Icao Sms M 02 - Basic Safety

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Module N 2 Basic

safety concepts

Revision N 13

ICAO Safety Management Systems (SMS) Course

06/05/09

Building an SMS

Safety
Management
System
Module 8

Module 10
Phased approach to
SSP and SMS
Implementation

SMS planning

Module 5
Risks
Module 1
SMS course
introduction
Module N 2

Module 9
SMS operation

Module 6
SMS regulation
Module 2
Basic safety
concepts

Module 7
Introduction to SMS

Module 3
Introduction
to safety
management

ICAO Safety Management Systems (SMS) Course

Module 4
Hazards
#

Objective
At the end of this module, participants will be able to explain

the strengths and weaknesses of traditional methods to


manage safety, and describe new perspectives and
methods for managing safety

Module N 2

ICAO Safety Management Systems (SMS) Course

Outline
Concept of safety
The evolution of safety thinking
A concept of accident causation Reason model
The organizational accident
People, context and safety SHEL(L) model
Errors and violations
Organizational culture
Safety investigation
Questions and answers
Points to remember
Exercise N 02/01 The Anytown City Airport accident
(See Handout N 1)
Module N 2

ICAO Safety Management Systems (SMS) Course

Concept of safety
What is 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 towards unsafe acts and conditions by
employees of aviation organizations
Error avoidance
Regulatory compliance
?
Module N 2

ICAO Safety Management Systems (SMS) Course

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 risk and controlled error are acceptable in
an inherently safe system
Module N 2

ICAO Safety Management Systems (SMS) Course

Concept of safety (Doc 9859)


Safety is the state in which the risk 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

Module N 2

ICAO Safety Management Systems (SMS) Course

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?

WHEN?

WHO?

But not always discloses:


WHY?
Module N 2

HOW?

ICAO Safety Management Systems (SMS) Course

The evolution of safety thinking


TECHNICAL FACTORS

TODAY

HUMAN FACTORS

ORGANIZATIONAL FACTORS

1950s

1970s

1990s

2000s

Fuente: James Reason


Module N 2

ICAO Safety Management Systems (SMS) Course

A concept of accident causation

Latent conditions trajectory

Actions
orover
inactions
bythe
people
(pilots,
controllers,
maintenance
Activities
Conditions
Factors
Resources
that
present
which
to
directly
protect
any
in
influence
against
organization
system
the
the
before
risks
has
efficiency
a
that
the
reasonable
accident,
organizations
of
people
made
degree
in
engineers, aerodrome staff, etc.) that have an immediate
involved in production
evident
aviation
of
activities
by
direct
triggering
workplaces.
control
generate
factors.
and must control.
adverse
effect.
Module N 2

ICAO Safety Management Systems (SMS) Course

The organizational accident


Organizational processes

Workplace
conditions

Active
failures

Policy-making
Planning
Communication
Allocation of resources
Supervision
...

Latent
conditions

Defences

Activities over which any organization has a reasonable degree


of direct control
Module N 2

ICAO Safety Management Systems (SMS) Course

The organizational accident


Organizational processes

Workplace
conditions

Active
failures

Inadequate hazard
identification and
risk management
Normalization of
deviance

Latent
conditions

Defences

Conditions present in the system before the accident, made evident


by triggering factors.
Module N 2

ICAO Safety Management Systems (SMS) Course

The organizational accident


Organizational processes

Workplace
conditions

Technology

Latent
conditions

Training
Active
failures

Regulations

Defences

Resources to protect against the risks that organizations involved


in production activities generate and must control.
Module N 2

ICAO Safety Management Systems (SMS) Course

The organizational accident


Organizational processes

Workplace
conditions

Active
failures

Workforce stability
Qualifications and
experience
Morale
Credibility
Ergonomics
...

Latent
conditions

Defences

Factors that directly influence the efficiency of people in


aviation workplaces.
Module N 2

ICAO Safety Management Systems (SMS) Course

The organizational accident


Organizational processes

Workplace
conditions

Latent
conditions

Errors
Active
failures

Violations

Defences

Actions or inactions by people (pilots, controllers, maintenance


engineers, aerodrome staff, etc.) that have an immediate adverse effect.
Module N 2

ICAO Safety Management Systems (SMS) Course

The perspective of the organizational accident


Organizational processes

Improve

Identify
Monitor

Module N 2

Latent
conditions

Reinforce

Active
failures

Contain

Workplace
conditions

ICAO Safety Management Systems (SMS) Course

Defences

People and safety


Aviation workplaces involve
complex interrelationships
among its many
components
To understand operational
performance, we must
understand how it may be
affected by the
interrelationships among
the various components
of the aviation work places
Module N 2

ICAO Safety Management Systems (SMS) Course

Source: Dedale

Module N 2

ICAO Safety Management Systems (SMS) Course

Processes and outcomes

Causes and
consequences
of operational
errors are not
linear in their
magnitude

Source: Dedale

Module N 2

ICAO Safety Management Systems (SMS) Course

The SHEL(L) model


Understanding the relationship between people and operational
contexts

S
S
HH L LLL
E
E
Module N 2

Software

Hardware
Environment

Liveware
Liveware, other
persons

ICAO Safety Management Systems (SMS) Course

Operational performance and technology


In production-intensive
industries like contemporary
aviation, technology is
essential
As a result of the massive
introduction of technology,
the operational
consequences of the
interactions between people
and technology are often
overlooked, leading to
human error
Module N 2

ICAO Safety Management Systems (SMS) Course

Understanding operational errors


Human error is considered
contributing factor in most
aviation occurrences
Even competent personnel
commit errors
Errors must be accepted as
a normal component of any
system where humans and
technology interact

Module N 2

ICAO Safety Management Systems (SMS) Course

Errors and safety A non linear relationship

Statistically, millions of
operational errors are made
before a major safety
breakdown occurs

Source: Dedale

Module N 2

ICAO Safety Management Systems (SMS) Course

Accident investigation Once in a million flights

Error

Module N 2

Deviation

Amplification

ICAO Safety Management Systems (SMS) Course

Degradation /
breakdown

Safety management On almost every flight

Error

Module N 2

Deviation

Amplification

ICAO Safety Management Systems (SMS) Course

Normal flight

Three strategies for the control of human error


Error reduction strategies
intervene at the source of
the error by reducing or
eliminating the contributing
factors

Human-centred design
Ergonomic factors
Training

Module N 2

ICAO Safety Management Systems (SMS) Course

Three strategies for the control of human error


Error capturing strategies
intervene once the error
has already been made,
capturing the error before it
generates adverse
consequences
Checklists
Task cards
Flight strips

Module N 2

ICAO Safety Management Systems (SMS) Course

Three strategies for the control of human error


Error tolerance strategies
intervene to increase the
ability of a system to accept
errors without serious
consequence

System redundancies
Structural inspections

Module N 2

ICAO Safety Management Systems (SMS) Course

Understanding violations Are we ready?


Accident
Incident

High

Violation space

Risk

Low
Minimum
Module N 2

System output
ICAO Safety Management Systems (SMS) Course

Exceptional violation space

Systems
production
objective(s)

Maximum
#

Culture
Culture binds people together as members of groups and

provides clues as to how to behave in both normal and


unusual situations
Culture influences the values, beliefs and behaviours that
people share with other members of various social groups

Module N 2

ICAO Safety Management Systems (SMS) Course

Three cultures
National

Organizational

National
Professional

Module N 2

ICAO Safety Management Systems (SMS) Course

Three distinct cultures


National culture encompasses the value system of
particular nations
Organizational/corporate culture differentiates the values
and behaviours of particular organizations (e.g. government
vs. private organizations)
Professional culture differentiates the values and
behaviours of particular professional groups (e.g. pilots, air
traffic controllers, maintenance engineers, aerodrome staff,
etc.)
No human endeavour is culture-free
Module N 2

ICAO Safety Management Systems (SMS) Course

Organizational/corporate culture
Sets the boundaries for acceptable behaviour in the
workplace by establishing norms and limits

Provides a frame work for managerial and employee


decision-making
This is how we do things here, and how we talk
about the way we do things here
Organizational/corporate culture shapes among many
others safety reporting procedures and practices by
operational personnel

Module N 2

ICAO Safety Management Systems (SMS) Course

Safety culture
A trendy notion with potential for misperceptions and
misunderstandings

A construct, an abstraction
It is the consequence of a series of organizational
processes (i.e., an outcome)
Safety culture is not an end in itself, but a means to
achieve an essential safety management prerequisite:

Effective safety reporting

Module N 2

ICAO Safety Management Systems (SMS) Course

Effective safety reporting Five basic traits


Information
People are knowledgeable about the human, technical and
organizational factors that determine the safety of the system
as a whole.
Willingness
People are willing to
report their errors and
experiences.

Effective safety
reporting

Accountability
People are encouraged (and rewarded) for providing essential
safety-related information. However, there is a clear line that
differentiates between acceptable and unacceptable behaviour.
Module N 2

Flexibility
People can adapt reporting
when facing unusual
circumstances, shifting from
the established mode to a
direct mode thus allowing
information to quickly reach
the appropriate decisionmaking level.
Learning

People have the competence


to draw conclusions from
safety information systems
and the will to implement
major reforms.

ICAO Safety Management Systems (SMS) Course

Three options

Source: Ron Westrum

Organizations and the management of information

Pathological Hide the information


Bureaucratic Restrain the information

Generative Value the information

Module N 2

ICAO Safety Management Systems (SMS) Course

Three possible organizational cultures


Source: Ron Westrum

Pathological

Bureaucratic

Generative

Information

Hidden

Ignored

Sought

Messengers

Shouted

Tolerated

Trained

Responsibilities

Shirked

Boxed

Shared

Reports

Discouraged

Allowed

Rewarded

Failures

Covered up

Merciful

Scrutinized

Crushed

Problematic

Welcomed

Conflicted
organization

Red tape
organization

Reliable
organization

New ideas
Resulting
organization
Module N 2

ICAO Safety Management Systems (SMS) Course

Safety investigation
For funereal purposes
To put losses behind
To reassert trust and faith in the system
To resume normal activities
To fulfil political purposes
For improved system reliability
To learn about system vulnerability
To develop strategies for change
To prioritize investment of resources
Module N 2

ICAO Safety Management Systems (SMS) Course

Investigation
The facts
An old generation four engine turboprop freighter flies
into severe icing conditions
Engines 2 and 3 flameout as consequence of ice
accretion, and seven minutes later engine 4 fails
The flight crew manages to re-start engine number 2
Electrical load shedding is not possible, and the electrical
system reverts to battery power
...
Module N 2

ICAO Safety Management Systems (SMS) Course

Investigation
... The facts
While attempting to conduct an emergency landing, all
electrical power is lost
All that is left to the flight crew is the self-powered
standby gyro, a flashlight and the self-powered engine
instruments
The flight crew is unable to maintain controlled flight, and
the aircraft crashes out of control

Module N 2

ICAO Safety Management Systems (SMS) Course

Investigation
Findings
Crew did not use the weather radar
Crew did not consult the emergency check-list
Demanding situation requiring decisive thinking and clear
action
Conditions exceeded certification condition for the
engines

Did not request diversion to a closer aerodrome


...
Module N 2

ICAO Safety Management Systems (SMS) Course

Investigation
... Findings
Crew did not use correct phraseology to declare
emergency
Poor crew resource management (CRM)
Mismanagement of aircraft systems
Emergency checklist presentation and visual
information
Flight operations internal quality assurance procedures

Module N 2

ICAO Safety Management Systems (SMS) Course

Investigation
Causes
Multiple engine failures
Incomplete performance of emergency drills
Crew actions in securing and re-starting engines
Drag from unfeathered propellers
Weight of ice
Poor CRM
Lack of contingency plans
Loss of situational awareness
Module N 2

ICAO Safety Management Systems (SMS) Course

Investigation
Safety recommendations
Authority should remind pilots to use correct phraseology
Authority should research into most effective form of
presentation of emergency reference material

Module N 2

ICAO Safety Management Systems (SMS) Course

Investigation
The facts
An old generation two engine turboprop commuter
aircraft engaged in a regular passenger transport
operation is conducting a non-precision approach in
marginal weather conditions in an uncontrolled, nonradar, remote airfield
The flight crew conducts a straight-in approach, not
following the published approach procedure

Module N 2

ICAO Safety Management Systems (SMS) Course

Investigation
... The facts

Upon reaching MDA, the flight crew does not acquire


visual references
The flight crew abandons MDA without having acquired
visual references to pursue the landing
The aircraft crashes into terrain short of the runway

Module N 2

ICAO Safety Management Systems (SMS) Course

Investigation
Findings
The crew made numerous mistakes

But
Crew composition legal but unfavourable in view of
demanding flight conditions
According to company practice, pilot made a direct
approach, which was against regulations

Module N 2

ICAO Safety Management Systems (SMS) Course

Investigation
But
The company had consistently misinterpreted regulations
Level of safety was not commensurate with the
requirements of a scheduled passenger operation
Aerodrome operator had neither the staff nor the
resources to ensure regularity of operations

Module N 2

ICAO Safety Management Systems (SMS) Course

Investigation
But

Lack of standards for commuter operations


Lack of supervision of air traffic facilities

Authorities disregard of previous safety violations


Legislation out of date

Module N 2

ICAO Safety Management Systems (SMS) Course

Investigation
But

Conflicting goals within the authority


Lack of resources within the authority

Lack of aviation policy to support the authority


Deficiencies in the training system

Module N 2

ICAO Safety Management Systems (SMS) Course

Investigation
Causes

Decision to continue approach below MDA without visual


contact
Performance pressures
Airlines poor safety culture

Module N 2

ICAO Safety Management Systems (SMS) Course

Investigation
Safety recommendations
Tip-of-the-arrow recommendations

But
Review the process of granting AOC
Review the training system
Define an aviation policy which provides support to the
task of the aviation administration

Module N 2

ICAO Safety Management Systems (SMS) Course

Investigation
But

Reform aviation legislation


Reinforce existing legislation as interim measure

Improve both accident investigation and aircraft and


airways inspection processes

Module N 2

ICAO Safety Management Systems (SMS) Course

Errors ...

are like mosquitoes


Module N 2

ICAO Safety Management Systems (SMS) Course

To fight them

... drain their breeding swamps.


Module N 2

ICAO Safety Management Systems (SMS) Course

Basic safety concepts

Questions and answers

Module N 2

ICAO Safety Management Systems (SMS) Course

Questions and answers


Q: How is safety defined in Document 9859?
A:
Safety is the state in which the risk 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.

Slide number: 7
Module N 2

ICAO Safety Management Systems (SMS) Course

Questions and answers


Q: Enumerate the five building blocks of the organizational
accident.
A:

Organizational processes

Workplace
conditions

Latent
conditions

Active
failures

Defences

Slide number: 16
Module N 2

ICAO Safety Management Systems (SMS) Course

Questions and answers


Q: Explain the components of the SHEL(L) Model.
A:
Software

S
H

L
E

Hardware

Environment
Liveware
Liveware, other
persons

Slide number: 20
Module N 2

ICAO Safety Management Systems (SMS) Course

Questions and answers


Q: Enumerate three basic traits underlying effective safety
reporting.
A:
Information
Flexibility
People are knowledgeable about the human, technical and
organizational factors that determine the safety of the system as a
whole.
Willingness
People are willing to report
their errors and
experiences.

Effective safety
reporting

Accountability
People are encouraged (and rewarded) for providing essential safetyrelated information. However, there is a clear line that differentiates
between acceptable and unacceptable behaviour.

People 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 .
Learning

People have the competence to


draw conclusions from safety
information systems and the will
to implement major reforms.

Slide number: 35
Module N 2

ICAO Safety Management Systems (SMS) Course

Questions and answers


Q: How can organizations be characterized, depending
upon their management of safety information?
A:
Pathological Hide the information

Bureaucratic Restrain the information


Generative Value the information

Slide number: 36
Module N 2

ICAO Safety Management Systems (SMS) Course

Points to remember
1. The organizational accident.

2. Operational contexts and human performance


3. Errors and violations.

4. Organizational culture and effective safety reporting.


5. The management of safety information.

Module N 2

ICAO Safety Management Systems (SMS) Course

Basic safety concepts

Exercise 02/01 The Anytown City Airport


accident (Handout N 1)

Module N 2

ICAO Safety Management Systems (SMS) Course

The Anytown City Airport accident


In the late hours of a summer Friday evening, while landing
on a runway heavily contaminated with water, a twin-engine
jet transport aircraft with four crew members and 65
passengers on board overran the westerly end of the
runway at Anytown City airport
The aircraft came to rest in the mud a short distance beyond
the end of the runway. There were no injuries to crew or
passengers, and there was no apparent damage to the
aircraft as a consequence of the overrun
However, a fire started and subsequently destroyed the
aircraft
Module N 2

ICAO Safety Management Systems (SMS) Course

The Anytown City Airport accident


Group activity:
A facilitator will be appointed, who will coordinate the
discussion
A summary of the discussion will be written on flip charts,
and a member of the group will brief on their findings in a
plenary session
Required task:
Read the text related to the accident of the twin-engined
jet transport at Anytown City Airport

Module N 2

ICAO Safety Management Systems (SMS) Course

The Anytown City Airport accident


required task:
From the investigation report of the above accident,
you should identify:
1. Organizational processes that influenced the
operation and which felt under the responsibility of
senior management (i.e. those accountable for the
allocation of resources)
2. Latent conditions in the system safety which
became precursors of active failures
3. Defences which failed to perform due to
weaknesses, inadequacies or plain absence
Module N 2

ICAO Safety Management Systems (SMS) Course

The Anytown City Airport accident


required task:

4. Workplace conditions, which may have influenced


operational personnel actions; and
5. Active failures, including errors and violations
When you have concluded the above, your task is to
complete the Table 02/01 Analysis (Handout N 1)
classifying your findings in accordance with the
organizational accident model

Module N 2

ICAO Safety Management Systems (SMS) Course

The organizational accident

Organizational processes

Workplace
conditions

Latent
conditions

Active
failures

Defences

Module N 2

ICAO Safety Management Systems (SMS) Course

Module N 2 Basic
safety concepts

Revision N 13

ICAO Safety Management Systems (SMS) Course

06/05/09

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