Module N° 2 Basic safety management concepts

1. Revision N° 5 ICAO State Safety Programme (SSP) Implementation Course 25/02/10 Module N° 2 Basic safety management concepts

2. SSP – A structured approach Module 8 SSP implementation plan Module 7 SSP training programme Module 4 ICAO SSP framework Module 5 ALoS related to an SSP Module 6 Prescription / Performance Module 2 Basic safety management concepts Module 3 ICAO SARPs related to safety management Module 1Introduction to the SSP implementation course Module 2 Basic safety management concepts

3. Objective • At the end of this module, participants will be able to explain the strengths and weaknesses of long-established approaches to manage safety and describe new perspectives and methods of managing safety by the State

4. Contents • A concept of accident causation • System performance in the real world • Safety management strategies – Levels of intervention and tools • Hazards and safety risks • Safety risk assessment • Questions and answers • Points to remember

5. Concept of safety • Consider (the weaknesses in the notion of perfection) • The elimination of accidents (and serious incidents) is unachievable • Failures will occur, in spite of the most accomplished prevention efforts • No human activity or human-made system can be guaranteed to be absolutely free from hazard and operational errors • Controlled safety risk and controlled error are acceptable in an inherently safe system

6. Concept of safety (Doc 9859) • Safety is the state in which the possibility 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 riskmanagement

7. Safety • Traditional approach – Preventing accidents • Focus on outcomes (causes) • Unsafe acts by operational personnel • Attach blame/punish for failures to “perform safely” • Address identified safety concern exclusively • Regulatory compliance • Identifies: WHAT? WHO? WHEN? • But not always discloses: WHY? HOW?

8. A concept of accident causation Organization People Defences Workplace Management decisions and organizational processes Working conditions Errors and violations Regulations Training Technology Latent conditions trajectory Activities over which any organization has a reasonable degree of directcontrol

9. A concept of accident causation Organization People Defences Workplace Management decisions and organizational processes Working conditions Errors and violations Regulations Training Technology Latent conditions trajectory Factors that directly influence the efficiency of people in aviation workplaces.

10. A concept of accident causation Organization People Defences Workplace Management decisions and organizational processes Working conditions Errors and violations Regulations Training Technology Latent conditions trajectory Actions or inactions by people (pilots, controllers, maintenance engineers, aerodrome staff, etc.) that have an immediate adverse effect.

11. A concept of accident causation Organization People Defences Workplace Management decisions and organizational processes Working conditions Errors and violations Regulations Training Technology Latent conditions trajectory Resources to protect against the risks that organizations involved in production activities generate and must control.

12. A concept of accident causation Organization People Defences Workplace Management decisions and organizational processes Working conditions Errors and violations Regulations Training Technology Latent conditions trajectory Conditions present in the system before the accident, made evident by triggering factors

13. System performance in the real world Baseline performance System design Practical drift Regulations Training Operational deployment Defences Technology Operational performance

14. Managing safety – “Navigating the drift” Baseline performance Practical drift Organization Operational performance Navigational aids Reactive Proactive Predictive

15. Navigational aids • Reactive method • The reactive method responds to the events that already happened, such as incidents and accidents • Proactive method • The proactive method • looks actively for the • identification of • safety risks • through the analysis • of the organization’s • activities Predictive method The predictive method captures system performance as it happens in real-time normal operations to identify potential future problems

16. Strategies – Levels of intervention and tools Safety management levels Middle Low High Predictive Proactive Reactive Reactive FDA Direct observation system Accident and incident reports ASR MOR ASR Surveys Audits Highly efficient Very efficient Efficient Insufficient HAZARDS

17. Three key definitions • Hazard – Condition or object 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 • Consequence – Potential outcome(s) of the hazard • Safety Risk – The assessment, expressed in terms of predicted probability and severity, of the consequence(s) of a hazard taking as reference the worst foreseeable situation

18. Three key definitions • Example • Unclear aerodrome signage is a hazard • A runway incursion is one of the consequences of the hazard • The assessment (quantification) of the consequences of the potential runway incursion expressed in terms of probability and severity is the safety risk

19. Understanding hazards • There is a natural tendency to describe hazards as their consequence(s) • “Unclear aerodrome signage” vs. “runway incursion” • Stating a hazard as consequence(s) • disguises the nature of the hazard • interferes with identifying other important consequences • Well-named hazards • allow to infer the sources or mechanisms of the hazard • allow to evaluate the loss outcome(s)

20. Types of Hazards • Natural • Technical • Economic

21. Examples of natural hazards • Severe weather or climatic events: • E.g.: hurricanes, major winter storms, drought, tornadoes, thunderstorms lightning, and wind shear • Adverse weather conditions: • E.g.: Icing, freezing precipitation, heavy rain, snow, winds, and restrictions to visibility

22. Examples of natural hazards • Geophysical events • E.g.: earthquakes, volcanic eruptions, tsunamis, floods and landslides • Geographical conditions • E.g.: adverse terrain or large bodies of water • Environmental events • E.g.: wildfires, wildlife activity, and insect or pest infestation • Public health events • E.g.: epidemics of influenza or other diseases

23. Examples of technical hazards • Deficiencies regarding • E.g.: aircraft and its components, systems, subsystems and related equipment • E.g.: an organization’s facilities, tools, and related equipment • E.g.: facilities, systems, sub-systems and related equipment that are external to the organization

24. Examples of economic hazards • Major trends related to • Growth • Recession • Cost of material or equipment • Etc.

25. Hazard analysis A ABC of hazard analysis State the generic hazard (Hazard statement) • Airport construction B Identify specific components of the hazard • Construction equipment • Closed taxiways • … C Naturally leading to specific consequence(s) • Aircraft colliding with construction equipment • Aircraft taking wrong taxiway • …

26. Safety risk management • What is it? • The analysisand elimination, and/or mitigation to an acceptable level of the safety risks of the consequences of identified hazards • What is the objective? • A balanced allocation of resources to address all safety risks and viable safety risks control and mitigation • Why is it important? • It is a data-driven approach to safety resources allocation, thus defensible and easier to explain

27. Definitions • Probability • The likelihood that an unsafe event or condition might occur • Severity • The possible effects of an unsafe event or condition, taking as reference the worst foreseeable situation

28. Safety risk probability Probability of occurrence Qualitative definition Meaning Value Frequent Likely to occur many times (has occurred frequently) 5 Occasional Likely to occur some times (has occurred infrequently) 4 Remote Unlikely, but possible to occur (has occurred rarely) 3 Improbable Very unlikely to occur (not known to have occurred) 2 Extremely improbable Almost inconceivable that the event will occur 1

29. Safety risk severity Severity of occurrences Value Meaning Aviation definition • Equipment destroyed • Multiple deaths A Catastrophic • A large reduction in safety margins, physical distress or a • workload such that the operators cannot be relied upon to • perform their tasks accurately or completely • Serious injury • Major equipment damage B Hazardous • A significant reduction in safety margins, a reduction in the • ability of the operators to cope with adverse operating • conditions as a result of increase in workload, or as a result • of conditions impairing their efficiency • Serious incident • Injury to persons C Major • Nuisance • Operating limitations • Use of emergency procedures • Minor incident Minor D Negligible E • Little consequences

30. Safety risk assessment matrix (example)

31. Safety risk tolerability

32. Warm-up exercise N° 02/01 • Scenario • Fuel spill on the apron area surface of approximately 25 m (75 ft) length and 5 m (15 ft) width, produced by an A310 ready to pushback and taxi for departure

33. Warm-up exercise N° 02/01– results 3. Assess the probability of the consequence: • Identify the hazard(s) • 4. Assess the severity of the consequence • 5. Determine the resulting safety risk index • 2. Determine the hazard(s) consequence(s) • 6. Establish the safety risk tolerability

34. Warm-up exercise N° 02/02 • Scenario • It was observed that airline baggage handling personnel generates FO(D) on the aerodrome apron area

35. Warm-up exercise N° 02/02– results 3. Assess the probability of the consequence: • Identify the hazard(s) • 4. Assess the severity of the consequence • 5. Determine the resulting safety risk index • 2. Determine the hazard(s) consequence(s) • 6. Establish the safety risk tolerability

36. Basic safety management concepts Questions and answers

37. Questions and answers • Q: What is the ICAO definition for safety in Doc 9859? • A: ? Slide number:

38. Questions and answers • Q: Explain the three different methods for “navigating the drift” • A: Slide number:

39. Questions and answers • Q: Define safety risk management • A: ? Slide number:

40. Points to remember • The concept of safety • Systems and operational performance in the real world • Levels of intervention and tools for managing safety • Hazard identification • Safety risk management

41. Module N° 2 Basic safety management concepts