Aviation Safety Management Systems Tony Cramp Senior Advisor (Americas) 17th May 2005 3/23/2016 File Title Lafayette Shell Aircraft International Underlying Safety Beliefs • How many factors need to be removed to prevent the accident? Theoretically only one, but with each factor removed the probability for an accident is lowered • The fundamental requirements for accident prevention are thus (i) the ruthless hunting out and elimination (the identification and management) of risk factors and (ii) using systems of work that are inherently safe • Everyone can contribute to causing an accident, we can also contribute to preventing one • A fundamental requirement for this is effective collaboration between line personnel and ‘management’ • These are 3rd Generation Safety beliefs Safety Paradigms: 3rd Generation • Safety is a corporate value. Safety practices consider the organizations particular “way of doing business” as well as corporate’s possibilities and constraints. What works well for one airline does not necessarily work equally well for others. • Accidents are caused by systems flaws. The failures observed at the “front end” of aviation operations are considered symptoms of deficiencies in the architecture of the aviation system. • Human error as a symptom. Error is accepted as normal component of human performance, unavoidable but manageable. Human error is a clue, which indicates where the safety investigation process must begin rather than end. • Proaction. Attention is focused on the processes incurred by the aviation system, regardless of the outcome of these processes. Safety Paradigms: 3rd Generation The finding of ‘human error’ should be the starting point of an investigation, not its conclusion Defences in Depth If we have these beliefs then the foundation of a strategy for preventing accidents would be to introduce controls at Organizational (Systemic), Team and Personal levels so as to achieve Organizational defenses in depth: A Systemic approach to the management of safety: Safety Management Systems Safety Management Systems The formal goals of an SMS are as follows: • To produce fully airworthy aircraft, in a safe working environment, that are subsequently operated safely • To ensure and demonstrate that safety is being managed as formally as any other critical business function • To ensure and demonstrate that the Organization is ‘responsible’ and exercising ‘due care’ (the counter to offence of ‘Corporate Killing’) But what is the bottom line? SMS is Not New! • The concept and practice of ‘System Safety’ was first introduced consequent to the Apollo 204 pad fire in 1967 and has been embedded in engineering ever since. • The Basic Principles of ‘System Safety in Engineering’ are: • • The assurance of safety is gained through the competence and safety-orientated procedures used by each individual engineer, however: • In complex systems it is easy to ‘overlook the wood for the trees’: there must be an autonomous, safety oversight process that has the ‘big picture’ and a ‘watchdog’ function, and: • There must be a system enforcing the effective communication of safety-critical information, and: • There must be a ‘Facilitative function’ that ensures hazard identification and resolution This engineering / astronautics approach then migrated into the Nuclear, Maritime, Rail, Oil/Chemical industries and has shown considerable benefits SMS in Aviation: The Challenge • Aviation is lagging some 15 years in implementing formal SMS: flight operations already heavily regulated and traditional Flight Safety methods have a high degree of effectiveness • SMS has been developed primarily outside of aviation: past experience e.g.CRM and QA, shows that systems from outside are not always introduced correctly or tailored correctly to aviation culture • Have to get past the SMS language used by other disciplines, mainly the ‘speak’ of HSE and Quality Assurance • BUT: SMS is rapidly becoming a Regulatory requirement (UK CAA, Transport Canada, FAA moving in this direction etc) as well as a Customer requirement (Shell, ExxonMobil) • The challenge is to take the benefits of SMS distilled to date and adapt and apply them to aviation in such a way that SMS is accepted and is demonstrated to add value SMS Primary Components Accident cause ⌗ 1. Inadequate Procedural Baseline SMS Primary Components ① Procedural baseline to assure safety in work Ops Manual, GMM/MPM, Ramp Procedures, Fuel Quality, OSHA Compliance SMS Primary Components The manual forms a ‘road map’, has an integrative function and if the SMS Manual consists of a template of the ‘ideal’ system, then it can be used for both assessment and development purposes ② SMS Manual ① (Full spectrum of policies, procedures, methods, practices to assure safety in work) SMS Manual can be written bottom- up, or preferably as a template ‘top-down’, gives the big-picture, highlights any major ‘holes’ in SMS Component ⌗1 Any holes? SMS Primary Components X Cause ⌗ 1. Inadequate Procedural Baseline Cause ⌗ 2. Uncontrolled Hazards SMS Primary Components ③ Safety Management Program ② SMS Manual ① Procedural baseline to assure safety in work Systems are for People? “Even the most well-considered safety system can be wrecked by the idiosyncratic behaviour of a single individual” SMS Component ⌗3: Safety Program Management 1. Proactive Safety Management • Encouraging and developing Management commitment • Creation of a Safety Culture • Safety structure and resources, committees and meetings • Ongoing hazard identification and management (HEMP) • Safety education (training, information dissemination) • ‘ Watchdog’ function 2. Reactive Safety Management • Occurrence investigation (‘occurrences’, incidents, accidents) • Data analysis • Continuous learning SMS Primary Components ③ ② Safety Program Management ④ SMS Manual Safety Case ① Procedural baseline to assure safety in work SMS Component ⌗ 4: The Safety Case 1. A Safety Case is a formal, organizational risk management exercise conducted proactively (e.g. prior to contract launch), or reactively (e.g. to gain control over the risks in current operations) 2. An aviation ‘Safety Case’ is defined as “The documented description of the major hazards that the aircraft operator faces and the means employed to control these hazards” 3. As opposed to the SMS Manual, which gives ‘big picture’ inputs, a Safety Case gives detailed inputs into the procedural baseline. It identifies individual controls required. 4. A Safety Case is a specific application of the HEMP 5. A safety case functions at Management, Supervisor and Line levels: a Living document. SMS Primary Components X Cause ⌗ 1. Inadequate Procedural Baseline X Cause ⌗ 2. Uncontrolled Risk Factors / Hazards Cause ⌗ 3. Failures in Communication SMS Primary Components ⑤ SIS ③ ② Safety Program Management SMS Manual ④ Safety Case ① Procedural baseline to assure safety in work Safety Information System 1. The fifth primary element is the Organization’s ‘Safety Information System’ (SIS) 2. Several studies have shown that in the vast majority of (aircraft) accidents there was always a piece of information available somewhere that had it been in the right place at the right time, the accident might well have been prevented 3. A SIS may take a variety of forms, from the basic verbal / written communication of safety information across the organization to sophisticated company ‘intranets’. Examples: Hazard report forms Regular safety meetings, with minutes recorded and distributed. Company newsletters Effective, updated notice boards Intranet employee notices SMS Primary Components X Cause ⌗ 1. Inadequate Procedural Baseline X Cause ⌗ 2. Uncontrolled Risk Factors / Hazards X Cause ⌗ 3. Failures in Communication Next Challenge! • How to integrate these components: Integrating Principles 1. After 200 years of industry and 100 years of flight surely there must be a package of elements or principles that if applied will give a high level of assurance of safety? 2. Currently, there is agreement that these elements and principles are best described in systems developed by the science of ‘Quality Assurance’ 3. The most current definition of an SMS is thus: • ‘A system for the proactive management of safety that is appropriate to the Operator’s size and complexity and integrates operations, maintenance, human resources and finance and draws upon quality principles’ SMS Primary Components ⑥ Quality System ⑤ SIS ③ ② SMS Manual Safety Program Management ④ Safety Case ① Procedural baseline to assure safety A Typical Safety-Orientated ‘Quality’ System Management Review Customer Satisfaction Remedial Action Investigation & Follow-up Principles & Policy Strategy Objectives Targets & Plans Standards Plan Feedback Culture Check Do Accountability & Competence Product Management COMMUNICATION Incident Reporting Risk Assessment Monitoring Audit Review Hazard Management SHELL ‘Model’ HSSE-MS Elements SMS Summary ⑥ Quality System ⑤ SIS ③ ② Safety Program Management SMS Manual See ‘Model Manual’ 33 Sub-Elements ④ Safety Case ① Procedural baseline to assure safety SMS Booklet The Safety Case 1. A Safety Case is a formal, organizational risk management exercise conducted proactively (e.g. prior to contract launch), or reactively (e.g. to gain control over the risks in current operations) 2. An aviation ‘Safety Case’ is defined as “The documented description of the major hazards that the aircraft operator faces and the means employed to control these hazards” 3. As opposed to the SMS Manual, which gives ‘big picture’ inputs, a Safety Case gives detailed inputs into the procedural baseline. It identifies individual controls required. 4. A Safety Case is a specific application of the HEMP 5. A safety case functions at Management, Supervisor and Line levels: a Living document. Hazards, Incidents, Accidents Byrd’s Triangle Eliminate hazards and you will eliminate accidents 1 Accident 10 Incidents 600 Hazards Hazard Identification: Fundamental Requirements 1. The fundamental requirements for effective hazard identification are: » To get past perceptions and to quantify wherever possible » To tap into the vast reservoir of knowledge that exists within Aviation and other complex industries » To ‘think outside the box’ » Be paranoid: believe everything and believe nothing: continually test for the truth Which hazards? Type specific Hazards Company Specific Hazards Generic Aviation Safety Hazards Aviation Safety Case = + Generic HSE Hazards Major Aviation Safety Hazards Operation Specific Hazards Location Specific Hazards Significant Workplace Hazards Workplace Safety Procedures (Defined in HSE-MS) Primary Sources for Identifying Hazards Safety Critical Processes External Sources Hazard Register Internal Sources Formal Hazard Models Hazard and Effects Register Note: 1. Hazard Use this control sheet, one for each hazardous event, to summarise the key information of the worked Hazardous Event normally held electronically in full detail in an Excel Document 2. Hazard Reference : and Description : Prepared by: Custodian: Authorized by: 3. Status of the hazardous event at the time of the risk assessment: 5. Remedial Actions Raised a. b. c. d. e. f. 6. Hazardous Event: Rev No: Date 4. Activities in which the Hazardous Event may occur: 4.1 4.2 4.3 7. Location: 8. Threats and Threat controls, 9. Escalations and escalation controls, 10. Recovery from Hazardous Event, 11. Escalation and Escalation controls – See appropriate Excel document. Document Reference No : 12. Risk Assessment People Environment 13. Consequence associated with hazard release: Asset Reputation 14. Mitigation from consequences : 15. Accountable Line Management Sign-off having accepted current status: Line Department: Name: Signature : 15. Date : Risk Analysis Process – When identified and objectively analyzed, each hazard shall be subjected to a risk analysis. This shall accomplished by using a risk matrix of a format commonly found in the industry – The matrix is self-explanatory and even though some of the aspects may well be subjective, it at least allows the partial quantification of risk factors. – The hazards are then ranked in terms of the rating obtained by use of the matrix – In terms of the Shell model, all hazards ranked as ‘intolerable’ shall be subjected to a ‘bow-tie’ analysis. The Risk Grading (Threat Analysis) Matrix The ‘Bow-Tie’ Process The Bow-Tie Process For those hazards assessed as being ‘Intolerable’, develop ‘controls in depth’ as follows: 1. Identify the Threats that might release the hazard 2. Identify Controls to contain the Threats 3. Identify factors that could prevent the Controls from being effective: Escalation Factors 4. Develop controls to contain the Escalation Factors: Escalation Controls 5. The hazard is released, but it’s consequence has not yet occurred: what controls make detection and recovery possible: Recovery Measures 6. Identify Escalation Factors hampering detection and recovery 7. Identify a final layer of Escalation Controls 8. Identify measures to mitigate the effects of the Consequence HAZARD THREAT CONTROL ESCALATION THE BOWTIE CONTROL Hazardous Event RECOVERY ESCALATION CONTROL CONSEQUENCE MITIGATION MEASURES TIGER Cage Door Locking System Twin Locks & Warning Lights Unserviceable Warning System Records & Maintenance Hazard Threat Control Escalation Control Tiger out of the Cage THE BOW-TIE Shoot Tiger, or drive back in cage Miss Tiger, or Tiger Evades Keeper Competent Keepers Tiger Bites Keeper Effective Emergency Response Plan Recovery Escalation Control Consequence Mitigation PEOPLE Errors, Mistakes, Violations Competence, Procedures, Systems Non Compliant Pactice Monitoring and Feedback Hazard Threat Control Escalation Control Human Error Inappropriate pilot control input THE BOW-TIE Make corrective control selection Input can not be made it time Competence & Awareness Aircraft Crashes Effective Emergency Response Recovery Escalation Control Consequence Mitigation Percentage of Accidents Reported in NASA Study Preventable by Individual Mitigation Measures Late FAR 29/Enhanced Handling FFS Training + CRM/LOFT Measures OC/QA/SMS HUMS/VHM Seven Key Initiatives HOMP/FOQA Perf Class 1/2e EGPWS/TCAS Requires development work Tail Rotor Impact Warning 0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 Percentage acidents prevented Hazard and Effects Register Note: 1. Hazard Use this control sheet, one for each hazardous event, to summarise the key information of the worked Hazardous Event normally held electronically in full detail in an Excel Document 2. Hazard Reference : and Description : Prepared by: Custodian: Authorized by: 3. Status of the hazardous event at the time of the risk assessment: 5. Remedial Actions Raised a. b. c. d. e. f. 6. Hazardous Event: Rev No: Date 4. Activities in which the Hazardous Event may occur: 4.1 4.2 4.3 7. Location: 8. Threats and Threat controls, 9. Escalations and escalation controls, 10. Recovery from Hazardous Event, 11. Escalation and Escalation controls – See appropriate Excel document. Document Reference No : 12. Risk Assessment People Environment 13. Consequence associated with hazard release: Asset Reputation 14. Mitigation from consequences : 15. Accountable Line Management Sign-off having accepted current status: Line Department: Name: Signature : 15. Date : So What is an SMS? 1. An SMS is a suite of standards, policies, procedures, practices etc that will assure the safe and effective execution of work (‘Quantitative’ Quality elements) 2. An SMS contains a structure for dynamic and flexible identification and control of risk to ALARP (‘Quantitative’ procedures and methods for the proactive management of safety: safety cases). This includes the requirement for a Safety Information System. 3. An SMS requires the application of Human Factors: communication, leadership and followership, conflict management, cultural aspects, motivation & commitment (‘Qualitative’ elements) 4. An SMS should encompass flight safety, ramp and maintenance safety, industrial (workplace) safety, occupational health, environmental protection and security 5. An SMS Manual should give the ‘big picture’ regarding safety management in the organization Conclusion • SMS is not a magic bullet: it is a set of tools and guidelines that if tailored to the Organization and diligently applied so that the probability of an accident will be reduced to a level that is as low as is reasonably practicable (ALARP) • Apply these tools and guidelines and you will have done all that can be reasonably expected of you as aviation professionals and as a ‘responsible operator’ 3/23/2016 File Title QUESTIONS Shell Aircraft International