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Safety Management Systems (SMS) An Introduction for Senior Management
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An Introduction to SMS The objective of this presentation is to provide the Senior Management with : an overview of ICAO Standards and Recommended Practices (SARPs) on safety management in Annexes 6, 11 and 14, and their underlying concepts, and a structured process for the implementation of a safety programme and an SMS, as proposed by ICAO
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Session No. 1 Basic Contemporary Safety Concepts
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For Starters The total elimination of risk is unachievable
Errors will occur, in spite of the most accomplished prevention efforts No human endeavour or human-made system can be free from risk and error Controlled risk and error are acceptable in an inherently safe system Notes
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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 Safety Management System is an organized approach to managing safety, including the necessary organizational structure, accountabilities, policies and procedures Notes
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Forensic Safety Management
Focus on the outcome (s) Unsafe acts at the tip of the arrow Blame & punishment for failure to “perform safely” Address specific safety concern exclusively Notes
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The Underlying Paradigm
Rule-based – The world as it should be Aviation system – as pre-specified – is perfect Compliance based Outcome oriented Accident investigation Notes
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Inefficiency and Perversity
The beatings will continue until morale improves 2. Punishment 1. Exhortations to professionalism and discipline 3. Remedial Training Notes 4. Add more procedures & regulations
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The evolution of safety thinking
TODAY 1950s 1970s 1990s 2000s TECHNICAL FACTORS HUMAN FACTORS ORGANIZATIONAL FACTORS
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A concept of accident causation
Management decisions and organizational processes Organization Working conditions Workplace Errors and violations People Regulations Training Technology Defences Accident Latent conditions trajectory Source: James Reason
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System Performance in the Real World
design Baseline performance Operational deployment Operational performance Operational drift Notes
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Managing Safety–Navigating the Drift
Baseline performance “Practical drift” Operational performance Organization Navigational aids Reactive Proactive Predictive Notes
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The Navigational Aids Reactive systems Accident investigation
Incident investigation Predictive systems Electronic safety data acquisition systems Direct observation safety data acquisition systems Proactive systems Mandatory reporting systems Confidential reporting systems Voluntary self-reporting systems Notes
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Safety Data Systems and Levels of Intervention
Safety management levels H i g h M d l e L o w Baseline performance “Practical drift” Operational performance organization Hazards Reactive Predictive Proactive Reactive FDA Direct observation systems ASR Surveys Audits ASR MOR Accident and incident reports Notes Highly efficient Very efficient Efficient Inefficient Desirable management level
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Managing Safety: Collapsing the Drift
Operational deployment System design Operational drift Operational performance Baseline performance Operational performance Operational deployment System design Baseline performance drift Notes
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Emerging Paradigm Rule-based – The world as it should be
Aviation system – as pre-specified – is perfect Compliance based Outcome oriented Accident investigation Performance-based – The world as it is Aviation system – as pre-specified – is imperfect Performance based Process oriented Safety data captured from daily, normal operations Notes
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Organizational processes
Performance-based Safety Organizational processes Latent conditions Workplace Defences Active failures Organizational processes Policy-making Planning Communication Allocation of resources Supervision … Notes Activities over which any organization has a reasonable degree of direct control
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Performance-based Safety
Organizational processes Latent conditions Workplace Defences Active failures Organizational processes Inadequate hazard identification and risk management Normalization of deviance Latent conditions Notes Conditions present in the system before the accident, made evident by triggering factors
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Performance-based Safety
Organizational processes Latent conditions Workplace Defences Active failures Organizational processes Latent conditions Defences Technology Training Regulations Notes Resources to protect against the risks that organizations involved in production activities must confront
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Performance-based Safety
Organizational processes Latent conditions Workplace Defences Active failures Organizational processes Workplace conditions Workforce stability Qualifications and experience Morale Credibility Ergonomics … Notes Factors that directly influence the efficiency of people in aviation workplaces
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Performance-based Safety
Organizational processes Latent conditions Workplace Defences Active failures Organizational processes Workplace conditions Active failures Errors Violations Notes Actions or inactions by people (pilots, controllers, maintenance engineers, aerodrome staff, etc.) that have an immediate adverse effect
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Performance-based Safety
Organizational processes Latent conditions Workplace Defences Active failures Organizational processes Latent conditions Workplace Defences Active failures Improve Identify Monitor Contain Reinforce Notes
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Performance-Based Safety: The ABC
Senior management’s commitment to the management of safety Initial analysis of system and establishment of risk controls (safety risk management) Continuous safety monitoring and analysis of safety data from normal operations (safety assurance) Notes
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