Module 1 - Basic Safety Concepts

SMS Course Outline

Module Z
Module 6
SMS Course
SMS Implementation
Summary

Module 5
Module 4
Safety Risk Assessment
Hazard Identification
and Mitigation

Module A Module 2
Module 1 Module 3
SMS Course Introduction to Safety
Basic Safety Concepts SMS Framework
Introduction Management

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 End-of-Module Objective

Condition In the classroom, having completed this module

delivery, the participants will be able to:

Performance explain the basic concepts of safety in the context of

aviation

in accordance with ICAO Annex 19 (Safety

Standards Management), ICAO Document 9859 Safety
Management Manual, and Civil Aviation Regulation –
Safety Management.

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 Intermediate Objective

1 Explain the principles, objectives and benefits of safety management

2 Describe the evolution of safety

3 Explain the concept of accident causation

4 Explain the SHEL(L) Model

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Module Outline

Concept of safety
The evolution of safety
The concept of accident causation

The organizational accident

The SHEL(L) Model

Understanding operational errors

Safety Management - Rationale

 Concept of Safety

What is safety? Consider (the weaknesses in the notion of

perfection)
• the elimination of aircraft accidents and/or
• Zero accidents? serious incidents remains the ultimate goal.
• Freedom from danger or • the aviation system cannot be completely free
risks? of hazards and associated risks.
• Error avoidance? • human activities or human-built systems
• Regulatory compliance? cannot be guaranteed to be absolutely free
• …? from operational errors and their
consequences.

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 Concept of Safety
requires the mitigation of
safety risk through a continuing
process of hazard identification Safety is a dynamic characteristic.
and safety risk management

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 Concept of Safety

Traditional approach in preventing Identified:

accidents: • What?
• Focused on outcomes (direct cause/s)
• Who?
• Unsafe acts by operational personnel
• When?
• Attached blame/punish line personnel
for failures to “perform safely“ But does not always disclose the:
• Addressed identified safety concern • Why?
exclusively • How?

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 Concept of Safety

ICAO Definition

“Safety is the state in which the possibility of harm to persons or of property

damage is reduced to, and maintained at or below, an acceptable level through a
continuing process of hazard identification and risk management.”
Ref. ICAO Doc 9859 3rd Edition

“Safety is the state in which risk associated with aviation activities, related to, or in
direct support of the operation of aircraft, are reduced and controlled to an
acceptable level.”
Ref. ICAO Doc 9859 4th Edition

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 Why Safety Management?

• The purpose of safety management is

to proactively mitigate safety risks
before they result in aviation accidents
and incidents.
• Safety management enables States to
manage their safety activities in a
more disciplined, integrative and
focused manner.

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 The Evolution of Safety

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 The Evolution of Safety

The technical era — from the early 1900s

until the late 1960s
Aviation emerged as a form of mass
transportation in which identified safety
deficiencies were initially related to technical
factors and technological failures. The focus of
safety endeavors was therefore placed on the
investigation and improvement of technical
factors. By the 1950s, technological
improvements led to a gradual decline in the
frequency of accidents, and safety processes
were broadened to encompass regulatory
compliance and oversight.

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 The Evolution of Safety

The human factors era — from the early

1970s until the mid-1990s
In the early 1970s, the frequency of
aviation accidents was significantly
reduced due to major technological
advances and enhancements to safety
regulations. Aviation became a safer mode
of transportation, and the focus of safety
endeavors was extended to include human
factors issues including the man/machine
interface.

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 The Evolution of Safety
The organizational era — from the mid-
1990s to the present day
During the organizational era, safety
began to be viewed from a systemic
perspective, which was to encompass
organizational factors in addition to
human and technical factors.
Consequently, the idea of the
“organizational accident” was introduced,
considering the impact of organizational
culture and politics on the effectiveness
of safety risk controls.

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 The Evolution of Safety

The total aviation system era — from the

2000s into the future
As of today, many States and service
providers have reached a higher level of
maturity with the implementation of their
SSP or SMSs respectively. There is a
growing recognition of the complexity of
the aviation system and the different
organizations that all play a part in
aviation safety. SMSs should not only
focus on their own safety performance
but should also consider the wider
context of the total aviation system.

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 Knowledge Check

• Q: How is safety defined in Document 9859 4th Ed.?

• A: ?
Safety is the state in which risk associated with aviation
activities, related to, or in direct support of the operation of
aircraft, are reduced and controlled to an acceptable level

?
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 The Concept of Accident Causation
The Swiss cheese model
Some holes due to
active failures

Hazard: A condition or
an object with the
potential to cause or
contribute to an aircraft
incident or accident.

Some holes due to

latent conditions

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 The Concept of Accident Causation
The Swiss cheese model
Some holes due to
active failures

Latent conditions: can exist in a system well before a damaging

outcome. The consequences of latent conditions may remain
dormant for a long time. Initially, these are not perceived as harmful,
but under certain conditions may become clear when the operational
level defenses are breached.
Some holes due to
latent conditions

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 The Concept of Accident Causation
The Swiss cheese model
Some holes due to
active failures
Active Failures: actions or inactions, including errors and rule-breaking that
have an immediate adverse effect. They are viewed with the benefit of
hindsight, as unsafe acts. Active failures are associated with front-line
personnel (pilots, air traffic controllers, aircraft maintenance, engineers, etc.)
and may result to harmful outcome.

Some holes due to

latent conditions

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 The Organizational Accident

Organizational processes

❖ Policy-making
❖ Planning
❖ Communication
❖ Allocation of resources
❖ Supervision

Activities over which any organization has a reasonable degree of

direct control
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 The Organizational Accident

Organizational processes

❖ Inadequate hazard Latent conditions

identification and safety
risk management

❖ Normalization of deviance

Conditions present in the system before the accident, made

evident by triggering factors.
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 The Organizational Accident

Organizational processes

Latent conditions
❖Technology
❖Training
❖Regulations Defenses

Resources to protect against the risks that organizations involved

in production activities generate and must control
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 The Organizational Accident

Organizational processes

Workplace ❖ Workforce stability

Latent conditions
conditions ❖ Qualifications and
experience
❖ Morale
❖ Management Credibility Defenses
❖ Ergonomics

Factors that directly influence the efficiency of people in aviation

workplaces.
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 The Organizational Accident

Organizational processes

Workplace
Latent conditions
conditions
❖Errors
❖Violations
Active failures Defenses

Actions or inactions by people (pilots, controllers, maintenance

engineers, aerodrome staff, etc.) that have an immediate adverse effect.

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 The Organizational Accident

Organizational processes

Workplace
Latent conditions
conditions

Active failures Defenses

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 The SHEL(L) Model

People, Context and Safety Maintenance

• The aviation system includes products,

Managers
Maintenance

service providers and State

Organization

organizations. Other
Organizations
Aircraft
Operator

• It is a complex system that requires an

assessment of the human contribution
to safety and an understanding of how
human performance may be affected State
Aircraft
Operator

by its multiple and interrelated Safety

Manager

components

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 The SHEL(L) Model

• Illustrates the relationship between the

central human and the workplace
components
• Contains the four satellite components:
➢Software (S): procedures, training,
support, etc.
➢Hardware (H): machines and equipment
➢Environment (E): the working
environment in which the rest of the L-H-S
systems function
➢Liveware (L): humans in the workplace

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 The SHEL(L) Model

Liveware-Hardware (L-H):
• This interface refers to the
relationship between the human Mismatch at the
and the physical attributes of L-H Interface may
equipment, machines and facilities. occur through:
• This considers the following:
➢ ergonomics of operating the • Poorly designed
equipment by personnel equipment
➢ how safety information is • Inappropriate or
displayed and how switches
and operating levers are
missing
labeled and operated so they operational
are logical and intuitive to material
operate.

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 The SHEL(L) Model

Liveware-Environment (L-E): Mismatch at the L-E Interface

• This interface involves the may include:
relationship between the human • Reduced performance and
errors resulting from
and the physical environment.
disturbed biological rhythms
• This includes such considerations (jet lag) as a result of long-
as: range flying and irregular
➢ Temperature, ambient light, work sleep patterns
• Pilot perceptual errors
noise, vibration and air
induced by environmental
quality conditions such as visual
➢ The external environment illusions during
including operational aspects approach/landing at
nighttime
such as weather factors,
infrastructure and terrain.

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 The SHEL(L) Model

Liveware-Software (L-S): Mismatch at the L-S

• This interface refers to the Interface may occur
relationship between the human through:
and the supporting systems found • Insufficient/inappropri
in the workplace, e.g. regulations, ate procedures
manuals, checklists, publications, • Misinterpretation of
processes and procedures and confusing or
computer software. ambiguous
• It includes such issues as: symbology/checklists
➢ Recency of experience, • Confusing, misleading
accuracy, format and or cluttered
presentation, vocabulary, documents, maps or
clarity and symbology charts

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 The SHEL(L) Model

Liveware-Liveware (L-L): Mismatch at the L-L Interface

• This interface is the relationship includes:
and interaction between people • Communication errors due to
in the work environment. misleading, ambiguous,
• Communication and inappropriate or poorly
constructed communication
interpersonal skills, as well as between individuals.
group dynamics, play a role in Communication errors have
determining human resulted in aviation accidents
performance. such as an air crash where
• Focus on team performance to officials concluded that poor
manage errors as well as overall English was the main
contributing factor of a mid
organizational culture are within air disaster at 14000 ft.
the scope of this interface.

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 Understanding operational errors

A mismatch between •Human error is considered a

the LIVEWARE and the contributory factor in most
other four components aviation occurrences.
contributes to human •Even competent personnel commit
error – thus, these errors.
interactions must be
•Errors must be accepted as a
assessed and
normal component of any system
considered in all
where humans and technology
sectors of the aviation
interact
system.

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 Errors and Violations

Effective SMS implementation by the product or service

provider is dependent upon a clear, mutual understanding of
errors and violations and the differentiation between the two.

The difference between errors and violation lies in intent.

A violation is a deliberate act or

omission to deviate from
An error is unintentional established procedures,
protocols, norms, or practices

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 Errors and Violations

Error is an action or An important goal is to set and

inaction by an maintain defenses to reduce
operational personnel likelihood of errors and reduce
that leads to consequences of errors when
deviations from they do occur. Errors must be
organizational or the identified, reported and
operational person’s analyzed so that appropriate
intentions or remedial action can be taken
expectations.

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 Errors and Violations

Error is an action or • Two categories:

inaction by an ➢ Slips/lapses
operational personnel ➢ Mistakes
that leads to • Three strategies for control of
deviations from human error:
organizational or the
operational person’s
➢ Error reduction strategies
intentions or ➢ Capturing strategies
expectations. ➢ Error tolerance strategies

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 Errors and Violations

• While intentional, violations are

NOT always malicious and may be
A violation is a done in the belief that the violation
deliberate act of willful facilitates mission achievement
misconduct or omission without creating adverse
resulting to deviation consequences (judgment error)
from established • Three categories:
procedures, protocols, ➢ situational
norms or practices ➢ routine
➢ Organizationally induced

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 Knowledge Check
• Q: Enumerate the five building blocks of the organizational
accident.
• A: ? Organizational processes

Improve Identify
Monitor
Workplace Latent
conditions conditions

Reinforce
Contain
Active
Defences

?
failures

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 Knowledge Check

• Q: Explain the components of the SHEL(L) Model.

• A: ?

• Software (S): procedures, training, support, etc.;

• Hardware (H): machines and equipment
• Environment (E): the working environment in which the rest
of the L-H-S systems function; and
• Liveware (L): humans in the workplace
?
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 Safety Management Rationale
What is the fundamental objective of a business organization?

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 The Management Dilemma

Management levels

Resources Resources

Safety practices Output

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 The Management Dilemma

Management levels

Resources Resources

Protection Production
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 The Management Dilemma

Resources

Protection

Production
Catastrophe
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 The Management Dilemma

Resources

Production

Protection

Bankruptcy

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 The Management Dilemma

The allocation of excessive resources to

protection or risk controls may result in the
product or service becoming unprofitable
Protection

Safety space is a metaphor for a zone

where an organization balances
desired production/profitability while
maintaining required safety
protection through safety risk
controls

Excess allocation of resources for

production at the expense of protection
can have an impact on safety performance

Production
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 The Management Dilemma

The allocation of excessive resources to

protection or risk controls may result in the
product or service becoming unprofitable
Protection

It is essential that the

management of an
organization acknowledge
the need to maintain an
appropriate safety space.

Excess allocation of resources for

production at the expense of protection
can have an impact on safety performance

Production
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 An Imperfect System

Scott A. Snook’s
Theory of
Practical Drift

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 Practical Drift

Once operationally deployed, the system

tends to perform initially as designed.
However, in reality at some point in time, an
operational performance may start to divert
from baseline performance as a consequence
of real life operations and changes in the
operational and regulatory environment. The
space formed between the baseline
performance and the operational
performance is called the practical drift.

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 Practical Drift

Some of the reasons for the practical drift

may include:
• Technology that does not always
operate as predicted.
• Procedures that cannot be executed as
planned under certain operational
conditions
• Regulations that are not applicable
within certain contextual limitations; and
• Introduction of changes to the system

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 Practical Drift Example

Practical Drift Example

?
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 Practical Drift Example

1 2

?
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 Practical Drift Example
4
6

?
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 Knowledge Check

• Q: The baseline performance expected was that the HUMS system would
always be operational and serviceable for all flights. What two reasons
caused the operational performance to divert from the baseline and
become an example of Practical Drift?
• A:
a. Procedures that cannot be executed as planned under certain operational
conditions.
b. Introduction of changes to the system
c. Regulations that are not applicable
d. Technology that does not always operate as predicted
?
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 Benefits of Safety Management
The benefits of implementing safety management are numerous, some of which include:
Better understanding of safety- • can benefit the organization’s understanding of inter-process relationships leading to
related interfaces and relationships better understanding of end to end processes and increased efficiencies

Enhanced early detection of safety • Improves State/service provider’s ability to detect emerging safety issues, preventing
hazards accidents/incidents through proactive hazard identification and safety risk management

Safety data-driven decision- • Improves safety data gathering and analysis which aids in making near real-time, better
making informed, valid decisions

• Possible reduction in operational cost by exposing inefficiencies in existing processes

Improved efficiencies and systems

Cost avoidance • Cost incurred due to accidents and incidents can be avoided

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 Your Questions

?
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Summary
The following topics Concept of safety
were covered in this
module: The evolution of safety
The concept of accident causation

The organizational accident

The SHEL(L) Model

Understanding operational errors

Safety Management - Rationale

THANK YOU