Principles and Elements of SMS A Review

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

2. Structure • Why SMS? • The principles • Shell’s experience • Implementation experience • Conclusion ICAO Seminar Baku

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4. 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 ICAO Seminar Baku

5. Security Policy Safety Policy Road Safety Plan Alcohol & Drugs Policy Audit Plans Safety Drills Safety Management SystemA framework for Safety Management Continuous Improvement Policy Mgt. policy Process Safety (HSE Cases) Task Structure No Structure ICAO Seminar Baku

6. A Pacific Southwest Airlines Boeing 727 as it goes down over San Diego, California after a mid-air collision with a Cessna in 1978. One-hundred-thirty-seven people along with 7 on the ground were killed. ICAO Seminar Baku

7. 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 ICAO Seminar Baku

8. 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 ICAO Seminar Baku

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

12. Flixborough1 June 1974 • Modification Control • Use suitably trained, educated and responsible people • Know what you don’t know ICAO Seminar Baku

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

14. Longford25 September 1998 • Training needs to impart and refresh knowledge. • Must identify other hazards and provide relevant training. • Corporate knowledge must be captured and kept alive ICAO Seminar Baku

15. 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 ICAO Seminar Baku

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

20. 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 ICAO Seminar Baku

21. 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 ICAO Seminar Baku

22. 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 ICAO Seminar Baku

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25. The Swiss cheese model ofaccident causation (Reason) Some holes due to active failures Hazards Other holes due to latent conditions Losses Successive layers of defences, barriers, & safeguards ICAO Seminar Baku

26. SAFETY MANAGEMENTBased on the Reason Model World Barriers or Controls Hazard/ Risk Work & Organisation Undesirable outcome ICAO Seminar Baku

27. Safety Management Cycle ICAO Seminar Baku

28. 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 ICAO Seminar Baku

29. 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? ICAO Seminar Baku

30. Bow-tie Concept Events and Circumstances Harm to people and damage to assets or environment BARRIERS HAZARD CONSEQUENCES Undesirable event with potential for harm or damage Engineering activities Maintenance activities ICAO Seminar Baku Operations activities

31. Bow-tie Conceptfor a specific threat Events and Circumstances Harm to people and damage to assets or environment BARRIERS HAZARD CONSEQUENCES Undesirable event with potential for harm or damage Engineering activities Maintenance activities ICAO Seminar Baku Operations activities

32. RISK ASSESSMENT MATRIX Potential Consequence of the Incident Increasing Probability D A B C E Unknown but possible in the aviationindustry Known in aviation industry Happened in this company Happened > 3 x in the Company Happened > 3 x in this location Rating People Env'ment Reputation Assets Zero Effect Zero damage No injury 0 No Impact Slight damage < US$ 10K Slight injury Slight Effect Slight Impact Manage Through Normal HSE-MS procedures 1 Minor damage < US$ 50K Minor injury Minor Effect Local I m p a c t 2 incorporate risk reduction measure Local damage < US$ 250K Serious injury Industry I m p a c t Localised Effect 3 Major damage < US$ 1M Major Effect Single fatality N a t i o n a l I m p a c t Intolerable 4 Extensive damage > US$ 1M Multiple fatality International I m p a c t Massive Effect 5 ICAO Seminar Baku

33. 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 ICAO Seminar Baku

34. 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 ICAO Seminar Baku

35. HSE MS Risk Assessment Matrix THESIS Shell’s HSE MANAGEMENTputting it together Minimum Expectations EP 95-0300 HAZOP/ HAZID EIA/SIA/HRA etc. EP 95000 Series Technical advice Group Guidance Design standards ICAO Seminar Baku

36. HSE MS “in place” Permit to Work System Contract/ Contractor Management Job Hazard Analysis Workplans Hazardous Situation Unsafe Act reporting HSE Self Appraisal Observation techniques Violation Survey Site Visits Trends/ benchmarking HSE Standards & Procedures Incident Investigation (Tripod Beta) Competency Programmes Incident Reporting Audits Reviews ICAO Seminar Baku

37. 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 ICAO Seminar Baku

38. 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 ICAO Seminar Baku

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40. 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 ICAO Seminar Baku

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