Introduction to

Safety
Management
GROUP NO. 2
AE 521: AVIATION SAFETY

3.1. The Safety

Stereotype

What is Stereotype?
Widely

held fixed image or idea

Thought

or Belief that can be adopted

Preconceived

notion

Clich
Not

accurately reflect Reality

Is Safety really the first priority?

No,

this is a Misperception that has

evolved into a universally accepted
stereotype

So, What then the first priority in

Aviation Organizations?
To

deliver the Services for which the

Organization was created

To

achieve Production Objectives

To

deliver Dividends

Why?
Because:
There

are Core components and

functions

Safety

is the consequence of the

management

Conclusion
Safety

is not priority of Aviation

Organizations but rather it is dealt by
the Safety Management which is another
core function

3.2. The
Management
Dilemma

Resources
Finite
Essential

to conduct Core Functions

Allocation of Resources
Dilemma of the Ps
Production
Protection

Goals(delivery of services)
Goals(safety)

Balance Allocation

Production Allocation

Protection Allocation

Example
Because

of the need to meet a schedule,

an airliner needs to land at a particular
airport at a particular time, regardless of
weather conditions, traffic volume,
airport limitations and similar constraints
which are absolutely related to the
delivery of the service.

Analysis
If

the service delivery efficiency

considerations is removed then the
operational safety would cease to be a
factor

If

the constraints are removed then it

would become impractical because it
destroys the industrys viability

Conclusion
Aviation

operations are dictated by the

service delivery considerations not
operational safety

Safety

Management ensures balance

and realistic allocation between
Production and Protection goals

3.3. The Need for

Safety Management

 Based

on predicted industry growth and the

potential for an increase in accidents as a
consequence of such growth.

Accident

reduction will always remain a

priority of aviation.

Fragile System

The first Era of Aviation, which spans from the

pioneering days of the early 1900s until
approximately the late 1960s.

safety understanding and prevention

strategies were mainly derived from accident
investigation.

The safety focus was on individuals and the

individual management of safety risks, which in turn
built upon the foundations provided by intensive
training programs.

Safe System

During the second era, from the early 1970s until

the mid-1990s the human era.

understanding of safety increased, which went

beyond individuals to look into the broader
system, was progressively developed.

emphasis shifted to the investigation of

incidents.

incident investigation was accompanied by a

mass introduction of technology.

Ultra Safe System

From the mid-1990s to the present day the organizational era,

aviation entered its third safety reliability era.

adoption of a business-like approach to the management of

safety, based upon the routine collection and analysis of daily
operational data.

The Practical Drift

Two topmost questions in the

mind of system designers:

what resources are necessary to achieve such

production goals? and

how can the system be protected from hazards

during the operations necessary to achieve the
production goals?

The end result of the process is an initial

system design based upon three basic
assumptions:

the technology needed to achieve the system

production goals.

the training necessary for people to properly

operate the technology.

the regulations and procedures that dictate

system and people behavior.

Assumptions are tested, baseline performance validated, and eventually

the system becomes operational.

Oftentimes, nevertheless, operational performance is different from

baseline performance.

In other words, once systems become operational, a gradual drift from the
baseline.

A practical drift from baseline performance to operational performance is

unavoidable in any system, no matter how careful and well thought out its
design planning may have been.

The fact remains, however, that in spite of all the systems shortcomings
leading to the drift, people operating inside the practical drift make the
system work on a daily basis. People deploy local adaptations and
personal strategies, thus circumventing system shortcomings.

the way we do business here, beyond what the book says".

3.4. Strategies for

Safety Management

Strategies for Safety Management

All

aviation organizations, even the soundest,

most resilient organizations, conduct their
daily operations inside the practical drift
The

practical drift is simply inherent to the

nature of dynamic and open socio-technical
production systems, of which aviation is a
prime example.

 During

this daily navigation, organizations

must
overcome
potentially
opposing
currents or obstacles:
The

hazards that arise as a consequence of

an unbalanced allocation of resources to
support the needs of the organization, and

The

non-resolution of the dilemma of the

two Ps

 In

order to successfully navigate the practical

drift, organizations need navigation aids that
generate the necessary information to
negotiate currents and obstacles.

Navigation aids available to aviation

organizations:
1.

Reactive

2.

Proactive

3.

Predictive

Reactive

aids require a very serious triggering event, with

oftentimes considerable damaging consequences,
to take place in order to launch the safety data
capture process.

based upon the notion of waiting until something

breaks to fix it.

appropriate for situations involving failures in

technology and/or unusual events.

The investigation of accidents and serious

incidents are examples of reactive navigation aids.

Proactive

require a less serious triggering event, probably

with little or no damaging consequences, to take
place in order to launch the safety data capture
process.

system failures can be minimized by identifying

safety risks within the system before it fails, and
taking the necessary actions to mitigate such
safety risks.

Mandatory and voluntary reporting systems,

safety audits and safety surveys are examples of
proactive navigation aids.

Predictive

do not require a triggering event to take place in

order to launch the safety data capture process.
Routine operational data are continually captured,
in real time.

based upon the notion that safety management is

best accomplished by trying to find trouble, not
just waiting for it to show up.

aggressively seek safety information that may be

indicative of emerging safety risks from a variety
of sources.

Predictive safety data collection systems

Are collected and analysed, and combined

with data from reactive and proactive safety
data collection systems.

Aggregation of data
allows organizations to
navigate around obstacles and currents and
position themselves optimally within the drift.

Hazard reporting systems, flight data analysis and

normal operations monitoring are examples of
predictive navigation aids

Summary of safety management

strategies

Hazards exist as a continuum along the practical

drift. If uncontained, they travel down the drift
with increasing damaging potential.

The more hazards progress unimpeded along the

practical drift, the more they gather momentum
and increase their damaging potential.

As hazards approach the point where the practical

drift is widest, they have developed maximum
potential for damage, including the potential for
serious breakdowns.

It is therefore essential for safety management to

capture hazards as close as possible to the point
of inception of the practical drift.

Strategies Levels of
intervention and tools

3.5. The Imperative

of Change

The Imperative of Change

As

global aviation activity and complexity

continue to grow, deeply changed operational
contexts with their new challenges make
traditional methods of managing safety
to an acceptable level less effective and
efficient.

Traditional safety paradigm relied on the

accident/serious incident investigation
process as its main safety intervention
and method:
a.

The aviation system performs most of the time as

per
design
specifications
(i.e.
baseline
performance);

b.

Regulatory
compliance
guarantees
baseline performance and therefore
safety (compliance-based); and

c.

only
major
deviations
leading
to
bad
consequences (i.e. outcomes) matter (outcome
oriented)

system
ensures

Managing
control:

safety

through

process

a.

Aviation system does not perform most of the

time as per design specifications (i.e. operational
performance leads to the practical drift);

b.

Rather than relying on regulatory compliance

exclusively, real-time performance of the system
is constantly monitored (performance-based);
and

c.

Minor, inconsequential deviations during routine

operations are constantly tracked and analysed
(process oriented)

3.6. Safety Management Eight

Building Blocks

1. Senior Managements
Commitment to the Management
of Safety
Managing

safety, just like any other

management activity, requires
allocation of resources. This
allocation of resources is, in all
organizations, a function of senior
management, hence the need for senior
managements commitment to the
management of safety. In plain

2. Effective Safety Reporting

It

is a known aphorism that one cannot

manage what one cannot measure. In
order to manage safety, organizations need
to acquire safety data on hazards that
allow for measurement to take place. Most
of such data will be acquired through
voluntary and self-reporting by operational
personnel. It is essential therefore for
organizations to develop working
environments where effective safety
reporting by operational personnel takes

3. Continuous Monitoring
Through

systems that collect safety data

on hazards during normal operations.
Safety data collection is just the first
step. Furthermore, it is essential to share
the safety information and intelligence
gleaned with those who operate the
system daily for they are the ones who
are in constant contact with the hazards,
the consequences of which effective
safety reporting aims to mitigate.

4. Investigation of Safety
Occurences
with

the objective of identifying systemic

safety deficiencies rather than assigning
blame. It is not as important to identify
who did it as it is to learn why it
happened. System resilience can be
much more effectively reinforced by
removing systemic deficiencies than by
removing supposedly unfit individuals.

5. Sharing Safety Lessons Learned

and Best Practices
Through

the active exchange of safety

information. Another well-known aphorism
eloquently illustrates the need for data
sharing and exchange of safety
information: learn from the mistakes of
others, you are not going to live long
enough to make them all yourself. The
aviation industrys excellent tradition of
sharing safety data must be maintained

6. Integration of Safety Training

for Operational Personnel
Seldom

do training curricula for operational

personnel include dedicated safety training.
There is an assumption that since safety is
everybodys responsibility, operational
personnel are safety experts in their own
right. The fallacy of this line of reasoning is
evident and is discussed in Chapter 7. There
is an urgent need to include dedicated
training addressing the basics of safety
management at all levels of operational

7. Effective Implementation of
Standard Operating Procedures
(SOPs)
Including

the use of checklists and briefings. SOPs,

checklists and briefings, whether on a flight deck, in
an air traffic control room, in a maintenance shop or
an aerodrome apron, are amongst the most effective
safety devices operational personnel have to
discharge their daily responsibilities. They are a
powerful mandate from the organization regarding
how senior management wants operations to be

8. Continuous Improvement of the

Overall Level of Safety
Managing

safety is not a one-day affair.

It is an ongoing activity that can be
successful only through continuous
improvement.

3.7. Four Responsibilities for

Managing Safety

1. Definition of Policies and

Procedures Regarding Safety
Policies

and procedures are

organizational mandates reflecting how
senior management wants operations to
be conducted. A clear definition of
policies and procedures is therefore
essential to provide operational
personnel clear guidance on the
operational behavior the organization
expects from operational personnel in

2. Allocation of Resources for

Safety Management Activities
Managing

safety requires resources. The

allocation of resources is a managerial
function. Management has the authority
and therefore the responsibility for the
allocation of resources to mitigate the
safety risks of the consequences of
hazards that threaten the capabilities of
the organization.

3. Adoption of Best Industry

Practices
The

tradition of aviation regarding safety

excellence has led to the continuous
development of robust safety practices.
Aviation has, in addition, a tradition
regarding exchange of safety
information through both institutional
and informal channels. These two
positive traits should be reinforced and
practiced to foster adoption of best

4. Incorporation of Regulations
Governing Civil Aviation Safety
There

might be a misperception that safety

management will make prevailing
regulatory frameworks redundant or
unnecessary. This is a misperception that
must be dispelled in the strongest terms.
There will always be a need for a regulatory
framework as the bedrock for safety
management endeavors. In fact, sensible
safety management can develop only from