TRAINING IN SAFETY MANAGEMENT SYSTEMS

TRAINING IN SAFETY MANAGEMENT SYSTEMS ARAB CIVIL AVIATION CONFERENCE Amman, Jordania 19-23 July 2009 1

Welcome to Safety Management System Workshop 2

Speakers: CHRISTER PRAHL ATM Safety Expert Electronic Engineer Degree in Communication Degree in Networking Pilot (IFR rated) 3

Speakers: MICHAEL NIELS THORSEN ATM Safety Expert Master of Science in Engineering Expert International Cooperation Expert Safety Management Implementation Expert Organisational Structures 4

Round the table Name and Position 5

Agenda for today: 09.00 10.30 10.30 11.00 11.00 12.30 12.30 14.00 14.00 15.00 15.00 15.30 15.30 16.30 16.30 17.00 Registration and Welcome Break ICAO presentation on Safety Management System SES Regulations Lunch The Safety System Break The Safety Management System Wrap - Up 6

General House-Rules Hand-outs will be given in connection with the lesson; CD will come at the end of the course; Questions during the lessons; Active participation is anticipated; Flexible approach, programme can be changed also on request; Turn off cell phone; Please stop the instructors if you don t understand them; 7

Objectives of the workshop Provide participants the knowledge of Safety Management Concept and ICAO Standards and Recommended Practices (SARPs) on safety management in Annexes 6, 11 and 14 and related guidance material AND TO Develop participants knowledge to certify and oversee the implementation of key components of an SMS, in compliance with relevant ICAO SARPs. 8

ICAO - Safety Management System What is Safety? Zero Accidents? Freedom from danger or risks? Error avoidance? Any suggestions? 9

ICAO - Safety Management System According to ICAO Doc 9859: Safety is the state in which the risk to harm the persons or property damages is reduced, and maintained at or below, an acceptable level through a continuing process of hazard identification and risk management. 10

ICAO - Safety Management System A safety management system (SMS) is an organised approach to managing safety, including the necessary organisational structures, accountabilities, policies and procedures. (ICAO Doc 9859 - Safety Management Manual) The objective of a Safety Management System is to provide a structured management approach to control safety risks in operations. Effective safety management must take into account the organisation s specific structures and processes related to safety of operations. 11

Safety Management System Structure and Contents 10: Phased approach to SMS Implementation 8: SMS planning 9: SMS operation 5: Risks 6: SMS regulation 7: Introduction to SMS 1: SMS course introduction 2: Basic safety concepts 3: Introduction to safety management 4: Hazards 12

Safety Management Manual Objectives Objectives of the Safety Management Manual are to provide States: Knowledge of safety management concepts, the ICAO Standards and Recommended Practices (SARPs) on safety management contained in Annexes 1, 6, 8, 11, 13 and 14, and related guidance material; Guidance on how to accept and oversee the implementation of the key components of an SMS in compliance with the relevant ICAO SARPs; Guidance on how to develop and implement an SSP in compliance with the relevant ICAO SARPs. 13

Safety Management Manual Concept SMS/SSP Implementation ICAO SARPS Safety Concepts 14

Generic SMS Requirements ICAO requirements for implementation of SMS are currently applicable to: Air Traffic Service Providers (Annex 11) Aerodrome Operators (Annex 14, Volume 1) Amendment to Annex 1, 6, 11, 13 and 14 are proposed in order to harmonise and extend provisions relating to safety management. 15

SES Regulation - Objectives The second SES package has been put forward by the European Commission in order to make the European sky safer and more sustainable by: Introducing a performance framework for European ATM with quantified target setting; Creating a single safety framework to enable harmonised development of safety regulations and their effective implementation; Opening the door to new technologies enabling the implementation of new operational concept and increasing safety levels by a factor of ten; Improving management of airport capacity. 16

The 1st SES legislative package The legislative package adopted in 2004 comprises four base regulations, which reinforce safety and foster the restructuring of European airspace and air navigation services. The regulations provide the framework for the creation of additional capacity and for improved efficiency and interoperability of ATM system in Europe. The Framework regulation (EC No 549/2004) - laying down the framework for the creation of the single European sky; The Service provision regulation (EC No 550/2004) - laying down common requirements for the provision of air navigation services; The Airspace regulation (EC No 551/2004) - on the organisation and use of airspace in the Single European sky; The Interoperability regulation (EC No 552/2004) - on the interoperability of the European Air Traffic Management network. 17

(EC) No 549/2004 - Framework The objective of the Framework regulation is to enhance current safety standards and overall efficiency of the general air traffic in Europe, to optimise ATM system capacity and minimise air traffic delays by establishing a harmonised regulatory framework for air traffic management in Europe. The Framework regulation establishes harmonised institutional, regulatory and consultation arrangements to enable the creation of the Single European Sky. In brief these are: National Supervisory Authorities (NSA) Single Sky Committee Military Issues Industry Consultation Body Implementing Rules Performance Review Safeguards 18

(EC) No 550/2004 Provision of Air Navigation Services in SES The Service provision regulation establishes common requirements to ensure that air navigation services are provided safely and efficiently, on a continuous and interoperable basis, throughout the European Community. It introduces a harmonised system of certification and lays down rules for designating service providers. The stipulations of this regulation apply to the provision of air navigation services to General Air Traffic (GAT) and can be summarised as follows: National Supervisory Authorities (NSA) Licensing of Controllers Common Requirements Certification of Air Navigation Service Providers (ANSPs) Designation of Air Traffic Service Providers Relations between Service Providers Transparency of Accounts Access to and Protection of Data Charging Schemes 19

(EC) No 551/2004 Organisation and use of Airspace in SES The objective of the Airspace regulation is to put an end to the fragmentation of European Union (EU) airspace and to create an efficient and safe airspace without frontiers. The organisation and management of airspace should be improved by merging all the national flight information regions (FIRs) into a single portion of airspace within which ATS will be provided according to the same rules and procedures. The Airspace regulation forms part of the first package of legislation on air traffic management designed to create a SES. This objective will make for improved safety, optimum use of European airspace, reduced air traffic delays and sustainable air transport growth. The following is summarising this regulation: Establishment of European Upper Flight Information Region (EUIR) Reconfiguration of Upper Airspace Optimised Route and Sector Design in the Upper Airspace Flexible Use of Airspace Safeguards 20

(EC) No 552/2004 Interoperability of the European ATM Network The aim of the Interoperability regulation is two-fold: To achieve interoperability between the different systems, constituents and associated procedures in the European ATM network by establishing a harmonised system for certification of components and systems; To ensure the introduction of new agreed and validated concepts of operations and technology in air traffic management. The following topics summarise the Interoperability regulation: Essential Requirements Implementing Rules for Interoperability Community Specifications EC Declaration of Conformity of Suitability for Use of Components Safeguards Transitional Arrangements 21

The SES Implementation Implementing the provision of the SES regulations would bring a number of significant benefits: Improved level of safety of air navigation services; A more effective and integrated air traffic management architecture; Demand driven air navigation service provision; Enhanced cross-boarder co-ordination; Improved decision-making and enhanced enforcement in ATM. 22

Regulations, Directive and Implementing Rules Regulations: Mandatory to the letter Directives: Mandatory with National exemptions Implementing Rules: Guidelines 23

The 1st SES legislative package The First Report on the implementation of the Single Sky Legislation was published in December 2007. It presents: the achievements, identifies new challenges proposes the way forward. Based on the report findings, the Commission came forward with proposals for a 2nd Single Sky package, including extension of EASA competencies to ATM and adoption of the European ATM Master Plan. 24

The 2nd SES legislative package To tackle issues such as traffic increase, financial burden and environmental awareness, the Commission has come up with 2 nd SES legislative package aimed to: Create a single safety framework to enable harmonised development of safety regulations and their effective implementation; Improve the performance of the ATM system through setting of targets; Open the door to new technologies enabling the implementation of new operational concept and increasing safety levels by a factor of ten; Improve management of airport capacity 25

(EC) No 2096/2005 Common Requirements for the Provision of Air Navigation Services The objective of this Regulation is to establish common requirements for the safe and efficient provision of air navigation services in the European Community and to set uniform and high safety standards for ANSPs. The common requirements cover the following areas: Technical and operational competence and capability Organisational structure and management Safety and quality management Security Human resources Financial strength Liability and insurance cover Quality of services Reporting requirements The common requirements do not cover military operations and training and do not apply to activities or resources allocated to activities outside the provision of air navigation services. 26

(EC) No 2096/2005 Common Requirements for the Provision of Air Navigation Services The Regulation identifies and adopts the mandatory provisions of the following EUROCONTROL Safety Regulatory Requirements (ESARRs) which are relevant for the certification of air navigation service providers: ESARR3 - on the use of safety management systems by air traffic management (ATM) service providers; ESARR4 - on risk assessment and mitigation in ATM; ESARR5 - on ATM services' personnel, in particular the requirements for engineering and technical personnel undertaking operational safety related tasks. The detailed requirements relating to safety of services are contained in Annex II to the Regulation. 27

(EC) No 2096/2005 Common Requirements for the Provision of Air Navigation Services Subjects summarising (EC) No 2096/2005 are as follows: Certification of ANSPs Derogations Demonstration of Compliance Compliance Monitoring Peer Review of NSAs 28

Similarities and Differences between ICAO and SES ICAO Methodology 29 What can we do about it? What can go wrong? Step 7: Documentation Step 6: Risk Mitigation Step 5: System Description Step 4: Likelihood Assessment Step 3: Severity Assessment Step 2: Hazard Identification Step 1: System Description Step 0: Planning EUROCONTROL Methodology (ESARR) System Safety Assessment (SSA) Preliminary System Safety Assessment (PSSA) Functional Hazard Assessment (FHA)

ICAO Safety Regulation ICAO Annex 11 Paragraph- 2.26 ATS Safety Management includes relevant requirements related to ATS Para 2.26.1 requires the States to implements systematic and appropriate Safety Management Programmes, further detailed in Para 2.26.4 Para 2.26.2, requires States to establish the acceptable level of safety and safety objectives applicable to the provision of ATS within their airspace and at their aerodromes with acceptable level of safety further detailed in 2.26.3 30

ICAO Provisions Para 2.26.5 requires that any significant safety-related change to the ATC system shall only be implemented after a safety assessment has demonstrated that an acceptable level of safety will be maintained. Para 2.26.5 also requires that the responsible authorities shall provide for post-implementation monitoring to verify that the defined levels of safety continues to be met 31

ICAO Provisions PANS-ATM doc.4444 includes in Chapter 2 requirements for: ATS maintaining acceptable level of safety (section 2.1) Implementation of systematic Safety Management Programmes (section 2.1) ATS Safety Management Activities (section 2.3) Monitoring of Safety Levels (section 2.4) Safety Reviews (section 2.5) Safety Assessments (section 2.6) Safety-enhancing measures (section 2.7) 32

ICAO Provisions PANS-ATM Doc 4444 clarifies a significant safety-related change as (examples): A new operating procedure, including departure and arrival procedures, to be applied within an airspace or at an aerodrome; A reorganization of the ATS route structure; A resectorisation of an airspace; Physical changes to the layout of runways and /or taxiways at an aerodrome; and Implementation of new communications, surveillance or other safetysignificant systems and equipment, including those providing new functionality and or capabilities. 33

Safety Management Manual The new Manual on Safety Management for Aerodromes and Air Traffic Services (Doc 9859) Provides detailed guidance on implementation of the provisions of Annexes 6, 11, 14 and the PANS-ATM First Draft was endorsed by 11th Air Navigation Conference (Montreal, Sep/Oct 2003) Current version in ICAO NET web Based on the same approach to safety as recommended by the ATM Operational Concept (Doc 9854) 34

The Concept of Safety Management Safety Culture Safety Monitoring Philosophy Of Safety Management Safety Policy Safety Assessment Safety Auditing Maintenance of Improvement of Safety Performance Safety Promotion Supporting Organisational Requirement Safety Management 35

Legal and Regulatory Foundation for Safety Management Implementation of safety management programs refers to the day to day keep safety oversight management by the service providers States shall establish systemic and suitable ATS safety management programs with defined levels and objectives (PANS-ATM, in force since November 2003) The acceptable level of safety shall be established by the States. As appropriate, the target levels of safety (TLS) will be established through regional air navigation agreements. Prior to any significant change to the safety-related ATC system, a safety assessment will be carried out, proving that an acceptable safety level may be obtained SMS includes the establishment of runway safety programs. 36

The Safety System Global Safety System Organizational structure - Staffing, documentation, resources and leadership commitment must be sufficient to support the desired process. Planning - Strategic planning and development of appropriate activities must be based on systematic and comprehensive assessment of risks. Management personnel standards - Safety must be integrated into line and operating management responsibilities, and their roles must be clearly defined in written standards of performance. Training for operations and emergencies Procedures - The organization must develop written procedures for design, operations and maintenance activities to control routine work and probable emergencies. Management of change Mechanical integrity - The organization must establish systematic and comprehensive means to assess the integrity of process equipment. Management of contractors - Safety must be a prominent consideration in the selection of contractors, and appropriate means to monitor the work of contractors must be in place and working. Involvement of the work force Accident/incident reporting, investigation and follow-up - Monitoring and auditing methods must be in place to monitor the on-going, day-to-day performance of the safety system, as well as to audit thoroughly compliance to all requirements on a periodic basis. 37

Global Safety System Documentation: AD Technical Implementing Rules Guidance Material Acceptance Means of Compliance Notices of proposal amendments ICAO EASA EUROCONTROL EC Guidelines Regulations Requirements, EU OPS Recommendations Legislation States Ministries CAA Service Providers National Legislation NSA Manuals Working Procedures Documentation Aviation Law Airport Law Regulations Standards 38

Global Safety System Organisation: The world global Safety System consist of all the existing safety management systems on all levels in all the areas of aviation like the service providers, the airspace users, the maintenance organisations etc. 39

Global Safety System Supporting Issues: Auditing Inspections 40

Global Safety System Security: Improved security of ATM systems and information Provides assistance and information In Flight Emergency Response ICAO Annex 17 41

Global Safety System Security: Until the events of 11 September 2001, the ICAO model was regarded as adequate and sufficient to ensure the safety of passengers, aircraft and goods. However, in December 2001 the ICAO adopted an Amendment 10 to Annex 17, which set out a number of additional safety and security requirements. These include the following: 1. Aircraft security check 2. Background check 3. Screening 4. Application of Security 5. Security Restricted Areas 6. Objectives 7. International cooperation 8. National Organization and appropriate authority 9. Airport Operations 10. Quality Control Programme 11. In-flight aircraft security measures 42

Global Safety System Security: ICAO Security Concept: National Civil Aviation Security Program National Aviation Security Committee Airport Security Program Operator Security Programs Quality Control Program National Training Program Authority Contingency Plan Airport Security Committee Airport Emergency Plan 43

Global Safety System Quality Definitions: Quality the totality of features and characteristics of a product or service that bear on its ability to satisfy a given need. Quality Policy the overall quality intentions and direction of an organisation as regards quality, as formally expressed by top management. Quality Management that aspect of the overall management function that determines and implements the quality policy. Quality System the organisational structure, responsibilities, procedures, processes and resources for implementing quality management. Total Quality Management a management approach of an organisation centred on quality, based on the participation of all its members and aimed at long term success through customer satisfaction and benefits to the members of the organisation and society. Quality Assurance the activities an organisation carries out to provide to external and internal parties confidence that the organisation will consistently meet the requirements for quality. 44

Global Safety System Quality: Airport Quality Process: Evaluation of user needs and expectations Design and implementation of service Operation and achievement of service Measurement of quality of service Evaluation and Corrective action 45

Global Safety System Quality Definitions: Airport Quality Elements: Safety Security Efficiency Service Capacity Environment Health 46

Global Safety System Quality: The implementation of QMS, completed in March 2002, included data and product quality assurance and control processes. These processes drew on the following existing resources: day-to-day consistency checking systems for both data and products, forecast verification system developed in 2000 which gave for each forecast a score relative to the ICAO desirable accuracy for each of the weather elements. The QMS also included on-going review processes for continual improvement and for the provision of adequate resources to sustain the QMS. Further, as important components of the QMS, customer needs assessment and satisfaction survey became an institutionalized part of the system. 47

Global Safety System Safety: As stated before: The world global Safety System consist of all the existing safety management systems on all levels in all the areas of aviation like the service providers, the airspace users, the maintenance organisations etc. 48

Global Safety System Safety Versus Quality and Security: It is accurate to say that SMS and QMS share many commonalities. They both: a) have to be planned and managed; b) depend upon measurement and monitoring; c) involve every function, process and person in the organization; and d) strive for continuous improvement. SMS differs from QMS in the following way: a) SMS focuses on the safety, human and organizational aspects of an organization (i.e. safety satisfaction); while b) QMS focuses on the products and services of an organization (i.e. customer satisfaction). 49

Safety Management System Safety The state in which the risk 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 risk management. Management Allocation of resources. System Organized set of processes and procedures. SMS An organised set of processes and procedures, based upon a principled allocation of resources, that allows the control of safety risks to an acceptable level 50

The Safety Management System What is SMS? A system for managing safety as part of the overall management objective and policy; Why SMS? To regulate airport operations and improve safety levels, especially in areas not covered by applicable ICAO or applicable national standards and regulations; How? Existence of comprehensive technical Standards/specifications, a safety management policy, their implementation and maintenance at all times. 51

The Safety Management System SMS Tool-box: The scope of SMS encompasses most of the activities of the organization. SMS must start from senior management, and safety must be considered at all levels of the organization. SMS aims to make continuous improvement to the overall level of safety. All aviation stakeholders have a role to play in SMS. 52

The Safety Management System The components of SMS: 1) Safety policy and objectives 2) Safety risk management 3) Safety assurance 4) Safety promotion 53

The Safety Management System SMS at glance: Safety Safety Policy and Objectives Safety Assurance Management Commitment Safety Risk Management Safety Promotion Effectiveness Efficiency Aviation Community Stakeholders 54

The Safety Management System The Elements of SMS: Safety policy and objectives Management commitment and responsibility Safety accountabilities of managers Appointment of key safety personnel SMS implementation plan Coordination of emergency response planning Documentation 55

The Safety Management System The Elements of SMS: Safety risk management Hazard identification processes Risk assessment and mitigation processes Safety assurance Safety performance monitoring and measurement The management of change Continuous improvement of the SMS Safety Promotion: Training and Education Safety Communication 56

Safety Risk Management What is Risk Management? The identification, analysis and elimination, and/or mitigation to an acceptable level of risks that threaten the capabilities of an organization. What is the objective of Risk Management? Aims at a balanced allocation of resources to address all risks and viable risk control and mitigation. Why is Risk Management important? A key component of safety management systems. Data-driven approach to safety resources allocation, thus defensible and easier to explain. 57

Safety Risk Management Four steps for hazard identification process: 1. Reporting hazards, events or safety concerns. 2. Collecting and storing the data. 3. Analyzing reports. 4. Distributing the information distilled from the analysis. 58

Safety Risk Management Risk Assessment and Mitigation Process Risk Assessment: Regularly Commitments Documentation Mitigation: Measures to address the potential hazard or to reduce the risk probability or severity. Risk mitigation = Risk control 59

Risk Management System Risk Management at glance: Hazard Identification Risk Analysis Probability Risk Analysis Severity Risk Assessment and Tolerability Risk Control/Mitigation Equipment, Procedures, Organisation, etc Analyse the likelihood of the consequence occurring Evaluate the seriousness of the consequence if it occurred Is the risk assessed acceptable and within the organisational safety performance criteria Yes, Accept the risk No, take action in order to reduce the risk to an acceptable level 60

Risk Management System Risk Mitigation at glance: Hazard identification and Risk Assessment Assessment of the defences within the safety system Control and Mitigation of the risks Accepting the mitigations of the risk(s) H H H H Each Consequence Technology Training Regulations Intolerable Region Tolerable Region Acceptable Region Does it address the risk(s)? Is it effective? Is it appropriate? Is additional mitigation warranted? Do the mitigations Strategies generate additional risks? Etc R R R R Each Risk Feedback safety assurance 61

Risk Management Assessment There is no such thing as absolute safety In aviation it is not possible to eliminate all risks. Risks can be managed to a level as low as reasonably practicable (ALARP) Risk mitigation must be balanced against: Time Cost Difficulty of taking measures to reduce or eliminate the risk (i.e. managed). Effective risk management seeks to maximize the benefits of accepting a risk (a reduction in time and cost) while minimizing the risk itself. Communicate the rationale for risk decisions to gain acceptance by stakeholders affected by them. 62

Safety Assurance Safety Assurance is built upon the following: Safety performance monitoring and measurement The management of change Continuous improvement of the SMS 63

Safety Assurance Safety performance monitoring and measurement The process by which the safety performance of the organization is verified in comparison to the approved safety policies and objectives. Safety reporting Safety studies Safety reviews Audits Surveys Internal safety investigations 64

Safety Assurance Safety Audits are used to ensure that the structure of the SMS is sound in terms of: Levels of staff; Compliance with approved procedures and instructions; Level of competency and training to: Operate equipment and facilities; and Maintain their levels of performance. Safety surveys examine particular elements or processes of a specific operation. Problem areas or bottlenecks in daily operations. Perceptions and opinions of operational personnel. Areas of dissent or confusion. Check list Questionnaires Informal confidential interviews 65

Safety Assurance Internal safety investigations include occurrences or events that are not required to be investigated or reported to State. In-flight turbulence (flight operations) Frequency congestion (ATC) Material failure (maintenance) Ramp vehicle operations (aerodrome) 66

Safety Information Sources The protection of safety information from inappropriate use is essential to ensure its continued availability in future, since the use of safety information for other than safety-related purposes may reduce the availability of such information, with an undesirable effect on safety. During the 35th Assembly of ICAO, it was noted that existing national laws and regulations in many States may not address adequately the protection of safety information from inappropriate use. Following the Assembly, ICAO has produced a legal guidance for the protection of information from SDCPS and it is included in Attachment E to Annex 13. 67

Annex 13 General Principles The sole purpose of protecting safety information from inappropriate use is to ensure its continued availability so that proper and timely preventive actions can be taken and aviation safety improved. It is not the purpose of protecting safety information to interfere with the proper administration of justice in States. National laws and regulations protecting safety information should ensure that a balance is struck between the need for the protection of safety information in order to improve aviation safety, and the need for the proper administration of justice. National laws and regulations protecting safety information should prevent its inappropriate use. Providing protection to qualified safety information under specified conditions is part of a State s safety responsibilities. Principles of Protection Safety information should qualify for protection from inappropriate use according to specified conditions that should include, but not necessarily be limited to: the collection of information was for explicit safety purposes and the disclosure of the information would inhibit its continued availability. The protection should be specific for each SDCPS, based upon the nature of the safety information it contains. A formal procedure should be established to provide protection to qualified safety information, in accordance with specified conditions. Safety information should not be used in a way different from the purposes for which it was collected. The use of safety information in disciplinary, civil, administrative and criminal proceedings should be carried out only under suitable safeguards provided by national law. 68

Annex 13 Principles of Exception Exceptions to the protection of safety information should only be granted by national laws and regulations when: There is evidence that the occurrence was caused by an act considered, in accordance with the law, to be conduct with intent to cause damage, or conduct with knowledge that damage would probably result, equivalent to reckless conduct, gross negligence or wilful misconduct; An appropriate authority considers that circumstances reasonably indicate that the occurrence may have been caused by conduct with intent to cause damage, or conduct with knowledge that damage would probably result, equivalent to reckless conduct, gross negligence or wilful misconduct; A review by an appropriate authority determines that the release of the safety information is necessary for the proper administration of justice, and that its release outweighs the adverse domestic and international impact such release may have on the future availability of safety information. Public Disclosure Subject to the principles of protection and exception outlined above, any person seeking disclosure of safety information should justify its release. Formal criteria for disclosure of safety information should be established and should include, but not necessarily be limited to, the following: Disclosure of the safety information is necessary to correct conditions that compromise safety and/or to change policies and regulations; Disclosure of the safety information does not inhibit its future availability in order to improve safety; Disclosure of relevant personal information included in the safety information complies with applicable privacy laws; Disclosure of the safety information is made in a de-identified, summarized or aggregate form. 69

Annex 13 Responsibility of the Custodian of Safety Information Each SDCPS should have a designated custodian. It is the responsibility of the custodian of safety information to apply all possible protection regarding the disclosure of the information, unless: The custodian of the safety information has the consent of the originator of the information for disclosure; or The custodian of the safety information is satisfied that the release of the safety information is in accordance with the principles of exception. Protection of Recorded Information Considering that ambient workplace recordings required by legislation, such as cockpit voice recorders (CVRs), may be perceived as constituting an invasion of privacy for operational personnel that other professions are not exposed to: Subject to the principles of protection and exception above, national laws and regulations should consider ambient workplace recordings required by legislation as privileged protected information, i.e. information deserving enhanced protection; and National laws and regulations should provide specific measures of protection to such recordings as to their confidentiality and access by the public. Such specific measures of protection of workplace recordings required by legislation may include the issuance of orders of non-public disclosure. 70

Change Management Process Aviation organizations experience permanent change due to expansion, introduction of new equipment or procedures. Changes can have the following output: Introduce new hazards. Impact the appropriateness of risk mitigation. Impact the effectiveness of risk mitigation 71

Change Management Process Mentioned Changes can be: External changes Change of regulatory requirements. Security. Reorganization of air traffic control Internal changes Management changes New equipment. New procedures 72

Change Management Process A formal management of change process should: identify changes within the organization which may affect established processes and services. prior to implementing changes describe the arrangements to ensure safety performance. 73

Improvement Process Continuing improvement aims at: Determining the immediate causes of below standard performance and their implications in the operation of the SMS. Rectifying situations involving below standard performance identified through safety assurance activities 74

Improvement Process The mentioned improvements are achieved through: Proactive evaluation of facilities, equipment, documentation and procedures through audits and surveys. Proactive evaluation of the individuals performance, to verify the fulfilment of their safety responsibilities. Reactive evaluations in order to verify the effectiveness of the system for control and mitigation of risks, for example: accidents, incidents and major events investigations 75

Safety Promotion Training and Education Who? Operational personnel Managers and supervisors Senior managers Accountable executive Why? To ensure that personnel are trained and competent to perform the SMS duties. How much? Appropriate to the individual s involvement in the SMS. 76

Safety Promotion Training and Education A building block approach: Operational personnel Organization safety policy SMS fundamentals and overview Managers and supervisors The safety process Hazard identification and risk management The management of change Senior managers Organizational safety standards and national regulations Safety assurance 77

Safety Promotion Safety Communication Safety communication aims to: Ensure that all staff are fully aware of the SMS. Convey safety critical information. Explain why particular actions are taken. Explain why safety procedures are introduced or changed. Convey nice-to-know information. 78

Safety Promotion Safety Communication The means to communicate may include: Safety policies and procedures News letters Bulletins Website Safety communication is an essential foundation for the development and maintenance of a positive culture. 79

Maintenance Internal Evaluation Process Management commitment Just culture Established processes 80

Maintenance Internal Audit Process An annual audit program should include: Definition of the audits, in terms of; criteria, scope, frequency, and methods; Description of the processes used to select the auditors; The requirement that individuals shall not audit their own work; Documented procedures for assignment of responsibilities, planning and conduct of audits, reporting results and maintaining records; Audits of contractors and vendors. 81

Maintenance External Audit Process Surveillance and compliance the authority needs to ensure that international, national and local standards are complied with prior to issuing any licence or approval and continue to be complied with afterwards; Areas and degree of risk the audit should assess how risks are identified and how any necessary changes are made to ensure that all safety standards are met; Competence the audited organisation should have adequately trained staff for all safety related positions Safety management ensure that the organisation s SMS is based on sound principles and procedures, and that the organisation is meeting its safety performance targets. 82

Maintenance Proactive and Reactive Evaluations Proactive before something has happened Taking actions Mitigate Training Reactive after something has happened Investigate why it is as it is Make improvements 83

Organisation Cultural Levels of the organisation The characteristics of a good company safety culture include: Informed - Managers know what is really going on and workforce is willing to report their own errors and near misses Wary - ready for the unexpected Just - a no blame culture, with a clear line between the acceptable and unacceptable Flexible - operates according to need Learning - willing to adapt and implement necessary reforms 84

Organisation The values of an Organisation: The safety management organisation is defining responsibilities, competence, commitment and communication of the involved organisations or persons. The culture is expressed by all parts of the organisation Flight deck Cabin crew Maintenance Ground staff The cabin staff and check-in personnel provide the main indication of the culture to the paying public 85

Organisation Top-down Managers Managers influencing and motivating all actors to take responsibility for their work and taking into account the safety. Flight Crew Engineers (Maintenance) Ground Staff (Luggage Personnel) 86

Procedures Safety Programme Safety Programme is an integrated set of regulations and activities aimed at improving safety. States are responsible for establishing a safety programme, encompassing the following responsibilities: Safety regulation Safety oversight Accident/incident investigation Mandatory/voluntary reporting systems Safety data analysis and exchange Safety assurance Safety promotion 87

State Safety Programme - SSP Service Providers State States shall establish a State safety programme (SSP), in order to achieve an acceptable level of safety (ALoS) in civil aviation. Acceptable level of safety (ALoS) to be achieved shall be established by the State. States shall require as part of their State Safety Programme (SSP) that a Service Providers implement Safety Management System acceptable to the State that as minimum: identifies safety hazards; ensures the implementation of remedial action necessary to maintain agreed safety performance. provides for continuing monitoring and regular assessment of the safety performance; and aims at a continuous improvement of the overall performance of the SMS. 88

Procedures State s safety programme Develop the State s safety programme around the following four components: 1. State s safety policy and objectives 2. State s safety risk management 3. State s safety assurance 4. State s safety promotion 89

Procedures Differences between State and Service Providers Legal considerations States Establishing acceptable level(s) of safety does not replace legal, regulatory, or other already established requirements, but it must support compliance with them. Establishing acceptable level(s) of safety for their safety programme leaves unaffected the obligations of States, and does not relieve States from compliance with SARPs Operators and service providers Establishing acceptable level(s) of safety for their safety management system leaves unaffected the obligations of operators or services providers and other related parties, and it does not relieve the operator, services providers and other related parties from compliance with SARPs and/or national regulations, as applicable. 90

Procedures State s safety programme + Service providers SMS = Integrated safety system Objective: Public Safety State Safety Programme Oversight Acceptance Oversight Objective: Objective: Manage and control safety risks Organisation s Safety Management System (SMS) Risk Management Safety Assurance Organisation s Production Processes Achieve commercial goals and customer saftisfaction 91

Safety Policy Safety Policy - A statement of the organisation s fundamental approach to achieve acceptable or tolerable safety. A written document that describes the generic principles upon which the SMS is build and operated upon. A typical safety policy document would consist of a policy statement that is further expanded by a number of basic safety management principles to be followed: commitment to safety, safety priority, safety responsibility, planning for safety, safety management, safety standards, safety achievement, safety assurance and safety promotion 92

Risk Management Risk management - The identification, analysis and elimination (and/or mitigation to an acceptable or tolerable level) of those hazards, as well as the subsequent risks, that threaten the viability of an organisation. Risk Management consists of the following three elements: Hazard identification Risk assessment Risk mitigation 93

Risk Management System Risk Management at glance: Hazard Identification Risk Analysis Probability Risk Analysis Severity Risk Assessment and Tolerability Risk Control/Mitigation Equipment, Procedures, Organisation, etc Analyse the likelihood of the consequence occurring Evaluate the seriousness of the consequence if it occurred Is the risk assessed acceptable and within the organisational safety performance criteria Yes, Accept the risk No, take action in order to reduce the risk to an acceptable level 94

Safety Assurance Safety assurance - all planned and systematic actions necessary to afford adequate confidence that a product, a service, an organisation or a functional system achieves acceptable or tolerable safety The objectives of Safety Assurance is to implement dedicated surveillance and documenting procedures and processes in order to ensure that risk are being properly managed. According to ICAO State Letter SA include the following activities: Safety performance monitoring and measurement Management of change Continuous improvement of the SMS 95

Safety Assurance Safety Assurance components: Safety Surveys Safety Monitoring Safety Records Regulators should continuously evaluate the implemented safety management arrangements and processes by aviation service providers by means of external regulatory safety auditing and other safety oversight methodologies. 96

Safety Promotion Just culture Key Performance Indicators Processes 97

Thank You for you attention today Any Questions? See You tomorrow 98

Agenda for today: 09.00 10.30 10.30 11.00 11.00 12.30 Managing Safety Break WS on Safety Culture 12.30 14.00 14.00 15.00 15.00 15.30 15.30 16.30 16.30 17.00 Lunch The Safety Components Break Joint session/discussions Wrap up Evaluation Hand over of Diploma 99

Managing Safety Safety Responsibility and accountability Safety responsibility: the obligation to carry forward an assigned safety related task to its successful conclusion. With responsibility goes authority to direct and take the necessary action to ensure success. Safety accountability: the obligation to demonstrate the task achievement and take responsibility for the safety performance in accordance with agreed expectations. Accountability is the obligation to answer for an action. Clear and correctly allocated safety accountabilities and responsibilities are prerequisite for achieving the organisation s safety objectives and for implementing an effective safety management and safety improvement process 100

Safety Manager (SM) An individual, responsible for the development, operation and continuous improvement of the safety management system deployed by an operator/service provider. He acts as a focal point for safety management issues in the organisation. The approach to the assignment of Safety manager s responsibilities may differ depending on the type, size of the organisation, its mission, complexity of operations and operating environment. 101

Safety Manager s Responsibilities The appointment of the Safety manager (SM) is an essential step in the establishment of the SMS organisational structure and a prerequisite for an efficient safety planning process. Irrespectively of any other duties that may be allocated to them, safety managers have the responsibility to: Promote safety awareness within the organisation; Ensure that safety management has the same or higher priority level throughout organisation as any other management and operational processes; Manage all aspects of the organisation s SMS, including: Monitoring the effectiveness of SMS; Initiating corrective actions when necessary; Providing safety reports on SMS performance on periodic basis; Providing safety advice to top management and proposing corrective actions on safety related-issues as needed; Ensuring that safety-related documentation and records are available and up-todate. 102

Safety Levels and Targets The term "acceptable risk" describes an event with a probability of occurrence and consequences acceptable to the society, i.e. the society is willing to take or be subjected to the risk that the event might bring. It is the role of the safety regulatory authorities to translate the society expectations and perceptions into a qualitative or quantitative target level of safety. Definition: The acceptable level of safety expresses the safety goals of an oversight authority, an operator, or a services provider. From the perspective of the relationship between oversight authorities and operators/services providers, it provides the minimum safety objective(s) acceptable to the oversight authority to be achieved by the operators/services providers while conducting their core business functions. 103

Safety Performance Targets Safety performance targets define the required level of safety performance of a system. A safety performance target comprises one or more safety performance indicators, together with desired outcomes expressed in terms of those indicators. Safety Targets can be presented in either: Absolute (i.e. less than 1 fatal accident per 1 000 000 operating hours) Relative Terms 104

Safety Indicators Definition on Safety Performance Indicators: A measure (or metric) used to express the level of safety performance achieved in a system. Enable the organisation to measure and demonstrate the achievement of the set target levels. Safety indicators differ among the various sectors of the aviation industry such as; air navigation services provision, airline operations and aerodrome operations 105

Safety Levels The relationship between acceptable level of safety, safety performance targets and safety performance indicators, and safety requirements is as follows: acceptable level of safety is the overarching concept; safety performance targets are the quantified objectives pertinent to the acceptable level of safety; safety performance indicators are the measures/metrics used to determine if the acceptable level of safety has been achieved 106

Key Performance Indicators Easy judgments Confirmed values Committed results 107

Promotion and Awareness Newsletters internal Posters Videos Intranet Presentations??? 108

Safety Culture A construct An outcome, not a process The introduction of safety management concepts lays the foundation upon which to build a safety culture Safety culture cannot be mandated or designed,, it evolves. It is generated top-down 109

Safety Culture How to create a Safety Culture? Depends on where you are starting from - you don t get to the end in one step, unfortunately, all the steps have to be traversed Becoming a Safety Culture involves acquiring and then maintaining a set of skills The two major factors are information and trust, so these have to be developed Be systematic (SMS are a start) and then learn to operate with the unknown as well Have the program run right from the top Appoint a senior champion who is dedicated and willing to stick it out, even when it gets hard The champion reports direct to the board Recognise that it will be uncomfortable, safety cultures are different, not just an add-on 110

Safety Culture A Way Forward developing a Safety Culture: Agree on ways to analyse incidents to reveal individual and system issues Develop reporting systems that are easy to use (compact, open-ended, impersonal) Encourage the workforce (air and ground) to realise that all incidents are worth reporting Experiment with changes when new information comes in, don t be afraid to admit failure first time round Practice management in wanting to know from near misses before they become accidents 111

Positive culture Source: David Marx Informed culture People are knowledgeable about the human, technical, organizational and environmental factors that determine the safety of the system as a whole. Reporting culture People are prepared to report their errors and experiences Positive culture Just culture People are encouraged (even rewarded) for providing essential safety-related information. However, there is a clear line that differentiates between acceptable and unacceptable behaviour. Flexible culture People can adapt organizational processes when facing high temporary operations or certain kinds of danger, shifting from the conventional hierarchical mode to a flatter mode. Learning culture People have the willingness and the competence to draw conclusions from safety information systems and the will to implement major reforms. 112

Just Culture Get rid of the idea that blame is a useful concept (this is hard to do) Define clear lines between the acceptable and the unacceptable Have those involved draw up the guidelines, do not impose from above if you want them to be accepted Have clear procedures about what to do with other forms of noncompliance 113

Just Culture Confidentiality People are reluctant to draw attention to errors made by themselves or their colleagues, due to personal embarrassment. They must be confident that their identity, or the identity of any person implicated in the report will not be disclosed without their permission or unless this is required by law. An assurance should also be given that any subsequent safety action taken will, as far as possible, ensure the anonymity of the persons involved. Punitive Action A person who breaks the law or breaches a regulation or company procedure through a deliberate act or gross negligence cannot expect immunity from prosecution. However, if the offence was unpremeditated and unintentional, and would not have come to light except for the report, he/she should be protected from punishment or prosecution. Loss of Licence The circumstances of a report may indicate that the performance of an individual is below the acceptable level. This may indicate the need for further training, or even cancellation of an individual's licence. Such action must never be punitive. 114

Workshop Safety Culture Just Culture Promotion Safety Awareness 115

The Safety Components Organizational cultural transformation is not for the faint of heart. In fact, many attempts at transforming an organization fail, for a variety of reasons: "Playing at it" or "dabbling" with it until it's no longer fun Not applying the kind of leadership that would best meet the needs of the situation Intervening in the wrong places or at the wrong time Not taking this work seriously enough Not giving it enough time or attention Senior leaders "delegating" this work (rather than committing and investing their own time and energies) Knowing what needs to be done but being unwilling to do it...to go all the way Not having the people and tools available internally to get the job done Inability to engage all the right people in the process Underestimating how big an undertaking this really is 116

Monitoring Continuous Documented Committed 117

Awareness Training Pamphlets News letters Seminars 118

Reporting Safety Records The documents collected by ATM providers to demonstrate to all stakeholders that the operations have been and continue to be undertaken in a safe manner. Safety Records are all documents developed under the umbrella of Quality and Safety Management System. 119

Examples of Safety Records Safety Assessment Report Incident Report Accidents Training Records Safety Performance Monitoring Records Safety Occurrence Report Safety Survey Report Other Examples?? Safety Assessments Policies, Strategies, Procedures SAFETY RECORDS Safety Monitoring Training 120

Manual Basic Safety Concept Introduction to Safety Management Hazards Safety Risks ICAO Safety Management requirements Introduction to Safety Management System (SMS) SMS Planning SMS Operation Phased approach to SMS implementation State Safety Programme (SSP) 121

Joint Session / Discussion 122

Wrap - up Today were following topics covered and discussed: ICAO Safety Management System SES Regulations The Safety System The Safety Management System 123

Any Questions? See You Tomorrow 124

ICAO - Safety Management System Use of SMS can be generally interpreted as applying a quality management approach to control safety risks. Similar to other management functions, safety management requires planning, organising, communicating and providing direction. The SMS development is built after the following structure: 1. Setting the Organisational Safety Policy 2. Safety Planning and Implementation of Safety Management Procedures 3. Risk and Quality Management methods 4. Safety Culture 125

Main SMS Components In line with the guidance outlined in ICAO Doc 9859 - Safety Management Manual, the SMS components may be assigned to the following broad domains: Safety Planning SMS Organisational Structure Safety Achievement Safety Assurance Safety Promotion A successful implementation and operation of an SMS is highly dependent on organisational aspects such as individual and group attitudes, values, competencies and patterns of behaviour which are frequently referred to as elements of the safety culture. A positive safety culture is characterised by a shared awareness of organisations personnel of the importance of safety in their operational tasks. 126

Organisational foundation for Safety Management Organisational Processes Workplace Conditions Active Failures Policy Making Planning Communication Allocation of resources Supervision Latent Conditions Defences Activities over which any organisation has a reasonable degree of direct control 127

Organisational foundation for Safety Management Organisational Processes Deficiencies in equipment design Incomplete/incorrect standard operating procedures Workplace Conditions Active Failures Inadequate hazard identification and risk management Normalization of deviance Latent Conditions Defences training deficiencies Conditions present in the system before the accident, made evident by triggering factors. 128

Organisational foundation for Safety Management Organisational Processes Workplace Conditions Active Failures Latent Conditions Defences Technology Training Regulations Resources to protect against risks that organisations involved in the production activities generate and must control. 129

Organisational foundation for Safety Management Organisational Processes Workplace Conditions Active Failures Workforce Stability Qualifications and experience Morale Credibility Ergonomics Latent Conditions Defences Factors that directly influence the efficiency of people in aviation workplaces 130

Organisational foundation for Safety Management Organisational Processes Workplace Conditions Active Failures Errors Violations Latent Conditions Defences Actions or inaction of people (pilots, ATCOs, maintenance engineers, Aerodrome staff, etc.) that have an immediate adverse effect 131

Organisational foundation for Safety Management Improve Workplace Conditions Organisational Processes Monitor Identify Latent Conditions Contain Active Failures Reinforce Defences Accident / Incident 132

SMS and QMS SMS results in the design and implementation of organizational processes and procedures to identify safety hazards and control/mitigate safety risks in aviation operation. QMS provides a structured approach to monitor that processes and procedures to identify safety hazards and control/mitigate safety risks in aviation operations function as intended and, when they do not, to improve them. 133