session no 1 basic contemporary safety concepts

SMS Course for Senior Management 6 / 142

Development and Course Improvement

Session No. 1 Basic Contemporary Safety

Concepts Safety Policy

Risk Management

Safety Assurance

Safety Promotion



End of Session Objective

• At the end of this session trainees will be familiar with the Basic Modern Safety Concepts.



Terminal Objectives

• Define and explain the terms “accident, incident, occurrence.

• Describe what the costs of an accidents and incidents are.

• Define and explain the term of safety.

• Emphasizing the need for hazard identification processes (Reactive; proactive; predictive).

• Describe the james reason accident causation model.

• Give an overview about the ABC Performance-Based Safety.



Session Content

– Accidents and Incidents Cost!

– Concept of safety (ICAO Doc 9859)

– Forensic Safety Management

– Inefficiency and Perversity

– System Performance

– Managing Safety–Navigating and Collapsing the Drift

– Safety Data Systems and Levels of Intervention

– Emerging Paradigm–Performance-Based System

– Performance-based Safety

– A balanced perspective



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.



Accidents Versus Incidents

• a) An accident is an occurrence during the operation of an aircraft which entails:

• 1) a fatality or serious injury;

• 2) substantial damage to the aircraft involving structural failure or requiring major repair; or

• 3) the aircraft is missing or is completely inaccessible.

An accident

• b) An incident is an occurrence, other than an accident, associated with the operation of an aircraft which affects or could affect the safety of operation. A serious incident is an incident involving circumstances indicating that an accident nearly occurred.

An incident

The ICAO definitions use the word “occurrence” to indicate an accident orincident.



Accidents and Incidents Cost!

Direct costs

Loss of aircraft Injuries to or death of flight crewmembers,

passengers

Insurance deductibles Costs not covered by

insurance



Accidents and Incidents Cost!

Indirect costs

Loss Of Use Of Equipment

Loss of staff

• Involved in accident issues

• Lower productivity

Investigation & Clean-up

Legal Claims

Fines Misplaced/Stranded

Passengers Negative Media

Exposure



8

Radome $19,712

Main Entry Door

$171,220

Cargo Door $58,327

Inlet Cowl $329,203

Inlet Cowl Segment $5,151

Aileron & Tab Assembly $183,545Outboard Flap Assembly

$255,845

Inboard Flap

Assembly $224,872

Elevator

Assembly

$264,708

L.E. Slat Assembly

$52,863

Wingtip Assembly $28,872

Ramp Damage Has Big Price Tag For Airlines

TAT Probe

$6,583

Pitot Static Probe

$5,157

AOA Vane

$4,300

Side cowl

$161,407

Parts prices only



Income lost

Event Direct Indirect TOTAL

Catering truck

hits airplane $17,000 $230,000 $247,000

Jetway hits

airplane $50,000 $600,000 $650,000

Landing event $1,900,000 $4,800,000 $6,700,000

Source: USAir/America West Airlines



Accidents Cost Small Operators, Too

Claim Flight Training

Operation

Fixed Wing Air

Taxi Operation

Helicopter

Air Taxi

Forced landing

(aircraft destroyed)

$150,000 $300,000 $900,000

Propeller makes

contact with object

on ground

$20,000 $30,000 $150,000

Hangar Rash $5,000 $10,000 $35,000

Flight cancellation

per day

$500-1,400 $3-5,000 $8-10,000



What is safety?

• Freedom from harm (Dictionary def’n.).

• Safety is not equivalent to risk free (U.S. Supreme Court, 1980).

• “Risk management” is a more practical term than “safety.” (Jerome Lederer ~1928).

• Carelessness and overconfidence are more dangerous than deliberately accepted risk (Wilbur Wright, 1901).

• Practical safety is RISK MANAGEMENT.



Concept of safety (ICAO 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



Traditional approach – Preventing accidents

• 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.



Inefficiency and Perversity

2. Punishment

3.Remedial

Training

4. Add more procedures & regulations

1. Exhortations to professionalism and discipline

The Beatings Will Continue Until Morale Improves



System Performance “In the Wild”

Operational deployment

System design

Baseline performance

Operational

drift



Managing Safety–Navigating the Drift Baseline performance

“Practical

drift”

Organization

Navigational aids

Reactive Proactive Predictive



The Navigational Aids

• Accident investigation

• Incident investigation

Reactive systems

• Mandatory reporting systems

• Confidential reporting systems

• Voluntary self-reporting systems

Proactive systems • Electronic safety data

acquisition systems

• Direct observation safety data acquisition systems

Predictive systems



Managing Safety: Collapsing the Drift

Operational

deployment

System design


Operational

drift Operational

deployment

System design

Operational drift





“Practical

drift”

organization

Predictive Proactive Reactive

Highly efficient Very efficient Efficient

Safety management levels

Reactive

Desirable management

level

Inefficient

ASR Surveys Audits

ASR

MOR

Accident and incident

reports

Hazards

FDA Direct

observation systems

Safety Data Systems and Levels of Intervention

FDA: Flight Data Analysis

ASR: Air Safety Report - (normally) aircrew report on a safety incident

MOR: Mandatory Occurrence Reporting



Emerging Paradigm–Performance-Based System

DETERMINISTIC

The world as it should be

Aviation system – as pre-specified – is perfect

Compliance based

Outcome oriented

• Accident investigation

ECOLOGICAL

The world as it is

Aviation system – as pre-specified – is imperfect

Performance based

Process oriented

• Safety data captured from daily, normal operations



Organizational processes

Latent

conditions

Workplace

conditions

Defences Active

failures


Performance-based Safety

Policy-making Planning

Communication Allocation of resources

Supervision

…

Activities over which any organization has a

reasonable degree of direct control




Latent

conditions

Workplace

conditions

Defences Active

failures

Performance-based Safety Organizational processes

Latent

conditions

Inadequate hazard

identification and risk

management

Normalization of deviance

Conditions present in the system before the accident, made evident by triggering factors




Latent

conditions

Workplace

conditions

Defences Active

failures


Latent

conditions

Defences

Technology

Training

Regulations

Resources to protect against the risks that organizations

involved in production activities must confront




Latent

conditions

Workplace

conditions

Defences Active

failures


Workplace

conditions

Factors that directly influence the efficiency of people in

aviation workplaces

Workforce stability Qualifications and

experience Morale Credibility Ergonomics …




Latent

conditions

Workplace

conditions

Defences Active

failures


Workplace

conditions

Active

failures

Actions or inactions by people (pilots, controllers, maintenance engineers, aerodrome staff, etc.) that have an immediate adverse effect

Errors

Violations




Latent

conditions

Workplace

conditions

Defences Active

failures

Performance-based Safety Organizational Processes

Latent

Conditions

Workplace

Conditions

Defences Active

Failures

Improve Identify

Monitor

Co

nta

in R

ein

forc

e



Performance-Based Safety: The ABC

Senior management’s commitment to the management of safety.

Initial analysis of system design and risk controls (safety risk management).

Continuous safety monitoring and analysis of safety data from normal operations (safety assurance).



In this Session we will look at some other abnormal situations of

the Pressurization System.

This is an example of an abnormal procedure.

The aircraft is in cruise and all systems are working normally.

SMS Part 1What is SMS?

session no 1 basic contemporary safety concepts

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