
Single failure, tirecomponents puncturing the
wing
Domino 5, consequences
Consequence or results reflected in:
Injury
Damage
Other
Consequences
Result
•Close Calls
•Incidents
•Accidents
Multiple Causation Concept
Accidents have a “cause”
Active Failures
Latent Conditions
38
Basic Error
Types
SLIP
ATTENTIONAL FAILURES:
• Omission
• Misordering
• Mistiming
• Reversal
LAPSE
MEMORY FAILURES:
• Omitting planned items
• Place-losing
• Forgetting intentions
UNINTENDED
ACTION
UNSAFE
ACTS
MISTAKE
RULE BASED MISTAKES:
• Misapplication of good rule
• Application of bad rule
KNOWLEDGE BASED MISTAKES:
• Lack of knowledge
• Many variable forms
INTENDED
ACTION
VIOLATION
Reason, 1990
• Routine violations
• Necessary violations
• Optimizing violations
• Acts of sabotage
Voltaire
“There are no such things as accidents”
What we call by that name is the effect
of some cause which we do not see.”
These are just normal, good people
caught up in unusual circumstances
SMS components
Information
Collection
INTRODUCTION
Monitor
Document
Plan & Implement
Develop
Countermeasures
Action!
Analysing
Data
39
SMS components
Supporting Sub Systems
Safety reporting of
events and concerns
Incident Investigation
Audit
Risk Management
Cabin Safety Monitoring
Flight Data Monitoring
Safety and quality audits
Line check (LOSA)
External information
Proficiency check
Crisis management, Accident response
Safety orientation and training
SMS components
Information
Collection
INTRODUCTION
Monitor
Document
Plan & Implement
Develop
Countermeasures
Action!
Analysing
Data
Recording a flight
ACMS, CVR
INTRODUCTION
Black box
Cabin Monitoring
Line check
Reporting
Weight & Balance
system
Documents
Technical
Statistics
Status before
every flight
40
Collecting data
Statement
It is a basic management axiom that one
cannot manage what one cannot measure
Challenge
What do we want to measure?
Where do we get the information from?
How do we manage the information?
Knowledge – The challenge
If too much safety-related information is
collected and stored there is a risk of
overwhelming responsible managers, thereby
compromising the utility of the data
Sound management of the organization’s
databases is fundamental to effective safety
management functions (such as trend
monitoring, risk assessment, cost-benefit
analyses and occurrence investigations
Management
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CSM - Cabin Safety Monitoring
Assess and keep track
of cabin safety issues
Reporting anonymous
Management
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OPC - Operational Proficiency Check
INTRODUCTION
Twice a year
Written test + oral
evaluation
Flying 2 x 2 hours
Additional Simulator
42
Management
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Line check
• Governments CAA
• Pilots observe on
jumpseat
• Once a year
LOSA - LOAS
Management
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43
Iceberg, Factors and Background
B3
B1
B3
B5
F7
B6
B7
F6
F1
Accident
INTRODUCTION
F14
B2
B3
F10 F4
F20
F16
F1
F22 F2 F11
F22
F1 F25
F21
F8
F3
F14
F9
F7 F21
F14
F21
Serious incident
F6 F2
Incidents
Principles of effective incident reporting
Trust
Non-punitive / Just Culture
Inclusive reporting data base
Independence
Ease of reporting
Acknowledgement
Promotion / Feed Back
Reporting
Confidential
Anonymous
44
Two approaches to occurrences
Individual
Who was to blame?
Systemic
Why did the safety system fail?
ICAO Safety Management Manual
”Since safety management aims to reduce the
probability and consequences of accidents, an
understanding of accident and incident
causation is essential to understand safety
management.
INTRODUCTION
Purpose of investigation
Describe what happened
Determine the real causes
Decide the risks
Develop controls
Define trends
Demonstrate concern
45
ICAO annex 13, definitions, accident (page 1-1)
An occurrence associated with the operation of an
aircraft which, in the case of a manned aircraft, takes
place between the time any person boards the
aircraft with the intention of flight until such time as
all such persons have disembarked, or in the case of
an unmanned aircraft, takes place between the time
the aircraft is ready to move with the purpose of
flight until such time as it comes to rest at the end of
the flight and the primary propulsion system is shut
down, in which:
ICAO annex 13, definitions, accident (page 1-1)
A: A person is fatally or seriously injured as
a result of:
being in the aircraft, or
direct contact with any part of the
aircraft, including parts which have
become detached from the aircraft, or
direct exposure to jet blast.
Except when the injuries are from natural causes, selfinflicted or
inflicted by other persons, or when the injuries are to stowaway hiding
outside the areas normally available to the passengers and crew or:
ICAO annex 13, definitions, accident (page 1-1)
B: the aircraft sustains damage or structural
failure which:
adversely affects the structural strength, performance or
flight characteristics of the aircraft, and
would normally require major repair or replacement of the
affected component.
except for engine failure or damage, when the damage is limited to a
single engine, (including its cowlings or accessories), to propellers, wing
tips, antennas, probes, vanes, tires, brakes, wheels, fairings, panels,
landing gear doors, windscreens, the aircraft skin (such as small dents or
puncture holes), or for minor damages to main rotor blades, tail rotor
blades, landing gear, and those resulting from hail or bird strike
(including holes in the radome); or
C: the aircraft is missing or completely inaccessible.
46
ICAO annex 13, definitions, incident (page 1-1)
An occurrence, other than an accident,
associated with the operation of an aircraft
which affects or could affect the safety of
operation.
ICAO annex 13, definitions, serious incident (page 1-2)
An incident involving circumstances indicating that there
was a high probability of an accident and associated
with the operation of an aircraft which, in the case of a
manned aircraft, takes place between the time any
person boards the aircraft with the intention of flight
until such time as all such persons have disembarked, or
in the case of an unmanned aircraft, takes place
between the time the aircraft is ready to move with the
purpose of flight until such time as it comes to rest at
the end of the flight and the primary propulsion system
is shut down.
(The difference between an accident or a serious incident lies only in the result.)
ICAO annex 13, access to crash site
State of Occurrence
State of Registry
State of Operator
State of Design
State of Manufacture
State having Suffered Fatalities
47
ICAO annex 13, definitions
Accredited representative:
A person designated by a State, on the basis of his her
qualification, for the purpose of participating in an
investigation conducted by another state.
Adviser:
A person appointed by a State, on the basis of his or her
qualifications, for the purpose of assisting it's accredited
representative in an investigation.
The Report ICAO Annex 13
Body:
I. Factual information
2. Analysis
3. Conclusions
4. Safety recommendations
The Report ICAO Annex 13
Synopsis
1. FACTUAL INFORMATION
1.1. History of the flight
1.2 Injuries to persons
1.3 Damage to aircraft
1.4 Other damage
1.5 Personnel information
1.6 Aircraft information
48
The Report ICAO Annex 13
1.7 Meteorological information
1.8 Aids to navigation
1.9 Communications
1.10 Aerodrome information
1.11 Flight recorders
1.12 Wreckage and impact information
1.13 Medical and pathological information
1.14 Fire
1.15 Survival aspects
The Report ICAO Annex 13
1.16 Tests and research
1.17 Organizational and management
information
1.18 Additional information
1.19 Useful or effective investigation techniques
The Report ICAO Annex 13
2. Analysis
3. Conclusion
Summary of findings
Cause
4. Recommendations
5. Appendices
49
Making recommendations
This the most powerful part of investigation
Use recommendations carefully
Don’t demand too much
Think about the consequences
Are there any 100% solutions?
REPORT WRITING
INTRODUCTION
Factual Info.
WHAT
ANALYSIS
Factual Info.
ANALYSIS
WHY
FINDINGS
FINDINGS
RECOMMENDATIONS
CAUSE
RECOMMENDATIONS
The sole
objective of the
investigation of
an accident shall
be the prevention
of accidents and
incidents. It is
not the purpose
of this activity to
apportion blame
or liability.
50
Management
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Audit - program
Audit is a systematic, independent and documented process
to judge effectiveness
Trained auditers
Audit schedule
Finding is a deviation from specified requirements or an obvious lack
of procedure.
Concern is a deviation from good practice, or activities that could lead
to reduced quality
Internal – subcontracted activities
External: in company but outside your department
Governments
Alliance
IOSA http://www.icao.org/
Management
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51
FDM - Flight Data Monitoring
The safety manager, should be responsible for
the identification and assessment…
A FDM programme should allow an operator to:
identify areas of operational risk and quantify current
safety margins;
identify and quantify operational risks by highlighting
occurrences of nonstandard, unusual or unsafe
circumstances
AMC1 ORO.AOC.130 Flight data monitoring - aeroplanes
FDM - Flight Data Monitoring
use the FDM information on the frequency of such
occurrences, combined with an estimation of the level
of severity, to assess the safety risks and to determine
which may become unacceptable if the discovered trend
continues;
put in place appropriate procedures for remedial action
once an unacceptable risk, either actually present or
predicted by trending, has been identified; and
confirm the effectiveness by continued monitoring.
AMC1 ORO.AOC.130 Flight data monitoring - aeroplanes
FDM - Flight Data Monitoring
• Registers certain values every
second
• Define standards
– (sub. standard & unacceptable)
• Statistics
• Undisciplined flying
52
FDM recording & analysis
Listed last 13 Months | Sub Std Unacceptable |
Approaches recorded
Gear not down 500/1000’
Slat / Flap 500/1000
Vref +40 below 500’
ROD >1500 below 1000/500
Bank > 20°below 500’
VMo / MMo exceedance
Vert acc > 2.0G and 1.5 – 2.0G
How to Detect Threats
Analysis of data
Observation of near mishaps
Safety surveys
Review of company plans, policies,
procedures, and instructions
The Goal
Generating a Safety Data Base
a tool for managers, safety managers and
regulatory authorities for monitoring
system safety issues
53
SMS components
Information
Collection
INTRODUCTION
Monitor
Document
Plan & Implement
Develop
Countermeasures
Action!
Analysing
Data
Analysing Data
Daily operation
Observation of near mishaps, Shops, Supply, Storage,
Administration, Flight Operations
Accident statistics
Advantages
Provides base line, Hard numbers
Disadvantages
Density, Misleading
Risk Management
Management Evaluation (Review)
Observation of near mishaps, Safety surveys, Review of
company plans, policies, procedures, and instructions
Conducting the Analysis
Conduct Risk Analysis based on:
Severity of mishap
Probability of occurrence
Exposure to threat(s)
54
SMS components
Information
Collection
INTRODUCTION
Monitor
Document
Plan & Implement
Develop
Countermeasures
Action!
Analysing
Data
Develop Countermeasures
Design for minimum hazard
Safety devices
Warning devices
Procedures and training
SMS components
Information
Collection
INTRODUCTION
Monitor
Document
Plan & Implement
Develop
Countermeasures
Action!
Analysing
Data
55
Document Plan and Implement
Timeline
Who does what, when and how
SMS components
Information
Collection
INTRODUCTION
Monitor
Document
Plan & Implement
Develop
Countermeasures
Action!
Analysing
Data
Timeline
Information collection: see something
Analysing: see some training issues
Action: need to add simulator training
Document: make a simulator pass
Monitor
56
Monitor
Monitor through SMS – Quality System
Needed effect ?
Side effect ?
When to close
The structure of a Management System
All chapters are numbered according to
process map and starts with the relevant
sub-processes.
Ma n a g em ent pro cesses
Pro d u ce, im plem ent an d follow-u p OF bu sin ess plan
Allo ca te
reso u rces
Meetin g
a d m in istration
Tra ffic Pro g ra m a ccep tan ce
Ma n a g em ent
Ev a lu a tio n
Pro d u ctio n o fFlig hts
Each sub-process is described in work
flow.
Ev a lu a tio n, a nalysis, co rrectiv e an d p rev entive a ctions
S u p p o rt pro cesses
Pro v id e
a d ministrati
v e su p p o rt
Dev elo
p OF
serv ic
es
Pro d u ce
d o cu m entatio
n
Co ntrol
of
training
a nd
q ualific
a tio n
Ma in ta in an d
im p ro v e OF
Qu a lity Sy stem
Ex ternal and
In tern a l
p u rch a sin g
INTRODUCTION
Relevant references and responsible
functions for each step in the work flow
are identified.
Ref.
1.
2.
FOM X.X.X
FOQS X.X.X
Resp.
FO-xyz
1.
Dsd ssfdsds fdsdffd dfds fsd
fsd fsd fsd fs dfdf fdsd fdfd f s a
a a a sdsdddf e a
2.
Dsd fssfdsd sfdsdffd dfds fsd
fsd fsd fsd fs dfdf fdsd fdfd f s a
a a a sdsdddf e a
Dsdfs sfd sdsfdsdffd dfds fsd fsd
fsd fsd fs dfdf fdsd fdfd f s a a a
a sdsdddf e a
3.
???????
CO-?
3.
4.
FOQS X.X.X
FO-?
4.
5.
FOM X.X.X
FO-?
Dsdfss fdsdsfd sdffd dfds fsd
fsd fsd fsd fs dfdf fdsd fdfd f s a
a a a sdsdddf e a
Workflow
1
Identify problem
2
Immediate
Action
3
Take action
4
Debrief involved
personell
5
Report
required?
Reference
Write report
7
Priority?
8
Birdstrike?
+
• Sadsads dfsa d f dc sef se drsf fd
• Dsfesdfsdfdsfsv dcfgf gfg gdrfgs
•cfc asf f rt es s f set es sz fsed srf
• Sadsads dfsa d f dc sef se drsf fd
• Dsfesdfsdfdsfsv dcfgf gfg gdrfgs
•cfc asf f rt es s f set es sz fsed srf
• Sadsads dfsa d f dc sef se drsf fd
• Dsfesdfsdfdsfsv dcfgf gfg gdrfgs
•cfc asf f rt es s f set es sz fsed srf
• Sadsads dfsa d f dc sef se drsf fd
• Dsfesdfsdfdsfsv dcfgf gfg gdrfgs
•cfc asf f rt es s f set es sz fsed srf
• Sadsads dfsa d f dc sef se drsf fd
• Dsfesdfsdfdsfsv dcfgf gfg gdrfgs
Responsible
Crew
No
Checklist
Checklist
Crew
Crew
Commander
No
OM-A
Crew
OM-A
Crew
OM-A
Commander
No further
action
Yes
6
Etc.
Template
Form
Checklist
Instruction
Description
(filing and records)
FO-xyz
Send bird
strike report
Commander &
Flight Safety
Yes
Send ATIR
Commander &
Flight Safety
Yes
Send ACAS
Yes
No
9
ATIR?
No
10
ACAS?
11
Preliminary
assessment
Commander &
Flight Safety
No
Local
instruction
F/O & Flight safety
57
Workflow
12
Investigation
13
Safety meeting
14
Issue Invest. report
15
Reference
Responsible
Investigator instruction
Chief Investigator
ICAO annex 13
Chief Investigator
Flight Ops instruction
Duty manager
Acc. Manager
Report
approved?
No
Yes
16
Recommendation?
17
Final assessment
18
Distribute CAA
19
Action?
Instruction
Local instruction
No
Flight Ops
Yes
20
Perform
action
22
Implementation
23
Acc. Manager
Safety meeting
21
Close & file records
Management
Flight Ops &
Flight Safety
Flight Safety
Commander &
Flight Safety
NPH
Local instruction
Flight Safety
Safety review board
The safety review board should be a high level
committee that considers matters of strategic
safety in support of the accountable
manager’s safety accountability.
The board should be chaired by the
accountable manager and be composed of
heads of functional areas.
AMC1 ORO.GEN.200(a)(1) Management system
Safety review board
The safety review board should monitor:
safety performance against the safety policy and
objectives;
that any safety action is taken in a timely manner;
and
the effectiveness of the operator’s safety
management processes
AMC1 ORO.GEN.200(a)(1) Management system
58
Safety Promotion
Safety
Assurance
Safety Policy
Safety Culture
Risk
Safety
Promotion
Management
ARO.GEN.135 Immediate reaction
to a safety problem
The competent authority
shall implement a system
to appropriately collect,
analyse and disseminate
safety information.
Domino theory
No risk free world
Know about threats
[domino] and control them
59
Safety Promotion
Critical Information
Mishap Reports
Lessons learned
General Information
Bulletin Boards
Safety Magazine
Briefings
E-mails
Posters
Pilot Meetings
Excellence in Safety Training
| Risk Safety Bulletin| Topic: Recession in Aviation |
STATUS
The worlds financial
situation and the threat
towards our airline faces
us with many challenges.
Our focus must be on
performing safe flights for
our passengers
The high operational and
professional focus must be
maintained.
Threats – What is the issue
Unsure about our company’s financial structure
Unsure about own job
Consequences
Using up mental capacity and ”wrong” focus
Increase in ”errors”
Loss of Situational Awareness
Result: increase possibility of making error
Focus & Awareness:
Be ”aware” that uncertainty affect human performance
Extra vigilance, use briefing cards and checklists
Motivate your fellow crewmembers on safety
”Increased” safety margins whenever possible
Captains and Pursers: Be a role models, build
confidence in your crew
”We do not need to be best,
just good enough on a bad day”
Risk Safety Bulletin | January 2009 | Prepared by ScandiAvia
Safety report
Short recap of the month.
1) Red flags, NIL.
Yellow flags, NIL.
2) Reports received
Risk assessment
3) FDM System
4) Crew Reports and Analysis
Level 1:
Level2:
Level 3:
5) Line Check System
6) Cabin Safety Monitoring
7) Human Resources
8) Reports from projects/working groups etc.
9) Deadlines / important dates / coming meetings
10) Miscellaneous
60
Follow up – Audit - Timelimits
Audit XX-2005 Procedures for aircraft handling on ground
F3, Definition of Departure check in Technical Manual x.x.x and respective Flight
Manual is not identical.
Due
31MAR06
Answer: It is signed by F/O but not distributed
Audit XX-2005 Sequrity. Duties not clarified in SEC manual.
Over due
15NOV05
Will be corrected on next revision (15MAR06)
Audit XX-2005 Stabilized Approach concept
C3, Descend rate not equal in Flight Manual and Training manual
Answer, F/O: A group of chief pilots and line pilots will revise stabilised approach
concept. Due time 15APR06. Local CAA informed and has accepted the timeline.
Due
15JUN06
Implementation date: ASAP after study completed, latest 15JUN06
The “Swiss cheese”model (Prof James Reason)
Some holes due
to active failures
Hazards
Other holes due
to latent failures
Losses
Incident and hazard Reporting
Hazards
Avoidable
consequenses
Making those holes visible so we can effectively
manage ERROR (Risk) within the organization
61
Flight safety is quality taken seriously
SAFETY MANAGEMENT SYSTEM
Keep focus
Safety
P olitikere
Operations.
Annet
Media
Ecomomy
Pilots
EASA SMS regulation
SMS should not be implemented through an
additional management system, but be fully
integrated in the organisation's existing
management system
Safety management should include every
facet of management that may impact
aviation safety (financial, operational, health
and safety, etc...)
Safety, as well as compliance with rules,
should be a concern for everybody
62
Case: (SMS)
Discuss the basic elements and
processes that you want to see in
order to have an effective SMS.
Time limit 30 minutes
Emergency Response Planning
Emergency Response
Morten Kjellesvig
Aviation Safety Management Course
Emergency Response - Policy
The professional handling of an
emergency is vital to your customers
and the public’s continued confidence
in your airline
63
ICAO and IOSA Require:
…a corporate emergency response plan (ERP)
for:
the central management and coordination of all
activities
should it be necessary to
respond to a major aircraft
accident … [resulting] in
fatalities, serious injuries or
considerable damage
Framework ERO
“If your airline or airport is involved in a
disaster, most people will accept the fact that
accidents happen.
They will not accept the fact that your
company was unprepared.”
The Emergency Response Organization
Emergency Group
Emergency
Director
Passenger
Manifest
Unit
Telephone
Enquiry
Unit
Communication
Unit
Site
Coordination
Group
Human
Support
Unit
Data
Collection
Unit
64
Emergency Group
Attendants
Head of Administration
Head of Marketing
Head of Communication
Head of Operations
Head of Cabin
Head of Ground operation
Head of Technical
Emergency Group - responsibilities
Appoint an Emergency Station
Be up to date & inform CEO
Make startegic decisions regarding emergency response
Appoint a CIT
Inform governments (FAA)
Decide whether to continue normal operation
Make financial decisions to passengers, crew and families
Participate in press conferences
Assess the need for resources to the total emergency
response
Appoint Head of Post Emergency Activities
Assistance from Alliance members
Emergency Director - responsibility
Manage and coordinate the Emergency
Organization
Head the Emergency Control Center
Regularly report to Emergency Group
Emergency Director – support
Legal Advice
Security
Insurance Handling
Log keeper
65
Passenger Manifest Unit - responsibilities
Coordinate the collection of data regarding
passengers
Obtain passenger flight documents
Cooperate closely with police authority
Deliver Passenger Manifest to ED
Site Coordination Unit - responsibilities
Strategically direct and support airline onsite
emergency operation
Cooperate with external emergency
organizations and authorities on the site
Arrange for relief flights and next of kin flights
Consider reinforcement of local and regional
resources
Site Coordination Unit - organization
Log keeper
Family Assistance Team
Company Investigation Team
Aircraft Recovery
Special Assistance Team
Kenyon.....
66
Human Support Unit - responsibilities
HSU is responsible for providing practical and
emotional support to passengers, crew,
personnel and their families affected by the
emergency situation.
Human Support Unit - organization
Financial Support
Company Medical Staff
Travel Service
Crew and Staff emergency support
Family Assistance Support Team
Data Collection Unit - organization
Flight Operation
Technical Data Representative
Crew Data Representative
Departure Station Data Representative
Cargo Data Representative
67
Telephone Enquiry Unit
• Serve as a contact for
relatives and friends of
passengers involved
• Could be located at
different places
• Manned by airline
personnel interested in
humans
• Toll free numbers
Communication Unit
Win the press
Obtain relevant information about the
emergency
Ensure that there is a contact person for
media relations on the crash site
Participate and prepare for press conferences
Produce and issue press releases
Produce and release internal information
General
Handling of media
Each unit should be headed by managers
Checklists
Change over (form)
Names involved
Date and time
Current emergency status
Decisions taken – to be taken
Other information
Next change over
68
Quality Assurance
To ensure that ED carries out all tasks as
required
Have a checklist
Include a check of all tasks
Reference to each task
Performed every hour
Checklists
Step #
Action
Information
5. Approve the....
See ERM 4.2.1
6. Contact....
Consult with ED
7. Inform the
chairman....
Consider a telephone
conference
8. Proceed to emergency
room
Building 3, room 412
Performed by
& time
Post Emergency Organization
Superseedes ERO
Lasts at least a year
Include
Activity plan – Control Gates & Milestones
Many of the same as in ERO
Quality Assurance checklist
69
Exercises – emergency training
High level training
EEG
Police
Emergency station
CAA
Other units within organization
Emergency exercises
Types of exercise
Organization
Exercise control
Exercise participants
Input providers
Fire department
Police
Hospital
Military
Journalists
Forms – reports - checklists
Preliminary Aircraft Accident Notification
Report
Aircraft Accident Notification Report
Emergency Group Briefing Agenda
Insurance checklist
Legal Checklist
Sabotage checklist
Checklist for different units
70
Those involved in an accident
May be traumatised
May feel guilty
May be frightened
May be in shock
Reaction after an accident or incident
Adrenalinkick
Pressure
Who to talk to – police – accident
board
The accident has happened
Secure passengers and crew.
Follow company procedures.
Take care of you self.
Contact Company for assistance.
Phone:
Keep crew together.
Have crew write what happened.
Write down everything about
the accident.
Do not make statements to media.
Demand written statements
from police.
Do not let you self interrogate.
without assistance (union).
Secure relevant data, pull C/B.
Only talk informal with people
you can trust.
Contact your family.
Consider continued flight duty.
71
Treatment of Crew
Flight Ops shall in each case evaluate if the flight crew shall be
removed from active flight duty in order to participate in the
investigation.
The Chairman of the investigation team shall evaluate as soon
as possible the crew involvement and thereafter provide
Flight Ops with the necessary information to determine the
possible reinstatement of the crew.
Flight Ops will communicate the decision directly to the crew
concerned.
Flight Ops shall inform licensing CAA.
It is our company’s policy that temporarily grounded crew
members should be returned to active duty as soon as
possible with due regard to all medical and psychological
effects.
SSP Doc 9859
Definition
“A safety programme is an integrated set of
regulations and activities aimed at improving
safety.” (ICAO Doc 9859)
Objective
To achieve an acceptable level of safety of aviation
services and products delivered by aviation
service providers - aircraft operators, air
navigation service providers, airport operators,
training and maintenance organisations.
State’s Safety Policy and Objectives
CAA Safety standards
CAA Safety responsibilities and accountabilities
Accident and incident investigation
Enforcement policy
Operators/service providers to deal with, and resolve,
events involving safety deviations and minor violations
internally, within the (SMS), to the satisfaction of the
authority. The enforcement policy includes provisions
for the CAA to deal with events involving gross
negligence and wilfull deviations through established
enforcement procedures.
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State’s Safety Risk Management
Safety requirements for service providers SMS
Approval of service providers acceptable levels
of safety
State’s Safety Assurance
Safety oversight
Safety data collection, analysis and exchange
Safety data driven targeting of oversight on
areas of greater concern or need
State’s Safety Promotion
Internal and external training, communication
and dissemination of safety information
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Annex 19
ICAO Annex 19 SARPs address
safety management activities of:
approved training organizations
international aircraft operators
approved maintenance organisations
organizations responsible for type design and/or
manufacture of aircraft
air traffic service providers
certified aerodromes
Difference SSP & SMS
SSP – an integrated set of regulations and activities
aimed at improving safety
specific safety activities that must be performed by the State
regulations and directives promulgated by the State
SMS – a management tool for the management of safety
by an organisation (shall be accepted by the State)
finding out what is wrong (hazard identification)
proposing and implementing a fix or fixes (remedial action)
making sure that the proposed fix or fixes work as intended
(continuous monitoring)
constantly improving the management system to ensure efficacy
and efficiency
ALoSP
Acceptable level of safety performance
(ALoSP). The minimum level of safety
performance of civil aviation in a State, as
defined in its State safety programme, or of a
service provider, as defined in its safety
management system, expressed in terms of
safety performance targets and safety
performance indicators.
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ALoSP 4.3.5.2
The State’s ALoSP criteria may vary depending on the
specific context of each State’s aviation system and
the maturity of its safety oversight system. The
primary focus is to achieve compliance with ICAO
requirements and to reduce high-consequence events
where such issues are evident.
The focus will progress to where the State is
concerned with a continuous improvement in safety
performance. A State’s ALoSP also expresses the
minimum safety objectives acceptable to the oversight
authority to be achieved by the aggregate service
providers under its authority.
Safety Case
An advanced proactive ”risk assessment”
More common in ATM
Same, same but different?
Runway turnoff B4
Quality system to detect the threats
Reporting system, Audits, Interviews, FDM
Management Review
History
Brainstorming
Workshops
Look through of procedures and checklists
Other operators
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Runway turnoff B4
Slipery RWY (Water – snow)
RWY not grooved
Visual ”signals” in order to observe speed
High speed taxi (TWR)
Hard right turn
Q
Tell me and I forget
Show me and I remember
Involve me and I understand
Benjamin Franklin
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No flight is so important
that we do not have
the time to do it safe!
INTRODUCTION
Safety Philosophy
Communicate for Safety!
Morten Kjellesvig
[email protected]
www.scandiavia.net
Thanks for YOUR attention!
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Risk Management Worksheet
1. Threat
2. Date assessed
3. Tracking nr.
4. Risk index before controls are
implemented
5. Risk index after controls are
implemented
6. Time limit for
implementation
7. Responsible for
implementation
8. Prepared by
9. Risk decision authority
Probability
Severity
Exposure
Other
Risk Management Worksheet
1. Threat
2. Date assessed
3. Tracking nr.
4. Risk index before controls are
implemented
5. Risk index after controls are
implemented
6. Time limit for
implementation
7. Responsible for
implementation
8. Prepared by
9. Risk decision authority
Probability
Severity
Exposure
Other