Safety Profile for UPS Flight 1307

ICAO Safety Management Systems (SMS) Course Module N° 2 – Basic safety concepts

Revision N° 11 ICAO Safety Management Systems (SMS) Course 29/09/08

Module N° 2 – Basic safety concepts

Module N° 2 ICAO Safety Management Systems (SMS) Course 2

Building an SMS

Module 1 SMS course introduction

Module 2 Basic safety

concepts

Module 3 Introduction

to safety management

Module 4 Hazards

Module 5 Risks

Module 6 SMS regulation

Module 7 Introduction to SMS

Module 8 SMS planning

Module 9 SMS operation

Module 10 Phased approach to SMS Implementation

Safety Management System

Module 2 Basic safety

concepts

Safety

Module N° 2 ICAO Safety Management Systems (SMS) Course 3

Objective

At the end of this module, participants will be able to

explain the strengths and weaknesses of traditional

methods to manage safety, and describe new perspectives

and methods for managing safety.

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Outline

Concept of safety The evolution of safety thinking A concept of accident causation – Reason model The organizational accident People, context and safety – SHEL(L) model Errors and violations Organizational culture Safety investigation Questions and answers Points to remember Exercise Nº 02/01 – The Anytown City Airport accident (See Handout N° 1)

ICAO Safety Management Systems (SMS) Course Module N° 2 – Basic safety concepts

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Concept of safety

What is safety Zero accidents (or serious incidents)? Freedom from danger or risks? Error avoidance Regulatory compliance? … ?

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Concept of safety

Consider (the weaknesses in the notion of perfection) The elimination of accidents (and serious incidents) is unachievable. Failures will occur, in spite of the most accomplished prevention efforts. No human endeavour or human-made system can be free from risk and error. Controlled risk and controlled error is acceptable in an inherently safe system.

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Concept of safety (Doc 9859)

Safety is the state in which the risk of harm to persons or

property damage is reduced to, and maintained at or below,

an acceptable level through a continuing process of

hazard identification and risk management.

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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 Identifies:

WHAT? WHO? WHEN?

WHY? HOW?

But not always discloses:

ICAO Safety Management Systems (SMS) Course Module N° 2 – Basic safety concepts

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The evolution of safety thinking

HUMAN FACTORS

TO DA

Y 1950s 1970s 1990s 2000s

Module N° 2 ICAO Safety Management Systems (SMS) Course 10

Latent conditions trajectory

TechnologyTrainingRegulations

Defences

Errorsandviolations

People

A concept of accident causation

Accident

Working conditions

WorkplaceOrganization

Management decisions and

organizational processes

Source: James Reason

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The organizational accident

Organizational processes

Activities over which any organization has a reasonable degree of direct control

Policy-making Planning Communication Allocation of resources Supervision ...

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The organizational accident

Conditions present in the system before the accident, made evident by triggering factors.

Inadequate hazard identification and risk management Normalization of deviance

ICAO Safety Management Systems (SMS) Course Module N° 2 – Basic safety concepts

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The organizational accident

Resources to protect against the risks that organizations involved in production activities generate and must control.

Technology Training Regulations Defences

Organizational processes

Latent conditions

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The organizational accident

Factors that directly influence the efficiency of people in aviation workplaces.

Workforce stability Qualifications and experience Morale Credibility Ergonomics ...

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The organizational accident

Actions or inactions by people (pilots, controllers, maintenance engineers, aerodrome staff, etc.) that have an immediate adverse effect.

Errors Violations

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The organizational accident

Improve Identify Monitor

Co nt

ai n

Reinforce

ICAO Safety Management Systems (SMS) Course Module N° 2 – Basic safety concepts

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People and safety

Aviation workplaces involve complex interrelationships among its many components. To understand operational performance, we must understand how it may be affected by the interrelationships among the various components of the aviation work places.

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AA

Understand Understand human performance human performance

within the within the operational context operational context where it takes placewhere it takes place

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Processes and outcomes

Causes and consequences of operational errors are not linear in their magnitude

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The SHEL(L) model

S H L

E

L S

H L L E

S H L L

E

Software Hardware Environment Liveware Liveware, other persons

Understanding the relationship between people and operational contexts

ICAO Safety Management Systems (SMS) Course Module N° 2 – Basic safety concepts

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Operational performance and technology

In production-intensive industries like contemporary aviation, technology is essential. As a result of the massive introduction of technology, the operational consequences of the interactions between people and technology are often overlooked, leading to human error.

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Understanding operational errors

Human error is considered contributing factor in most aviation occurrences. Even competent personnel commit errors. Errors must be accepted as a normal component of any system where humans and technology interact.

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Errors and safety – A non linear relationship

Statistically, millions of operational errors are made

before a major safety breakdown occurs

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Accident investigation – Once in a million flights

Flaps omitted Flaps omitted

Error

Checklist failure

Checklist failure

Deviation

Unheeded warning

Unheeded warning

Amplification Degradation/ breakdown

ICAO Safety Management Systems (SMS) Course Module N° 2 – Basic safety concepts

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Safety management – On almost every flight

Flaps omitted Flaps omitted

Error

Checklist works

Checklist works

Deviation

Effective warning

Effective warning

Amplification Degradation/ breakdown

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Three strategies for the control of human error

Error reduction strategies intervene at the source of the error by reducing or eliminating the contributing factors.

Human-centred design Ergonomic factors Training …

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Error capturing strategies intervene once the error has already been made, capturing the error before it generates adverse consequences.

Checklists Task cards Flight strips …

Three strategies for the control of human error

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Error tolerance strategies intervene to increase the ability of a system to accept errors without serious consequence.

System redundancies

Structural inspections

…

Three strategies for the control of human error

ICAO Safety Management Systems (SMS) Course Module N° 2 – Basic safety concepts

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Understanding violations – Are we ready?

System output MaximumMinimum

Risk

High

Low

Tech nolo

gy

Trai ning

Reg ulat

ions

Safety space

Vi ol

at io

n sp

ac e

Ex ce

pt io

na l v

io la

tio n

sp ac

e

Incident Accident

System’s production objective(s)

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Culture

Culture binds people together as members of groups and

provides clues as to how to behave in both normal and

unusual situations.

Culture influences the values, beliefs and behaviours that

people share with other members of various social groups.

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National

Three cultures

Organizational

Professional

National

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Three distinct cultures

National culture encompasses the value system of particular nations. Organizational/corporate culture differentiates the values and behaviours of particular organizations (e.g. government vs. private organizations). Professional culture differentiates the values and behaviours of particular professional groups (e.g. pilots, air traffic controllers, maintenance engineers, aerodrome staff, etc.). No human endeavour is culture-free

ICAO Safety Management Systems (SMS) Course Module N° 2 – Basic safety concepts

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Organizational/corporate culture

Sets the boundaries for acceptable behaviour in the workplace by establishing norms and limits. Provides a frame work for managerial and employee decision-making

“This is how we do things here, and how we talk about the way we do things here”.

Organizational/corporate culture shapes – among many others – safety reporting procedures and practices by operational personnel.

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Safety culture

A trendy notion with potential for misperceptions and misunderstandings

A construct, an abstraction It is the consequence of a series of organizational processes (i.e., an outcome)

Safety culture is not an end in itself, but a means to achieve an essential safety management prerequisite:

Effective safety reporting

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Effective safety reporting – Five basic traits Information

People are knowledgeable about the human, technical and organizational factors that determine the safety of the system

as a whole.

Flexibility People can adapt reporting

when facing unusual circumstances, shifting from the established mode to a direct mode thus allowing

information to quickly reach the appropriate decision-

making level.

Learning

People have the competence to draw conclusions from

safety information systems and the will to implement

major reforms.

Willingness

People are willing to report their errors and

experiences.

Accountability

People are encouraged (and rewarded) for providing essential safety-related information. However, there is a clear line that

differentiates between acceptable and unacceptable behaviour.

Effective safety reporting

Module N° 2 ICAO Safety Management Systems (SMS) Course 36

Three options

Organizations and the management of information

Pathological – Hide the information

Bureaucratic – Restrain the information

Generative – Value the information

Source: Ron Westrum

ICAO Safety Management Systems (SMS) Course Module N° 2 – Basic safety concepts

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Three possible organizational cultures

Hidden

Shouted

Shirked

Discouraged

Covered up

Crushed Conflicted

organization

Ignored

Tolerated

Boxed

Allowed

Merciful

Problematic “Red tape”

organization

Sought

Trained

Shared

Rewarded

Scrutinized

Welcomed Reliable

organization

PathologicalPathological BureaucraticBureaucratic GenerativeGenerative

InformationInformation

MessengersMessengers

ResponsibilitiesResponsibilities

ReportsReports

FailuresFailures

New ideasNew ideas Resulting Resulting organizationorganization

Source: Ron Westrum

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Safety investigation

For “funereal” purposes To put losses behind To reassert trust and faith in the system To resume normal activities To fulfil political purposes

For improved system reliability To learn about system vulnerability To develop strategies for change To prioritize investment of resources

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Investigation

The facts An old generation four engine turboprop freighter flies into severe icing conditions. Engines 2 and 3 flameout as consequence of ice accretion, and seven minutes later engine 4 fails. The flight crew manages to re-start engine number 2. Electrical load shedding is not possible, and the electrical system reverts to battery power. ...

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Investigation

... The facts While attempting to conduct an emergency landing, all electrical power is lost. All that is left to the flight crew is the self-powered standby gyro, a flashlight and the self-powered engine instruments. The flight crew is unable to maintain controlled flight, and the aircraft crashes out of control.

ICAO Safety Management Systems (SMS) Course Module N° 2 – Basic safety concepts

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Investigation

Findings Crew did not use the weather radar. Crew did not consult the emergency check-list. Demanding situation requiring decisive thinking and clear action. Conditions exceeded certification condition for the engines. Did not request diversion to a closer aerodrome. ...

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Investigation

... Findings Crew did not use correct phraseology to declare emergency. Poor crew resource management (CRM). Mismanagement of aircraft systems. Emergency checklist – presentation and visual information. Flight operations internal quality assurance procedures.

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Investigation

Causes Multiple engine failures Incomplete performance of emergency drills Crew actions in securing and re-starting engines Drag from unfeathered propellers Weight of ice Poor CRM Lack of contingency plans Loss of situational awareness

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Investigation

Safety recommendations

Authority should remind pilots to use correct

phraseology.

Authority should research into most effective form of

presentation of emergency reference material.

ICAO Safety Management Systems (SMS) Course Module N° 2 – Basic safety concepts

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Investigation

The facts An old generation two engine turboprop commuter aircraft engaged in a regular passenger transport operation is conducting a non-precision approach in marginal weather conditions in an uncontrolled, non- radar, remote airfield. The flight crew conducts a straight-in approach, not following the published approach procedure. …

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Investigation

... The facts

Upon reaching MDA, the flight crew does not acquire

visual references.

The flight crew abandons MDA without having acquired

visual references to pursue the landing.

The aircraft crashes into terrain short of the runway.

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Investigation

Findings

The crew made numerous mistakes.

But Crew composition legal but unfavourable in view of demanding flight conditions.

According to company practice, pilot made a direct approach, which was against regulations.

… Module N° 2 ICAO Safety Management Systems (SMS) Course 48

Investigation

… But The company had consistently misinterpreted regulations. Level of safety was not commensurate with the requirements of a scheduled passenger operation. Aerodrome operator had neither the staff nor the resources to ensure regularity of operations.

…

ICAO Safety Management Systems (SMS) Course Module N° 2 – Basic safety concepts

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Investigation

… But

Lack of standards for commuter operations.

Lack of supervision of air traffic facilities.

Authorities’ disregard of previous safety violations.

Legislation out of date.

…

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Investigation

… But

Conflicting goals within the authority.

Lack of resources within the authority.

Lack of aviation policy to support the authority.

Deficiencies in the training system.

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Investigation

Causes

Decision to continue approach below MDA without

visual contact.

Performance pressures.

Airline’s poor safety culture.

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Investigation

Safety recommendations “Tip-of-the-arrow” recommendations.

But Review the process of granting AOC. Review the training system. Define an aviation policy which provides support to the task of the aviation administration. …

ICAO Safety Management Systems (SMS) Course Module N° 2 – Basic safety concepts

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Investigation

… But

Reform aviation legislation.

Reinforce existing legislation as interim measure.

Improve both accident investigation and aircraft and

airways inspection processes.

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Errors ...

… are like mosquitoes …

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To fight them …

... drain their breeding swamps.... drain their breeding swamps. Module N° 2 ICAO Safety Management Systems (SMS) Course 56

Questions and answers Basic safety concepts

ICAO Safety Management Systems (SMS) Course Module N° 2 – Basic safety concepts

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Questions and answers

Q: How is safety defined in document 9859? A:

Safety is the state in which the risk of harm to persons or property damage is reduced to, and maintained at or below, an acceptable level through a continuing process of hazard identification and risk management.

Slide number: 7

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Questions and answers

Q: Enumerate the five building blocks of the organizational accident. A:

Slide number: 16

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Questions and answers

Q: Explain the components of the SHEL(L) Model. A:

Slide number: 20

Software Hardware Environment Liveware Liveware, other persons

S

H L L E

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Questions and answers Q: Enumerate three basic traits underlying effective safety reporting. A:

Slide number: 35

Information People are knowledgeable about the human, technical and

organizational factors that determine the safety of the system as a whole.

Flexibility People can adapt reporting

when facing unusual circumstances, shifting from the

established mode to a direct mode thus allowing information to quickly reach the appropriate

decision-making level .

Learning

People have the competence to draw conclusions from safety

information systems and the will to implement major reforms.

Willingness

People are willing to report their errors and

experiences.

Accountability

People are encouraged (and rewarded) for providing essential safety- related information. However, there is a clear line that differentiates

between acceptable and unacceptable behaviour.

Effective safety reporting

ICAO Safety Management Systems (SMS) Course Module N° 2 – Basic safety concepts

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Questions and answers

Q: How can organizations be characterized, depending upon their management of safety information?

A:

Pathological – Hide the information Bureaucratic – Restrain the information Generative – Value the information

Slide number: 36

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Points to remember

1. The organizational accident.

2. Operational contexts and human performance

3. Errors and violations.

4. Organizational culture and effective safety reporting.

5. The management of safety information.

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Basic safety concepts

Exercise 02/01 – The Anytown City Airport accident (Handout Nº 1)

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The Anytown City Airport accident

In the late hours of a summer Friday evening, while landing on a runway heavily contaminated with water, a twin-engine jet transport aircraft with four crew members and 65 passengers on board overran the westerly end of the runway at Anytown City airport. The aircraft came to rest in the mud a short distance beyond the end of the runway. There were no injuries to crew or passengers, and there was no apparent damage to the aircraft as a consequence of the overrun. However, a fire started and subsequently destroyed the aircraft.

ICAO Safety Management Systems (SMS) Course Module N° 2 – Basic safety concepts

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The Anytown City Airport accident

Group activity: A facilitator will be appointed, who will coordinate the discussion. A summary of the discussion will be written on flip charts, and a member of the group will brief on their findings in a plenary session.

Required task: Read the text related to the accident of the twin-engined jet transport at Anytown City Airport. …

Module N° 2 ICAO Safety Management Systems (SMS) Course 66

The Anytown City Airport accident

… required task: From the investigation report of the above accident, you should identify:

1. Organizational processes that influenced the operation and which felt under the responsibility of senior management (i.e. those accountable for the allocation of resources);

2. Latent conditions in the system safety which became precursors of active failures;

3. Defences which failed to perform due to weaknesses, inadequacies or plain absence; …

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The Anytown City Airport accident

… required task:

4. Workplace conditions, which may have influenced operational personnel actions; and

5. Active failures, including errors and violations

When you have concluded the above, your task is to complete the Table 02/01 – Analysis (Handout N° 1) classifying your findings in accordance with the organizational accident model.

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The organizational accident

ICAO Safety Management Systems (SMS) Course Module N° 2 – Basic safety concepts

Revision N° 11 ICAO Safety Management Systems (SMS) Course 29/09/08

Module N° 2 – Basic safety concepts