An Introduction to
Safety Management System (SMS)
Safety Risk
Safety Policy Management
Safety Safety
Assurance Promotion
Outline
Fundamentals of Safety Concept
ConceptofofSafety
Safety
Evolution
Safety Management System Evolution of SafeThinking
of Safe Thinking
Accident Causation
Accident Causation
Components of SMS Organizational
OrganizationalAccident
Accident
People,
Legislation People, Context&&Safety
Context Safety––SHEL
SHEL
Errors & Violations
Errors & Violations
Summary Organizational
OrganizationalCulture
Culture
Safety Investigation
Safety Investigation
Outline
Fundamentals of Safety
Safety Management System Safety Stereotype
Safety Stereotype
Components of SMS Management Dilemma
Management Dilemma
Need for Safety Management
Legislation Need for Safety Management
Strategies for Safety Management
Strategies for Safety Management
Summary Imperative of Change
Imperative of Change
Building Blocks – SMS
Building Blocks – SMS
Responsibilities of Managing Safety
Responsibilities of Managing Safety
Outline
Fundamentals of Safety
Safety Management System
Components of SMS Safety Policy
Safety Policy
Safety Risk Management
Legislation Safety Risk Management
Safety Promotion
Safety Promotion
Summary Safety Assurance
Safety Assurance
The Concept of Safety
Zero accidents or serious incidents — a view widely held by the travelling
public;
Freedom from hazards, i.e. those factors which cause or are likely to cause
harm;
Attitudes of employees of aviation organizations towards unsafe acts and
conditions;
Error avoidance; and
Regulatory compliance.
What is Safety?
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.
Evolution of Safety Thinking
Traditional Approach:
Focus on outcomes (causes)
Unsafe acts by operational personnel
Assign blame/punish for failure to “perform safety”
Address identified safety concern exclusively
Identifies:
WHAT? WHO? WHEN?
But not always disclose:
WHY? HOW?
Evolution of Safety Thinking
TECHNICAL FACTORS
TODAY
HUMAN FACTORS
ORGANIZATIONAL FACTORS
1950s 1970s 1990s 2000
Accident Causation
Organization Workplace People Defences Accident
Technology
Training
Regulations
Management
decision &
organizational
processes
Working
conditions
Errors &
violations
Organizational Accident
Organizational processes
Improve Identify
Monitor
Work place conditions Latent conditions
Reinforce
Reinforce
Contain
Contain
Active failures Defences
People, Context & Safety
People & Safety
People, Context & Safety
Understanding Human
Performance
People, Context & Safety
Understanding Human
Performance
People, Context & Safety
Processes & Outcomes
SHEL(L) Model
SS
S - Software
H - Hardware
H
H LL LL E - Environment
L - Livewire
EE
SHEL(L) Model
Important factors affecting human performance:
a) Physical factors
b) Physiological factors
c) Psychological factors
d) Psycho-social factors
SHEL(L) Model
Interfaces between different components of the aviation system:
a) Liveware-Hardware (L-H)
b) Liveware-Software (L-S)
c) Liveware-Liveware (L-L)
d) Liveware-Environment (L-E)
Errors & Violations
Flaps omitted Checklist failure Incident /
Unheeded warning Accident
Degradation /
Error Deviation Amplification Breakdown
Operational Errors – Investigation of major
breakdowns
Errors & Violations
Flaps omitted Checklist failure Unheeded warning
Normal flight
Error Deviation Amplification
Safety Management – On almost every flight
3 Strategies to Control Operational Errors
1. Reduction strategies
a) Human-centred design;
b) Ergonomic factors; and
c) Training.
2. Capturing strategies
d) Checklists;
e) Task cards; and
f) Flight strips.
3. Tolerance strategies
g) system redundancies; and
h) structural inspections.
Errors vs. Violations
General types of violations:
1. Situational violations occur due to the particular factors that exist at the
time, such as time pressure or high workload.
2. Routine violations are violations which have become “the normal way of
doing business” within a workgroup.
3. Organization-induced violations, which can be viewed as an extension of
routine violations. The full potential of the safety message that violations
can convey can be understood only when considered against the
demands imposed by the organization regarding the delivery of the
services for which the organization was created.
Errors vs. Violations
Regulations
Accident
High Technology
Incident
Training System’s
production
objectives
RISK
Violation Space
violation Space
Exceptional
Safety Space
Low
Minimum SYSTEM OUTPUT Maximum
Understanding Violations
Organizational Culture
National
Organizational
Professional
Organizational Culture
Organizational literature proposes three characterizations of organizations,
depending on how they respond to information on hazards and safety
information management:
a) pathological — hide the information;
b) bureaucratic — restrain the information; and
c) generative — value the information.
Organizational Culture
a) National culture differentiates the national characteristics and value
systems of particular nations.
b) Professional culture differentiates the characteristics and value systems
of particular professional groups
c) Organizational culture differentiates the characteristics and value
systems of particular organizations
Organizational Culture
Poor Bureaucratic Positive
Information Hidden Ignored Sought
Messenger Shouted Tolerated Trained
Responsibilities Shirked Boxed Shared
Reports Discouraged Allowed Rewarded
Failures Covered up Merciful Scrutinized
New Ideas Crushed Problematic Welcomed
Resulting Conflicted Red tape organization Reliable organization
organization organization
Effective Safety Reporting
Effective safety reporting builds upon certain basic attributes, such as:
a) Senior management places strong emphasis on hazard identification as
part of the strategy for the management of safety;
b) Senior management and operational personnel hold a realistic view of the
hazards faced by the organization’s service delivery activities;
c) Senior management defines the operational requirements needed to
support active hazard reporting, ensures that key safety data are properly
registered, demonstrates a receptive attitude to the reporting of hazards
by operational personnel and implements measures to address the
consequences of hazards;
Effective Safety Reporting
d) Senior management ensures that key safety data are properly safeguarded
and promotes a system of checks and);
e) Personnel are formally trained to recognize and report hazards and
understand the incidence and consequences of hazards in the activities
supporting delivery of services; and
f) There is a low incidence of hazardous behaviour, and a safety ethic which
discourages such behaviour.
Effective Safety Reporting – 5 basic traits
Information
People are knowledgeable about the human, technical
and organizational factors that determine the safety of
the system as a whole
Flexibility
People can adapt reporting when facing
unusual circumstances, shifting from
Willingness the established mode to a direct mode
People are willing to report thus allowing information to quickly
their errors and experiences Effective safety reach the appropriate decision-making
Reporting level
Accountability Learning
People are encouraged (and rewarded) for People have the competence to draw
providing essential safety-related conclusions from safety information
information. However, there is a clear line systems and the will to implement
that differentiates between acceptable and major reforms
unacceptable behaviour
Safety Investigation
to put losses behind;
to reassert trust and faith in the system;
to resume normal activities; and
to fulfil political purposes.
Safety Investigation
Safety investigation for improved system reliability:
a) to learn about system vulnerability;
b) to develop strategies for change; and
c) to prioritize investment of safety resources.
Outline
Fundamentals of Safety
Safety Management System Safety Stereotype
Safety Stereotype
Components of SMS Management Dilemma
Management Dilemma
Need for Safety Management
Legislation Need for Safety Management
Strategies for Safety Management
Strategies for Safety Management
Summary Imperative of Change
Imperative of Change
Building Blocks – SMS
Building Blocks – SMS
Responsibilities of Managing Safety
Responsibilities of Managing Safety
Safety Stereotype
The safety stereotype:
safety first vs. safety is an organizational process
Safety is not first priority in aviation
safety is just organizational process
.
Management Dilemma
Dilemma of 2 P’s:
Production
Protection
Management Dilemma
Management Levels
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Need for Safety Management
Minor-major accident Major air disaster are rare
Major air disaster are rare
Incidents occur more frequently
Incidents occur more frequently
Ignoring the major could lead to an
Ignoring the major could lead to an
increase
increasenumber
numberofofmore
moreserious
serious
accidents
accidents
Need for Safety Management
Minor-major accident
Economics of Safety Accidents cost money
Accidents cost money
Insurance can help but not all
Insurance can help but not all
There are many uninsured cost
There are many uninsured cost
Lost of confidence of the travelling
Lost of confidence of the travelling
public
public
Need for Safety Management
Minor-major accident
Economics of Safety
Publics perceived safety while traveling
Prerequisite for a sustainable
Prerequisite for a sustainable
aviation
aviationbusiness
business
Strategies for Safety Management
Baseline performance
System
Design
Training
Technology
Regulations
Operational
deployment Op
era
ti on
al
p erf
orm
an
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Source: Scott A. Snook
The practical drift
Strategies for Safety Management
Reactive
Proactive
Predictive
Strategies for Safety Management
Reactive
Reactive method
method
The
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reactivemethod
method Proactive
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eventsthat
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analysisofofthe
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organization’sactivities
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performance
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real-timenormal
normal
operations
operationstotoidentify
identify
potential
potentialfuture
futureproblems
problems
Strategies for Safety Management
Safety management levels
High Middle Low
Hazards Predictive Proactive Reactive Reactive
FDA ASR ASR Accident and
Direct Survey MOR incident
observation Audits reports
systems
Highly efficient Very efficient Efficient Insufficient
Desirable management
levels
High
Strategies – Levels of intervention and tools
Imperative of Change
The management of change
Aircraft and Equipment are changing overtime
Hazards that are by product of change
Change can introduce new hazard
Formal Process for the Management of change
Critically of system and activities
Stability of systems and operational environment
Past performance
Imperative of Change
The traditional safety paradigm relied on the accident/serious incident
investigation process as its main safety intervention and method, and it was
built upon three basic assumptions:
a) The aviation system performs most of the time as per design
specifications (i.e. baseline performance);
b) Regulatory compliance guarantees system baseline performance
and therefore ensures safety (compliance-based); and
c) Because regulatory compliance guarantees system baseline
performance, minor, largely inconsequential deviations during
routine operations (i.e. processes) do not matter, only major
deviations leading to bad consequences (i.e. outcomes) matter
(outcome oriented).
Imperative of Change
It is based on the notion of managing safety through process control, beyond
the investigation of occurrences, and it builds upon three basic assumptions
also:
a) The aviation system does not perform most of the time as per
design specifications (i.e. operational performance leads to the
practical drift);
b) Rather than relying on regulatory compliance exclusively, real-
time performance of the system is constantly monitored
(performance-based); and
c) Minor, inconsequential deviations during routine operations are
constantly tracked and analysed (process oriented).
8 Building Blocks - SMS
1. Senior Management’s commitment to the management of safety
2. Effective safety reporting
3. Continuous monitoring
4. Investigation of safety occurrences
5. Sharing safety lessons learned and best practices
6. Integration of safety training for operational personnel
7. Effective implementation of standard operating procedures (SOP’s)
8. Continuous improvement of the overall level of safety
4 Responsibilities of Managing Safety
The responsibilities for managing safety can be grouped into four generic and
basic areas, as follows:
a) Definition of policies and procedures regarding safety. Policies and
procedures are organizational mandates reflecting how senior
management wants operations to be conducted.
b) Allocation of resources for safety management activities. Managing
safety requires resources. The allocation of resources is a managerial
function.
c) Adoption of best industry practices. The tradition of aviation regarding
safety excellence has led to the continuous development of robust safety
practices. Aviation has, in addition, a tradition regarding exchange of
safety information through both institutional and informal channels.
4 Responsibilities of Managing Safety
d) Incorporation of regulations governing civil aviation safety. There will
always be a need for a regulatory framework as the bedrock for safety
management endeavours. In fact, sensible safety management can
develop only from sensible regulations.
Summary
In summary, safety management:
a) includes the entire operation;
b) focuses on processes, making a clear differentiation between
processes and outcomes;
c) is data-driven;
d) involves constant monitoring;
e) is strictly documented;
f) aims at gradual improvement as opposed to dramatic change; and
g) is based on strategic planning as opposed to piecemeal initiatives.
The End
Questions & Answers
