Post on 10-Apr-2018
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TRAINING IN SAFETY
MANAGEMENT SYSTEMS
ARAB CIVIL AVIATION CONFERENCE
Amman, Jordania 19-23 July 2009
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Welcome to SafetyManagement
System Workshop
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Speakers:
CHRISTER PRAHLATM Safety Expert
Electronic Engineer
Degree in Communication
Degree in Networking
Pilot (IFR rated)
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Speakers:
MICHAEL NIELS THORSENATM Safety Expert
Master of Science in Engineering
Expert International Cooperation
Expert Safety Management Implementation
Expert Organisational Structures
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Round the table
Name and Position
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Agenda for today:
Wrap - Up16.30 17.00
The Safety Management System15.30 16.30
Break15.00 15.30
The Safety System14.00 15.00
Lunch12.30 14.00
ICAO presentation on Safety Management System
SES Regulations
11.00 12.30
Break10.30 11.00
Registration and Welcome09.00 10.30
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Objectives of the workshop
Provide participants the knowledge of SafetyManagement Concept and ICAO Standards andRecommended Practices (SARPs) on safety management inAnnexes 6, 11 and 14 and related guidance material
AND TO
Develop participants knowledge to certify and overseethe implementation of key components of an SMS, in
compliance with relevant ICAO SARPs.
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ICAO - Safety Management System
What is Safety? Zero Accidents?
Freedom from danger or risks?
Error avoidance?
Any suggestions?
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ICAO - Safety Management System
According to ICAO Doc 9859:
Safety is the state in which the risk to harm the
persons or property damages is reduced, and
maintained at or below, an acceptable level
through a continuing process ofhazard
identification and risk management.
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ICAO - Safety Management System
Asafety management system (SMS) is an organised approach to
managing safety, including the necessary organisational structures,
accountabilities, policies and procedures.
(ICAO Doc 9859 - Safety Management Manual)
The objective of a Safety Management System is to provide a
structured management approach to control safety risks in operations.
Effective safety management must take into account the organisationsspecific structures and processes related to safety of operations.
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Safety Management SystemStructure and Contents
1: SMS course
introduction
2: Basic safety
concepts
3: Introductionto safety
management4: Hazards
5: Risks 6: SMS regulation7: Introduction to
SMS
8: SMS planning 9: SMS operation
10: Phased approach
to SMS
Implementation
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Safety Management ManualObjectives
Objectives of the Safety Management Manual are to provide States:
Knowledge of safety management concepts, the ICAO Standards andRecommended Practices (SARPs) on safety management contained in Annexes
1, 6, 8, 11, 13 and 14, and related guidance material;
Guidance on how to accept and oversee the implementation of the keycomponents of an SMS in compliance with the relevant ICAO SARPs;
Guidance on how to develop and implement an SSP in compliance with therelevant ICAO SARPs.
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Safety Management ManualConcept
SMS/SSPImplementation
ICAO SARPS Safety Concepts
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Generic SMS Requirements
ICAO requirements for implementation of SMS are currently applicable to:
Air Traffic Service Providers (Annex 11)
Aerodrome Operators (Annex 14, Volume 1)
Amendment to Annex 1, 6, 11, 13 and 14 are proposed in order to harmoniseand extend provisions relating to safety management.
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SES Regulation - Objectives
The second SES package has been put forward by the European
Commission in order to make the European sky safer and more
sustainable by:
Introducing a performance framework for European ATM with quantifiedtarget setting;
Creating a single safety framework to enable harmonised development ofsafety regulations and their effective implementation;
Opening the door to new technologies enabling the implementation ofnew operational concept and increasing safety levels by a factor of ten;
Improving management of airport capacity.
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The 1st SES legislative package
The legislative package adopted in 2004 comprises four base regulations,
which reinforce safety and foster the restructuring of European airspaceand air navigation services. The regulations provide the framework for thecreation of additional capacity and for improved efficiency andinteroperability of ATM system in Europe.
The Framework regulation (EC No 549/2004) - laying down theframework for the creation of the single European sky;
The Service provision regulation (EC No 550/2004) - laying downcommon requirements for the provision of air navigation services;
The Airspace regulation (EC No 551/2004) - on the organisation anduse of airspace in the Single European sky;
The Interoperability regulation (EC No 552/2004) - on theinteroperability of the European Air Traffic Management network.
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(EC) No 549/2004 - FrameworkThe objective of the Framework regulation is to enhance current safety
standards and overall efficiency of the general air traffic in Europe,
to optimise ATM system capacity and minimise air traffic delays by
establishing a harmonised regulatory framework for air trafficmanagement in Europe.
The Framework regulation establishes harmonised institutional, regulatory
and consultation arrangements to enable the creation of the Single European
Sky.
In brief these are: National Supervisory Authorities (NSA)
Single Sky Committee
Military Issues
Industry Consultation Body
Implementing Rules
Performance Review
Safeguards
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(EC) No 550/2004 Provision of AirNavigation Services in SES
The Service provision regulation establishes common requirements to ensurethat air navigation services are provided safely and efficiently, on a continuous and
interoperable basis, throughout the European Community. It introduces aharmonised system of certification and lays down rules for designating serviceproviders.
The stipulations of this regulation apply to the provision of air navigation
services to General Air Traffic (GAT) and can be summarised as follows:
National Supervisory Authorities (NSA)
Licensing of Controllers
Common Requirements
Certification of Air Navigation Service Providers (ANSPs) Designation of Air Traffic Service Providers
Relations between Service Providers
Transparency of Accounts
Access to and Protection of Data
Charging Schemes
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(EC) No 551/2004 Organisationand use of Airspace in SES
The objective of the Airspace regulation is to put an end to the fragmentation of European
Union (EU) airspace and to create an efficient and safe airspace without frontiers. Theorganisation and management of airspace should be improved by merging all the nationalflight information regions (FIRs) into a single portion of airspace within which ATS will beprovided according to the same rules and procedures.
The Airspace regulation forms part of the first package of legislation on air traffic management
designed to create a SES. This objective will make for improved safety, optimum use ofEuropean
airspace, reduced air traffic delays and sustainable air transport growth.
The following is summarising this regulation:
Establishment of European Upper Flight Information Region (EUIR) Reconfiguration of Upper Airspace
Optimised Route and Sector Design in the Upper Airspace
Flexible Use of Airspace
Safeguards
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(EC) No 552/2004 Interoperabilityof the European ATM Network
The aim of the Interoperability regulation is two-fold:
To achieve interoperability between the different systems, constituents andassociated procedures in the European ATM network by establishing aharmonised system for certification of components and systems;
To ensure the introduction of new agreed and validated concepts of operationsand technology in air traffic management.
The following topics summarise the Interoperability regulation:
Essential Requirements
Implementing Rules for Interoperability
Community Specifications EC Declaration of Conformity of Suitability for Use of Components
Safeguards
Transitional Arrangements
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The SES Implementation
Implementing the provision of the SES regulations would bring a number of
significant benefits:
Improved level of safety of air navigation services;
A more effective and integrated air traffic management architecture;
Demand driven air navigation service provision;
Enhanced cross-boarder co-ordination;
Improved decision-making and enhanced enforcement in ATM.
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Regulations, Directive andImplementing Rules
Regulations: Mandatory to the letter
Directives: Mandatory with National exemptions
Implementing Rules: Guidelines
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The 1st SES legislative package
The First Report on the implementation of the Single Sky Legislation
was published in December 2007.
It presents:
the achievements,
identifies new challenges
proposes the way forward.
Based on the report findings, the Commission came forward withproposals for a 2nd Single Sky package, including extension of EASA
competencies to ATM and adoption of the European ATM Master Plan.
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The 2nd SES legislative packageTo tackle issues such as traffic increase, financial burden and
environmental awareness, the Commission has come up with 2nd SES
legislative package aimed to:
Create a single safety framework to enable harmonised developmentof safety regulations and their effective implementation;
Improve the performance of the ATM system through setting oftargets;
Open the door to new technologies enabling the implementation ofnew operational concept and increasing safety levels by a factor of
ten; Improve management of airport capacity
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(EC) No 2096/2005 Common Requirementsfor the Provision of Air Navigation Services
The objective of this Regulation is to establish common requirements for the safe and
efficient provision of air navigation services in the European Community and to set uniformand high safety standards for ANSPs.
The common requirements cover the follow ing areas:
Technical and operational competence and capability
Organisational structure and management Safety and quality management Security Human resources Financial strength Liability and insurance cover
Quality of services
Reporting requirements
The common requirements do not cover military operations and training and do not apply toactivities or resources allocated to activities outside the provision of air navigation services.
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(EC) No 2096/2005 Common Requirementsfor the Provision of Air Navigation Services
The Regulation identifies and adopts the mandatory provisions of the following
EUROCONTROL Safety Regulatory Requirements (ESARRs) which are relevant for thecertification of air navigation service providers:
ESARR3 - on the use of safety management systems by air traffic management(ATM) service providers;
ESARR4 - on risk assessment and mitigation in ATM;
ESARR5 - on ATM services' personnel, in particular the requirements for engineeringand technical personnel undertaking operational safety related tasks.
The detailed requirements relating to safety of services are contained in Annex II tothe Regulation.
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(EC) No 2096/2005 Common Requirementsfor the Provision of Air Navigation Services
Subjects summarising (EC) No 2096/2005 are as follows:
Certification of ANSPs
Derogations Demonstration of Compliance
Compliance Monitoring
Peer Review of NSAs
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Similarities and Differences betweenICAO and SES
EUROCONTROL Methodology (ESARR)
ICAO Methodology
Step0:
Planning
Step1:
SystemDescript
ion
Step2:
HazardIdentifica
tion
Step3:
SeverityAssessm
ent
Step4:
LikelihoodAssessment
Step5:
SystemDescript
ion
Step6:
RiskMitigatio
n
Step7:
Documentatio
n
FunctionalHazard Assessment
(FHA)
PreliminarySystem SafetyAssessment
(PSSA)
System SafetyAssessment
(SSA)
Whatcan
gowrong?
What
canw
e
doabouti
t?
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ICAO Safety Regulation
ICAO Annex 11 Paragraph- 2.26 ATS Safety Management
includes relevant requirements related to ATS
Para 2.26.1 requires the States to implements systematic andappropriate Safety Management Programmes, further detailed in
Para 2.26.4
Para 2.26.2, requires States to establish the acceptable level ofsafety and safety objectivesapplicable to the provision of ATSwithin their airspace and at their aerodromes with acceptable level
of safety further detailed in 2.26.3
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ICAO Provisions
Para 2.26.5 requires that any significant safety-related change to
the ATC system shall only be implemented after a safetyassessment has demonstrated that an acceptable level of safety willbe maintained.
Para 2.26.5 also requires that the responsible authorities shallprovide for post-implementation monitoring to verify that thedefined levels of safety continues to be met
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ICAO Provisions
PANS-ATM doc.4444 includes in Chapter 2 requirements for:
ATS maintaining acceptable level of safety (section 2.1)
Implementation of systematic Safety Management Programmes (section 2.1)
ATS Safety Management Activities (section 2.3)
Monitoring of Safety Levels (section 2.4) Safety Reviews (section 2.5)
Safety Assessments (section 2.6)
Safety-enhancing measures (section 2.7)
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ICAO Provisions
PANS-ATM Doc 4444 clarifies a significant safety-related change as
(examples):
A new operating procedure, including departure and arrival procedures, tobe applied within an airspace or at an aerodrome;
A reorganization of the ATS route structure;
A resectorisation of an airspace;
Physical changes to the layout of runways and /or taxiways at anaerodrome; and
Implementation of new communications, surveillance or other safety-
significant systems and equipment, including those providing newfunctionality and or capabilities.
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Safety Management Manual
The new Manual on Safety Management for Aerodromes and Air
Traffic Services (Doc 9859)
Provides detailed guidance on implementation of the provisions of Annexes
6, 11, 14 and the PANS-ATM
First Draft was endorsed by 11th Air Navigation Conference (Montreal, Sep/Oct 2003)
Current version in ICAO NET web
Based on the same approach to safety as recommended by the ATM Operational Concept(Doc 9854)
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The Concept of Safety Management
SafetyMonitoring
SafetyAssessment
SafetyAuditing
SafetyPromotion
SupportingOrganisationalRequirement
Safety Management
SafetyCulture
SafetyPolicy
PhilosophyOf Safety
Management
Maintenance ofImprovement of
Safety Performance
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Legal and Regulatory Foundationfor Safety Management
Implementation of safety management programs refers to the day
to day keep safety oversight management by the service providers
States shall establish systemic and suitable ATS safety managementprograms with defined levels and objectives (PANS-ATM, in force since
November 2003) The acceptable level of safety shall be established by the States. Asappropriate, the target levels of safety (TLS) will be established throughregional air navigation agreements.
Prior to any significant change to the safety-related ATC system, a safety
assessment will be carried out, proving that an acceptable safety level maybe obtained
SMS includes the establishment of runway safety programs.
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The Safety System Global Safety System
Organizational structure - Staffing, documentation, resources and leadership commitment
must be sufficient to support the desired process. Planning - Strategic planning and development of appropriate activities must be based onsystematic and comprehensive assessment of risks.
Management personnel standards - Safety must be integrated into line and operatingmanagement responsibilities, and their roles must be clearly defined in written standards ofperformance.
Training for operations and emergencies
Procedures - The organization must develop written procedures for design, operations andmaintenance activities to control routine work and probable emergencies.
Management of change Mechanical integrity - The organization must establish systematic and comprehensive
means to assess the integrity of process equipment. Management of contractors - Safety must be a prominent consideration in the selection of
contractors, and appropriate means to monitor the work of contractors must be in placeand working. Involvement of the work force Accident/incident reporting, investigation and follow-up - Monitoring and auditing methods
must be in place to monitor the on-going, day-to-day performance of the safety system, aswell as to audit thoroughly compliance to all requirements on a periodic basis.
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Global Safety SystemDocumentation:
ICAO
EASA
EUROCONTROL
EC
States
Ministries
CAA
Guidelines
RegulationsRequirements, EU OPS
RecommendationsLegislation
National LegislationNSA
Service Providers
ManualsWorking Procedures
Documentation
AD Technical Implementing Rules
Guidance Material Acceptance Means of Compliance Notices of proposal amendments
Aviation LawAirport Law
RegulationsStandards
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Global Safety SystemOrganisation:
The world global Safety System consist of allthe existing safety management systems onall levels in all the areas of aviation like theservice providers, the airspace users, themaintenance organisations etc.
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Global Safety SystemSupporting Issues:
Auditing
Inspections
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Global Safety SystemSecurity:
Improved security of ATM systems andinformation
Provides assistance and information In Flight Emergency Response
ICAO Annex 17
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Global Safety SystemSecurity:
Until the events of11 September 2001, the ICAO model was regarded as adequate andsufficient to ensure the safety of passengers, aircraft and goods. However, in December2001 the ICAO adopted anAmendment 10 to Annex 17, which set out a number ofadditional safety and security requirements. These include the following:
1. Aircraft security check2. Background check
3. Screening4. Application of Security5. Security Restricted Areas6. Objectives7. International cooperation
8. National Organization and appropriate authority9. Airport Operations10. Quality Control Programme11. In-flight aircraft security measures
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Global Safety SystemSecurity:
ContingencyPlan
AirportEmergency
Plan
National Civil Aviation Security Program
AirportSecurityProgram
OperatorSecurity
Programs
NationalTrainingProgram
QualityControlProgram
Airport SecurityCommittee
Authority
National Aviation Security Committee
ICAO Security Concept:
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Global Safety SystemQuality Definitions:
Quality the totality of features and characteristics of a product or service that bear onits ability to satisfy a given need.
Quality Policy the overall quality intentions and direction of an organisation as regardsquality, as formally expressed by top management.
Quality Management that aspect of the overall management function that determinesand implements the quality policy.
Quality System the organisational structure, responsibilities, procedures, processes andresources for implementing quality management.
Total Quality Management a management approach of an organisation centred onquality, based on the participation of all its members and aimed at long term success
through customer satisfaction and benefits to the members of the organisation and society.
Quality Assurance the activities an organisation carries out to provide to external andinternal parties confidence that the organisation will consistently meet the requirements forquality.
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Global Safety SystemQuality:
Airport Quality P rocess:
Evaluation of user needs and expectations
Design and implementation of service
Operation and achievement of service
Measurement of quality of service
Evaluation and Corrective action
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Global Safety SystemQuality Definitions:
Airport Quality Elements:
Safety
Security
EfficiencyService
Capacity
Environment
Health
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Global Safety SystemQuality:
The implementation of QMS, completed in March 2002, included data and
product quality assurance and control processes. These processes drew onthe following existing resources:
day-to-day consistency checking systems for both data and products, forecast verification system developed in 2000 which gave for each
forecast a score relative to the ICAO desirable accuracy for each of theweather elements. The QMS also included on-going review processes for continual
improvement and for the provision of adequate resources to sustain theQMS.
Further, as important components of the QMS, customer needsassessment and satisfaction survey became an institutionalized part of thesystem.
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Global Safety SystemSafety:
The world global Safety System consist of all
the existing safety management systems onall levels in all the areas of aviation like theservice providers, the airspace users, the
maintenance organisations etc.
As stated before:
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Global Safety SystemSafety Versus Quality and Security:
It is accurate to say that SMS and QMS share many commonalities. They both:
a) have to be planned and managed;b) depend upon measurement and monitoring;
c) involve every function, process and person in the organization; and
d) strive for continuous improvement.
SMS differs from QMS in the fol low ing way:
a) SMS focuses on the safety, human and organizational aspects of an organization(i.e. safety satisfaction);
while
b) QMS focuses on the products and services of an organization (i.e. customersatisfaction).
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Safety Management System
Safety The state in which the risk of harm to persons
or property damage is reduced to, and maintained at orbelow, an acceptable level through a continuing processof hazard identification and risk management.
ManagementAllocation of resources.
System Organized set of processes and procedures.
SMS An organised set of processes and procedures,based upon a principled allocation of resources, that allows
the control of safety risks to an acceptable level
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The Safety Management System
What is SMS?
A system for managing safety as part of the overallmanagement objective and policy;
Why SMS? To regulate airport operations and improve safety levels,
especially in areas not covered by applicable ICAO orapplicable national standards and regulations;
How? Existence of comprehensive technical
Standards/specifications, a safety management policy, theirimplementation and maintenance at all times.
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The Safety Management SystemSMS Tool-box: 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.
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The Safety Management System
The components of SMS:
1) Safety policy and objectives
2) Safety risk management
3) Safety assurance
4) Safety promotion
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The Safety Management SystemSMS at glance:
Safety
Effectiveness Efficiency
ManagementCommitment
Safety RiskManagement
Safety Promotion
Safety Policy andObjectives
Safety Assurance
Aviation Community Stakeholders
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The Safety Management SystemThe Elements of SMS:
Safety policy and objectives
Management commitment and responsibility
Safety accountabilities of managers
Appointment of key safety personnel SMS implementation plan
Coordination of emergency response planning
Documentation
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The Safety Management SystemThe Elements of SMS:
Safety risk management Hazard identification processes
Risk assessment and mitigation processes
Safety assurance
Safety performance monitoring and measurement
The management of change
Continuous improvement of the SMS
Safety Promotion:
Training and Education
Safety Communication
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Safety Risk Management
What is Risk Management?
The identification, analysis and elimination, and/ormitigation to an acceptable level of risks that threaten thecapabilities of an organization.
What is the objective of Risk Management?
Aims at a balanced allocation of resources to address allrisks and viable riskcontrol and mitigation.
Why is Risk Management important? A key component of safety management systems. Data-driven approach to safety resources allocation, thus
defensible and easier to explain.
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Safety Risk Management
Four steps for hazard identification process:
1. Reporting hazards, events or safety concerns.
2. Collecting and storing the data.
3.Analyzing reports.4. Distributing the information distilled from the analysis.
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Safety Risk ManagementRisk Assessment and Mitigation Process
Risk Assessment:
Regularly
Commitments
Documentation
Mitigation:Measures to address the potential hazard or toreduce the risk probability or severity.
Risk mitigation = Risk control
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Risk Management SystemRisk Management at glance:
Hazard Identification
Risk AnalysisProbability
Risk Analysis
Severity
Risk Assessment andTolerability
RiskControl/Mitigation
Equipment, Procedures, Organisation, etc
Analyse the likelihood of the consequenceoccurring
Evaluate the seriousness of the consequence
if it occurred
Is the risk assessed acceptable and withinthe organisational safety performance criteria
Yes, Accept the risk
No, take action in order to reduce the risk toan acceptable level
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Risk Management SystemRisk Mitigation at glance:
Hazard identification andRisk Assessment
Assessment of thedefences within the
safety system
Control andMitigation of the risks
Accepting the mitigationsof the risk(s)
H H H H
Each Consequence
R R R R
Each Risk
TechnologyTraining
Regulations
IntolerableRegion
TolerableRegion
AcceptableRegion
Does it addressthe risk(s)?
Is it effective?Is it appropriate?
Is additional mitigationwarranted?
Do the mitigationsStrategies generate
additional risks?Etc
Feedback safety assurance
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Risk Management Assessment There is no such thing as absolute safety In aviation it is not possible to
eliminate all risks.
Risks can be managed to a levelas low as reasonably practicable(ALARP)
Risk mitigation must be balanced against: Time
Cost Difficulty of taking measures to reduce or eliminate the risk (i.e. managed).
Effective risk management seeks to maxim ize the benefits of accepting arisk
(a reduction in time and cost) while minimizing the risk itself.
Communicate the rationale for risk decisions to gain acceptance by stakeholdersaffected by them.
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Safety Assurance
Safety Assurance is built upon the following:
Safety performance monitoring and measurement
The management of change
Continuous improvement of the SMS
S f t A
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Safety Assurance
Safety performance monitoring and measurement
The process by which the safety performance of theorganization is verified in comparison to the approved safetypolicies and objectives.
Safety reporting Safety studies Safety reviews Audits
Surveys Internal safety investigations
Safet Ass ance
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Safety Assurance
Safety Audits are used to ensure that the structure of the SMS is sound in terms of:
Levels of staff;
Compliance with approved procedures and instructions;
Level of competency and training to:
Operate equipment and facilities; and
Maintain their levels of performance.
Safety surveys examine particular elements or processes of a specific operation.
Problem areas or bottlenecks in daily operations.
Perceptions and opinions of operational personnel.
Areas of dissent or confusion.
Check listQuestionnaires
Informal confidential interviews
Safety Assurance
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Safety Assurance
Internal safety investigations include occurrences or events
that are not required to be investigated or reported to State.
In-flight turbulence (flight operations)
Frequency congestion (ATC)
Material failure (maintenance)
Ramp vehicle operations (aerodrome)
Safety Information Sources
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Safety Information Sources
The protection of safety information from inappropriate use is essentialto ensure its continued availability in future, since the use of safety
information for other than safety-related purposes may reduce theavailability of such information, with an undesirable effect on safety.
During the 35th Assembly of ICAO, it was noted that existing nationallaws and regulations in many States may not address adequately the
protection of safety information from inappropriate use.
Following the Assembly, ICAO has produced a legal guidance for theprotection of information from SDCPS and it is included in Attachment Eto Annex 13.
Annex 13
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Annex 13
General Principles The sole purpose of protecting safety information from inappropriate use is to ensure its continued
availability so that proper and timely preventive actions can be taken and aviation safety improved.
It is not the purpose of protecting safety information to interfere with the proper administration of justicein States.
National laws and regulations protecting safety information should ensure that a balance is struckbetween the need for the protection of safety information in order to improve aviation safety, and theneed for the proper administration of justice.
National laws and regulations protecting safety information should prevent its inappropriate use. Providing protection to qualified safety information under specified conditions is part of a States safety
responsibilities.Principles of Protection Safety information should qualify for protection from inappropriate use according to specified conditions
that should include, but not necessarily be limited to: the collection of information was for explicit safetypurposes and the disclosure of the information would inhibit its continued availability.
The protection should be specific for each SDCPS, based upon the nature of the safety information itcontains.
A formal procedure should be established to provide protection to qualified safety information, inaccordance with specified conditions. Safety information should not be used in a way different from the purposes for which it was collected. The use of safety information in disciplinary, civil, administrative and criminal proceedings should be
carried out only under suitable safeguards provided by national law.
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Annex 13
Principles of Exception Exceptions to the protection of safety information should only be granted by national laws and
regulations when: There is evidence that the occurrence was caused by an act considered, in accordance with the
law, to be conduct with intent to cause damage, or conduct with knowledge that damage would
probably result, equivalent to reckless conduct, gross negligence or wilful misconduct; An appropriate authority considers that circumstances reasonably indicate that the occurrence
may have been caused by conduct with intent to cause damage, or conduct with knowledge thatdamage would probably result, equivalent to reckless conduct, gross negligence or wilfulmisconduct;
A review by an appropriate authority determines that the release of the safety information isnecessary for the proper administration of justice, and that its release outweighs the adverse
domestic and international impact such release may have on the future availability of safetyinformation.Public Disclosure Subject to the principles of protection and exception outlined above, any person seeking
disclosure of safety information should justify its release. Formal criteria for disclosure of safety information should be established and should include, but
not necessarily be limited to, the following:
Disclosure of the safety information is necessary to correct conditions that compromise safetyand/or to change policies and regulations;
Disclosure of the safety information does not inhibit its future availability in order to improvesafety;
Disclosure of relevant personal information included in the safety information complies withapplicable privacy laws;
Disclosure of the safety information is made in a de-identified, summarized or aggregate form.
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Annex 13
Responsibility of the Custodian of Safety Information Each SDCPS should have a designated custodian. It is the responsibility of the custodian of safety
information to apply all possible protection regarding the disclosure of the information, unless: The custodian of the safety information has the consent of the originator of the information for
disclosure; or The custodian of the safety information is satisfied that the release of the safety information is in
accordance with the principles of exception.
Protection of Recorded Information Considering that ambient workplace recordings required by legislation, such as cockpit voice
recorders (CVRs), may be perceived as constituting an invasion of privacy for operationalpersonnel that other professions are not exposed to:
Subject to the principles of protection and exception above, national laws and regulations shouldconsider ambient workplace recordings required by legislation as privileged protected information,i.e. information deserving enhanced protection; and
National laws and regulations should provide specific measures of protection to such recordingsas to their confidentiality and access by the public. Such specific measures of protection ofworkplace recordings required by legislation may include the issuance of orders of non-publicdisclosure.
Change Management Process
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Change Management Process
Aviation organizations experience permanent change due
to expansion, introduction of new equipment or procedures.
Changes can have the following output:
Introduce new hazards.
Impact the appropriateness of risk mitigation.
Impact the effectiveness of risk mitigation
Change Management Process
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Change Management Process
Mentioned Changes can be:
External changes Change of regulatory requirements. Security.
Reorganization of air traffic control
Internal changes Management changes
New equipment. New procedures
Change Management Process
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Change Management Process
A formal management of change process should:
identify changes within the organization which mayaffect established processes and services.
prior to implementing changes describe thearrangements to ensure safety performance.
Improvement Process
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Improvement Process
Continuing improvement aims at:
Determining the immediate causes of below standardperformance and their implications in the operation ofthe SMS.
Rectifying situations involving below standardperformance identified through safety assuranceactivities
Improvement Process
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Improvement Process
The mentioned improvements are achieved through:
Proactive evaluation of facilities, equipment,documentation and procedures through audits andsurveys.
Proactive evaluation of the individuals performance, toverify the fulfilment of their safety responsibilities.
Reactive evaluations in order to verify the effectiveness
of the system for control and mitigation of risks, forexample: accidents, incidents and major eventsinvestigations
Safety Promotion
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Safety PromotionTraining and Education
Who?
Operational personnel Managers and supervisors Senior managers Accountable executive
Why? To ensure that personnel are trained and competent
to perform the SMS duties.
How much? Appropriate to the individuals involvement in the
SMS.
Safety Promotion
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Safety PromotionTraining and Education
A building b lock approach:
Operational personnel Organization safety policy
SMS fundamentals and overview
Managers and supervisors
The safety process
Hazard identification and risk management
The management of change
Senior managers Organizational safety standards and national regulations
Safety assurance
Safety Promotion
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ySafety Communication
Safety communication aims to:
Ensure that all staff are fully aware of the SMS.
Convey safety critical information.
Explain why particular actions are taken.
Explain why safety procedures are introduced or changed.
Convey nice-to-know information.
Safety Promotion
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ySafety Communication
The means to communicate may include:
Safety policies and procedures News letters
Bulletins
Website
Safety communication is an essential foundation for the
development and maintenance of a positive culture.
Maintenance
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Internal Evaluation Process
Management commitment
Just culture
Established processes
Maintenance
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Internal Audit Process
An annual audit program should include:
Definition of the audits, in terms of;
criteria,
scope,
frequency, and methods;
Description of the processes used to select the auditors;
The requirement that individuals shall not audit their own work;
Documented procedures for assignment of responsibilities, planningand conduct of audits, reporting results and maintaining records;
Audits of contractors and vendors.
Maintenance
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External Audit Process
Surveillance and compliancethe authority needs to ensure that international, national and local
standards are complied with prior to issuing any licence or approval andcontinue to be complied with afterwards;
Areas and degree of riskthe audit should assess how risks are identified and how any necessarychanges are made to ensure that all safety standards are met;
Competencethe audited organisation should have adequately trained staff for allsafety related positions
Safety managementensure that the organisations SMS is based on sound principles and
procedures, and that the organisation is meeting its safety performancetargets.
Maintenance
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Proactive and Reactive Evaluations
Proactive before something has happened
Taking actions
Mitigate
Training
Reactive after something has happened
Investigate why it is as it is
Make improvements
Organisation
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Cultural Levels of the organisation
The characteristics of a good company safety culture include:
Informed - Managers know what is really going on and workforce iswilling to report their own errors and near misses
Wary - ready for the unexpected Just - a no blame culture, with a clear line between the acceptable
and unacceptable Flexible - operates according to need Learning - willing to adapt and implement necessary reforms
Organisation
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The values of an Organisation:
The safety management organisation is definingresponsibilities, competence, commitment and communication ofthe involved organisations or persons.
The culture is expressed by all parts of the organisation
Flight deck
Cabin crew
Maintenance
Ground staff
The cabin staff and check-in personnel provide the main indicationof the culture to the paying public
Organisation
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Top-down
Managers
Flight Crew
Engineers
(Maintenance)
Ground Staff
(Luggage Personnel)
Managers influencing and motivating allactors to take responsibility for theirwork and taking into account thesafety.
ProceduresS f P
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Safety Programme
Safety Programme is an integrated set of regulations and activities
aimed at improving safety.States are responsible for establishing a safety programme,
encompassing the following responsibilities:
Safety regulation
Safety oversight Accident/incident investigation
Mandatory/voluntary reporting systems
Safety data analysis and
exchange Safety assurance
Safety promotion
State Safety Programme - SSP
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State
States shall establish a State safetyprogramme (SSP), in order to achieve anacceptable level of safety (ALoS) incivil aviation.
Acceptable level of safety (ALoS) to beachieved shall be established by theState.
Service Prov iders
States shall require as part of theirState Safety Programme (SSP) that aService Providers implement SafetyManagement System acceptable to theState that as minimum:
identifies safety hazards;
ensures the implementation ofremedial action necessary tomaintain agreed safetyperformance.provides for continuing monitoringand regular assessment ofthe safety performance; andaims at a continuous improvementof the overall performance of the SMS.
P d
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ProceduresStates safety programme
Develop the States safety programme around the
following four components:1. States safety policy and objectives
2. States safety risk management
3. States safety assurance
4. States safety promotion
ProceduresDiff b t St t d S i P id
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Differences between State and Service Providers
Legal considerations States
Establishing acceptable level(s) ofsafety does not replace legal,
regulatory, or other already
established requirements, but it
must support compliance with them.
Establishing acceptable level(s) of
safety for their safety programme
leaves unaffected the obligations of
States, and does not relieve States
from compliance with SARPs
Operators and service providers
Establishing acceptable level(s) of
safety for their safety management
system leaves unaffected the
obligations of operators or services
providers and other related parties,
and it does not relieve the operator,services providers and other related
parties from compliance with SARPs
and/or national regulations, as
applicable.
ProceduresStates safety programme + Service providers SMS
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States safety programme + Service providers SMS =
Integrated safety system
State SafetyProgramme
Organisations Safety
ManagementSystem (SMS)
Organisations
ProductionProcesses
OversightAcceptance
Oversight
Risk ManagementSafety Assurance
Objective:Public Safety
Objective:
Manage andcontrolsafety risks
Objective:
Achieve
commercialgoals andcustomersaftisfaction
Safety Policy
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A typical safety policy document would consist of a policy statement that isfurther expanded by a number of basic safety management principles to be
followed: commitment to safety, safety priority, safety responsibility, planning for safety,
safety management, safety standards, safety achievement, safety assurance and safety promotion
Safety Policy - A statement of the organisations fundamentalapproach to achieve acceptable or tolerable safety.
A written document that describes the generic principles upon which theSMS is build and operated upon.
Risk Management
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Risk management - The identification, analysis andelimination (and/or mitigation to an acceptable or tolerable level) of thosehazards, as well as the subsequent risks, that threaten the viability of anorganisation.
Risk Management consists of the following three elements:
Hazard identification
Risk assessment
Risk mitigation
Risk Management SystemRisk Management at glance:
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Risk Management at glance:
Hazard Identification
Risk AnalysisProbability
Risk Analysis
SeverityRisk Assessment and
Tolerability
RiskControl/Mitigation
Equipment, Procedures, Organisation, etc
Analyse the likelihood of the consequenceoccurring
Evaluate the seriousness of the consequence
if it occurredIs the risk assessed acceptable and within
the organisational safety performance criteria
Yes, Accept the risk
No, take action in order to reduce the risk toan acceptable level
Safety Assurance
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Safety assurance - all planned and systematic actions necessary toafford adequate confidence that a product, a service, an organisation or afunctional system achieves acceptable or tolerable safety
The objectives of Safety Assurance is to implement dedicated surveillance anddocumenting procedures and processes in order to ensure that risk arebeing properly managed.
According to ICAO State Letter SA include the following activities:
Safety performance monitoring and measurement
Management of change
Continuous improvement of the SMS
Safety Assurance
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Safety Assurance components:
Safety Surveys Safety Monitoring
Safety Records
Regulators should continuously evaluate the implemented safetymanagement arrangements and processes by aviation serviceproviders by means of external regulatory safety auditing and othersafety oversight methodologies.
Safety Promotion
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Just culture
Key Performance Indicators
Processes
Thank You for youattention today
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attention today
Any Questions?See You tomorrow
Agenda for today:
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Wrap up
Evaluation
Hand over of Diploma
16.30 17.00
Joint session/discussions15.30 16.30
Break15.00 15.30
The Safety Components14.00 15.00
Lunch12.30 14.00
WS on Safety Culture11.00 12.30
Break10.30 11.00
Managing Safety09.00 10.30
Managing SafetySafety Responsibility and accountability
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Safety Responsibility and accountability
Safety responsibility: the obligation to carry forward an assignedsafety related task to its successful conclusion. With responsibility
goes authority to direct and take the necessary action to ensuresuccess.
Safety accountability: the obligation to demonstrate the taskachievement and take responsibility for the safety performance inaccordance with agreed expectations. Accountability is theobligation to answer for an action.
Clear and correctly allocated safety accountabilities and responsibilitiesare prerequisite for achieving the organisations safety objectives
and for implementing an effective safety management and safetyimprovement process
Safety Manager (SM)
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An individual, responsible for the development, operation and
continuous improvement of the safety management system deployed
by an operator/service provider.
He acts as a focal point for safety management issues in the
organisation.
The approach to the assignment of Safety managers responsibilities
may differ depending on the type, size of the organisation, its
mission, complexity of operations and operating environment.
Safety Managers
Responsibilities
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ResponsibilitiesThe appointment of the Safety manager (SM) is an essential step in the establishment ofthe SMS organisational structure and a prerequisite for an efficient safety planning
process. Irrespectively of any other duties that may be allocated to them, safetymanagers have the responsibility to:
Promote safety awareness within the organisation; Ensure that safety management has the same or higher priority level throughout
organisation as any other management and operational processes;
Manage all aspects of the organisations SMS, including: Monitoring the effectiveness of SMS; Initiating corrective actions when necessary; Providing safety reports on SMS performance on periodic basis; Providing safety advice to top management and proposing corrective actions on
safety related-issues as needed; Ensuring that safety-related documentation and records are available and up-to-
date.
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Safety Performance Targets
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Safety performance targets define the required level of safety performance of a
system. A safety performance target comprises one or more safety
performance indicators, together with desired outcomes expressed in terms of
those indicators.
Safety Targets can be presented in either:
Absolute (i.e. less than 1 fatal accident per 1 000 000 operating hours)
Relative Terms
Safety Indicators
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Definition on Safety Performance Indicators:A measure (or metric) used toexpress the level of safety performance achieved in a system.
Enable the organisation to measure and demonstrate the achievement ofthe set target levels.
Safety indicators differ among the various sectors of the aviation industrysuch as;
air navigation services provision,
airline operations and
aerodrome operations
Safety Levels
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The relationship between acceptable level of safety, safetyperformance targets and safety performance indicators, and
safety requirements is as follows:
acceptable level of safety is the overarching concept;
safety performance targets are the quantified objectives
pertinent to the acceptable level of safety; safety performance indicators are the measures/metrics used to
determine if the acceptable level of safety has been achieved
Key Performance Indicators
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Easy judgments
Confirmed values
Committed results
Promotion and Awareness
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Newsletters internal
Posters
Videos
Intranet Presentations???
Safety Culture
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A construct
An outcome, not a process The introduction of safety management concepts lays the
foundation upon which to build a safety culture
Safety culture cannot beSafety culture cannot bemandatedmandatedorordesigneddesigned, it, itevolves.evolves.
I t is generatedIt is generated toptop--downdown
Safety CultureHow to create a Safety Culture?
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Depends on where you are starting from - you dont get to theend in one step, unfortunately, all the steps have to be traversed
Becoming a Safety Culture involves acquiring and thenmaintaining a set of skills
The two major factors are information and trust, so these haveto be developed
Be systematic (SMS are a start) and then learn to operate withthe unknown as well
Have the program run right from the top Appoint a senior champion who is dedicated and willing to stick it
out, even when it gets hard
The champion reports direct to the board Recognise that it will be uncomfortable, safety cultures are
different, not just an add-on
Safety CultureA Way Forward developing a Safety Culture:
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Agree on ways to analyse incidents to reveal individual and system issues
Develop reporting systems that are easy to use (compact, open-ended,
impersonal) Encourage the workforce (air andground) to realise that allincidents are worth
reporting
Experiment with changes when new information comes in, dont be afraid toadmit failure first time round
Practice management in wanting to know from near misses beforethey becomeaccidents
Positive culture
Source: David Marx
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Positive
culture
Flexible culturePeople can adapt
organizational processes whenfacing high temporary
operations or certain kinds ofdanger, shifting from theconventional hierarchicalmode to a flatter mode.
Learning culture
People have the willingnessand the competence to draw
conclusions from safety
information systems and the
will to implement major
reforms.
Informed culturePeople are knowledgeable about the human,
technical, organizational and environmental factorsthat determine the safety of the system as a whole.
Reporting culture
People are prepared to
report their errors and
experiences
Just culturePeople are encouraged (even rewarded) for providing
essential safety-related information. However, there is a clear
line that differentiates between acceptable and unacceptablebehaviour.
Just Culture
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Get rid of the idea that blame is a useful concept (this is hard to do)
Define clear lines between the acceptable and the unacceptable
Have those involved draw up the guidelines, do not impose from above ifyou want them to be accepted
Have clear procedures about what to do with other forms of non-compliance
Just Culture
Confidentiality
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Confidentiality People are reluctant to draw attention to errors made by themselves or their
colleagues, due to personal embarrassment. They must be confident that theiridentity, or the identity of any person implicated in the report will not be
disclosed without their permission or unless this is required by law. Anassurance should also be given that any subsequent safety action taken will, asfar as possible, ensure the anonymity of the persons involved.
Punitive Action A person who breaks the law or breaches a regulation or company procedure
through a deliberate act or gross negligence cannot expect immunity fromprosecution. However, if the offence was unpremeditated and unintentional, andwould not have come to light except for the report, he/she should be protectedfrom punishment or prosecution.
Loss of Licence The circumstances of a report may indicate that the performance of anindividual is below the acceptable level. This may indicate the need for furthertraining, or even cancellation of an individual's licence. Such action must neverbe punitive.
Workshop
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Safety Culture
Just Culture
PromotionSafety Awareness
The Safety Components
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Organizational cultural transformation is not for the faint of heart. In fact, manyattempts at transforming an organization fail, for a variety of reasons:
"Playing at it" or "dabbling" with it until it's no longer fun Not applying the kind of leadership that would best meet the needs of the
situation Intervening in the wrong places or at the wrong time Not taking this work seriously enough
Not giving it enough time or attention Senior leaders "delegating" this work (rather than committing and investing
their own time and energies) Knowing what needs to be done but being unwilling to do it...to go all the way Not having the people and tools available internally to get the job done
Inability to engage all the right people in the process Underestimating how big an undertaking this really is
Monitoring
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Continuous
Documented
Committed
Awareness
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Training
Pamphlets
News letters
Seminars
ReportingSafety Records
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The documents collected by ATM providers to demonstrate toall stakeholders that the operations have been and continueto be undertaken in a safe manner.
Safety Records are all documents developed under the
umbrella of Quality and Safety Management System.
Examples of Safety Records
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Safety Assessment Report
Incident Report
Accidents Training Records
Safety Performance MonitoringRecords
Safety Occurrence Report Safety Survey Report
Other Examples??Policies, Strategies,
Procedures
Training
Safety Monitoring
Safety Assessments
SAFETYRECORDS
Manual
Basic Safety Concept
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y p
Introduction to Safety Management
Hazards
Safety Risks
ICAO Safety Managementrequirements
Introduction to Safety ManagementSystem (SMS)
SMS Planning
SMS Operation
Phased approach to SMSimplementation
State Safety Programme (SSP)
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Joint Session / Discussion
Wrap - up
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Today were follow ing topics covered and
discussed:
ICAO Safety Management System
SES Regulations
The Safety System
The Safety Management System
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Any Questions?
See You Tomorrow
ICAO - Safety Management System
Use of SMS can be generally interpreted as applying a quality management
h t t l f t i k Si il t th t f ti f t
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approach to control safety risks. Similar to other management functions, safety
management requires planning, organising, communicating and providing direction.
The SMS development is built after the following structure:
1. Setting the Organisational Safety Policy
2. Safety Planning and Implementation of Safety Management Procedures
3. Risk and Quality Management methods
4. Safety Culture
Main SMS Components
In line with the guidance outlined in ICAO Doc 9859 - Safety Management Manual,the SMS components may be assigned to the following broad domains:
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the SMS components may be assigned to the following broad domains:
Safety Planning
SMS Organisational Structure Safety Achievement Safety Assurance Safety Promotion
A successful implementation and operation of an SMS is highly dependent onorganisational aspects such as individual and group attitudes, values, competencies andpatterns of behaviour which are frequently referred to as elements of the safetyculture.
A positive safety culture is characterised by a shared awareness of organisationspersonnel of the importance of safety in their operational tasks.
Organisational foundation for
Safety Management
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Organisational Processes
WorkplaceConditions
ActiveFailures
LatentConditions
Defences
Policy Making
Planning
Communication
Allocation of resources
Supervision
Activities over which any organisation has a reasonable degreeof direct control
Organisational foundation for
Safety ManagementDeficiencies in
equipment design
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Organisational Processes
WorkplaceConditions
ActiveFailures
LatentConditions
Defences
Inadequate hazardidentification and riskmanagement
Normalization of deviance
Conditions present in the system before the accident, madeevident by triggering factors.
training deficiencies
Incomplete/incorrect standardoperating procedures
equipment design
Organisational foundation for
Safety Management
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Organisational Processes
WorkplaceConditions
ActiveFailures
LatentConditions
Defences
Resources to protect against risks that organisations involved in theproduction activities generate and must control.
Technology
Training
Regulations
Organisational foundation for
Safety Management
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Organisational Processes
WorkplaceConditions
ActiveFailures
LatentConditions
Defences
Workforce Stability
Qualifications and experience
Morale
Credibility
Ergonomics
Factors that directly influence the efficiency of people inaviation workplaces
Organisational foundation for
Safety Management
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Organisational Processes
WorkplaceConditions
ActiveFailures
LatentConditions
Defences
Errors
Violations
Actions or inaction of people (pilots, ATCOs, maintenance engineers,Aerodrome staff, etc.) that have an immediate adverse effect
Organisational foundation for
Safety Management
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Organisational Processes
WorkplaceConditions
ActiveFailures
LatentConditions
Defences
Accident / Incident
Monitor
IdentifyImprove
Contain Reinforce
SMS and QMS
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SMS results in the design and implementation of organizationalprocesses and procedures to identify safety hazards andcontrol/mitigate safety risks in aviation operation.
QMS provides a structured approach to monitor that processes andprocedures to identify safety hazards and control/mitigate safety
risks in aviation operations function as intended and, when they donot, to improve them.