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1
SMS Systems Cliff Edwards
2
OVERVIEW
  • Industry Approach to Safety
  • The Need for Change
  • Management Systems
  • Key Elements of a Safety Management System
  • Conclusions
  • Hazard Management

3
  • Approach to Safety - Safety Is No Accident
  • Is it a clever play on words? Or the truth?
  • Unfortunately, in many companies safety is an
    accident!
  • Safety was not the planned outcome, but the
    result of how things worked out!
  • Operations that dont plan for safety require
    individuals to do the right thing without
    direction.
  • As professionals, pilots, engineers and others,
    often achieve the levels of safety sought! But
    can we rely on that?
  • Are we doing enough? - We dont believe so!

4
  • Approach to safety - Why?
  • Is there a need to change?
  • Public transport aviation is a fundamentally safe
    industry

- - but aviation is facing difficult times in the
coming years, made worse by the events of
September 11th, - - the effects of that disaster
have had far reaching implications on aviation
and remain likely to have an impact on the
potential for accidents and incidents, and - -
the industry faces falling incomes, rising costs
and the loss of experience.
  • The safety record to date has been driven
    primarily by regulatory compliance and the
    experience and training of its participants

5
Approach to Safety - Current Accident Rates
The current accident rates are flat lined, this
relates to the number of hull losses per year -
regulation is not making it safer
Predictions of future needs show a doubling of
number of flights by 2015, concurrent with - a
move towards low cost operations, and - a
falling resource of experienced staff to carry
out the work The rate is likely to increase.
6
OVERVIEW
  • Industry Approach to Safety
  • The Need for Change
  • Management Systems
  • Key Elements of a Safety Management System
  • Conclusions
  • Hazard Management

7
  • The Need for Change
  • Whether for business survival, quality or safety,
    there has never been a more important time to
    improve performance.
  • Our industry leaders are faced with very few
    choices to achieve the improvements that they
    need to make to survive these are
  • Improved fiscal control, and/or higher fares.
  • Reductions in competition through mergers or
    buy-outs.
  • Improved utilisation of the aircraft and staff.
  • Improved reliability of the aircraft and its
    maintenance.
  • Improved safety, through loss control measures
  • If nothing changes the safety record will get
    worse!

8
The Need for Change - What do Top Safety
Performing Companies do? Better safety
performance in World Class companies is
achieved through their Management of Safety and
the development of the Safety Culture of the
Company.
  • World Class Safety Performers deliver 4 key
    business elements
  • Committed and involved leadership providing
    vision and seeing their initiatives through to
    conclusion.
  • Individual accountability cascaded throughout the
    workforce.
  • An empowered workforce that feel, and are,
    involved in the process of delivering a quality
    product safely.
  • A workforce that is compliant with its standards
    and committed to the Companys objectives.
  • These are the keystone tenets of a Safety
    Management System.

9
OVERVIEW
  • Industry Approach to Safety
  • The Need for Change
  • Management Systems
  • Key Elements of a Safety Management System
  • Conclusions
  • Hazard Management

10
  • Management Systems
  • Most Companies have a number of systems of
    management
  • The Boards management system.
  • Financial Management.
  • Quality Assurance.
  • Safety Management.
  • Local Fiefdoms.
  • The way things are run around here.
  • In reality, there should be only one real system
    of management in any Company and that must be
    modelled to manage all facets of the business.

11
Management Systems - Leadership Management?
  • To meet the challenge requires clear objectives,
    effective direction, stated plans and
    demonstrated commitment.
  • Although named as the Accountable Managers, CEOs
    often are not involved and have little knowledge
    of these systems, or the problems in the
    workplace.
  • Top management often delegate the responsibility
    for systems such as QA and SMS to allow
    themselves the chance to get on with running the
    business - this is flawed thinking.
  • It is almost certain that top management will be
    involved in the management of the finances, due
    to the associated risks.
  • Safety Management should be no different.

12
  • Management Systems - Why Introduce an SMS?
  • If you are contracted to the Shell Group, its a
    contractual requirement.
  • If youre a public transport operator, JAR-Ops
    1/3.037 statesAn Operator shall establish an
    accident prevention and flight safety programme,
    which may be integrated with the Quality system,
    including programmes to achieve and maintain risk
    awareness by all persons involved in operations.
    Effectively an SMS.
  • UK operators are required to operate to the
    Health and Safety Executive statutes
  • Companies are required to manage the risks of
    their business,
  • HSG65 guidance on the means of compliance
    describes a SMS.

13
  • Management Systems - Definitions
  • Safety Management Systems
  • A Safety Management System is the methodology by
    which a company manages safety throughout its
    organisation, utilising a systematic approach to
    ensure that all parts of the business are
    addressed, and that all risks are identified and
    subsequently managed.
  • Safety Cases
  • Safety Cases (one or many) are subordinate to an
    SMS - as a minimum, they incorporate the process
    used to demonstrate the Companys fitness for
    purpose through the identification and control
    of the major risks.

14
  • Objective
  • To produce fully airworthy aircraft, in a safe
    working environment, that are subsequently
    operated safely.
  • This being achieved by well led teams, who are
    competent and focussed on working safely in all
    aspects of their roles, in particular those for
    which they are accountable.
  • Working in a company whose management is
    committed to and establishes safe systems of work
    and a positive safety culture.

15
OVERVIEW
  • Industry Approach to Safety
  • The Need for Change
  • Management Systems
  • Key Elements of a Safety Management System
  • Conclusions
  • Hazard Management

16
  • Key Elements of an SMS
  • As in other systems of Management, where
    financial or quality risks are the focus, Safety
    Management Systems bring a systematic approach
    the the management of safety risks.
  • The same model system that is embedded in ISO
    9000-2000 is used, because this is an approach
    that is capable of managing any part of the
    business.
  • The management system needs to be underpinned by
    other tools, such the Risk Assessment Matrix,
    or a hazard analysis Bow-Tie.
  • As in all Management Systems, an SMS can only add
    value to the organisation if Top Management are
    actively driving it.

17
Principles Policy
Objectives
Management Review
Strategy
Targets Plans
Customer Satisfaction
Standards
Remedial Action
Accountability Competence
Culture
Investigation Follow-up
Product Management
Incident Reporting
Risk Assessment
Hazard Management
Monitoring
Audit
Review
18
Key Elements Principles - Policy - Objectives -
Targets - Strategy
  • Principles are the stance that a Company decides
    to take on specific issues (e.g. its business or
    safety principles).
  • Policies are the statements that the Company
    makes to ensure that the principles can be put
    into practice and are understood by the staff
    customers.
  • Objectives are the intentions of the Company to
    get from where it is now, to where it wants to be
    in the future.
  • Targets are the time-scales that the Company sets
    itself to achieve its objectives.
  • Strategy is the means that the Company employs to
    achieve the objectives in accordance with its
    principles.

19
  • Key Elements - Commitment
  • Introducing new systems of working such as QA/SMS
    takes significant commitment.
  • From Management to support and fund the initial
    resource requirements.
  • From the System Custodian to shape working
    processes.
  • From the Staff who must use the processes.
  • And they all need ongoing reinforcement that it
    will make a difference this comes from passion
    and commitment.

Commitment is often stated, but only sometimes
demonstrated by management this weakens the
safety climate in the company. If you dont mean
it Dont Say It
20
  • Key Elements - Accountability and Competence
  • Accountability for each position should be
    clearly defined.
  • The accountabilities of the CEO should be
    cascaded down throughout the organisation.
  • Accountabilities could be seen at three levels,
    as they apply to the individual, the team and the
    company.
  • Achievement against accountabilities and
    competence to fulfil them should be reviewed in
    the Company appraisal process.
  • The post holder must be competent to carry out
    the tasks they are accountable for, typically
    this requires job profiles.
  • Shortfalls in competencies should be addressed
    through the annual Training Plan.

21
  • Key Elements - Planning
  • In business, success is achieved by planning.
  • The business needs a Business Plan, QA needs a
    Quality Plan, Safety needs a Safety Plan.
  • Resource allocation needs to be planned to meet
    the safety programme and safety targets.
  • Resources are people, time, equipment, facilities
    and funding.
  • Good plans will only add value if there are
    adequate resources to execute them.

22
  • Key Elements - Performance Measurement
  • Whats not measured is not managed? - generally
    true
  • Companies are able to develop through their
    management teams knowing what needs to be
    improved.
  • Commercial performance is usually measured.
  • Operational performance is often measured through
    the use of key performance indicators, such as
    on time departures.
  • Safety performance may not be measured, because
    this displays the companys failures (incidents
    or accidents).
  • Companies might also demonstrate control of its
    hazards and risks, as a positive means of
    measuring safety.

23
  • Key Elements - Process Management
  • This is the doing part of the business. Fly
    or Maintain aircraft typically, are key
    processes in an aircraft operation.
  • To apply a systematic approach to the business,
    each critical process should be reviewed and
    improved if necessary.
  • The risk to the business of not applying the
    process effectively should be evaluated and
    appropriate steps taken to manage those processes
    assessed as critical to the business.
  • A Safety Management System requires clear focus
    on the risk bearing processes that, if not done
    correctly, will cause harm.
  • The controls of hazard management are embedded in
    the normal systems of working in aviation
    (checklists, competencies, training and system
    redundancy.

24
  • Key Elements - Risk Assessment
  • Many companies have no accidents in the year, but
    they all have Risks.
  • Each Risk should be evaluated and appropriate
    controls put in place to ensure it is controlled.
  • Three things you can do with Risk remove, reduce
    or manage it. The latter is more common in
    aviation.
  • The effort expended to manage a Risk should be
    based on its potential impact on the company.
  • However, some level of Risk is acceptable.
  • Staff using the Risk bearing processes should be
    involved in their analysis and assessment.

25
  • Key Elements - Hazard Management
  • Identify and categorise potential sources of harm
    (Hazards).
  • Identify all undesirable events associated with
    each hazard which, could result in harm being
    caused (Threats).
  • Develop or improve appropriate measures to
    prevent occurrence (Controls).
  • Define the measures necessary to re-establish a
    safe operating situation (Recovery Measures).
  • Reduce the impact of any consequences incurred
    (Mitigation Measures).

26
  • Key Elements - Review
  • The process of checking if what is in place
    remains valid.
  • Policies, standards, processes and procedures
    should be routinely reviewed to confirm their
    ongoing validity.
  • The outcomes of business (good or bad) should be
    reviewed.
  • Review is one of the least used verification
    tools.
  • Reviews should be carried out by users, as it
    requires their unique knowledge to add value.
  • The outcomes of reviews are best tracked through
    a common Remedial Action Process.

27
  • Key Elements - Monitoring
  • Monitoring is about finding out how people
    achieve tasks, as opposed to how they are
    expected to to do them (actual versus plan).
  • Monitoring is unpopular as it deals face-to-face
    with people and their miscommunications, errors
    and violations.
  • Monitoring is not intended to be a trapping
    exercise, but to understand the problems of the
    workplace.
  • Monitoring should be done on two levels
  • Compliance monitoring as a form of audit,
  • Task monitoring done by line staff (peers or
    supervisors).

28
  • Key Elements - Audit
  • Audit is the process of verification that
    formally requires parts of the business to be
    checked against standards, or trained-for
    actions.
  • Audit is often limited to site inspections and
    document checks.
  • Audit should be focussed more at the processes
    rather than its locations.
  • Audits should be planned to cover all aspects of
    the business, but the frequency should reflect
    the level of problems found.
  • Audit findings requiring resolution should be
    formally recorded in the Remedial Action process.

29
Key Elements - Incident Reporting
Investigation
  • Open incident reporting is a matter of Culture.
  • Improvement and learning can come from incidents
    and accidents, albeit they are unwanted
    investments.
  • The approach should be to get a return from
    investments from whatever you do, including the
    errors experienced.
  • Learning comes from investigation and analysis of
    the facts, primary causes and underlying causal
    factors.
  • Often underlying causal factors are embedded in
    the systems of work that require line management
    action to resolve.
  • Learning can also be shared through safety data
    exchange.

30
  • Key Elements - Remedial Action
  • From numerous sources, remedial actions will be
    raised.
  • Remedial actions should be recorded in a single
    control system, which must enhance visibility for
    Line Management.
  • Targets dates set for action and agreed with the
    Line Manager.
  • Follow-up action by the Safety Manager should
    ensure that appropriate action has been taken and
    is now working.
  • The remedial actions not being addressed on
    target should be reported through the Management
    Review Board.

31
  • Key Elements - Customer Satisfaction
  • ISO 9000-2000 Quality System sets Customer
    Satisfaction as a key requirement this is the
    same for safety management.
  • Measurement of customer satisfaction is rarely
    done well and, even less, seen as part of the the
    management system.
  • Customer Safety is an issue of satisfaction, and
    safety management systems can aid the development
    of this.
  • Dissatisfied customer dont come back and as an
    industry we are highly reliant on return
    business.

32
  • Key Elements - Management Review
  • Periodically there must be a formal Management
    Review Process.
  • Management Review is the final step of feedback
    in the closed loop
  • Top management must be involved in the Management
    Review Board process, in order for them to be
    informed.
  • Reviews include Policy, Objectives, Customer
    Satisfaction, Training, Audits, KPIs, Supplier
    Performance, Changes and Remedial Actions not
    yet resolved.

33
  • Key Elements - Culture
  • Culture of the Company determines the approach
    everybody takes toward work, especially safety
    and risk taking.
  • There may be sub-cultures, but the corporate
    culture is a reflection of the managements
    commitment and leadership.
  • The culture of the Company can be changed but it
    is a slow process and is easily damaged - there
    are no quick fixes.
  • Safety cultures range from blame to no blame
    but the aim should be for a Just and Learning
    Culture, and open to improvement.

34
OVERVIEW
  • Industry Approach to Safety
  • The Need for Change
  • Management Systems
  • Key Elements of a Safety Management System
  • Conclusions
  • Hazard Management

35
  • Conclusion
  • We have talked about ensuring Safety is No
    Accident - not only thinking about safety, but
    planning for it and following through on those
    plans into execution.
  • Real commitment, from management and staff can
    make its management system work, if it is key to
    the Companys vision and mission.
  • We have to Change the Face of Safety in
    aviation to make it a core business issue that
    involves everybody in the Company.
  • If you continue to do more of what you have
    already done, you will only get more of what you
    already have

36
OVERVIEW
  • Industry Approach to Safety
  • The Need for Change
  • Management Systems
  • Key Elements of a Safety Management System
  • Conclusions
  • Hazard Management

37
Hazard Management
  • Hazard and Effects Management Programmes
  • These require that you
  • IDENTIFY the hazard
  • ASSESS its potential (risk assessment)
  • CONTROL the Hazard, (keep it contained through
    one of three approaches
  • Remove the hazard
  • Reduce the exposure to the hazard
  • Manage the hazard through having effective
    systems and controls in place.
  • RECOVER from the effects of the release of the
    hazard.
  • In Business it is not possible to be free of
    risk, and in that environment occasionally a
    hazard will be released, and a hazardous event
    occurs, in this case it is essential to be
    prepared to deal with it and its consequences.

38
HAZARD/RISK MANAGEMENT
  • Identify and categorise potential sources of harm
    (Hazards).
  • Systematically evaluate the worst case
    potentially of each hazard (Risk Assessment).
  • Identify all undesirable events or circumstances
    associated with each hazard which, either in
    isolation or combination, could result in harm
    being caused (Threats).
  • Develop or improve appropriate measures to
    prevent occurrence (Controls).
  • Define the measures necessary to re-establish a
    safe operating situation (Recovery Measures).
  • Reduce the impact of any consequences incurred
    (Mitigation Measures).

39
Training
Accountability
Threat
Competencies
HAZARDS
HAZARDS CFIT, Fuel People Unairworthy Aircraft
Physical Barriers
Redundant Systems
Threat
Threat
Procedures
Awareness
Assurance
Threat
40
  • Key Elements - Risk Assessment
  • Many companies have no accidents in the year, but
    they all have Risks.
  • Each Risk should be evaluated and appropriate
    controls put in place to ensure it is controlled.
  • Three things you can do with Risk remove, reduce
    or manage it. The latter is more common in
    aviation.
  • The effort expended to manage a Risk should be
    based on its potential impact on the company.
  • Some level of Risk is acceptable.
  • Staff using the Risk bearing processes should be
    involved in their analysis and assessment.

41
RISK ASSESSMENT MATRIX
Potential Consequence of the Incident
Increasing Probability
D
B
C
E
A
Happened gt 3 x in this location
Known in aviation industry
Happened gt 3 x in the Company
Unknown but possible in the aviationindustry
Happened in this company
Env'ment
Assets
Reputation
People
Rating
Zero damage
Zero Effect
0
No injury
No Impact
Slight damage lt US 10K
Slight injury
Slight Effect
Slight Impact
Manage Through Normal HSE-MS procedures
1
Minor damage lt US 50K
Minor injury
Minor Effect
Local I m p a c t
2
incorporate risk reduction measure
Local damage lt US 250K
Serious injury
Industry I m p a c t
3
Localised Effect
Major damage lt US 1M
Single fatality
Major Effect
N a t i o n a l I m p a c t
Intolerable
4
Extensive damage gt US 1M
Multiple fatality
International I m p a c t
Massive Effect
5
42
HAZARD
THREAT
PROACTIVE
CONTROL
ESCALATION
T H E B O W - T I E
CONTROL
H E M P
I d e n t i f y A s s e s s C o n t r o l R e c
o v e r y
RECOVERY
REACTIVE
ESCALATION
CONTROL
CONSEQUENCE
MITIGATION MEASURES
43
HAZARDOUS EVENT MAP
Deviation from Intended Aircrew Flight
Training/ Air test Missions
Aircraft Systems Failures Inc. Dynamic Failures
Exceedance of Aircraft Limitations
Flight Operations
Proximity to a Third Party or Obstacle
Loss of Separation with other Aircraft
Loss of containment of Dangerous Goods
Uncontrolled people in close proximity to a
running propeller
Aircraft Deviates from Intended Safe Flight Path
Internal Interface Operations
Flammable Materials in proximity to a source of
ignition
Static Out of Balance situations
Aircraft Deviates from Intended Ground Track
Unairworthy Aircraft Released to Service
Ground Operations and Maintenance
Encountering Unexpected External Conditions
Uncontrolled GSE in proximity to the Aircraft
Encountering Adverse Weather Conditions
Loss of containment of fuel or oil
Use of unsafe lifting equipment
Encounter with a potential HSE occurrence
Interface with Ramp Agents
Loss of containment of fluid and gas under
pressure
Interface with Maintenance Contractors
Interfaces with Contractors
44
SMS TERMINOLOGY
Hazard A situation with the potential to cause
harm. ThreatSomething with the potential to
release a hazard. Threat Control A measure put
in place to prevent the release of a
hazard. Escalation FactorA condition that
prevents a threat control, or recovery measure
being effective. Escalation Control A further
measure put in place to control an escalation
factor. Hazardous Event The initial release of
the hazard, that can lead to an accident.
45
SMS TERMINOLOGY
Recovery MeasureMeasures taken to return the
situation to normal after the initial release of
a hazard. ConsequenceThe final result of the
release of a hazard that was not
controlled. Mitigation MeasureSteps taken to
return the situation to as near normal as
possible after the consequence has occurred. Bow
Tie ModelA means of visually displaying the
hazard management process.
46
HAZARD
THREAT
PROACTIVE
CONTROL
ESCALATION
T H E B O W - T I E
CONTROL
H E M P
I d e n t i f y A s s e s s C o n t r o l R e c
o v e r y
RECOVERY
REACTIVE
ESCALATION
CONTROL
CONSEQUENCE
MITIGATION MEASURES
47
Interactive Workshop Task
  • We will work through a small bow-tie in which I
    will facilitate you to brainstorm a hazard
    analysis.
  • Hazardous event - Maintenance error
    (mis-assembly) during an overnight maintenance
    task
  • What is the Hazard?
  • Human Action - Error
  • What are the threats that could cause this type
    of error
  • Distraction, Fatigue,
  • Non procedural working, Time pressures
  • Insufficient information, Insufficient
    planning,
  • Lack of task competence, Inadequate use of
    worksheet,
  • Poor access to task.

48
HAZARD
THREAT
PROACTIVE
CONTROL
ESCALATION
T H E B O W - T I E
CONTROL
H E M P
I d e n t i f y A s s e s s C o n t r o l R e c
o v e r y
RECOVERY
REACTIVE
ESCALATION
CONTROL
CONSEQUENCE
MITIGATION MEASURES
49
Interactive Workshop Task
What are the controls for these threats?
  • Distraction,
  • Fatigue,
  • Non procedural working,
  • Time pressures
  • Insufficient information,
  • Insufficient planning,
  • Lack of task competence,
  • Inadequate use of worksheets,
  • Poor access to task.
  • Use of Worksheets, Handover, supervision, cross
    checks
  • Limitations, rostering, awareness, culture
  • Procedures, Quality Control/Assurance, workplace
    monitoring, supervision.
  • Planning, procedures, supervision, culture
  • Reviews, procedures, audits, standards
  • Planning standards, Reviews Supervision
  • Competence Standards, Training, Approvals
  • Supervision, Quality Assurance, training,
    worksheet standards.
  • Planning, special tooling, duplicate checks.

50
HAZARD
THREAT
PROACTIVE
CONTROL
ESCALATION
T H E B O W - T I E
CONTROL
H E M P
I d e n t i f y A s s e s s C o n t r o l R e c
o v e r y
RECOVERY
REACTIVE
ESCALATION
CONTROL
CONSEQUENCE
MITIGATION MEASURES
51
Interactive Workshop Task
What are the escalation factors for these
controls?
  • Use of Worksheets, HandoverSupervision, Cross
    checks
  • Limitations, rostering, awareness, culture
  • Procedures, QC/QAWorkplace monitoring,
    Supervision.
  • Not up to date when distracted, No formalised
    handoverLack of, or nil supervision, No culture
    of go back and check in place
  • Limitations not complied with, Inadequate
    rostering, Lack of awareness, Culture
    encourages long working hours
  • Lack of or non compliance QC/QA do not work on
    night shiftsNo culture of Workplace monitoring,
    Lack of, or no Supervision.

52
Interactive Workshop Task
What are the Recovery Measures
  • Open reporting
  • Duplicate inspections
  • Ground Test
  • Flight test or flight
  • Supportive culture, recall or advise the aircraft
  • Critical tasks only
  • Procedures for Ground Test
  • Flight crew deal with the emergency when
    identified

53
HAZARD
THREAT
PROACTIVE
CONTROL
ESCALATION
T H E B O W - T I E
CONTROL
H E M P
I d e n t i f y A s s e s s C o n t r o l R e c
o v e r y
RECOVERY
REACTIVE
ESCALATION
CONTROL
CONSEQUENCE
MITIGATION MEASURES
54
EXAMPLE SMS MANAGEMENT OF HUMAN ERROR
Staff competencies checked against profiles
Compliant practices always used
Workplace culture supportive
55
SMS TERMINOLOGY
Risk A measure of probability or frequency of a
hazardous event occurring and the severity of its
consequences. Accident An unintended event or
sequence of events that cause death, ill health,
injury, environmental or material
damage. Accountability Those elements of work
that are managed, delegated supervised or
contracted and for which the individual is
responsible. Responsibility Those elements of
work that you do yourself and are required to
perform to specified standards.
56
SMS TERMINOLOGY
Safety Management A systematic and explicit
approach to managing risk. Safety Case A
documented account to show that hazards have been
identified and controlled and that measures are
in place to reduce the risks to As Low As
Reasonably Practicable (ALARP). (The safety case
utilises methodologies to remove, reduce or
control the hazards and by the application of
quality type closed loop processes).
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