safety management systems (sms) fundmentals: safety risk management component

Federal AviationAdministration

SL-1

Safety Risk ManagementComponent

Federal AviationAdministrationSMS Details:

Policy (Structure)

Risk Management

Safety Assurance

Safety Promotion


SL-2

Definitions• Safety management systems provide a

systematic way to control risk and to provide assurance that those risk controls are effective.

• Safety Risk Management performs the process of controlling risk thru hazard identification, analysis, risk assessment and developing risk controls.


SL-3

Levels of Risk Management

• Process Risk Management

– Policy (What)

– Procedure (How)

– Controls

• Operational Risk Management

– Operational Control (Flight/Task/Mission)

– Crew/Team (Real time decision making)


SL-4

System DescriptionWhat is System Description & Task Analysis? • It is a system design function.• It is a predictive method of hazard identification.• It is the foundation for sound safety analysis.

When is it used? • Used during implementation phases of SMS.• Used in the development of operational processes.• Used when a new Hazard is identified• Used in conjunction with all operational changes.

Who uses System Description & Task Analysis?• Personnel within the organization who form an appropriately

diverse team: – Stakeholders – Subject Matter Experts

ICAO Doc. 9859

SystemDescription

HazardIdentification

RiskControl

RiskAssmt

RiskAnalysis


SL-5

Processes

Workplace Conditions:Activities

• Equipment• Information (Procedures)• Facilities• Phys. Envir.• Other Proc. (Interfaces)• Training• Supv./Mgmt. (Controls)• ….

e.g,

SystemFactors &Attributes

Variable Human

Performance

SRM

SystemDescription


RiskControl

RiskAssmt

RiskAnalysis

System Description

Facts


SL-6

Typical Workplace Conditions

• Equipment: Human-machine interface, facilities, tools…

• Information: Procedures, guidance...

• Environment: Physical, cultural…

• Training: Formal, OJT, recurrent…

• Company/regulator factors: The RULES...

Barry Strauch (2004). Investigating Human Error


SL-7

Process (System or Safety) Attributes

• Responsibility

• Authority

• Procedures

• Controls

• Process Measures

• Interfaces


SL-8

Controls (C)•Procedural•Supervision•Assurance Processes

Responsibility (R)•Accountable for process output

Authority (A)Empowered to:•Make key decisions•Alter process

ExternalDecision byOrganization

InternalPrevious ProcessInterface – (I)

Inputs

Process

Outputs

•Destination – Interface (I)•Deliverable – Performance Measures (PM)

Processes

Activities(Things People

do)

Procedures (P)


SL-9

Activities

ProcessPeople•Employees•Contractors•Organization

Materials

ProductsServices

FacilitiesEquipmentTools

Knowledgeware•Manuals•Job Aids•Software

CustomerRequirements

LawsRegulationsStandards

Environment•Physical•Operational•Cultural

Systems

Training


SL-10

Conditions (Hazards) Related to Human Error

• Time pressure

• Poor procedures and documentation

• Teamwork (Too much, too little)

• Shift turnovers/crew briefings

• Group norms (Values, culture)

• Fatigue management (shifts/circadian problems)

Alan Hobbs, ATSB (2008)


SL-11

• Lack of System Knowledge

• Poor, worn out, missing or equipment/facilities

• Human-machine interface (e.g. design for maintainability)

Conditions (Hazards) Related to Human Error (Cont.)


SL-12

Activities and Conditions: Deicing

Activities/TasksThings people do

Workplace ConditionsSystem and Environment

Prepare truck / equipment Day/Night

Verify type of fluid Weather – precip / cold

Fluid temp / concentration Protective clothing

Position at aircraft Equipment condition

Communicate with crew Shift change

Apply fluid Employee demographics

Communicate with crew

Depart ramp area


SL-13

Hazard Identification

A hazard is any real or potential condition…

ICAO Doc. 9859ICAO Doc. 9859

SystemDescription


RiskControl

RiskAssmt

RiskAnalysis

that can result in injury, illness, or death to people; damage to, or loss of, a system (hardware or software), equipment, or property; and/or damage to the operating environment.


SL-14

Processes



Hazards

Deficient Conditionsimpacting activities =

ConsequencesActive Failures

VariablePerformance

e.g.


Causing… Resulting in…

SRM Hazard Identification from Workplace Conditions

Inference

SystemDescription


RiskControl

RiskAssmt

RiskAnalysis


SL-15

Risk Analysis

Important to distinguish between: Hazard – a condition

Consequence – result

Risk – likelihood & severity of the consequence

Analyzing risk involves the consideration of both the likelihood and the severity of any adverse consequences.

ICAO Doc. 9859

SystemDescription


RiskControl

RiskAssmt

RiskAnalysis


SL-16

Hazards

Deficient Conditionsimpacting activities =

ConsequencesActive Failures

L S

VariablePerformance

Risk

Risk

ikelihood everity

Causing… Resulting in…

SRM From Hazard to Risk

SystemDescription


RiskControl

RiskAssmt

RiskAnalysis

Judgment


SL-17

Failures and Consequences

Active failuresDirect results of human activity

Potential ConsequencesAccident/incident severity

Incorrect fluid typeAircraft required to be de-iced again

Wrong fluid concentration Take-off delay

Fluid sprayed into

pitot-static ports

Maintenance action required

Incomplete deicing Take-off accident due to ice

Hold-over time too long


SL-18

Extremely

improbable

Improbable

Remote

Occasional

Frequent

Risk Likelihood Negligible

EMinor

DMajor

CHazardous

BCatastrophic

A

1E1D1C1B1A1

2E2D2C2B2A2

3E3D3C3B3A3

4E4D4C4B4A4

5E5D5C5B5A5

Risk SeveritySystem

Description


RiskControl

RiskAssmt

RiskAnalysis

Risk AssessmentRisk assessment determines the level of risk to use in making a bottom line decision.

A risk matrix is a tool used for risk assessment. It can vary in form yet it accomplishes the same purpose.


SL-19

Risk Control = Risk Mitigation

A major component of any safety system is the defenses (controls) put in place to protect people, property or the environment.

These defenses are used to reduce the likelihood or severity of the consequences associated with any given hazard or condition. ICAO Doc. 9859

SystemDescription


RiskControl

RiskAssmt

RiskAnalysis


SL-20

Processes



e.g.


Variable Human

Performance

Risk Controls

SRM Risk Control/Mitigation

SystemDescription


RiskControl

RiskAssmt

RiskAnalysis

safety management systems (sms) fundmentals: safety risk management component

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