AVIATION SAFETY

MANAGEMENT
WHY SAFETY, WHEN SECURITY?

SAFETY
VS
SECURITY
Are Causes and
consequences
of operational errors
not linear
in their magnitude?
Yes!Causes and
consequences
of operational errors
are not linear
in their magnitude
• Human error is
considered contributing
factor in most
occurrences.
• Even competent
personnel commit
errors.
• Errors must be accepted
as a normal component
of any system where
humans & technology
interact
Safety vs. Reliability
More reliable a
system is,
The safer it is,
and vice versa
International Civil Aviation Organization
 The ICAO Annexes
Annex 1 - Personnel Licensing
Annex 2 - Rules of the Air
Annex 3 - Meteorological Services
Annex 4 - Aeronautical Charts
Annex 5 - Units of Measurement
Annex 6 - Operation of Aircraft
Annex 7 - Aircraft Nationality and Registration Marks
Annex 8 - Airworthiness of Aircraft
Annex 9 - Facilitation
Annex 10 - Aeronautical Telecommunications
Annex 11 - Air Traffic Services
Annex 12 - Search and Rescue
Annex 13 - Aircraft Accident and Incident Investigation
Annex 14 - Volume I "Aerodrome Design and Operations"
Annex 15 - Aeronautical Information Services
Annex 16 - Environmental Protection
Annex 17 - Security
Annex 18 - The Safe Transportation of Dangerous Goods by Air
Annex 19- Safety Management System
ICAO`s STANDARDS & RECOMMENDED PRACTICES

ANNEXURE—6
Part-I
a) Operation of aircraft.
b) International Commercial Air Transport.
c) Aeroplanes.
Part-II
d) International Operations.
b) Helicopters
ANNEXURE—11
a) Air Traffic Service
ANNEXURE—14
a) Aerodromes
 SAFETY TASKS
1. IDENTIFY HAZARDS.
2. ENSURE THAT REMEDIAL ACTIONS .NECESSARY
TO MITIGATE THE RISKS/HAZARDS, ARE
IMPLEMENTED.
3. CONTINUOUS MONITORING & REGULAR
ASSESSMENT OF THE SAFETY LEVEL ACHIEVED.
RESPONSIBILITIES FOR SAFETY PROGRAM

1. INDIVIDUAL OPERATORS
2. MAINTENANCE ORGANIZATIONS
3. AIR TRAFFIC SERVICE PROVIDERS
4. CERTIFIED AERODROME
OPERATORS
 ICAO Annex 14:
"A systematic approach to managing
safety, including the necessary
organizational structures,
accountabilities, policy and
procedures"
 DEFINITION OF SAFETY
Freedom from those conditions
that can cause death, injury,
occupational illness, or damage to
or loss of equipment or property, or
damage to the environment.
IN OTHER WORD
Safety is “the degree to which accidental
harm is detected, reacted & prevented to”
FIELDS OF HAZARDS
Aviation Safety Management System
With the expected growth in air transportation, there is a
need to make greater efforts and adopt new measures to
continue improving
Aviation Safety.

The use of Safety Management Systems can

contribute to this effort by helping airlines detect and
correct safety problems before they result in aircraft
accidents or incidents.
The management dilemma
Man
a gem
ent
leve
ls
Resources +

ORGANIZATION
Protection

Production

Catastrophe
The management dilemma
ve ls
nt le
m e
age
n
Ma
+ Resources

ORGANIZATION Production

Protection

Bankruptcy
 The Management Dilemma

Management levels

Resources

ORGANIZATION
Resources

Protection Production
 Main goals of a
Safety Management Process:

1. Identify possible hazards with significant risk of

an accident, injury or damage
2. Select appropriate corrective action to eliminate
this risk or to reduce it to acceptable levels
3. Monitor the corrective action taken and test its
efficiency
 DEFINITION OF
RISK MANAGEMENT

The identification, analysis and

elimination, and/or mitigation to an
acceptable level of risks that threaten
the capabilities of an organization
 Risk Assessment
1. Generation and verification of safety requirements;

2. Identification of all relevant failure conditions;

3. Consideration of all significant combinations of failures

causing failure conditions;

4. Generation of output reports starting from the stage of

Functional Hazard Analysis and ending by the System
Safety Assessment verifying that the design meets safety
requirements.
Designations for Risk Probability?

Frequent

Occasional

Remote

Improbable

Extremely
improbable
Designations for Risk Severity

Catastrophic

Hazardous

Major

Minor

Negligible
 Safety
 Traditional approach – Preventing accidents
 Focus on outcomes (causes)
 Unsafe acts by operational personnel
 Attach blame/punish for failures to “perform safely”
 Address identified safety concern exclusively
 Regulatory compliance
 Identifies:

WHAT? WHO? WHEN?

But not always discloses:

WHY? HOW?
 The evolution of safety thinking

TECHNICAL FACTORS

HUMAN FACTORS

TODAY
ORGANIZATIONAL FACTORS

1950s 1970s 1990s 2000s

Fuente: James Reason
 A concept of accident causation

Organization Workplace People Defences

Regulations
Management Working conditions Errors Training
Technology
decisions and and

ORGANIZATION
organizational violations
processes

Latent conditions trajectory

Actions
Activities
Factors
Resources ortoinactions
Conditions
that
over directly
protect
present
which by
in people
influence
any
against
the (pilots,
organization
system
the
the risks controllers,
efficiency
before
has
thata maintenance
organizations
the
of
reasonable
people
accident,
in degree
made
involved
engineers, aerodrome staff, etc.) that have an immediate adverse
in production evident
activities
aviation
byoftriggering
direct
generate
workplaces.
effect. control
factors.
and must control.
Accident investigation – Once in a million flights

Unh Inci
Fla
ps o
Che
ckli eed acc dent /
mitt st fa ed iden
ed ilure w arn t
ing

Error Deviation Amplification Degradation /

breakdown
Safety management – On almost every flight

Fla Che Effe

ps o ckli ctiv
mitt st w ew
ed ork arn
s ing

Error Deviation Normal flight

Effective safety reporting
“Five basic traits”
HUMAN ERROR
 HUMAN ERROR

HUMAN ERROR IS DEFINED AS

A HUMAN ACTION
WITH
UNINTENDED CONSEQUENCES
 KINDS OF HUMAN ERROR

ACTIVE ERROR
An active error is the specific individual
activity that is an obvious event.

LATENT ERROR
A latent error is the company issues
that lead up to the event.
 TYPES OF HUMAN ERROR
UNINTENTIONAL
An unintentional error is an unintentional
wandering or deviation from accuracy.
INTENTIONAL
Knowingly or intentionally choose to do
something wrong by violating or deviating
from safe practice, procedures, Standards
or regulations.
 Errors ...

… are like mosquitoes …

To fight them …

... drain their breeding swamps.

HAZARDS
 DEFINITION OF HAZARD

Hazard is a condition or an
object with the potential of
causing injuries/fatalities to
personnel, damage to
equipment or structures, loss of
material, or reduction of ability
to perform a prescribed function.
In and by themselves, hazards are
not “bad things”. Hazards are not
necessarily damaging or negative
components of a system. It is only
when hazards interface with the
operations of the system that
their damaging potential may
become of safety concern.
DEFINITION OF CONSEQUENCE

Consequence is defined as the

Potential outcome(s) of a
Hazard
 HAZARD IDENTIFICATION
1.Design Factors, including equipment and task design.
2.Procedures & Operating Practices, including their
documentation and checklists, and their validation under
actual operating conditions;
3.Communications, including means, terminology and
language;
4.Personnel Factors, such as company policies for
recruitment, training, remuneration and allocation of
resources.
 HAZARD IDENTIFICATION
5.Organizational Factors, such as the compatibility
of production and safety goals, the allocation of
resources, operating pressures and the corporate safety
culture;
6.Work Environment Factors, such as ambient
noise and vibration, temperature, lighting and the
availability of protective equipment and clothing;
7.Regulatory Oversight Factors, including the
applicability and enforceability of regulations; the
certification of equipment, personnel and procedures;
and the adequacy of oversight;
 HAZARD IDENTIFICATION

8.Defences, including such factors as the

provision of adequate detection and warning
systems, the error tolerance of equipment and
the extent to which the equipment is resilient
against errors and failures; and
9.Human performance, including medical
conditions and physical limitations.
 HAZARD ANALYSIS
• Step A – State the generic hazard (hazard statement )
o Airport construction
• Step B – Identify specific hazards or components of the
generic hazard
o Construction equipment
o Closed taxiways
o Etc.
• Step C – Link specific hazards to specific consequence(s)
o Aircraft colliding with construction equipment (construction
equipment)
o Aircraft taking into wrong taxiway (closed taxiways)
o Etc.
 DEFINITION OF SAFETY RISK

Assessment, expressed in terms of

predicted probability and
severity, of the consequence(s) of
a hazard taking as reference the
worst foreseeable situation.
 RISK TRILOGY

1. a wind of 25 knots blowing directly across the

runway is a hazard;
2. the potential for a runway lateral excursion, because
a pilot might not be able to control the aircraft during
takeoff or landing, is one of the consequences of the
hazard;
3. the assessment of the consequences of a runway
lateral excursion, expressed in terms of probability &
severity as an alpha-numerical convention, is the
safety risk.
SAFETY, every body`s responsibility
Designations for Risk Probability?

Frequent

Occasional

Remote

Improbable

Extremely
improbable
Designations for Risk Severity

Catastrophic

Hazardous

Major

Minor

Negligible
SAFETY RISK PROBABILITY TABLE
SAFETY RISK SEVERITY TABLE
Designations for
Designations for
Risk Severity Risk Probability?
Catastrophic A Frequent 5

Hazardous B Occasional 4

Major C Remote 3
Improbable
Minor D 2
Extremely
Negligible E improbable 1
Process of Safety Risk Management
 THE FIVE FUNDAMENTALS
SAFETY RISK MANAGEMENT

• There is no such thing as absolute safety – In aviation it is not possible to

eliminate all safety risks.

• Safety risks must be managed to a level “as low as reasonably practicable”

• Safety risk mitigation must be balanced against:
o time
o cost
o difficulty of taking measures to reduce or eliminate the safety risk .

• Effective safety risk management seeks to maximize the benefits of accepting a

safety risk (most frequently, a reduction in either time and/or cost in the delivery of
the service) while minimizing the safety risk itself.

• Communicate the rationale for safety risk decisions to gain acceptance by

stakeholders affected by them.
Three possible organizational cultures
AVIATION SAFETY
 SAFETY MANAGEMENT
(EIGHT BUILDING-BLOCKS)

1. Senior Management`s Commitment to the Management of

Safety:-Managing safety, just like other management activity, requires
allocation of resources. no money, no safety.

2.Effective safety reporting. It is a known aphorism that “one

cannot manage what one cannot measure”. In order to manage safety,
organizations need to acquire safety data on hazards that
allows for measurement to take place. Most of such data will be
acquired through voluntary and self-reporting by operational
personnel. It is essential therefore for organizations to develop working
environments where effective safety reporting by operational
personnel takes place.
3.Continuous monitoring:- through systems that collect
safety data on hazards during normal operations. However, safety
data collection is just the first step. Beyond collection,
organizations extract safety information and safety intelligence
from data, because data that is collected and locked in a drawer is
as good as no data at all. Furthermore, it is essential to share the
safety information and intelligence gleaned with those who
operate the system daily, for it is them who are in constant
contact with the hazards the consequences of which effective
safety reporting aims to mitigate
4.Investigation of safety occurrences :-with
the objective of identifying systemic safety deficiencies
rather than assigning blame. It is not as important to
identify “who did it” as it is to learn “why it happened”.
System resilience can be much more effectively
reinforced by removing systemic deficiencies than by
removing supposedly “unfit” individuals.
5. Sharing safety lessons learned and best practices:-
through the active exchange of safety information. Another well-
known aphorism eloquently illustrates the need for data sharing

and exchange of safety information: “learn from the mistakes of

others, you are not going to live long enough to make them all
yourself”. The aviation industry’s excellent tradition of safety
data sharing must be maintained and if at all possible reinforced.
6. Integration of safety training for operational
personnel. Seldom training curricula for operational
personnel include dedicated safety training. There is an
assumption that since that “safety is every body`s
responsibility”, operational personnel are safety experts in
their own right. The fallacy of this line of reasoning is evident,
There is an urgent need to include dedicated training
addressing the basics of safety management at all levels of
operational personnel training.
7. Effective implementation of Standard Operating
Procedures (SOPs), including the use of checklists
and briefings. SOPs, checklist and briefings, whether in a
flight deck, an air traffic control room, a maintenance shop
or an aerodrome apron, are amongst the most effective
safety devices operational personnel has to discharge their
daily responsibilities. They are a powerful mandate from
the organization, regarding how senior management wants
operations to be conducted. The safety value of realistic,
properly written and constantly adhered to SOPs, checklist
and briefings should never be underestimated.
8. Continuous improvement of the overall
level of safety:- Managing safety is not one day affair.
The war for safety management is not a conventional warfare,
where the front lines are well defined, known to everybody,
and one major battle will decide the outcome of the war. The
war for safety management, managing safety, is akin to
guerrilla warfare: the front lines are not clear, the enemy is not
always visible, and gains are measured by inches. It is an on-
going activity that can only be successful through
“ continuous improvement”
 SYSTEM DESCRIPTION OF AN AERODROME

1.Facilities,
2.Equipment,
3.Personnel,
4. Processes,
5.& Procedures.
 Different Functions

1. Operational management
2. Aerodrome management
3. Passenger terminal building
management
4. Air traffic and aeronautical information
and communications services
5. Safety and Security management
AVIATION SAFETY
MANAGEMENT
1. Operational Management
a) Movement area access control;
.Air
.Land
.Sea
b) Aerodrome emergency planning;
.Emergency procedures manual
.Emergency simulation practices
c) Rescue and fire fighting;
• Capability
o Equipment
o Foam/water/dry powder discharge rate
• Facility maintenance
• Staff training and experience

-
 .Equipment mobilization plan
.Reduction of capability (notice)
.Water hydrant system
d) Movement area inspection and maintenance;
.Aerodrome manual
.Inspection forms
.Maintenance
e) Visual aids maintenance;
.Inspections
.Schedule
f) Construction management;
.Control of works
.Site management
g) Apron safety management, including vehicle traffic;
• Rules and regulation for airside operations
• Airside management
o Airside vehicle management
o Airside vehicle license
o Vehicle examination
o Safety specification
o Aircraft servicing coordination
• Equipment parking
• Apron discipline
• Push-back operations
• Traffic signs and markings
• Aircraft damage control
Fuel spillage control
Vehicle and equipment damage control
Apron safety check lists including ramp activity audit and working on
height
Contracted and sub-contracted activities
STERILE COCKPIT