1. Returning to the Core Principles of Proactive Safety Management…
“Back to Basics”
JR Russell
Good afternoon. My name is JR Russell and I’m with Proactive safety systems. I want to begin by thanking the FSF and NBAA for allowing me this opportunity to make this presentation. It is truly an honor and privilege to be here and make this presentation…so thank you very much.
The motivation for this presentation came from an article written by Bill Voss, in the May 2012 issue of Aero Safety World. In that article titled SMS Reconsidered…Mr. Voss stated that more and more folks are experiencing a “burn out” effect with respect to SMS.
For whatever reasons, some folks have made SMS so complex that organizations can become so overwhelmed with the complexities that they fail to realize the benefits of their SMS because their SMS is NOT effective SMS.
Ask yourself this question….if an SMS is overly complex…will that SMS be considered “user-friendly?” An SMS that is NOT user-friendly will not have the participation of the front line employees…and without the participation of the front line employees, an SMS is not effective. If an SMS is not effective…what’s the use in having one in the first place?
Organizations have limited resources available and those limited resources need to be allocated properly…allocated to the areas of highest risk…an EFFECTIVE SMS will identify the areas of highest risk…allowing for better decisions to be made…and ultimately a safer operation.
So, this presentation was developed to cut through the confusion and make the point that SMS does not need to be complex…matter of fact, you should do everything in your power to make sure your SMS is not complex…and one way to cut thru all the confusion and complexities is to return to the core principles of SMS and get Back to the Basics…

2. Methods of Safety Management
Reactive Proactive Predictive
Lets spend a little time going over the 3 methods of safety management….Reactive Proactive and Predictive..
Reactive is forensic…it is investigative in nature…something has happened and now an investigation needs to be done so that lessons can be learned and action can be taken to ensure it doesn’t happen again. Bottom line…reactive safety is AFTER THE FACT…
Proactive is forward looking. Proactive utilizes data to identify threats and put measures in place to mitigate the level of risk of the identified threats and hazards. Proactive safety anticipates things…it is forward looking…proactive safety allows an organization to mitigate risk of an identified threat BEFORE that threat causes an incident or accident.
Predictive safety is forward looking as well. Predictive safety allows an operator to make good decisions without first waiting for a report to come in, or data to be analyzed…predictive safety is quicker to the punch.
Let’s compare these 3 methods of safety management as they relate to increasing safety and reducing risks.
Reactive is forensic…you are reacting to an event that has already occurred. Reactive is important, but since it happens AFTER an incident or accident occurs…one could say it is not the most efficient way to manage safety.
Proactive gets you looking forward…proactive allows you to identify and prepare for the potential threats you see on the horizon.
Predictive is like proactive in that it is looking forward, yet while proactive requires some type of data (hazard reports, FOQA data, etc.)…predictive approach to safety management allows for good decisions to be made before the data identifies a negative trend.
Let’s talk about each one of these approaches to safety management in a little more detail

3. Approaches to Safety Management
PREDICTIVE = Very efficient
INCREASING SAFETY
PROACTIVE = Efficient
Looking at this graph where the Y axis is increasing safety and the X axis is Reducing Risk….
We can see that reactive is the least efficient…primarily because it is after the fact, or after something bad has already happened.
Obvioulsy an organization is safer and has lower risk if that organization is proactive…forward looking…anticipating things.
And the most efficient and safest method of safety management is the predictive method. Predictive safety management does not require data to be analyzed before a decision to mitigate or eliminate a threat is made. Predictive allows an operator to make an informed decision before any data comes in.
Like I said before, we’ll go thru an example to help crystallize these concepts of safety management.
If you put the various approaches to safety management on a scale of Increasing safety while reducing risks you will see that reactive is not as efficient as proactive and proactive is not as efficient as predictive.
REACTIVE = Inefficient
REDUCING RISK

4. Reactive Safety
Based upon the notion of waiting until something breaks to fix it.
The contribution of the reactive approach to safety management depends on the extent to which the investigation goes beyond the active failures - and looks for the latent failures as well.
Let’s discuss reactive safety in a little more detail….
Now I don’t mean to be discarding the idea of reactive safety management. An organization needs a well-functioning reactive safety management system. We must learn from those incidents and accidents and a good internal investigative process is required to get the most from the lessons learned.
The most important item to point out about reactive safety management is to go beyond the ACTIVE FAILURES that led to the incident and look for the LATENT FAILURES that contributed to the event. In order for a reactive process to be most effective in preventing a similar incident is to go beyond Human Error and look for the latent conditions that contributed to the active failure. A reactive safety process must go beyond the active failures, and look for any latent conditions that contributed to the incident. That is where the real value of reactive safety is gained….in finding the latent conditions that contributed to the active failure.
Lets go thru a quick example of reactive safety management….

5. Examples of Latent Conditions
Training deficiencies
Poor equipment design
Lack of resources
Poor communications
Poor safety culture
Gaps in supervision
Less than adequate tools and equipment
Addressing latent conditions offers the best potential for safety improvements
Latent, or hidden conditions….conditions that can lie dormant for a period of time.
It could be years before a latent condition combines with local circumstances and active failures to penetrate the system’s layers of defense.
Latent conditions increase the likelihood of active failures occurring in your operation.
Finding and then addressing latent conditions offers the best potential for safety improvements.
Be sure your Reactive or investigative processes include a search for the latent conditions that had a part in contributing to the active failure. Remember, the greatest potential for gaining safety improvements is to address latent conditions.

6. Reactive Safety Reactive… Focused on the outcome
An unstable approach into XYZ led to a runway excursion.
An investigation is done, and a report is generated with recommendations to prevent a similar incident.
So…reactive safety management focuses on the outcome. It’s after the fact… or forensic. Here’s an example to illustrate the differences between reactive, proactive, and predictive safety management.
An unstable approach into airport XYZ led to a long landing and a runway excursion.
An investigation is done and a report is generated with recommendations to prevent a similar accident. Remind me again of what the reactive process should be focusing on??? LATENT CONDITIONS that contributed to the accident. It’s easy to conclude the report with Pilot error…the crew continued an unstable approach instead of going around…resulting in a long landing and runway excursion.
Why did they continue? Are your procedures clear? Do your crews get enough training in flying stabilized approaches and performing go arounds when an approach becomes unstable? What were the latent failures that contributed to this accident?

7. Proactive
Proactive… Hazards are identified from the information gleaned from reports submitted by front line employees
A rise in unstable approaches has been noticed into XYZ airport. Action is taken to reverse the negative trend of increasing unstable approaches into XYZ.
In this example, the hazard was identified prior to a runway excursion happening. Runway 28 is undergoing some construction and therefore the glide slope is unusable and NOTAM’d OTS. Pilots missed the NOTAM and therefore not anticipating the G/S being OTS and were caught off guard and got behind the aircraft resulting in unstable approaches.
In this example, the threat was identified from a report submitted by one of the pilots…describing how they missed the NOTAM about the glide slope being unusable and therefore were not prepared to fly an non-precision approach which resulted in them being unstable below (high) at 500’. Let’s say this operator has C-FOQA installed on their aircraft and so they check the FOQA data and see that several recent approaches into XYZ were unstable. In other words, they recognized a negative trend developing. This negative trend, in and of itself can be considered as a threat.
So…this operator was fortunate to have identified this threat before it led to an incident or accident. They put out the word to the crews about the GS being OTS and reminded them to carefully read the NOTAM’s and be prepared to fly a non-precision approach.
Well…the trend was reversed…the unstable approaches declined and no runway excursion was experienced.
They were proactive….a threat was identified, mitigating measures were put into effect, the data was checked to verify the measures put into place were effective…and this organization avoided an accident.

8. Predictive
Predictive… Ability to identify a potential hazard based on previous data/models/reports obtained.
Unstable approaches trended upward when airport XYZ experienced runway construction, causing the glide slope to be unusable. Based on that knowledge, we can predict a rise in unstable approaches into airport ABC due to the proposed runway construction.
So…lets discuss predictive safety management. Continuing with this same theme… airport ABC is about to undergo construction to one of their runways. You know from previous experience that unstable approaches trended upward when airport XYZ had construction on their runway, so one can anticipate a rise in the likelihood of unstable approaches into airport ABC. You really don’t need to wait for data to point out a rise in unstable approaches…you can go ahead and be predictive and put measures into place immediately.

9. Methods of Safety Management…A Review
Reactive Proactive Predictive
Reactive is forensic…you are reacting to an event that has already occurred. Reactive is important, but since it happens AFTER an incident or accident occurs…one could say it is the least efficient way to manage safety.
Proactive gets you looking forward…proactive allows you to identify threats from reports or data and prepare for those threats before they contribute to an incident or accident.
Predictive is like proactive in that it is looking forward, yet while proactive requires some type of data (hazard reports, FOQA data, etc.)…predictive approach to safety management allows for good decisions to be made immediately…without waiting for a report or data to identify a potential threat.

10. Proactive Safety Management
“Don’t ever let an airplane take you someplace where your brain hasn’t arrived at least a couple of minutes earlier.” – Anonymous
So…now that we’ve reviewed the methods of safety management and agree that being proactive and even predictive is the way to go…let’s now review how an SMS is used to fulfill the role of making an organization safer by making it more proactive and predictive.
It’s never a good feeling when you find yourself a little behind your airplane. Maybe you’ve been distracted or maybe you did not take the time to brief an approach but whatever the reason, you find yourself trying to mentally catch up to the airplane…and that is not a good feeling. You want stay ahead of the airplane…you talk about things before they happen…you flight plan, you do a departure briefing, you do an approach briefing…you ANTICIPATE things…you work hard at staying ahead of your airplane. By doing so, you provide a safer, more efficient flight…with fewer surprises. We humans handle situations much better if we are not caught by surprise…if we’ve anticipated something happening, and have briefed our plan of action…then we are much better suited to handle the situation properly and safely.
Just like my old baseball coach used to say…”the 2 most important words in baseball are think and anticipate.” Flying is not different…think, anticipate, and talk about it. Get everyone thinking about it.
I believe an SMS does the same thing for an organization. It allows the organization to stay out in front of their operation and anticipate things. We do much better when we anticipate threats and come up with a plan to deal with them. We do much better when we are in a proactive mode…our actions are more effective when we have anticipated a situation and have had time to think about it and plan for it. The results are generally much more favorable than if we find ourselves just reacting to a situation. It’s human nature. “Be Prepared.”
So, just as we strive to stay ahead of the airplane….we should strive to stay ahead of our operation…and an effective SMS will help you do that…to stay ahead of your operation.
I’d like you to take a moment and think about how you would define “safety.”

11. Safety…
“the state in which the risk 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 risk management” (ICAO Safety Management Manual).
How would you define safety? The absence of threats? An environment where the risks are managed to as low as reasonably practical?
Let’s look at the definition from the ICAO Safety Management Manual….
I believe this definition of safety sums up the core principles of an SMS….

12. “…a continuous process of hazard identification and risk management.”
Hazard I.D. – Risk Assessment - Mitigation
There it is in a nutshell….a continuous process….hazard identification and risk management.
A continuous process means you are always on the lookout for threats and hazards.
Lets talk about some potential sources for threat identification…

13. Finding Threats/Hazards
Sources for hazard identification…
Front line employees
Safety data (internal and external sources)
Other operators
Industry sources
In order to become proactive, an organization must be have a continuous process of actively looking for hazards. Hazards can be identified from a number of different sources. The point is to be on the lookout for hazards. An identified hazard allows an operator to prepare for that hazard.
Hazards can be identified from internal sources (hazard reports) or external sources.
Have you ever read an article in Aero Safety World that identified a potential threat to your operation? Or perhaps you read a report from the NTSB, or saw something on the NBAA’s website. The point is, there are all kinds of resources out there that can help an organization identify potential threats. Your internal data (reports, FOQA, etc.) is not your only source for threat identification.
If you put some thought to the subject, I’m sure you can come up with several examples of external sources that you can use to identify potential threats and hazards.
The point is, to constantly be on the lookout for hazards…remember… “a continuous process”…right? Remember, the first step to being proactive and predictive is Identifying the hazard…

14. Risk Assessment
A risk assessment need not be overly complicated. And keep in mind, not every identified threat requires a formal risk assessment to be made. If you are able to make the decision to mitigate the risk without going thru the steps of a formal risk assessment, then more do it. Pay attention to your gut. If your gut is telling you something, you better listen. However, an effective SMS has a process for analyzing the risk when needed to help with the decision making process…do we need to mitigate? Should we eliminate the threat? Should we do nothing? The point I want to make here is to keep it as simple as possible. Always keep in mind, the more complex something is, the less likely it will be used. It’s an inverse relationship….more complexity means less usefulness. And like we mentioned earlier…if a tool is NOT user-friendly, then chances are…that tool is not going to be used.
OK…so we’ve assessed the risk of an identified threat and have determined we need to do something to mitigate the level of risk.
Let’s talk about mitigation strategies….

15. Examples of Mitigation Strategies
Communication
Training
Procedural Changes
Revise Manuals
Equipment upgrades/changes
First and foremost is Communication. Communication should be part of every mitigation strategy. In many cases, communication is the only mitigation strategy to be used…and that’s fine. Sometimes all you really need to do is get the word out and make people aware of the threat. Communicate.
Training is another important mitigation strategy. Whether it is in-house training or training received from an external training provider…training can be an extremely effective tool to mitigate the level of risk.
Perhaps you decide to change a procedure to more effectively mitigate a threat. Or maybe you need to revise your manuals to make something more clearly understood.
Upgrading equipment will help mitigate certain threats. Examples are ehanced GPWS, or Predictive Windshear, or synthetic vision…to name a few.
These are a few examples of “mitigation tools” available to an organization.
Let’s summarize what I’ve been talking about when it comes to the core principles of an SMS….

16. Continuous Loop Safety ™
Determine potential
consequences
Identify
hazards
Modify strategies if needed
Collect
additional
hazard
data
Assess
risks
Proactive Safety Management
Evaluate
Strategies
(Safety Assurance)
Eliminate or develop
mitigation
strategies
This is a flow chart to illustrate…A continuing process of hazard identification and risk management.
Identify the hazard
Determine potential consequences…most hazards have more than one potential consequence…think about which potential consequence you are going to risk assess.
Then make the decision to either eliminate the risk…or mitigate the risk…or do nothing
If the decision is to mitigate the risk…a strategy is developed and approved…then someone is assigned the responsibility to see the strategy implemented…then the strategy is evaluated to verify it is doing what it was planned to do….modify the strategy if needed…then look for more hazards and begin the cycle over. This is a continuous process of hazard identification and risk management. This is proactive safety management.
Implement
strategies
Assign responsibilities
Approve
strategies

17. Real World Example
Safety report narrative = “ During our night, VMC arrival into RNO we were cleared for a visual to runway 16R. Approximately 15 miles northeast of the airport we could see the runway. We began our descent on a dog-leg to final and approximately 8 – 10 miles north northeast of the airport we received a terrain warning…”

18. What was identified in the report?
Terrain around RNO…no surprise
Terrain warnings occurring on approach to RNO (something we did not know)
How frequently are these warnings occurring?
What is the identified hazard? Terrain
The fact that a terrain warning was received is obviously something that was not known until the safety report was filed by the crew member.
What are the 2 factors that must be analyzed to perform a risk analysis? Severity and Frequency… the severity is something we can determine at this point, but what about the frequency? Can we determine the frequency of terrain warnings occurring?
If we are able to determine the frequency, we can then determine our level of risk associated with this hazard…

19. What is the level of Risk?
CFIT
What is the level of Risk?

20. Put a Safety Tool to Work
The Safety team decided to look at FOQA data to determine the frequency of terrain warnings into RNO
Well in this example, the flight department utilizes FOQA data. FOQA data can then be used to get a feel for the liklihood of these terrain warnings occurring.

21. What did they find?
FOQA data showed 3.5% of flights approaching RNO received terrain warnings
Now we have an idea of the liklihood of terrain warnings occurring….3.5% of the approaches into RNO have received terrain warnings.
With this info, we can now begin to assess/analyze the level of risk involved…(next slide)
WHOOP WHOOP
TERRAIN
TERRAIN
PULL UP

22. Take action to mitigate the risk
Now what?
Take action to mitigate the risk
The risk level is not acceptable, so something needs to be done….but what?
What would you do to mitigate the risk of CFIT into RNO if this were your flight department?
Take time here for a really good discussion about steps to mitigate the risk.

23. Mitigation Measures
The first step is raising the level of awareness…Get the word out…Communicate!
Also Consider :
procedural changes
manual changes
changes to the training programs
Always, the first step is to communicate the hazard to the rest of the department. Making them aware of the hazard is one of the most effective actions you can do to mitigate the risk.
Then you’ll need to consider other ways to mitigate the risk…maybe you need to change your procedures, or your manual, or perhaps focus some of your training on CFIT….
So….this exercise provides for a good example of how an effective SMS works….identifying hazards, assessing the risk, mitigating the level of risk, and insuring the mitigating steps actually work as planned.
Now we’ll explore each of the 4 pillars in more detail….starting with Safety Policy….next slide…
15-30 for all of RNO example

24. **HIGH TERRAIN ALL QUADRANTS**
Display EGPWS data, if available.
Brief terrain location and minimum altitudes from all applicable charts.
If a GPWS terrain caution or warning occurs at night or in IMC, immediately
accomplish the escape maneuver.
Off course clearances are NOT ACCEPTABLE unless terrain clearance is
guaranteed.

25. What are the benefits of a proactive approach to safety management?
“We stay in front of our operation…less reactive”
“Involves the entire operation…team building”
“Allows us to make better decisions”
“Raises everyone’s awareness”
When I come across an effective SMS, I ask the operator to list the benefits from their perspective…in other words…I ask them to tell me the value of an effective SMS to their organization.
These are some of the more common answers….
Stay out in front….proactive right?
Involves the entire team…very important that everyone feels they can contribute and are expected to contribute. This one doesn’t happen if the level of complexity is such that the SMS is not user-friendly. Very important point.
Allows for better decisions…decisions are made based on the input of the front line employees. I’m sure many of you have experienced a change in procedures or some other type of change that just did not make much sense. The reason it didn’t make much sense is because it was implemented without the input of the front line employees.
Raises everyone’s awareness…the information is shared so that everyone can benefit from it. Good communication is vital!

26. In Summary… Avoid unnecessary complexities
Remember the foundation of an effective SMS… “a continuous process of hazard identification and risk management.”
JR Russell
Use good common sense a you develop and evolve your SMS.
Keep it simple and remember the primary objective…hazard identification and risk management.
I want to thank the FSF again for allowing me the honor and privilege to make this presentation and I hope you’ve found it to be helpful.
Please feel free to contact me with any questions or comments…