safety management federal aviation system - mitrecaasd.org · federal aviation administration...

SMS Program Office

Version Date: 6/23/2008

Federal AviationAdministration

Safety Management

System

Introduction to SMS


SL-2-INTIntroduction to SMS

Reminders

• Cell Phones on vibrate

• Restrooms, fire exits, etc.

• Questions are welcome, just raise your hand.

• Please complete the attendance sheet

Introductions



Objective

• Discuss – at a high level – the concept of a

Safety Management System

By the end of this briefing, you will be able to:



What is Safety?

• Freedom from harm (dictionary definition)

• Safety is not equivalent to risk free (U.S.

Supreme Court, 1980)

• Carelessness and overconfidence are more

dangerous than deliberately accepted risk

(Wilbur Wright, 1901)

• “Risk management” is a more practical term

than “safety.” (Jerome Lederer ~1928)



Concept of Safety

“Safety is the state in which the risk of harm

to persons or property is reduced to, and

maintained at or below, an acceptable level

through a continuing process of hazard

identification and risk management”

ICAO Doc 9859



WHAT?

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

Identifies:

WHO? WHEN?

WHY? HOW?

But not always discloses:



Reactive

Proactive

Accidents 1

30

10

600

Unreported Incidents

Heinrich Theory



Shappell & Wiegmann, 2002

Projected Traffic Growth and Accident Rates

Adapted from Flight Safety Foundation (1997)

1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015

Year

0

5

10

15

20

25

30

35

Dep

artu

re (

mil

lion

s) /

Rat

e p

er m

illi

on

0

10

20

30

40

50

60

70

Accid

ents

Accidents

Traffic Growth

Accident Rate

1

2

3

1 Based on current accident rate

2 Based on industry estimates

3 Based on current accident rate

Number of Commercial Jet Accidents, Accident Rate

and Traffic Growth - Past, Present and Future

Projected Traffic Growth and Accident Rate

Adapted from the Flight Safety Foundation (1997)

© Weigmann & Shappell (2002)



The Evolution of Safety Thinking

TECHNICAL FACTORS

HUMAN FACTORS

ORGANIZATIONAL FACTORS

TO

DA

Y

1950s 1970s 1990s 2000s



Why Change Our Thinking about Safety?

Business case

Safety case



What is the Fundamental Objective of

a Business Organization?



The Business Case

• Aviation organization management requires

managing many business processes.

• Safety management is a core business

function just as financial management, HR

management, etc.

• This constitutes a management challenge.



The Management Challenge – 1st View

Management levels

Protection Production



Protection

Production

The Management Challenge – 2nd

View

Catastrophe



The Management Challenge – 3rd View

BankruptcyProtection

Production



Safety Space

Production

Pro

tect

ion

Bankruptcy

Catastrophe

Source: James ReasonICAO Doc. 9859, Sec. 4.8.3




• Infuses safety into all parts of the system

– People

– Tools

– Procedures

– Materials

– Equipment

– Software

• To maintain the balance of production and

protection

Management levels

Protection Production



Accidents are Expensive!

• Accidents make bad business sense.

• Insurance does not cover the risks.

• Safety management is a prerequisite for a sustainable

aviation business.

• Few organizations can survive the economic

consequences of a major accident.

ICAO Doc. 9859



Accidents Cost!

Direct costs

• Loss of aircraft

• Injuries to or death of flight crewmembers, passengers

• Insurance deductibles

• Costs not covered by insurance

Indirect costs

• Loss of use of equipment

• Loss of staff– Involved in accident issues

– Lower productivity

• Investigation & clean-up

• Legal claims

• Fines

• Misplaced/stranded passengers

• Negative media exposure



Incidents Cost, Too!

Event Direct Indirect

Catering truck hits airplane $17,000 $230,000

Jetway hits airplane $50,000 $600,000

Landing event $1,900,000 $4,800,000

Source: USAir/America West Airlines



Accidents Cost Small Operators, Too

Claim Flight Training

Operation

Fixed Wing Air

Taxi Operation

Helicopter

Air Taxi

Forced landing

(aircraft destroyed)

$150,000 $300,000 $900,000

Propeller makes

contact with object

on ground

$20,000 $30,000 $150,000

Hangar Rash $5,000 $10,000 $35,000

Flight cancellation

per day

$500-1,400 $3-5,000 $8-10,000



Now, What is the common

denominator

?

Man/Machine Interface



Understanding Operational Errors

• Human error: a contributing

factor in most aviation

occurrences

• Even competent personnel

commit errors.

• Errors are a normal

component of any system

where humans and

technology interact.



Errors and Safety – A Non Linear

Relationship

Statistically, millions of

operational errors are made

before a major safety

breakdown occurs



Once in a Million Flights

Error Deviation Amplification



Processes Provide Interfaces

Process: an interrelated set of activities that

transforms inputs into outputs (ISO 9000-2000)

– Basis of system understanding

– Things people do…not things people have done

If you can’t describe what you’re doing as a process…

you don’t know what you’re doing.

W. Edwards Deming



Drifting from Effective System

Performance

System design

Operational

deployment

Baseline performance

“Practical drift”



Safety Management Strategies

Reactive

(Past)

Responds to

events that have

already

happened, such as

incidents and

accidents

Proactive

(Present)

Actively seeks the

identification of

hazardous

conditions

through the analysis

of the organization’s

processes

Predictive

(Future)

Analyzes

system

processes and

environment to

identify potential

future problems



ICAO Requirements



The International Picture

Annex 6 - Operation of

Aircraft

Annex 8 - Airworthiness of

Aircraft

Annex 11 - Air Traffic

Services

Annex 14 - Aerodromes

Current ICAO safety management requirements



State’s Safety Programme (FAA)

Implementation

Develop the State’s safety programme

around the following four components:

1. State’s safety policy and objectives

2. State’s safety risk management

3. State’s safety assurance

4. State’s safety promotion

The AVS SMS will become the US safety

program



What do ICAO Standards and

Recommended Practices (SARP)

require?

• State – safety programme

– Regulations and activities aimed at improving safety

– AVS SMS

• Operators and service providers

– Safety efforts included as part of the normal

management framework of aviation operations

– Safety Management System (SMS)



Purpose: To make known to

certificate holders such as air

carriers, Code of Federal

Regulation (14 CFR), part 142

training centers, and 14 CFR

part 145 repair stations of the

coming implementation of SMS

worldwide, and to recommend

reference materials they may

use to prepare for their own

implementation.

Information for Operators

08022



FAA Rulemaking Effort

• Part 121 Rulemaking Project Record (RPR)

opened Nov. 2006

• Project cancelled Jan. 2008

• Project team commissioned to create

integrated SMS Rule for all CFR parts

– Objective: harmonization of requirements

– Strategy is being formulated

– Aviation Rulemaking Committee (ARC)



ICAO Milestones

• Compliance dates for Annex 6 (Operation

of airplanes)

– Current: 1 January 2009

– Proposed: 19 November 2009



SMS Fundamentals



A systemic approach to managing safety,

including the necessary organizational

structures, accountabilities, policies and

procedures.

“SMS”

Safety Management Systems

ICAO Definition

ICAO Doc. 9859, Sec. 1.4.2



SMS: What it is and is not…

What it isn’t:

• Not a substitute for

compliance

• Not a substitute for oversight

• Not a replacement for system

safety

• Not a requirement for a new

department

What it is:

• Compliance is integral to safety

management

• An effective interface for safety

management

• SMS completes the system

safety circle

• SMS is a set of decision making

processes for senior and line

management



Is SMS ATOS?

• SMS

– Management system

– Only service provider can

manage

• ATOS

– Oversight system

– Used to meet regulator

responsibilities

SMS, ATOS and QMS

Is SMS QMS?

• Same principles but

different objectives

• QMS Objective

– Customer satisfaction

• SMS Objective

– Aviation safety



Primary References

• ICAO Doc 9859: Safety

Management Manual

• AC 120-92

• AVS Doctrine – Order

VS 8000.1

• SMS Requirements

Order VS 8000.367

• AC 120-XX Vol. Imple.



SMS Guidance Material



System Safety

• "The application of special technical and

managerial skills in a systematic, forward

looking manner to identify and control hazards

throughout the life cycle of a project, program,

or activity" (Roland & Moriarty, 1990)

• Traditional approach concentrates on technical

• SMS adds emphasis on management elements



Safety

Assurance

Policy

(Structure)

Safety

Promotion

Risk

Management

Four Components (“Pillars”) of

SMS



The 4 SMS Components

1. Policy

• All management systems must define

policies, procedures, and organizational

structures to accomplish their goals.

• Policy establishes the structure of the SMS.

Policy

(Structure)

Risk

Management

Safety

Assurance

Safety

Promotion




2. Safety Risk Management.

• A formal system of hazard identification,

analysis and risk management is essential

in controlling risk to acceptable levels.

Policy

(Structure)

Risk

Management

Safety

Assurance

Safety

Promotion




3. Safety Assurance.

• Once controls are identified, the SMS must

ensure they are continuously practiced and

continue to be effective in a changing

environment.

Policy

(Structure)

Risk

Management

Safety

Assurance

Safety

Promotion




4. Safety Promotion.

• The organization must promote safety as a

core value with practices that support a

positive safety culture.

Policy

(Structure)

Risk

Management

Safety

Assurance

Safety

Promotion



A Positive “Safety” Culture is…

…An informed culture where People understand hazards and risks.

– Staff work continuously to identify and overcome threats

…A reporting culture where

– People are encouraged to voice safety concerns

– Those concerns are analyzed and appropriate action is taken

– The workforce knows and agrees on what is acceptable and unacceptable (shared values)

Dr. James Reason



…A learning culture where:

– People are encouraged to develop and apply their skills and knowledge to enhance organizational safety

– Management updates staff on safety issues

– Safety reports are fed back to staff so everyone learns

…A just culture where:

– The workforce knows and agrees on what isacceptable and unacceptable (shared values)

– Errors are understood but willful violationsare not tolerated

A Positive “Safety” Culture is…



"The greatest difficulty in the world is

not for people to accept new ideas, but

to make them forget about old ideas."

John Maynard Keynes



System

Analysis

(Design)

System

Operation

Hazard

Ident

Risk

Control

Risk

Assmt

Risk

AnalysisAnalysis

Data

Acquisition

& Process

Corrective

Action

System

Assmt

SRM SA

Action:

Problem

Resolution

Design Performance

Assessment

Analysis

Information

System

Description

& Analysis



The AVSSMS: The Safety Programme Oversight & SMS AVSSMS

FAA’s Safety

Management

(Oversight)

System

Air Carrier

Technical Program Requirements• Systems

• Subsystems

• Elements

DA PA

FAA (ATOS)

Oversight Program

Management(8 Modules)

S

R

M

S

A

Cert C.O.S.

Surveillance

ProductionProtection

Operational

Process

Operator’s Safety

Management

System

Public:

Users



SMS Implementation



Existing Programs

• Regulatory Oversight

– ATOS

• Safety Assurance

– CASS

– IEP

• Employee Reporting

– ASRS

– ASAP

• Compliance and Enforcement: Interfaces

– VDRP



SMS Voluntary Implementation &

Pilot Project

• Pilot Project activities commenced in 2007

• Development and interface with oversight systems

• AFS combined effort

• Objectives: – Development of guidance material,

– Implementation strategies, and

– Oversight systems

– Provide experience for FAA and operators

• Development Partners

https://avssharepoint.faa.gov/afs/8/wprfaast/smsmgt/SMS%20Dccumnet%20Library/SMS%20Level%20Zero%20Stuff/SMS%20Level%200%20092408/Vertical-Org%20Chart%20080708.ppt



SMS Design Levels

0Orientation &

Commitment

2Reactive

Processes

3Proactive

Processes

4Continuous

Improvement

1Planning &

OrganizationPhase 1:

Readiness

Phase 2:

Experience



Organizations



AFS SMS Program Office

• Change to 1100.2 Order signed 4/17/08

• Office tasked with:

– AFS SMS Policy

– Focal point for SMS rulemaking

– Oversight and coordination of voluntary SMS implementation and testing

– Integration with oversight systems

– Policy, guidance, and tool development

– Training and outreach development and coordination



Standardization and Assistance Team

• Under direction of AFS SMS PMO

• Team members currently from:

– SMS PMO

– FAASTeam

– HQ Policy Divisions

• Standardization and Assistance to operators and CMTs in voluntary SMS projects

• All activities coordinated with appropriate certificate oversight offices



MITRE Corporation Involvement

• MITRE is a Federally-Funded Research and

Development Corporation (FFRDC)

• MITRE assists the AFS SMS PMO in:

– SMS Pilot Project (SMSPP) activities

– Studies and analysis to support development of

SMS implementation and oversight strategies



Safety Management Focus Group

(SMFG)

• Voluntary implementation user’s group

• Provides a two-way communications

mechanism between SMS PMO and

participants in voluntary implementation

• Provides a forum for knowledge sharing

among participants




1. Identify hazards and control risk

2. Provide assurance that risk controls are

effective

Provides a systematic way to:



The Bridge: CAA & Service Provider

Civil

Aviation

Authority

(FAA)

Service

Providers

SMS

State’s safety programme



“Carelessness and overconfidence are more

dangerous than deliberately accepted risk”

Wilbur Wright, 1901

Questions?

Wilbur Wright gliding, 1901

Photographs: Library of Congress



CONTACT INFORMATIONDonald N. Arendt, Manager AFS SMS PMO

Federal Aviation Administration AFS-940

Suite 131

45005 Aviation Drive

Dulles, VA 20166-7537

(703) 661-0516

[email protected]

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