1. SAFETY MANAGEMENT SYSTEMS
Almaty, 5 to 9 September 2005

2. SUMMARY Safety culture What is SMS? Safety versus efficiency Why SMS?
Safety through SMS
Basic safety process
Traditional versus current
Safety management
What is SMS?
Why SMS?
Definitions
Systems approach
SMS Strategy
SMS principles
Building an SMS
Almaty, 5 – 9 September 2005

3. SAFETY MANAGEMENT SYSTEM
Businesslike approach to safety
Managing safety risks
Setting goals
Planning
Measuring performance
Integral part of an organization
Organizational culture
Way people work
SMS is
A safety management system is a businesslike approach to safety. It is a systematic, explicit and comprehensive process for managing safety risks. As with all management systems, a safety management system provides for goal setting, planning, and measuring performance. A safety management system is woven into the fabric of an organization. It becomes part of the culture, the way people do their jobs.
Almaty, 5 – 9 September 2005

4. WHY SMS? Accident causes Causal factors Organizational issues
Human errors?
Causal factors
Chain links
Organizational issues
Making the system safer
Actions by an organization
Systems approach to safety management
Address latent failures
ICAO requirements
In recent years a great deal of effort has been devoted to understanding how accidents happen in aviation and other industries.
It is now generally accepted that most accidents result from human error.
It would be easy to conclude that these human errors indicate carelessness or incompetence on the job but that would not be accurate.
Investigators are finding that the human is only the last link in a chain that leads to an accident.
We will not prevent accidents by changing people; we will only prevent accidents when we address the underlying causal factors.
In the 1990's the term ‘organizational accident' was retained because most of the links in an accident chain are under the control of the organization.
Since the greatest threats to aviation safety originate in organizational issues, making the system even safer will require action by the organization.
Extensive research and consultation of world leaders in safety lead to conclude that the most efficient way to make the civil aviation system even safer will be to adopt a systems approach to safety management. ICAO aims at supporting safety management systems
Almaty, 5 – 9 September 2005

5. ERROR and/or FAULT = FAILURE
NOTIONS
Failure - system
Fault - equipment
Error - human
Active failures – can be observed
Latent failures – (hidden) hazards, unsafe conditions
ERROR and/or FAULT = FAILURE
A system failure is any occurrence that results in the inability to provide the level of service, which the system is intended to provide. Failure of one element of the system does not necessarily result in a system failure. If an alternate that provides the required level of service is available, and there is no interruption of service in the changeover, the system as a whole has not failed.
A system failure is any occurrence which results in the inability to provide the level of service that the system is intended to provide.
A fault is any occurrence that results in an equipment malfunction.
An error is a failure in human performance.
When a failure actually occurs in a system, its results can be observed. Such a failure is classified as an active failure
The direct causes of active failures are generally the result of equipment faults or errors committed by operational personnel.
The term latent failure is used to describe the existence in a system of hazards or unsafe conditions which, given a particular sequence of triggering events, could lead to a failure of the system.
Latent failures, however, always have a human element. They may be the result of undetected design flaws. They may be related to unrecognized consequences of officially approved procedures. There have also been a number of cases where latent failures have been the direct result of decisions taken by the management of the organization.
For example, latent failures exist when the culture of the organization encourages taking short cuts rather than always following approved procedures. The direct cause of a failure associated with taking short cuts would be the failure of a person at the operational level to follow correct procedures. However, if there is general acceptance of this sort of behaviour amongst operational personnel, and management are either unaware of this or take no action, there is a latent failure in the system at the management level.
Almaty, 5 – 9 September 2005

6. SYSTEMS APPROACH System includes Role of organization
People
Procedures
Technology
Role of organization
Prevention of
Accidents
Incidents
Safety management includes:
whole range of activities
all levels of organization
To ensure that all possible sources of hazards which could affect safety are identified, safety management requires a systems approach. The “system” includes all the people, procedures and technology needed to operate or support the aviation system.
Modern approaches to safety management have been shaped by various concepts introduced (Chapter 3 - Understanding Safety, ICAO Safety Management Manual refers), and in particular, the role of organizational issues as contributory factors in accidents and incidents. Safety cannot be achieved simply by introducing rules or directives concerning the procedures to be followed by operational staff.
The scope of safety management encompasses almost the whole range of activities of the organization concerned. It is for this reason that safety management must start from the senior level of management, and that potential effects on safety must be examined at all levels of the organization.
Almaty, 5 – 9 September 2005

7. Reactive strategy – investigate accidents and incidents
SMS STRATEGIES (1/2)
Reactive strategy – investigate accidents and incidents
Focused on compliance
Measured on accidents and incidents limited by:
Actual failures
Insufficient data
“root causes”unknown
Constant catching up required to match human inventiveness for new errors
Reactive strategy: Investigate accidents and reportable incidents. This strategy is useful for situations involving failures in technology or unusual events. The utility of the reactive approach for accident prevention purposes depends on the extent to which the investigation goes beyond determining the causes, to include an examination of all the contributory factors. The reactive approach tends to be marked by:
1) Management’s safety focus being on compliance with minimum requirements;
2) Safety measurement being based on reportable accidents and incidents with such limitations in value as:
—  Any analysis is limited to examining actual failures;
— Insufficient data is available to accurately determine trends, especially those attributable to human errors; and
— Little insight is available into the ‘root causes’ and latent unsafe conditions, which facilitate human errors; and
Constant catching up is required to match human inventiveness for new types of errors
Almaty, 5 – 9 September 2005

8. SMS STRATEGIES (2/2)
Proactive strategy - constant and aggressive seek for information through:
Reporting systems
Identifying latent conditions
Safety surveys
Data analysis
Operational inspections
Operational audits
Proactive safety strategy: Prevent accidents by aggressively seeking information from a variety of sources which may be indicative of emerging safety problems. Organizations pursuing a proactive strategy for accident prevention believe that the risk of accidents can be minimized by identifying vulnerabilities before they fail, and by taking the necessary actions to reduce those risks. To do this, they actively seek systemic unsafe conditions through such tools as:
1) Hazard and incident reporting systems which promote the identification of latent unsafe conditions;
2) Safety surveys to elicit feedback from front-line personnel about areas of dissatisfaction and unsatisfactory conditions which may have accident potential;
3) Flight data recorder analysis for identifying operational exceedances and confirming normal operating procedures;
4) Operational inspections or audits of all aspects of operations, to identify vulnerable areas before accidents, incidents, or minor safety events confirm a problem exists; and
5) A policy for consideration and embodiment of manufacturers’ service bulletins; etc
Almaty, 5 – 9 September 2005

9. KEY SAFETY MANAGEMENT ACTIVITIES
Organization
Safety assessments
Occurrence reporting
Hazard identification
Investigation & analysis
Performance monitoring
Safety promotion
Safety monitoring
Those organizations which manage safety most successfully practice several common activities. They tend to do specific things; for example:
Organization. They are organized to establish a culture of safety and reduce their accidental losses. Larger organizations may implement a formal safety management system as outlined in Part 3 of this manual.
Safety assessments. They systematically analyze proposed changes to equipment or procedures to identify and mitigate weaknesses before change is implemented.
Occurrence reporting. They have established formal procedures for reporting safety occurrences and other unsafe conditions.
Hazard identification schemes. They employ both reactive and proactive schemes for identifying safety hazards throughout their organization, such as voluntary incident reporting, safety surveys, operational safety audits, safety assessments, etc. Part 4 outlines several safety processes that are effective for the identification of safety hazards; for example, Flight Data Analysis (FDA) and Line Operations Safety Audits (LOSA).
Investigation and analysis. They follow-up on reported occurrences and unsafe conditions, if necessary, initiating competent safety investigations and safety analyses.
Performance monitoring. They actively seek feedback necessary to close the loop of the accident prevention cycle using such techniques as trend monitoring and internal safety audits.
Safety promotion. They actively disseminate the results of safety investigations and analyses, sharing safety lessons learned both internally within the organization and outside if warranted.
Safety monitoring. They systematically monitor and assess safety performance.
Almaty, 5 – 9 September 2005

10. SMS PRINCIPLES The Four Principles (4 Ps) of Safety Management:
Philosophy
Policy
Procedure
Practices
The 4 Ps of safety management
Almaty, 5 – 9 September 2005

11. SMS PHILOSOPHY Safety management starts with Management Philosophy:
recognizing that there will always be threats to safety;
setting the organization's standards; and
confirming that safety is everyone's responsibility.
Almaty, 5 – 9 September 2005

12. SMS POLICY Specify how safety will be achieved:
clear statements of responsibility, authority, and accountability;
development of organizational processes and structures to incorporate safety goals into every aspect of the operation; and
development of the skills and knowledge necessary to do the job.
Almaty, 5 – 9 September 2005

13. SMS PROCEDURES clear direction to all staff;
What management wants people to do to execute the policy:
clear direction to all staff;
means for planning, organizing, and controlling; and
means for monitoring and assessing safety status and processes (e.g. reporting and communication)
Almaty, 5 – 9 September 2005

14. SMS PRACTICES What really happens on the job:
following well designed, effective procedures;
avoiding the shortcuts that can detract from safety; and
taking appropriate action when a safety concern is identified.
The organizational structures and activities that make up a safety management system are found throughout an organization.
Every employee contributes to the safety health of the organization.
In larger organizations, safety management activity will be more visible in some departments than in others, but the system must be integrated into "the way things are done" throughout the establishment.
This will be achieved by the implementation and continuing support of a coherent safety policy which leads to well designed procedures.
Almaty, 5 – 9 September 2005

15. Good ideas do not guarantee success
BUILDING A SMS
Good ideas do not guarantee success
Resistance to change
Three critical elements to success:
Commitment
Cognizance
Competence
Management initiatives are not always successful and each time a new idea is introduced people ask whether this is a worthwhile initiative, or a fad that will pass soon enough. Having a good idea does not guarantee success. Many good ideas have failed in practice because one or more of the three critical elements was missing: commitment, cognizance, and competence. These three "C's" of leadership will determine, in large part, whether safety management achieves its goals and leads to a pervasive safety culture in an organization:
Commitment: In the face of operational and commercial pressures do company leaders have the will to make safety management tools work effectively?
Cognizance: Do the leaders understand the nature and principles of managing for safety?
Competence: Are safety management policy and procedures appropriate, understood, and properly applied at all levels in the organization?
Transition
PLAN
Strategy
Almaty, 5 – 9 September 2005

16. Organisation’s culture is defined by: “… how we do things around here”
SAFETY CULTURE
Organisation’s culture is defined by:
“… what people do”
“… how we do things around here”
Safety culture is:
“Informed” culture
“Just” culture
“Reporting” culture
“Learning” culture
An organization's culture is defined by what the people do. The decisions people make tell us something about the values of the organization. For instance, the extent to which managers and employees act on commitments to safety tell us more than words about what values motivate their actions. A good gauge of safety culture is "How we do things around here." A safety culture may be slow to mature, but, with management support, it can be accomplished.
A safety culture is: a informed, just, reporting and learning culture.
Almaty, 5 – 9 September 2005

17. Staff work continuously to
INFORMED CULTURE
People understand
Hazards
Risks
Staff work continuously to
Identify
Overcome threats to safety
An informed culture - people understand the hazards and risks involved in their own operation
staff work continuously to identify and overcome threats to safety
Almaty, 5 – 9 September 2005

18. Errors Willful violations Everyone agrees on Human factors understood
JUST CULTURE
Errors
Human factors understood
Willful violations
Not tolerated
Everyone agrees on
Acceptable
Unacceptable
A just culture - errors must be understood but wilful violations cannot be tolerated
the workforce knows and agrees on what is acceptable and unacceptable
Almaty, 5 – 9 September 2005

19. People encouraged to voice safety concerns Safety concerns
REPORTING CULTURE
People encouraged to voice safety concerns
Safety concerns
Reported
Analyzed
Action taken
Feed-back
A reporting culture - people are encouraged to voice safety concerns;
when safety concerns are reported they are analyzed and appropriate action is taken
Almaty, 5 – 9 September 2005

20. People encouraged to develop and apply
LEARNING CULTURE
People encouraged to develop and apply
Skills
Knowledge
Staff updated and informed on safety issues
Safety reports are fed back to staff
A learning culture - people are encouraged to develop and apply their own skills and knowledge to enhance organizational safety.
Staff are updated on safety issues by management and safety reports are fed back to staff so that everyone learns the lessons.
Almaty, 5 – 9 September 2005

21. ENCOURAGING SAFETY CULTURE
Management:
Practices what it preaches
Allocates adequate resources
Acknowledges safety concerns and suggestions
Gives feedback on decisions
Feedbacks are timely, relevant and clear
“Do nothing” decisions - explained
management practices what it preaches regarding safety;
management allocates adequate resources to maintain an operation that is efficient and safe;
management acknowledges safety concerns and suggestions:
management gives feedback on decisions, even if the decision is to do nothing;
if no action is contemplated, that decision is explained; and
feedback is timely, relevant and clear.
Almaty, 5 – 9 September 2005

22. SAFETY VERSUS EFFICIENCY
Traditional thinking:
Avoid costs
Cost of occurrences
Cost of accidents
Current (modern) thinking:
Safety and efficiency linked:
Safety reduces losses
Safety enhances productivity
Safety is good for business
There are two ways of thinking about safety. Traditionally, safety has been about avoiding costs. Many organizations have been bankrupted by the cost of a major accident. This makes a strong case for safety, but cost of occurrences is only part of the story. Research shows that safety and efficiency are positively linked. Safety pays off in reduced losses and enhanced productivity. Safety is good for business.
Almaty, 5 – 9 September 2005

23. SAFETY THROUGH SMS SMS approach: Proactive
Anticipates and addresses issues (e.g. latent failures)
Deals effectively with incidents and accidents
Applies lessons learned to improve safety
Reduces losses
Improves productivity
A safety management system will provide an organization with the capacity to anticipate and address safety issues before they lead to an incident or accident. A safety management system also provides management with the ability to deal effectively with accidents and near misses so that valuable lessons are applied to improve safety and efficiency. The safety management system approach reduces losses and improves productivity.
Almaty, 5 – 9 September 2005

24. BASIC SAFETY PROCESS Evaluate A N A L Y C O R R E REPORT:
safety concern
problem
hazard
occurrence
A N A L Y S E
C O R R E C T
Evaluate
Not resolved
The basic safety process is accomplished in five steps:
A safety issue or concern is raised, a hazard is identified, or an incident or accident happens;
The concern or event is reported or brought to the attention of management;
The event, hazard, or issue is analyzed to determine its cause or source;
Corrective action, control or mitigation is developed and implemented; and
The corrective action is evaluated to make sure it is effective. If the safety issue is resolved, the action can be documented and the safety enhancement maintained. If the problem or issue is not resolved, it should be re-analyzed until it is resolved.
Resolved
Almaty, 5 – 9 September 2005

25. TRADITIONAL VERSUS CURRENT (1/2)
Traditional approach
Independent safety officer
Reporting to head of organization
No authority
Results achieved
Ability to persuade management
The traditional safety approach depended on a safety officer (or department in a larger organization) independent from operations management, but reporting to the Chief Executive Officer or Chief Operating Officer of the company. The safety officer or department had, in effect, no authority to make changes that would enhance safety. The safety officer or department's effectiveness depended on the ability to persuade management to act.
Almaty, 5 – 9 September 2005

26. TRADITIONAL VERSUS CURRENT (2/2)
Current Approach
SMS basic safety process
Part of organization’s management
No additional regulations
No additional safety oversight
Managers accountable
Safety-related actions
No action
Implementing safety management systems does not involve imposing an additional layer of regulatory and safety oversight on the industry.
Safety management systems incorporate the basic safety process, described above, into the management of an organization.
A safety management system holds managers accountable for safety related action or inaction.
Almaty, 5 – 9 September 2005

27. Management of organisation is
SAFETY MANAGEMENT
Management of organisation is
Responsible
Accountable
Authority and accountability co-exist
The safety management system philosophy requires that responsibility and accountability for safety resides within the management structure of the organization.
The directors and senior management are ultimately responsible for safety, as they are for other aspects of the enterprise. This is the logic that underlies the SMS orientation.
When SMS is implemented, it will require certain aviation organizations to identify their ‘accountable executive'. This is the person who has financial and executive control over an entity subject to the regulations.
The accountable executive is the certificate holder. Should an organization hold more than one certificate, (eg., an operator who holds an air operator certificate and has an approved maintenance organization) there would be only one accountable executive.
The safety management system approach ensures that authority and accountability co-exist.
Almaty, 5 – 9 September 2005

28. Review Safety culture What is SMS? Safety versus efficiency Why SMS?
Definitions
Systems approach
SMS Strategy
SMS principles
Building an SMS
Safety culture
Safety versus efficiency
Safety through SMS
Basic safety process
Traditional versus current
Safety management
Almaty, 5 – 9 September 2005

29. ? QUESTIONS, COMMENTS Do you have any questions or comments?
Almaty, 5 – 9 September 2005

30. SAFETY MANAGEMENT SYSTEMS
Almaty, 5 to 9 September 2005
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