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Aviation Safety and Security
Safety
TE-02 Group 2
Jonathan
Zi Jian
Christian
Jun Hao
Shawn
https://www.mot.gov.sg/docs/default-source/about-mot/investigation-report/12-dec-2002.pdf
Accident Information
- On 12 December 2002, Garuda B737-300 Aircraft, PK-GGG collided with a SIAEC maintenance vehicle.
- Accident occurred in near CIA terminal 1.
- Investigation results show that the collision was due to the vehicle driver's failure to maintain a safe distance.
Introduction
The Objective of this Prezi presentation-
- Educate potential aviators from AEG & AEL
- Share on Aviation Safety, Hazards Identification/Consequences, Swiss Cheese Model and more..
Objective
Introduction to Aviation Safety
Definition of Safety
ICAO defines safety as “the state in which the possibility of harm to persons or of property damage is reduced to, and maintained at or below, an acceptable level through a continuing process of hazard identification and safety risk management.”
Safety
Key Objectives
- To eliminate aircraft accidents, incidents and serious incidents
- To mitigate safety risks and hazards.
What is Aviation Safety?
Characteristic
- Safety is a dynamic characteristic of the aviation system
- Safety risks must be continuously mitigated and kept under an appropriate level of control, to maintain an appropriate balance between production and protection
Reality & Characteristic
Reality
- Impossible for the aviation system to be completely free of hazards and associated risks.
- Cannot guarantee that human activities or human-built systems are absolutely free from operational errors and their consequences
Enhancing Aviation Safety
ICAO states that aviation safety can be enhanced through the effective implementation of targeted safety programs that address safety deficiencies.
Enhancing Aviation Safety
http://www.raso-wa.org/wpimages/wp69e20bb8_01_1a.jpg
How has aviation safety evolved over the years?
- It has evolved steadily, in a positive way with the advancement of technology and resources we have to date.
- It progress into 3 eras focusing on different aspects of aviation safety
Evolution
Technical Era
- Early 1900s-late 1960s
- Aviation emerged as a form of mass transportation
- Many safety deficiencies were related to technical factors and technological failures
- Focus on investigation and improvement of technical failures
- By 1950s
- Technological improvements led to a gradual decline in frequency of accidents
- Safety processes were broadened to encompass regulatory compliance and oversight
Human Factors Era
- Early 1970s-mid 1990s
- Frequency of aviation accidents reduced due to major technological advances and enhancements to safety regulations
- Deeper focus on human factors issue, including man/machine interface
- Despite investing resources in error mitigation, errors still constantly recur due to human performance
- Recognised only in the early 1900s that individuals operating in a complex environment which includes many factors having the ability to affect behaviour.
Organisational Era
Organizational Era
- Mid 1990s-Today
- Safety viewed from a systematic perspective, encompassing organisational factors
- Introduction to "Organisational Accident"
- New approach of routine collection and analysis of data using proactive and reactive methodologies to monitor known safety risks and detect emerging safety issues
- These enhancements served as a basis for the development of safety management approach
http://www.tmsconsulting.com.au/wp-content/uploads/2019/02/Organisational_Culture_tms_blog.png
Why was "Organisational Accident" introduced?
Due to considerations on the impact of organisational culture and policies on the effectiveness of safety risk controls
Organisational Accident
Evolution of safety from problem statement
Linking to problem statement
From the 1950s, the various eras of safety endeavours to identify potential hazards/risks has significantly reduced the number of accidents and serious incidents from occurring.
The incident of Changi B737 jeep collision were due to multiple factors.
Hence, it would be a learning point for us to further mitigate these potential hazards and risks.
Safety All Around Us
OSHE vs Aviation
Safety
Aviation Safety is adhered from ICAO’s Annex 19 on Safety Management.
In Singapore, Occupational Safety, Health and Environment (OSHE) follows MOM’s guide on Workplace Safety and Health (WSH)
Occupational, Safety, Health and Environment
Definition of OSHE
Describes policies and procedures in place to ensure the safety and health of employees within a workplace. Involves hazard identification and control according to government standards and ongoing safety training and education for employees.
Accidents over the years
Evolution of Safety
In 1984, CAAS was established to oversee aviation in Singapore. Their field of responsibility includes the following:
• Growing Singapore as a Global Air Hub
• Ensuring Safe & Efficient Air Traffic Flows
• Upholding a Safe Aviation Environment
• Developing the Aviation Industry
• Contributing to International Aviation
• Contingency Planning & Crisis Management
Data provided by International Air Transport Association (IATA)
However, in the case of the GA733 collision with SIAEC vehicle-
The employee of SIA operating the vehicle did not conform to the safety guidelines of maintaining safe workplace by being negligent to his surroundings when manoeuvring around the apron area where the GA733 aircraft was parked.
Relation to Case Study
Workplace safety is the general safety guidelines on all workplaces from office to construction sites. However, for aviation safety we will focus on the airport, aircraft, airport staff and passenger’s safety as the main priority. Under MOM’s WSH guidelines, it requires both employees and employers to maintain a safe workplace for all people.
What is an Accident
- Accident is an occurrence associated with the operation of an aircraft
- Takes place between the time any person boards the aircraft with the intention of flight until such time as all persons have disembarked.
- Person being seriously injured / fatal as a result of being in the aircraft
- Aircraft sustains damage or structural failure
- Aircraft is missing or completely inaccessible
E.g. Crash, Mid-air Collision, Serious Runway incursion
Asiana Airlines Flight 214
Accident vs Incident
https://en.wikipedia.org/wiki/Asiana_Airlines_Flight_214#/media/File:NTSBAsiana214Fuselage2.jpg
Accident vs Accidents?
Classification of Accident
Organisation Accident
- A direct result of company poor regulation and judgement.
- Characteristic:
- Very rare, but it has widespread consequences with many defenses and many causes.
- Example: car collision due to poor maintenance.
Individual Accident
- Mostly occurs due to errors and violation of individual.
- Characteristic:
- Frequent with limited consequence and few or no defences and limited cause.
- Result of an individual mishap or miscalculation
- Example: Individual drive at the opposite side of the road.
Incident,
Serious Incident
What is an Incident
- Incident is an occurrence, other than an accident, associated with the operation of an aircraft which affects or could affect the safety of such operation.
- E.g. in-flight fire, in-flight engine loss, Minor Runway Incursion, Undercarriage failure
Serious Incident
https://www.youtube.com/watch?v=STkls1DKGIA
- Result in high probability of an accident and associated with the operation of an aircraft.
- E.g. Near mid-air collision, Controlled flight into terrain, Aborted take-off on a closed runway
https://www.msn.com/en-us/news/world/myanmar-passenger-jet-lands-safely-after-landing-gear-fails/ar-AABfL8O
4 Types of Concept
Concept of Accident
- Organisation
- Management decision making and organisational processes
- Workplaces,
- Working conditions
- E.g. Follow regulation or not
- Human being,
- Human errors and disruptions
- Protection
- Guidelines, training, technologies
SHELL MODEL
The SHELL model is a method that helps understand the relationships between human factors, humans and system resources/ environment.
Definitions
Definition
Software
The rules, procedures, written documents etc., which are part of the standard operating procedures.
Hardware
Air Traffic Control suites, their configuration, controls and surfaces, displays and functional systems.
Environment:
The situation in which the L-H-S system must function, the social and economic climate as well as the natural environment.
Liveware:
Human beings within the aviation system
Characteristics
Characteristics
Liveware-Software
- Interface between humans and software
- Software has to be capable of being implemented
- Difficulties with error prone phraseologies, symbology and conceptual system designs require attention
- Mismatches may lead to
- Insufficient/Inappropriate procedures executed
- Confusion and misinterpretation of documents, symbols etc.
- Overall may lead to an unsafe act.
Liveware-Software
Liveware-Hardware
- Interface between humans and equipment
- Human – machine systems include information processing characteristics of the user and controls with proper movement, coding and location
- Mismatch may lead to:
- Poorly designed equipment
- Failed warning systems
- Badly located devices
- Overall may lead to unsafe act
Liveware-Hardware
Liveware-Environment
Liveware-Environment
- Interface between people and environment
- Liveware - environmental interactions are that which may be out of direct control of humans (eg. temp weather etc) but are within which aircraft operate at.
- Mismatch may lead to:
- Reduced performance rooted from irregular sleep patterns
- Human error
Liveware-Liveware
- Interface between humans.
- Concern of conflict with leadership, co-operation, teamwork and personality interactions
- Mismatch may lead to:
- Reduced performance and error from an imbalanced authority relationship between aircraft captain and first officer.
Liveware-Liveware
Concept of Unsafe Act
Concept of unsafe Act
- Study by American and Australian aviators to prove that human errors and violations played a major role in many accidents
- Skill-based errors such as thinking, perceiving and doing
- "Small-scale" and "exceptional" violations are the two violation types
Errors & Violations
Errors
&
Violations
Error:
- An action or inaction by an operational person that leads to deviations from organizational or the operational person’s intentions or expectations.
- Consists of Slips and Lapses and Mistakes.
- Slips and Lapses
- Individual has a correct intention, but has flawed execution of the action,
- When action carried out incorrectly, it is a slip
- When an action is not carried out/incorrectly carried out, it is a lapse
Violations:
- A deliberate act of wilful misconduct or omission resulting in a deviation from established regulations, procedures, norms or practices.
Slips and Lapses
Slips and Lapses
- Individual has a correct intention, but has flawed execution of the action,
- When action carried out incorrectly, it is a slip
- When an action is not carried out/incorrectly carried out, it is a lapse
Mistakes
- The individual attempts to solve the problem in accordance with a set of memorised rules but commits a rule-based error.
- These errors depend on the application of a good rule to a wrong situation or an application of the wrong rule.
- In the case of a mistake, the individual had succeeded in doing what they intended, but it did not work. The goal or plan was wrong.
https://upload.wikimedia.org/wikipedia/commons/thumb/e/e8/Swiss_cheese_model_of_accident_causation.png/330px-Swiss_cheese_model_of_accident_causation.png
Linking Swiss Cheese Model to hazard
Holes = Weakness of the different stages of preventive barriers
Arrow = Hazards
Not identifying hazards during early stages will develop overtime into severe consequences (accidents & serious incidents)
If potential structural risks are detected early, hazards will not be able to pass through the holes, preventing accidents and incidents from occurring
Hazard
Consequences definition
Consequences
ICAO defines consequences as "Potential outcome(s) that can be triggered by a hazard."
https://previews.123rf.com/images/rahoong/rahoong1403/rahoong140300057/26344725-picture-of-symbol-is-intended-to-alert-the-safety-hazards-that-may-occur-with-hazard-word-white-back.jpg
Hazards
ICAO defines hazards as "A condition, object or activity with potential of causing injuries to personnel, damage to equipment or structures, loss of material, or reduction of ability to perform a prescribed function."
Hazards Definition
Types of hazards
Types of Hazards
1) Technical Hazards
Factors related to:
- Aircraft (components, systems)
- Organisational & external facilities (conditions of workshop, hangers, subsystems)
- Physical ergonomics (physiological and body effects under physical load)
4) Human Hazards
Factors related to personnel having:
- Medical (illness and heat attack)
- Psychological (depression or fatigue)
- Cognitive (suicidal thoughts, poor memory, slow motor response)
- Physical limitations (mobility issues)
3) Organisational Hazards
Factors related to:
- Economic growth/recession
- Operational policies/procedures (inflexible policies)
- Process of materials/equipment acquisition (tedious process)
- Organisational culture (not following organisation's best practices)
- Work paradigms/teamwork (changing of policies due to merging organisation)
2) Environmental Hazards
Factors related to:
- Adverse weather conditions or climate events (thunderstorms, heavy snow, strong crosswinds)
- Natural disasters (wildfires, earthquakes)
- Geography (mountains terrain)
- Public health events (SARS. Ebola)
• https://www.google.com/url?sa=i&source=images&cd=&ved=2ahUKEwjWor2TgsHiAhVv7HMBHRnjB0cQjRx6BAgBEAU&url=https%3A%2F%2Fwww.thoughtco.com%2Fthunderstorm-vs-tornado-vs-hurricane-3444281&psig=AOvVaw1mmOohcg1jJykAbIOX2jcY&ust=1559228806364653
• https://media3.s-nbcnews.com/j/newscms/2017_39/2173966/171001-world-a380-ugc-730a_6e942bd2d3634f0873d70148169e9d6b.fit-760w.jpg
• https://www.thetechy.com/wp-content/uploads/2017/02/Depositphotos_44074529_l-team.jpg
• https://wexnermedical.osu.edu/-/media/images/wexnermedical/global/modules/global/featuredpagelistingcallout/patient-care/healthcare-services/sports-medicine/conditions-and-injury-types/sholdersportsinjuries.jpg?la=en&hash=461E1E3BF2EAB93A70B9BA79C6E9031B0D8BC8DF
General characteristic of hazards
General characteristic of Hazards
- An inevitable part of aviation activities.
- Exist at all levels in the organization.
- Can directly or indirectly trigger an outcome that may be fatal or non-fatal.
- Cause negative impacts and consequences in one way or another.
- The possible consequences of hazard can be addressed through various mitigation strategies.
Aviation vs OSHE Hazards
Aviation Hazard vs OSHE Hazard
Hazards identifying methodology
Methods To Identify Hazards
1) REACTIVE
- Analysis of past outcomes or events.
- Hazards are identified through investigation of safety occurrences.
- Incidents and accidents are clear indicators of system deficiencies and should be used to determine the hazards that either contributed to the event or are latent.
2) PROACTIVE
- Analysis of
3) PREDICTIVE
Consequences of hazards
Consequences of Hazards
Risk
- ICAO states that Safety risk is the projected likelihood and severity of the consequence or outcome from an existing hazard or situation.
Risk Management
Risk Probability: What are the chances of it occurring?
Risk Assessment
Risk Severity: How bad is the outcome?
Risk Tolerability
- Risk Tolerability takes into consideration Severity and Tolerability.
- Used to derive a Risk tolerability Matrix:
Risk Tolerability
Risk Mitigation
Involves using technology, training and/or regulation
Approaches to mitigation
- Avoidance - Suspension of activity
- Reduction - Acceptable level of safety risk exposure
- Segregation of exposure - Using defences or isolating against the hazard.
Things to consider:
1) Effectiveness - How far is it reduced?
2) Cost/Benefit - Is it worth it?
3) Practicality - Can it be done?
4) Acceptability - Will they like it?
5) Enforceability - Will people follow it?
6) Durability - Is it sustainable?
7) Residual safety risks - What is the risk remaining?
8) Unintended consequences - What sort of harm can it cause?
Internal Risk Control
- From internal sources.
- Example: Own experience, own values and attitudes
- Enforced by ownself
Risk Control
External Risk Control
- From external sources.
- Example:Company policy, rules and regulations, external training programme
- Enforced by External Parties
As Low As Reasonably Practicable
ALARP
ALARP is a term often used in the regulation and management of safety-critical and safety-involved systems.
The ALARP principle is that the residual risk shall be reduced as far as reasonably practicable.
A hazard is something (e.g. an object, a property of a substance, a phenomenon or an activity) that can cause adverse effects.
A risk is the likelihood that a hazard will cause its adverse effects, together with a measure of the effect.
Definitions
Evolution of the
view on safety
Evolution
As technology and safety procedures advances with time. The view on safety has been kept on the minimal through implementation of safety trainings, safer equipment and workplace. However still, in recent years, aviation safety has been dragged through the mud with a series of unfortunate aviation accidents and incidents. Airports and Airplane manufacturing companies are taking extra steps to make sure safety is prioritized before any other factors.
How can we reduce hazards?
Strategies for reducing Hazard?
• Hazard Identification Process
• Identification of hazards with the potential to cause major accidents
• Measures to limit major accident consequences
• ALARP Methodology
3 Regions
Level of Societal Concern
Unacceptable/Intolerable Region considered unacceptable regardless of the benefits associated with this activity.
Tolerable Region is where the consequence and/or likelihood is of concern. This is where the level must be ALARP.
Acceptable Region is regarded as sufficiently low, insignificant and adequately controlled.
Human Factors Classification System
- To investigate Human Factors
- Accidents are caused by a combination of Active Failures and Latent Conditions.
- These consequences are a result of the defences having faults that allows hazards to pass through
- Active Failures - Unsafe Acts
- Latent Conditions - Preconditions for Unsafe Acts, Unsafe Supervision and Organisational Influences
Swiss Cheese Model
Introduction to Swiss Cheese Model
- Aviation system has multiple defenses
- Not all defenses work properly
- Might cause a safety occurrence
Introduction to Swiss Cheese Model
Active Failures vs Latent Conditions
Active
vs
Latent Conditions
Active Failures : Actions or inactions, including errors and rule-breaking, that have an immediate adverse effect.
Latent Conditions : Due to decisions made by other people that lie dormant in the background until it combines with an active failure causing a potential hazard to occur.
Unsuccessful
Successful
vs
Unsuccessful
Successful
Conclusion
Double click to edit
Part 2
- We need to take an organisational perspective in solving the issue.
- It involves OSHE safety as it involes a worker and it is an aviation safety incident as it involves an aircraft
- It is considered an incident as it resulted in damage to the landing gear
Part 3
Using the Swiss Cheese Model, we are able to evaluate the different probable factors that caused the incident to happen.
- Unsafe acts: Not maintaining a Proper lookout.
- Preconditions for unsafe acts: Weather, fatigue etc
- Unsafe Supervision: There was no monitoring of his unsafe practices
- Organisational influences: Lack of proper company policies
Part 4
- The hazard can be mitigated using a reactive approach by learning from what happened from this issue
- This is an issue with the liveware-hardware interface
- The probability should be considered as extremely probable as any vehicles move about in the airside
- The severity should be considered as catastrophic as the vehicle might ram into the fuel tank
- Hence, this should regarded as unacceptable and intolerable by the organization and action needs to be taken to avoid this issue.
- The employee will be able to take it in as experience and use it to internally control risks
- However, we can only mitigate risk to a certain level. We can do so by using the ALARP scale and ensuring that risks are mitigated to the acceptable or tolerable level
References
- https://www.icao.int/safety/iStars/Pages/Accident-Statistics.aspx
- http://etraintoday.com/blog/near-miss-vs-an-accident/
- https://www.caas.gov.sg/docs/default-source/pdf/air-navigation-(investigation-of-accidents-and-incidents)-order.pdf
- https://www.mot.gov.sg/docs/default-source/about-mot/investigation-report/12-dec-2002.pdf
- https://www.icao.int/safety/SafetyManagement/Documents/Doc.9859.3rd%20Edition.alltext.en.pdf
- https://www.icao.int/safety/airnavigation/NationalityMarks/annexes_booklet_en.pdf