Post on 15-Jan-2016
description
Safety Management
- The Payback
Presented by
Jane Gothard Head of International Safety NATS
Moscow – 15th September 2005
History of NATS Safety Management System (SMS)
1989 CAA Safety Management Review
Objective: To identify changes in organisational structure and safety management which are required to assure ATC safety in the present and future environment.
• Considered safety management in its widest context;
• Separation of safety regulation from NATS operations to be made obvious;
• Need for explicit commitment to safety;
• Recommendations based on best practice in other safety critical industries.
• Zagreb Mid-Air Collision 1976
• Tenerife air disaster 1977
• Challenger Space Shuttle disaster 1986
• Herald of Free Enterprise ferry disaster Zeebrugge1987
• Clapham Junction Rail Disaster 1988
• Piper Alfa Oil Platform disaster 1988
A Catalogue of Disaster
• An organisation’s commitment to safety must be explicit - set a clear safety policy;
• Senior Management are responsible for way safety is managed - Responsibilities for safety need to be explicit;
• A top-down safety strategy should be established;
• Free flow of information and openness is essential to ensure that safety issues are acknowledged and communicated to the relevant parts of the organisation;
• Engineering systems need to be maintained in accordance with their design principles;
• A central focus on safety is useful;
• There is a need to audit procedures;
Lessons from Accident Investigations
The 1989 CAA Safety Management Review identified the need for:
• a single document to provide a comprehensive description of NATS approach to safety management;
• a system-wide policy of safety management which:
• defines responsibilities and accountabilities;
• provides a formal basis for translating NATS Objectives relating to safety into detailed engineering and operational requirements.
• A dictionary of common definitions such as safety, reliability and integrity as they are understood in the NATS context.
1989 CAA Safety Management Review
SMS - The Drivers
What do you need?
• To understand current performance;
• To identify weaknesses / deficiencies;
• To comply with regulatory requirements;
• To stay in business.
SMS - The Drivers
What do you want?
• A means of achieving continuous improvement in safety performance;
• Improved safety performance;
• Minimal additional cost / cost control.
SMS Development
• Know where you are starting from - define a baseline
• Set the Scope - a realistic manageable level
• Set clear objectives - accept that you will not achieve everything right away.
• Obtain Senior Management buy-in - in both the philosophical and financial sense!
• Build in ‘Line’ ownership
• Engage expert support and identify internal resource
• Take the regulator along with you
• Set Policy;
• Identify accountabilities;
• Define processes and procedures;
• Develop and implement a communication plan;
• Test achievement regularly - identify successes;
• Expand and improve.
SMS Development - System Design
Safety has first priority within the core values that underline all
NATS activities, and it is NATS safety objective to maintain and,
where practicable, improve safety levels in all our activities.
To achieve this, it is NATS policy that an explicit, pro-active
approach to safety management is maintained to minimise NATS
contribution to the risk of an aircraft accident as far as is reasonably
practicable.
NATS Safety Policy
• Organisational Change
• System Safety Analysis
• System Acceptance Procedures
• Quantitative Safety Levels
• Documentation
General Safety Management Principles
• Incident Investigation
• Lesson Dissemination
• Safety Improvement
• Training
• Supervision
• Monitoring Performance
• Auditing Arrangements
General Safety Management Principles
POLICY
ACCOUNTABILITIES
PRINCIPLES
PROCEDURES
How is it achieved
Action
What is required
Who is responsible
NATS Safety Management System
To maintain an effective SMS;
To provide assurance that the SMS is being implemented effectively;
To provide specialist advice and assistance where required;
To provide specialist safety management training at all levels;
To act as a proactive focal point for all safety management issues.
The Role of the Corporate Centre
The Reality of Achievement
A Safety Management System will enable you to:
• Identify the risks;
• Determine the priorities - explicit risk management;
• Develop and execute a realistic plan;
• Improve safety performance and demonstrate that you have improved;
• Create a learning organisation.
169
117
8
7
3321
4
11
0%
2%
4%
6%
8%
10%
12%
14%
16%
SSE4
SSE3
SSE2
SSE1
M ay include double counting of events
Excluded root causes with risk below 2%
An Example - Relative Risk of Events
Data for illustration purposes only
12 11 9 7 7 4 4 4 4 3 1 2 2 2 6 8 8 815 17 17 21 24 25 30 30 26 26 26 26
20 20 20 18 17 17 13 13 16 16 18 19 20 20 22 24 27 25 25 30 2930
291
306311323324326328330328
317305
271
254243
252242238
252255252256257257
275
291288274
263260
233226222223222217
210203205
218228227
237250
264269277
293294301
311311320
0
50
100
150
200
250
300
350
2000
/12
2001
/02
2001
/04
2001
/06
2001
/08
2001
/10
2001
/12
2002
/02
2002
/04
2002
/06
2002
/08
2002
/10
2002
/12
2003
/02
2003
/04
2003
/06
2003
/08
2003
/10
2003
/12
2004
/02
2004
/04
2004
/06
2004
/08
2004
/10
2004
/12
2005
/02
SSE1-4 Level Busts
An Example - Level Busts
12 month Rolling Total Data for illustration purposes only
Level Busts – By Cause
0% 5% 10% 15% 20% 25% 30%
CRM
Altimeter Setting
Climbed above SID
Equipment Malfunction
Acft took wrong call
ATC missed read back
Manual flying
Acft misinterpret ATC
OAT
Weather
Other
Unknown
Ca
us
e
% Frequency
2002 2003 2004Data for illustration purposes only
Level Busts – An Action Plan
• Raising awareness - Pilots & Controllers
• Engaging industry- Airlines & Chart Manufacturers
• Changing procedures- Phraseology
• Taking advantage of new technology - Developing controller tools
4 Important elements have been addressed:
An SMS makes good business sense:
• Maintain approval to operate - continue in business;
• Compete on equal terms with other ATSPs - Best practice;
• Reduce Insurance Premiums;
• Reduce burden of cost of remedial work and investigations;
The Reality of Achievement
• You will achieve a state of continual unease but,
• You will know what to worry about;
• You will be able to worry constructively;
• Big worries will become little worries;
• Your customers / stakeholders/ Regulators will worry you less;
• You will get more sleep!
The Reality of Achievement
The Reality of Achievement
is
You can always do more !