INTRODUCTION IN SAFETY MANAGEMENT

Training

by

D. Snoeken CMM/ Safety Manager

Flight School Seppe

15-12-2014

SUBJECTS

- Objective SMS- SMS Manual- Safety Evolution in Aviation- Threats to Safety and Quality- Human Error Defined- Human Error- Human Factors- Human Error Model- Error Mechanism Categories- Strategic Approach- Safety/ Risk Management- Safety Policy/ Just Culture

OBJECTIVE

The objective is to explain the need for a Safety Management System

WHY A SAFETY MANAGEMENT MANUAL?

To Manage Safety!

Why do we have to Manage Safety?

SAFETY EVOLUTION IN AVIATION

TODA

Y

Organizational Factors

Human Factors

Technical Factors

1950s 1970s 1990s 2000s

Threats to Safety en Quality “ We have

met the enemy……and he is us!”

Errors happen!

HUMAN ERROR DEFINED

An inappropriate or undesirable human decision or behavior that reduces or has the potential to reduce effectiveness, safety, or system performance

A human action/decision that exceeds system tolerances

• “An action is taken that was ‘not intended by the actor

HUMAN ERROR

ACCIDENTS

INCIDENTS

ERRORS AND UNREPORTED

OCCURRENCES

Accidents are only the tip of the iceberg!

For every accident there are 600 errors and/or

unreported occurrences

HUMAN FACTORS

Stress

Complacency

Distraction

Fatigue

Communication

Resources

Knowledge

Assertiveness

Awareness

Norms

Pressure

Lack of communication Complacency Lack of knowledge Distractions Lack of teamwork Fatigue Lack of resources Pressure Lack of assertiveness Stress Lack of awareness Norms

CREW DOOR

BATT. DOOR

Loadmaster exits crew door to check battery door.

Engines were running WHAT IF?

Loadmaster killed as he walks into prop. Body and remains scattered over 100 feet.

HUMAN ERROR MODEL

Basic Errors

Unsafe Acts

Unintended Action

Intended Action

Slip

Lapse

Mistake

Violation

Skill-Based-Attentional

Failures

Skill-Based-Memory Failures

Rule-based orKnowledge-based

Mistakes

Routine violationsExceptional violations

Sabotage

INC

IDE

NT

/ AC

CID

EN

T

Attention Failures Memory FailuresFailures in Execution

Misapplication of a good ruleApplication of a bad rule

Dec

isio

n E

rror

sError Mechanism Categories

Skill Based:

Rule Based:

Knowledge Based:Inaccurate knowledge of the system Incomplete knowledge of the system

WHAT TO DO ABOUT IT?

Instead of trying to change the human condition – change the conditions under which people work

Reduce the error-provoking nature of the task, the team, the workplace and the organization

Strengthen and improve defenses to limit and contain the bad effects of those errors that will still occur

STRATEGIC APPROACH

Re + Md → ØE

error defenses Events

Reducing Managing ZEROleadstoand

SWISS CHEESE MODEL

ACCIDENT&

INJURY

Hazard

Organizational Influences

Unsafe Supervision

Pre-Conditions for Unsafe Acts

Unsafe Acts

Latent Conditions Latent Conditions Latent Conditions Active Conditions

Failed or Absent Defenses

SAFETY MANAGEMENT

INTRODUCTION IN RISK MANAGEMNT

Een continue proces net als het kwaliteits proces

Identificeren – Analyseren – Mitigeren – Monitoren - ..........enz

We blijven rondgaan totdat het risiko aanvaarbaar laag is

SAFETY POLICYBelangrijke verklaring van de Accontable Manager waarin hij verklaart verantwordelijk te zijn voor al onze operaties en services!

Dit betekent nogal wat!!

Dit kan alleen als wij er allemaal aan mee doen!!!

Hij moedigt dan ook iedereen aan potentiele gevaren en gevaarlijke

situaties te melden!!

JUST-CULTURE

Een Rechtvaardige Cultuur is hiervoor een NOODZAAK

De melder van voorvallen mag NOOIT gestraft worden

Dat mogen we verwachten van onze Accountable Manager maar ook van de

Overheid!!

DE POSITIVE CULTURE

VRAGEN?