Safety Risk Management Component

1. Policy (Structure) Risk Management Safety Assurance Safety Promotion Federal Aviation Administration SMS Details: Safety Risk Management Component

2. Definitions • Safety management systems provide a systematic way to control risk and to provide assurance that those risk controls are effective. • Safety Risk Management performs the process of controlling risk thru hazard identification, analysis, risk assessment and developing risk controls.

3. Levels of Risk Management • Process Risk Management • Policy (What) • Procedure (How) • Controls • Operational Risk Management • Operational Control (Flight/Task/Mission) • Crew/Team (Real time decision making)

4. System Description Hazard Identification Risk Analysis Risk Assmt Risk Control System Description What is System Description & Task Analysis? • It is a system design function. • It is a predictive method of hazard identification. • It is the foundation for sound safety analysis. When is it used? • Used during implementation phases of SMS. • Used in the development of operational processes. • Used when a new Hazardis identified • Used in conjunction with all operational changes. Who uses System Description & Task Analysis? • Personnel within the organization who form an appropriately diverse team: • Stakeholders • Subject Matter Experts ICAO Doc. 9859

5. System Description Processes Activities Workplace Conditions: e.g, • Equipment • Information (Procedures) • Facilities • Phys. Envir. • Other Proc. (Interfaces) • Training • Supv./Mgmt. (Controls) • …. Hazard Identification System Factors & Attributes Variable Human Performance Risk Analysis Risk Assmt Risk Control SRM System Description Facts

6. Typical Workplace Conditions • Equipment: Human-machine interface, facilities, tools… • Information: Procedures, guidance... • Environment: Physical, cultural… • Training: Formal, OJT, recurrent… • Company/regulator factors: The RULES... Barry Strauch (2004). Investigating Human Error

7. Process(System or Safety) Attributes • Responsibility • Authority • Procedures • Controls • Process Measures • Interfaces

8. External Internal Decision by Organization Previous Process Interface – (I) Process Controls (C) Responsibility(R) Activities (Things People do) • Procedural • Supervision • Assurance • Processes • Accountable for • process output Authority (A) • Empowered to: • Make key decisions • Alter process Inputs Procedures (P) Outputs • Destination – Interface (I) • Deliverable – Performance • Measures (PM) Processes

9. Process Activities Customer Requirements Materials Laws Regulations Standards • People • Employees • Contractors • Organization Training Facilities Equipment Tools • Knowledgeware • Manuals • Job Aids • Software • Environment • Physical • Operational • Cultural Products Services Systems

10. Conditions (Hazards) Related to Human Error • Time pressure • Poor procedures and documentation • Teamwork (Too much, too little) • Shift turnovers/crew briefings • Group norms (Values, culture) • Fatigue management (shifts/circadian problems) Alan Hobbs, ATSB (2008)

11. Conditions (Hazards) Related to Human Error (Cont.) • Lack of System Knowledge • Poor, worn out, missing or equipment/facilities • Human-machine interface (e.g. design for maintainability)

12. Activities and Conditions: Deicing

13. System Description Hazard Identification Risk Analysis Risk Assmt Risk Control Hazard Identification A hazard is any real or potential condition… that can result ininjury, illness, or death to people; damage to, or loss of, a system (hardware or software), equipment, or property; and/or damage to the operating environment. ICAO Doc. 9859

14. System Description Processes Activities Workplace Conditions: e.g. • Equipment • Information (Procedures) • Facilities • Phys. Envir. • Other Proc. (Interfaces) • Training • Supv./Mgmt. (Controls) • …. Hazard Identification System Factors & Attributes Risk Analysis Deficient Conditions impacting activities = Risk Assmt Variable Performance Hazards Causing… Resulting in… Risk Control Active Failures Consequences SRM Hazard Identification from Workplace Conditions Inference

15. System Description Hazard Identification Risk Analysis Risk Assmt Risk Control Risk Analysis • Important to distinguish between: • Hazard – a condition • Consequence – result • Risk – likelihood & severity of the consequence • Analyzing risk involves the consideration of both the likelihood and the severity of any adverse consequences. ICAO Doc. 9859

16. System Description Deficient Conditions impacting activities = Variable Performance Hazards Hazard Identification Causing… Resulting in… Active Failures Consequences Risk Analysis L ikelihood S everity Risk Assmt Risk Risk Risk Control SRM From Hazard to Risk Judgment

17. Failures and Consequences

18. System Description Risk Likelihood Risk Severity Catastrophic A Hazardous B Major C Minor D Negligible E Hazard Identification Frequent 5 5A 5B 5C 5D 5E Occasional 4 4A 4B 4C 4D 4E Risk Analysis Remote 3 3A 3B 3C 3D 3E Improbable 2 2A 2B 2C 2D 2E Risk Assmt Extremely improbable 1 1A 1B 1C 1D 1E Risk Control Risk Assessment Risk assessment determines the level of risk to use in making a bottom line decision. A risk matrix is a tool used for risk assessment. It can vary in form yet it accomplishes the same purpose.

19. System Description Hazard Identification Risk Analysis Risk Assmt Risk Control Risk Control = Risk Mitigation A major component of any safety system is the defenses (controls) put in place to protect people, property or the environment. These defenses are used to reduce the likelihood or severity of the consequences associated with any given hazard or condition. ICAO Doc. 9859

20. System Description Processes Activities Workplace Conditions: e.g. • Equipment • Information (Procedures) • Facilities • Phys. Envir. • Other Proc. (Interfaces) • Training • Supv./Mgmt. (Controls) • …. Hazard Identification System Factors & Attributes Variable Human Performance Risk Analysis Risk Assmt Risk Controls Risk Control Risk Control/Mitigation SRM