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International Civil Aviation Organization
STATE SAFETY PROGRAME (SSP)
SAFETY MANAGEMENT SYSTEM (SMS)
Mexico City, June 2013
Outline
1. Introduction 2. SSP 3. SMs 4. Annex 13, requirements 5. Managing Safety Performance 6. Safety Management Process 7. Occurrence Classification
The first ultra-safe industrial system
Ultra-safe system (mid 1990’s onwards) Business management approach to safety (SMS) Routine collection and analysis of operational data
10-3
10-5
10-7
Fragile system (1920’s -1970’s) Individual risk management & intensive training Accident investigation
Safe system (1970’s – mid 1990’s) Technology & regulations Incident investigation
Global Aviation Safety Roadmap - GASR
• There is no ATM / ATC technology that directly addresses safety management. However, ATC can contribute to enhance safety
• Implementation of technologies upon specific ATM requirements
• Improve safety Education and Training programmes
SMS SARPs – Applicability Roadmap
Safety Management SARPs for Service Providers Annex Intended Audience Denomination Date Applicable
11 Air traffic services providers
Safety Management Programme
Nov, 2001
14 Certified Aerodromes Safety Management Programme
Nov, 2001
2005 – Harmonization of Safety Management SARPs 6, 11 and 14 A/C Operators & AMOs SMS Jan, 2009
2008 – 2nd Harmonization of Safety Management SARPs 1 Training Organizations SMS Nov, 2010 8 Manufacturers SMS Nov, 2013
1, 6, 11, 14 SMS Framework Nov, 2010
Safety Management SARPs for States Annex States Denomination Date Applicable
2005 – Harmonization of Safety Management SARPs 6, 11 and 14 States Safety Programme Nov, 2006
2008 – 2nd Harmonization of Safety Management SARPs 1, 8 and 13 States SSP Nov, 2010
1, 6, 8, 11, 13, 14 States SSP Framework * Nov, 2010 *Attachment
OPERATIONAL FLEXIBILITY DIFFICULT BECAUSE OF BUDGET MECHANISMS
BUDGETS REFLECT STRATEGIES
ANALYSES INTERNAL & EXTERNAL FACTORS AS IMPACT ON OPERATIONS
INTERNAL & EXTERNAL FACTORS TRIGGERS STRATEGIC THINKING
PROGRAMME & CLIENT EMPHASIS NOT ALWAYS CLEAR
CLEAR CHOICES MADE ON PROGRAMME & CLIENT PRIORITIES
DELIVERABLES ARE PROSCRIPTIVE AND USEABILITY IS DIFFICULT
DELIVERABLES ARE CONCISE, PRACTICAL & INCORPORATE PERFORMANCE MONITORING
POSITIONING OF THE ORGANIZATION IN THE “PUBLIC PLACE” NOT EVIDENT
DEFINES THE STRATEGIC POSITIONING OF PROGRAMMES, SERVICES & CLIENTS IN THE “PUBLIC PLACE”
TRADITIONAL STRATEGIC PLANNING
PERFORMANCE BUSINESS PLANNING APPROACH
vs
Collect Data
Re-evaluate Situation
Implement Strategies
Assign Responsibilities
Approve Strategies
Collect Additional Data
Develop Strategies
Prioritize Unsafe Conditions
Analyze Data
Safety Management
Process
Safety Management Process
STATE SAFETY PROGRAMME (SSP)
States shall require, as part of their SSP, that an ATS provider implement a safety management system acceptable to the State , as a minimum: a) identifies safety hazards;
b) ensures that remedial action necessary to maintain safety performance is implemented;
c) provides for continuous monitoring and regular assessment of the safety performance; and
d) aims at a continuous improvement of the overall performance of the safety management system.
A SMS shall clearly define lines of safety accountability throughout the air traffic services provider, including a direct accountability for safety on the part of senior management
Annex 11 Provisions (2)
• States shall establish a SSP, in order to achieve an acceptable level of safety in civil aviation – SMM, Doc 9859
• States shall require that an ATS provider implement a SMS acceptable to the State that: – a) identifies safety hazards;
– b) ensures the implementation of remedial action necessary to maintain
agreed safety performance;
– c) provides for continuous monitoring and regular assessment of the safety performance; and
– d) aims at a continuous improvement of the overall performance of the safety management system.
WHY Performance Driven ?
• Performance Based Approach is based on the following three principles: – Strong focus on desired/required results. – Informed decision making, driven by the
desired/required results. – Reliance on facts and data for decision
making.
Strong focus on desired/required results
• In stead of prescribing solutions, desired/required performance is specified.
• Management attention is shifted from a resource and solution centric view (how will we do it) towards a primary focus on desired/required (performance) results (what is the outcome we are expected to achieve).
• This implies finding out – what the current performance situation is, – what the most appropriate results should be, – clarifying who is accountable for achieving those results.
Performance-Based System
Ecological – The world as it is • Aviation system – as pre-specified – is imperfect • Performance based • Process oriented Safety data captured from daily, normal operations
Deterministic – The world as it should be Aviation system – as pre-specified – is perfect Compliance based Outcome oriented Accident/serious incident investigation
Performance-Based Safety: The ABC
A. Senior management’s commitment to the management of safety
B. Initial analysis of system design and risk controls (safety risk management)
C. Continuous safety monitoring and analysis of safety data from normal operations (safety assurance)
Operational drift
Managing Safety Performance
Operational deployment
System design
Operational drift
Baseline performance
Safety Pyramid
Fatal Accidents
Reportable Occurrences
Serious Incidents
ICAO ADREP System (Annex 13)
Accidents
Incidents Additional Prevention
without any harmful consequence
Data collection and forecasting
Quantification of current/expected performance
Application of Performance Policy
Global categorization framework
Tim
e, lo
catio
n an
d st
akeh
olde
r spe
cific
What performance policy will focus on
Definition of Performance Policy
11 standard KPAs
Supporting Metrics
Performance Indicators
Performance Targets
Focus Areas
Instantiated Objectives
Generic Objectives
KPAs
When Where Who
What (specific definition of what will be improved)
What (less general)
What (very general)
Indicator Values
Data
Definitions and qualitative statements
Numbers with a context (time, location, etc.)
(data aggregation + indicator value calculation)
Performance Measurement Taxonomy
Linkage SSP - SMS
SMS • ANSPs Risk Management Process
SSP • CAA Safety Management = ALoSP
Linkage SSP - SMS
CNS
AGA
ATS
AIS
MET
SAR
QA
SMS Safety performance indicators / targets
Values associated with
• Accuracy
• Availability
• Integrity
• Continuity
Risk assessment
Risk probability
Risk severity
Catastroph
ic
A
Hazardou
s
B
Major
C
Minor
D
Negligibl
e
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 management
Intolerable region
Acceptable region The risk is acceptable
as it currently stands
The risk is unacceptable at any level
Tolerable region If the risk can be mitigated, it is acceptable. Cost benefit
analysis required.
As Low
Reasonably Practicable
As
Mayor
Mayor
Minor
ANS Deficiencies - GANDD
• translate into risks against safety of the international civil
aviation
– “U” priority = Urgent requirements having direct impact on
safety and requiring immediate corrective actions
– “A” priority = Top priority requirements necessary for air
navigation safety
– “B” priority = Intermediate requirements necessary for air
navigation regularity and efficiency
Annex 11 ATS Safety Assessment:
2.27.5 Any significant safety-related change to the ATC system, including implementation of a reduced separation minimum or a new procedure, shall only be effected after a safety assessment has demonstrated that an acceptable level of safety will be met and users have been consulted. When appropriate, the responsible authority shall ensure that adequate provision is made for post-implementation monitoring to verify that the defined level of safety continues to be met. Note — When, due to the nature of the change, the acceptable level of safety cannot be expressed in quantitative terms, the safety assessment may rely on operational judgment.
• RVSM = TLS of 5 x 10-9 fatal accidents /aircraft flight hour
Trails
Simulation
Flight validation / verification
PANS-ATM Safety Assessment
PANS-ATM Safety Assessment
Vertical Separation
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Target Level of Safety (TLS)
• ICAO developed quantitative safety metric • Expressed in terms of fatal accidents per flight hour • Adopted by Regional Planning Groups • RMAs estimate safety risk against TLS using ICAO methodology • All RVSM implementations have taken place with estimates of safety risk
that were lower than the TLS • Post-implementation estimates of risk in some regions have exceeded
TLS • Risk estimates against TLS drive all important remedial actions to reduce
safety risk
• An estimate of risk expressed in fatal accidents per flight hour is not a measurement of actual safety
Accident Incident investigation
ICAO Requirements – Annex 13
State of occurrence or conducting investigation. Accident and serious incident
Notification Preliminary report (ADREP)
Final Report Data Report
State of Registry All aircraft Accident > 2,250 All aircraft
State of the Operator All aircraft Accident > 2,250 All aircraft
State of Design All aircraft Accident > 2,250 All aircraft
State of Manufacture All aircraft Accident > 2,250 All aircraft
ICAO >2,250 or turbojet
Accident > 2,250 > 5,700 Acc > 2,250 Inc > 5,700
Others (interests, fatalities, information)
Accident > 2,250 All aircraft
ICAO Requirements – Annex 13
1. State safety policy and objectives 1.1 State safety legislative framework 1.2 State safety responsibilities and accountabilities 1.3 Accident and incident investigation 1.4 Enforcement policy
2. State safety risk management 2.1 Safety requirements for service providers SMS 2.2 Agreement on service providers safety performance
3. State safety assurance 3.1 Safety oversight 3.2 Safety data collection, analysis and exchange 3.3 Safety data driven targeting of oversight on areas of greater concern or need
4. State safety promotion 4.1 Internal training, communication and dissemination of safety information 4.2 External training, communication and dissemination of safety information
ICAO State Safety Programme (SSP) Framework
ICAO Requirements - SSP
Why ECCAIRS ? Implements fully the ADREP taxonomy Contains full suite of tools to collect, analyze, and
exchange safety data Currently being used/evaluated by 53 States and 16
International Organizations representing all regions FREE for: - States - Int’l Organizations - Civil aviation related entities
Why ECCAIRS ?
ECCAIRS as an Enabler Supports culture
• Confidence to use the system • Trust in the information - Danger : loss of integrity • Respect the limitations - Danger : simplification
Measure a limited set of Safety Indicators HOWEVER, Does NOT set Safety Targets, does not
identify safety improvements
Suite of products providing: Data entry and retrieval Analysis Utilities System tools Data integration Data dissemination
Why ECCAIRS ?
ECCAIRS Usage
Incident
Investigation
Analysis Data entry
Initial Notification
As an investigation tool Can be used as a checklist. Contains most of the required topics of a final
report. Is able to support analysis and conclusions Includes safety recommendations
ECCAIRS Usage
Factual information example
Format • History of flight:
– Flight number – Type of operation – Last point of departure – Time of departure (local time or
UTC) – Point of intended landing. – Flight preparation – Description of the flight and
events leading to the accident, including reconstruction of the significant portion of the flight path, if appropriate.
– Location (latitude, longitude, elevation)
– Time of the accident (local time or UTC), whether day or night.
ECCAIRS
Chain of Events
Safety recommendations
Occurrence Classification
Class: According to severity
Category: Accident/incident types
Occurrence Classification
Accident Serious incident Incident Major incident Significant incident
Occurrence without safety effect Not determined
Occurrance…
• Identify the occurrence class – Controlled flight into terrain only marginally avoided. – Aborted take-offs on a closed or engaged runway, on a taxiway1
or unassigned runway. – Landings or attempted landings on a closed or engaged runway,
on a taxiway1 or unassigned runway. – Gross failures to achieve predicted performance during take-off
or initial climb. – Events requiring the emergency use of oxygen by the flight crew. – Multiple malfunctions of one or more aircraft systems seriously
affecting the operation of the aircraft. – Flight crew incapacitation in flight. – Fuel quantity requiring the declaration of an emergency by the
pilot.
Occurrence Categories
36 categories Representative of the occurrence More than one can be selected
List of categories
1. ADRM: Aerodrome 2. AMAN: Abrupt maneuvre 3. ARC: Abnormal runway contact 4. ATM: ATM/CNS 5. BIRD: Birdstrike 6. CABIN: Cabin safety events 7. CFIT: Controlled flight into terrain 8. CTOL: Collisions with obstacle (s) during take-off or landing 9. EXTL: External load occurrences 10. EVAC: Evacuation 11. F-NI: Fire/Smoke (non-impact) 12. F-POST: Fire/smoke (post-impact)
13. FUEL: Fuel related 14. GCOL: Ground collision 15. GTOW: Glider towing related events 16. ICE: Icing 17. LALT: Low altitude operations 18. LOC-G: Loss of control – ground 19. LOC-I: Loss of control – inflight 20. LOLI: Loss of lifting conditions en-route 21. MAC: AIRPROX/near miss/midair collsion 22. RAMP: Ground handling 23. RE: Runway excursion 24. RI-A: Runway incursion – animal
List of categories
25. RI-VAP: Runway incursion – vehicle, a/c or person 26. RI-O: Runway incursion – other 27. RI-VA: Runway incursion – vehicle or a/c 28. SCF-NP: System/component failure or malfunction (non-
powerplant) 29. SCF-PP: Powerplant failure or malfunction 30. SEC: Seurity related 31. TURB: Turbulence encounter 32. UIMC: Unintended flight in IMC 33. USOS: Undershoot/overshoot 34. WSTRW: Windshear or thunderstorm 35. OTHR: Other 36. UNK: Unknown or undetermined
List of categories
Delivering ALoS – Safety action plans
• Tools and means to deliver the safety targets of an SSP: 1. Regulations 2. Training 3. Technology
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SMS implementation phases – Summary
PHASE I
Planning SMS Elements:
1.1; 1.2; 1.3 and 1.5 ; [and 1.4]
PHASE II
Implementation of reactive safety management
processes Elements: 2.1 and 2.2
PHASE III
Implementation of proactive and
predictive safety management
processes Elements: 2.1 and 2.2
PHASE IV
Implementation of operational safety
assurance Elements:
1.1; 3.1; 3.2 ;3.3 4.1 and 4.5
Timeline
Develop documentation – Element 1.5
Develop and establish means for safety communication – Element 4.2
Develop and deliver training – Element 4.1
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System today
47
State Civil Aviation Authority
State Civil Aviation Authority
Safety
measurement
Capture
Storage
Service providers
Airport N° 1
Airport N° 2
Airport N° 3
Initial ALoS
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State Civil Aviation Authority
State Civil Aviation Authority
Safety
measurement
Capture
Storage
Service providers
Airport N° 1
Airport N° 2
Airport N° 3
Initial ALoS
Initial ALoS
49
State Civil Aviation Authority
State Civil Aviation Authority
Protected safety
data
Capture
Storage
Process
Analysis
Service providers
Airport N° 1
Airport N° 2
Airport N° 3
Initial ALoS
Exchange of protected safety data
Safety data collection & processing system
Mature ALoS
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State Civil Aviation Authority
State Civil Aviation Authority
Protected safety
data
Capture
Storage
Process
Analysis
Service providers
Airport N° 1
Airport N° 2
Airport N° 3
Initial ALoS
Exchange of protected safety data
Safety data collection & processing system
Summary
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Set o
f act
ivitie
s Se
t of a
ctivi
ties
ATS Service provider
Aerodrome operator AMO Aircraft
operator N° 1
SSP (ALoS)
ATS Service provider
Aerodrome operator AMO
Aircraft operator N° 2
Training organization
SMS SMS SMS SMS SMS
State accepts and oversees individual service providers’ SMS
Safety performance
State accepts and oversees individual service providers’ SMS
State agrees and supervises individual service provider’s SMS safety performance
Safety performance Safety performance Safety performance Safety performance
Safety performance Safety performance Safety performance Safety performance Safety performance
Training organization
SMS SMS SMS SMS SMS
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