Basic Safety

Fundamental
 7. SAFETY CULTURE
1. CONCEPT OF SAFETY

01
6. SAFETY POLICY AND
07
OBJECTIVES 2. EVOLUTION OF
06 02 SAFETY

03
5. HAZARD
05 3. ACCIDENT
IDENTIFICATION 04 CAUSATION

4. MANAGEMENT
DILLEMA
 SATU
CONCEPT REFF.
OF SAFETY
1. ICAO Annex 19, 2nd edition, The Safety Management
2. ICAO Doc 9859, 4th edition, Safety Management Manual
3. UU No. 1 tahun 2009, Penerbangan
4. PP No. 3 tahun 2001, Keamanan dan Keselamatan Penerbangan
5. PM 62 tahun 2017, CASR 19 Sistem Manajemen Keselamatan (
Safety Management System)
 SATU
CONCEPT SAFETY…
OF SAFETY
1. Zero accidents (or serious incidents)?
2. Freedom from danger or risks?
3. Error avoidance
4. Regulatory compliance?
5. ?
 SATU
CONCEPT SAFETY…
OF SAFETY
The state in which risks associated with aviation activities, related to,
or in direct support of the operation of aircraft, are reduced and
controlled to an acceptable level.
Acceptable level of safety performance (ALoSP). means minimum
level of safety performance of service provider, as defined in its
safety management system, expressed in terms of safety
performance targets and safety performance indicators.
 SATU
CONCEPT SAFETY…
OF SAFETY
Safety performance target, means medium or long-term objectives
of a services provider SMS, determined weighing what is desirable
and what is realistic for an individual services provider, and
expressed in numerical terms.
Safety performance indicator, means established objectives of a
services provider SMS, linked to major components of a services
provider SMS, and expressed in numerical terms.
 DUA
EVOLUTION
OF SAFETY
Technical Era,
permulaan 1900 sd akhir 1960

Human Factor Era,

permulaan 1970 sd 1990

Organizational Era,
pertengahan 1990

Total System Era

awal tahun 2000
 TIGA
Accident, An occurrence associated with the operation of an aircraft
ACCIDENT
CAUSATION
that takes place between the time any person boards the aircraft
with the intention of flight until such time as all such persons have
disembarked in which a person is fatally or seriously injured, the
aircraft sustains substantial damage, or the aircraft is missing or is
completely inaccessible.
Incident, An occurrence other than an aircraft accident, associated
with the operation of an aircraft, which affects or could affect the
safety of operations.
 TIGA
THE DOMINO THEORY,
ACCIDENT
CAUSATION
Heinrich's Domino Theory states that accidents result from a chain
of sequential events, metaphorically like a line of dominoes falling
over. When one of the dominoes falls, it triggers the next one, and
the next... - but removing a key factor (such as an unsafe condition
or an unsafe act) prevents the start of the chain reaction.
 TIGA
THE DOMINO THEORY,
ACCIDENT
CAUSATION
domino 1: kepercayaan dan lingkungan sosial pekerja, yang
mempengaruhi keterampilan, kepercayaan, dan "sifat karakter"
pekerja, Heinrich menulis bahwa "Kecerobohan, keras kepala,
keserakahan, dan sifat karakter yang tidak diinginkan lainnya dapat
diturunkan melalui warisan".
 TIGA
THE DOMINO THEORY,
ACCIDENT
CAUSATION
domino 2: kecerobohan pekerja atau kesalahan pribadi, yang
menyebabkan mereka kurang memperhatikan tugas
 TIGA
THE DOMINO THEORY,
ACCIDENT
CAUSATION
domino 3: tindakan tidak aman atau bahaya mekanis/fisik, seperti
kesalahan pekerja (berdiri di bawah beban yang ditangguhkan,
menghidupkan mesin tanpa peringatan…) atau kegagalan peralatan
teknis atau mesin yang tidak terlindungi dengan baik
 TIGA
THE DOMINO THEORY,
ACCIDENT
CAUSATION
domino 3: tindakan tidak aman atau bahaya mekanis/fisik, seperti
kesalahan pekerja (berdiri di bawah beban yang ditangguhkan,
menghidupkan mesin tanpa peringatan…) atau kegagalan peralatan
teknis atau mesin yang tidak terlindungi dengan baik
domino 4: the accident
domino 5: injuries or loss, the consequences of the accident
 TIGA
THE DOMINO THEORY,
ACCIDENT
CAUSATION

PENYEBAB PENYEBAB
PENYEBAB ACCIDENT KERUGIAN
TIDAK LANGSUNG
DASAR
LANGSUNG

1. KURANG 1. FAKTOR 1. TINDAKAN 1. KONTAK 1. CEDERA,

PROSEDUR/ PEKERJAAN TIDAK AMAN DENGAN KEMATIAN
ATURAN 2. FAKTOR 2. KONDISI SUMBER 2. KERUSAKAN
2. KURANG PERSONAL TIDAK AMAN BAHAYA PERALATAN
SARANA 2. KEGAGALAN 3. MATERIAL,
3. KURANG FUNGSI PRODUK
KESADARAN GAGAL
4. KURANG 4. LINGKUNGA
KEPATUHAN N
TERCEMAR
 TIGA
ICEBERG THEORY,
ACCIDENT
CAUSATION
 TIGA
ICEBERG THEORY,
ACCIDENT
CAUSATION
 TIGA
JAMES REASON THEORY,
ACCIDENT
CAUSATION
.
 TIGA
JAMES REASON THEORY,
ACCIDENT
CAUSATION
.
 TIGA SCOTT A. SNOOK’S THEORY,
ACCIDENT
CAUSATION .

TIGA ASUMSI DASAR PRACTICAL DRIFT

i. Tersedia sistem teknologi yang dibutuhkan untuk mencapai tujuan produksi;
ii. Personel sudah terlatih, kompeten, dan termotivasi untuk mengoperasikan
teknologi dengan benar sebagaimana dimaksud;
iii. Terdapat kebijakan dan prosedur akan mendikte sistem dan perilaku manusia.
 EMPAT
MANAGEMENT
DILLEMA
 EMPAT
MANAGEMENT
DILLEMA
 EMPAT
MANAGEMENT
DILLEMA
 EMPAT
MANAGEMENT
DILLEMA
▪ Production –
drive to increase
capacity and
productivity
▪ Protection – drive
to increase safety
risk controls

Management
Dilemma -
Balancing
Production &
Protection
 LIMA
HAZARD
IDENTIFICATIO A condition or an object with the potential
N
to cause or contribute to an aircraft
incident or accident
 LIMA
HAZARD
IDENTIFICATIO The two main METHODOLOGIES for identifying hazards are :
N
1. Reactive - analysis of past outcomes or events,
2. Proactive - existing or real-time operational situations
 LIMA
HAZARD
IDENTIFICATIO 1. Accident/ incident investigation reports (Reactive)
N
2. Audit, inspection or survey reports (Proactive)
3. Voluntary hazard/ incident reports (Proactive)
4. Operational data monitoring systems, etc (Proactive)
 LIMA
HAZARD
IDENTIFICATIO
TYPE OF HAZARDS
N
1. Natural
2. Technical
3. Economic
 ENAM
SAFETY POLICY
AND
OBJECTIVES
Safety policy and objectives define roles, responsibilities, and
relationships outlined in aviation service providers' policies and
procedures.
1. Policies;
2. Processes and procedures; and
3. Organizational structures of key safety personnel.
 ENAM
SAFETY POLICY
AND
FIVE ELEMENTS OF AVIATION SMS PLANNING AND DESIGN
OBJECTIVES
REQUIREMENTS
1. Management Commitment and Responsibility;
i. A safety policy; and often
ii. A CEO Commitment to Safety statement.
2. Safety Accountabilities; Duties & Requirements of Key Safety Personnel
i. All senior management positions;
ii. All staff management positions;
iii. All employees; and
iv. All stakeholders (customers and contractors)
 ENAM
SAFETY POLICY
AND
FIVE ELEMENTS OF AVIATION SMS PLANNING AND DESIGN
OBJECTIVES
REQUIREMENTS
3. Appointment of Key Safety Personnel;
i. managing SMS implementation for the accountable executive;
ii. preparing SMS documentation for auditors;
iii. investigating safety concerns;
iv. addressing audit findings and audit concerns; and
v. disseminating safety promotion materials to stakeholders.
4. Coordination of Emergency Response Planning;
i. Documented;
ii. Regularly reviewed;
iii. Practiced (including documentation); and
iv. Made accessible by all key ERP personnel.
 ENAM
SAFETY POLICY
AND
FIVE ELEMENTS OF AVIATION SMS PLANNING AND DESIGN
OBJECTIVES
REQUIREMENTS
5. SMS Documentation.
i. Safety policy and objectives;
ii. SMS requirements;
iii. SMS processes and procedures;
iv. Accountabilities, responsibilities and authorities for processes and
procedures; and
v. SMS outputs.
TUJUH
SAFETY
CULTURE
WHY IS SAFETY CULTURE SO IMPORTANT ?
The probability (risk) of being killed in an aircraft accident varies from 1
in 260,000 (Africa)
1 in 11,000,000 (45 million 2012 USA)
A difference of 42 times better
TUJUH
SAFETY
CULTURE
THREE “C’s”
COMMITMENT
COMPETENCE
COGNIZANCE
TUJUH
SAFETY
CULTURE
SIX STEPS TO A SAFETY CULTURE
1. JUST CULTURE
i. Foundation of any safety culture
ii. Where “Honest & At-Risk” mistakes do not result in discipline
iii. Where an Administrative policy spells out “Reckless Behaviour”
iv. Where persons can admit to an error without fear of
punishment
TUJUH
SAFETY
CULTURE
SIX STEPS TO A SAFETY CULTURE
2. TRUSTING CULTURE
HIGH
SYNERGISTIC - WE CAN SOLVE
THE PROBLEM (WIN WIN)

RESPECTFUL - COMPROMISE (WIN LOSE –

LOSE WIN)

TRUST
DEFENSIVE – US VS. THEM (LOSE LOSE)

LOW COOPERATION HIGH

TUJUH
SAFETY
CULTURE
SIX STEPS TO A SAFETY CULTURE
3. REPORTING CULTURE
provides the means to capture the lessons to be learned arising from
human errors, near misses or free lessons
YOU CAN’T FIX WHAT YOU DON’T KNOW
TUJUH
SAFETY
CULTURE
SIX STEPS TO A SAFETY CULTURE
4. LEARNING CULTURE
i. Where human factors training is provided to all on an ongoing basis
ii. Where incident data is kept and analyzed to find trends and
develop Safety nets
iii. Where major changes are carried out when the present system is
not sufficiently Safe
iv. Where feedback is provided as a means of learning from all
incidents
TUJUH
SAFETY
CULTURE
SIX STEPS TO A SAFETY CULTURE
5. INFORMED CULTURE
Where everyone knows the organization’s true Safety commitment
i. A Mission Statement - Posted
ii. A Safety Policy – Posted
iii. . An Administrative Policy – Known by all
iv. 4. Long term Safety goals – Known by all who work toward
them
v. 5. Optional - Core Values Statement - Posted
TUJUH
SAFETY
CULTURE
SIX STEPS TO A SAFETY CULTURE
6. FLEXIBLE CULTURE
i. Where necessary changes are made in order to improve Safety
ii. Where the organization is constantly looking for better ways to
work Safer
iii. Where the status quo is not considered an option in the quest
to lower errors
iv. Where there is a “Chronic Unease” that in spite of all efforts,
human error will still occur
v. Where an Emergency Response Plan (ERP) is in place in the
event of an error occurring
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