ICAO SMS Module #5 - Risks 2008-11 (E) PDF

Building an SMS
Safety Module 10
Phased approach to
Management SMS Implementation
System Module 8 Module 9

Module N 5 Risks SMS planning SMS operation
Module 5 Module 6 Module 7

Risks SMS regulation Introduction to SMS
Module 1 Module 2 Module 3

Introduction Module 4
SMS course Basic safety to safety
introduction concepts Hazards
management
Revision N 11 ICAO Safety Management Systems (SMS) Course 01/10/08 Module N 5 ICAO Safety Management Systems (SMS) Course 2
Objective Outline
Definition of risk
At the end of this module, participants will be able to apply First fundamental Risk management
Second fundamental Risk probability
the fundamentals of risk management through a case Third fundamental Risk severity
Fourth fundamental - Risk assessment and tolerability
study. Fifth fundamental Risk control/mitigation
Risk management warm-up exercises
Questions and answers
Points to remember
Exercise 05/01 Accident of a Boeing B-747 at an
International Airport (See Handout N 4)
Module N 5 ICAO Safety Management Systems (SMS) Course 3 Module N 5 ICAO Safety Management Systems (SMS) Course 4
ICAO Safety Management Systems (SMS) Course

Module N 5 Risks
Definition of risk First fundamental Risk management
Risk The assessment, expressed in terms of predicted What is it?
probability and severity, of the consequence(s) of a The identification, analysis and elimination, and/or
hazard taking as reference the worst foreseeable situation. mitigation to an acceptable level of risks that threaten
A wind of 15 knots blowing directly across the runway is the capabilities of an organization.
a hazard. What is the objective?
The potential that a pilot may not be able to control the Aims at a balanced allocation of resources to address
aircraft during takeoff or landing is one of the all risks and viable risk control and mitigation.
consequences of the hazard. Why is it important?
The assessment of the consequences of the potential A key component of safety management systems.
loss of control of the aircraft by the pilot expressed in Data-driven approach to safety resources allocation,
terms of probability and severity is the risk. thus defensible and easier to explain.
Risk management Cost-benefit analysis

Direct costs
The risk is The obvious costs, which are easily determined. The
Intolerable region
unacceptable high costs of exposure of hazards can be reduced by
at any level
insurance coverage.
As The risk is Purchasing insurance only transfers monetary risk,
acceptable
Low based on does not address the safety hazard
As Tolerable region mitigation.
Indirect costs
Cost benefit
Reasonably analysis
Practicable is required. The uninsured costs. An understanding of uninsured
Acceptable
costs (or indirect costs) is fundamental to understand
The risk is
region
acceptable as it
the economics of safety.
currently stands

Module N 5 Risks
Cost-benefit analysis Second fundamental - Risk probability
Indirect costs may amount to Definition(s)
more than the direct costs
resulting from exposure to Probability The likelihood that an unsafe event or
hazards:
Loss of business condition might occur.
Damage to the reputation
Loss of use of equipment
Loss of staff productivity
Legal actions and claims
Fines and citations
Insurance deductibles
Second fundamental - Risk probability Second fundamental - Risk probability
Questions for assessing the probability of an occurrence: questions such as:
Is there a history of occurrences like the one being What number of operating or maintenance personnel
assessed, or is the occurrence an isolated event? must follow the procedure (s) in question?
What other equipment, or similar type components, How frequently is the equipment or procedure under
might have similar defects? assessment used?

Module N 5 Risks
Second fundamental - Risk probability Third fundamental Risk severity
Probability of occurrence Definition(s)

Qualitative
definition
Meaning Value Severity The possible consequences of an unsafe
Frequent Likely to occur many times (has occurred frequently) 5 event or condition, taking as reference the worst
Occasional Likely to occur some times (has occurred infrequently) 4 foreseeable situation.
Remote Unlikely, but possible to occur (has occurred rarely) 3
Improbable Very unlikely to occur (not known to have occurred) 2
Extremely
Almost inconceivable that the event will occur 1
improbable
Third fundamental Risk severity Third fundamental Risk severity

Define the severity in terms of consequences for: Questions for assessing the severity of an occurrence:
Property How many lives may be lost?
Finance Employees
Liability Passengers
People Bystanders
Environment General public
Image What is the environmental impact?
Public confidence Spill of fuel or other hazardous product
Physical disruption of natural habitat

Module N 5 Risks
Third fundamental Risk severity Third fundamental Risk severity
questions such as: Severity of occurrences
What is the severity of the property or financial Aviation definition Meaning Value
damage? Catastrophic
Equipment destroyed.
Multiple deaths. A
Direct operator property loss A large reduction in safety margins, physical distress or a
workload such that the operators cannot be relied upon to
Damage to aviation infrastructure Hazardous perform their tasks accurately or completely. B
Serious injury.
Third party damage Major equipment damage.
Financial impact and economic impact for the State A significant reduction in safety margins, a reduction in the
ability of the operators to cope with adverse operating
Are there organizational, management or regulatory Major
conditions as a result of increase in workload, or as a result
of conditions impairing their efficiency.
C
implications that might generate larger threats to public Serious incident.
Injury to persons.
safety? Nuisance.
Operating limitations.
What are the likely political implications and/or media Minor
Use of emergency procedures. D
Minor incident.
interest? Negligible Little consequences E
Fourth fundamental Risk assessment Fourth fundamental Risk tolerability

Risk severity
Assessment risk
Risk Risk management Suggested criteria
probability Catastrophic Hazardous Major Minor Negligible index
A B C D E
Intolerable region
5A, 5B, 5C, Unacceptable under the
4A, 4B, 3A existing circumstances
Frequent 5 5A 5B 5C 5D 5E
Occasional 4 4A 4B 4C 4D 4E 5D, 5E, 4C, 4D, Acceptable based on risk
Tolerable region 4E, 3B, 3C, 3D, mitigation. It might require
management decision
Remote 3 3A 3B 3C 3D 3E 2A, 2B, 2C
Acceptable
2 2A 2D 2E region 3E, 2D, 2E, 1A,

Improbable 2B 2C Acceptable
1B ,1C, 1D, 1E
Extremely
improbable 1 1A 1B 1C 1D 1E

Module N 5 Risks
Fifth fundamental Risk control/mitigation Fifth fundamental Risk control/mitigation
Definition(s) Strategies
Mitigation Measures to address the potential hazard Avoidance The operation or activity is cancelled
or to reduce the risk probability or severity. because risks exceed the benefits of continuing the
Risk mitigation = Risk control operation or activity.
Operations into an aerodrome surrounded by
(Mitigate To make milder, less severe or less harsh) complex geography and without the necessary aids
are cancelled.
Fifth fundamental Risk control/mitigation Fifth fundamental Risk control/mitigation

Strategies Strategies
Reduction The frequency of the operation or activity is Segregation of exposure Action is taken to isolate
reduced, or action is taken to reduce the magnitude of the effects of the consequences of the hazard or build-in
the consequences of the accepted risks. redundancy to protect against it.
Operations into an aerodrome surrounded by
Operations into an aerodrome surrounded by complex geography are limited to aircraft with
complex geography and without the necessary aids specific/performance navigation capabilities.
are limited to day-time, visual conditions.
Non RVSM equipped aircraft not allowed to operate
into RVSM airspace.

Module N 5 Risks
Safety risk management at a glance Risk mitigation Defences
Hazard
Equipment, procedures, organization, etc. Recalling the three basic defences in aviation:
identification
Analyse the likelihood of the consequence Risk analysis Technology

occurring Probability
Training
Evaluate the seriousness of the consequence if it Risk analysis
does occur Severity
Regulations
Is the assessed risk(s) acceptable and within the Risk assessment
organizations safety performance criteria and tolerability
No, take action to Risk control

Yes, accept the risk(s) reduce the risk(s) to
an acceptable level /mitigation
Risk mitigation Defences Risk mitigation at a glance

As part of the risk mitigation, determine: Hazard/consequence
identification
and risk assessment
Do defences to protect against such risk (s) exist?
Do defences function as intended?
Are the defences practical for use under actual working H H H H Tec Does it address the
h Intolerable region
Tra nolog risk(s)?
conditions? Reg in
ula ing
y
Is it effective?
Each tion
consequence s Is it appropriate?
Is staff involved aware of the risks and the defences in Is additional or
different mitigation
place? Tolerable region
warranted?
R R R R Do the mitigation
Are additional risk mitigation measures required? Acceptable
region
strategies generates
additional risk(s)
Each Risk
Feedback (Safety assurance)


Module N 5 Risks
As a reminder Risk management process at a glance
Feedback and
There is no such thing as absolute safety In aviation it is not record the hazard A safety concern is perceived
identification and
possible to eliminate all risks. assessment and Identify hazards/consequences
and assess risks
Risks can be managed to a level as low as reasonably risk mitigation
practicable (ALARP) Define the level

of probability
Define the level
of severity
Risk mitigation must be balanced against:
Define the level of risk
time
cost Take action
and continue YES Is the risk level acceptable? NO
difficulty of taking measures to reduce or eliminate the risk (i.e. the operation
managed). Take action
Effective risk management seeks to maximize the benefits of and continue
the operation
YES Can the risk be eliminated? NO
accepting a risk (a reduction in time and cost) while minimizing the

risk itself. YES Can the risk be mitigated?
Communicate the rationale for risk decisions to gain acceptance by Take action
Can the residual risk be Cancel the
stakeholders affected by them. and continue YES accepted? (if any) NO operation
the operation
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
A310 ready to pushback and taxi for departure.
Report by the apron responsible person:
Risks After the A310 pushback the spill was contained and the
Risk management warm-up exercises apron area was decontaminated.

Module N 5 Risks
Warm-up exercise N05/01 results Warm-up exercise N05/02
Scenario:
Risk probability Remote It was observed that airline baggage handling personnel
Fuel spill
generates FO(D) on the aerodrome apron area .
Risk severity Hazardous
It should be noted that airline baggage handling
personnel are not complying with safety standards as
Risk index 3B set in the aerodrome operating manual. This is
1. Fire considered a hazard that can produce incident or
2. Contamination
3. Sliding vehicle Acceptable based on accident in the movement area.
risk mitigation. It might
Risk tolerability require management
decision
Warm-up exercise N05/02 results Warm-up exercise N 05/03

Scenario:
Foreign object
Risk probability Remote A parked aircraft shows damage in the left wing root
near the fuselage. Such damage was caused by a
maintenance stair hitting the aircraft as a consequence
Risk severity Hazardous of the wind, apparently because the stair was not
properly restrained.
Risk index 3B Report by the apron responsible person:
1. Engine ingestion
2. Property damage
In conditions of strong winds it is essential that all
Acceptable based on
3. Tire damage
risk mitigation. It might equipment around aircraft is properly restrained and
Risk tolerability require management
decision
locked, thus preventing the possibility of aircraft
damage.

Module N 5 Risks
Warm-up exercise N 05/03 results Warm-up exercise N 05/04
Scenario:
Risk probability Occasional The vehicle and ramp equipment parking area behind
Unsecured equipment
the fingers shows a large amount of FO(D) (food, trays,
plastics, pillows, etc.) left behind by an airline.
Risk severity Minor Report by the apron responsible person:
The presence of decomposed food and others
Risk index 4D dangerous material was informed to the airline, since in
1. Damage to aircraft addition to FO(D), this presents a bacteriological danger
2. Injury to persons
Acceptable based on for people who operate in this sector, also attracting
Risk tolerability require management animals to the operative apron.
decision

Scenario:
Risk probability Occasional A loose wheel, apparently from a baggage cart, was
Foreign object observed in the handling area. The driver apparently did
not notice what happened. The wheel rolled at high
Risk severity Major speed through the area, hitting the fence accessing the
fuel zone.
Risk index 4C This could have caused injuries to ramp personnel in
1. Attract wildlife addition to material damage to equipment and/or
2. Vehicle accident
3. Bacteriological Acceptable based on aerodrome facilities. We have insisted in the past on the
Risk tolerability require management periodic verification of all equipment and vehicles that
decision operate in the aerodrome apron area.

Module N 5 Risks
Scenario:
Risk probability Remote The absence of airline personnel attending the stairs
Unsecured wheel
was observed in three occasions, in flights from different
companies. The presence of airline personnel is
Risk severity Major necessary to guide passengers when embarking and
disembarking.
Risk index 3C Report by the apron responsible person:
1. Injury to persons This is a risk for passengers, since they should access
2. Damage to property
Acceptable based on the apron to board aircraft in an orderly manner under
Risk tolerability require management the guidance of airline personnel.
decision
Warm-up exercise N 05/06 results
Risk probability Remote

Unaccompanied
passengers in the
ramp
Risk severity Major
Risks
Risk index 3C
1. Injury to persons
2. Damage to equipment
Questions and answers
3. Interruption of Acceptable based on
operations Risk tolerability require management
decision

Module N 5 Risks
Questions and answers Questions and answers
Q: Define risk management. Q: What are the five designations for risk probability?
A: A:
The identification, analysis and elimination, and/or
mitigation of risks that threaten the capabilities of an
organization to an acceptable level.
Slide number: 6 Slide number: 13

Questions and answers Questions and answers
Q: What are the five designations for risk severity? Q: Describe the three basic risk mitigation strategies.
A:
A: Avoidance The operation or activity is cancelled
because 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 magnitude of
the consequences of the accepted 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.
Slide number: 18 Slide number: 22, 23 and 24

Module N 5 Risks
Hazards and risks Closing the loop Points to remember
Hazard Condition, object or activity with the potential of causing
injuries to personnel, damage to equipment or structures, loss of
1. The risk assessment matrix.
material, or reduction of ability to perform a prescribed function. 2. The risk assessment criteria table.
Consequence Potential outcome(s) of the hazard.
Risk The assessment, expressed in terms of predicted probability 3. Risk mitigation: avoid, reduce, segregate.
and severity, of the consequence(s) of a hazard taking as reference
the worst foreseeable situation.
A wind of 15 knots blowing directly across the runway is a hazard.
The potential that a pilot may not be able to control the aircraft
during takeoff or landing is one of the consequences of the
hazard.
The assessment of the consequences of the potential loss of
control of the aircraft by the pilot expressed in terms of probability
and severity is the risk.
Boeing B-747 at Taipei International Airport
Group activity
A facilitator will be appointed, who will coordinate the

discussion.
A summary of the discussion will be written on flip

Risks
charts, and a member of the group will brief on their
Exercise 05/01 Accident Boeing
B-747 at Taipei International Airport findings in a plenary session.
(Handout N 4)

Module N 5 Risks
Boeing B-747 at Taipei International Airport Boeing B-747 at Taipei International Airport
Scenario Scenario
A Boeing 747 service from Singapore to Los Angeles On takeoff the aircraft hit concrete barriers, excavators
via Taipei, crashed on takeoff from Taipei's CKS
International Airport at 23:18 local time. and other equipment on the runway 05R.
The flight had been cleared for take off from runway The aircraft crashed back onto the runway, breaking up
05L. and bursting into flames while sliding down the runway
Runway 05R was closed due to construction work. and crashing into other equipment related to work
being done on runway 05R.
The flight attempted the take off from runway 05R.
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).
Notams 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.

Module N 5 Risks
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
risk(s).
Assess existing defences to control the risk(s) and
resulting risk index.
Propose further action to reduce the risk(s) and resulting
risk index.
Complete the attached log (Table 05/01).

Module N 5 Risks
Table 05/01 Hazard identification and risk
management
Type of Specific Existing defences Further action to
N operation Generic
hazard components Hazard-related to control risk(s) reduce risk(s) and
or activity of the hazard consequences and risk index resulting risk index
1 Risk index: Risk index:

Risk tolerability: Risk tolerability:
2 Risk index:
Risk tolerability:
Risk index:
Risk tolerability:
Module N 5 Risks


Module N 5 ICAO Safety Management Systems (SMS) Course 61 Revision N 11 ICAO Safety Management Systems (SMS) Course 01/10/08

Module N 5 Risks

ICAO SMS Module #5 - Risks 2008-11 (E) PDF

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Building an SMS

System Module 8 Module 9

Module 5 Module 6 Module 7

Module 1 Module 2 Module 3

ICAO Safety Management Systems (SMS) Course

Risk management Cost-benefit analysis

ICAO Safety Management Systems (SMS) Course

Second fundamental - Risk probability Second fundamental - Risk probability

Questions for assessing the probability of an occurrence: questions such as:

ICAO Safety Management Systems (SMS) Course

Probability of occurrence Definition(s)

Improbable Very unlikely to occur (not known to have occurred) 2

Third fundamental Risk severity Third fundamental Risk severity

ICAO Safety Management Systems (SMS) Course

Fourth fundamental Risk assessment Fourth fundamental Risk tolerability

2 2A 2D 2E region 3E, 2D, 2E, 1A,

ICAO Safety Management Systems (SMS) Course

Fifth fundamental Risk control/mitigation Fifth fundamental Risk control/mitigation

ICAO Safety Management Systems (SMS) Course

Analyse the likelihood of the consequence Risk analysis Technology

No, take action to Risk control

Risk mitigation Defences Risk mitigation at a glance

Feedback (Safety assurance)

ICAO Safety Management Systems (SMS) Course

practicable (ALARP) Define the level

accepting a risk (a reduction in time and cost) while minimizing the

Warm-up exercise N 05/01

ICAO Safety Management Systems (SMS) Course

Warm-up exercise N05/02 results Warm-up exercise N 05/03

ICAO Safety Management Systems (SMS) Course

Warm-up exercise N 05/04 results Warm-up exercise N 05/05

ICAO Safety Management Systems (SMS) Course

Warm-up exercise N 05/06 results

Risk probability Remote

ICAO Safety Management Systems (SMS) Course

Slide number: 6 Slide number: 13

Questions and answers Questions and answers

ICAO Safety Management Systems (SMS) Course

Boeing B-747 at Taipei International Airport

A facilitator will be appointed, who will coordinate the

A summary of the discussion will be written on flip

ICAO Safety Management Systems (SMS) Course

ICAO Safety Management Systems (SMS) Course

ICAO Safety Management Systems (SMS) Course

1 Risk index: Risk index:

4 Risk index: Risk index:

5 Risk index: Risk index:

ICAO Safety Management Systems (SMS) Course

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