'riprendiamo il filo

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• .riprendiamo il filo

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IL FILO CONDUTTORE

• Fattori di successo della sfida
• La motivazione nell intraprendere e condurre la
  sfida
• La comprensione, ladozione e la condivisione dei
  valori alla base della missione
• Il soddisfacimento dei fabbisogni organizzativi

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LA SICUREZZA

• è
• VALORE FONDANTE

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un evento infausto sarebbe FATALE per l Impresa
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• La SICUREZZA è VALORE FONDANTE
• del Trasporto Aereo
• E interesse dell Imprenditore che la cultura
  positiva della SICUREZZA si radichi a tutti il
  livelli organizzativi
• La SICUREZZA è un BENE FINANZIARIO
• dell Imprenditore

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• L Operatore necessita della gestione
  sistematica e proattiva dei rischi associati
  alle
• Operazioni Volo
• Operazioni a Terra
• Attività di Engineering Maintenance
• ovvero nacessita di un
• Safety Management System
• da estendere anche alle attività in outsourcing
  (manutenzione, handling, aeroporti)

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SAFETY MANAGEMENT SYSTEM

• Attingiamo dalle norme
• JAR-OPS 1.037 ltltan 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 operationsgtgt
• basato su ICAO Recommended Practice (Annex 6 Pt1)

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SAFETY MANAGEMENT SYSTEM

• normativa Comunitaria e Nazionale
• recepimento della
• Direttiva Comunitaria 2003/42 EC
• Occurrence Reporting in Civil Aviation
• tramite
• Decreto Legislativo n 213/06

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SAFETY MANAGEMENT SYSTEM

• riferiamoci ad una presentazione didattica ICAO
  della tematica SMS

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ICAO SMS Project

• Two basic concepts
• Safety programme An overarching and integrated
  set of provisions
• Safety management system A means for the
  implementation of a safety programme
• Two levels of responsibility for implementation
• State
• Operator (Airline, ATS provider, aerodrome
  operator)

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Worldwide Hull Loss Projection
If current accident rate holds

• Based on Expected Fleet Growth

49
50
Projection
Actuals
41.2
Hull loss projection at current accident rate
40
Annual hull losses
37
Standard deviation
23.6
30
26
25
21
21
21
21
21
21
20.6
20
20
20
20
16
14
Industry goal 50 reduction in accident rate
14
12
11
10
2010
2015
1990
1996
2000
2005
1985
Year
Source Boeing
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Concept of safety (Doc 9859)

• Safety is the state in which the risk of harm to
  persons or property damage is reduced to, and
  maintained at or below, an acceptable level
  through a continuing process of hazard
  identification and risk management.

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The evolution of safety thinking
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Concept of safety

• Consider
• The elimination of accidents (and serious
  incidents) is unachievable.
• Failures will occur, in spite of the most
  accomplished prevention efforts.
• No human endeavour or human-made system can be
  free from risk and error.
• Controlled risk and error is acceptable in an
  inherently safe system.

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A concept of accident causation
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A concept of accident causation
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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
19
The organizational accident
20
The organizational accident
21
The organizational accident
22
The organizational accident
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People and safety

• Aviation workplaces involve complex
  interrelationships among its many components.
• To understand operational performance, we must
  understand how it may be affected by the
  interrelationships among the various components
  of the aviation work places.

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Processes and outcomes
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People and safety SHEL model
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People and safety SHEL model
Hardware
Software

• procedures
• set of rules
• habit

• aircraft - facilities
• tools - work area
• equipment

• Liveware
• build
• cognizance
• capability
• awareness
• stress

Liveware, other persons
Environment

• work group
• communication
• leadership
• behavior

• weather
• organization
• policy
• remuneration

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Operational performance and technology

• In production-intensive industries like aviation,
  technology is essential.
• The operational consequences of the interactions
  between people and technology are often
  overlooked, leading to human error.

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Understanding operational errors

• Human error is considered contributing factor in
  most aviation occurrences.
• Even competent personnel commit errors.
• Errors must be accepted as a normal component of
  any system where humans and technology interact.

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Errors and safety A non linear relationship

• Statistically, millions of operational errors are
  made before a major safety breakdown occurs

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Accident investigation Once in a million flights
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Safety management On almost every flight

• Flaps
• omitted

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Errors and consequences

• Three strategies for the control of human error
• Error reduction strategies intervene at the
  source of the error by reducing or eliminating
  the contributing factors.
• Human-centred design
• Ergonomic factors
• Training

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Errors and consequences

• Three strategies for the control of human error
• Error capturing strategies intervene once the
  error has already been made, capturing the error
  before it generates adverse consequences.
• Checklists
• Task cards
• Flight strips

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Errors and consequences

• Three strategies for the control of human error
• Error tolerance strategies intervene to increase
  the ability of a system to accept errors without
  serious consequence.
• System redundancies
• Structural inspections

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Understanding violations Are we ready?
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Culture

• Culture binds people together as members of
  groups and provides clues as to how to behave in
  both normal and unusual situations.
• Culture influences the values, beliefs and
  behaviours that people share with other members
  of various social groups.

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Three cultures
National

Organizational
Professional
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Three distinct cultures

• National culture encompasses the value system of
  particular nations.
• Organizational/corporate culture differentiates
  the values and behaviours of particular
  organizations (e.g. government vs. private
  organizations).
• Professional culture differentiates the values
  and behaviours of particular professional groups
  (e.g. pilots, air traffic controllers,
  maintenance engineers, aerodrome staff, etc.).
• No human endeavour is culture-free

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Safety culture

• A construct
• An outcome, not a process
• The introduction of safety management concepts
  lays the foundation upon which to build a safety
  culture
• Safety culture cannot be mandated or
  designed, it evolves.
• It is generated top-down

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Three options

• Organizations and the management of information
• Pathological Hide the information
• Bureaucratic Restraint the information
• Generative Value the information

Source Ron Westrum
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Three possible organizational cultures
Source Ron Westrum
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Why SM ? The first ultra-safe industrial system
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The essential is invisible to the eyes
Heinrich ratio
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Navigating the drift
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Strategies Summary
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Strategies Levels of intervention and tools
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The imperative of change

• As global aviation activity and complexity
  continues to grow, traditional methods for
  managing safety risks to an acceptable level
  become less effective and efficient.
• Evolving methods for understanding and managing
  safety risks are necessary.

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Safety management Nine building blocks

• Senior managements commitment to the management
  of safety.
• Effective safety reporting.
• Continuous monitoring through systems to collect,
  analyse, and share safety-related data arising
  from normal operations.

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Safety management Nine building blocks

• Investigation of safety occurrences with the
  objective of identifying systemic safety
  deficiencies rather than assigning blame.
• Sharing safety lessons learned and best practices
  through the active exchange of safety
  information.
• Integration of safety training (including Human
  Factors) for operational personnel.

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Safety management Nine building blocks

• Effective implementation of Standard Operating
  Procedures (SOPs), including the use of
  checklists and briefings.
• Continuous improvement of the overall level of
  safety.
• An organizational culture that fosters safe
  practices, encourages safety communications and
  actively manages safety with the same attention
  to results as financial management.

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Responsibilities for managing safety

• These responsibilities fall into four basic
  areas
• Definition of policies and procedures regarding
  safety.
• Allocation of resources for safety management
  activities.
• Adoption of best industry practices.
• Incorporating regulations governing civil
  aviation safety.

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Two definitions

• Hazard Condition, object or activity with the
  potential of causing injuries to personnel,
  damage to equipment or structures, loss of
  material, or reduction of ability to perform a
  prescribed function.
• Risk The chance of a loss or injury, measured
  in terms of severity and probability. The chance
  that something is going to happen, and the
  consequences if it does.
• A wind of 15 knots blowing directly across the
  runway is a hazard. The possibility that a pilot
  may not be able to control the aircraft during
  take off or landing, resulting in an accident, is
  one risk .

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Examples of hazards
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Examples of hazards
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The focus of hazard identification

• Hazard identification is a wasted effort if
  restricted to the aftermath of rare occurrences
  where there is serious injury, or significant
  damage.

Accidents
1 5
Serious incidents
30 100
Incidents
100 1000
Latent conditions
1000 4000
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In summary

• Hazard an existing condition
• Risk the chance that an event can happen

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Risk assessment at a glance
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Risk probability

• Definition(s)
• Probability The chance that a situation of
  danger might occur.

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Second fundamental Risk probability
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Risk severity

• Definition(s)
• Severity The possible consequences of a
  situation of danger, taking as reference the
  worst foreseeable situation.

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Risk severity

• Define the severity in terms of
• Property
• Health
• Finance
• Liability
• People
• Environment
• Image
• Public confidence

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Third fundamental Risk severity
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Fourth fundamental Risk assessment
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Fourth fundamental Risk tolerability
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Risk management
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Fifth fundamental Risk control/mitigation

• Definition(s)
• Mitigation Measures to eliminate the potential
  hazard or to reduce the risk probability or
  severity.
• Risk mitigation Risk control
• (Mitigate To make milder, less severe or less
  harsh)

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Risk mitigation Defences

• Recalling the three basic defences in aviation
• Technology
• Training
• Regulations

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Risk mitigation at a glance
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Risk management process at a glance
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As of 23 November 2006

• States shall establish a Safety Programme, in
  order to achieve an acceptable level of safety
  in
• The operation of aircraft
• The maintenance of aircraft
• The provision of air traffic services
• Aerodrome operations
• The acceptable level of safety to be achieved
  shall be established by the State(s) concerned

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As of 23 November 2006

• States shall require, as part of their safety
  programme, that an operator, maintenance
  organization, ATS provider, certified aerodrome
  operator implements a Safety Management System
  accepted by the State that, as a minimum
• Identifies safety hazards
• Ensures that remedial action necessary to
  maintain an acceptable level of safety is
  implemented
• Provides for continuous monitoring and regular
  assessment of the safety level achieved
• Aims to make continuous improvement to the
  overall level of safety

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What is the fundamental objective of a business
organization?
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The management dilemma
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Safety programme SMS relationships
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Clarifying the use of terms

• Safety oversight Is what the CAA performs with
  regard to the operators/service providers SMS.
• Safety assurance Is what the operators/service
  providers do with regard to safety performance
  monitoring and measurement
• Safety audit Is what the CAA performs with
  regard to its safety programme and the
  operators/service providers perform with regard
  to the SMS.

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In summary

• Safety The state in which the risk of harm to
  persons or property damage is reduced to, and
  maintained at or below, an acceptable level
  through a continuing process of hazard
  identification and risk management.
• Management Allocation of resources.
• System Organized set of processes and
  procedures.

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The components of SMS

• Safety policy and objectives
• Safety risk management
• Safety assurance
• Safety promotion

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The elements of SMS

• Safety policy and objectives
• 1.1 Management commitment and responsibility
• 1.2 Safety accountabilities of managers
• 1.3 Appointment of key safety personnel
• 1.4 SMS implementation plan
• 1.5 Coordination of the emergency response plan
• 1.6 Documentation
• Safety risk management
• 2.1 Hazard identification processes
• 2.2 Risk assessment and mitigation processes
• 2.3 Internal safety investigations

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The elements of SMS

• Safety assurance
• 3.1 Safety performance monitoring and
  measurement
• 3.2 The management of change
• 3.3 Continuous improvement of the safety
  system
• Safety promotion
• 4.1 Training and education
• 4.2 Safety communication

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Safety responsibilities An example
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SAFETY REVIEW BOARD
Board of Director
ACCOUNTABLE MGR
safety policy
MARKETING COMMERCIALE
AMMINISTRAZIONE FINANZA
FLIGHT OPERATIONS P.H.
MAINTENANCE P.H.
Safety Action Groups
CREW TRAINING P.H.
GROUND OPERATIONS P.H.
QUALITY MGR
SAFETY MGR
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CAMO è di QUALITA ed è SICURA
Accident/incident prevention loop
CAMO P.H. SORVEGLIANZA CONTINUA ESERCIZIO
PIANIFICAZIONE
CONTROLLER
INGEGNERIA
LOGISTICA CONTRATTI
MANUTENZIONE
ACCOUTABLE MGR
SAFETY MGR
QUALITY MGR
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The final objective Integration
Safety programme SMS State integrated safety
management system
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Errors ...
are like mosquitoes
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To fight them
... drain their breeding swamps.
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grazie della vostra attenzione