SAFETY

MANAGEMENT
SYSTEM
Week 4
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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Typical Causes Of Aircraft Accidents At
The Beginning Of The 21st Century

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The Subject of Human Performance and
Limitations in Aviation
• Safety and efficiency of flight operations.
• Health, fitness and well-being.
• Operating skills.
• Awareness of the common areas of human error.
• Judgement and decision-making.
• Leadership qualities.
• Crew co-ordination.
• Use of check lists and charts.
• Getting maximum benefit from training.
• Good communications.

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A competent pilot:
• Possesses a high sense of responsibility.
• Has high ability (academic and piloting/aircraft handling skills).
• Is well motivated.
• Is a good communicator.
• Is flexible.
• Is physically fit.
• Is reliable.
• Has a balanced personality.
• Is a team player.
• Remains calm under stress.
• Has an eye for detail.
• Is competent in Risk Assessment.
• Is competent in the skills of Stress and Crew Management.

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The five most common specific causes of pilot
induced accidents, in order of frequency of
occurrence, are:
• Loss of directional control.
• Poor judgement.
• Airspeed not maintained.
• Poor pre-flight planning and pre-flight decision making.
• Not maintaining ground clearance.

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The phases of flight most prone to accidents,
starting with the most common are:
• Intermediate and Final Approach.
• Landing.
• Take-off.
• Descent.

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What is human performance?
• In general, we can define human performance as how much people do the
work they need to do in their jobs.
• Human Performance (HP) represents the human contribution to system
performance and refers to how people perform their work. Throughout the
aviation system, people are both the source of some of the risks and an
integral part of identifying and managing all risks. (ICAO)

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HP-related areas of work
• Collection and analysis of safety data
• Change management and introduction of new systems
• Fatigue management
• HP considerations in automated systems
• Safety risk management
• Personnel Training and Licensing

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Key HP
concepts
• Human Performance
Principles
• Human-Centred Design
• Systems Thinking

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Human Performance
Principals
Principle 1: People's performance is shaped by
their capabilities and limitations
• People have various physical and mental
capabilities, such as strength, flexibility, memory,
attention, resourcefulness and creativity.
• People have limitations too. Some are based on
physiology.
• People also have cognitive constraints.
• To free up cognitive resources for other tasks,
people can make quick, automatic responses when
performing frequent activities and well-practised
routines.

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Principle 2: People interpret
situations differently and perform
in ways that make sense to them

• People are always trying to make sense

of the world around them. They look for
patterns and predictability.
• People do not go to work with the
intention of making an error or of
contributing to a safety event.

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Principle 3: People adapt to meet the demands of
a complex and dynamic work environment
• People are key to the aviation system, creating
resilience by constantly adjusting and adapting to
overcome delays, adverse weather and other unexpected
situations.
• As a result of this continuous adaptation, the work
actually performed by people is often different from
how the work was originally expected to be performed.
• To be effective under these dynamic conditions, people
need to be able to do more than simply complete a
series of pre-identified procedural steps.

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Principle 4: People assess
risks and make trade-offs

• The aviation work environment presents

people with conflicting goals. Any activity
in aviation must balance safety objectives
and other organizational objectives, such
as on-time performance, cost savings and
environmental protection.
• Trade-offs can sometimes result in errors
or in deviations from published rules or
procedures. This flexibility might be
perceived as a safety deficiency.

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Principle 5:People's performance is influenced by working with
other people, technology, and the environment

• Human performance can be positively or

negatively affected by interacting with other
people and with all elements of the socio-
technical system.
• When people work together as a group, they
can do more collectively than any individual
can do alone. In the same way that some
physical capabilities of the group are greater
than the individual capabilities of any group
member
• Similar to the way their performance is
influenced by working with other people,
people's performance is also influenced by
the technology.

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Human-centered design (HCD)
• Human-centered design (HCD) - also known as user-centered design – is
an approach that helps ensure that the product being designed – such as
systems, equipment, procedures, services, or regulations - is useful and
usable and will support skilled performance in the workplace so that
intended operational benefits can be realized.
• Its goal is to make it easy to use the product effectively and reduce the
risks of unintended consequences.

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 A concept of use (or operation)

Features
of an A focus on user needs and capabilities

HCD Multi-disciplinary design teams

approach Iterative testing to improve design

effectiveness
A concept of use (or operation)
HCD starts with a "concept of use" that describes:
• the desired performance outcomes of using the product being developed; and
• how users will interact with the product to achieve the desired outcomes.
The concept of use is based on:
1. baseline assumptions about what the users need to know and are able to do;
2. how they will do it; and
3. a description of the operational context (including assumptions about the
environment in which the design will operate and to what other systems or
elements of a system it connects). For example, in developing a new
technology, it is at this early stage that decisions are made about what
functions the technology will perform and what will be the role of the humans
interacting with it.

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A focus on user needs and
capabilities
• ​An HCD approach focuses on user needs and capabilities,
with the identification of design requirements that lead to
features and functions needed to support human
performance, that make it easy to use the product as
intended.

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Multi-disciplinary design
teams
• An HCD approach uses is driven by multi-disciplinary
design teams and stakeholder representatives and is refined
by user-centred evaluations.
• Users, both direct and indirect, are engaged throughout the
design process to make sure that use of the product will
result in the expected performance outcomes, and that it can
be used as expected without needing any “work-arounds”.

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Iterative testing to improve design
effectiveness

An HCD approach uses an

It also allows identification of
iterative process that considers
any associated procedures and
the whole user experience under
the knowledge or skill gaps that
varying conditions of use,
will need to be addressed to
building on lessons learned
support effective
through multiple analyses,
implementation.
simulations and scenarios.

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Fatigue Management
Yiğit Kanbur

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What is Human Factors?
• Human factors involves gathering information about human abilities,
limitations, and other characteristics and applying it to tools, machines,
systems, tasks, jobs, and environments to produce safe, comfortable, and
effective human use.
• In aviation, human factors is dedicated to better understanding how
humans can most safely and efficiently be integrated with the technology.

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Elements of Human Factors

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Human Error

• Human error is defined as a human

action with unintended consequences.
• Human error is not avoidable but it is
manageable.

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The “Dirty Dozen”
• Due to a large number of maintenance-related aviation accidents and
incidents that occurred in the late 1980s and early 1990s, Transport
Canada identified twelve human factors that degrade people’s ability to
perform effectively and safely.

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The “Dirty Dozen”
1. Lack of communication 9. Lack of knowledge
2. Distraction 10. Fatigue
3. Lack of resources 11. Lack of assertiveness
4. Stress 12. Norms
5. Complacency
6. Lack of teamwork
7. Pressure
8. Lack of awareness

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Lack of communication
• Poor communication often appears at the top of contributing and causal
factors in accident reports, and is therefore one of the most critical human
factor elements.
• Detailed information must be passed before, during and after any task,
and especially across the handover of shifts.

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Distraction
• Distraction could be anything that draws a person’s attention away from
the task on which they are employed.
• Psychologists say that distraction is the number one cause of forgetting
things: hence the need to avoid becoming distracted and to avoid
distracting others.
• To reduce errors from distraction it is best to complete a task before
responding.

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Lack of
resources
• Resources may include personnel,
time, data, tools, skill, experience
and knowledge etc. A lack of any
of these resources can interfere
with one’s ability to complete a
task.

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Stress
• There are many types of stress. Typically in the aviation environment there
are two distinct types - acute and chronic.
• Acute stress arises from real-time demands placed on our senses, mental
processing and physical body; such as dealing with an emergency, or
working under time pressure with inadequate resources.
• Chronic stress is accumulated and results from long-term demands placed
on the physiology by life’s demands, such as family relations, finances,
illness, bereavement, divorce, or even winning the lottery.

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Complacency
• Complacency can be described as a feeling of self-satisfaction
accompanied by a loss of awareness of potential dangers.
• Following written instructions, and adhering to procedures that increase
vigilance, such as inspection routines, can provide suitable stimulus.

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Lack of teamwork
• In aviation many tasks and operations are team affairs; no single person
(or organisation) can be responsible for the safe outcomes of all tasks.
• Some of the key teamwork skills include: leadership, followership,
effective communication, trust building, motivation of self and others, and
praise giving.

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Pressure
• Pressure is to be expected when working in a dynamic environment.
However, when the pressure to meet a deadline interferes with our ability
to complete tasks correctly, then it has become too much.
• Pressure can be created by lack of resources, especially time; and also
from our own inability to cope with a situation.

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Lack of awareness
• Working in isolation and only considering one’s own responsibilities can
lead to tunnel vision; a partial view, and a lack of awareness of the affect
our actions can have on others and the wider task.
• It is important to build experience throughout our careers, especially
concerning the roles and responsibilities of those we work with, and our
own place in the wider Team.
• Vigilance is closely related to situational awareness, and workplace
procedures, such as scanning, two-way communication and use of
checklists will help to maintain vigilance.

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Lack of knowledge
• The regulatory requirements for training and qualification can be
comprehensive, and organisations are forced to strictly enforce these
requirements.
• It is important for employees to undertake continuing professional
development and for the most experienced workers to share their
knowledge with colleagues.

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Fatigue
• Fatigue is a natural physiological reaction to prolonged physical and/or
mental stress.
• It is important that workers are aware of the signs and symptoms of
fatigue – in themselves and others. Fatigue self-management involves a
three-sided programme of regular sleep, healthy diet (including reduced
use of alcohol and other drugs), and exercise.

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Lack of assertiveness
• Assertiveness is a communication and behavioural style that allows us to
express feelings, opinions, concerns, beliefs and needs in a positive and
productive manner.
• Assertiveness techniques can be learnt and they focus on keeping calm,
being rational, using specific examples rather than generalisations, and
inviting feedback.

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Norms
• Workplace practices develop over time, through experience, and often
under the influence of a specific workplace culture. These practices can
be both, good and bad, safe and unsafe; they are referred to as “the way
we do things round here” and become Norms.
• Help maintain a positive environment with your good attitude and work
habits

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Human Factors Analysis and
Classification System
(HFACS)

• The Human Factors Analysis and Classification System (HFACS) was

developed by Dr Scott Shappell and Dr Doug Wiegmann. It is a broad human
error framework that was originally used by the US Air Force to investigate
and analyse human factors aspects of aviation.
• HFACS is heavily based upon James Reason's Swiss cheese model (Reason
1990).
• The HFACS framework provides a tool to assist in the investigation process
and target training and prevention efforts.
• The goal of HFACS is not to attribute blame; it is to understand the underlying
causal factors that lead to an accident.

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The HFACS
Framework
HFACS Level 1: Unsafe Acts
Errors
• Skill-Based Errors: Errors which occur in the operator’s execution of a
routine, highly practiced task relating to procedure, training or proficiency
and result in an unsafe situation (e.g., fail to prioritise attention, checklist
error, negative habit).
• Decision Errors: Errors which occur when the behaviors or actions of the
operators proceed as intended yet the chosen plan proves inadequate to
achieve the desired end-state and results in an unsafe situation (e.g,
exceeded ability, rule-based error, inappropriate procedure).
• Perceptual Errors: Errors which occur when an operator's sensory input
is degraded and a decision is made based upon faulty information.
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HFACS Level 1: Unsafe Acts
Violations
Routine Violations: Violations which are a habitual action on the part of the
operator and are tolerated by the governing authority.
Exceptional Violations: Violations which are an isolated departure from
authority, neither typical of the individual nor condoned by management.

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HFACS Level 2: Preconditions for Unsafe
Acts
The Preconditions for Unsafe Acts level is divided into three categories:

• environmental factors,
• condition of operators, and
• personnel factors.

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HFACS Level 2: Preconditions for Unsafe
Acts
Environmental Factors
• Physical Environment: Refers to factors that include both the operational
setting (e.g., weather, altitude, terrain) and the ambient environment (e.g.,
heat, vibration, lighting, toxins).
• Technological Environment: Refers to factors that include a variety of
design and automation issues including the design of equipment and
controls, display/interface characteristics, checklist layouts, task factors
and automation.

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Condition of Operators
• Adverse Mental State: Refers to factors that include those mental
conditions that affect performance (e.g., stress, mental fatigue,
motivation).
• Adverse Physiological State: Refers to factors that include those medical
or physiological conditions that affect performance (e.g, medical illness,
physical fatigue, hypoxia).
• Physical/Mental Limitations: Refers to the circumstance when an
operator lacks the physical or mental capabilities to cope with a situation,
and this affects performance (e.g., visual limitations, insufficient reaction
time).
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HFACS Level 2: Preconditions for Unsafe
Acts
Personnel Factors
• Crew Resource Management: Refers to factors that include
communication, coordination, planning, and teamwork issues.
• Personal Readiness: Refers to off-duty activities required to perform
optimally on the job such as adhering to crew rest requirements, alcohol
restrictions, and other off-duty mandates.

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HFACS Level 3: Unsafe Supervision
The Unsafe Supervision level is divided into four categories.
• Inadequate Supervision: The role of any supervisor is to provide their staff with the
opportunity to succeed, and they must provide guidance, training, leadership,
oversight, or incentives to ensure the task is performed safely and efficiently.
• Plan Inappropriate Operation: Refers to those operations that can be acceptable and
different during emergencies, but unacceptable during normal operation (e.g., risk
management, crew pairing, operational tempo).
• Fail to Correct Known Problem: Refers to those instances when deficiencies are
known to the supervisor, yet are allowed to continue unabated (e.g, report unsafe
tendencies, initiate corrective action, correct a safety hazard).
• Supervisory Violation: Refers to those instances when existing rules and regulations
are willfully disregarded by supervisors (e.g., enforcement of rules and regulations,
authorized unnecessary hazard, inadequate documentation).

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Unsafe Supervision Examples

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HFACS Level 4: Organizational Influences
Organizational Influences level is divided into three categories.
• Resource Management: Refers to the organizational-level decision-
making regarding the allocation and maintenance of organizational assets
(e.g., human resources, monetary/budget resources, equipment/facility
recourse).
• Organizational Climate: Refers to the working atmosphere within the
organization (e.g., structure, policies, culture).
• Operational Process: Refers to organizational decisions and rules that
govern the everyday activities within an organization (e.g., operations,
procedures, oversight).
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Use of HFACS
• By using the HFACS framework for accident investigation, organizations
are able to identify the breakdowns within the entire system that allowed
an accident to occur.
• HFACS provides a structure to review and analyze historical accident and
safety data.
• The HFACS framework may also be useful as a tool for guiding future
accident investigations in the field and for developing better accident
databases

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Sum Up

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Questions and
Answers

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