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Safety Management Systems i
3SMS for AviAtionA PrActicAl GuideSaety RiSk ManageMent
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Safety Risk Management
cs
What s safet rs manaement? 01
identfn safet hazards 01
Rs assessment and mtaton 05
ALARP 09
Case stud fatue rs manaement 12
Toolt Safet rs manaement 17
2012 Civil Aviation Saety AuthorityFor urther inormation visit www.casa.gov.au
This work is copyright. You may download, display, print and reproduce this material in unaltered orm only (retaining this notice) or your personal, non-commercial useor use within your organisation. Apart rom any use as permitted under the Copyright Act 1968, all other rights are reserved. Requests or urther authorisation should bedirected to: Saety Promotion, Civil Aviation Saety Authority, GPO Box 2005 Canberra ACT 2601, or email [email protected]
This kit is or inormation purposes only. It should not be used as the sole source o inormation and should be used in the context o other authoritative sources.The case studies eaturing Bush Air and Bush Maintenance Services are entirely fctitious. Any resemblance to actual organisations and/or persons is purely coincidental.
1105.1511
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Safety Management Systems 01
Wha s say smaagm?
Saety risk management: the identication,
analysis and elimination (and/or mitigation to an
acceptable or tolerable level) o the hazards, as
well as the subsequent risks, that threaten theviability o an organisation. (ICAO Doc. 9859)
Beore an SMS can be eectively built or
improved, you must identiy the saety hazards
to your operation and ensure you have controls
in place to manage risk. An SMS should be
risk based. For example, the risks involved in
operating helicopters regularly at low level are
quite dierent to those o an RPT service, so
each operators SMS will need to refect that.
Saety risk management is a careul examination
o what, in your work, could cause harm, so
that you can weigh up whether you have taken
enough precautions, or should do more to
prevent harm.
History shows that aircrat accidents not only
ruin lives, but also aect business i output
is lost, assets or equipment are damaged,
insurance costs increase, or you have to go to
court. Legally, you must assess the risks to sae
operations in your workplace, and implement a
plan to control those risks.
Saety risk management is a key component o
an SMS and involves two undamental saety-
related activities:
1. Identiying saety hazards
2. Assessing the risks and mitigating them
(reducing the potential o those risks to
cause harm).
iyg say hazas
A hazardis anything that could cause
harm, damage or injury, or have a negative
consequence, such as bad weather, mountainous
terrain, FOD, lack o emergency equipment,
high workload/atigue or use o alcohol and
other drugs.
There are many ways o identiying hazards and
quantiying risks, but to do it successully you
have to think laterally, unencumbered by past
ideas and experiences. Operational hazards can
be obvious, such as lack o training, or they may
be subtle, such as the insidious eects o long-
term atigue.
thr r svrl usul mhods o
d hzrds:
Brainstorming - small discussion groups meet
to generate ideas in a non-judgmental way
Formal review o standards, procedures
and systems
Sta surveys or questionnaires
One person standing back rom the operation
and monitoring it critically and objectively
Internal or external saety assessments
Hazard reporting systems.
Hazard identication generally involves
three steps:
1. Stating the generic hazard (hazard statement)
e.g. atigue/high workload, bad weather
2. Identiying specic components o the
hazard e.g. errors because o atigue
3. Identiying project-specic risk/s associated
with each hazard e.g. maintenance errors
resulting rom atigue, especially at times
o Circadian low (2am-6am), CFIT, uel
exhaustion because o bad weather.
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02 Safety Risk Management
I you are a small aviation organisation with only
a ew sta, you simply need to apply discipline
and make the time to examine all acets o your
operations and identiy their hazards. You need to
either eliminate the hazards where possible, vary
the operation, or redesign in a practical way to
protect rom the hazards. You need to be able to
be satised that all risks are acceptable.
For larger organisations, setting up discussion
groups with as many sta and line managers as
possible is a good way o identiying hazards. The
group discussions will also encourage sta to
become more actively involved in establishing or
improving your SMS.
To avoid accidents and incidents any organisation
should have multiple layers o controls or
deences in place. However, controls are neveroolproo or example, having well-trained
maintenance engineers does not ensure that
aircrat components are always tted correctly,
and standard operating procedures or fight crew
are only as eective as those who ollow them.
Regularly identiy what deences you have
against recognised saety hazards.
Step 1: identf safet hazards
Focus group discussions should ask participants
to brainstorm the types o saety hazards they
think may threaten the saety o passengers,
employees or contractors. The group should also
consider those hazards which could damage
equipment, or harm the environment. Forexample, or fight crew, uel exhaustion would
be a hazard that could result in the loss o both
an aircrat and its passengers. For maintenance
engineers, atigue might be a hazard during night
shit operations.
There may also be systemic hazards
organisational actors that could result in
the loss o an aircrat, or injury to or the death
o passengers. These hazards include:
insucient training; lack o policies orprocedures; and people not ollowing these
policies or procedures.
Step 2: Ran and assess the severt ofthe safet hazards
Assess the hazards critically. Factors to consider
are the likelihood (how oten the hazard might
result in a saety occurrence), and the severity
(how bad the outcome would be) o any
consequences. For example, a serious in-fight
re might be an unlikely occurrence, but it would
be catastrophic i it were to occur. It would rank
above a bird strike which, although much more
likely to occur, tends to be less severe. Keep the
process simple and get global views about how
signicant an issue the hazard really is, in the
context o all the hazards identied.
Step 3: identf the controls/defences
n place to manae the hazardsOnce you list the hazards and rank their order
o risk, you should identiy possible deences
(hazard controls) against them. One deence
against an in-fight re is a re extinguisher; a
deence against aircrat uel contamination is
correct uel ltration procedures and regular uel
testing. This step should provide a list o current
controls/deences against each hazard: some
controls will deend against multiple hazards.
Sx smpl sps r susd s
rl wr s ssm:
1. Identiy saety hazards across your
operations that could harm people,
equipment, property or the environment.
2. Rank the likelihood and severity o
these hazards
3. Identiy the current deences/controls
in place to manage them
4. Evaluate the eectiveness o each
deence/control
5. Identiy additional deences/controls
where required
6. Record/(and continue to monitor) all this
inormation in a hazard register.
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Safety Management Systems 03
Step 4: Assess the eectiveness of thecurrent controls/defences
How eective is each hazard control/deence?
Would the control prevent the occurrence (i.e.
does it remove the hazard?), or just minimise
the likelihood or the consequence? You can
determine how eective a hazard control isby asking, or example: Does the crew know
how to use the re extinguishers, and are the
extinguishers correctly maintained? You will then
have a list o eective controls, as well as a list o
which controls need improvement.
Step 5: identf further controls/defences requred
Examine each hazard and its control/s to
determine whether the risk is adequately
managed or controlled. I it is, the operation
can continue. I not, consider how to improve
the hazard control, or to remove or avoid thehazard entirely. For example, you could provide
recurrent training or crew in the correct use o
re extinguishers.
You should manage the risk to a point o
ALARPas low as reasonably practicable. You
should consider/apply all possible means o
mitigation until the cost o mitigation is grossly
disproportionate to the benet you obtain.
In some instances, there could be a range osolutions to manage a risk. Typically, some are
engineering solutions (e.g. redesign), which,
although probably the most eective, may
also be expensive. Others involve control (e.g.
operating procedures) and personnel (e.g.
training) and might be less costly. The solution
need not be costly to be eective.
Bush Maintenance Services has a close call
involving engine cowl asteners. Trevor Brown,
the saety ocer and senior LAME, hears
rom the apprentice, Ryan Johnson, that an
aircrat went out with the asteners missing.
The other LAME, Geo White, was due to
nish the service on his shit, but had ooty
practice or the nals that weekend, and let
in a rush, saying over his shoulder as he raced
out o the hangar, Mate, shes all done. Just
give her a wipe-over; the doc will be here in
the morning. Ryan had done double shits
16 hours straightand had to have the
Beechcrat nished or the local doctor to fy
to the city in the morning. During the graveyard
shit, he wipes away an oil leak on the
hydraulics, but bone tired, does not notice
the missing asteners.
When the GP arrives in the morning, he
discovers the missing asteners on his walk-
around, and is understandably unimpressed.
I you cant get this right, what else have
you missed? he asks pointedly.
Bruce Jones calls a toolbox meeting. There
are things that stand between us and an
accident. Weve got to make sure theyreworking properly. How do we learn rom this,
and make sure it doesnt happen again? Bush
Air wont want us doing any more o their
maintenance, nor will Outback Exploration,
i we cant show more proessionalism.
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04 Safety Risk Management
Step 6: Record all ths nformaton n ahazard rester
This is important not only or your internal risk
management processes, but also in case you
ever need to provide inormation to CASA, the
ATSB or other regulators.
Ater completing these steps, you should have
the ollowing:
A list o saety hazards identied by
employees, ranked in order o importance
A list o current controls/deences in place to
manage these hazards
A list o urther controls/deences required to
improve saety across the operation
Sta involvement in identiying saetydeciencies and priority areas or improved risk
management
Who is going to do it.
Hazard identication checklist
SMS iteMS
Hazard
identication
processes
The organisation has established
various ways to proactively
identiy hazards through
discussion groups (condentialwhere possible in some
smaller organisations this may
be dicult or impossible),
reporting, or surveys.
The organisation uses the
database o reported hazards to:
- identiy hot spots needing
particular attention
- conduct trend analysis which
can help to improve hazard
identication.
Procedures are maintained
or the internal and external
reporting and recording o
hazards and other saety-related
issues to enable analysis and
organisational learning.
The organisation has processes
in place to ensure identied
hazards are dealt with in a timely
manner, and the results o any
actions are ed back to sta.
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Safety Management Systems 05
rs assssm a mga
The term riskreers to the chance that somebody
could be harmed by various hazards, together
with an indication o how serious the harm
could be.
Risk management is an integral componento saety management and involves ve
essential steps:
exmpl: One o the saety concerns or
air transport operators is incorrect loading o
passengers or reight on the aircrat, which can
lead to accidents.
safet rs manaement
Equipment, procedures,
organisation, e.g.
Hazard
identication
Analyse the likelihood o the
consequence occurring
Risk analysis
probability
Evaluate the seriousness
o the consequence i it
does occur
Risk analysis
severity
Is the assessed risk/s
acceptable and within
the organisations saety
perormance criteria?
Risk assessment
and tolerability
Yes,
accept
the risk/s
No, take action
to reduce the
risk/s to an
acceptable level
Risk control/
mitigation
I you work in, or run a larger organisation, you
can ask an advisor to help you. I you are not
condent, ask someone competent or advice.
In all cases, you should make sure that you
involve your sta or their representatives in the
process. They will have useul inormation about
how the work is done that will make your risk
assessments more thorough and eective.
Step 1: identf the hazards
Work out how sae operations could be harmed.
The hazard identication methods already
mentioned are a good start. However, when you
are in your workplace day ater day, it is easy to
overlook hazards, so here are some tips to help
you identiy the ones that matter:
Walk around your workplace looking or thingsthat could reasonably be expected to cause
harm. Involve your employees: they may have
noticed things that are not immediately obvious
to you.
Review your accident recordsthey can oten
help to identiy less-obvious hazards.
Review previous saety occurrences and
maintenance errors. These will help in
understanding risks and their potentiallikelihood and consequences.
Review CASA or ATSB reports.
Ask similar organisations what they ound and
have done about it.
Do ovrcomplc h procss. You should
already have a good idea o the risks and o any
control measures that you can easily apply. You
probably already know whether, or example, you
have employees who commute a long distanceto work areas, or areas o maintenance which
are more prone to risk. I so, check that you have
taken reasonable precautions to avoid incidents.
I you run a small organisation and are condent
you understand whats involved, you can do the
assessment yoursel. You do not have to be a
risk specialist.
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06 Safety Risk Management
Step 2: Decde what mht be harmedand how the harm mht be caused
For each hazard you need to be clear about what
might cause harm. This will then help you identiy
the best way to manage the risk. That doesnt
mean listing everyone by name, but rather
identiying groups o people (e.g. fight crew,cabin crew and passengers).
In each case, you should identiy what might
occur. You will also need to identiy the possible
reasons (root causes) o the hazard.
An online search or SMS sotware will provide
numerous potential suppliers o aordable
sotware to manage all this.
Wh?
Incorrect aircrat loading can aect the saety
o fight crew, cabin crew, passengers on board
and people on the ground.
Cuss?
Incorrect aircrat loading can result rom:
Poor weight and balance calculations
Failure to weigh baggage correctly
Miscommunication between fight crew
and aircrat loading sta
Failure to secure reight properly
Loading o the wrong baggage/reight on
the fight
Inormation entered incorrectly into the
fight management system.
Identication of the severity/consequence of the event
Take into account any current mitigation measures and assess the severity in terms o the worst
possible realistic scenario.
Lvl Svr/
Cosquc
Dscrpor
5 Severe Catastrophic (at least one atality, huge nancial loss)4 Major Major (extensive injuries to one or more people, major nancial loss
3 Moderate Moderate (medical treatment required, high nancial loss)
2 Minor Minor (rst aid treatment at the workplace, medium nancial loss)
1 Negligible Insignicant (no injuries, low nancial loss)
Lelhood of occurrence
Take into account any current mitigation measures and assess the likelihood/probability o the risk
occurring.
Lvl Llhood Dscrpor
5 Almost certain Imminentis expected to occur in most circumstances
4 Likely Once in the next month, will probably occur in most circumstances
3 Possible Once in the next 12 months, might occur at some time
2 Unlikely Once in the next 15 years, could occur at some time
1 Rare Once in the next 10 yearsmay occur only in exceptional
circumstances
The saety manager/ocer will enter the results into the saety report and hazard log.
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Safety Management Systems 07
practice and see i there is more you should
be doing to bring yoursel up to standard.
Ask yoursel:
Can I eliminate the hazard altogether?
I not, how can I control the risks so that
harm is unlikely?
Can I try a less risky option? Prevent access to
the hazard? Reduce exposure to the hazard?
Improving saety need not cost an enormous
amount. For instance, placing a mirror on a
dangerous blind corner o the airport apron to
help prevent vehicle accidents is a low-cost
precaution, considering the risks. Failure to take
simple precautions can be much more costly i
an accident does happen.
evlu rs lvl An important task inanalysing risk is to determine the risk level based
on its likelihoodand consequence.
Likelihood consists o two parts:
The likelihood o a single event occurring
The likelihood o the event occurring based
on exposure and repetition (how oten the
task is perormed, such as cycles o aircrat
maintenance etc.)
A simple way to determine the likelihoodis to
rank the hazard based on its potential requency
o ocurrence. This can be done on a simple ve-
point scale, rom rare to almost certain.
Consequenceis the potential impact or outcome
that may result rom the hazard. This can range
rom insignicant to catastrophic.
Use the risk tolerability matrix to assess how
tolerable the risk is using the results obtained
rom the assessment o the consequences
and likelihood.
Cosquc
1 2 3 4 5
Negligible
Minor
Moderate
Major
Severe
Likelihood 5 Almost certain 6 7 8 9 10
4 Likely 5 6 7 8 9
3 Possible 4 5 6 7 8
2 Unlikely 3 4 5 6 7
1 Rare 2 3 4 5 6
> 7 exrm
rs
Detailed treatment plan
required
6 to 7 Hh rs Needs senior
management attention
and treatment plan as
appropriate
4 to 5 Mdum
rs
Manager-level attention
and monitoring as
appropriate< 4 Low rs Manage by local-level
procedures
The saety manager/saety ocer will enter the
results into the hazard register
arcr lod s rulr cv,
so h likelihoodo corrc lodo h wro hold s ssssds possbl d h potentialconsequencec b modr,rsul corrc lodb corsd s hh, vh pol or dm o rcrsrucur, or h rcr b ou owh d blc olrcs.
Step 3: Evaluate the rss
Having identied the hazards, you then have to
decide what to do about them. You must do
everything reasonably practicable to mitigate the
risks o identied hazards. You can work this out
or yoursel, but the easiest way is to compare
what you are doing with good practice and/or
with what your competitors are doing.
Examine what you are already doing. Think about
what controls you have in place and how the
work is organised. Then compare this with good
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08 Safety Risk Management
I, as in many organisations, you nd that there
are a number o improvements to be made,
both large and small, do not try to do everything
at once. Make a plan o action to deal with
the most signicant risks rst. CASA inspectors
acknowledge the eorts o aviation organisations
that are clearly trying to make improvements.
However, you cannot continue operations i a
risk is assessed as intolerable, until that risk is
mitigated to acceptable level.
You need to allocate tasks to the right people,
with timelines or getting the job done. One large
successul operator makes sure things are done
by having the CEO as the only person who can
approve extensions. There must be a very good
reason or any extension request.
A good plan o action oten includes a mixture
o dierent things. There may be a ew cost-
eective or easy improvements you can do
quickly, perhaps as a temporary solution until
more reliable controls are in place. Remember
to prioritise and tackle the most important
things rst. As you complete each action, tick it
o your plan.
While the majority o saety deences/controls
in place were assessed as eective, additional
measures are required, which are detailed in
a risk management plan outlining short-and
longer-term measures:
Shor-rm
Extra nets and straps to be made available
to secure cargo correctly
Standard load sheet to be held in the cockpit
at all times.
Lo-rm
Standard training or all people involved in
baggage handling.
Dcd o prcuos Once you determine
the risk levels, assess the saety deences or
controls in place to work out how eective they
are against the hazard or hazardous event.
Step 4: Record your ndings andmplement them
Having assessed the risk and the deences
in place, decide how to implement your risk
management plans. You may avoid the risk,
accept the risk in order to pursue an opportunity,
remove the risk, or share the risk with another
party (see ISO 31000:2009).
Putting the results o your risk assessment into
practice will make a dierence when looking
ater people and your business.
Record the results o your risk assessment and
share them with your sta. It is important to
document what you have done so that you can
review it at a later date i anything changes.
A risk assessment does not have to be perect,
but it must be suitable and sucient. You need
to be able to show that:
you made a proper check
you asked who might be aected
you dealt with all the signicant hazards, taking
into account the number o people who could
be involved
your precautions are reasonable and any
residual risk is low
you involved your sta, or their
representatives, in the process.
Saety deences/controls in place to prevent
incorrect aircrat loading:
Standard industry weights used or
passengers
Securing cargo more eectively
Cargo and baggage weighed separately
Standard load sheet used by pilots to
calculate weight and centre o gravity
o the aircrat
Correctly calibrated scales
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Safety Management Systems 09
Step 5: Monitor the eectiveness ofour mplementaton
Monitor your agreed implementation solutions
to make sure they are working, and i they are
not, reassess.
Step 6: Revew our assessment andupdate f necessar
Few workplaces stay the same. Sooner or later,
you will bring in new equipment and procedures
which could lead to new hazards. It makes
sense, thereore, to review what you are doing
regularly. As a minimum, once a year you should
review where you are, to make sure you are still
improving, or at least not sliding back.
Review your risk assessment. Have there been
any changes? Are there improvements youstill need to make? Have your workers spotted
a problem? Have you learnt anything rom
accidents or near misses? Make sure your risk
assessment stays up to date.
When you are running a business it is all too easy
to orget about reviewing your risk assessment,
until something goes wrong and it is too late.
S rvw d or hs rsssssm. Wr dow d o
our dr s ul v, or r our ol cldr.
During the year, i there is a signicant change,
dont wait. Check your risk assessment and,
where necessary, amend it. I possible, think
about the risk assessment when you are planning
the change that way you can be more fexible
and proactive.
AlArP*
Where risk is concerned, there is no such thing
as absolute saety. Risk management is oten
based on the concept o ALARP or as low as
reasonably practicable. There is wide acceptance
that not all risk can be eliminated. There are
practical limits to how ar the industry and
the community will go in paying to reduce
adverse risks.
The concept o ALARP will be replaced by
ALoS (acceptable level o saety) in the very
near uture.
th aLaRP prcpl d cos-bf lss
All eorts should be made to reduce risks
to the lowest level possible until a point is
reached at which the cost o introducing
urther saety measures signicantly
outweighs the saety benet.
A risk should be tolerated only i it can be
demonstrated that there is a clear benet in
doing so (i.e. there is a compelling operational
need in the organisation).
The ALARP principle identies three categories
o risk:
1. Uccpbl Risks are classied as
unacceptable regardless o the benets
associated with the activity. An unacceptable
risk must be eliminated or reduced so that
it alls into one o the other two categories,
or there must be exceptional reasons or the
activity or practice to continue.
2. tolrbl Risks that people are generally
prepared to tolerate to secure their benets.
Tolerable risks must be properly assessed and
controlled to keep the residual risk ALARP,
and must be reviewed periodically to ensure
they remain that way (e.g. the potential
risk o pedestrians, walking between the
terminal and the aircrat, being struck by a
moving vehicle is only tolerated IF appropriate
barricading, security escort and lighting are
in place).
Monitoring process documented:
Internal audit conducted every six monthson aircrat loading procedures
Date or an independent annual audit noted
in diary
Sta to be reminded ormally at least twice
in scheduled monthly saety briengs about
the saety reporting process in place to
report aircrat loading issues
Results o reports communicated to sta
through company education program.
* the concept o ALARP will be replaced by ALoS (acceptable level o
saety) in the very near uture
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10 Safety Risk Management
3. Brodl ccpbl Risks are considered
suciently low and well controlled. Further
risk reduction is required only i reasonably
practicable measures are available. Broadly
acceptable risks are those that people would
regard as insignicant or trivial in their daily
lives, or which exist, but have no practicable
mitigator (e.g. most organisations accept that
sta could be injured on their way to work,
but have little control over what happens on
public roads).
To determine whether a risk is tolerable
(in the ALARP approach), you need to consider
a number o criteria:
Ll rqurms Aviation organisationsmust comply with applicable CASA and
relevant state-based legislation. A control
based on a legal requirement must always
be considered reasonably practicable.
expr judm A proposed control should
be considered reasonably practicable i an
appropriate group o experts has established
it has a clear saety benet, and the costs
associated with its introduction are considered
reasonable.
Cos-bf lss Where expert
judgement or contemporary good practice
does not provide clear evidence that a specic
control or group o controls are reasonably
practicable, a cost-benet analysis may be
necessary. This establishes whether the cost
o implementing a specic control is grossly
disproportionate to its saety benet.
idusr ood prcc I the proposed control
represents current, relevant, established good
practice, that is sucient evidence to conclude
that it is reasonably practicable. For example, it:
- complies with aviation industry standards,
rules or procedures
- is a practice o other operators that aresimilar in scale and operation to your own
- is established and widely implemented in
another industry sector
- matches other countries legislated
enorcement o the practice
- is proven to have demonstrably improved
saety, or can be implemented without
signicant modication or cost.
Unacceptable regionRisk cannot be justied unless
in extraordinary circumstances
Risk is tolerable only i:
Further risk reduction is impracticable
or i its cost is grossly disproportionate
to the improvement gained,
Society desires the benet o the
activity, given the associated risk
Level o residual risk regarded as
negligible and urther measures to
reduce risk not usually required.
No need or detailed working to
demonstrate ALARP
nlbl rs
Tolerable region
Increasin
gindividualrisks
andsocie
talconcerns
The ALARP approach
Broadly
acceptable
region
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Safety Management Systems 11
ALARP applcaton
1. idfco o hzrd
A small certied aerodrome operator, located
in outback Australia, identies a saety hazard
wildlie wandering on to the runway, and
potentially colliding with aircrat.
Hazard = wildlie on runway, specifcally
wallabies, eral camels and donkeys.
2. Dcd who should b volvd h
ssssm procss
Aircrat operations during taxiing, take-o
and landing are exposed to this hazard.
The hazard is caused by inconsistent wildlie
management, seasonal conditions and the
absence o a perimeter ence.
3. evlu h rss d dcd o
prcuos
Discussions with aircrat operators and other
stakeholders using the aerodrome reveal no
identied incidents involving wildlie have
resulted in a collision. However, over the
last six months there have been ve
near-miss reports, two o which involved
minor evasive action (braking by the pilotin command) to avoid collision. The risk
is assessed as moderate, based on a
combination o possible (likelihood) and
minor (consequence).
The aerodrome operator decides that two
controls could manage the risk: an improved
wildlie management program, including
possible seasonal eradication o animals; and
constructing an aireld perimeter ence to
prevent wildlie access.
The airport operator decides the airport
perimeter ence is the most eective control
o the two available, and applies ALARP to
determine i this is justiable. They consider
the ollowing to determine whether the risks
are tolerable:
Legal requirementsThis is a certied
aerodrome under CASR Part 139, with
only one weekly RPT service and a variety
o charter and general aviation operations.
Thereore, there is no explicit aviation regulatory
requirement or a perimeter ence.
Expert judgementStakeholders consulted about
the possible construction o a ence agree that
it is an eective control, but the ence must bemaintained and inspected regularly.
Cost beneft analysisThe cost o the perimeter
ence construction and ongoing maintenance
program is determined to be beyond the
unds o the aerodrome operator, and local
government is unable to assist with nances.
The small number o incidents thereore
suggests that the cost is not justiable.
Industry practiceA quick survey o similar-
sized registered aerodromes suggests that not
all have perimeter ences, and some are only
partially enced. While perimeter encing is
recommended, industry practice suggests that
this is not consistent.
4. Rcord our fds d mplm
hm
The aerodrome operator decides thereore that
a perimeter ence is not justied, based on its
cost to build, that such a ence is not consistentwith industry practice, and that there is a limited
risk o wildlie on the runway colliding with an
aircrat. However, to ensure that the risks are
acceptable based on ALARP principles, they
decide to improve wildlie management through
a more targeted seasonal wildlie management
program keeping the grass down to minimise
ood supplies and regular sweeps o the runway
to deter wildlie.
5. Rvw our ssssm d upd cssr
They review the wildlie management
program annually, with aerodrome users
reminded to report wildlie activity on or
near the aerodrome.
They also contact CASA or resources to assist
in wildlie identication and management, and
develop a wildlie hazard management plan.
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12 Safety Risk Management
cas sy ag smaagm
What s fatue?
Fatigue is an experience o physical and/or
psychological weariness.I you become atigued, the eect can be the
same as i you have consumed alcohol. Fatigue
can, or example, aect your ability to react
quickly to emergencies; communicate clearly
and determine the sae limits o your actions;
as well as your ability to operate productively.
Managing atigue is an important component o
saety management, given that it is a signicant
and preventable actor in transport incidents/
accidents. For example, 20-30 per cent o road
incidents and 5-15 per cent o all atal road
accidents involve driver atigue.
What causes fatue?
Both work-and non-work-related actors
aect atigue.
Work-related atigue actors:
The hours you have to work (and the impact
o these hours on the opportunity to sleep)
The timing and duration o breaks within shits
The work you do
Your work environment.
Non-work-related atigue actors:
Long commutes to and rom work
Sleep disorders aecting the quantity and/or
quality o your sleep recovery
Your amily and social responsibilities
Having a second job.
Rs mtaton checlst
SMS iteMS
Risk mitigation
processes
The organisation has
a ormal saety risk
management process
used to:
- identiy hazards
associated with the
organisations operations
- analyse and assess
the risks associated
with those hazards
- implement controls to
prevent uture accidents,
incidents or occurrences.
This saety risk
management process
meets the ollowing
risk management
requirements to:
- (a) communicate
and consult
- (b) establish the context
- (c) identiy risks
- (d) analyse risks
- (e) evaluate risks
- () treat/mitigate risks
- (g) monitor and review.
There is a ormal record
o each stage o the risk
management process,
including assumptions,
methods, data sources,
analysis, results and
reasons or decisions.
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Safety Management Systems 13
Consequences of fatue
General consequences can include:
Lapses in attention/concentration
Poor risk assessment, and incomplete
or inaccurate assessment o potential
consequences
Ineciency in production, on-time
perormance, resource use (e.g. uel),
and/or motivation
Impaired or delayed decision making
A higher likelihood o ocusing on the most
obvious data or stimuli, to the exclusion o
other equally important inormation.
The table below indicates the typical behavioural
symptoms o atigue. I an employee has
experienced three or more o the specied
symptoms in a 15-minute period they are likely
to be atigued.
Fatue manaement countermeasures
Counter measures to prevent atigue-related
errors are listed below:
Nappn
Generally, the longer the nap the greater its
recovery value. Naps should provide at least20 minutes o sleep, but no longer than two
hours, to be o the greatest benet.
Longer naps can lead to sleep inertia - the
groggy eeling you have when someone wakes
you up during a deep sleep. So, beore returning
to work ater such a nap, people should have
10-20 minutes o recovery to overcome the
eects o sleep inertia.
Behavoural smptoms of fatue
PHySiCaL SyMPtOMS MentaL SyMPtOMS eMOtiOnaL SyMPtOMS
Yawning
Heavy eyelids
Eye rubbing
Head drooping
Inappropriate or
unintentional napping
Falling asleep
Poor coordination
Diculty concentrating on the current
work task
Lapses in attention
Diculty remembering what you are
meant to be doing
Failure to communicate important
inormation to a colleague
Failure to anticipate events or actions
Unintentionally doing the wrong thing
(errors o commission)
Unintentionally ailing to do the right
thing (errors o omission)
More quiet or withdrawn
than normal
Lethargic or lacking
in energy
Lacking in motivation to
do the task well
Irritable or bad-tempered
behaviour with colleagues,
amily or riends
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14 Safety Risk Management
Small- to medium-sized air transport operators
do not currently need custom-built crew rest
acilities or napping on their aircrat. Consider
a simple but eective strategy used by one
helicopter charter operator:
nOte
Mc r pr moor
Look out or the ollowing symptoms that may
indicate you or your co-workers are atigued:
Communication that goes unanswered, orchecklists that go unchecked
Diminished motor skills writing that trails
o into nothing, poor concentration, impaired
driving skills
Obvious tiredness drooping head, eyes hal
closed or staring
Diminished vision diculty in ocusing
Slow reactions
Short-term memory problems unable to
remember inormation you have just been told
Channelled concentration xation on a single,
possibly unimportant issue, neglecting others,
and unable to maintain an overview o the job
Easily distracted by trivia or, at the other
extreme, xation on a single issue
Poor or clumsy handling o tools/operation
o equipment Increased mistakes making poor decisions,
or no decisions at all
Abnormal moods mood swings, depressed,
periodically elated and energetic, diminished
standards.
Nappn faclt
A Bankstown-based helicopter charter operator
recognises that ater long and demanding
operations, its aircrew get into their cars and
in some cases drive or up to two hours to get
home. To oset the risk o atigue, all aircrew
have access to a dedicated rest acility located
at the rear o the maintenance hangar. The
chie pilot believes that this allows his crew
to take naps, and is one o their most valuable
atigue countermeasures.
Supervsor and co-worer montorn
I your workers are at increased risk o a atigue-
related error, you may be able to ask peers or
supervisors to monitor atigue-related behaviours.
However, you need to guide people about what
to look out or. You must provide this inormation
in advance, to minimise misperceptions that
people are being watched.
You can make monitoring as simple as morerequent verbal contact (or example, regularly
throughout the shit), or you can make it
more ormal by mandating veried additional
supervisory checks (at hourly intervals
during night shit work, or example) or
saety-critical duties.
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Safety Management Systems 15
I you notice any o these symptoms, what
should you do?
Deal with the problem within your own team
rst by raising it (do not accuse) with the
person concerned. I notice you are looking
very tired; is everything OK?
Try to nd out why the person is atigued
Ask how you can help
I the problem continues, reach agreement
with the person that their supervisor should
be involved to allow or more ormal atigue
countermeasures
Emphasise that atigue is a saety-critical issue,
and work cannot continue until it is dealt with.
Tas rotaton and/or tas reallocaton
Task rotation has signicant potential as a atigue
control measure. In many cases, workload can
be made more engaging by varying the tasks
undertaken across a shit.
Task rotation can be more dicult in small
organisations with limited numbers o skilled
sta. However, where you have groups o skilled
sta, and particular rosters are known to be more
susceptible to atigue, or a saety-critical task is
under time pressure, a tag team approach to the
job can be useul. You might be able to alternate
sta between doing the job and quality control
cross-checking.
When atigue-related symptoms are recognised,
either by sel-assessment or supervisor
monitoring, consider task reallocation, especially
where there are high risks to the individual, to
peers, and/or to the general public.
For example, less risky tasks might be simpleprocedural tasks, word and data processing,
quality checks and basic communication. This
control only reduces exposure to high-impact
hazards, but does not mitigate the atigue itsel.
Mnmum accommodaton requrements forall overnht operatons
To ensure aircrew have the best opportunity
or good-quality sleep during overnight
operations, they require the ollowing minimum
accommodation:
A single room or each aircrew member,
which:
- has easy access to the worksite
- is air conditioned
- is comortable, clean and to a high
standard.
- has access to quality in-house meals.
I these minimum conditions are not met,
please inorm the chie pilot immediately.
Sutable overnht accommodaton and meals
I your organisation conducts overnight
operations, you may want to organise minimum
accommodation requirements with your
customers to ensure your sta have adequate
ood and rest acilities.
A small aircrat charter organisation has theollowing policy:
Strategic use of caeine
Caeine can provide a short-term improvement
in alertness. How intense and long lasting that
eect is depends on how much caeine the
body is used to, and how oten it is consumed.
Not surprisingly, the more requent and the
higher the caeine intake, the less noticeable
will be the improvement in alertness, so it should
only be used (with caution) as a contingency.
Reulator requrements
Two principal regimes require Australian aviation
operators to manage atigue: the various state
Occupational Health and Saety(OH&S) Acts
and CASA regulations.
The various Occupational Health and SaetyActs
adopt a generalised duty-o-care approach
employers must ensure that their workplaces are
as ree rom risk o harm as reasonably possible.
The broad ormulation o this duty covers the
risks posed by atigue.
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16 Safety Risk Management
Under CASA requirements, air transport
operators can choose to operate entirely under
prescriptive limits based on Civil Aviation Order
(CAO) Part 48 Flight Time Limitations; apply or
a standard industry exemption to CAO 48 and
operate under a atigue risk management system
(FRMS); or operate under a combination o both
(where some parts o the operation, one feet
or example, operate under an FRMS and the
rest do not). There is also relevant material or
maintenance organisations in Part 145.
SMS and FRMS compared
An FRMS is really a saety management
approach to dealing with the risks imposed by
atigue, so there are similarities between the
components o an SMS and FRMS, as shown
on the next page.
Fatue rs manaement sstem (FRMS)
Fatigue risk management systems are
increasingly being adopted by air transport
operators to control the risks o atigue-related
accidents and incidents. An FRMS is simply a
component o the overall saety management
system and includes controls such as:
Polc d procdurs documents how
atigue risk is managed and by whom
evluo d rvw measures program
eectiveness and recommends improvements
aud assesses operational compliance
with the atigue program policy, procedures
documents and ongoing legislative
requirements
Rcord p provides documented
evidence o atigue risk management
and is one element o an evaluation andreview process
educo d r trains individual
employees and stakeholders to manage
atigue risk competently
Commuco d cosulo
communicates and coordinates inormation
about atigue.
An eective atigue program requires multiple
atigue countermeasures or deences:
Provide sucient sleep opportunities to all
employees. Employees should take advantage
o these. Adopting prescriptive duty time
limitations and designing rosters to manage
atigue are other possible controls.
Ensure employees take responsibility or
obtaining sucient sleep, and report to you
i that has not been possible. Encourage
employees to report any atigue risk issues
through their direct supervisor, or by using a
more ormal saety occurrence report orm.
Train your employees to recognise their own
(and others), atigue-related behavioural
symptoms, and manage them appropriately.
Provide atigue management training
at induction, as well as ongoing atigue
management rereshers or employees,
contractors and stakeholders.
This ramework reduces the likelihood that an
individual will be exposed to atigue-related
risk. However, atigue-related risk cannot be
eliminated. Implement countermeasures such
as task rotation, task allocation, strategic use o
caeine, napping and co-worker/peer monitoringto reduce the risk o atigue-related errors.
Once a atigue-related incident has been
reported, carry out a thorough investigation
to identiy any additional risk controls or risk
management strategies required.
Busy liestyles, long commuting distances
and amily responsibilities can lead to atigue.
Thereore, it is important to acknowledge that
no one is immune to atigue. All sta and
contractors have a role to play in contributing
to managing and mitigating its potentially
hazardous eects.
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Safety Management Systems 17
toolkitSAFETy RiSk MANAgEMENT
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18 Safety Risk Management
ix ms
This is yoursaety toolkit with some best-practice
tips and practical tools that can be adapted
to meet your organisations needs. We hope
you nd them useul, whether you are urther
developing your SMS, starting an SMS rom
scratch, or simply looking or some ideas to
improve your existing SMS.
This list summarises the checklists/templates
you will nd at the back o each o the respective
booklets.
This is not an exhaustive list o resources.
There are many systems and products across
various industries, so this toolkit can only include
a very small sample o practices and/or tools
or inormation.
Inclusion o materials does not imply
endorsement or recommendation. Each
organisation must select the most appropriate
products or its individual and specic needs.
Boolet 1 Bascs
Jargon busters
Reerences
Boolet 2 - Safet polc and objectves tools
SMS organisation checklist
Saety policy statement
Saety managers job description
Role o the saety committee
SMS implementation plan
Ten steps to implementing an SMS
SMS gap analysis checklist
An eective emergency response
plan (ERP)
Language and layout o procedures/
documentation
Document register
Sample saety leadership rules
Aviation saety liesavers policy
Just culture procedure
Appendix A Workfow process or applying
the just culture procedures
Appendix B Bush Air counselling/discipline
decision chart
Boolet 3 - Safet rs manaement tools
error prvo srs or
orsos
Rs rsr
Smpl hzrd iD
gudc o job d s ds
a sx-sp mhod or volv s
s hzrd dfco
Hzrd rpor orm
Boolet 4 - Safet assurance tools
Generic issues to be considered when
monitoring and measuring saety perormance
Audit scope planner
Basic audit checklist
Inormation relevant to a saety investigation
Event notication and investigation report
Aviation saety incident investigation report
Corrective/preventative action plan
Checklist or assessing institutional resilience
against accidents (CAIR)
Practical saety culture improvement strategy
Saety culture index
Boolet 5 - Safet promoton tools
How to conduct a training needs analysis
Sample saety inormation bulletin on atigue
How to give a saety brieng/toolbox talk
Aviation saety toolbox talk
Saety brieng/toolbox meeting
attendance orm
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Safety Management Systems 19
e p sags gasas
Three strategies aimed at error prevention, which
is actually a orm o risk mitigation, are briefy
outlined below. These strategies are relevant
to fight operations, air trac control, or aircratmaintenance.
error rduco srs are intended to
intervene directly at the source o the error itsel,
by reducing or eliminating the contributing actors
to it. They seek improved task reliability by
eliminating any adverse conditions leading to an
increased risk o error. Error reduction is the most
requently used strategy.
Examples o error reduction strategies
include improving the access to a part or
maintenance, improving the lighting in which
the task is to be perormed and providing
better training.
error cpur assumes the error has already
been made. The intent is to capture the error
beore any adverse consequences o the error
are elt. Error capturing does not directly reduce
or eliminate the error.
Error capturing strategies include post-taskinspection, verication or testing, or example,
cross-checking a checklist. (However, a
possible drawback to this error prevention
strategy is that people may be less vigilant
when they know there is an extra deence in
place to capture their errors.)
error olrc reers to the ability o a system
to accept an error without serious consequence.
For example, as a strategy to prevent the loss o
both engines on an aircrat involved in extendedtwin-engine operations, some regulatory
authorities prohibit the same maintenance task
being perormed on both engines prior to a fight.
Examples o measures to increase error
tolerance are the incorporation o multiple
hydraulic or electrical systems on the aircrat,
and a structural inspection program allowing
multiple opportunities to detect a atigue crack
beore it reaches critical length.
gudance on error preventon/rsmtaton ssues to be consderedb oransatons
ICAO advocates some undamental strategies
aimed at error prevention, which is a orm o
risk mitigation. These include:
An open and transparent error-reporting
program (not one ocusing on culpability
and blame)
Human actors training provided with the
specic application o error identication,
capture and management
Non-jeopardy-based observational auditing
programs that examine the threat and error
management skills o saety-critical workers
The organisation advocating strict adherence
to standard operating procedures (SOPs)
and standard communication phraseology
Equipment design being human-centred
Systems to continually learn the lessons
o previous occurrences
Consideration given to using automation
where possible, particularly or routine
and monotonous tasks relying heavily onoperator vigilance.
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20 Safety Risk Management
rs gs
[sr m o orso] Rs rsr Lo umbr
The risk
What can happen?
How can this happen?
Existing
controls
The consequences o an
event happening
Additional
mitigation
required
Residual risk Action and
owners
Monitoring
and review
requirements
Date: xx/xx/xxxx Version: x Form SMS 3
Reportrefe
rence
number
Dateenteredin
register
Severity
Severity
Likelihood
Likelihood
Levelofris
k
Levelofris
k
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Safety Management Systems 21
Smpl hzrd iD
Hzrd iD Sh hdovr & u
Mitigators Eectiveness Reason Further controls/
deences required
Responsibility
Shit handover
procedures
No In a manual in
Bruces oce
nobody reads them
Hal-hour overlap
between shits to allow
or proper brieng,
and or log to be ully
completed
Cheryl Jones
Shit handover
log
No Not in central enough
place goes missing
To be transerred
to hangar PC, and
completed online
Cheryl Jones
Regular stasaety meetings
No Not held consistentlyenough
Schedule regularortnightly toolbox
meetings.
Trevor Brown(saety ocer)
Rostering No Not enough sta
to cover the
required shits
With planned growth,
take on new sta
Bruce Jones
Recording No Ad hoc system is only
done sometimes
Hazard & risk register
on hangar PC. Everyone
gives and receives
eedback
Trevor Brown &
Cheryl Jones
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22 Safety Risk Management
Ga jb aas sg
Job and task design can contribute to system
saety. Improving the design o jobs and tasks,
and the workspaces in which they are perormed,
can signicantly improve human perormanceand reduce the potential or human error.
Task design is essentially about matching the
person and the task - making sure that tasks and
activities are appropriate and suited to the human
operators or teams capabilities, limitations and
personal needs. For example, tasks that involve
excessive time pressure, complex sequences o
operations, reliance on memory, are physically
or mentally atiguing etc. are likely to have a
negative impact on perormance.
A typical approach may be to:
1. identiy saety-critical tasks, and those
who perorm them
2. design the task objectives, sequences and
actions to be perormed
3. structure the task so it supports the sae
perormance by the individual or team
4. consider the working environment so itsupports the sae perormance o the task
5. assess the potential risks associated
with non compliance, human capabilities
and limitations
6. implement risk management strategies
to manage identied risks
7. evaluate saety perormance against the
stated objectives.
Examples o design elements that can be
included are:
procedures and rules
equipment, tools and materials
human machine interace (HMI)
inormation requirements
manning and workload
workspace
capabilities and skills required
team structures
communication links
rostering
rewards and incentives
supervision.
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Safety Management Systems 23
A sx-sp mh involving sta in safetyhazard identication
To avoid accidents and incidents, any
organisation should have multiple layers
o controls or deences. However, controlsare never oolproo or example, having
well-trained maintenance engineers does
not ensure that aircrat components are
always tted correctly. Standard operating
procedures or fight crew are only as eective
as those who ollow them. Air transport
operators and maintenance organisations
should regularly identiy what deences they
have to contain recognised saety hazards as
an early warning saety system. To achieve this, six simple steps are
suggested:
1. Identiy saety hazards across your operations
that could harm people, equipment, property
or the environment.
2. Rank the likelihood and severity o these
hazards
3. Identiy the current deences/controls in place
to manage them
4. Evaluate the eectiveness o each
deence/control
5. Identiy additional deences/controls
where required
6. Record all this inormation in a
hazard register.
Ater completing these steps, you should have
the ollowing:
A list o saety hazards identied by
employees, ranked in order o importance
A list o current controls/deences in place
to manage these hazards
A list o urther controls/deences required
to improve saety across the operation
Sta involvement in identiying saety
deciencies and priority areas or improved
risk management.
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24 Safety Risk Management
Haza p m
Rpord b:
Name: __________________________________ Position: _________________________
Subjc:
[ ] Workplace hazard [ ] Hazardous work practice [ ] Public hazard [ ] Aviation saety hazard
Dscrpo o hzrd d co :
____________________________________________________________________________________________
____________________________________________________________________________________________
is urhr co rqurd? ys [ ] no [ ]
Rpord o:
Aviation saety ocer: _______________________________
Saety committee/rep: yes/no
Reporting persons name: ____________________________Signature: _______________________________
Date: ___________________________________
Suprvsor us ol
Date report received:__________________
Action taken or recommended:
____________________________________________________________________________________________
____________________________________________________________________________________________
Date implemented: ___________________
Name: ____________________________________________ Signature: _______________________________
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Safety Management Systems 25
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