Principles and Elements of SMS A Review

1. April 2006 ICAO Seminar Baku Principles and Elements of SMSA Review Patrick Hudson ICAO/Leiden University

2. April 2006 ICAO Seminar Baku Structure Why SMS? The principles Shell�s experience Implementation experience Conclusion

3. April 2006 ICAO Seminar Baku This slide is intended to show that there are various ways of improving safety performance and that tackling technology and standards and safety systems usually comes first, but in order to continuously improve the softer behavioural stuff must be tackled too. This is what constitutes Culture, which addresses the �softer� human issues, but also multiplies the effectiveness of the technology and management systems. This slide is intended to show that there are various ways of improving safety performance and that tackling technology and standards and safety systems usually comes first, but in order to continuously improve the softer behavioural stuff must be tackled too. This is what constitutes Culture, which addresses the �softer� human issues, but also multiplies the effectiveness of the technology and management systems.

4. April 2006 ICAO Seminar Baku Why Safety Management Systems? Safety is a right for customers and staff Poor safety performance is a sensitive indicator of poor operations �If you can�t manage safety, how can you show you can manage anything else?� Safety management systems are about getting systematic about the problems

5. April 2006 ICAO Seminar Baku Safety Management SystemA framework for Safety Management

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7. April 2006 ICAO Seminar Baku Early Safety Management Early safety management was an unstructured mixture of �good things� Progress was based upon response to accidents Measures were outcome based (crashes etc) There were no process definitions (how to do it) Regulations prescribed exactly what to do (what to do) This works very well to start with, but expectations have been raised over the years, now everyone expects that every flight is safe

8. April 2006 ICAO Seminar Baku Types of Certification There are three distinct ways of guaranteeing safety Type I - Classical ICAO/FAA/JAA certification Type II - Safety Cases and SMS Type III - Safety Culture and Good Practice These different approaches are complementary, especially II and III Types I and II are Imagination Limited Can people imagine what might go wrong Type III involves doing The Right Thing anyway

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11. April 2006 ICAO Seminar Baku Why have a Safety Management System? A number of major disasters in the Petrochemical industry Flixborough Seveso Bhopal Nuclear disasters Three Mile Island Chernobyl

12. April 2006 ICAO Seminar Baku Flixborough1 June 1974

13. April 2006 ICAO Seminar Baku SevesoJuly 1976 Understanding safe state to leave reactions Multiple layers of protection Automated Reaction stop systems for exothermic systems

14. April 2006 ICAO Seminar Baku Longford25 September 1998

15. April 2006 ICAO Seminar Baku Piper Alpha 1988 the Piper Alpha platform was destroyed The platform had just been audited by the regulator Lord Cullen�s report set up a new regime Goal Setting ISO 9000 type management systems Safety Case to provide assurance - a documented proof that the SMS is both in operation and effective

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19. April 2006 ICAO Seminar Baku Piper Alpha Cost $1,500,000,000 167 killed Occidental UK went out of business in two years

20. April 2006 ICAO Seminar Baku The Cullen Report Cullen investigated the Piper Alpha disaster Report was published 1990 Requirement made for every offshore facility to have an SMS in place by November 1992 Proof by submission of a safety case If there was no acceptable safety case the operation would be shut down immediately

21. April 2006 ICAO Seminar Baku Shell International�s Approach Shell is the largest operator in the North Sea - SMS was made mandatory Shell decided to get in first rather than wait A considered approach was designed The requirement for SMS was to be made world-wide for all Shell Group companies

22. April 2006 ICAO Seminar Baku Shell�s Approach - don�t do everything Decision to operate in terms of hazards and a limited set of events to avoid Developed the Bow-tie model (next slides) Identification of safety critical activities to provide assurance Getting in first meant that they wouldn�t have to operate a system foreign to their culture

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25. April 2006 ICAO Seminar Baku The Swiss cheese model ofaccident causation (Reason)

26. April 2006 ICAO Seminar Baku SAFETY MANAGEMENTBased on the Reason Model Good understanding of the world in which you operate ditto of the work identify what can go wrong and lead to undesirable outcomes put barriers in place (hard vs soft) assign tasks to people to make barriers and keep them in place people to be competent people require instructions and standards communication essential to inform each other of malfunctioning barriers, so that others can make sure that their barrier remains effective Good understanding of the world in which you operate ditto of the work identify what can go wrong and lead to undesirable outcomes put barriers in place (hard vs soft) assign tasks to people to make barriers and keep them in place people to be competent people require instructions and standards communication essential to inform each other of malfunctioning barriers, so that others can make sure that their barrier remains effective

27. April 2006 ICAO Seminar Baku Safety Management Cycle

28. April 2006 ICAO Seminar Baku Hazard-based approach Construct a generic hazard register Assess which are relevant for a particular operation Use a Business Process Model to identify safety critical processes that allow management of the hazards Construct Bow Ties for control and recovery

29. April 2006 ICAO Seminar Baku HEMP HEMP - Hazard and Effects Management Process Identify - What are the hazards? Assess - how big are those hazards? Control - how do we control the hazards? Recover - what if it still goes wrong?

30. April 2006 ICAO Seminar Baku Bow-tie Concept Explain model Barriers to stop progression from left to right Risk management is about identifying hazards, putting barriers in place and keeping them in place. Barriers can be : hardware, procedures, competence emergency preparedness etc Activities required to achieve this: policy, organisation, standards, improvement loops etc. EXPLAIN VARIOUS DOCUMENTED SYSTEMS: HSE-MS, demonstration of assurance that there is a system to identify barriers and keep them in place HSE-Case, specifying which specific barriers have been put in place, to what specification, who is responsible for keeping it in place, required competency etc. PTW, workplace hazards management system; controlling the Hazards during execution of tasks Most of these elements have been discussed during the previous days. I will concentrate on the various improvement loops and, as many of our activities involve contractors, the management of contractors Explain model Barriers to stop progression from left to right Risk management is about identifying hazards, putting barriers in place and keeping them in place. Barriers can be : hardware, procedures, competence emergency preparedness etc Activities required to achieve this: policy, organisation, standards, improvement loops etc. EXPLAIN VARIOUS DOCUMENTED SYSTEMS: HSE-MS, demonstration of assurance that there is a system to identify barriers and keep them in place HSE-Case, specifying which specific barriers have been put in place, to what specification, who is responsible for keeping it in place, required competency etc. PTW, workplace hazards management system; controlling the Hazards during execution of tasks Most of these elements have been discussed during the previous days. I will concentrate on the various improvement loops and, as many of our activities involve contractors, the management of contractors

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32. April 2006 ICAO Seminar Baku Bow-tie Conceptfor a specific threat Explain model Barriers to stop progression from left to right Risk management is about identifying hazards, putting barriers in place and keeping them in place. Barriers can be : hardware, procedures, competence emergency preparedness etc Activities required to achieve this: policy, organisation, standards, improvement loops etc. EXPLAIN VARIOUS DOCUMENTED SYSTEMS: HSE-MS, demonstration of assurance that there is a system to identify barriers and keep them in place HSE-Case, specifying which specific barriers have been put in place, to what specification, who is responsible for keeping it in place, required competency etc. PTW, workplace hazards management system; controlling the Hazards during execution of tasks Most of these elements have been discussed during the previous days. I will concentrate on the various improvement loops and, as many of our activities involve contractors, the management of contractors Explain model Barriers to stop progression from left to right Risk management is about identifying hazards, putting barriers in place and keeping them in place. Barriers can be : hardware, procedures, competence emergency preparedness etc Activities required to achieve this: policy, organisation, standards, improvement loops etc. EXPLAIN VARIOUS DOCUMENTED SYSTEMS: HSE-MS, demonstration of assurance that there is a system to identify barriers and keep them in place HSE-Case, specifying which specific barriers have been put in place, to what specification, who is responsible for keeping it in place, required competency etc. PTW, workplace hazards management system; controlling the Hazards during execution of tasks Most of these elements have been discussed during the previous days. I will concentrate on the various improvement loops and, as many of our activities involve contractors, the management of contractors

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34. April 2006 ICAO Seminar Baku Hazard Management and Control Bow Ties describe the hazards and the relevant controls Controls are provided by elements in the business processes Top events are a restricted set of unwanted events, not the final outcomes

35. April 2006 ICAO Seminar Baku Bow Ties as Standard The Bow Tie is now the standard for the FAA in the USA There are a number of computer packages for making and maintaining bow ties The information needed can be shared Local differences are easily accommodated

36. April 2006 ICAO Seminar Baku Shell�s HSE MANAGEMENTputting it together Good understanding of the world in which you operate ditto of the work identify what can go wrong and lead to undesirable outcomes put barriers in place (hard vs soft) assign tasks to people to make barriers and keep them in place people to be competent people require instructions and standards communication essential to inform each other of malfunctioning barriers, so that others can make sure that their barrier remains effective Good understanding of the world in which you operate ditto of the work identify what can go wrong and lead to undesirable outcomes put barriers in place (hard vs soft) assign tasks to people to make barriers and keep them in place people to be competent people require instructions and standards communication essential to inform each other of malfunctioning barriers, so that others can make sure that their barrier remains effective

37. April 2006 ICAO Seminar Baku HSE MS �in place�

38. April 2006 ICAO Seminar Baku Advantages of an SMS The SMS provides a structure for measuring in system audits Bow ties provide a structure for operational audits Are the barriers there? Are the barriers intact and in operation Is there sufficient defence- are there single point trajectories where everything relies on a single defence? The analysis of barriers and operations also provides a basis for incident investigation that is consistent with the Reason model

39. April 2006 ICAO Seminar Baku What does it take? Regulators can force implementation, but it is much easier if you want to do it anyway Top management has to be convinced that implementing an SMS is in their interest Shell had to implement in the North Sea, but decided to make SMS obligatory world-wide in view of the benefits to Shell group BP and ExxonMobil have taken exactly the same approach with GHSSER and OIMS You have to do it yourself Hiring consultants can only be as support An off-the-shelf SMS will soon fail

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42. April 2006 ICAO Seminar Baku Conclusion Safety management systems turn safety into a systematic process Development can be done with sharing of information and experience - you don�t compete on safety SMS models can be used to unify management, audit and incident investigation SMS does not guarantee everything - to get ahead you need to develop a safety culture as well - tomorrow

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