Safety Management System

Transcription

1 Safety Management System SMS Program Office Version Date: 6/23/2008

2 Reminders Cell Phones on vibrate Restrooms, fire exits, etc. Questions are welcome, just raise your hand. Please complete the attendance sheet Introductions SL-2-INT

3 Objective By the end of this briefing, you will be able to: Discuss at a high level the concept of a Safety Management System SL-3-INT

4 What is Safety? Freedom from harm (dictionary definition) Safety is not equivalent to risk free (U.S. Supreme Court, 1980) Carelessness and overconfidence are more dangerous than deliberately accepted risk (Wilbur Wright, 1901) Risk management is a more practical term than safety. (Jerome Lederer ~1928) SL-4-INT

5 Concept of Safety Safety is the state in which the risk of harm to persons or property is reduced to, and maintained at or below, an acceptable level through a continuing process of hazard identification and risk management ICAO Doc 9859 SL-5-INT

6 Traditional approach Preventing accidents Focus on outcomes (causes) Unsafe acts by operational personnel Attach blame/punish for failures to perform safely Address identified safety concern exclusively Identifies: WHAT? WHO? WHEN? But not always discloses: WHY? HOW? SL-6-INT

7 Heinrich Theory Accidents 1 Reactive Unreported Incidents Proactive SL-7-INT

8 Departure (millions) / Rate per million Accidents Projected Traffic Growth and Accident Rates Projected Traffic Growth and Accident Rate Number of Commercial Jet Accidents, Accident Rate and Traffic Growth - Past, Present and Future Accidents Traffic Growth 1 Based on current accident rate 2 Based on industry estimates 3 Based on current accident rate Accident Rate Year Adapted from the Flight Safety Foundation (1997) apted Weigmann from Flight & Shappell Safety Foundation (2002) (1997) appell & Wiegmann, 2002 SL-8-INT

9 TODAY The Evolution of Safety Thinking TECHNICAL FACTORS HUMAN FACTORS ORGANIZATIONAL FACTORS 1950s 1970s 1990s 2000s SL-9-INT

10 Why Change Our Thinking about Safety? Business case Safety case SL-10-INT

11 What is the Fundamental Objective of a Business Organization? SL-11-INT

12 The Business Case Aviation organization management requires managing many business processes. Safety management is a core business function just as financial management, HR management, etc. This constitutes a management challenge. SL-12-INT

13 The Management Challenge 1st View Management levels Protection Production SL-13-INT

14 The Management Challenge 2 nd View Protection Production Catastrophe SL-14-INT

15 The Management Challenge 3 rd View Production Bankruptcy Protection SL-15-INT

16 Protection Safety Space Bankruptcy Source: James Reason Production Catastrophe ICAO Doc. 9859, Sec SL-16-INT

17 Safety Management System Infuses safety into all parts of the system People Tools Procedures Materials Equipment Software Management levels Protection Production To maintain the balance of production and protection SL-17-INT

18 Accidents are Expensive! Accidents make bad business sense. Insurance does not cover the risks. Safety management is a prerequisite for a sustainable aviation business. Few organizations can survive the economic consequences of a major accident. ICAO Doc SL-18-INT

19 Accidents Cost! Direct costs Loss of aircraft Injuries to or death of flight crewmembers, passengers Insurance deductibles Costs not covered by insurance Indirect costs Loss of use of equipment Loss of staff Involved in accident issues Lower productivity Investigation & clean-up Legal claims Fines Misplaced/stranded passengers Negative media exposure SL-19-INT

20 Incidents Cost, Too! Event Direct Indirect Catering truck hits airplane $17,000 $230,000 Jetway hits airplane $50,000 $600,000 Landing event $1,900,000 $4,800,000 Source: USAir/America West Airlines SL-20-INT

21 Accidents Cost Small Operators, Too Claim Forced landing (aircraft destroyed) Flight Training Operation Fixed Wing Air Taxi Operation Helicopter Air Taxi $150,000 $300,000 $900,000 Propeller makes contact with object on ground $20,000 $30,000 $150,000 Hangar Rash $5,000 $10,000 $35,000 Flight cancellation per day $500-1,400 $3-5,000 $8-10,000 SL-21-INT

22 Now, What is the common denominator? Man/Machine Interface SL-22-INT

23 Understanding Operational Errors Human error: a contributing factor in most aviation occurrences Even competent personnel commit errors. Errors are a normal component of any system where humans and technology interact. SL-23-INT

24 Errors and Safety A Non Linear Relationship Statistically, millions of operational errors are made before a major safety breakdown occurs SL-24-INT

25 Once in a Million Flights Error Deviation Amplification SL-25-INT

26 Once in a Million Flights Error Deviation Amplification SL-26-INT

27 Processes Provide Interfaces Process: an interrelated set of activities that transforms inputs into outputs (ISO ) Basis of system understanding Things people do not things people have done If you can t describe what you re doing as a process you don t know what you re doing. W. Edwards Deming SL-27-INT

28 Drifting from Effective System Performance System design Operational deployment Baseline performance Practical drift SL-28-INT

29 Safety Management Strategies Reactive (Past) Proactive (Present) Predictive (Future) Responds to events that have already happened, such as incidents and accidents Actively seeks the identification of hazardous conditions through the analysis of the organization s processes Analyzes system processes and environment to identify potential future problems SL-29-INT

30 ICAO Requirements SL-30-INT

31 The International Picture Current ICAO safety management requirements Annex 6 - Operation of Aircraft Annex 8 - Airworthiness of Aircraft Annex 11 - Air Traffic Services Annex 14 - Aerodromes SL-31-INT

32 State s Safety Programme (FAA) Implementation Develop the State s safety programme around the following four components: 1. State s safety policy and objectives 2. State s safety risk management 3. State s safety assurance 4. State s safety promotion The AVS SMS will become the US safety program SL-32-INT

33 What do ICAO Standards and Recommended Practices (SARP) require? State safety programme Regulations and activities aimed at improving safety AVS SMS Operators and service providers Safety efforts included as part of the normal management framework of aviation operations Safety Management System (SMS) SL-33-INT

34 Purpose: To make known to certificate holders such as air carriers, Code of Federal Regulation (14 CFR), part 142 training centers, and 14 CFR part 145 repair stations of the coming implementation of SMS worldwide, and to recommend reference materials they may use to prepare for their own implementation. Information for Operators SL-34-INT

35 FAA Rulemaking Effort Part 121 Rulemaking Project Record (RPR) opened Nov Project cancelled Jan Project team commissioned to create integrated SMS Rule for all CFR parts Objective: harmonization of requirements Strategy is being formulated Aviation Rulemaking Committee (ARC) SL-35-INT

36 ICAO Milestones Compliance dates for Annex 6 (Operation of airplanes) Current: 1 January 2009 Proposed: 19 November 2009 SL-36-INT

37 SMS Fundamentals SL-37-INT

38 ICAO Definition Safety Management Systems SMS A systemic approach to managing safety, including the necessary organizational structures, accountabilities, policies and procedures. ICAO Doc. 9859, Sec SL-38-INT

39 SMS: What it is and is not What it isn t: Not a substitute for compliance Not a substitute for oversight Not a replacement for system safety Not a requirement for a new department What it is: Compliance is integral to safety management An effective interface for safety management SMS completes the system safety circle SMS is a set of decision making processes for senior and line management SL-39-INT

40 SMS, ATOS and QMS Is SMS ATOS? SMS Management system Only service provider can manage ATOS Oversight system Used to meet regulator responsibilities Is SMS QMS? Same principles but different objectives QMS Objective Customer satisfaction SMS Objective Aviation safety SL-40-INT

41 Primary References ICAO Doc 9859: Safety Management Manual AC AVS Doctrine Order VS SMS Requirements Order VS AC 120-XX Vol. Imple. SL-41-INT

42 SMS Guidance Material SL-42-INT

43 System Safety "The application of special technical and managerial skills in a systematic, forward looking manner to identify and control hazards throughout the life cycle of a project, program, or activity" (Roland & Moriarty, 1990) Traditional approach concentrates on technical SMS adds emphasis on management elements SL-43-INT

44 Four Components ( Pillars ) of SMS Policy (Structure) Risk Management Safety Assurance Safety Promotion SL-44-INT

45 The 4 SMS Components Policy (Structure) Risk Management Safety Assurance 1. Policy Safety Promotion All management systems must define policies, procedures, and organizational structures to accomplish their goals. Policy establishes the structure of the SMS. SL-45-INT

46 The 4 SMS Components Policy (Structure) Risk Management Safety Assurance 2. Safety Risk Management. Safety Promotion A formal system of hazard identification, analysis and risk management is essential in controlling risk to acceptable levels. SL-46-INT

47 The 4 SMS Components Policy (Structure) Risk Management Safety Assurance 3. Safety Assurance. Safety Promotion Once controls are identified, the SMS must ensure they are continuously practiced and continue to be effective in a changing environment. SL-47-INT

48 The 4 SMS Components Policy (Structure) Risk Management Safety Assurance 4. Safety Promotion. Safety Promotion The organization must promote safety as a core value with practices that support a positive safety culture. SL-48-INT

49 A Positive Safety Culture is An informed culture where People understand hazards and risks. Staff work continuously to identify and overcome threats A reporting culture where People are encouraged to voice safety concerns Those concerns are analyzed and appropriate action is taken The workforce knows and agrees on what is acceptable and unacceptable (shared values) Dr. James Reason SL-49-INT

50 A Positive Safety Culture is A learning culture where: People are encouraged to develop and apply their skills and knowledge to enhance organizational safety Management updates staff on safety issues Safety reports are fed back to staff so everyone learns A just culture where: The workforce knows and agrees on what is acceptable and unacceptable (shared values) Errors are understood but willful violations are not tolerated SL-50-INT

51 "The greatest difficulty in the world is not for people to accept new ideas, but to make them forget about old ideas." John Maynard Keynes SL-51-INT

52 Design Performance SRM System Analysis (Design) SA System Operation System Description & Analysis Hazard Ident Data Acquisition & Process Information Risk Analysis Analysis Analysis Risk Assmt System Assmt Assessment Risk Control Corrective Action Action: Problem Resolution SL-52-INT

53 The AVSSMS: The Safety Programme Oversight & SMS AVSSMS FAA (ATOS) Oversight Program Management (8 Modules) DA PA Protection FAA s Safety Management (Oversight) System Air Carrier Technical Program Requirements Systems Subsystems Elements Surveillance Production S R M S A Operator s Safety Management System Operational Process Public: Users Cert C.O.S. SL-53-INT

54 SMS Implementation SL-54-INT

55 Existing Programs Regulatory Oversight ATOS Safety Assurance CASS IEP Employee Reporting ASRS ASAP Compliance and Enforcement: Interfaces VDRP SL-55-INT

56 SMS Voluntary Implementation & Pilot Project Pilot Project activities commenced in 2007 Development and interface with oversight systems AFS combined effort Objectives: Development of guidance material, Implementation strategies, and Oversight systems Provide experience for FAA and operators Development Partners SL-56-INT

57 SMS Design Levels Phase 2: 4 Continuous Improvement Experience 3 Proactive Processes 2 Reactive Processes 0 1 Orientation & Commitment Planning & Organization Phase 1: Readiness SL-57-INT

58 Organizations SL-58-INT

59 AFS SMS Program Office Change to Order signed 4/17/08 Office tasked with: AFS SMS Policy Focal point for SMS rulemaking Oversight and coordination of voluntary SMS implementation and testing Integration with oversight systems Policy, guidance, and tool development Training and outreach development and coordination SL-59-INT

60 Standardization and Assistance Team Under direction of AFS SMS PMO Team members currently from: SMS PMO FAASTeam HQ Policy Divisions Standardization and Assistance to operators and CMTs in voluntary SMS projects All activities coordinated with appropriate certificate oversight offices SL-60-INT

61 MITRE Corporation Involvement MITRE is a Federally-Funded Research and Development Corporation (FFRDC) MITRE assists the AFS SMS PMO in: SMS Pilot Project (SMSPP) activities Studies and analysis to support development of SMS implementation and oversight strategies SL-61-INT

62 Safety Management Focus Group (SMFG) Voluntary implementation user s group Provides a two-way communications mechanism between SMS PMO and participants in voluntary implementation Provides a forum for knowledge sharing among participants SL-62-INT

63 Safety Management System Provides a systematic way to: 1. Identify hazards and control risk 2. Provide assurance that risk controls are effective SL-63-INT

64 The Bridge: CAA & Service Provider Civil Aviation Authority (FAA) Service Providers SMS State s safety programme SL-64-INT

65 Carelessness and overconfidence are more dangerous than deliberately accepted risk Wilbur Wright, 1901 Questions? Wilbur Wright gliding, 1901 Photographs: Library of Congress SL-65-INT

66 CONTACT INFORMATION Donald N. Arendt, Manager AFS SMS PMO AFS-940 Suite Aviation Drive Dulles, VA (703) SL-66-INT