AVASEC MILO DINOSAUR

What is Aviation Safety and Objectives?

Definition of Aviation Safety

• Aviation Safety is the state of an aviation system or organization in which risks associated with aviation activities, related to, or in direct support of the operation of aircraft, are reduced and controlled to an acceptable level.

Evolution of Aviation Safety

Evolution means the changes throughout the time, the changes we see from the past till present.

There are 3 era of Aviation safety:

• Technical Factor

• Human Factor

• Organisational Factor

Technical Factors

Early days of aviation can be characterized as the “technical era” where safety concerns were mostly related to technical factors

• Focus of safety endeavours placed on the investigation and improvement of technical factors

• Equipment failures or operational errors are never the cause of breaches in safety defences, but rather the triggers

Human Factors

The early 1970s saw major technological advances with the introduction of jet engines, radar, autopilots, flight directors, improved navigation and communications

• Focus of safety endeavors shifted to Human Performance and Human Factors

• Endeavours tended to focus on the individual to complete their mission

Organisation Factors

Although scientific literature was available regarding how features of an operational context can influence human performance and shape events and outcomes, it was not until the 1990s that aviation acknowledged that fact

• These are activities over which any organization has a reasonable degree of direct control

• Typical examples include: Policy making, planning, communication, allocation of resources, supervision and so forth

• The two fundamental organizational processes are allocation of resources and communication

Downsides:

• Breeding grounds for a dual pathway towards failure – for Workspace Conditions and for Latent Conditions

Aviation Safety & Accidents/Incidents

Safety is paramount in Aviation.

Safety reduces chances of injuries and increases productivity of the industry.

To do so we need to control risks of Accidents/Incidents

ICAO - International Civil Aviation Organisation

Works with the convention’s 192 member states and industry groups to reach consensus on international civil aviation standards and recommended practices (SARPS) and policies

ICAO ANNEX 13 - Aircraft Accident & Investigation

• States shall investigate or delegate the investigation of accidents which have occurred in their territory
• Sets out the rules on the notification, investigation and reporting of the accident.
• Sole objective of the investigation of an accident or incident is to prevent accidents and incidents and not to blame

What is an Accident?

"An occurrence associated with the operation of an aircraft, which takes place between the time any person boards the aircraft with the intention of flight until all such persons have disembarked, where a person is fatally or seriously injured, the aircraft sustains damage or structural failure or the aircraft is missing or is completely inaccessible."

Examples:

• Air Traffic Controller Error
• Birdstrike
• Bombings
• Collisions
• Controlled flight into terrain

Accident Classifications

Accidents can be classified into many different categories including:

Hull Loss Accident: Aircraft damage is not repairable, or is damaged but not repaired.

Major Accident: Aircraft is destroyed, multiple fatalities, one fatality and the aircraft sustained substantial damage

Fatal Accident: One or more fatalities to occupants of the aircraft substantial damage accident. For example: A single fatality without substantial damage, at least one serious injury and the aircraft substantially damaged

Minor Accident: Aircraft sustained minor damage

Aircraft incident: An occurrence other than an accident that affects or could affect the safety of operations

Individual Accidents

Examples

Characteristics

Characteristics

• Lack of team spirit
• Lack of strict operational procedures
• Poor information flow
• fatigue by workers

• Frequent
• Limited causes
• Limited Consquences
• Specific person or group is the agent and victim

Accidents as a result of the inactions or inactions of indivduals

Organisational Accidents

Accidents as a result of the inactions or inactions of companies or organizations

Examples

Characteristics

• Rare
• Many people
• Multiple causes
• Devastating consequences
• Product of technology

• Poor inspection program
• Lack of certified skilled labour
• Ineffective operation of safety regulation
• Shortage of safety management manuals

Severity

There are various classifications for severity of an accident/incident including:

Accident: Based on ICAO Annex 13

Serious Incident: An incident involving circumstances indicating that an accident nearly occurred

Major Incident: incident associated with the safety and operation of an aircraft, leading to a near collision between aircraft, with ground or obstacles

Significant Incident: an accident, a serious or major incident could have occurred, if the risk had not been managed within safety margins, or if another aircraft had been in the vicinity

No Safety Effect: no safety significance

Not Determined: Inadequate information available, Inconclusive, Conflicting evidence

Frequency

Incident

Annex 13 further defines an aviation incident as 'an occurrence, other than an accident, associated with the operation of an aircraft which affects or could affect the safety of operation'

Examples:

• Disruptive person
• Assault
• Liquid, aerosols and gels
• Prohibited item detected
• Prohibited item on board
• Screening refusal

Accidents/Incidents + Hazards/Risks

To achieve a sufficient level of safety and reduce accidents/incidents we need to reduce areas where accidents/incidents can occur.

Doing so is to reduce the areas of risk and hazards.

What are hazards?

Hazard is any source of potential damage, harm or adverse health effects on something or someone.

People - Heath effects

Organisations - Loss of property or equipment

Environment

Wide variety of sources can lead to hazards.

Hazards in the Aviation Industry

Biological Hazards

From dealing with situations that involve interaction with biological substances/threats (e.g. passengers who are infected with a disease/lavatory services and human waste)

Chemical Hazards

From dealing with chemicals such as jet fuel, cleaning agents, etc.

Chemical Hazards Solution

Use Personal Protective Equipment (PPE)

Biological Hazards Solution

Use protective equipment such as masks and gloves.

Physical Hazards

From dealing with agents/factors that can cause harm

i.e. Noise, Electricals, Temperature, etc.

Psychosocial Hazards

From dealing with stress in the workplace, long working hours, etc.

Psychosocial Hazards Solution

Implement workshift limitations, enforce Standard Operating Procedures (SOP), regulations, etc,

Physical Hazards Solution

Use of hearing protection, use of jetblast fence, grounding of electricity from the GPU, etc.

Identifying Hazards

Definition:

Process used to identify hazards

It is critical to constantly identify and assess hazards so that it can be minimized and prevented. Incidents and Accidents that happen can denote system's deficiencies.

Hazard Identification consists of 2 methods:

Identifying Hazards

Reactive Hazard Identification Methods

• Through trend monitoring and investigation of safety occurrences
• Responds to accidents and incidents that has already happened

Example:

• Identifying the cause of injury after it occurred

Proactive Hazard Identification Methods

• Through analysing organisation's performance and activities for threats and potential failures
• Looks actively for indentification of safety risks

Common ways:

• Safety Surveys
• Operational safety audits
• Safety monitoring
• safety assessments

Examples:

• Conducting job safety analyses
• Carrying out safety inspections and audits of workplace & work procedures

Managing Hazards

To provide high level of safety towards workers, all hazards/potential hazards must be identified and assessed. This way, hazards can be eliminated.

1st Step - Identifying Hazards

2nd Step - Assessing the Risks

3rd Step - Controlling the Risks (Hierarchy of Control)

4th Step - Reviewing Control Measures

3rd Step - Hierarchy of Controls

What are risks?

Definition of risk:​

Risk is the assessed potential for adverse consequences resulting from a hazard. It is the likelihood that the hazard’s potential to cause harm will be realised. ​

(ICAO Doc 9859)​

i.e.​

A risk is a chance that a person may be injured due to a hazard

What are risks?

When there’s a hazard, there’s a risk of injury​

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Hazards provide the possibility of injury/harm to personnel. Therefore risks are inherent to all hazards. ​

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Anything can be unsafe: it’s just a matter of how unsafe.

Risk Analysis & Risk Management

To reduce injury, we must minimize areas where injury can occur.​

That is to reduce and manage all possible risks to hazards.​

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To attain that goal, risk analysis and risk management must occur.

Risk Management

Risk management is the identification, evaluation, and prioritization of risks, followed by corrective action to minimize, monitor, and/or control the probability that an incident occurs, and how much impact results.​

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The main priority of risk management is to assure that uncertainty does not affect the whole operations of the workplace. The risk is assessed, then treated/mitigated.​

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Risk Assessment consists of 5 steps:

Risk Assessment - Risk tolerability

To assess and classify the risk, assessments must be made. This is important as there is a finite amount of resources a company/firm can make to treat the risk. ​

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By using a risk matrix, they can be classified into categories, so decisions can be made as to how and whether to treat the risk or not. That way, safety can be ensured in a more effective manner.

Risk Assessment

1st Step: Identify the risk

The risk is found and identified

The nature of the risk, location, description and all other information are collected.

4th Step: Treat the risk

The risk is treated and dealt with to reduce or eliminate the chance of injury.

The risk is mitigated and dealt with to reduce or eliminate the possibility of injury/harm.

2nd Step: Analyze the risk

The risk is analyzed to determine the probability and consequences that may arise

The details of the risk are all consired and the possible consequences + probability of occurrence are determined.

5th Step: Monitor the risk

The risk is monitored to ensure that objective is met.

The risk is monitored to ensure that it is controlled and does not develop into a bigger one.

3rd Step: Evaluate the risk

The risk is evaluated and ranked with other risks to find out which is more critical.

The magnitude of the risk is determined by looking at the probability of the risk occurring and what consequences may result.

Methods to reduce risk (Risk Management)

There are 4 ways to reduce risk:​

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• Avoidance (eliminate, withdraw from or not become involved)​

Reduce risk by avoiding the danger (passive measure)​

• Reduction (optimize – mitigate)​

Reduce risk by implementing measures (active measure)​

• Sharing (transfer – outsource or insure)​

Reduce risk by making it another person’s responsibility​

• Retention (accept and budget)​

Do nothing and accept the consequences when it occurs, plan accordingly to treat the risk when it occurs.

Risk Assessment - Risk Tolerability

Risks can be categorised into such groups:​

Acceptable means that no further action needs to be taken (unless the risk can be reduced further at little cost or effort);​

Undesirable (or tolerable) means that the affected persons are prepared to live with the risk in order to have certain benefits, in the understanding that the risk is being mitigated as best as possible;​

Unacceptable means that operations under the current conditions must cease until the risk is reduced to at least the tolerable level.”

Main Cause of Risks - Human Factors

In the aviation context, human factors can be the cause for many incidents and accidents.​

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Lack of awareness, fatigue, disorientation, and more have been cited as reasons that accidents and incidents occur.​

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This is as all humans have limitations to their performance. ​

Therefore it’s important to know and understand the limitations to ourselves.

Hazards vs Risks

In many cases, the hazards remain while the risk can be minimized through safety tactics.

Example:

Scenario 1

The hazard exists. It is the water spill on the ground.

The risk can be high, medium or low depending on its location, type of floor, amount of people and other factors

Scenario 2

The hazard still exists. It is the water spill remains.

However, the risk is lowered as there is now a signage to warn people of the water spill. This means that the chances of people slipping from this water spill is less than before.

Relationship between Hazards, Risk and Accidents

Ways to reduce hazards/risks

There are many ways to reduce hazards and risk but not every single method is effective in controlling everything on its own.

To control most if not all hazards/incidents, multiple layers of protection should be implemented to minimize risks and hazards.

Accident Causation: Swiss Cheese Model

What is the Swiss Cheese Model?

This model of accident causation is primarily used in risk analysis and management.

Like a Swiss cheese slice, each layer of the model has holes – though unlike in cheese, the holes constantly change in terms of shape, size and location.

The model depicts the different layers of security against potential hazards. Despite having many layers, there are “holes” (flaws) in each layer that can allow hazards through if aligned.

SHELL Model

To understand the relationship between aviation system resource & environment, and the human component.

The "software"/non-physical aspects of aviation operations and the way information within the system is handled/organised.

This includes rules, regulations and policies.

The humans who interact with the system.

This includes Pilots, Cabin Crew, ATCO, Ramp Agents, etc.

The "hardware"/physical aspects of the aviation system.

This includes aircraft, tools and equipments.

The environment where the Software/Hardware/Liveware operates, inclusive of natural variables (E.g. Weather, Terrain, Time of Day) and other variables that can affect the person (E.g. Noise, Humidity, Pressure, etc.)

Human Errors

Human errors are the result of actions/inactions that fail to produce the desired outcome. These errors often arise from incorrect plans or actions.

Such errors can generally be split into two main categories.

Human Errors

Category 2

Category 1

Action planned was wrong/inappropriate.

Action was carried out correctly.

Action planned was correct/appropriate.

Action was carried out wrongly.

Human Errors - Category 1

"A person wants to achieve a specific outcome. The action is appropiate, but carried out wrongly/unsuccessfully. The outcome is not achieved."

There is a failure in execution.

Execution errors are called slips and lapses. They result from failures in the execution process.

Slips are like careless mistakes. They're often associated with attention and perceptual failures.

Lapses are like forgotten tasks. They typically involve issues with memory.

Human Errors - Category 2

"A person wants to achieve a specific outcome. The action is inappropiate, but carried out correctly/successfully. The outcome is not achieved."

There is a failure in decision.

A failure in the plan has occured.

This planning error can originate from decisions based on a set of memorised rules or based on prior knowledges/assumptions.

If rules/knowledge are applied incorrectly, a mistake in the decision can be made.

Unsafe Acts

PLANNING FAILURES (MISTAKES)

LAPSES

SLIPS

1. Internal events involving memory failures

2. Occur when action is omitted or not carried out.

Eg, missed emergency procedures that happened during stressful events.

1. Associated with attentional

or preceptual failures due to observational actions

2. Occur when approciate actions are carried out incorrectly

Eg, Focusing too much on issue and missing out the side effects of the issue.

1. Application of a good rule to a wrong situation, or on a application of a wrong rule to correct situation.

2. Occur when a person did what they intended to do, but it didn’t work out due to limited information and resources.

Eg, AirFrance Flight 447 (Aircraft crashed due to mistake in stall recovery)

Resulted from failure in execution and/or storage stage of an action squence

What are Violations (Unsafe Acts)

Violations are action/inactions that arise from noncompliance of rules and regulations. Violations can consist of the following types:

Unintentional Violation

Due to procedures that are impossible/too complex to follow.

Situational

Violation

Due to factors in the situation/work enviroment that provides workers an incentive to take shortcuts and commit a violation.

Exceptional

Violation

Due to unusual situations that provides workers an incentive to commit the violation as it is the safer option.

Routine

Violation

Due to habits that is accepted by the organization as low risk.

Optimising

Violation

Due to boredom or wanting to make the task more interesting

What are Violations Pt. 2 (Unsafe Acts)

Violations can be the result of stress, resource constraints, negative cultures, etc.

Ways to manage violations:

• Good leadership, planning, training & resourcing
• Being aware of own responsibility
• Fully understand the existing violations
• Having appropriate communication and feedback systems
• Set boundaries and limit

Types of failures

Latent

Active

1. Link directly to accident and usually caused by front line personel such as aircraft maintenance engineers

2, Caused by unsafe acts

Eg, China Airlines Flight 358

1. Occurred in the past

2. Created by decisions made by different people from physical team

3. Caused by absence or weaknesses of defences, barriers, and safeguards in the system

4. Usually hidden within organisation until failures are triggered by an event with serious consquences.

Eg, Indonesia AirAsia Flight 8501

Swiss Cheese Model + Occupational Work

Multiple protections and rules/regulations can help reduce the risks and prevent an accident from happening.

But to limit the hazards and risk, we also have to consider the occupational hazard (Liveware) aspect of the work.

An unsafe working environment will give rise to greater risks and hazards.

What is OSHE?

OSHE Refers to Occupational Safety, Health, and Environment

The safety aspect of OSHE is with regards to the occupation, health, and environment.

OSHE Consists of the following parts:

Occupational Safety

Occupational

Health

Occupational Environment

A multidisciplinary field that us concerned with the safety aspect of the industry/workplace

The physical and social environment that is directly associated with the workplace

The healthcare that enables a worker to work in his/her job with the least amount of harm to their health

Need for OSHE?

Every workplace has certain occupational hazards.

• Occupational hazards being a risk or danger from working in the particular industry/area

It can be present in many forms which pose an inherent danger in the work and poses a safety risk for others.

In the Aviation Industry, these aspects of hazards and risk are present due to the environment of the airport, the equipment used, and the stress and psychological effects that can develop from working in a dynamic and strict environment with timelines to meet.

Need for OSHE?

To ensure that all workers have a safe working environment and minimize areas which can cause hurt/injury to the workers...

We need to eliminate and reduce issues where there's a possibility of a safety risk to workers.

OSHE in the Aviation Context

There are many hazards in the Aviation Industry.

As workers working in the Industry have to interact with huge machinery, tight working schedules and complex operations, safety is paramount.

Otherwise, an unsafe workplace can create delays and issues that could potentially have a domino-effect that affects the entire industry.

These hazards includes...

Other Ways to combat OSHE Hazards in Aviation

• On the Ramp:

No personnel or equipment shall be within the ERA (Equipment Restraint Area) and PLB (Passenger Loading Bridge) Safety Zone until the aircraft anti-collision lights and the aircraft engines are switched off.

(CAG GOSM 5.2)

All personnel shall ensure that they:

• wear a high visibility safety vest at all times;
• do NOT smoke;
• observe ramp safety rules (e.g. no horseplay on the job);
• do not walk between ULDs or trailers;

(CAG GOSM 15.1)

Structured Approach to Safety

With a very broad range of methologies and ways to provide the safest working environment and reduce accidents/incidents, there should be a structured way that safety is managed

A disorganized and chaotic approach is not only less effective, but could create more risks and hazards.

What is Safety Management System (SMS)?

'A Safety Management System (SMS) is a systematic approach to managing safety, including the necessary organizational structures, accountabilities, policies and procedures. As per ICAO requirements, service providers are responsible for establishing an SMS, which is accepted and overseen by their State.'

Objective:

To provide a structured management approach to control safety risks in operation

What is Safety Management System (SMS)?

SMS Framework consists of 4 pillars:

1) Safety Policy

2) Safety Risk Management

3) Safety Assurance

4) Safety Promotion

What is Safety Policy?

Definition of Safety Policy:

A statement of the organisation’s fundamental approach to achieve acceptable or tolerable safety” (EUROCONTROL, ESARR 3 “Use of Safety Management Systems by ATM Service Provider”)

Purpose:

• Establishes senior management’s commitment to continually improve safety, defines the method, processes and organisational structure to meet safety goals
• Establishes management commitment to safety performance through SMS
• Establishes clear safety objectives and commitment to manage to those objectives
• Establishes transparency in management of safety
• Accountability management and employees builds upon the process and procedures that already exist
• Facilitates cross-organisational communication and cooperation

What is Safety Risk Management (SRM)?

Definition of SRM:

"a formal process within the SMS composed of describing the system, identifying the hazards, assessing the risk, analysing the risk, and controlling the risk. The SRM process is embedded in the processes used to provide the product/service; it is not a separate/distinct process.” (FAA AC120-92A)

Purpose:

• The SRM process is embedded in the processes used to provide the product or services, it is not a separate or distinct process
• SRM is to determine the need for, and adequacy of , new revised risk control based on the assessment of acceptable risk
• A formal process within the SMR that composed of describing the system, Identifying the hazards, assessing the risk, analysing the risk, and controlling the risk

What is Safe Assurance (SA)?

Definition of Safe Assurance:

A formal management process within the SMS that systematically provides confidence that an organization’s products/services meet or exceed safety requirements. (FAA AC No: 120-92A).

Purpose:

• Evaluates the continues effectiveness of implemented risk control strategies, support the identification of new hazards
• SMS process management function that systematically provide confidence that organisational output meet or exceed the safety requirement
• Ensure compliance with SMS requirement and FAA orders, standards, policies, and directive.
• Provide insight and analysis regarding method or opportunities for improving safety and minimizing risk
• Existing assurance function will continue to evaluate and improve service

What is Safety Promotion (SP)?

Definition of Safety Promotion:

'Means, processes and procedures that ensure that personnel are trained and competent to perform their safety management duties and allow for communication of safety issues among operational personnel and with the organisation’s management.'

Purpose:

• Includes training, communication, and often actions to create a positive safety culture within all levels of the workforce
• Safety promotion activities within the SMS framework includes, providing SMS training, matching competency requirements to system requirement
• Non-technical safety promotion activities includes, advocating and strengthening a positive safety culture, system and safety communication awareness and disseminating safety lesson learned

References

• Swiss Cheese Model. (n.d.). Retrieved from https://almostadoctor.co.uk/encyclopedia/swiss-cheese-model
• Accidents, Errors and Swiss Cheese. (n.d.). Retrieved from http://www.dangreller.com/accidents-errors-and-swiss-cheese/
• Hazard and Risk. (n.d.). Retrieved from http://www.hsa.ie/eng/Topics/Hazards/
• Identify the hazards. (n.d.). Retrieved from http://www.hse.gov.uk/risk/identify-the-hazards.htm
• Evaluate the risks. (n.d.). Retrieved from http://www.hse.gov.uk/risk/evaluate-the-risks.htm
• F. (2017, September 11). Safety Management System. Retrieved from https://www.faa.gov/about/initiatives/sms/explained/components/
• S. (2017, September 22). Safety Management System. Retrieved from https://www.skybrary.aero/index.php/Safety_Management_System

References

• S. (2016). Human Error Types. Retrieved from https://www.skybrary.aero/index.php/Human_Error_Types
• M. (2010). Aviation Knowledge. Retrieved from http://aviationknowledge.wikidot.com/aviation:shell-model
• D. (2013). Accidents, Errors and Swiss Cheese. Retrieved from http://www.dangreller.com/accidents-errors-and-swiss-cheese/
• Occupational Health. (n.d.). Retrieved from https://www.niehs.nih.gov/health/topics/population/occupational/index.cfm
• McDiarmid, M. A., & Gehle, K. (2006, September). Preconception Brief: Occupational/Environmental Exposures. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2335294/
• Department of Labor logoUNITED STATESDEPARTMENT OF LABOR. (n.d.). Retrieved from https://www.osha.gov/laws-regs/mou/2000-08-09
• Canadian Centre for Occupational Health. (2018, May 10). Hazard and Risk : OSH Answers. Retrieved from https://www.ccohs.ca/oshanswers/hsprograms/hazard_risk.html
• U. (n.d.). UNITED STATES DEPARTMENT OF LABOR. Retrieved from https://www.osha.gov/shpguidelines/hazard-prevention.html