Transcript SAFETY MANAGEMENT

SAFETY
MANAGEMENT
EDGARS GINDRA
20.09.2007 LV CAA AOD
SMS regulation
Operation of aircraft
 Maintenance of aircraft
 Air traffic services
 Aerodromes

– Two audience groups
 States
 Service
providers
– Three distinct requirements
 Safety
programme
 SMS
 Management
accountability
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The amendment 30 to ICAO Annex
6 Part I
3.2.1 States shall establish a safety
programme in order to achieve an
acceptable level of safety in the operation
of aircraft.
 3.2.4 From 1 January 2009, States shall
require, as part of their safety
programme, that an operator implement a
safety management system acceptable to
the State of the Operator that, as a
minimum:

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The amendment 30 to ICAO Annex
6 Part I
a)
b)
c)
d)
Identifies safety hazards;
Ensures that remedial action necessary
to maintain an acceptable level of safety
is implemented;
Provides for continuous monitoring and
regular assessment of the safety level
achieved; and
Aims to make continuous improvement
to the overall level of safety.
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The amendment 30 to ICAO Annex
6 Part I
3.2.5 A safety management system shall
clearly define lines of safety accountability
throughout the operator’s organization,
including a direct accountability for safety
on the part of senior management.
 3.2.9 An operator shall establish a flight
safety documents system, for the use and
guidance of operational personnel, as part
of its safety management system.

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What is a safety programme?
An integrated set of regulations and
activities aimed at improving safety.
 States are responsible for establishing a
safety programme:

–
–
–
–
–
–
Safety regulation
Safety oversight
Accident/incident investigation
Mandatory/voluntary reporting systems
Safety data analysis
Safety promotion
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Clarifying the use of terms



Safety oversight – Is what the CAA performs
with regard to the operators/service providers
SMS.
Safety assurance – Is what the
operators/service providers do with regard to
safety performance monitoring and
measurement
Safety audit – Is what the CAA performs with
regard to its safety programme and the
operators/service providers perform with regard
to the SMS.
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Acceptable level of safety –
a concept
 High
level safety management goals
of an oversight authority (or a
service provider)
 Minimum safety performance that
service providers should achieve
while conducting their core business
functions
 A reference against which one can
measure safety performance
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What is an SMS?
A systematic approach to managing
safety, including the necessary
organizational structures, accountabilities,
policies and procedures.
 Providers are responsible for establishing
an SMS.
 States are responsible of the acceptance
and oversight for providers’ SMS.

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In summary

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.
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Safety programme – SMS
relationships
Protection
Production
Objective:
Public
safety
State
safety
programme
Oversight
Acceptance
Oversight
Objective:
Manage and
control
safety risk
Organization’s
safety
management
system (SMS)
Risk management
Safety assurance
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Organization’s
production
processes
Objective:
Achieve
commercial
goals and
customer
satisfaction
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ESARR ADVISORY MATERIAL
 Annex
14 establishes that, as of 24
November 2005, certified
aerodromes shall have in operation a
safety management system.
 ESARR 3 can be used by aerodrome
operators to implement the SMS
required in the SARPs contained in
ICAO Annex 14.
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ESARR ADVISORY MATERIAL
 As
a result, Safety Management
Systems (SMS) will have to be
implemented, not only in the
provision of ATM service associated
to aerodromes but also as regards
the complete operation of the
certified aerodromes at which those
services are provided.
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ESARR ADVISORY MATERIAL
 ESARR
3 addresses the management
of safety in any ATM service provided
without confining the SMS scope to
ATS as Annex 11 wherever it appears
necessary.
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INTER-RELATIONSHIP BETWEEN
SMS IN ATM AND AERODROMES
A
-
-
single organization is involved.
That means that the organization will
have to implement:
SMS compliant with ESARR 3 (and
ICAO Annex 11) in its ATM services;
SMS compliant with ICAO Annex 14
in its aerodrome operations.
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INTER-RELATIONSHIP BETWEEN
SMS IN ATM AND AERODROMES
 Two
-
different organizations are
involved. Two basic alternatives may
be considered:
Two separate SMS. Each organization
implements its own SMS (one
according to ESARR 3 to cover the
ATM services, and one according to
ICAO Annex 14 and specific national
regulations.
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INTER-RELATIONSHIP BETWEEN
SMS IN ATM AND AERODROMES
- A common SMS. The ATM and
aerodrome safety regulator (s) could
accept a set of arrangements
proposed by both organizations to
establish a “common SMS”.
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Regulation (EC) 2096/2005
laying down common requirements for the provision of air
navigation services
Article 3 Granting of certificates
Shall comply with the specific additional
requirements set in Annex II 3. Safety
of services
 Safety
management system
 Safety requirements for risk assessment and
mitigation with regard to changes
 Safety requirements for engineering and
technical personnel undertaking operational
safety related tasks
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SMS – Introductory concepts
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.

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Identifying aviation system
stakeholders
 It
is important to identify aviation
system stakeholders to ensure that
stakeholders relevant to risk decision
are taken into consideration and
contribute with their knowledge
before the decision is taken.
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Aviation system stakeholders
Aviation professionals
 Aircraft owners and operators
 Manufactures
 Aviation regulatory authorities
 Industry trade associations
 Regional air traffic service providers
 Professional associations and federations
 International aviation organizations
 Investigative agencies
 The flying public

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First fundamental – System
description
 Most
hazards are generated by
operational interactions among
different system components. It is
therefore essential to describe the
system in terms of its components as
one of the first activities when
planning an SMS.
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System description








The system interactions with other systems in
the air transportation system.
The system functions.
Required Human Factors considerations of the
system operation.
Hardware components of the system.
Software components of the system.
Related procedures that define guidance for the
operation and use of the system.
Operational environment.
Contracted and purchased products and
services.
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Second fundamental – Gap
analysis






An analysis of safety arrangements existing
within the organization.
The organizational structures necessary for an
SMS may be found throughout an organization.
Various activities of an SMS are probably already
in place and are working.
SMS development should build upon existing
organizational structures.
Conduct the gap analysis against the components
and elements of the SMS.
Once completed and documented the gap
analysis forms the basis of the implementation
plan.
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Third fundamental – SMS and
QMS
SMS differs from quality systems in that:
 SMS focuses on the safety, human and organizational aspects of
an operation (i.e., safety satisfaction)
 QMS focus the product (s) of an operation (i.e., customer
satisfaction)
 SMS results in the design and implementation of organizational
processes and procedures to identify hazards and control/mitigate
risks in aviation operation.
 QMS techniques provide a structured process for ensuring that
these processes and procedures achieve their intended objectives
and, where they fall short, to improve them.
 SMS builds partly upon QMS principles.
 SMS should include both safety and quality policies.
 The coverage of quality policies should be limited to quality in
support of safety.
 Safety objectives should receive primacy where conflicts are
identified.

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SMS planning
The components of SMS




Safety
Safety
Safety
Safety
policy and objectives
risk management
assurance
promotion
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The elements of SMS
1. Safety policy and objectives
1.1 Management commitment and
responsibility
1.2 Safety accountabilities of managers
1.3 Appointment of key safety personnel
1.4 SMS implementation plan
1.5 Coordination of the emergency
response plan
1.6 Documentation
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The elements of SMS
2. Safety risk management
2.1 Hazard identification process
2.2 Risk assessment and mitigation
processes
2.3 Internal safety investigations
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The elements of SMS
3. Safety assurance
3.1 Safety performance monitoring
and measurement
3.2 The management of change
3.3 Continuous improvement of the
safety system
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The elements of SMS
4. Safety promotion
4.1 Training and education
4.2 Safety communication
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Safety responsibilities
Accountable executive
Safety Review
Board (SRB)
Director of
operations
Director of
maintenance
Other directorates
Safety services
office
Flight
safety officer
Maintenance
safety officer
Safety Action
Group (s)
(SAG)
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Appointment of key safety
personnel
The safety office – Corporate functions
 Advising senior management on safety
matters
 Assisting line managers
 Overseeing hazard identification
systems
 The safety manager – Responsibilities
 Responsible individual and focal point
for the development and maintenance of
an effective safety management system

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Appointment of key safety
personnel

The safety manager – Functions
 Manages the SMS implementation plan on
behalf of the accountable executive
 Facilitates hazard identification and risk
analysis and management
 Monitors corrective actions to ensure their
accomplishment
 Provides periodic reports on safety
performance
 Maintains safety documentation
 Plans and organizes staff safety training
 Provides independent advice on safety matters
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Appointment of key safety
personnel

The Safety Review Board (SRB)
 High level committee
 Strategic safety functions




Chaired by the accountable executive
It may include the Board of Directors
Composed of heads of functional areas
SRB monitors:
 Safety performance against the safety policy
and objectives
 Effectiveness of the SMS implementation plan
 Effectiveness of the safety supervision of
subcontracted operations
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Appointment of key safety
personnel
SRB ensures that appropriate resources
are allocated to achieve the established
safety performance
 SRB gives strategic direction to the SAG
 Safety Action Group (SAG):
 Reports to SRB and takes strategic
direction from SRB
 Members:

 Managers
and supervisors from functional areas
 Front-line personnel
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Appointment of key safety
personnel

SAG:
 Oversees operational safety within the
functional area
 Resolves identified risks
 Assesses the impact on safety of operational
changes
 Implements corrective action plans
 Ensures that corrective action is taken in a
timely manner
 Review the effectiveness of previous safety
recommendations
 Safety promotion
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SMS implementation plan

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Contents
Safety policy
Safety planning, objectives and goals
System description
Gap analysis
SMS components
Safety roles and responsibilities
Safety reporting policy
Means of employee involvement
Safety communication
Safety performance measurement
Management review (of safety performance)
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PHASED APPROACH TO SMS
IMPLEMENTATION

Phase 1
- Provides a blueprint on how the SMS requirements will
be met and integrated to the organization’s work activities
- Provides an accountability framework for the
implementation of the SMS =
1) Identify the accountable executive and the safety
accountabilities of managers
Elements 1.1 and 1.2
2) Identify the person or planning group within the
organization responsible for implementing the SMS
Element 1.3
3) Describe the system (Air operator, ATC services provider,
approved maintenance organization, certified aerodrome
operator)
Element 1.4
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PHASED APPROACH TO SMS
IMPLEMENTATION

Phase 2
- Puts into practice those elements of the SMS
implementation plan that refer to:
1) Safety risk management component



Reactive processes
Investigation and analysis
Hazard identification and risk management
Elements 2.1, 2.2 and 2.3
2) Training relevant to:


The SMS implementation plan components
The safety risk management component (Reactive processes)
Element 4.1
3) Documentation relevant to:


The SMS implementation plan components
The safety risk management component (Reactive processes)
Elements 1.4 and 1.6
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PHASED APPROACH TO SMS
IMPLEMENTATION

Phase 3
- Puts into practice those elements of the SMS
implementation plan that refer to:
1) Safety risk management component



Proactive and predictive processes
Investigation and analysis
Hazard identification and risk management
Elements 2.1, 2.2 and 2.3
2) Training relevant to proactive and predictive
processes
Element 4.1
3) Documentation relevant to proactive and predictive
processes
Elements 1.4 and 1.6
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PHASED APPROACH TO SMS
IMPLEMENTATION

Phase 4
1) Operational safety assurance
Development of acceptable level (s) of safety
Development of safety indicators and targets
SMS continuous improvement
Elements 3.1, 3.2 and 3.3
2) Training relevant to operational safety assurance
Element 4.1
3) Documentation relevant to operational safety
assurance
Element 1.6
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CAA - Four steps for SMS
implementation

Step 1
State’s safety programme
 Conduct a gap analysis vis-à-vis the current
status in the State of the following:






Safety regulation
Safety oversight (capabilities and planning)
Accident/incident investigation
Mandatory/voluntary/confidential reporting systems
Safety data analysis
Safety promotion
 Develop the State safety programme around
four components of the ICAO SMS framework
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Safety analysis and safety studies
 Analytical
methods and tools:
– Statistical analysis (to quantify
situations);
– Trend analysis (predictions may be
made, and to trigger “alarms”);
– Normative comparisons (to sample real
world experience under similar
operating conditions);
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Safety analysis and safety studies
– Simulation and testing (simulation in
the field under actual operating
conditions);
– Expert panel ( to evaluate evidence of
an unsafe condition and evaluating the
best course for corrective action);
– Cost-benefit analysis (the costs of
implementing the proposed measures
are weighed against the expected
benefits over time).
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Safety analysis and safety studies
Safety studies require data, appropriate
analysis and effective communication.
 Safety studies conducted by State
authorities, airlines, manufactures, and
professional and industry associations.
 Safety recommendations may arise from
the investigation of accidents and serious
incidents and also from safety studies.
 Safety studies have application to hazard
identification and analysis in flight
operations, maintenance, cabin safety, air
traffic control, airport operations, etc.

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Safety analysis and safety studies
 Selecting
study issues
– Significant safety issues lists (SIL)
based on the accident and incident
record in such areas as runway
incursions, ground proximity warnings,
TCAS, and prioritized in terms of the
risks to the organization or the industry;
– Support among participants and
contributors.
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Safety analysis and safety studies

SIL should be reviewed and updated
annually, adding new high-risk issues and
deleting lesser-risk issues:
–
–
–
–
–
–
–
Frequency of GPWS warnings;
Frequency of TCAS advisories;
Runway incursions;
Altitude deviations (busts);
Call sign confusion;
Un-stabilised approaches; and
Air proximities (near misses) at selected
aerodromes.
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CAA - Four steps for SMS
implementation

Step 2
Implementation SMS SARPs
 Develop SMS regulations for
operators/service providers
 Refer
to the SMS components and elements
 Refer
to ICAO Doc 9859
 Prepare guidance material for the
implementation of SMS
 Operators/service providers may need
to use third party assistance to implement
their SMS
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CAA - Four steps for SMS
implementation

Step 3
CAA training programme
 Develop a training programme for
CAA officers to:
 Provide
knowledge of safety management
concepts and ICAO SARPs on safety
management in Annexes 6, 11 and 14, and
related guidance material; and
 Develop knowledge to certify and oversee the
implementation of key components of an SMS,
in compliance with the national regulations and
relevant ICAO SARPs
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CAA - Four steps for SMS
implementation
 Step
4
CAA enforcement policy
 Revision of enforcement policy
 Operators/service
providers allowed to
deal with deviations/minor violations
internally, within the context of the
SMS, to the satisfaction of the authority
 Gross negligence, willful deviation and
so forth to be dealt through established
enforcement procedures
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State safety programme –
SMS harmonization
 State’s
safety programme
components
– Safety
– Safety
– Safety
– Safety
policy and objectives
risk management
assurance
promotion
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Safety policy and objectives
 How the CAA will oversee the
management of safety in the State
A
definition of CAA requirements,
responsibilities and accountabilities
regarding the State safety programme
 Similar to the equivalent SMS component
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Safety risk management
 Establishment of controls which govern
how service providers SMS will operate
 Standards/requirements
 Same
for service providers SMS
processes as SMS
 Hazard identification and risk
management
 Different
outputs
 New/modified rules and/or
regulations (i.e., controls) which
govern how service providers SMS
operate
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Hazard identification processes

Concept of safety
Consider
- The elimination of accidents (and serious incidents) is
unachievable.
- Failures will occur, in spite of the most accomplished
prevention efforts.
- No human endeavour or human-made system can be free
from risk and error.
- Controlled risk and error is acceptable in an inherently
safe system.
Safety is 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.
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Hazard identification processes

The organizational accident
From the Investigation Report identify:
a) Organizational processes that influenced
the operation and which felt under the
responsibility of senior management (i.e. those
accountable for the allocation of resources):
- Policy-making
- Planning
- Communication
- Allocation of resources
- Supervision
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The organizational accident
Organizational processes






Policy-making
Planning
Communication
Allocation of resources
Supervision
…
Activities over which any organization has a
reasonable degree of direct control
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The organizational accident
Organizational processes
 Inadequate hazard
identification and risk
management
 Normalization of
deviance
Latent
conditions
Conditions present in the system before the accident,
made evident by triggering factors.
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Hazard identification processes
b) Latent conditions in the system safety
which became precursors of active failures:
- Inadequate hazard identification and risk
management
- Normalization of deviance
c) Defences which fail to perform due to
weaknesses, inadequacies or plain absence:
- Technology
- Regulations
- Training and checking
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The organizational accident
Organizational processes
Latent
conditions
Technology
Regulations
Training and checking
Defences
Resources to protect against the risks that organizations
involved in production activities must confront.
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Hazard identification processes
d) Workplace conditions which may
have influenced operational personnel
actions:
- Workforce stability
- Qualifications and experience
- Morale
- Credibility
- Ergonomics
e) Active failures, including errors and
violations.
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The organizational accident
Organizational processes
Workplace
conditions
Workforce stability
Qualifications and
experience
Morale
Credibility
Ergonomics
…
Factors that directly influence the efficiency of people in
aviation workplaces.
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The organizational accident
Organizational processes
Workplace
conditions
Active
failures
 Errors
 Violations
Actions or inactions by people (pilots, controllers,
maintenance engineers, aerodrome staff, etc.) that
have an immediate adverse effect.
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The organizational accident
Organizational processes
Improve
Monitor
Latent
conditions
Reinforce
Contain
Workplace
conditions
Active
failures
Identify
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Defences
63
Hazard identification processes

Two definitions
Hazard – Condition, object or activity 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.
Risk – The chance of a loss or injury, measured in
terms of severity and probability. The chance that
something is going to happen, and the consequences if it
does.
Example
A wind of 15 knots blowing directly across the runway is a
hazard.
The possibility that the pilot may not be able to control the
aircraft during take-off or landing, resulting in an accident,
is one risk.
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Hazard identification processes

First fundamental – Understanding hazards
- Natural tendency to describe the hazards
as an outcome (“Runway incursion” vs.
“Unclear aerodrome signage”
- Stating hazards as outcomes disguises
their nature and interferes with identifying
other important outcomes
- However, well-named hazards allows to
infer the sources or mechanisms and loss
outcome (s)
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Hazard identification processes

Examples of hazards
For Operator (Flight crew):
- Unfamiliar phraseology
- ATC procedures
- Similar call signs
- Terrain
- Flight diversions
- System malfunctions
- Unfamiliar airports
- Heavy traffic
- Missed approaches
- Weather
- Automation events
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Hazard identification processes

Second fundamental – Hazard identification
The scope for hazards in aviation is wide, and may be related to:
- Design factors, including equipment and task design.
- Procedures and operating practices, including documentation and
checklists.
- Communications, including means, terminology and language.
- Organizational factors, such as company policies for recruitment,
training, remuneration and allocation of resources.
- Work environment factors, such as ambient noise and vibration,
temperature, lighting and protective equipment and clothing.
- Regulatory factors, including the applicability and enforceability of
regulations; certification of equipment, personnel and procedures; and the
adequacy of oversight.
- Defences, including detection and warning systems and the extent to
which the equipment is resilient against errors and failures.
- Human performance, including medical conditions and physical
limitations.
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Hazard identification processes

Third fundamental – Hazard analysis
ABC of hazard analysis
A – State the generic hazard (hazard statement)
 Airport construction
B – Identify specific components of the hazard
 Construction equipment
 Closed taxiways
C – Naturally leading to specific risk (s)
 Aircraft colliding with construction equipment
 Aircraft taking wrong taxiway
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Hazard identification processes

At the intersection of protection and production
– The acronym ALARP is used to describe a safety risk which
has been reduced to a level that is as low as reasonably
practicable.
– In determining what is reasonably practicable consideration
is given to both the technical feasibility and the cost of further
reducing the safety risk.
– This includes a cost/benefit study

Direct costs
– The obvious costs, which are easily determined. The high costs
of exposure of hazards can be reduced by insurance coverage.

Indirect costs
– The uninsured costs. An understanding of these uninsured
costs (or indirect costs) is fundamental to understanding the
economics of safety
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The management dilemma
Management levels
Resources
Resources
Protection
Production
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The management dilemma
Protection
Production
Catastrophe
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The management dilemma
Production
Protection
Bankruptcy
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Safety space
Protection
Bankruptcy
Catastrophe
Source: James Reason
Production
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Safety management – The response to
the dilemma



Safety issues are a byproduct of activities
related to production/services delivery.
An analysis of an organization's resources and
goals allows for a balanced and realistic
allocation of resources between protection
and production goals, which supports the
needs of the organization.
The product/service provided by any aviation
organization must be delivered safely (i.e.
protecting users and stakeholders).
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Hazard identification processes

Fourth fundamental – Documentation of hazards
Appropriate documentation management:
– A formal procedure to translate operational safety data
into hazard-related information.
– The “safety library” of an organization.
– The need for standardization – facilitating tracking and
analysis of hazards by common:






Definitions
Understanding
Validation
Reporting
Measurement
Management
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Risk management

First fundamental – Risk management
The identification, analysis and elimination
(and/or mitigation to an acceptable level) of
those hazards, as well as the subsequent risks
that threaten the viability of an organization.
Risk management facilitates the balancing act
between assessed risks and viable risk
mitigation. Risk management is an integral
component of safety management. It involves a
logical process of objective analysis, particularly
in the evaluation of the risks.
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Hazard information management at a
glance
METHOD
HAZARDS
Reactive method
ASR
MOR
Incident reports
Accident reports
Proactive method
HAZARDS
ASR
Surveys
Audits
Predictive method
FDA
Direct
observation
systems
IDENTIFICATION
Assess and
prioritize risks
Develop
control and
mitigation
strategies
Inform
person(s)
responsible for
implementing
strategies
MANAGEMENT
DOCUMENTATION
Safety
management
information
Assign
responsibilities
Implement
strategies
Re-evaluate
strategies
and
processes
INFORMATION
S
A
F
E
T
Y
L
I
B
R
A
R
Y
Trend analysis
Safety bulletins
Report
distribution
Seminars and
workshops
Feedback
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Risk management

Second fundamental – Risk probability
Definition (s)
 Probability – The chance that a situation of danger
might occur.
Questions for assessing the probability of an occurrence:
 Is there a history of occurrences like the one being
assessed, or is the occurrence an isolated event?
 What other equipment, or similar type components,
might have similar defects?
 What number of operating or maintenance personnel
must follow the procedure (s) in question?
 How frequently is the equipment or procedure under
assessment used?
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Second fundamental – Risk probability
Probability of occurrence
Qualitative
definition
Meaning
Value
Likely to occur many times (has occurred frequently)
5
Likely to occur some times (has occurred infrequently)
4
Unlikely, but possible to occur (has occurred rarely)
3
Improbable Very unlikely to occur (not known to have occurred)
2
Extremely
improbable
1
Frequent
Occasional
Remote
Almost inconceivable that the event will occur
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Risk management

Third fundamental – Risk severity
Definition (s)
 Severity – The possible consequences of a situation of danger,
taking as reference the worst foreseeable situation.
Define the severity in terms of:








Property
Health
Finance
Liability
People
Environment
Image
Public confidence
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Risk management
Questions for assessing the severity of an occurrence:
 How many lives are at risk?
–
–
–
–
Employees
Passengers
Bystanders
General public
 What is the environmental impact?
– Spill of fuel or other hazardous product
– Physical disruption of natural habitat
 What is the severity of the property of financial damage?
–
–
–
–
Direct operator property loss
Damage to aviation infrastructure
Third party damage
Financial impact and economic impact for the State
 Are there organizational, management or regulatory implications
that might generate larger threats to public safety?
 What are the likely political implications and/or media interest?
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Third fundamental – Risk severity
Severity of occurrences
Aviation
definition
Catastrophic
Hazardous
Meaning


Equipment destroyed
Multiple deaths

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 or death to a number of people.
Major equipment damage


Minor
Negligible
A
B


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.




Nuisance.
Operating limitations.
Use of emergency procedures.
Minor incident.
D

Little consequences
E

Major
Value
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C
82
Fourth fundamental – Risk assessment
Risk severity
Catastrophic
Hazardous
Major
Minor
Negligible
A
B
C
D
E
5 – Frequent
5A
5B
5C
5D
5E
4 – Occasional
4A
4B
4C
4D
4E
3 – Remote
3A
3B
3C
3D
3E
2 – Improbable
2A
2B
2C
2D
2E
1 – Extremely
improbable
1A
1B
1C
1D
1E
Risk probability
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Fourth fundamental – Risk tolerability
Assessment risk index
Suggested criteria
5A, 5B, 5C, 4A, 4B, 3A
Unacceptable under the existing
circumstances
5D,5E, 4C, 3B, 3C, 2A,
2B
Risk control/mitigation requires
management decision
4D, 4E, 3D, 2C, 1A, 1B
Acceptable after
review of the operation
3E, 2D, 2E, 1C, 1D, 1E
Acceptable
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Risk assessment at a glance
Identify the hazards to equipment
, property,
personnel or the organization
.
Identify the risk(s) and assess
the chances of it (them) occurring?
HAZARD
IDENTIFICATION
RISK ASSESSMENT
Probability
Evaluate the seriousness of the risk(s) occurring
RISK ASSESSMENT
Severity
Is (are) the consequent risk(s) acceptable and within
the organization’s safety performance criteria?
RISK ASSESSMENT
Tolerability
YES
Accept the risk(s)
NO
Take action to reduce
the risk(s) to an
acceptable level
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RISK CONTROL/MITIGATION
85
Risk management

Fifth fundamental- Risk control/mitigation
Definition (s)
 Mitigation – Measures to eliminate the potential hazard or to reduce the risk
probability or severity.
–
Risk mitigation = Risk control
Strategies
 Avoidance – The operation or activity is cancelled because risks exceed the
benefits of continuing the operation or activity.
(Operations into an aerodrome surrounded by complex geography and without the
necessary aids are cancelled.)
 Reduction – The frequency of the operation or activity is reduced, or action is
taken to reduce the magnitude of the consequences of the accepted risks.
(Operations into an aerodrome surrounded by complex geography and without the
necessary aids are continued based upon the availability of specific aids and
application of specific procedures.)
 Segregation of exposure – Action is taken to isolate the effects of risks or buildin redundancy to protect against it, i.e., reduce the severity of risk.
(Operations into an aerodrome surrounded by complex geography are limited to daytime, visual conditions.)
(Non RVSM equipped aircraft not allowed to operate into RVSM airspace.
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Risk management

Risk mitigation – Defences (Technology,
Training, Regulations)
As part of the risk mitigation, determine:
 Do defences to protect against such risk (s)
exist?
 Do defences function as intended?
 Are the defences practical for use under actual
working conditions?
 Is staff involved aware of the risks and the
defences in place?
 Are additional risk mitigation measures
required?
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Risk mitigation at a glance
Hazard identification
and
risk management
Assessment of the
defences within
the safety system
Control and
mitigation
of the risk (s)
H H H H
 Does the mitigation
Regulations
EACH HAZARD
EACH RISK
Intolerable
region
Training
Technology
R R R R
Accepting the
mitigation of
the risk
A
L
A
R
P
Tolerable
region
Acceptable
region
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address the hazard?
 Does it address the
risk (s)?
 Is it effective?
 Is it appropriate?
 Is additional or
different
mitigation warranted?
 Do the mitigation
strategies generate
additional risk (s)
88
Risk management process at a glance
A safety concern is perceived
Feedback and
record the
hazard
identification
and
assessment
and/or risk
mitigation
Identify hazards and assess risks
Define the level of
severity
Define the level of
probability
Define the level
of risk
Is the risk level acceptable?
Take action and
continue the
operation
Yes
Can the risk be eliminated?
Take action and
continue the
operation
Take action and
continue the
operation
No
No
Yes
Yes
Can the risk be mitigated?
Yes
Can the residual risk
be accepted (If any)?
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No
Cancel the
operation
89
Risk control/mitigation log
Risk
reference
Generic hazard
Risk(s) description
Current measures
to reduce risk(s) and
risk index
Risk index:
Risk tolerability:
Further actions to reduce
risk(s) and resulting risk index
Responsibility
Risk index:
Risk tolerability:
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Risk management considerations
for State Administrations
 Policy
development through to the
“go/no-go” decisions:
– Policy. To what extent should a State
accept the certification paperwork of
another State?
– Regulatory change. From the many
(often-conflicting) recommendations
made for regulatory change, how are
decisions made?
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Risk management considerations
for State Administrations
 Situations
when risk management
should be applied:
– Start-up or rapidly expanding
companies;
– Corporate mergers;
– Companies facing bankruptcy or other
financial difficulties;
– companies facing serious labourmanagement difficulties;
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Risk management considerations
for State Administrations
– Introduction of major new equipment by
an operator;
– Certification of a new aircraft type, new
airport, etc.;
– Introduction of new communication,
navigation or surveillance equipment
and procedures; and
– Significant change to air regulations or
other laws potentially impacting on
aviation safety.
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Risk management considerations
for State Administrations
– Priority setting. How are decisions made for
determining those areas of safety warranting
emphasis during safety oversight audits?
– Operational management. How are decisions
made when insufficient resources are available
to carry out all planned activities?
– Operational inspections. At the front line, how
are decisions made when critical errors are
discovered of normal working hours?
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Risk management considerations
for State Administrations

Risk management by State
administrations will be affected by such
factors as:
– Time available to make the decision
(grounding an aircraft, revoking a certificate,
etc.);
– Resources available to effect the necessary
actions;
– Number of people affected by required actions
(company-wide, fleet-wide, regional, national,
international, etc.);
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Risk management considerations
for State Administrations
– Potential impact of the State’s decision
for action (or inaction); and
– Cultural and political will to take the
action required.
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Risk management considerations
for State Administrations
 Benefits
of risk management for
State administrations:
– Avoiding costly mistakes during the
decision-making process;
– Ensuring that all aspects of the risk are
identified and considered ehen making
decisions;
– Ensuring that the legitimate interests of
affected stakeholders are considered;
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Risk management considerations
for State Administrations
– Providing decision-makers with a solid
defence in support of decisions;
– Making decisions easier to explain to
stakeholders and the general public;
and
– Providing significant savings in time and
money.
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Safety assurance
 Ensuring that the operation of
service providers SMS follows
established controls
(standards)/requirements)
 Oversight,
inspections and audits
 Data tracking and analysis
 Data driven targeting of
oversight on areas of greater
concern/need
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The essential is invisible to the eyes
Number of occurrences
1–5
Accidents
30 – 100
Serious incidents
100 – 1000
Incidents
1000 – 4000
Latent conditions
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Safety promotion
 Support the integration of the
State safety programme with the
operation of service providers SMS
 Training,
communication and dissemination
of safety information
 Dual-track promotion
 Within the CAA
 Among service providers it
oversees
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The final objective –
Integration
Safety programme + SMS = State integrated safety
management system
Protection
Objective:
Public
safety
Production
State
safety
programme
Oversight
Acceptance
Oversight
Organization’s
Objective:
safety
Manage and
management
control
safety risk
system (SMS)
Organization’s
production
processes
Risk management
Safety assurance
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Objective:
Achieve
commercial
goals and
customer
satisfaction
102