APPLA SMS Seminar, Lisbon September 2013 Module … Docs/APP… · APPLA SMS Seminar, Lisbon September 2013 Module 04 Safety Risk 1 ... APPLA SMS Seminar, Lisbon September 2013

APPLA SMS Seminar, Lisbon September 2013

Module 04 Safety Risk 1

Module Nº 04 APPLA SMS SEMINAR LISBON

Module N° 4 APPLA SMS SEMINAR LISBON

2

Intro

SMS seminar

introduction

Module 1

Basic safety

concepts

Introduction Module 2 Introduction to safety

management

Module 3

Hazards

Module 4

Safety risks

Module 5

Introduction to

SMS

Module 6SM framework I

(SMS)

Module 7SM Framework II

(SSP)

Module 8Phased approach to

SMS Implementation

Module 9ICAO Framework

I (SARPS)

Module 10ICAO Framework II

(Guidance Material)

Module 11EU SM Framework

Seminar Structure

SafetyManagementSystem

Module 2 Introduction to safety

management

Module 3

Hazards

Module 4

Safety risks


3

Objective

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

apply the fundamentals of safety risk management

through a case study




4

Outline

� Definition of safety risk� First fundamental – Safety risk management � Second fundamental – Safety risk probability � Third fundamental – Safety risk severity� Fourth fundamental - Safety risk index/tolerability� Fifth fundamental – Safety risk control/mitigation� Safety risk management warm-up exercises� Questions and answers � Points to remember� Practical exercise–Accident of a Boeing B-747 at an

International Airport (see Handout)


5

Definition of safety risk

�Safety risk –The predicted probability and severity of the consequences or outcomes of a hazard.

A wind of 15 knots blowing directly across the runway is ahazard

A pilot may not be able to control the aircraft during takeoff orlanding is one of theconsequences of the hazard

The assessment (quantification) of the consequences of the potentialloss of control of the aircraft by the pilot, expressed in terms ofprobability and severity, is thesafety risk


6

First Fundamental Safety Risk Management

�What is it?�The analysisand elimination, and/or mitigation to

an acceptable level, of the safety risks of the consequences of identified hazards

�What is the objective?�A balanced allocation of resources to address all

safety risks and viable safety risks control and mitigation

�Why is it important?�It is a data-driven approach to safety resources

allocation, thus defensible and easier to explain




7

Safety risk management

Intolerable region

Tolerable region

Acceptableregion

The safety risk is

unacceptable as it

currently stands

The safety risk is acceptable based on

mitigation.Cost/benefitanalysis is required.

The safety risk is

acceptable as it

currently stands

AsLowAsReasonablyPracticable


8

Cost-benefit analysis

�Direct costs

�The obvious costs, which are easily determined. The high costs of exposure to hazards can be reduced by insurance coverage

�purchasing insurance only transfers monetary risk, it does not address the safety hazard

�Indirect costs

�The uninsured costs. An understanding of uninsured costs (or indirect costs) is fundamental to understand the economics of safety


9

Cost-benefit analysis

� Indirect costs may amount to more than the direct costs resulting from exposure to hazards�Loss of business �Damage to the reputation �Loss of use of equipment�Loss of staff productivity�Legal actions and claims�Fines and citations�Insurance deductibles




10

Second fundamentalSafety risk probability

�Definition

�Probability – The

likelihood that an

unsafe event or

condition might occur


11


�Questionsfor assessing the probability of an occurrence

�Is there a history of occurrences like the one being

assessed, or is the occurrence an isolated event?

�What other equipment, or similar type components,

might have similar defects?

�When or how often could something go wrong?


12


�… questions such as

�what number of operating or maintenance personnel

must follow the procedure(s) in question?

�how frequently is the equipment or procedure under

assessment used?




13


Probability of occurrence

MeaningQualitative

definitionValue

Frequent

Occasional

Remote

Improbable

Extremely

improbable

Likely to occur many times (has occurred frequently)

Likely to occur sometimes (has occurred infrequently)

Unlikely, but possible to occur (has occurred rarely)

Very unlikely to occur (not known to have occurred)

Almost inconceivable that the event will occur

5

4

3

2

1


14

Third fundamental Safety risk severity

�Definition

�Severity– The

possible effects of an

unsafe event or

condition, taking as

reference the worst

foreseeable

consequence


15

Third fundamental Safety risk severity

�A large reduction in safety margins, physical distress or a workload such that the operators cannot be relied upon to perform their tasks accurately or completely.

�Serious injury. �Major equipment damage.

�Equipment destroyed.�Multiple deaths.

�A significant reduction in safety margins, a reduction in the ability of the operators to cope with adverse operating conditions as a result of increase in workload, or as a result of conditions impairing their efficiency.

�Serious incident. �Injury to persons.

�Nuisance. �Operating limitations. �Use of emergency procedures. �Minor incident.

�Little consequences

Meaning

Severity of occurrences

ValueAviation definition

Catastrophic

Hazardous

Major

Minor

Negligible

A

B

C

D

E




16

Fourth fundamentalSafety risk index/tolerability

Safety risk severitySafety risk probability Catastrophic

AMajor

CMinor

DNegligible

EHazardous

BB

Frequent 5

Occasional 4

Remote 3

Improbable 2

Extremelyimprobable 1

5A5A 5B5B 5C5C 5D5D 5E5E






17

Fourth fundamental – Safety risk index/tolerability

Assessment safety

risk indexSuggested criteria

Intolerable region

Tolerable region

Acceptable

region

5A, 5B, 5C, 4A, 5A, 5B, 5C, 4A, 4B, 3A4B, 3A

Unacceptable under the

existing circumstances

3E, 2D, 2E, 1A, 3E, 2D, 2E, 1A, 1B ,1C, 1D, 1E1B ,1C, 1D, 1E

Acceptable

5D, 5E, 4C, 4D, 5D, 5E, 4C, 4D, 4E, 3B, 3C, 3D, 4E, 3B, 3C, 3D,

2A, 2B, 2C 2A, 2B, 2C

Acceptable based on

safety risk

mitigation. It might require

management decision.

Safety risk management


18

Fifth fundamental – Safety risk control/mitigation

�Definition

�Mitigation – Measures to address the potential hazard or to reduce the safety risk probability or severity of the consequence(s) of the hazard

�Safety risk mitigation = Safety risk control

(Mitigate – To make milder, less severe or less harsh)




19


�Strategies

�Avoidance– The operation or activity is cancelled because assessed safety risks exceed the benefits of continuing the operation or activity

�Operations at an aerodrome surrounded by complex geography and without the necessary aids are cancelled


20


�Strategies

�Reduction –The operation or activity is subject to limitations, or action is taken to reduce the severity of the consequence(s) of the hazard(s)

�Operations at an aerodrome surrounded by complex geography and without the necessary aids are limited to day-time, visual conditions


21

Fifth fundamentalSafety risk control/mitigation

�Strategies

�Segregation of exposure –Action is taken to isolate the effects of the consequence(s) of the hazard(s) or build in redundancy to protect against it

�Operations at an aerodrome surrounded by complex geography are limited to aircraft with specific performance navigation capabilities




22

Safety risk mitigation – Defences

�Recalling the three basic

defences in aviation

�Technology

�Training

�Regulations


23

Safety risk mitigation – Defences

�As part of the safety risk mitigation, determine

�Do defences to protect against such safety risk(s) exist?

�Do defences function as intended?

�Are the defences practical for use under actual working conditions?

�Is staff involved aware of the safety risks and the defences in place?

�Are additional safety risk mitigation measures required?


24

Safety risk mitigation at a glance

Feedback (Safety assurance)

Hazard/consequence identificationand safety risk assessment

Assessment of the defences within the safety system

Control and mitigation of the safety risk(s)

Accepting the mitigation of the safety risk(s)

�Are the safety risk(s)

addressed?

� Is the mitigation

effective and

appropriate?

�Are additional or

different mitigation

warranted?

�Are additional safety

risk(s) generated?

HH HH HH HH

RR RR RR RR

Each Each consequenceconsequence

Each safety riskEach safety risk

Intolerable region

Tolerable region

Acceptable

region



Module N° 3 ICAO Safety Management Systems (SMS) Course 25

Safety risk management warm-up exercises

Module N° 4 – Safety risks


26

Warm-up exercise N°05/01

�Scenario

�Fuel spill on the apron area surface of approximately 25 m (75 ft) length and 5 m (15 ft) width, produced by an aircraft ready to pushback and taxi for departure


27

Warm-up exercise N °05/01-results

1. Identify the hazard(s)

2. Determine the hazard(s) consequence(s)

3. Assess the probability of the consequences:

4. Assess the severity

of the

consequences

5. Determine the

resulting safety risk

index

6. Establish the

safety risk

tolerability

Remote

Catastrophic

3A

Unacceptable under the existing circumstances

Fuel spill

a) Fire

b) Contamination

c) Sliding vehicle

a) Fire




28


�Scenario

�It was observed that airline baggage handling personnel generate a large amount of potentially hazardous FO(D) on the aerodrome apron area


29

Warm-up exercise N °05/02 – results





of the

consequences

5. Determine the


index

6. Establish the

safety risk

tolerability

Remote

Major

3C

Acceptable based on the safety risk mitigation. It

might require management decision.

Foreign object

a) Engine ingestion

b) Property damage

c) Tire damage

a)Engine ingestion


30


�Scenario

�Maintenance stairs are observed to be unsecure in the vicinity of parked aircraft




31






of the

consequences

5. Determine the


index

6. Establish the

safety risk

tolerability

Improbable

Minor

2D

Acceptable

Unsecured stairs

a) Damage to aircraft

b) Injury to persons

a) Damage to aircraft


32


�Scenario

�The vehicle and ramp equipment parking areas behind the air bridges show a large amount of FO(D) (food, trays, plastics, pillows, etc.) left behind by an airline


33






of the

consequences

5. Determine the


index

6. Establish the

safety risk

tolerability

Occasional

Major

4C

Acceptable based on safety risk mitigation. It

might require management decision.

Foreign object

a) Attract wildlife

b) Vehicle accident

c) Bacteriological

a) Attract wildlife




34


�Scenario

�Vehicles and construction equipment located on the taxiway are very close to the threshold of RWY 05R without any marks or signals


35






of the

consequences

5. Determine the


index

6. Establish the

safety risk

tolerability

Remote

Catastrophic

3A

Unacceptable under the existing circumstances

Construction equipment

a) Collision

a) Collision

b) Runway incursion


36

In conclusion

1. Every system is inherently vulnerable, safety-wise

2. Safety vulnerabilities in a system are describedin terms of

� hazards

� consequences

� safety risks

3. Effective safety risk management seeks to maximize the benefits of accepting a safety risk(a reduction in time and cost) while minimizing the safety risk itself



Module 04 APPLA SMS Seminar Lisbon

37

Questions and answers

Module N° 4 – Safety risks


38


�Q: Define safety risk management

�A:

�The analysisand elimination, and/or mitigation to an acceptable level of the safety risks of the consequences of identified hazards


39


�Q: Name five example designations for safety risk

probability

�A:

Improbable

Frequent

Occasional

Remote

Extremelyimprobable




40


�Q: Name five example designations for safety risk

severity

�A: Catastrophic

Hazardous

Major

Minor

Negligible


41


�Q: Describe the three basic safety risk mitigation strategies�A:

�Avoidance– The operation or activity is cancelled because safety risks exceed the benefits of continuing the operation or activity

�Reduction–The frequency of the operation or activity is reduced, or action is taken to reduce the severity of the consequences of the accepted safety risks

�Segregation of exposure – Action is taken to isolate the effects of the consequences of the hazard or build-in redundancy to protect against it


42

Points to remember

1. The safety risk index/tolerability

2. The safety risk assessment criteria table

3. Safety risk mitigation: avoid, reduce, segregate



Module 04 APPLA SMS Seminar Lisbon

43

Practical exercise- Accident Boeing B-747 at Taipei International Airport

Module N° 4 – Safety Risks


44

Boeing B-747 at Taipei International Airport

�Group activity

�A facilitator, who will coordinate the discussion,

will be appointed

�A summary of the discussion will be written on flip

charts, and a member of the group will provide a

brief on their findings in a plenary session


45


� Scenario

� A Boeing 747 service from Singapore to Los Angeles via Taipei, crashed on takeoff from Taipei's CKS International Airport at 23:18 local time

� The flight had been cleared for take off from runway 05L

� Runway 05R was closed due to construction work

� The flight attempted the take off from runway 05R




46


� … Scenario

�On takeoff the aircraft hit concrete barriers,

excavators and other equipment on runway 05R

�The aircraft crashed back onto the runway,

breaking up and bursting into flames while sliding

down the runway and crashing into other

equipment related to work being done on runway

05R


47


� … Scenario

�Subsequent investigation of the accident confirmed that the flight crew mistakenly attempted takeoff on runway 05R (9029x150ft), instead of the planned runway 05L (12008x200ft)

�NOTAM indicated that, at the time of the accident, runway 05R was closed for repairs, and that numerous pieces of construction equipment were parked on the runway


48





49



50



51


� Your task:

� Read the text related to the accident of the Boeing 747 at Taipei

International Airport

� List the type of operation or activity

� State the generic hazard(s)

� State the specific components of the hazard(s)

� State the hazard-related consequences and assess the safety risk(s)

� Assess existing defences to control the safety risk(s) and resulting safety

risk index

� Propose further action to reduce the safety risk(s) and resulting safety

risk index

� Complete the attached log (Table 05/01)




52

Table 05/01 – Hazard Identification and Safety Sisk Management

Existing defencesto control safety risk(s)and safety risk index

Further action to reduce safety risk(s) and resulting safety

risk index

Generic hazard

Type of operationor activity

Nº

1

2

3

4

5

Hazard-related consequences

Safety risk index:Safety risk tolerability:

Specificcomponents of the hazard











53

Useful tips

�Elect a facilitator

�Start with a general discussion on the objective of the task and the material available for this exercise (no more than 10 minutes)

�Select one of the participants of the group to prepare the final report on the laptop

�Be prepared to deliver the results of the exercises (in a pen drive)to the course instructor at least five minutes before the time allocated

Module Nº 04 APPLA SMS SEMINAR LISBON

Documents

APPLA SMS Seminar, Lisbon September 2013 Module … Docs/APP… · APPLA SMS Seminar, Lisbon September 2013 Module 04 Safety Risk 1 ... APPLA SMS Seminar, Lisbon September 2013