ICAO Safety Management Systems (SMS) Course Module N° 4 – Hazards

Revision N° 11 ICAO Safety Management Systems (SMS) Course 29/09/08

Module N° 4 – Hazards

Module N° 4 ICAO Safety Management Systems (SMS) Course 2

Building an SMS

Module 1 SMS course introduction

Module 2 Basic safety

concepts

Module 3 Introduction

to safety management

Module 4 Hazards

Module 5 Risks

Module 6 SMS regulation

Module 7 Introduction to SMS

Module 8 SMS planning

Module 9 SMS operation

Module 10 Phased approach to SMS Implementation

Safety Management System

Module 3 Introduction

to safety management

Module 4 Hazards

Module 5 Risks

Management

Module N° 4 ICAO Safety Management Systems (SMS) Course 3

Objective

At the end of this module, participants will be able to apply

the fundamentals of hazard identification and analysis

through a case study.

Module N° 4 ICAO Safety Management Systems (SMS) Course 4

Outline

Two definitions First fundamental – Understanding hazards Second fundamental – Hazard identification Third fundamental – Hazard analysis Fourth fundamental – Documentation of hazards Questions and answers Points to remember Exercise 04/01 – International airport construction project (See Handout N° 3)

ICAO Safety Management Systems (SMS) Course Module N° 4 – Hazards

Module N° 4 ICAO Safety Management Systems (SMS) Course 5

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. Consequence – Potential outcome(s) of the hazard.

A wind of 15 knots blowing directly across the runway is a hazard. The potential that a pilot may not be able to control the aircraft during takeoff or landing is one of the consequences of the hazard.

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First fundamental – Understanding hazards

There is a natural tendency to describe hazards as their consequence(s).

“Unclear aerodrome signage” vs. “runway incursion”

Stating a hazard as consequence(s) disguises the nature of the hazard interferes with identifying other important consequences.

Well-named hazards allow to infer the sources or mechanisms of the hazard allow to evaluate the loss outcome(s).

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First fundamental – Understanding hazards

Types of hazards

Natural

Technical

Economic

Module N° 4 ICAO Safety Management Systems (SMS) Course 8

Examples of natural hazards

Severe weather or climatic events:

E.g.: hurricanes, major winter storms, drought, tornadoes, thunderstorms lighting, and wind shear.

Adverse weather conditions: E.g.: Icing, freezing precipitation, heavy rain, snow, winds, and restrictions to visibility.

ICAO Safety Management Systems (SMS) Course Module N° 4 – Hazards

Module N° 4 ICAO Safety Management Systems (SMS) Course 9

Examples of natural hazards

Geophysical events: E.g.: earthquakes, volcanoes, tsunamis, floods and landslides.

Geographical conditions: E.g.: adverse terrain or large bodies of water.

Environmental events: E.g.: wildfires, wildlife activity, and insect or pest infestation.

Public health events: E.g.: epidemics of influenza or other diseases.

Module N° 4 ICAO Safety Management Systems (SMS) Course 10

Examples of technical hazards Deficiencies regarding:

E.g.: aircraft and aircraft components, systems, subsystems and related equipment. E.g.: an organization’s facilities, tools, and related equipment. E.g.: facilities, systems, sub- systems and related equipment that are external to the organization.

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Examples of economics hazards

Major trends related to:

Growth.

Recession.

Cost of material or equipment.

Etc.

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Second fundamental – Hazard identification

In order to identify hazards, consider:

Design factors, including equipment and task design.

Procedures and operating practices, including documentation and checklists.

Communications, including means, terminology and language.

…

ICAO Safety Management Systems (SMS) Course Module N° 4 – Hazards

Module N° 4 ICAO Safety Management Systems (SMS) Course 13

Second fundamental – Hazard identification

… consider: 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. …

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Second fundamental – Hazard identification

… consider: 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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Sources of hazard identification Internal

Flight Data Analysis Company voluntary reporting system Audits and surveys

External Accident reports State mandatory occurrence system

As a reminder Predictive Proactive Reactive

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Hazard identification

By whom? By anybody By designated personnel

How? Through formal processes Depends on the organization

When? Anytime Under specific conditions

ICAO Safety Management Systems (SMS) Course Module N° 4 – Hazards

Module N° 4 ICAO Safety Management Systems (SMS) Course 17

Hazard identification

Specific conditions

Unexplained increase in safety-related events or infractions.

Major operational changes are foreseen.

Periods of significant organizational change.

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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 consequence(s) Aircraft colliding with construction equipment Aircraft taking wrong taxiway …

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Third fundamental – Hazard analysis

Efficient and safe operations or provision of service require a constant balance between production goals…

maintaining regular aerodrome operations during a runway construction project

…and safety goals maintaining existing margins of safety in aerodrome operations during runway construction project

Aviation workplaces may contain hazards which may not be cost-effective to address even when operations must continue (further discussed in Module 5).

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Fourth fundamental – Documentation of hazards

Appropriate documentation management is important as:

It is a formal procedure to translate operational safety data into hazard- related information. It becomes the “safety library” of an organization.

ICAO Safety Management Systems (SMS) Course Module N° 4 – Hazards

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Fourth fundamental – Documentation of hazards

Tracking and analysis of hazards is facilitated by standardizing:

Definitions Understanding Validation Reporting Measurement Management

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Fourth fundamental – Documentation of hazards

Reactive method •ASR •MOR •Incident reports •Accident reports

Proactive method •ASR •Surveys •Audits

Predictive method •FDA •Direct observation systems

Method Identification Management Documentation Information

Inform person(s)

responsible for implementing

strategies

Trend analysis

Ha za

rd s

Ha za

rd s

Ha za

rd s

Ha za

rd s

FeedbackFeedback

Develop control and mitigation

strategies

Assign responsibilities

Implement strategies

Safety bulletins

Report distribution

Seminars and workshops

Assess the consequences and prioritize

the risks

Safety management information

Re-evaluate strategies

and processes

Module N° 4 ICAO Safety Management Systems (SMS) Course 23

The focus of hazard identification Hazard identification is a wasted effort if restricted to the aftermath of rare occurrences where there is serious injury, or significant damage.

1 1 –– 55 AccidentsAccidents

30 30 –– 100100 Serious incidentsSerious incidents

100 100 –– 10001000 IncidentsIncidents

1000 1000 –– 40004000 Latent conditionsLatent conditions

“Practical drift”

“Practical drift” SMS

Module N° 4 ICAO Safety Management Systems (SMS) Course 24

The focus of hazard identification Hazard identification is a wasted effort if restricted to the aftermath of rare occurrences where there is serious injury, or significant damage.

1 1 –– 55 AccidentsAccidents

30 30 –– 100100 Serious incidentsSerious incidents

100 100 –– 10001000 IncidentsIncidents

1000 1000 –– 40004000 Latent conditionsLatent conditions

“Practical drift”

“Practical drift” SMS

ICAO Safety Management Systems (SMS) Course Module N° 4 – Hazards

Module N° 4 ICAO Safety Management Systems (SMS) Course 25

Questions and answers Hazards

Module N° 4 ICAO Safety Management Systems (SMS) Course 26

Questions and answers

Q: Define the concept of hazard. A:

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.

Slide number: 5

Module N° 4 ICAO Safety Management Systems (SMS) Course 27

Questions and answers

Q: Provide three examples of areas/factors to consider when identifying hazards. A:

Design factors, including equipment and task design. Procedures and operating practices, including documentation and checklists. Communications, including means, terminology and language

Slide number: 12

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Questions and answers

Q: Name three specific circumstances when hazard identification is essential.

A:

Unexplained increase in safety-related events or infractions.

Major operational changes are foreseen.

Periods of significant organizational change.

Slide number: 17

ICAO Safety Management Systems (SMS) Course Module N° 4 – Hazards

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Points to remember

1. Hazards have potential consequences.

2. Sources of hazard identification

3. ABC of hazard management.

4. Hazard documentation: the “safety library” of an

organization.

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Hazards

Exercise 04/01 – International airport construction project (Handout N° 3)

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International airport construction project

Group activity: A facilitator will be appointed, who will coordinate the discussion. A summary of the discussion will be written on flip charts, and a member of the group will brief on their findings in a plenary session.

Scenario: Construction project to extend and repave one of the two crossing runways at an international airport (100,000 movements a year).

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Aerodrome layout

ICAO Safety Management Systems (SMS) Course Module N° 4 – Hazards

Module N° 4 ICAO Safety Management Systems (SMS) Course 33

Three-phase construction project

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Scope of the work

Phase 1: Extend the length of RWY 09-27 by 900 meters westward and width from 30 to 45 meters from a point 100 m from the intersection with RWY 18-36, and strengthen the runway extension (from asphalt to concrete) to increase its Pavement Classification Number (PCN). Extend the length of TWY Delta by 900 meters westward. Estimated time to complete the work:

Seven (7) months.

Module N° 4 ICAO Safety Management Systems (SMS) Course 35

Scope of the work

Phase 2:

Construct and enlarge new threshold entrance and holding zone at TWY Charlie.

Extend the width of RWY 09-27 from 30 to 45 meters and strengthen (from asphalt to concrete) this part of the runway up to a point 200 m before intersection TWY A-B to increase its PCN.

Estimated time to complete the work:

Five (5) months.

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Scope of the work

Phase 3:

Complete the construction work of RWY 09-27 for the central area of the last 350 m at the intersection of RWY 09-27 and RWY 18-36 (from asphalt to concrete), increase its width from 30 to 45 meters and its PCN.

Estimated time to complete the work:

Two (2) months.

ICAO Safety Management Systems (SMS) Course Module N° 4 – Hazards

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Scope of the work

Runway 18-36 utilization during the construction work

Continuous utilization of RWY 18-36 during the three-

phase construction project.

RWY 18-36 length is 3.850 m and the distance available

from threshold RWY 18 to intersection RWY 09-27 is

2.600 m.

Information must be provided to airport users.

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Identify hazards

Your task Identify the hazards using brainstorming techniques.

Brainstorm a list of possible hazards, their components and their consequences (use a flip chart).

Complete the attached log (Table 04/01) as follows: List type of operation or activity State the generic hazard (hazard statement) Identify specific components of the hazard List hazard-related consequences

It is recommended to conduct the analysis per phase of construction.

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Table 04/01 – Hazard identification Type of

operation or activity

Generic hazard (hazard statement)

Specific components of

the hazard N°

1

2

3

4

5

Hazard-related consequences

Revision N° 11 ICAO Safety Management Systems (SMS) Course 29/09/08

Module N° 4 – Hazards

ICAO Safety Management Systems (SMS) Course Module N° 3 – Introduction to safety management

Revision N° 11 ICAO Safety Management Systems (SMS) Course 29/09/08

Module N° 3 – Introduction to safety management

Module N° 3 ICAO Safety Management Systems (SMS) Course 2

Building an SMS

Module 1 SMS course introduction

Module 2 Basic safety

concepts

Module 3 Introduction

to safety management

Module 4 Hazards

Module 5 Risks

Module 6 SMS regulation

Module 7 Introduction to SMS

Module 8 SMS planning

Module 9 SMS operation

Module 10 Phased approach to SMS Implementation

Safety Management System

Module 3 Introduction

to safety management

Module 4 Hazards

Module 5 Risks

Management

Module N° 3 ICAO Safety Management Systems (SMS) Course 3

Objective

At the end of this module, participants will be able to

explain the need for, the strategies and the key features of

safety management.

Module N° 3 ICAO Safety Management Systems (SMS) Course 4

Outline

The safety stereotype The management dilemma Need for safety management Strategies for safety management The imperative of change Safety management – Eight building blocks Four responsibilities for managing safety Questions and answers Points to remember Exercise Nº 03/01 – The Anyfield Airport accident (See Handout N° 2)

ICAO Safety Management Systems (SMS) Course Module N° 3 – Introduction to safety management

Module N° 3 ICAO Safety Management Systems (SMS) Course 5

The safety stereotype

Module N° 3 ICAO Safety Management Systems (SMS) Course 6

Is it?

Module N° 3 ICAO Safety Management Systems (SMS) Course 7

Really?

Module N° 3 ICAO Safety Management Systems (SMS) Course 8

What is the fundamental objective of a business organization?

ICAO Safety Management Systems (SMS) Course Module N° 3 – Introduction to safety management

Module N° 3 ICAO Safety Management Systems (SMS) Course 9

Safety management – Rationale

In order to achieve its production objectives, the management of any aviation organization requires the management of many business processes.

Managing safety is one such business process.

Safety management is a core business function just as financial management, HR management, etc.

This brings about a potential dilemma for management.

Module N° 3 ICAO Safety Management Systems (SMS) Course 10

The management dilemma

Management levels

Protection Production

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The management dilemma

Management levels

Protection

Production

Catastrophe Module N° 3 ICAO Safety Management Systems (SMS) Course 12

The management dilemma

Protection

Production

Man age

men t lev

els

Bankruptcy

ICAO Safety Management Systems (SMS) Course Module N° 3 – Introduction to safety management

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Saf ety

spa ce

Bankruptcy

Catastrophe

Production

P ro

te ct

io n

Safety space

Financial management ?

Safety management

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Safety management – The response to the dilemma

Safety issues are a by-product 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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Why SM ? – The first ultra-safe industrial system

Fragile system (1920’s -1970’s) Individual risk management & intensive training Accident investigation

Safe system (1970’s – mid 1990’s) Technology and regulations Incident investigation

Ultra-safe system (mid 1990’s onwards) Business management approach to safety (SMS) Routine collection and analysis of operational data Less than one catastrophic

breakdown per million production cycles

10-3

10-5

10-7

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Why SM? An imperfect system

“Practical drift”

Operational deployment

System design

Baseline performance

Operational performance

Baseline performance

Operational deployment

Baseline performance

Operational performance

“Practical drift”

SMS

ICAO Safety Management Systems (SMS) Course Module N° 3 – Introduction to safety management

Module N° 3 ICAO Safety Management Systems (SMS) Course 17

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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Navigating the drift

“Practical drift”Operational performance

Baseline performance

Organization

Navigational aids

Reactive Proactive Predictive

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Reactive safety management

Investigation of accidents and serious incidents Based upon the notion of waiting until something breaks to fix it. Most appropriate for:

situations involving failures in technology. unusual events.

The contribution of reactive approaches to safety management depends on the extent to which the investigation goes beyond the triggering cause(s), and includes contributory factors and findings as to risks.

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Proactive safety management

Mandatory and voluntary reporting systems, safety audits and surveys.

Based upon the notion that system failures can be minimized by:

identifying safety risks within the system before it fails; and

taking the necessary actions to reduce such safety risks.

ICAO Safety Management Systems (SMS) Course Module N° 3 – Introduction to safety management

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Predictive safety management

Confidential reporting systems, flight data analysis, normal operations monitoring.

Based upon the notion that safety management is best accomplished by looking for trouble, not waiting for it.

Aggressively seek information from a variety of sources which may be indicative of emerging safety risks.

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Strategies – Summary

Reactive methodReactive method

The reactive method The reactive method responds to theresponds to the

events that already events that already happened, such ashappened, such as

incidents and incidents and accidentsaccidents

Proactive methodProactive method

The proactive The proactive method method

looks actively for the looks actively for the identification ofidentification of

safety risks safety risks through the analysis through the analysis of the organizationof the organization’’s s

activitiesactivities

Predictive methodPredictive method

The predictiveThe predictive method captures method captures

systemsystem performance as performance as

it happens in it happens in realreal–time time

normal operationsnormal operations

Module N° 3 ICAO Safety Management Systems (SMS) Course 23

Strategies – Levels of intervention and tools

“Practical drift” Operational performance

Baseline performance

Organization

Predictive

Highly efficient

FDA Direct

observation system

Proactive

Very efficient

ASR Surveys Audits

Reactive

ASR MOR

Efficient Insufficient

Accident and incident

reports

ReactivePredictive

Highly efficient

FDA Direct

observation system

Proactive

Very efficient

ASR Surveys Audits

Reactive

ASR MOR

Efficient

Desirable management levels

Module N° 3 ICAO Safety Management Systems (SMS) Course 24

The imperative of change

As global aviation activity and complexity continues to

grow, traditional methods for managing safety risks to an

acceptable level become less effective and inefficient.

Evolving methods for understanding and managing safety

risks are necessary.

ICAO Safety Management Systems (SMS) Course Module N° 3 – Introduction to safety management

Module N° 3 ICAO Safety Management Systems (SMS) Course 25

The changing of the guard

Traditional – Accident/serious incident investigation Aviation system performs most of the time as per design specifications (base line performance). Compliance based. Outcome oriented.

Evolving – Safety management Aviation system does not perform most of the time as per design specifications (practical drift). Performance based. Process oriented.

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Safety management – Eight building blocks

Senior management’s commitment to the management

of safety.

Effective safety reporting.

Continuous monitoring through systems to collect,

analyse, and share safety-related data arising from

normal operations.

Module N° 3 ICAO Safety Management Systems (SMS) Course 27

Safety management – Eight building blocks

Investigation of safety occurrences with the objective of

identifying systemic safety deficiencies rather than

assigning blame.

Sharing safety lessons learned and best practices

through the active exchange of safety information.

Integration of safety training for operational personnel.

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Safety management – Eight building blocks

Effective implementation of Standard Operating Procedures (SOPs), including the use of checklists and briefings.

Continuous improvement of the overall level of safety.

The result of implementing the eight building blocks: An organizational culture that fosters safe practices,

encourages effective safety communication, and actively manages safety with the same attention to

results as financial management.

ICAO Safety Management Systems (SMS) Course Module N° 3 – Introduction to safety management

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Responsibilities for managing safety

These responsibilities fall into four basic areas:

Definition of policies and procedures regarding safety.

Allocation of resources for safety management

activities.

Adoption of best industry practices.

Incorporating regulations governing civil aviation

safety. Module N° 3 ICAO Safety Management Systems (SMS) Course 30

The safety management process at a glance

Safety management

process

Identify hazards

Assess risks

Prioritize risks

Develop elimination/ mitigation strategies

Approve control

strategies Assign

responsibilities

Implement control

strategies

Re-evaluate control

strategies

Collect additional

hazard data

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In summary

Managing safety requires resources.

Allocation of resources is a managerial function.

Management has the authority and the responsibility to

manage safety risks in the organization.

Management thus is accountable for safety outcome.

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In summary

Safety management Includes the entire operation Focus on processes (Clear difference between processes and outcomes) Data-driven (constant monitoring) Strictly documented Gradual improvement as opposed to dramatic change Strategic planning as opposed to piecemeal initiatives

ICAO Safety Management Systems (SMS) Course Module N° 3 – Introduction to safety management

Module N° 3 ICAO Safety Management Systems (SMS) Course 33

A balanced perspective

…The pilot-in-command must bear responsibility for the

decision to land and take-off in Dryden… However, it is

equally clear that the air transportation system failed

him by allowing him to be placed in a situation where he

did not have all the necessary tools that should have

supported him in making the proper decision …

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Question and answers Introduction to safety management

Module N° 3 ICAO Safety Management Systems (SMS) Course 35

Questions and answers

Q: Explain the management dilemma regarding safety management. A:

Management levels

Protection Production

Slide number: 10

Module N° 3 ICAO Safety Management Systems (SMS) Course 36

Questions and answers

Q: Explain the difference between reactive, proactive and predictive safety strategies. A:

Slide number: 22

Reactive methodReactive method

The reactive method The reactive method responds to theresponds to the

events that already events that already happened, such ashappened, such as

incidents and incidents and accidentsaccidents

Proactive methodProactive method

The proactive The proactive method method

looks actively for the looks actively for the identification ofidentification of

safety risks safety risks through the analysis through the analysis of the organiza