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Safety Management Systems
SMS Systems
Cliff Edwards
Safety Management Systems
OVERVIEW
Industry Approach to Safety
The Need for Change
Management Systems
Key Elements of a Safety Management System
Conclusions
Hazard Management
Safety Management Systems
Approach to Safety - “Safety Is No Accident”:
Is it a clever play on words? Or the truth?
• Unfortunately, in many companies “safety is an accident”!
• Safety was not the planned outcome, but the result of “how
things worked out”!
• Operations that don’t plan for safety require individuals to do
“the right thing” without direction.
• As “professionals,” pilots, engineers and others, often achieve
the levels of safety sought! But can we rely on that?
• Are we doing enough? - We don’t believe so!
Safety Management Systems
Approach to safety - Why?
Is there a need to change?
• Public transport aviation is a fundamentally safe industry:
- - but aviation is facing difficult times in the coming years, made
worse by the events of September 11th,
- - the effects of that disaster have had far reaching implications
on aviation and remain likely to have an impact on the potential
for accidents and incidents, and
- - the industry faces falling incomes, rising costs and the loss of
experience.
• The safety record to date has been driven primarily by
regulatory compliance and the experience and training
of its participants
Safety Management Systems
Approach to Safety - Current Accident Rates:
The current accident rates are flat lined, this relates to the
number of hull losses per year - regulation is not making it safer
1 .2
1
0 .8
0 .6 FA R
0 .4
0 .2
0
1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015
Predictions of future needs show a doubling of number of flights
by 2015, concurrent with:
- a move towards low cost operations, and
- a falling resource of experienced staff to carry out the work
The rate is likely to increase.
Safety Management Systems
OVERVIEW
Industry Approach to Safety
The Need for Change
Management Systems
Key Elements of a Safety Management System
Conclusions
Hazard Management
Safety Management Systems
The Need for Change
• Whether for business survival, quality or safety, there
has never been a more important time to improve
performance.
• Our industry leaders are faced with very few choices
to achieve the improvements that they need to make
to survive; these are:
• Improved fiscal control, and/or higher fares.
• Reductions in competition through mergers or buy-outs.
• Improved utilisation of the aircraft and staff.
• Improved reliability of the aircraft and its maintenance.
• Improved safety, through loss control measures
• If nothing changes the safety record will get worse!
Safety Management Systems
The Need for Change - What do Top Safety
Performing Companies do?
Better safety performance in “World Class” companies is achieved
through their “Management of Safety” and the development of the
“Safety Culture” of the Company.
World Class Safety Performers deliver 4 key business elements:
• Committed and involved leadership providing vision and
seeing their initiatives through to conclusion.
• Individual accountability cascaded throughout the workforce.
• An empowered workforce that feel, and are, involved in the
process of delivering a quality product safely.
• A workforce that is compliant with its standards and committed
to the Company’s objectives.
These are the keystone tenets of a Safety Management System.
Safety Management Systems
OVERVIEW
Industry Approach to Safety
The Need for Change
Management Systems
Key Elements of a Safety Management System
Conclusions
Hazard Management
Safety Management Systems
Management Systems:
• Most Companies have a number of systems of
management:
• The Board’s management system.
• Financial Management.
• Quality Assurance.
• Safety Management.
• Local Fiefdoms.
• The way things are run around here.
• In reality, there should be only one real system of
management in any Company and that must be
modelled to manage all facets of the business.
Safety Management Systems
Management Systems - Leadership & Management?
• To meet the challenge requires clear objectives, effective
direction, stated plans and demonstrated commitment.
• Although named as the Accountable Managers, CEO’s often
are not involved and have little knowledge of these systems, or
the problems in the workplace.
• Top management often delegate the responsibility for systems
such as QA and SMS to allow themselves the chance to get on
with running the business - this is flawed thinking.
• It is almost certain that top management will be involved in the
management of the finances, due to the associated risks.
• Safety Management should be no different.
Safety Management Systems
Management Systems - Why Introduce an SMS?
• If you are contracted to the Shell Group, it’s a contractual
requirement.
• If you’re a public transport operator, JAR-Ops 1/3.037 states:
“An Operator shall establish an accident prevention and flight
safety programme, which may be integrated with the Quality
system, including programmes to achieve and maintain risk
awareness by all persons involved in operations”. Effectively
an SMS.
• UK operators are required to operate to the Health and Safety
Executive statutes
Companies are required to manage the risks of their business,
HSG65 guidance on the means of compliance describes a SMS.
Safety Management Systems
Management Systems - Definitions
Safety Management Systems
A Safety Management System is the methodology by which a
company manages safety throughout its organisation, utilising a
systematic approach to ensure that all parts of the business are
addressed, and that all risks are identified and subsequently
managed.
Safety Cases
Safety Cases (one or many) are subordinate to an SMS - as a
minimum, they incorporate the process used to demonstrate the
Company’s “fitness for purpose” through the identification and
control of the major risks.
Safety Management Systems
OVERVIEW
Industry Approach to Safety
The Need for Change
Management Systems
Key Elements of a Safety Management System
Conclusions
Hazard Management
Safety Management Systems
Key Elements of an SMS
• As in other systems of Management, where financial or quality
risks are the focus, Safety Management Systems bring a
systematic approach the the management of safety risks.
• The same model system that is embedded in ISO 9000-2000 is
used, because this is an approach that is capable of managing
any part of the business.
• The management system needs to be underpinned by other
tools, such the “Risk Assessment Matrix”, or a hazard analysis
“Bow-Tie”.
• As in all Management Systems, an SMS can only add value to
the organisation if Top Management are actively driving it.
Safety Management Systems
Principles
Management & Policy Objectives
Review
Strategy Targets & Plans
Customer
Satisfaction Plan
Standards
Remedial Action Accountability &
Feedback Culture Do
Competence
Investigation Check Product
& Follow-up Management
Incident Reporting Risk Assessment
Hazard
Monitoring Audit
Management
Review
Safety Management Systems
Key Elements: Principles - Policy - Objectives -
Targets - Strategy:
• Principles are the stance that a Company decides to take on
specific issues (e.g. its business or safety principles).
• Policies are the statements that the Company makes to ensure
that the principles can be put into practice and are understood
by the staff & customers.
• Objectives are the intentions of the Company to get from
where it is now, to where it wants to be in the future.
• Targets are the time-scales that the Company sets itself to
achieve its objectives.
• Strategy is the means that the Company employs to achieve
the objectives in accordance with its principles.
Safety Management Systems
Key Elements - Commitment:
• Introducing new systems of working such as QA/SMS takes
significant commitment.
• From Management to support and fund the initial resource
requirements.
• From the System Custodian to shape working processes.
• From the Staff who must use the processes.
• And they all need ongoing reinforcement that it will make a
difference; this comes from passion and commitment.
Commitment is often stated, but only sometimes
demonstrated by management; this weakens the safety
climate in the company.
“If you don’t mean it Don’t Say It”
Safety Management Systems
Key Elements - Accountability and Competence:
• Accountability for each position should be clearly defined.
• The accountabilities of the CEO should be cascaded down
throughout the organisation.
• Accountabilities could be seen at three levels, as they apply to
the individual, the team and the company.
• Achievement against accountabilities and competence to fulfil
them should be reviewed in the Company appraisal process.
• The post holder must be competent to carry out the tasks they
are accountable for, typically this requires job profiles.
• Shortfalls in competencies should be addressed through the
annual Training Plan.
Safety Management Systems
Key Elements - Planning:
• In business, success is achieved by planning.
• The business needs a Business Plan, QA needs a
Quality Plan, Safety needs a Safety Plan.
• Resource allocation needs to be planned to meet the
safety programme and safety targets.
• Resources are people, time, equipment, facilities and
funding.
• Good plans will only add value if there are adequate
resources to execute them.
Safety Management Systems
Key Elements - Performance Measurement:
“What’s not measured is not managed?” - generally true
• Companies are able to develop through their management
teams knowing what needs to be improved.
• Commercial performance is usually measured.
• Operational performance is often measured through the use of
key performance indicators, such as “on time departures”.
• Safety performance may not be measured, because this
displays the company’s failures (incidents or accidents).
• Companies might also demonstrate control of its hazards and
risks, as a positive means of measuring safety.
Safety Management Systems
Key Elements - Process Management:
• This is the “doing” part of the business. “Fly” or “Maintain
aircraft” typically, are key processes in an aircraft operation.
• To apply a systematic approach to the business, each critical
process should be reviewed and improved if necessary.
• The risk to the business of not applying the process effectively
should be evaluated and appropriate steps taken to manage
those processes assessed as critical to the business.
• A Safety Management System requires clear focus on the risk
bearing processes that, if not done correctly, will cause harm.
• The controls of hazard management are embedded in the
normal systems of working in aviation (checklists,
competencies, training and system redundancy.
Safety Management Systems
Key Elements - Risk Assessment:
• Many companies have no accidents in the year, but they all have
“Risks”.
• Each Risk should be evaluated and appropriate controls put in
place to ensure it is controlled.
• Three things you can do with Risk: remove, reduce or manage it.
The latter is more common in aviation.
• The effort expended to manage a Risk should be based on its
potential impact on the company.
• However, some level of Risk is acceptable.
• Staff using the Risk bearing processes should be involved in
their analysis and assessment.
Safety Management Systems
Key Elements - Hazard Management:
• Identify and categorise potential sources of harm (Hazards).
• Identify all undesirable events associated with each hazard
which, could result in harm being caused (Threats).
• Develop or improve appropriate measures to prevent
occurrence (Controls).
• Define the measures necessary to re-establish a safe
operating situation (Recovery Measures).
• Reduce the impact of any consequences incurred (Mitigation
Measures).
Safety Management Systems
Key Elements - Review:
• The process of checking if what is “in place” remains valid.
• Policies, standards, processes and procedures should be
routinely reviewed to confirm their ongoing validity.
• The outcomes of business (good or bad) should be reviewed.
• Review is one of the least used verification tools.
• Reviews should be carried out by users, as it requires their
unique knowledge to add value.
• The outcomes of reviews are best tracked through a common
Remedial Action Process.
Safety Management Systems
Key Elements - Monitoring:
• Monitoring is about finding out how people achieve tasks, as
opposed to how they are expected to to do them (actual
versus plan).
• Monitoring is unpopular as it deals face-to-face with people
and their miscommunications, errors and violations.
• Monitoring is not intended to be a trapping exercise, but to
understand the problems of the workplace.
• Monitoring should be done on two levels:
Compliance monitoring as a form of audit,
Task monitoring done by line staff (peers or supervisors).
Safety Management Systems
Key Elements - Audit:
• Audit is the process of verification that formally requires
parts of the business to be checked against standards, or
trained-for actions.
• Audit is often limited to site inspections and document
checks.
• Audit should be focussed more at the processes rather than
its locations.
• Audits should be planned to cover all aspects of the
business, but the frequency should reflect the level of
problems found.
• Audit findings requiring resolution should be formally
recorded in the Remedial Action process.
Safety Management Systems
Key Elements - Incident Reporting & Investigation:
• Open incident reporting is a matter of Culture.
• Improvement and learning can come from incidents and
accidents, albeit they are “unwanted investments”.
• The approach should be to get “a return from investments”
from whatever you do, including the errors experienced.
• Learning comes from investigation and analysis of the facts,
primary causes and underlying causal factors.
• Often underlying causal factors are embedded in the systems
of work that require line management action to resolve.
• Learning can also be shared through “safety data exchange”.
Safety Management Systems
Key Elements - Remedial Action:
• From numerous sources, remedial actions will be raised.
• Remedial actions should be recorded in a single control
system, which must enhance visibility for Line Management.
• Targets dates set for action and agreed with the Line
Manager.
• Follow-up action by the Safety Manager should ensure that
appropriate action has been taken and is now working.
• The remedial actions not being addressed on target should
be reported through the Management Review Board.
Safety Management Systems
Key Elements - Customer Satisfaction:
• ISO 9000-2000 Quality System sets Customer Satisfaction as
a key requirement; this is the same for safety management.
• Measurement of customer satisfaction is rarely done well
and, even less, seen as part of the the management system.
• Customer Safety is an issue of satisfaction, and safety
management systems can aid the development of this.
• Dissatisfied customer don’t come back and as an industry
we are highly reliant on return business.
Safety Management Systems
Key Elements - Management Review:
• Periodically there must be a formal Management Review
Process.
• Management Review is the final step of feedback in the closed
loop
• Top management must be involved in the Management Review
Board process, in order for them to be informed.
• Reviews include Policy, Objectives, Customer Satisfaction,
Training, Audits, KPIs, Supplier Performance, Changes and
Remedial Actions not yet resolved.
Safety Management Systems
Key Elements - Culture:
• Culture of the Company determines the approach everybody
takes toward work, especially safety and risk taking.
• There may be sub-cultures, but the corporate culture is a
reflection of the management’s commitment and leadership.
• The culture of the Company can be changed but it is a slow
process and is easily damaged - there are no “quick fixes”.
• Safety cultures range from “blame” to “no blame” but the aim
should be for a “Just and Learning Culture”, and open to
improvement.
Safety Management Systems
OVERVIEW
Industry Approach to Safety
The Need for Change
Management Systems
Key Elements of a Safety Management System
Conclusions
Hazard Management
Safety Management Systems
Conclusion:
• We have talked about ensuring “Safety is No Accident” - not
only thinking about safety, but planning for it and following
through on those plans into execution.
• Real commitment, from management and staff can make its
management system work, if it is key to the Company’s vision
and mission.
• We have to “Change the Face of Safety” in aviation to make it a
core business issue that involves everybody in the Company.
• “If you continue to do more of what you
have already done, you will only get more
of what you already have”
Safety Management Systems
OVERVIEW
Industry Approach to Safety
The Need for Change
Management Systems
Key Elements of a Safety Management System
Conclusions
Hazard Management
Safety Management Systems
Hazard Management
Hazard and Effects Management Programmes:
These require that you
• IDENTIFY the hazard
• ASSESS its potential (risk assessment)
• CONTROL the Hazard, (keep it contained through one of
three approaches –
• Remove the hazard
• Reduce the exposure to the hazard
• Manage the hazard through having effective systems and controls in
place.
• RECOVER from the effects of the release of the hazard.
• In Business it is not possible to be free of risk, and in that
environment occasionally a hazard will be released, and a hazardous
event occurs, in this case it is essential to be prepared to deal with it
and its consequences.
Safety Management Systems
Threat
Accountability Training
Competencies
HAZARDS
Redundant
Systems
Barriers
Physical CFIT, Fuel
Threat HAZARDS
People Threat
Unairworthy
Aircraft
Procedures
Awareness Assurance
Threat
Safety Management Systems
Key Elements - Risk Assessment:
• Many companies have no accidents in the year, but they all have
“Risks”.
• Each Risk should be evaluated and appropriate controls put in
place to ensure it is controlled.
• Three things you can do with Risk: remove, reduce or manage it.
The latter is more common in aviation.
• The effort expended to manage a Risk should be based on its
potential impact on the company.
• Some level of Risk is acceptable.
• Staff using the Risk bearing processes should be involved in
their analysis and assessment.
Safety Management Systems
RISK ASSESSMENT MATRIX
Potential Consequence of the Incident Increasing Probability
A B C D E
Rating People Env'ment Assets Reputation Unknown but Known Happened Happened Happened
possible in in aviation in this > 3 x in the > 3 x in this
the aviation industry company Company location
industry
0 No
injury
Zero
Effect
Zero
damage
No Impact
Slight Slight Slight Slight
1 injury Effect damage < Impact
US$ 10K
Minor Minor
Minor Local
2 injury Effect
damage <
Impact
US$ 50K
Local
Serious Industry
3 injury
Localised
Effect
damage <
Impact
US$ 250K
Major Major
Single National
4 fatality Effect damage <
Impact
US$ 1M
Multiple Massive Extensive International
5 fatality Effect damage > Impact
US$ 1M
Safety Management Systems
HAZARD
THREAT
CONTROL
PROACTIVE
ESCALATION
THE CONTROL
H E M P
Hazardous
BOW- Identif y
Event
Assess
TIE Control
Recovery
RECOVERY
ESCALATION REACTIVE
CONTROL
CONSEQUENCE
MITIGATION MEASURES
Safety Management Systems HAZARDOUS EVENT MAP
Deviation from Aircraft Exceedance of
Intended Aircrew Systems Failures
Flight Operations
Flight Training/ Inc. Dynamic Aircraft
Air test Missions Failures Limitations
Loss of Proximity Aircraft Deviates Loss of Uncontrolled
containment to a Third people in close
of Dangerous Party or from Intended Separation with proximity to a
Goods Obstacle Safe Flight Path other Aircraft running propeller
Internal Interface Operations
Flammable
Materials
Unairworthy Aircraft Deviates Static Out of
in proximity to a Aircraft Released from Intended Balance
source of ignition to Service Ground Track situations
Uncontrolled
Ground Operations
Encountering Loss of Encountering
Unexpected
Use of unsafe
and Maintenance
GSE in proximity Adverse Weather containment External lifting
to the Aircraft Conditions of fuel or oil Conditions equipment
Loss of Interface with Encounter
Interface with containment
Interfaces with Contractors
Ramp Agents of fluid and gas
under pressure
Maintenance
Contractors
with a potential
HSE occurrence
Safety Management Systems
SMS TERMINOLOGY
Hazard
A situation with the potential to cause harm.
Threat
Something with the potential to release a hazard.
Threat Control
A measure put in place to prevent the release of a hazard.
Escalation Factor
A condition that prevents a threat control, or recovery measure
being effective.
Escalation Control
A further measure put in place to control an escalation factor.
Hazardous Event
The initial release of the hazard, that can lead to an accident.
Safety Management Systems
SMS TERMINOLOGY
Recovery Measure
Measures taken to return the situation to normal after the
initial release of a hazard.
Consequence
The final result of the release of a hazard that was not
controlled.
Mitigation Measure
Steps taken to return the situation to as near normal as possible
after the consequence has occurred.
Bow Tie Model
A means of visually displaying the hazard management
process.
Safety Management Systems
HAZARD
THREAT
CONTROL
PROACTIVE
ESCALATION
THE CONTROL
H E M P
Hazardous
BOW- Identif y
Event
Assess
TIE Control
Recovery
RECOVERY
ESCALATION REACTIVE
CONTROL
CONSEQUENCE
MITIGATION MEASURES
Safety Management Systems
Interactive Workshop Task:
We will work through a small bow-tie in which I will facilitate you to
brainstorm a hazard analysis.
• Hazardous event :- Maintenance error (mis-assembly) during an
overnight maintenance task
• What is the Hazard?
• Human Action - Error
• What are the threats that could cause this type of error
• Distraction, Fatigue,
• Non procedural working, Time pressures
• Insufficient information, Insufficient planning,
• Lack of task competence, Inadequate use of worksheet,
• Poor access to task.
Safety Management Systems
HAZARD
THREAT
CONTROL
PROACTIVE
ESCALATION
THE CONTROL
H E M P
Hazardous
BOW- Identif y
Event
Assess
TIE Control
Recovery
RECOVERY
ESCALATION REACTIVE
CONTROL
CONSEQUENCE
MITIGATION MEASURES
Safety Management Systems
Interactive Workshop Task:
What are the controls for these threats?
• Distraction, • Use of Worksheets, Handover, supervision,
cross checks
• Fatigue, • Limitations, rostering, awareness, culture
• Non procedural • Procedures, Quality Control/Assurance,
working, workplace monitoring, supervision.
• Time pressures • Planning, procedures, supervision, culture
• Insufficient • Reviews, procedures, audits, standards
information,
• Insufficient planning, • Planning standards, Reviews Supervision
• Lack of task • Competence Standards, Training, Approvals
competence,
• Inadequate use of • Supervision, Quality Assurance, training,
worksheets, worksheet standards.
• Poor access to task. • Planning, special tooling, duplicate checks.
Safety Management Systems
HAZARD
THREAT
CONTROL
PROACTIVE
ESCALATION
THE CONTROL
H E M P
Hazardous
BOW- Identif y
Event
Assess
TIE Control
Recovery
RECOVERY
ESCALATION REACTIVE
CONTROL
CONSEQUENCE
MITIGATION MEASURES
Safety Management Systems
Interactive Workshop Task:
What are the escalation factors for these controls?
• Use of Worksheets, • Not up to date when distracted,
Handover No formalised handover
Supervision, Lack of, or nil supervision,
Cross checks No culture of go back and check in place
• Limitations, • Limitations not complied with,
rostering, Inadequate rostering,
awareness, Lack of awareness,
culture Culture encourages long working hours
• Procedures, • Lack of or non compliance
QC/QA QC/QA do not work on night shifts
Workplace monitoring, No culture of Workplace monitoring,
Supervision. Lack of, or no Supervision.
Safety Management Systems
Interactive Workshop Task:
What are the Recovery Measures
• Open reporting • Supportive culture, recall or advise
the aircraft
• Duplicate inspections • Critical tasks only
• Ground Test • Procedures for Ground Test
• Flight test or flight • Flight crew deal with the
emergency when identified
Safety Management Systems
HAZARD
THREAT
CONTROL
PROACTIVE
ESCALATION
THE CONTROL
H E M P
Hazardous
BOW- Identif y
Event
Assess
TIE Control
Recovery
RECOVERY
ESCALATION REACTIVE
CONTROL
CONSEQUENCE
MITIGATION MEASURES
Safety Management Systems
Engineer to carry out EXAMPLE SMS MANAGEMENT
night maintenance task OF HUMAN ERROR
Resource planning Working time Staff competencies
allocates enough time limitations regulated checked against profiles
QA department does Night Shift Supervisor
random night audits To monitor task progress
Effective task cards Compliant practices Workplace culture
available always used supportive
Worksheet completion
informative & correct
•Management accountabilities clearly understood
Handover of work is •Hazardous events identified
Tell me Show me •Risk assessments carried out and reported
•Controls identified, tested and monitored
Post maintenance •Systematic audit programme in place
checks always done •Management reviews carried out routinely
Safety Management Systems
SMS TERMINOLOGY
Risk
A measure of probability or frequency of a hazardous event
occurring and the severity of its consequences.
Accident
An unintended event or sequence of events that cause death, ill
health, injury, environmental or material damage.
Accountability
Those elements of work that are managed, delegated supervised or
contracted and for which the individual is responsible.
Responsibility
Those elements of work that you do yourself and are required to
perform to specified standards.
Safety Management Systems
SMS TERMINOLOGY
Safety Management:
A systematic and explicit approach to managing risk.
Safety Case:
A documented account to show that hazards have been
identified and controlled and that measures are in place to
reduce the risks to As Low As Reasonably Practicable (ALARP).
(The safety case utilises methodologies to remove, reduce or
control the hazards and by the application of quality type
closed loop processes).
