SAFETY

MANAGEMENT
SYSTEM
Week 2
Lecturer Niyazi Cem GÜRSOY

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Course Content
1. Introduction
2. Development of safety concept – Accident statistics
3. Approaches/models to accident investigations
4. Human Performance and Limitations
5. Positive Safety Culture
6. Introduction to safety management
7. Hazards
8. Safety risks
9. ICAO Safety Management SARP’s
10. SMS-Safety Management System
11. SMS - Planning
12. SMS - Operation
13. Phased implementation approach to SMS
14. SSP-State Safety Programme

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• Development of Safety Concept - Accident Statistics

• Historical Development

• World Accident Statistics

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Remember;
• 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.

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Early Days of Aviation
• In the early years, commercial aviation activity was very low. The
production of aircraft was more for military purposes.
• Design and production stages were not checked properly.
• Accidents happened frequently, with corrective measures flights went on.
• In fact, it was difficult to study the accident because of limited
technological capacities and knowledge. In the accident reviews, technical
reasons are first looked at, if not found, the actions of the operational
personnel (mostly pilots) were assessed.

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• This approach, called the Traditional Approach
• was not able to carry out extensive reviews and evaluations. In the
accident examinations, mostly these questions used to be asked:
• What happened?
• When?
• Who did it?
• And so on.
• Necessary knowledge and the technology took time to form. Many
accidents were marked as "technical failure" or "pilotage" in this period.
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 Focus on outcomes (causes)

Unsafe acts by operational personnel

Traditional
Approach – Attach blame/punish for failures to
“perform safely”
preventing
Address identified safety concern
accidents exclusively
Regulatory compliance

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Identifies

WHAT ? WHO ? WHEN ?

Not always asked

WHY ? HOW ?

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• From the 1950s onwards, this approach began to change with the increase
in commercial activity To answer the questions . "Why?» and «How?»
began to be sought. The examinations made were not enough.
• In the 1970s, the aviation industry turned into public transport. Significant
technological developments are begun to emerge. The jet era has begun,
autopilots, routers, and many ground navigation systems have begun to be
used. This period called Technical Age, the number of accidents
continued to be quite high.
• Aircraft technology required pilot coordination, team skill management,
line orientations, etc. New applications went into effect.

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• Between the 1970s and 1990s, the human impact in the accident occurred in the
forefront. A lot of studies were started to reduce accidents caused by human
error in this period which is called Human Age.
• The focus of safety has shifted to «human factors». During this period, which
continued until the mid-1990s and was called the Golden Age, the living
environment of people has also begun to be taken into consideration.
• Today, there is no longer «waiting for accident» approach. All the necessary
precautions to avoid an accident should be taken in advance. The social and
work environment, working conditions, human factors and technical
applications are all under constant examinations.
• The goal is simple; No accident... but it's not that easy ...

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The Evolution of Safety Thinking

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12
Occurrences

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 Accident

• An occurrence associated with the

operation of an aircraft ..., in which:
a) a person is fatally or seriously injured
…
Any
of b) the aircraft sustains damage or
this structural failure
c) the aircraft is missing or is
completely inaccessible

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a person is fatally or seriously injured
• being in the aircraft, or
• direct contact with any part of the aircraft, including parts which have
become detached from the aircraft, or
• direct exposure to jet blast, except when the injuries are from natural
causes, self-inflicted or inflicted by other persons, or when the injuries are
to stowaways hiding outside the areas normally available to the passengers
and crew; or

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the aircraft sustains damage or structural
failure which:
• adversely affects the structural strength, performance or flight
characteristics of the aircraft, and
• would normally require major repair or replacement of the affected
component, except for engine failure or damage, when the damage is
limited to a single engine (including its cowlings or accessories), to
propellers, wing tips, antennas, probes, vanes, tires, brakes, wheels,
fairings, panels, landing gear doors, windscreens, the aircraft skin (such as
small dents or puncture holes), or for minor damages to main rotor blades,
tail rotor blades, landing gear, and those resulting from hail or bird strike
(including holes in the radome);

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Accident Classifications
• Hull Loss Accident: An accident in which the aircraft damage is not
repairable or is damaged but not repaired.
• Hull loss accidents include when the aircraft is missing, or if the wreckage
is inaccessible.

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Major Accident
• Major Accident: An accident in which any of the following three
conditions are met:
The aircraft is destroyed
There were multiple fatalities
There was one fatality and the aircraft sustained substantial damage

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Fatal Accident
• Fatal Accident: An accident causing one or more fatalities to occupants of
the aircraft Substantial Damage Accident: An accident in which the
aircraft sustained substantial damage Serious Accident: An accident in
which either of the following two conditions are met:
A single fatality without substantial damage
At least one serious injury and aircraft substantially damaged

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• Minor Accident: An accident in which the aircraft sustained minor damage
• Aircraft incident: An occurrence other than an accident that affects or
could affect the safety of operations

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Serious Incident
• A “serious incident” means an incident involving circumstances indicating
that there was a high probability of an accident and is associated with the
operation of an aircraft.

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 Serious Injury
A “serious injury” means an injury which is sustained by a person in an accident
and which:
(a) requires hospitalisation for more than 48 hours, commencing within seven days
from the date the injury was received; or
(b) results in a fracture of a bone, excluding simple fractures of fingers, toes, or
nose; or
(c) involves lacerations which cause severe haemorrhage, nerve, muscle or tendon
damage; or
(d) involves injury to an internal organ; or
(e) involves second- or third-degree burns, or any burns affecting more than 5 per
cent of the body surface; or
(f) involves verified exposure to infectious substances or harmful radiation.
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Accident Statistics
The number of fatal airliner (14+ passengers) hull-loss accidents and fatalities per year is
given. The figures do not include corporate jet and military transport accidents/hijackings.

Airliner Airliner Airliner Airliner

Year Year
Accidents Fatalities Accidents Fatalities
2021 20 1762010 32 943
2020 8 1372009 32 763
2019 23 2892008 35 595
2018 18 5612007 32 774
2017 14 592006 33 905
2016 17 2582005 40 1075
2015 14 1862004 35 462
2014 20 6922003 34 705
2013 28 2322002 42 1002
2012 23 4762001 36 879
2011 36 5252000 43 1148

https://aviation-safety.net/statistics/period/stats.php
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3000

2500

2000

1500

1000

500

0
1960 1970 1980 1990 2000 2010 2020 2030
Airliner Accidents Airliner Fatalities
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Source; ICAO Safety Report, 2022
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https://aviation-safety.net/graphics/infographics/ASN_infographic_2019.jpg 27
Source; ICAO Safety Report, 2022
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 Total accidents
by occurrence
category in 2021
• Abrupt Maneuver (AMAN)
• Abnormal runway contact (ARC);
• Cabin safety events (CABIN)
• Controlled flight into or toward terrain (CFIT)
• Evacuation (EVAC)
• Ground collision (GCOL);
• Icing (ICE);
• Loss of control in-flight (LOC-I)
• Ground handling (RAMP)
• System/component failure or malfunction
(non-powerplant) (SCF-NP).
• Turbulence encounter (TURB)

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Worldwide Commercial Jet Fleet 1959
through 2021

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Worldwide Commercial Jet Fleet 2012
through 2021

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Accident Rates and Onboard Fatalities per One Million Departures

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Source; Boeing, 2022 33
Source; Boeing, 2022 34
Source; CAA, 2013 35
Source; CAA, 2013

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Breakdown of all fatal accidents by causal
group (for all causal factors) for the ten-year
period 2002 to 2011

Source; CAA, 2013

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Top-ten consequences for all fatal accidents
for the ten-year period 2002 to 2011

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List of Circumstantial Factors attributed to
Worldwide Fatal Accidents – 2002 to 2011
• Global Fatal Accident Review 2002 to 2011 Page 110
• List of Consequences attributed to Worldwide Fatal Accidents – 2002 to
2011 Page 124

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Questions and
Answers

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