2024

Safety Management System

Deklerck Yana
[Bedrijfsnaam]
23-4-2024
Inhoud
What is Safety? .......................................................................................................... 3
What is SMS and What Does it Do? ........................................................................... 3
Components of an SMS as per ICAO Annex 19 ......................................................... 4
Strategies for Managing Safety Risks ......................................................................... 5
How can we implement these strategies? .................................................................. 5
SMM ( Safety Management) ....................................................................................... 5
Errors vs violations .................................................................................................. 5
Errors................................................................................................................... 5
Violations ............................................................................................................. 7
Elements that can Contribute to Safety Risks ......................................................... 7
Effective safety reporting ............................................................................................ 8
Beyond Incident-Based Reporting: ......................................................................... 8
Employee Safety Reporting (ESR): ......................................................................... 8
Benefits of Effective ESR Programs:....................................................................... 8
Conclusion:.......................................................................................................... 9
Shelle module ............................................................................................................. 9
Introduction: ............................................................................................................ 9
The Liveware Block: Humans at the Center ............................................................ 9
Interfaces Between System Components: .............................................................. 9
Mitigating Human Error: ........................................................................................ 10
The Practical Drift ..................................................................................................... 10
What is Practical Drift: ........................................................................................... 10
Causes of Practical Drift in Aircraft Maintenance: .................................................. 11
Conclusion:........................................................................................................ 12
The Swiss Cheese Model in Aircraft Maintenance .................................................... 12
Layers of Defense in Aircraft Maintenance ............................................................ 12
How Holes Can Align and Cause Problems .......................................................... 13
Preventing Accidents: Plugging the Holes............................................................. 13
Balancing safety and production ............................................................................... 14
Balancing Production and Safety: ......................................................................... 14
Safety Space Explained: ....................................................................................... 14
The safety Space Zone: ........................................................................................ 14
Examples:.......................................................................................................... 14
Safety Boundaries and Monitoring: ....................................................................... 15
Conclusion:........................................................................................................ 15
Understanding Aviation Safety and ICAO
Annex 19
This report dives into the concept of safety in aviation and explores the significance
of the Safety Management System (SMS) as outlined in ICAO Annex 19.

What is Safety?
Safety, in the context of aviation, refers to a state where risks associated with aircraft
operations are minimized and controlled to an acceptable level. It is a system-wide
property, meaning it encompasses the entire aviation ecosystem, not just isolated
components. While some level of controlled risk and error might be unavoidable, a
robust safety culture strives to create an
inherently safe environment.

ICAO, the International Civil Aviation

Organization, constantly strives to improve
aviation safety. Even with a downward trend in
accidents and incidents, there's always room for
further improvements.

What is SMS and What Does it Do?

An SMS, or Safety Management System, is a systematic
approach for managing safety within an aviation
organization. It serves as a framework to proactively
identify and manage safety risks throughout operations.

Here are some key objectives of an SMS:

• Maintaining a Balance: Striking a balance between prioritizing production

and safety is crucial. SMS helps achieve this by ensuring safety remains a top
concern without hindering operational efficiency.
• Continuous Risk Identification and Assessment: A core function of SMS is
to continually identify potential and existing safety hazards. Once identified,
the associated risks are assessed to determine their severity.
 • Developing and Implementing Mitigating Actions: Following risk
assessment, an SMS helps establish and implement appropriate corrective
measures to minimize or eliminate identified risks.
• Continuous Monitoring and Evaluation: The effectiveness of implemented
safety measures is constantly monitored and evaluated to ensure they remain
suitable.

Components of an SMS as per ICAO Annex 19

ICAO Annex 19 outlines the following core components of an effective SMS:

• Safety policy and objectives: This establishes the organization's

commitment to safety and defines its safety goals.
• Safety risk management: A systematic process for identifying hazards,
assessing risks, and developing mitigation strategies.
• Safety assurance: This involves oversight by regulatory bodies to ensure
organizations are adhering to safety regulations and their SMS is functioning
effectively.
• Safety promotion: Creating a positive safety culture that encourages open
communication, reporting of safety concerns, and continuous learning is
promoted.

The Annex also mandates that specific service providers within an aviation State
must implement an SMS. These providers include:

• Training Organizations
• Airlines conducting international commercial air transport.
• Maintenance Organizations
• Aircraft Manufacturers
• Air Traffic Service Providers
• Certified Aerodrome Operators
Strategies for Managing Safety Risks
ICAO Annex 19 highlights three risk management strategies:

• Reactive: Responding to incidents and accidents after they have occurred.

• Proactive: Actively seeking out potential
hazards by analyzing organizational processes.
• Predictive: Analyzing systems and
environments to identify potential future
problems.

How can we implement these strategies?

SMM ( Safety Management)

Errors vs violations

Errors

An error is an action or inaction by an operation person

that leads to deviations from organizational or the
operation person’s intentions or expectations.

Humans will always make errors regardless of the

training or technology.
But the goal of the SMS is to minimize errors and make a system that reduce the
consequences.

We try to reduce the likelihood by improving the procedures, ergonomics and

training and implementing error-catching mechanisms like checklist, inspections and
systems with redundancy to tolerate errors.

Slips and Lapses

slips and lapses are failures in the execution of the intended action.
Slips are actions that do not go as
planned, while lapses are memory
failures. For example, operating the flap
lever instead of the (intended) gear lever
is a slip. Forgetting a checklist item is a
lapse.

Mistakes
Mistakes are failures in the plan of action. Even if execution of the plan were correct,
it would not be possible to achieve the intended outcome.

We have safety strategies to control and eliminate errors such as reduction

strategies, capturing strategies, tolerance strategies.

Reduction strategies
Reduction strategies provide direct intervention to reduce or eliminate the factors
contributing to the error. Examples of reduction
strategies include improvement of ergonomic factors
and reducing environmental distractions.

Capturing strategies
Capturing strategies assume the error will be made.
The intent is to capture the error before any adverse
consequences of the error is felt. Capturing strategies
are different from reduction strategies in that they
utilize checklists and other procedural interventions
rather than directly eliminating the error.
Tolerating strategies
Tolerance strategies refer to the ability of a system to accept that an error will be
made but without experiencing profound consequences. The incorporation of
redundant systems or multiple inspection processes are examples of measures that
increase system tolerance to errors.

Violations
Violation: a deliberate act of willful misconduct or omission resulting in a deviation
from established regulations, procedures, norms, or practices.

Situational violations are committed in

response to factors experienced in a
specific context, such as time pressure or
high workload.

Routine violations become the normal way

of doing business within a work group.
Such violations are committed in response
to situations in which compliance with
established procedures makes task
completion difficult. This may be due to practicality/ workability issues, deficiencies in
human-technology interface design and others that cause persons to adopt
workaround procedures, which eventually become routine.
These deviations, referred to as drift, may continue without consequence. But, over
time they may become frequent and result in potentially severe consequences. In
some cases, routine violations are well grounded and may result in the incorporation
of the routine violation as an accepted procedure after a proper safety assessment
has been conducted and it shows that safety is not compromised.

Organizationally induced violations may be considered as an extension of routine

violations. This type of violation tends to occur when an organization attempts to
meet increased output demands by ignoring or stretching its safety defenses.

Elements that can Contribute to Safety Risks

An SMS considers various elements that can influence safety risks, including:

• People: Human factors such as fatigue, decision-making, and training can

impact safety.
 • Tools and Equipment: The reliability and proper functioning of tools and
equipment are crucial for safe operations.
• Materials: The quality and suitability of materials used in aircraft and related
systems are vital for safety.
• Software: The proper functioning of software systems plays a significant role in
ensuring safety.

Effective safety reporting

A critical element of any successful Safety Management
System (SMS) is an effective safety reporting system.
This system not only measures the current safety state
of an organization, but also provides valuable data for
proactive safety improvements.

Beyond Incident-Based Reporting:

• Traditional safety reporting systems primarily focus on accidents, injuries, and
fatalities.
• While these reports are essential for safety monitoring, they have limitations
for proactive safety management. They offer little insight into the underlying
factors or "precursors" that could have led to the incident.

Employee Safety Reporting (ESR):

• ESR programs represent a shift towards proactive safety management.
• They collect and analyze risk-based data before incidents occur, focusing on
near misses, hazards, and safety concerns.
• A well-designed ESR program can generate valuable data on potential risks,
allowing organizations to make data-driven decisions to manage and mitigate
those risks.

Benefits of Effective ESR Programs:

• Actionable Data: ESR programs provide a rich source of information for
identifying and addressing safety concerns before they escalate into incidents.
• Data-Driven Decisions: The collected data allows for evidence-based risk
management strategies.
Conclusion:

Effective safety reporting systems are essential for proactive safety management. By
moving beyond a focus on incidents alone and embracing ESR programs,
organizations can leverage valuable data to identify and address potential safety
issues, ultimately creating a safer work environment.

Shelle module
Introduction:

Human factors play a critical role in aviation safety. The

SHELL model provides a valuable framework for
understanding the interactions between humans and other
system components that can influence safety performance.

The Liveware Block: Humans at the Center

The SHELL model places humans, or "Liveware," at the center. Humans are
adaptable but prone to variations in performance due to inherent limitations. Unlike
standardized hardware, the "edges" of the Liveware block are jagged, representing
these limitations.

Interfaces Between System Components:

The model emphasizes the importance of understanding the interfaces between

Liveware and other system components (Software, Hardware, Environment) to avoid
compromising human performance. These interfaces are:

• Liveware-Hardware (L-H): This interface focuses on the interaction between

humans and physical equipment. Humans naturally adapt to imperfections in
this interface, but this can mask serious deficiencies that may only become
evident during an incident.
• Liveware-Software (L-S): This interface examines the relationship between
humans and supporting systems like regulations, manuals, checklists, and
software. Factors like information accuracy, format, and clarity are crucial for
optimal human performance.
• Liveware-Liveware (L-L): This interface considers the interactions between
people in aviation operations. Communication, teamwork, and group dynamics
 significantly impact overall safety. Crew Resource Management (CRM)
training focuses on managing operational errors across teams.
• Liveware-Environment (L-E): This interface explores the relationship
between humans and both internal and external environments.
o Internal environment includes factors like temperature, noise, and air
quality.
o External environment includes weather, aviation infrastructure, and
terrain.
o This interface also considers psychological and physiological factors
like fatigue, stress, and illness, which can be influenced by the external
environment. Additionally, the aviation work environment can disrupt
sleep patterns and introduce pressure to deviate from standard
procedures.

Mitigating Human Error:

According to the SHELL model, mismatches between Liveware and other

components contribute to human error. By carefully analyzing and addressing these
interfaces, organizations can significantly improve aviation safety.

Conclusion:

The SHELL model provides a valuable tool for understanding human factors in
aviation safety. By focusing on the interactions between humans and other system
components, organizations can create a safer and more efficient operating
environment.

The Practical Drift

This chapter explores the concept of practical drift, a theory developed by Scott A.
Snook, and its influence on aircraft maintenance safety. Practical drift describes how
the actual performance of a system, in this case, aircraft maintenance, can deviate
from its originally intended design. This deviation occurs because operational realities
and challenges are not always fully anticipated during the initial design phase.

What is Practical Drift:

System Design: During aircraft maintenance
system design, considerations are made for
potential limitations, human-technology interactions, and operational context to
establish expected performance and hazards. The initial design assumes three key
factors:

- Available technology to achieve maintenance goals.

- Professionally trained personnel to operate the technology.
- Regulations and procedures guiding system and human behavior.

This initial design forms the baseline (ideal) performance level).

Operational Drift: However, real-world operations expose unforeseen situations and
changes to the operational environment. These factors cause a gradual departure
from the baseline performance, known as "practical drift."

Causes of Practical Drift in Aircraft Maintenance:

Technology: Technological limitations or unexpected malfunctions can deviate from

expected performance.
Procedures: Procedures may be impractical or difficult to execute under certain
operational conditions.
Regulations: Regulatory limitations may not fully address specific contextual
situations.
System Changes: Adding new components or modifying the system can create
unforeseen interaction issues.
External Systems: Interactions with other systems (e.g., logistics) can lead to
performance deviations.
Coping Mechanisms and Risks:

Workarounds: Personnel operating within the practical drift zone may develop local
adaptations ("workarounds") or personal strategies to keep the system functioning.
Learning Potential: Analyzing these workarounds can offer valuable insights into
successful safety adaptations and identify areas for improvement.

Early Detection: Capturing information within the early stages of practical drift allows
for proactive risk mitigation and system adjustments.
Controlling Practical Drift:
Unchecked Deviations: While workarounds may maintain daily operations,
unchecked proliferation can lead to a significant deviation from the baseline,
increasing the risk of incidents and accidents.

Systematic Capture: Systematically capturing and analyzing data on practices within

the practical drift zone is crucial for identifying and addressing safety risks.
Redesign and Improvement: Based on the captured data, formal interventions like
system redesign or procedural improvements can be implemented.

Conclusion:
By understanding practical drift and its influence on aircraft maintenance,
organizations can implement strategies to minimize its negative consequences.
Proactive identification and analysis of workarounds alongside systematic data
capture are crucial for maintaining a high level of aviation safety.

The Swiss Cheese Model in Aircraft Maintenance

The Swiss Cheese Model (SCM) is a powerful tool for
understanding how seemingly minor issues in aircraft
maintenance can contribute to accidents. Here is how it
applies specifically to this domain:

Layers of Defense in Aircraft Maintenance

• Slice 1: Maintenance Procedures: This layer
encompasses the established protocols for aircraft maintenance, including
inspections, part replacements, and repairs. Weaknesses in these procedures,
like unclear manuals or inadequate training, create holes.
• Slice 2: Maintenance Personnel: The skills, experience, and attention to
detail of maintenance technicians play a crucial
role. Fatigue, complacency, or knowledge gaps
create holes in this layer.
• Slice 3: Quality Control: Thorough inspections
and oversight procedures ensure the quality of
maintenance work. Shortages of inspectors,
inadequate inspections, or bypassing procedures
create holes.
 • Slice 4: Spare Parts Management: Ensuring the availability of genuine, high-
quality parts is vital. Counterfeiting, improper storage, or delays in obtaining
parts create holes.
• Slice 5: Documentation and Communication: Clear documentation of
maintenance actions and effective communication between mechanics, pilots,
and air traffic control are crucial. Missing records, unclear communication, or
language barriers create holes.

How Holes Can Align and Cause Problems

Imagine the following scenario:

• A complex repair manual has confusing instructions

(hole in slice 1).
• A mechanic, pressured to meet deadlines,
overlooks a critical step (hole in slice 2).
• An overworked inspector misses a crucial detail
during the final check (hole in slice 3).
• A counterfeit part, mistakenly installed due to
supply chain issues, weakens a crucial system (hole in slice 4).
• Miscommunication between mechanics and pilots leads to confusion about the
aircraft's status (hole in slice 5).

If these holes align, even a seemingly minor issue with the aircraft could escalate into
a serious problem.

Preventing Accidents: Plugging the Holes

The Swiss Cheese Model emphasizes proactive measures to prevent these holes
from aligning:

• Standardized and Up-to-Date Procedures: Regularly reviewing and

updating maintenance manuals for clarity and comprehensiveness.
• Training and Supervision: Providing ongoing training to mechanics and
ensuring proper oversight and support.
• Quality Control Measures: Implementing robust inspection processes with
multiple checks and clear documentation.
• Supply Chain Management: Establishing rigorous procedures for part
procurement to ensure authenticity and quality.
• Communication Protocols: Creating clear communication channels between
maintenance personnel, pilots, and air traffic control.
By focusing on strengthening each layer of defense, the aviation industry can
significantly reduce the risk of accidents stemming from maintenance issues.

Balancing safety and production

Effective Safety Management Systems (SMS) identify hazards and assess their
associated risks. The goal is to eliminate or mitigate these risks, ultimately achieving
an acceptable level of safety. However, this process involves balancing safety with
production demands, a concept explored through the "safety space" principle.

Balancing Production and Safety:

• Resource Allocation: SMS processes require resource allocation to manage
safety risks.
• Safety Space: This concept describes the balance between production goals
and resource allocation for safety protection.

Safety Space Explained:

• Production and Safety Risks: In any organization, production and safety
risks are inherently linked. Increased production output can elevate safety
risks if necessary, resources or process improvements aren't implemented.
• Defining Production & Safety Objectives: Organizations must define both
production and safety objectives, striking a balance between desired output
and acceptable safety risk.
• Safety Defenses: Organizations define "defenses" (technology, training,
procedures) to keep safety risks under control. Similarly, states utilize
defenses like personnel training, technology oversight, and procedures for
effective safety management.

The safety Space Zone:

The safety space is the zone where an organization balances production and safety.
Effective safety risk controls allow them to maintain a desired level of production
while ensuring adequate safety protection.

Examples:
• Investments: A manufacturer or air navigation service provider may invest in
modern technologies to increase efficiency while simultaneously improving
 safety performance. Decisions concerning such investments should consider
both value addition and potential safety risks.
• Resource Allocation: Excessive focus on production at the expense of safety
could lead to accidents. Conversely, too much focus on safety could
compromise the organization's financial viability.

Safety Boundaries and Monitoring:

• Defining the Safety Boundary: It is vital to define a "safety boundary" that
provides early warning of an unbalanced resource allocation.
• Continual Review: Management should continually review and adjust the
safety space boundaries to ensure they accurately reflect current conditions
(Figure 1-7 illustration recommended, reference its location in the report).

Conclusion:
Balancing production and safety are crucial for both service providers and states in
aviation. The "safety space" concept provides a valuable framework for achieving this
balance and ensuring sustainable aviation safety.