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 $183,545
Outboard 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
Flightcancellation
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
“Practical
drift”
Organization
Navigational aids
Reactive Proactive Predictive

The Navigational Aids
• Accident investigation
• Incident investigation
Reactive
systems
• Mandatoryreporting
systems
• Confidentialreporting
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
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
Organizational Processes
Latent
Conditions
Workplace
Conditions
Defences
Active
Failures
Improve Identify
Monitor
Contain
Reinforce

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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