Module 1

Basic Safety Concepts

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 Concept of Safety
What is safety?
Consider (the weaknesses in the notion of perfection)
• Zero accidents? • the elimination of aircraft accidents and/or serious
incidents remains the ultimate goal.
• Freedom from danger or risks? • the aviation system cannot be completely free of
• Error avoidance? hazards and associated risks.
• Regulatory compliance? • human activities or human-built systems cannot
be guaranteed to be absolutely free from
• …? operational errors and their consequences.

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 Concept of Safety

requires the mitigation of safety

risk through a continuing process Safety is a dynamic characteristic.
of hazard identification and
safety risk management

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 Concept of Safety
Traditional approach in preventing Identified:
accidents: • What?
• Focused on outcomes (direct cause/s) • Who?
• Unsafe acts by operational personnel • When?
• Attached blame/punish line personnel But does not always disclose
for failures to “perform safely“
the:
• Addressed identified safety concern
exclusively • Why?
• How?

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 Concept of Safety
Within the context of aviation, safety is “the state in which
the possibility of harm to persons or of property damage is
reduced to, and maintained at or below, an acceptable level
through a continuing process of hazard identification and
safety risk management.”

ICAO Document 9859 3rd Edition

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 Why Safety Management?
• The purpose of safety management is to
proactively mitigate safety risks before they
result in aviation accidents and incidents.
• Safety management enables States to
manage their safety activities in a more
disciplined, integrative and focused manner.

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 The Evolution of Safety

TECHNICAL ERA

Future
HUMAN FACTORS ERA

ORGANIZATIONAL ERA

TOTAL AVIATION SYSTEM ERA

1950’s 1970’s 1990’s 2000’s 2010’s

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 The Evolution of Safety

The technical era — from the early

1900s until the late 1960s
Aviation emerged as a form of mass
transportation in which identified safety
deficiencies were initially related to
technical factors and technological
failures. The focus of safety endeavors
was therefore placed on the investigation
and improvement of technical factors. By
the 1950s, technological improvements led
to a gradual decline in the frequency of
accidents, and safety processes were
broadened to encompass regulatory
compliance and oversight.

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 The Evolution of Safety

The human factors era — from the

early 1970s until the mid-1990s
In the early 1970s, the frequency of
aviation accidents was significantly
reduced due to major technological
advances and enhancements to safety
regulations. Aviation became a safer
mode of transportation, and the focus
of safety endeavors was extended to
include human factors issues including
the man/machine interface.

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 The Evolution of Safety

The organizational era — from the

mid-1990s to the present day
During the organizational era, safety
began to be viewed from a systemic
perspective, which was to encompass
organizational factors in addition to
human and technical factors.
Consequently, the idea of the
“organizational accident” was
introduced, considering the impact of
organizational culture and politics on the
effectiveness of safety risk controls.

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 The Evolution of Safety

The total aviation system era —

from the 2000s into the future
As of today, many States and service
providers have reached a higher level of
maturity with the implementation of their
SSP or SMSs respectively. There is a
growing recognition of the complexity of
the aviation system and the different
organizations that all play a part in
aviation safety. SMSs should not only
focus on their own safety performance
but should also consider the wider
context of the total aviation system.

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 The Concept of Accident Causation
The Swiss cheese model Some holes due to
active failures

Hazard: A condition or
an object with the
potential to cause or
contribute to an
aircraft incident or
accident.

Some holes due to

latent conditions

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 The Concept of Accident Causation
The Swiss cheese model Some holes due to
active failures

Latent conditions: can exist in a system well before a

damaging outcome. The consequences of latent conditions may
remain dormant for a long time. Initially, these are not perceived
as harmful, but under certain conditions may become clear when
the operational level defenses are breached.
Some holes due to
latent conditions

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 The Concept of Accident Causation
The Swiss cheese model Some holes due to
active failures
Active Failures: actions or inactions, including errors and rule-breaking that
have an immediate adverse effect. They are viewed with the benefit of hindsight,
as unsafe acts. Active failures are associated with front-line personnel (pilots, air
traffic controllers, aircraft maintenance, engineers, etc.) and may result to
harmful outcome.

Some holes due to

latent conditions

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 The Organizational Accident
Organizational processes

❖ Policy-making
❖ Planning
❖ Communication
❖ Allocation of resources
❖ Supervision

Activities over which any organization has a reasonable degree of direct control

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 The Organizational Accident
Organizational processes

Latent conditions
❖Inadequate hazard
identification
and Safety risk management

❖Normalization of deviance

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

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 The Organizational Accident
Organizational processes

Latent conditions
❖ Technology
❖ Training
❖ Regulations Defenses

Resources to protect against the risks that organizations involved in production activities
generate and must control
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 The Organizational Accident
Organizational processes

Workplace
conditions ❖Workforce stability Latent conditions
❖Qualifications and experience
❖Morale
Defenses
❖Management Credibility
❖Ergonomics

Factors that directly influence the efficiency of people in aviation workplaces.

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 The Organizational Accident
Organizational processes

Workplace
Latent conditions
conditions
❖Errors
❖Violations
Active failures Defenses

Actions or inactions by people (pilots, controllers, maintenance engineers, aerodrome

staff, etc.) that have an immediate adverse effect.

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 The Organizational Accident
Organizational processes

Workplace
Latent conditions
conditions

Active failures Defenses

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 The SHEL(L) Model
People, Context and Safety Maintenance
Managers

• The aviation system includes products, Maintenance

Organization

service providers and State organizations.

Other Aircraft

• It is a complex system that requires an Organizations Operator

assessment of the human contribution to

safety and an understanding of how
human performance may be affected by Aircraft
its multiple and interrelated components State
Operator

Safety
Manager

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 The SHEL(L) Model

• Illustrates the relationship between the central

human and the workplace components
• Contains the four satellite components:
➢ Software (S): procedures, training, support, etc.
➢ Hardware (H): machines and equipment
➢ Environment (E): the working environment in
which the rest of the L-H-S systems function
➢ Liveware (L): humans in the workplace

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 The SHEL(L) Model

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 The SHEL(L) Model

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 The SHEL(L) Model

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 The SHEL(L) Model

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 Understanding operational errors
A mismatch between
the LIVEWARE and the • Human error is considered a contributory
other four components factor in most aviation occurrences.
contributes to human • Even competent personnel commit
error – thus, these errors.
interactions must be
assessed and • Errors must be accepted as a normal
considered in all component of any system where humans
sectors of the aviation and technology interact
system.

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 Errors and Violations
Effective SMS implementation by the product or service provider
is dependent upon clear, mutual understanding of errors and
violations and the differentiation between the two.
The difference between errors and violation lies in intent.

A violation is a deliberate
act or omission to deviate
An error is unintentional from established
procedures, protocols,
norms or practices

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 Errors and Violations

Error is an action or
An important goal is to set and maintain
inaction by an
defenses to reduce likelihood of errors
operational
personnel that
and reduce consequences of errors
leads to deviations when they do occur. Errors must be
from organizational identified, reported and analyzed so
or the operational that appropriate remedial action can be
person’s intentions taken
or expectations.

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 Errors and Violations
• Two categories:
Error is an action or
inaction by an ➢ Slips/lapses
operational ➢ Mistakes
personnel that • Three strategies for control of human error:
leads to deviations
from organizational ➢ Error reduction strategies
or the operational ➢ Capturing strategies
person’s intentions ➢ Error tolerance strategies
or expectations.

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 Errors and Violations
A violation is a • While intentional, violations are NOT always
deliberate act of malicious and may be done in the belief that
willful misconduct the violation facilitates mission achievement
or omission without creating adverse consequences
resulting to (judgment error)
deviation from • Three categories:
established
procedures, ➢ situational
protocols, norms or ➢ routine
practices ➢ Organizationally induced

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 Knowledge Check
• Q: Explain the components of the SHEL(L) Model.
• A: ?
• Software (S): procedures, training, support, etc.;
• Hardware (H): machines and equipment
• Environment (E): the working environment in
which the rest of the L-H-S systems function;
and
• Liveware (L): humans in the workplace

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?
PPT 1.32
 Safety Management Rationale
What is the fundamental objective of a business organization?

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 The Management Dilemma

Management levels

Resources Resources

Safety practices Output

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 The Management Dilemma

Management levels

Resources Resources

Protection Production
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 The Management Dilemma

Resources
Resources

Protection Production

Protection Production

Bankruptcy Catastrophe
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 The Management Dilemma
The allocation of excessive resources to
protection or risk controls may result in the
product or service becoming unprofitable
Protection

Safety space is a
It is essential metaphor
that the f or a
management
zone where of an
an organization balances
desired
organization acknowledge the while
production/profitability
need torequired
maintaining maintain an prot ection
safety
appropriate safetyrisk
through safety space.
controls

Excess allocation of resources for

production at the expense of protection
can have an impact on safety
performance

Production
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 An Imperfect System

Scott A. Snook’s
Theory of
Practical Drift
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 Practical Drift

Once operationally deployed, the system tends

to perform initially as designed. However, in
reality at some point in time, an operational
performance may start to divert from baseline
performance as a consequence of real life
operations and changes in the operational and
regulatory environment. The space formed
between the baseline performance and the
operational performance is called the practical
drift.

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 Practical Drift

Some of the reasons for the practical drift may

include:
• Technology that does not always operate
as predicted.
• Procedures that cannot be executed as
planned under certain operational
conditions
• Regulations that are not applicable within
certain contextual limitations; and
• Introduction of changes to the system

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 Knowledge Check
• Q: The baseline performance expected was that the HUMS system would
always be operational and serviceable for all flights. What two reasons
caused the operational performance to divert from the baseline and become
an example of Practical Drift?
• A:
a. Procedures that cannot be executed as planned under certain operational
conditions.
b. Introduction of changes to the system
c. Regulations that are not applicable
d. Technology that does not always operate as predicted

SMS v12.1 January 2022 Civil Aviation Training Center - Manila

?
PPT 1.41
 Benefits of Safety Management
The benefits of implementing safety management are numerous, some of which include:
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Improved efficiencies exposing inefficiencies in existing
Cost ipnrcoucreresdsedsua entdo saycsctie dmensts and
Cost avoidance incidents can be avoided
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 Your Questions

?
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 Summary
The following topics were covered in this module:

Concept and Evolution of Safety

Concept of Accident Causation and Organizational Accident

The SHEL(L) Model

Understanding Operational Errors

Safety Management - Rationale

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 THANK YOU

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