1. SMS Introduction
Allan Nõmmik

2. 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.
… ?

3. 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.

4. 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.

5. 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
Identifies:
WHAT?
WHO?
WHEN?
WHY?
HOW?
But not always discloses:

6. The evolution of safety thinking
TODAY
1950s
2000s
1970s
1990s
TECHNICAL FACTORS
HUMAN FACTORS
ORGANIZATIONAL FACTORS
Fuente: James Reason

7. A concept of accident causation
Latent conditions trajectory
Technology
Training
Regulations
Defences
Errors
and
violations
People
Accident
Working conditions
Workplace
Organization
Management decisions and organizational processes
Source: James Reason

8. The organizational accident
Organizational processes
Latent
conditions
Workplace
Defences
Active
failures
Activities over which any organization has a reasonable degree of direct control
Policy-making
Planning
Communication
Allocation of resources
Supervision
...

9. The organizational accident
Organizational processes
Latent
conditions
Workplace
Defences
Active
failures
Conditions present in the system before the accident, made evident by triggering factors.
Inadequate hazard identification and risk management
Normalization of deviance

10. The organizational accident
Organizational processes
Latent
conditions
Workplace
Defences
Active
failures
Resources to protect against the risks that organizations involved in production activities generate and must control.
Technology
Training
Regulations

11. The organizational accident
Organizational processes
Latent
conditions
Workplace
Defences
Active
failures
Factors that directly influence the efficiency of people in aviation workplaces.
Workforce stability
Qualifications and experience
Morale
Credibility
Ergonomics
...

12. The organizational accident
Organizational processes
Latent
conditions
Workplace
Defences
Active
failures
Actions or inactions by people (pilots, controllers, maintenance engineers, aerodrome staff, etc.) that have an immediate adverse effect.
Errors
Violations

13. The perspective of the organizational accident
Organizational processes
Latent
conditions
Workplace
Defences
Active
failures
Improve
Identify
Monitor
Contain
Reinforce

14. 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.
Source: Dedale

15. A B Understand human performance within the operational context
where it takes place

16. Processes and outcomes
Causes and consequences of operational errors are not linear in their magnitude
Source: Dedale

17. Errors and safety – A non linear relationship
Statistically, millions of operational errors are made before a major safety breakdown occurs
Source: Dedale

18. Accident investigation – Once in a million flights
Flaps omitted
Checklist failure
Unheeded warning
Error
Deviation
Amplification
Degradation /
breakdown
Incident /
accident

19. Safety management – On almost every flight
Flaps omitted
Checklist works
Effective warning
Error
Normal flight
Deviation
Amplification

20. In this airport safety is first
Really?
In this
airport
safety
is first

21. What is the fundamental objective of a business organization?

22. Safety management – Rationale
In order to achieve its production objectives, the management of any aviation organization requires the management of many business processes.
Managing safety is one such business process.
Safety management is a core business function just as financial management, HR management, etc.
There is no aviation organization that has been created to deliver only safety.
This brings about a potential dilemma for management.

23. The management dilemma
Management levels
Protection
Production
Resources

24. The management dilemma
Management levels
Protection
Production
Catastrophe
Resources +

25. The management dilemma
Protection
Production
Management levels
Bankruptcy
+ Resources

26. Safety space
Safety space
Bankruptcy
Catastrophe
Production
Protection

27. The essential is invisible to the eyes
Number of occurrences
1 – 5
Accidents
30 – 100
Serious incidents
100 – 1000
Incidents
1000 – 4000
Latent conditions

28. The predictive method captures
Strategies – Summary
Reactive method
The reactive method responds to the events that already happened, such as incidents and accidents
Proactive method
The proactive method
looks actively for the
identification of
safety risks
through the analysis
of the organization’s
activities
Predictive method
The predictive method captures
system performance as it happens in real-time normal operations to identify potential future problems

29. Hazards and risks
Hazard – Condition or object with the potential of causing injuries to personnel, damage to equipment or structures, loss of material, or reduction of ability to perform a prescribed function.
Consequence – Potential outcome(s) of the hazard.
Risk – The assessment, expressed in terms of predicted probability and severity, of the consequence(s) of a hazard taking as reference the worst foreseeable situation.
A wind of 15 knots blowing directly across the runway is a hazard.
A pilot may not be able to control the aircraft during takeoff or landing is one of the consequences of the hazard.
The assessment of the consequences of the potential loss of control of the aircraft by the pilot expressed in terms of probability and severity is the risk.

30. First fundamental – Understanding hazards
Types of hazards
Natural
Technical
Economic

31. First fundamental – Risk management
What is it?
The identification, analysis and elimination, and/or mitigation to an acceptable level of risks that threaten the capabilities of an organization.
What is the objective?
Aims at a balanced allocation of resources to address all risks and viable risk control and mitigation.
Why is it important?
A key component of safety management systems.
Data-driven approach to safety resources allocation, thus defensible and easier to explain.

32. Risk management As Low Reasonably Practicable Intolerable region
The risk is
unacceptable under the
existing circumstances As
Low
Reasonably
Practicable
Tolerable region
The risk is acceptable based on
mitigation.
Cost benefit
analysis
is required.
Acceptable
region
The risk is acceptable as it
currently stands

33. Cost-benefit analysis
Direct costs
The obvious costs, which are easily determined. The high costs of exposure of hazards can be reduced by insurance coverage.
Purchasing insurance only transfers monetary risk, does not address the safety hazard
Indirect costs
The uninsured costs. An understanding of uninsured costs (or indirect costs) is fundamental to understand the economics of safety.

34. Cost-benefit analysis
Indirect costs may amount to more than the direct costs resulting from exposure to hazards:
Loss of business
Damage to the reputation
Loss of use of equipment
Loss of staff productivity
Legal actions and claims
Fines and citations
Insurance deductibles

35. Second fundamental – Risk probability
Definition
Probability – The likelihood that an unsafe event or condition might occur.

36. Second fundamental – Risk probability
Probability of occurrence
Meaning
Qualitative definition
Value
Frequent
Occasional
Remote
Improbable
Extremely
improbable
Likely to occur many times (has occurred frequently)
Likely to occur some times (has occurred infrequently)
Unlikely, but possible to occur (has occurred rarely)
Very unlikely to occur (not known to have occurred)
Almost inconceivable that the event will occur 5 4 3 2 1

37. Third fundamental – Risk severity
Definition
Severity – The possible effects of an unsafe event or condition, taking as reference the worst foreseeable situation.

38. Third fundamental – Risk severity
Define the severity in terms of effects for:
Property
Finance
Liability
People
Environment
Image
Public confidence

39. Third fundamental – Risk severity
A large reduction in safety margins, physical distress or a
workload such that the operators cannot be relied upon to
perform their tasks accurately or completely.
Serious injury.
Major equipment damage.
Equipment destroyed.
Multiple deaths.
A significant reduction in safety margins, a reduction in the
ability of the operators to cope with adverse operating
conditions as a result of increase in workload, or as a result
of conditions impairing their efficiency.
Serious incident.
Injury to persons.
Nuisance.
Operating limitations.
Use of emergency procedures.
Minor incident.
Little consequences
Meaning
Severity of occurrences
Value
Aviation definition
Catastrophic
Hazardous
Major
Minor
Negligible A B C D E

40. Fourth fundamental – Risk index/tolerability
Risk severity
Risk probability
Catastrophic A
Major C
Minor D
Negligible E
Hazardous B
Frequent 5
Occasional 4
Remote 3
Improbable 2
Extremely
improbable 1 5A 5B 5C 5D 5E 4A 4B 4C 4D 4E 3A 3B 3C 3D 3E 2A 2B 2C 2D 2E 1A 1B 1C 1D 1E

41. Fourth fundamental – Risk index/tolerability
Assessment risk index
Suggested criteria
Intolerable region
Tolerable region
Acceptable
region
5A, 5B, 5C, 4A, 4B, 3A
Unacceptable under the
existing circumstances
3E, 2D, 2E, 1A, 1B ,1C, 1D, 1E
5D, 5E, 4C, 4D, 4E, 3B, 3C, 3D, 2A, 2B, 2C
Acceptable based on risk
mitigation. It might require
management decision
Risk management

42. Fifth fundamental – Risk control/mitigation
Definition
Mitigation – Measures to address the potential hazard or to reduce the risk probability or severity.
Risk mitigation = Risk control
(Mitigate – To make milder, less severe or less harsh)

43. Fifth fundamental – Risk control/mitigation
Strategies
Avoidance – The operation or activity is cancelled because risks exceed the benefits of continuing the operation or activity.
Operations into an aerodrome surrounded by complex geography and without the necessary aids are cancelled.

44. Fifth fundamental – Risk control/mitigation
Strategies
Reduction –The operation or activity is subject to limitations, or action is taken to reduce the magnitude of the consequences of the accepted risks.
Operations into an aerodrome surrounded by complex geography and without the necessary aids are limited to day-time, visual conditions.

45. Fifth fundamental – Risk control/mitigation
Strategies
Segregation of exposure – Action is taken to isolate the effects of the consequences of the hazard or build-in redundancy to protect against it.
Non RVSM equipped aircraft not allowed to operate into RVSM airspace.
Operations into an aerodrome surrounded by complex geography are limited to aircraft with specific/performance navigation capabilities.

46. Safety risk management at a glance
Hazard
identification
Risk analysis
Probability
Yes, accept the risk(s)
Risk control
/mitigation
Severity
Risk assessment
and tolerability
Equipment, procedures, organization, etc.
Analyse the likelihood of the consequence occurring
Evaluate the seriousness of the consequence if it does occur
Is the assessed risk(s) acceptable and within the organization’s safety performance criteria
No, take action to reduce the risk(s) to an acceptable level

47. Risk mitigation – Defences
Recalling the three basic defences in aviation:
Technology
Training
Regulations
Technology
Training
Regulations

48. Acceptable level of safety (ALoS)
ALoS – A three-legged concept
High level safety management objectives of an SSP
Safety measurement
Minimum safety performance the State should achieve through the implementation of its SSP
Safety performance measurement
An indirect reference against of the measure safety performance of the service providers.

49. A fundamental differentiation
Safety performance measurement
Quantification of the outcomes of low-level, low consequences processes
Number of FOD events per number of ramp OPS
Number of ground vehicle events in taxiways per number of airport OPS
Provide a measure of the actual performance of an individual SSP or SMS (Beyond accident rates and regulatory compliance) 49

50. A fundamental differentiation
Safety measurement
Not a continuous process.
A spot check.
Conducted following pre-specified timeframes.
Safety performance measurement
Continuous process.
Monitoring and measurement of selected operational activities necessary for the provision of services.

51. ALoS of an SSP Will comply all applicable international standards.
Safety requirements
Airspace management – Constant Descend Arrivals (CDA) procedures implemented – Arrival procedure charts designed for stabilized approaches.
Installation of ASDE/X in 5 international [State] airports.
Safety performance targets
By 2010, reduce CFIT events to 0.04 per 100,0000 operations on all large public transport aircraft in [State] airspace.
By 2011, reduce runway incursions to 0.6 per 10,000 operations in 5 international [State] airports.
Safety performance indicators
0.08 CFIT events per 100,0000 operations on all large public transport aircraft in [State] airspace.
1.2 runway incursions per 10,000 operations in 5 international [State] airports areas – large passenger aircraft, large freighter aircraft, small public transport aircraft, large public transport helicopters and general aviation.
State
Will comply all applicable international standards. 51

52. Service providers
Approved training organizations that are exposed to safety risks during the provision of their services;
Aircraft operators;
Approved maintenance organizations;
Organizations responsible for design and/or manufacture of aircraft;
Air traffic services providers; and
Certified aerodromes.
The ICAO SMS framework (Module 8)

53. What is an SMS?
A systematic approach to managing safety, including the necessary organizational structures, accountabilities, policies and procedures.
Service providers are responsible for establishing an SMS.
States are responsible, under the SSP, for the acceptance and oversight of organizations’ SMS.

54. Safety performance of an SMS
The safety performance of an SMS represents safety performance measurement exclusively.
The safety performance of an SMS is expressed in practical terms by two measures or metrics:
Safety performance indicators
Safety performance targets
It is delivered through various tools and means:
Safety requirements. 54

55. Safety performance of an SMS
Safety performance indicators
Short-term, tactical, measurable objectives reflecting the safety performance of an SMS.
They include safety performance measurement exclusively.
Expressed in numerical terms.
Safety performance targets
Long-term, strategic, measurable objectives reflecting the safety performance of an SMS. 55

56. Safety performance of an SMS
Legal considerations
Establishing safety performance for the SMS leaves unaffected the obligations of services providers and other related parties, and it does not relieve the services providers and other related parties from compliance with SARPs and/or national regulations, as applicable.

57. Safety performance of an SMS
Safety requirements
Training course for drivers / installation of specific signage.
Thrice-daily walk-in ramp inspection programme. …
Safety performance targets
Maintain no more than 20 events of unauthorized vehicles on the taxiways per 10,000 operations.
By January 2010 reduce to 8 FOD events on the apron per 10,000 operations.
Safety performance indicators
20 events of unauthorized vehicles on the taxiways per 10,000 operations.
15 FOD events on the apron per 10,000 operations.
...
Service provider
Will comply all applicable national and international standards. 57

58. Basic safety management requirements – Part III
A safety management system (SMS) shall clearly define lines of safety accountability throughout a service provider organization, including a direct accountability for safety on the part of senior management.
(Accountability – Obligation or willingness to account for one’s actions)

59. SSP – SMS relationship Protection Production State Safety
Programme (SSP)
Organization’s
Management
system (SMS)
Objective:
Establish
acceptable
level of
safety (ALoS)
for civil
aviation
Safety policy
and
objectives
Safety risk
management
Support
production
goals and
customer
satisfaction
Safety assurance
Safety promotion
Services provider
Acceptance
Compliance
oversight
Performance-based

60. In summary State Service provider
States shall establish a State safety programme (SSP), in order to achieve an acceptable level of safety (ALoS) in civil aviation.
The acceptable level of safety (ALoS) to be achieved shall be established by the State.
Identify safety hazards.
Ensure ensures remedial action to maintain safety performance.
Provides continuing monitoring and regular assessment of the safety performance.
Aims at a continuous improvement of the overall performance of the SMS.

61. The objective
Performance
based
Prescription
Realistic
Implementation

62. In summary Performance-based Prescription
Regulations as administrative controls
Rigid regulatory framework
Inspections
Audits
Regulatory compliance
Performance-based
Regulations as safety risk controls
Dynamic regulatory framework:
Data based identification and prioritization of safety risks
Develop regulations to control safety risks
Effective safety performance

63. Safety risk management
2.1 – Hazard identification (Module 4)
The organization shall develop and maintain a formal process that ensures that hazards in operations are identified.
Hazard identification shall be based on a combination of reactive, proactive and predictive methods of safety data collection.

64. ICAO requirements
Compliance with all relevant regulations and ICAO standards, other than those specifically SMS-related, is a key component of an SMS.
Many of these regulations and ICAO standards, include operational provisions that will be part of an SMS.

65. SMS – Introductory concepts
A toolbox
The scope of SMS encompasses most of the activities of the organization.
SMS must start from senior management, and safety must be considered at all levels of the organization.
SMS aims to make continuous improvement to the overall level of safety.
All aviation stakeholders have a role to play in SMS.
Accident and
investigations
incident
Safety studies
Internal safety investigations
Safety reviews
Confidential reporting system
LOSA
MOR
Safety
survey
audit
FDA
ASR
NOSS
Safety library

66. SMS features
Systematic – Safety management activities are in accordance with a pre-determined plan, and applied in a consistent manner throughout the organization.
Proactive – An approach that emphasizes hazard identification and risk control and mitigation, before events that affect safety occur.
Explicit – All safety management activities are documented and visible.

67. Clarifying the use of terms
Safety oversight
Is what the CAA performs with regard to the service providers SMS.
Safety assurance
Is what the service providers do with regard to safety performance monitoring and measurement.
Safety audit
Is what the CAA performs with regard to its safety programme and the service providers perform with regard to the SMS.

68. SMS sets forth to destroy all these misperceptions
SMS – Nothing new?
Rounding up the usual suspects
In aviation, safety is first.
Safety is everybody’s responsibility.
If ain’t broke, why fix it?
If you believe safety is expensive, try an accident.
70% accidents are due to human error.
SMS sets forth to destroy all these misperceptions

69. The components of SMS Safety policy and objectives
Safety risk management
Safety assurance
Safety promotion

70. Safety responsibilities – An example
Heads of other areas
Head of operations
Head of
maintenance
Safety Services
Office
Safety Review
Board (SRB)
Safety Action
Group(s)
(SAG)
Accountable Executive
Operations
safety officer
Maintenance

71. Safety responsibilities
Heads of other areas
Head of operations
Head of
maintenance
Safety Services
Office
Safety Review
Board (SRB)
Safety Action
Group(s)
(SAG)
Accountable Executive
Operations
safety officer
Maintenance

72. Safety responsibilities
Heads of other areas
Head of operations
Head of
maintenance
Safety Services
Office
Safety Review
Board (SRB)
Safety Action
Group(s)
(SAG)
Accountable Executive
Operations
safety officer
Maintenance

73. The bridge
SSP
State
Service
providers
SMS

74. State safety programme
Definition
An integrated set of regulations and activities aimed at improving safety.
Requirement
States shall establish a State safety programme (SSP), in order to achieve an acceptable level of safety in civil aviation.