Chapter 2: Safety Management Fundamentals
This Chapter provides some background for the subsequent Chapters on how aviation has addressed safety issues in the past and the development of a more proactive approach.
This chapter covers parts 2.1-2.5 of the 4th edition of the SMM.
2.1 The concept of safety and its evolution
Aviation safety is a dynamic concept, since new safety hazards and risks are continuously emerging and need to be mitigated. Safety systems to date have focused largely on individual safety performance and local control, with minimal regard for the wider context of the total aviation system. This has led to growing recognition of the complexity of the aviation system and the different organisations that all play a part in aviation safety. There are numerous examples of accidents and incidents showing that the interfaces between organizations have contributed to negative outcomes.
2.2 Humans in the system
Human factors can influence an organization’s safety in both positive and negative ways. Consideration of human factors is an integral part of safety management and is necessary to understand, identify and mitigate risks and optimize organizational safety.
2.3 Accident causation
Safety risks can be generated by active failures and latent conditions. The concept of accident causation is an active field of study and many types of models exist to illustrate the events taking place leading up to an accident.
2.4 Management Dilemma
Organization must maintain profitability to stay in business by balancing output (production/profitability) with acceptable safety risks (and the costs involved in implementing safety risk controls.
Hazard Identification Risk Mitigation Worksheet
Safety risks should be managed to an acceptable level by mitigating the safety risk through the application of appropriate safety risk controls. This should be balanced against the time, cost and difficulty of taking action to reduce or eliminate the safety risk. The level of safety risk can be lowered by reducing the severity of potential consequences, reducing the likelihood of occurrence or by reducing exposure to that safety risk.
This example relates to hazard identification and risk mitigation.
Click to download:
Hazard Identification Risk Mitigation worksheet .xlsx
Source: Safety Management toolkit originally posted in April 2013 on the ICAO Safety Management public website.
2.5 Safety Risk Management
Safety risk management is a key component of safety management, and includes hazard identification, safety risk assessment and safety risk mitigation. Cost-benefit or cost-effectiveness analysis is normally carried out during the safety risk mitigation activities.
Guidance for the implementation of risk management methodologies
1. Risk Matrix Example
This is an example of a safety risk matrix used by Incheon airport that includes severity expressed in terms of human loss(casualties), Hardware loss(cost in $) and operational loss (airport closure for example). Stakeholders visualize better when they can see what it will cost them. Using the cost approach has improved the safety culture, ground handlers for example are more careful on the airside. This example also applies to 9.3.
Click to download:
Source: Airports Council International
Aligned with Annex 19, edition 1.
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2. Risk Management and Change
This poster provides safety and information at airside entrances. The visibility and reminder factor makes it a strong awareness product. There are no challenges nor limitations to implement and get reference for operators of certified aerodromes.
Click to download:
Risk Management and Change .pdf
Source: Dominican Civil Aviation Institute (IDAC)
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3. Risk Pre-assessment Scan and Scope (PASS) tool
This is the first step of the TCCA risk assessment process. The PASS tool indicates to the user which Risk Assessment (RA) tool to use. It suggests the most effective tool to support the risk analysis, in accordance with the perceived level of complexity, and severity of impact; and helps to frame the scope of the RA. It is not required to use the PASS tool in the case of repetitive RA (e.g., case where the hazard remains the same). For those cases, previous results of the PASS can be used.
Click link to download:
Appendix 4 - Risk Pre-Assessment Scan (PASS) Tool.xlsx
Source: Transport Canada Civil Aviation (TCCA)
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4. Implementation of Measures to Prevent Objects Falling off Airplanes
Japan published this guidance material to make Japanese and foreign airlines as well as relevant organizations familiar with concrete measures to prevent objects falling of airplanes and help them strengthen activities against objects falling off airplanes.
Click link to download:
Implementation of Measures to Prevent Objects Falling off Airplanes .pdf
Source: Civil Aviation Bureau of Japan
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5. Canada Risk Management Procedure
Example of Risk Assessment tools and techniques to support decision-making.
Click link to download:
Appendix 5 - Template: Risk Management Process - Basic Tool .pdf
Appendix 8 - Risk Index Matrix Reference .pdf
Appendix 9 - Terms of Reference - Risk Assessment .pdf
Example of Complete risk assessment using the tool .pdf
Risk Management Process for Aviation Safety Activities .pdf
Source: Canada/Transport Canada
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6. Hazard Identification & Risk Mitigation (HIRM) Worksheet
This HIRM Worksheet provides user with a systematic process to account for existing/ additional preventive controls and recovery measures during safety risk mitigation tasks. There are guided criteria to derive Risk-Severity and Risk-Likelihood values in a more comprehensive and consistent manner. This Worksheet constitutes the documentation of a safety risk mitigation task for each specific Hazard > Top-Event > Consequence risk scenario.
Click link to download:
Hazard Identification and Risk Mitigation (HIRM) Worksheet.xlsx
Source: Civil Aviation Authority of Singapore (CAAS)
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7. Safety Management System Resource Kit – Booklet 3
Practical guidance on the implementation of Safety Risk Management requirements of an SMS.
Click link to download:
SMS 3 Safety Risk Management - 3rd Edition .pdf
Source: Civil Aviation Safety Authority (CASA), Australia
2.6 SRM Methodologies
1. Summary of Safety Risk Management Methodologies and Tools
This document includes reference material and hyperlinks to support the virtual course developed by ICAO about Safety Risk Management Fundamentals. It contains alternative approaches to hazard analysis and safety risk management. Some are already used in aviation, whereas some are still new to aviation and being implemented.
Click link to download:
Summary of SRM Methodologies and Tools .pdf
Source: International Civil Aviation Organization (ICAO)
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2. SRM Methodologies - ISO 31000 Risk management guidelines
This document is intended to support safety experts in the application of International Standard ISO1 31000 Second edition 2018-02 Risk management - Guidelines (ISO 31000) for managing safety risk in aviation. It provides a common, global guideline on the management of any type of risk faced by any organization regardless of industry or sector.
Click link to download:
SRM Methodologies ISO 31000 Risk Management - guidelines .pdf
Source: International Civil Aviation Organization (ICAO)
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3. Bowtie guidelines
The Bowtie model organizes the risk and event factors to better understand the risk situation. It is a visual representation of how threats and hazards interact to produce consequences and the barriers and mitigations that could prevent an event or reduce its impact. The Bowtie model can be said to have a general application. It can effectively be used in safety risk management practice and applied in aviation sectors (both industry and regulators).
Click link to download:
Source: International Civil Aviation Organization (ICAO)
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4. SRM Methodologies -Aviation Risk Management Solutions (ARMS) and Event Risk Classification (ERC)
The aviation Risk Management Solution (ARMS) is a risk assessment methodology that comprises two methods:
1. ERC – Event Risk Classification, and
2. SIRA – Safety Issue Risk Assessment.
This document considers solely the Event Risk Classification (ERC) element, which a reactive rather than a proactive approach to risk assessments. The purpose of ERC is therefore to assess past events (e.g. incidents, occurrences, accidents) so they can be given a risk value (also known as a risk index value). This enables different events to be scored in a standardised way and prioritised. Appropriate action can then be taken depending on the risk value.
Click link to download:
SRM Methodology - ARMS & ERC.pdf
Source: International Civil Aviation Organization (ICAO)
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5. SRM Methodologies - STPA - System-Theoretic Process Analysis
System-Theoretic Process Analysis (STPA) is a proactive and holistic hazard analysis and risk management tool. It derives from an accident causality model called System-Theoretic Accident Model and Processes (STAMP). Unlike other methods (e.g., Fault/Event Tree Analyses, Hazard and Operability (HAZOP), etc.),STPA attempts to identify hazards and risks across an entire system and not to focus on risks at the task level, which are typically associated with the human operator(s).
Click link to download:
Source: International Civil Aviation Organization (ICAO)
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6. SRM Methodologies - FRAM - Functional Resonance Analysis Method
Originally developed for accident investigation purposes, FRAM can be the basis for analysing events, risks or system designs in either a retrospective or prospective manner. It is not focused solely on the failure cases and their causes and consequences, but also on how to understand complex sociotechnical systems in order to improve their resilient behaviour.
FRAM analysis aims to:
• Describe the functioning of a system (i.e., everyday work or a particular event); and/or
• Understand how the different human, technological, and organisational functions behave within a system to achieve its goals, and may be impacted by variability (i.e., variability of a single function or a combination thereof).
Click link to download:
Source: International Civil Aviation Organization (ICAO)
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7. SRM Methodologies - Use of the Risk Matrix
The risk matrix methodology is a practical model to quickly visualize the level of risk and decide whether further actions should be taken. By computing the severity and the probability of the consequences of a hazard in a risk matrix, the user will determine the safety risk tolerability and decide whether the entity needs to take actions and deploy risk mitigations strategies. Actions related to mitigations strategies consist of three options: reduce probability, reduce severity or reduce both.
Click link to download:
SRM Methodologies - Use of the Risk Matrix.pdf
Source: International Civil Aviation Organization (ICAO)
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8. SRM Methodologies - Specific Operations Risk Assessment (SORA)
SORA provides a safety risk assessment methodology to guide both the applicant and the competent authority (National Aviation Authority) in evaluating the safety risks and determining whether an Unmanned Aircraft System (UAS) operation in the ‘specific’ category can be created, evaluated and conducted in a safe manner.
Click link to download:
Source: International Civil Aviation Organization (ICAO)