Safety Management Systems (SMS) Fundmentals: Safety Risk Management Component
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Transcript of Safety Management Systems (SMS) Fundmentals: Safety Risk Management Component
Federal AviationAdministration
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Safety Risk ManagementComponent
Federal AviationAdministrationSMS Details:
Policy (Structure)
Risk Management
Safety Assurance
Safety Promotion
Federal AviationAdministration
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Definitions• Safety management systems provide a
systematic way to control risk and to provide assurance that those risk controls are effective.
• Safety Risk Management performs the process of controlling risk thru hazard identification, analysis, risk assessment and developing risk controls.
Federal AviationAdministration
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Levels of Risk Management
• Process Risk Management
– Policy (What)
– Procedure (How)
– Controls
• Operational Risk Management
– Operational Control (Flight/Task/Mission)
– Crew/Team (Real time decision making)
Federal AviationAdministration
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System DescriptionWhat is System Description & Task Analysis? • It is a system design function.• It is a predictive method of hazard identification.• It is the foundation for sound safety analysis.
When is it used? • Used during implementation phases of SMS.• Used in the development of operational processes.• Used when a new Hazard is identified• Used in conjunction with all operational changes.
Who uses System Description & Task Analysis?• Personnel within the organization who form an appropriately
diverse team: – Stakeholders – Subject Matter Experts
ICAO Doc. 9859
SystemDescription
HazardIdentification
RiskControl
RiskAssmt
RiskAnalysis
Federal AviationAdministration
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Processes
Workplace Conditions:Activities
• Equipment• Information (Procedures)• Facilities• Phys. Envir.• Other Proc. (Interfaces)• Training• Supv./Mgmt. (Controls)• ….
e.g,
SystemFactors &Attributes
Variable Human
Performance
SRM
SystemDescription
HazardIdentification
RiskControl
RiskAssmt
RiskAnalysis
System Description
Facts
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Typical Workplace Conditions
• Equipment: Human-machine interface, facilities, tools…
• Information: Procedures, guidance...
• Environment: Physical, cultural…
• Training: Formal, OJT, recurrent…
• Company/regulator factors: The RULES...
Barry Strauch (2004). Investigating Human Error
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Process (System or Safety) Attributes
• Responsibility
• Authority
• Procedures
• Controls
• Process Measures
• Interfaces
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Controls (C)•Procedural•Supervision•Assurance Processes
Responsibility (R)•Accountable for process output
Authority (A)Empowered to:•Make key decisions•Alter process
ExternalDecision byOrganization
InternalPrevious ProcessInterface – (I)
Inputs
Process
Outputs
•Destination – Interface (I)•Deliverable – Performance Measures (PM)
Processes
Activities(Things People
do)
Procedures (P)
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Activities
ProcessPeople•Employees•Contractors•Organization
Materials
ProductsServices
FacilitiesEquipmentTools
Knowledgeware•Manuals•Job Aids•Software
CustomerRequirements
LawsRegulationsStandards
Environment•Physical•Operational•Cultural
Systems
Training
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Conditions (Hazards) Related to Human Error
• Time pressure
• Poor procedures and documentation
• Teamwork (Too much, too little)
• Shift turnovers/crew briefings
• Group norms (Values, culture)
• Fatigue management (shifts/circadian problems)
Alan Hobbs, ATSB (2008)
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• Lack of System Knowledge
• Poor, worn out, missing or equipment/facilities
• Human-machine interface (e.g. design for maintainability)
Conditions (Hazards) Related to Human Error (Cont.)
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Activities and Conditions: Deicing
Activities/TasksThings people do
Workplace ConditionsSystem and Environment
Prepare truck / equipment Day/Night
Verify type of fluid Weather – precip / cold
Fluid temp / concentration Protective clothing
Position at aircraft Equipment condition
Communicate with crew Shift change
Apply fluid Employee demographics
Communicate with crew
Depart ramp area
Federal AviationAdministration
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Hazard Identification
A hazard is any real or potential condition…
ICAO Doc. 9859ICAO Doc. 9859
SystemDescription
HazardIdentification
RiskControl
RiskAssmt
RiskAnalysis
that can result in injury, illness, or death to people; damage to, or loss of, a system (hardware or software), equipment, or property; and/or damage to the operating environment.
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Processes
Workplace Conditions:Activities
• Equipment• Information (Procedures)• Facilities• Phys. Envir.• Other Proc. (Interfaces)• Training• Supv./Mgmt. (Controls)• ….
Hazards
Deficient Conditionsimpacting activities =
ConsequencesActive Failures
VariablePerformance
e.g.
SystemFactors &Attributes
Causing… Resulting in…
SRM Hazard Identification from Workplace Conditions
Inference
SystemDescription
HazardIdentification
RiskControl
RiskAssmt
RiskAnalysis
Federal AviationAdministration
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Risk Analysis
Important to distinguish between: Hazard – a condition
Consequence – result
Risk – likelihood & severity of the consequence
Analyzing risk involves the consideration of both the likelihood and the severity of any adverse consequences.
ICAO Doc. 9859
SystemDescription
HazardIdentification
RiskControl
RiskAssmt
RiskAnalysis
Federal AviationAdministration
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Hazards
Deficient Conditionsimpacting activities =
ConsequencesActive Failures
L S
VariablePerformance
Risk
Risk
ikelihood everity
Causing… Resulting in…
SRM From Hazard to Risk
SystemDescription
HazardIdentification
RiskControl
RiskAssmt
RiskAnalysis
Judgment
Federal AviationAdministration
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Failures and Consequences
Active failuresDirect results of human activity
Potential ConsequencesAccident/incident severity
Incorrect fluid typeAircraft required to be de-iced again
Wrong fluid concentration Take-off delay
Fluid sprayed into
pitot-static ports
Maintenance action required
Incomplete deicing Take-off accident due to ice
Hold-over time too long
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Extremely
improbable
Improbable
Remote
Occasional
Frequent
Risk Likelihood Negligible
EMinor
DMajor
CHazardous
BCatastrophic
A
1E1D1C1B1A1
2E2D2C2B2A2
3E3D3C3B3A3
4E4D4C4B4A4
5E5D5C5B5A5
Risk SeveritySystem
Description
HazardIdentification
RiskControl
RiskAssmt
RiskAnalysis
Risk AssessmentRisk assessment determines the level of risk to use in making a bottom line decision.
A risk matrix is a tool used for risk assessment. It can vary in form yet it accomplishes the same purpose.
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Risk Control = Risk Mitigation
A major component of any safety system is the defenses (controls) put in place to protect people, property or the environment.
These defenses are used to reduce the likelihood or severity of the consequences associated with any given hazard or condition. ICAO Doc. 9859
SystemDescription
HazardIdentification
RiskControl
RiskAssmt
RiskAnalysis
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Processes
Workplace Conditions:Activities
• Equipment• Information (Procedures)• Facilities• Phys. Envir.• Other Proc. (Interfaces)• Training• Supv./Mgmt. (Controls)• ….
e.g.
SystemFactors &Attributes
Variable Human
Performance
Risk Controls
SRM Risk Control/Mitigation
SystemDescription
HazardIdentification
RiskControl
RiskAssmt
RiskAnalysis