1. Safety Management System Seminar for NAM/CAR/SAM Regions ATS safety management Mexico City, 14–16 March 2006 International Civil Aviation Organization North American, Central American and Caribbean Regional Office

2. ATS safety management  ICAO purposes, strategic objetives  States responsability  ICAO requirements, Annex 11 (ATS)  ATS safety management programs  Quality Assurance programme  Risk measure  Safety culture  Next steps  ATM performance

3. ICAO purposes  Safety has always been the most important issue in all aviation activities.  This is reflected in the aims and objectives of ICAO as stated in Article 44 of the Convention on International Civil Aviation (Doc 7300), which charges ICAO with ensuring the safe and orderly growth of international civil aviation throughout the world.

4. ICAO STRATEGIC OBJECTIVES ( for the period 2005-2010 ) Adopted by Council on 17 December 2004  ICAO works to achieve its vision of safe, secure and sustainable development of civil aviation through cooperation amongst its member States.  To implement this vision, the Organization has established the following Strategic Objectives for the period 2005-2010:  A: Safety - Enhance global civil aviation safety  B: Security - Enhance global civil aviation security  C: Environmental Protection - Minimize the adverse effect of global civil aviation on the environment  D: Efficiency - Enhance the efficiency of aviation operations  E: Continuity - Maintain the continuity of aviation operations  F: Rule of Law - Strengthen law governing international civil aviation

5. The State responsibility  The State, as the signatory to the Chicago Convention, is responsible for providing a regulatory safety framework for implementation of ICAO SARPS within the airspace and at aerodromes for which it has responsibility in accordance with the basis of the safety management requirements  Where a State is also an ATM service provider:  It is important keep clear distinction between the regulatory functions and the service provision functions  The regulatory division must maintain effective safety oversight of the ATM service provisions

6. ICAO Requirements ATS Safety Management  In 2001 provisions relating to safety management were introduced in Annex 11.  Annex 11 contains provisions regarding the establishment of ATS safety management programms, and includes a requirement to establish objetives and acceptable level of safety.  Complementary procedures also were introduced in the Doc 4444, PANS-ATM. (November 2003)  Additionally, new Standards and Recommended Practices (SARPS) related to Safety Management System will be introduced accordingly.

7. ATS Safety Management  Implementation of ATS safety management programs refers to the day to day keep safety oversight management by the ATS service providers  States shall establish systemic and suitable ATS safety management programs with defined levels and objectives  As appropriate, target levels of safety (TLS) will be established through regional air navigation agreement  Prior to any significant change to the safety-related ATC system, a safety assessment will be carried out, proving that an acceptable safety level may be obtained

8. ATS Safety Management  The acceptable level of safety may be specified in qualitative or quantitative terms. a) a maximum probability of an undesirable event, such as collision, loss of separation or runway incursion; b) a maximum number of accidents per flight hour; c) a maximum number of incidents per aircraft movement; d) a maximum number of valid short-term conflict alerts (STCA) per aircraft movement.

9. ATS safety management programme Shall:  identify actual and potential hazards and determine the need for remedial action;  ensure that remedial action necessary to maintain an acceptable level of safety is implemented; and  provide continuous monitoring and regular assessment of the safety level achieved.

10. ATS Safety Management… Monitoring of safety levels  actual or potential safety hazards or deficiencies related to the provision of ATS,  procedures, communications, navigation and surveillance systems and other safety significant systems and equipment as well as controller work loads  Collection and evaluation of safety-related data  Review of incidents and  Other safety-related reports

11. ATS Safety Management… Safety reviews  training, experience and expertise;  full understanding of SARPs, PANS, safe operating practices and  Human Factors principles  Regulatory, operational and technical framework

12. ATS … Safety Assessment  Safety Assessment calculates the risk of accidents index  Required full commitment of States, ATS providers and users as well as Operators  If safety meets expected levels then change is feasible

13. ATS … Safety Assessment  The safety assessment is a systematic approach, as whole criteria to evaluate the acceptability of the risk and severity: the safety assessment process needs to address both factors.  If the initial assessment of the risk indicates that it does not satisfy the safety assessment criteria, requiring the introduction of mitigation measures, it will be necessary to re- evaluate the risk in order to determine the mitigation measures for the desired effect.  It means that some of the previous steps should be repeated; the process may, in fact, need to be repeated more than once, until a satisfactory combination of mitigation measures is found.

14.  Have proved to be an efficient tool fostering the establishment of diverse complementary programmes for the assessment of ATS performance (units, ATCOs) such as;  verification and training for ATC proficiency  incident reporting and investigation  verification on the use of aeronautical phraseology  incident prevention measures  Quality improvements  Safety management  evolutes to systemic approach of ATM performance ATS Quality Assurance Program

15.  Risk measure expressed in terms of fatal aircraft accidents are indicators of individual risk, since they do not take account of the number of people affected.  A risk measure expressed in terms of number of fatalities would be more appropriate for expressing societal risk.  Acceptability is usually based on comparison with a severity/probability matrix  An acceptable limit expressed in terms of incidents would be significantly different from a limit expressed in terms of fatal aircraft accidents. Risk measures

16. RISK CLASSIFICATION SCHEME Probability of Occurrence Extremely improbable Extremely remoteRemote Reasonably probable Frequent Severity Catastrophic ReviewUnacceptable Hazardous Review Unacceptable Major AcceptableReview Minor Acceptable Review

17. Classification of safety occurrences and causal factors  It is much easier if events and causal factors are classified using a standard scheme and the classified data, called a taxonomy, is comprised of a hierarchy of classes of events.  ICAO has, maintained a global data base of accidents and serious incidents notified by States through the Aircraft Accident Data Reporting System (ADREP), which, contains a greatly expanded taxonomy of ATS-related categories ( http://eccairs-www.jrc.it/) http://eccairs-www.jrc.it/  Taxonomies should be used for classification of ATS-related safety occurrence data for internal investigation and analysis purposes, as well as for reporting accident and incident data to ADREP.  Sharing information online for the classification of risk and the suitable measures to its solution; regional collaboration for the harmonization and exchange of experience

18. Positive safety culture a) Senior management place strong emphasis on safety as part of the strategy of controlling risks; b) Decision-makers and operational personnel hold a realistic view of the short- and long-term hazards involved in the organization’s activities; c) Those in senior positions:  1) Foster a climate in which there is a positive attitude towards criticisms, comments and feedback from lower levels of the organization on safety matters;  2) Do not influence /force their views on subordinates; and  3) Implement measures to contain the consequences of identified safety deficiencies;

19. d) Senior management promote a non-punitive working environment (not immunity); e) There is an awareness of the importance of communicating relevant safety information at all levels of the organization (within and outside); f) There are realistic and workable rules relating to hazards, to safety and to potential sources of damage; g) Personnel are well trained and understand the consequences of unsafe acts. h) There is a low incidence of risk-taking behaviour, and a safety ethic which discourages such behaviour Positive safety culture

20. Characteristics of different safety cultures Safety Culture: Characteristics PoorBureaucraticPositive Hazard information is:SuppressedIgnoredActively sought Safety messengers are:Discouraged or punished ToleratedTrained and encouraged Responsibility for safety is:AvoidedFragmentedShared Dissemination of safety information is: DiscourageAllowed but discouraged Rewarded Failures lead to:Cover upsLocal fixesInquiries and systemic reform New ideas are:CrushedNew problems (not opportunities) Welcomed

21. Next steps…  Uniform system safety approach in accordance with the AN-conf/11 outcomes  Globally standardized implementation of safety management processes and practices  Avoids unnecessary duplication  Collect right data to monitor level of safety  Broader view of ATM system expectations

22. ATM community (Doc 9854)  Aerodrome community  Airspace providers  Airspace users  ATM service providers  a) State agencies;  b) State-owned self-financing corporations;  c) privatized ATM service providers;  d) regional ATM service providers; and  e) independent private sector ATM service providers of ground and space-based CNS/ATM services  ATM support industry  International Civil Aviation Organization (ICAO)  Regulatory authorities  States

23. ATM Performance  When the ATM system delivered trajectory equals the user preferred trajectory, the ATM system is operating well  Value is created when the ATM system consistently and cost-effectively delivers User Preferred Trajectory

24. ATM Performance framework.. Enhancements to safety, finances and the efficiency through the adoption of collaborative decisions towards the evolution of a holistic and co- operation environment should be facilitated to fulfill the expectations of the ATM community, as well as to improve safety of all the system in a balanced manner  Future ATM system must be based on Performance indicators and user expectations:  Safety  Capacity  Efficiency  Regularity  Flexibility

25. ATM performance metrics  New guidance material on measuring performance and productivity includes an approach to development of performance metrics in the areas of safety, delay, flight efficiency, productivity and cost-effectiveness.  Comparing different organization’s performance might be benefit to understand performance drivers and shortfalls and thus establishing best practices.  ATM Requirements and Performance Panel (ATMRPP) is working to finalize a set of ATM system requirements that will guide development of technical SARPs for ATM research, development, and implementation planning activities.