Safety Management

- The Payback

Presented by

Jane Gothard Head of International Safety NATS

Moscow – 15th September 2005

History of NATS Safety Management System (SMS)

1989 CAA Safety Management Review

Objective: To identify changes in organisational structure and safety management which are required to assure ATC safety in the present and future environment.

• Considered safety management in its widest context;

• Separation of safety regulation from NATS operations to be made obvious;

• Need for explicit commitment to safety;

• Recommendations based on best practice in other safety critical industries.

• Zagreb Mid-Air Collision 1976

• Tenerife air disaster 1977

• Challenger Space Shuttle disaster 1986

• Herald of Free Enterprise ferry disaster Zeebrugge1987

• Clapham Junction Rail Disaster 1988

• Piper Alfa Oil Platform disaster 1988

A Catalogue of Disaster

• An organisation’s commitment to safety must be explicit - set a clear safety policy;

• Senior Management are responsible for way safety is managed - Responsibilities for safety need to be explicit;

• A top-down safety strategy should be established;

• Free flow of information and openness is essential to ensure that safety issues are acknowledged and communicated to the relevant parts of the organisation;

• Engineering systems need to be maintained in accordance with their design principles;

• A central focus on safety is useful;

• There is a need to audit procedures;

Lessons from Accident Investigations

The 1989 CAA Safety Management Review identified the need for:

• a single document to provide a comprehensive description of NATS approach to safety management;

• a system-wide policy of safety management which:

• defines responsibilities and accountabilities;

• provides a formal basis for translating NATS Objectives relating to safety into detailed engineering and operational requirements.

• A dictionary of common definitions such as safety, reliability and integrity as they are understood in the NATS context.

1989 CAA Safety Management Review

SMS - The Drivers

What do you need?

• To understand current performance;

• To identify weaknesses / deficiencies;

• To comply with regulatory requirements;

• To stay in business.

SMS - The Drivers

What do you want?

• A means of achieving continuous improvement in safety performance;

• Improved safety performance;

• Minimal additional cost / cost control.

SMS Development

• Know where you are starting from - define a baseline

• Set the Scope - a realistic manageable level

• Set clear objectives - accept that you will not achieve everything right away.

• Obtain Senior Management buy-in - in both the philosophical and financial sense!

• Build in ‘Line’ ownership

• Engage expert support and identify internal resource

• Take the regulator along with you

• Set Policy;

• Identify accountabilities;

• Define processes and procedures;

• Develop and implement a communication plan;

• Test achievement regularly - identify successes;

• Expand and improve.

SMS Development - System Design

Safety has first priority within the core values that underline all

NATS activities, and it is NATS safety objective to maintain and,

where practicable, improve safety levels in all our activities.

To achieve this, it is NATS policy that an explicit, pro-active

approach to safety management is maintained to minimise NATS

contribution to the risk of an aircraft accident as far as is reasonably

practicable.

NATS Safety Policy

• Organisational Change

• System Safety Analysis

• System Acceptance Procedures

• Quantitative Safety Levels

• Documentation

General Safety Management Principles

• Incident Investigation

• Lesson Dissemination

• Safety Improvement

• Training

• Supervision

• Monitoring Performance

• Auditing Arrangements

General Safety Management Principles

POLICY

ACCOUNTABILITIES

PRINCIPLES

PROCEDURES

How is it achieved

Action

What is required

Who is responsible

NATS Safety Management System

To maintain an effective SMS;

To provide assurance that the SMS is being implemented effectively;

To provide specialist advice and assistance where required;

To provide specialist safety management training at all levels;

To act as a proactive focal point for all safety management issues.

The Role of the Corporate Centre

The Reality of Achievement

A Safety Management System will enable you to:

• Identify the risks;

• Determine the priorities - explicit risk management;

• Develop and execute a realistic plan;

• Improve safety performance and demonstrate that you have improved;

• Create a learning organisation.

169

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8

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3321

4

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0%

2%

4%

6%

8%

10%

12%

14%

16%

SSE4

SSE3

SSE2

SSE1

M ay include double counting of events

Excluded root causes with risk below 2%

An Example - Relative Risk of Events

Data for illustration purposes only

12 11 9 7 7 4 4 4 4 3 1 2 2 2 6 8 8 815 17 17 21 24 25 30 30 26 26 26 26

20 20 20 18 17 17 13 13 16 16 18 19 20 20 22 24 27 25 25 30 2930

291

306311323324326328330328

317305

271

254243

252242238

252255252256257257

275

291288274

263260

233226222223222217

210203205

218228227

237250

264269277

293294301

311311320

0

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/12

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SSE1-4 Level Busts

An Example - Level Busts

12 month Rolling Total Data for illustration purposes only

Level Busts – By Cause

0% 5% 10% 15% 20% 25% 30%

CRM

Altimeter Setting

Climbed above SID

Equipment Malfunction

Acft took wrong call

ATC missed read back

Manual flying

Acft misinterpret ATC

OAT

Weather

Other

Unknown

Ca

us

e

% Frequency

2002 2003 2004Data for illustration purposes only

Level Busts – An Action Plan

• Raising awareness - Pilots & Controllers

• Engaging industry- Airlines & Chart Manufacturers

• Changing procedures- Phraseology

• Taking advantage of new technology - Developing controller tools

4 Important elements have been addressed:

An SMS makes good business sense:

• Maintain approval to operate - continue in business;

• Compete on equal terms with other ATSPs - Best practice;

• Reduce Insurance Premiums;

• Reduce burden of cost of remedial work and investigations;

The Reality of Achievement

• You will achieve a state of continual unease but,

• You will know what to worry about;

• You will be able to worry constructively;

• Big worries will become little worries;

• Your customers / stakeholders/ Regulators will worry you less;

• You will get more sleep!

The Reality of Achievement

The Reality of Achievement

is

You can always do more !