Presented by. John McGraw. San Juan, Puerto Rico. January 27, 2015

Transcription

1 2015 SMS

2 Presented by John McGraw San Juan, Puerto Rico January 27, Page 1

3 Brief Evolution of Safety What is SMS? Regulatory Update Core Components Company Safety Culture SMS Tools Your Questions Seminar Topics: 2 Page 2

4 Evolution of Safety Where we ve been: A brief history 3 Page 3

5 Evolution of Safety Safety Eras: Machine Period Human Period Organizational Period From Mike Doiron, Moncton Flight College, New Brunswick 4 Page 4

6 Fly Fix Fly Evolution of Safety Machine Period: 1920 s 1960 s Quick development of safety fixes Improvements to engines, airframe, systems, design and airworthiness standards Responded to high incidence of mechanical based accidents Blame and Train philosophy 5 Page 5

7 Evolution of Safety Human Period: 1960 s 1970 s Response to the 70-80% of human factor accidents Focus on human / machine interface Ergonomics, crew resource management, decision making Emphasis on inter-relationships Improved selection, training 6 Page 6

8 Evolution of Safety Organizational Period: 1980 s 1990 s Focus on organization and management Response to underlying factors which set up accident potential The Reason Model of organizational failure Attempt to explain why accidents continue to occur and identify organizational influences 7 Page 7

9 Evolution of Safety James Reason s Swiss Cheese Model Defenses??? Decision-Makers Line Management Line Activities Organizational Preconditions, i.e., Company Culture Adapted from Human Error: Models & Management, Dr. James Reason, University of Manchester 8 Page 8

10 Evolution of Safety Active Failures: Unsafe acts committed by people who are in direct contact with the system. These failures consist of: slips, lapses, mistakes, procedural violations, etc. Followers of this person approach often look no further for the causes of an adverse event once they have identified the unsafe acts. 9 Page 9

11 Evolution of Safety Latent Conditions: Conditions that are resident within the system, and arise from decisions made by designers, builders, procedure writers, top management, etc. Translate into error-provoking conditions within the workplace, such as: time pressure, understaffing, inadequate equipment, fatigue, inexperience, etc. Create long-lasting holes or weaknesses in the defenses. 10 Page 10

12 Evolution of Safety Latent Conditions (cont.): Might lie dormant within the system for many years before combining with active failures to create an accident opportunity. Can be identified and remedied before an adverse event occurs. Understanding this leads to proactive risk management. 11 Page 11

13 Organizational Influences James Reason s Swiss Cheese Model Defenses??? Decision-Makers Line Management Line Activities Organizational Preconditions, i.e., Company Culture Adapted from Human Error: Models & Management, Dr. James Reason, University of Manchester 12 Page 12

14 Study of Organizational Influences in Accidents 1. Inadequate procedures or directives (21%), e.g., ill-defined or conflicting policies, no formal oversight of operation. 2. Inadequate training (initial/upgrade) (18%), e.g, opportunities for training not implemented or available. 3. Inadequate surveillance of operations (13%), e.g., organizational climate issues, chain-of-command, quality assurance and trend information. 4. Insufficient standards/requirements (12%), e.g, clearly defined objectives, adherence to policy. 5. Inadequate information sharing (12%), e.g., logbooks, etc. 13 Page 13

15 Study of Organizational Influences in Accidents 6. Inadequate supervision of operations by management (10%), e.g., failure to provide oversight, guidance, etc. 7. Company/management induced pressure (6%), e.g., threats to job status, pay, etc. 8. Faulty documentation (4%), e.g., checklists, signoffs, etc. 9. Inadequate substantiation process (1%), e.g, well-defined, verified process, accountability, standards of operation. 10. Inadequate facilities/facilities management (1%), e.g., inadequate environmental controls, lighting, etc. 14 Page 14

16 Organizational Influences Types of Organizations Pathological Bureaucratic Generative From Complex Organizations: Growth, Struggle and Change, Ron Westrum 15 Page 15

17 Organizational Influences Pathological Organization Blame the messenger Hide information Cover up failure Crush new ideas Shirk responsibility No employee/employer bridging 16 Page 16

18 Organizational Influences Whack-a-Mole Theory of Safety Management 17 Page 17

19 Organizational Influences Bureaucratic Organization Very structured process Lacks flexibility Paperwork & meetings, meetings, meetings Sometimes effective 18 Page 18

20 Organizational Influences Generative Organization Actively seek information Shared responsibility Welcome new ideas Continuous evaluation Employee/employer bridging rewarded 19 Page 19

21 How We View Safety What is Safety? 20 Page 20

22 The Traditional View No Accidents = Safety 21 Page 21

23 The Traditional View We rely on past success to determine if the operation is safe. 22 Page 22

24 What is Safety? Freedom from harm (Dictionary definition) Safety is not equivalent to risk free (U.S. Supreme Court, 1980) Risk management is a more practical term than safety. (Jerome Lederer ~1928) Carelessness and overconfidence are more dangerous than deliberately accepted risk (Wilbur Wright, 1901) Practical safety is risk management 23 Page 23

25 Safety Defined 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. -- ICAO Safety Management Manual (Doc 9859) 24 Page 24

26 Our Role We are Risk Managers 25 Page 25

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29 28 Page 28

30 Understanding Human Error Human error is considered a contributing factor in most aviation occurrences. Even competent individuals commit errors. Errors must be accepted as a normal component of any system where humans and technology interact. 29 Page 29

31 FAA: 12 Main Causes of Human Error The Dirty Dozen Lack of Communication Complacency Lack of Knowledge Distraction Lack of Teamwork Fatigue Lack of Resources Pressure Lack of Assertiveness Stress Lack of Situational Awareness Norms 30 Page 30

32 How We Judge Human Error: That point where the assumed omnipotence of the participant failed to meet the expectations of the reviewer. 31 Page 31

33 Key SMS Concept Hazard Identification & Risk Management 32 Page 32

34 Company Culture Safety is Our Top Priority. 33 Page 33

35 Company Culture Priority: A precedence established by order of importance or urgency. 34 Page 34

36 Company Culture Safety as a core value. 35 Page 35

37 Company Culture Value: A principle, standard, or quality considered worthwhile or desirable. 36 Page 36

38 Company Culture As your business needs change, so will the needs and focus of safety. However, as a core value it will always be present. 37 Page 37

39 Key SMS Concept Company safety culture flows from the top down. It cannot be mandated or designed, it evolves. 38 Page 38

40 Company Culture Characteristics of a Positive Safety Culture: 1. Leadership and commitment of top management. 2. Safety role of line management. 3. Involvement of all employees. 4. Effective communications and commonly understood and agreed goals. 5. Learning and responsiveness to change. 6. Attention to workplace safety and health. 7. A questioning attitude and a rigorous and prudent approach by everyone. 39 Page 39

41 Company Culture High Reliability Organization (HRO): An organization that has succeeded in avoiding catastrophy in an environment where normal accidents can be expected due to risk factors and complexity. 40 Page 40

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43 Company Culture Traits of a Healthy Culture (HROs): Preoccupation with failure (track small failures) Reluctance to (over)simplify Sensitivity to operations Commitment to resilience (ability to recover) Deference to expertise 42 Page 42

44 Company Culture So what do HROs do? Process Auditing Vigilance for Quality Degradation Reward System Perception of Risk Leadership and Supervision 43 Page 43

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46 SMS Defined A systemic approach to managing safety, including the necessary organizational structures, accountabilities, policies and procedures. -- ICAO Safety Management Manual (Doc 9859) 45 Page 45

47 SMS Characteristics SMS: Provides a foundation to organize safety through planning, goal setting, training, program implementation and performance measurement Is information and data driven Is a business-like approach to safety management Is based upon best practices 46 Page 46

48 Management Dilemma Resources Management levels Resources Protection Production 47 Page 47

49 Management Dilemma Protection Production Catastrophe

50 Management Dilemma Production Protection Bankruptcy

51 Navigating the Drift Bankruptcy Protection Safety Space Catastrophe Production 50 Page 50

52 Navigating the Drift Murphy s Law is wrong: Everything that can go wrong usually goes right, and then we draw the wrong conclusion. --William Langewiesche 51 Page 51

53 Navigating the Drift Strategies: Discourage cutting corners Don t give mixed messages Empower employees Ask questions Listen to everyone Develop a systematic approach to managing risk 52 Page 52

54 ICAO Requirements: Commercial Operators ICAO Annex 6 (Operation of Aircraft), Part 1 (Commercial Air Transport): 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 53 Page 53

55 ICAO Requirements: Private Operators ICAO Annex 6, Part 2 (International General Aviation), as of November 2010, requires for Large and Turbo-Jet Airplanes: SMS Operations manual Fatigue management system Operational control procedures Flight crew training program MEL (if an MMEL has been established) Maintenance program 54 Page 54

56 Annex 6, Part 2 SMS Requirements Safety Management System An operator shall establish and maintain a safety management system that is appropriate to the size and complexity of the operation Recommendation. The safety management system should as a minimum include: a) a process to identify actual and potential safety hazards and assess the associated risks; b) a process to develop and implement remedial action necessary to maintain an acceptable level of safety; and c) provision for continuous monitoring and regular assessment of the appropriateness and effectiveness of safety management activities. 55 Page 55

57 FAA Requirements: Commercial Operator Part 121 air carriers are now required to implement a safety management system (SMS) New rule was issued January Operators have 36 months to comply AC B issued as well 56 Page 56

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59 InFO: SMS for General Aviation Operators Several third-party organizations have developed materials that meet the ICAO SMS standards for GA operations and sponsor practices to validate these programs implementation. Third party organizations offering SMS services include: International Business Aviation Council (IBAC): International Standard for Business Aviation Operations (IS-BAO), Air Charter Safety Foundation (ACSF) Industry Audit Standard, and Medallion Foundation in Alaska. 58 Page 58

60 SMS: Core Components 59 Page 59

61 Four Components of SMS 1. Safety Policy 2. Safety Risk Management 3. Safety Assurance 4. Safety Promotion 60 Page 60

62 SMS Component 1: Safety Policy 1. Safety Policy: All management systems must define policies, procedures, and organizational structures to accomplish their goals. Policy establishes the structure of the SMS. 61 Page 61

63 SMS Components 2 & 3: SRM and Safety Assurance 2. Safety Risk Management (SRM): A formal system of hazard identification, analysis and risk management is essential in controlling risk to acceptable levels. 3. Safety Assurance: Once controls are identified, the SMS must assure they are continuously practiced and continue to be effective in a changing environment. 62 Page 62

64 SMS Component 4: Safety Promotion 4. Safety Promotion: The organization must promote safety as a core value with practices that support a positive safety culture. 63 Page 63

65 SMS References Industry Information and Guidance: ACSF SMS resource page: FltPlan.com SMS Tools: FAA SMS Homepage: ICAO Safety Management Manual (9859): Transport Canada - Introduction to SMS: Risk Management and Decision-Making Guide, TP Page 64

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67 Contact Information Russ Lawton: Phone: or Mail: Air Charter Safety Foundation 818 Connecticut Ave. NW Washington, DC Page 66

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