Slide title

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SMS Systems Cliff Edwards
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OVERVIEW

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

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• 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!

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• 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

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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.
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OVERVIEW

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

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• 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!

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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.

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OVERVIEW

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

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• 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.

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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.

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• 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.

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• 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.

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• 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.

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OVERVIEW

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

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• 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.

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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
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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.

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• 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
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• 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.

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• 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.

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• 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.

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• 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.

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• 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.

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• 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).

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• 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.

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• 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).

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• 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.

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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.

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• 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.

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• 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.

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• 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.

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• 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.

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OVERVIEW

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

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• 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

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OVERVIEW

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

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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.

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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).

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Training
Accountability
Threat
Competencies
HAZARDS
HAZARDS CFIT, Fuel People Unairworthy Aircraft
Physical Barriers
Redundant Systems
Threat
Threat
Procedures
Awareness
Assurance
Threat
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• 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.

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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
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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
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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
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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.
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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.
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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
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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.

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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.

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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.

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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

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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
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EXAMPLE SMS MANAGEMENT OF HUMAN ERROR
Staff competencies checked against profiles
Compliant practices always used
Workplace culture supportive
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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.
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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).