Module N° 5 –

Safety risks

Revision N° 14 Safety Management Systems (SMS) Course ‹#›

 Course structure

Safety Module 10
Phased approach to
Management SMS Implementation

System Module 8 Module 9

SMS framework - I SMS framework - II

Module 6
Module 5 Module 7
ICAO Safety
Safety risks Introduction to SMS
Management SARPs

Module 1 Module 2 Module 3

Introduction Module 4
SMS course Basic safety to safety Hazards
introduction concepts management

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 Objective
At the end of this module, participants will be able to apply the
fundamentals of safety risk management through a case study

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 Outline
 Definition of safety risk
 First fundamental – Safety risk management
 Second fundamental – Safety risk probability
 Third fundamental – Safety risk severity
 Fourth fundamental - Safety risk index/tolerability
 Fifth fundamental – Safety risk control/mitigation
 Safety risk management warm-up exercises
 Questions and answers
 Points to remember
 Practical exercise N° 3 – Accident of a Boeing B-747 at an
International Airport (see Handout N° 3)

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 Definition of safety risk
Safety risk – The assessment, expressed in terms of
predicted probability and severity, of the consequence(s) of a
hazard taking as reference the worst foreseeable situation
A wind of 15 knots blowing directly across the runway is a
hazard
A pilot may not be able to control the aircraft during takeoff
or landing is one of the consequences of the hazard
The assessment (quantification) of the consequences of
the potential loss of control of the aircraft by the pilot,
expressed in terms of probability and severity, is the safety
risk

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 First Fundamental – Safety risk
management
What is it?
The analysis and elimination, and/or mitigation to an
acceptable level, of the safety risks of the consequences of
identified hazards
What is the objective?
A balanced allocation of resources to address all safety
risks and viable safety risks control and mitigation
Why is it important?
It is a data-driven approach to safety resources allocation,
thus defensible and easier to explain

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 Safety risk management

The safety risk is

Intolerable region unacceptable as
it currently
stands

The safety risk is

As acceptable
Low based on
mitigation.
As Tolerable region Cost/benefit
Reasonably analysis
is required.
Practicable
Acceptable
The safety risk is
region
acceptable as it
currently stands

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 Cost-benefit analysis
Direct costs
The obvious costs, which are easily determined. The high
costs of exposure to hazards can be reduced by insurance
coverage
purchasing insurance only transfers monetary risk, it
does not address the safety hazard
Indirect costs
The uninsured costs. An understanding of uninsured costs
(or indirect costs) is fundamental to understand the
economics of safety
Module N° 5 Safety Management Systems (SMS) Course ‹#›
 Cost-benefit analysis
Indirect costs may amount to
more than the direct costs
resulting from exposure to
hazards
Loss of business
Damage to the reputation
Loss of use of equipment
Loss of staff productivity
Legal actions and claims
Fines and citations
Insurance deductibles

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 Second fundamental – Safety risk
probability

Definition

Probability – The
likelihood that an unsafe
event or condition might
occur

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 Second fundamental – Safety risk
probability

Questions for assessing the probability of an occurrence

Is there a history of occurrences like the one being

assessed, or is the occurrence an isolated event?

What other equipment, or similar type components, might

have similar defects?

When or how often could something go wrong?

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 Second fundamental – Safety risk
probability

… questions such as

what number of operating or maintenance personnel must

follow the procedure(s) in question?

how frequently is the equipment or procedure under

assessment used?

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 Second fundamental – Safety risk
probability

Probability of occurrence
Qualitative
Meaning Value
definition

Frequent Likely to occur many times (has occurred frequently) 5

Occasional Likely to occur sometimes (has occurred infrequently) 4

Remote Unlikely, but possible to occur (has occurred rarely) 3

Improbable Very unlikely to occur (not known to have occurred) 2

Extremely
improbable Almost inconceivable that the event will occur 1

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 Third fundamental – Safety risk
severity
Definition

Severity – The possible

effects of an unsafe event
or condition, taking as
reference the worst
foreseeable
consequence

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 Third fundamental – Safety risk
severity
Severity of occurrences
Aviation definition Meaning Value
Equipment destroyed.
Catastrophic Multiple deaths. A
A large reduction in safety margins, physical distress or a
workload such that the operators cannot be relied upon to
Hazardous perform their tasks accurately or completely. B
Serious injury.
Major equipment damage.
A significant reduction in safety margins, a reduction in the
ability of the operators to cope with adverse operating
conditions as a result of increase in workload, or as a result C
Major of conditions impairing their efficiency.
Serious incident.
Injury to persons.
Nuisance.
Minor Operating limitations.
Use of emergency procedures. D
Minor incident.
Negligible Little consequences E
Module N° 5 Safety Management Systems (SMS) Course ‹#›
 Fourth fundamental – Safety risk
index/tolerability
Safety risk severity
Safety risk
probability Catastrophic Hazardous Major Minor Negligible
A B C D E
Frequent 5 5A 5B 5C 5D 5E
Occasional 4 4A 4B 4C 4D 4E
Remote 3 3A 3B 3C 3D 3E
Improbable 2 2A 2B 2C 2D 2E
Extremely
improbable 1 1A 1B 1C 1D 1E
Module N° 5 Safety Management Systems (SMS) Course ‹#›
 Fourth fundamental – Safety risk
index/tolerability

Assessment safety
Safety risk management Suggested criteria
risk index

Intolerable region
5A, 5B, 5C, 4A, Unacceptable under the
4B, 3A existing circumstances

5D, 5E, 4C, 4D, 4E, Acceptable based on

safety risk
Tolerable region 3B, 3C, 3D, 2A, 2B, mitigation. It might require
2C management decision.
Acceptable
region
3E, 2D, 2E, 1A,
Acceptable
1B ,1C, 1D, 1E

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 Fifth fundamental – Safety risk
control/mitigation
Definition

Mitigation – Measures to address the potential hazard or

to reduce the safety risk probability or severity of the
consequence(s) of the hazard

Safety risk mitigation = Safety risk control

(Mitigate – To make milder, less severe or less harsh)

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 Fifth fundamental – Safety risk
control/mitigation
Strategies
Avoidance – The operation or activity is cancelled because
assessed safety risks exceed the benefits of continuing the
operation or activity
Operations at an aerodrome surrounded by complex
geography and without the necessary aids are cancelled

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 Fifth fundamental – Safety risk
control/mitigation
Strategies
Reduction –The operation or activity is subject to
limitations, or action is taken to reduce the severity of the
consequence(s) of the hazard(s)
Operations at an aerodrome surrounded by complex
geography and without the necessary aids are limited to
day-time, visual conditions

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 Fifth fundamental – Safety risk
control/mitigation
Strategies
Segregation of exposure – Action is taken to isolate the
effects of the consequence(s) of the hazard(s) or build in
redundancy to protect against it
Operations at an aerodrome surrounded by complex
geography are limited to aircraft with specific
performance navigation capabilities

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 Safety risk mitigation – Defences
Recalling the three basic
defences in aviation

Technology

Training

Regulations

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 Safety risk mitigation – Defences
As part of the safety risk mitigation, determine
Do defences to protect against such safety risk(s) exist?
Do defences function as intended?
Are the defences practical for use under actual working
conditions?
Is staff involved aware of the safety risks and the defences
in place?
Are additional safety risk mitigation measures required?

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 Safety risk mitigation at a glance
Hazard/consequence Assessment of the Control and Accepting the
identification
and safety risk defences within the mitigation of the mitigation of the
assessment safety system safety risk(s) safety risk(s)

H H H H Are the safety risk(s)

Intolerable region addressed?
Is the mitigation
Each
consequence effective and
appropriate?
Tolerable region Are additional or
R R R R different mitigation
warranted?
Acceptable
region
Are additional safety
risk(s) generated?
Each safety risk

Feedback (Safety assurance)

Module N° 5 Safety Management Systems (SMS) Course ‹#›

Module N° 5 – Safety risks

Safety risk management warm-up exercises

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 Warm-up exercise N° 05/01
Scenario
Fuel spill on the apron area surface of approximately 25 m
(75 ft) length and 5 m (15 ft) width, produced by an aircraft
ready to pushback and taxi for departure

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 Warm-up exercise N°05/01 –
results

1. Identify the hazard(s) 3. Assess the

probability of the
Fuel spill consequences: Remote
a) Fire

4. Assess the severity

of the Catastrophic
consequences

2. Determine the 5. Determine the

hazard(s)
consequence(s)
resulting safety risk 3A
index
a) Fire
b) Contamination
6. Establish the Unacceptable under the
c) Sliding vehicle existing circumstances
safety risk
tolerability

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 Warm-up exercise N° 05/02
Scenario
It was observed that airline baggage handling personnel
generate a large amount of potentially hazardous FO(D) on
the aerodrome apron area

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 Warm-up exercise N°05/02 –
results
1. Identify the hazard(s) 3. Assess the
probability of the
Foreign object consequences: Remote
a)Engine ingestion

4. Assess the severity

of the Major
consequences

2. Determine the 5. Determine the

hazard(s)
consequence(s)
resulting safety risk 3C
index
a) Engine ingestion
b) Property damage
6. Establish the Acceptable based on the
c) Tire damage safety risk mitigation. It
safety risk
might require management
tolerability decision.

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 Warm-up exercise N° 05/03
Scenario
Maintenance stairs are observed to be unsecure in the
vicinity of parked aircraft

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 Warm-up exercise N°05/03 –
results
1. Identify the hazard(s) 3. Assess the
probability of the
Unsecured stairs consequences: Improbable
a) Damage to aircraft

4. Assess the severity

of the Minor
consequences

2. Determine the 5. Determine the

hazard(s)
consequence(s)
resulting safety risk 2D
index
a) Damage to aircraft
b) Injury to persons
6. Establish the Acceptable
safety risk
tolerability

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 Warm-up exercise N° 05/04
Scenario
The vehicle and ramp equipment parking areas behind the
air bridges show a large amount of FO(D) (food, trays,
plastics, pillows, etc.) left behind by an airline

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 Warm-up exercise N°05/04 –
results
1. Identify the hazard(s) 3. Assess the
probability of the
Foreign object consequences: Occasional
a) Attract wildlife

4. Assess the severity

of the Major
consequences

2. Determine the 5. Determine the

hazard(s)
consequence(s)
resulting safety risk 4C
index
a) Attract wildlife
b) Vehicle accident
6. Establish the Acceptable based on
c) Bacteriological safety risk mitigation. It
safety risk
might require
tolerability management decision.

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 Warm-up exercise N° 05/05
Scenario
Vehicles and construction equipment located on the
taxiway are very close to the threshold of RWY 05R without
any marks or signals

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 Warm-up exercise N°05/05 –
results
1. Identify the hazard(s) 3. Assess the
probability of the
Construction equipment consequences: Remote
a) Collision

4. Assess the severity

of the Catastrophic
consequences

2. Determine the 5. Determine the

hazard(s)
consequence(s)
resulting safety risk 3A
index
a) Collision
b) Runway incursion
6. Establish the Unacceptable under the
safety risk existing circumstances
tolerability

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 In conclusion
1. Every system is inherently vulnerable, safety-wise
2. Safety vulnerabilities in a system are described in terms of
 hazards
 consequences
 safety risks
3. Effective safety risk management seeks to maximize the
benefits of accepting a safety risk (a reduction in time and
cost) while minimizing the safety risk itself

Module N° 5 Safety Management Systems (SMS) Course ‹#›

Module N° 5 – Safety risks

Questions and answers

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 Questions and answers
Q: Define safety risk management
A:
The analysis and elimination, and/or mitigation to an
acceptable level of the safety risks of the consequences of
identified hazards

Slide number: 6

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 Questions and answers
Q: Name five example designations for safety risk probability
A:
Frequent

Occasional

Remote

Improbable

Extremely
improbable
Slide number: 13

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 Questions and answers
Q: Name five example designations for safety risk severity
A:
Catastrophic

Hazardous

Major

Minor
Negligible

Slide number: 15

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 Questions and answers
Q: Describe the three basic safety risk mitigation strategies
A:
Avoidance – The operation or activity is cancelled because
safety risks exceed the benefits of continuing the operation
or activity
Reduction –The frequency of the operation or activity is
reduced, or action is taken to reduce the severity of the
consequences of the accepted safety risks
Segregation of exposure – Action is taken to isolate the
effects of the consequences of the hazard or build-in
redundancy to protect against it

Slide number: 19, 20 and 21

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 Points to remember
1. The safety risk index/tolerability
2. The safety risk assessment criteria table
3. Safety risk mitigation: avoid, reduce, segregate

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 Module N° 5 – Safety Risks
Practical exercise N° 3 – Accident Boeing
B-747 at Taipei International Airport
(Handout N° 3)

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 Boeing B-747 at Taipei International
Airport
Group activity

A facilitator, who will coordinate the discussion, will be

appointed

A summary of the discussion will be written on flip charts,

and a member of the group will provide a brief on their
findings in a plenary session

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 Boeing B-747 at Taipei International
Airport
 Scenario
 A Boeing 747 service from Singapore to Los Angeles
via Taipei, crashed on takeoff from Taipei's CKS
International Airport at 23:18 local time
 The flight had been cleared for take off from runway
05L
 Runway 05R was closed due to construction work
 The flight attempted the take off from runway 05R

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 Boeing B-747 at Taipei International
Airport
 … Scenario
On takeoff the aircraft hit concrete barriers, excavators
and other equipment on runway 05R
The aircraft crashed back onto the runway, breaking up
and bursting into flames while sliding down the runway
and crashing into other equipment related to work being
done on runway 05R

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 Boeing B-747 at Taipei International
Airport
 … Scenario
Subsequent investigation of the accident confirmed that
the flight crew mistakenly attempted takeoff on runway
05R (9029x150ft), instead of the planned runway 05L
(12008x200ft)
NOTAM indicated that, at the time of the accident,
runway 05R was closed for repairs, and that numerous
pieces of construction equipment were parked on the
runway

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 Boeing B-747 at Taipei International
Airport

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 Boeing B-747 at Taipei International
Airport

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 Boeing B-747 at Taipei International
Airport

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 Boeing B-747 at Taipei International
Airport
 Your task:
 Read the text related to the accident of the Boeing 747 at Taipei
International Airport
 List the type of operation or activity
 State the generic hazard(s)
 State the specific components of the hazard(s)
 State the hazard-related consequences and assess the safety risk(s)
 Assess existing defences to control the safety risk(s) and resulting safety
risk index
 Propose further action to reduce the safety risk(s) and resulting safety
risk index
 Complete the attached log (Table 05/01)

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 Table 05/01 – Hazard identification and safety
risk management
Further action to
Type of Specific Existing defences reduce safety risk(s)
Nº operation Generic
hazard components Hazard-related to control safety risk(s) and resulting safety
or activity of the hazard consequences and safety risk index
risk index

1 Safety risk index: Safety risk index:

Safety risk tolerability: Safety risk tolerability:

2 Safety risk index: Safety risk index:

Safety risk tolerability: Safety risk tolerability:

3
Safety risk index: Safety risk index:
Safety risk tolerability: Safety risk tolerability:

4 Safety risk index: Safety risk index:

Safety risk tolerability: Safety risk tolerability:

5
Safety risk index: Safety risk index:
Safety risk tolerability: Safety risk tolerability:

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 Useful tips
Elect a facilitator
Start with a general discussion on the objective of the task
and the material available for this exercise (no more than 10
minutes)
Select one of the participants of the group to prepare the final
report on the laptop
Be prepared to deliver the results of the exercises (in a pen
drive) to the course instructor at least five minutes before the
time allocated

Module N° 5 Safety Management Systems (SMS) Course ‹#›

 Module N° 5 –
Safety risks

Revision N° 14 Safety Management Systems (SMS) Course ‹#›