Module 4
Hazard Identification
SMS Course Outline
Module Z
Module 6 SMS
SMS Implementation Course
Summary
Module 5
Module 4
Safety Risk
Hazard
Assessment and
Identification
Mitigation
Module 2
Module A Module 1 Introduction to Module 3
SMS Course Basic Safety Safety SMS Framework
Introduction Concepts Management
SMS v1.0 May 2024
PPT 4.2
End-of-Module Objective
Condition In the classroom, having completed this module
delivery, the participants will be able to:
Performance to apply the fundamentals of hazard identification and
analysis;
through a case study in accordance with ICAO Annex 19
Standards (Safety Management) and ICAO Document 9859 Safety
Management Manual.
SMS v1.0 May 2024
PPT 4.3
Intermediate Objective
1 Define the safety risk management component of SMS
Define the hazard identification element of safety risk management
2
component of an SMS
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PPT 4.4
Module Outline
Recall SMS Framework: Safety Risk
Management
Understanding Hazards and
Consequences
Hazard Identification
Hazard Analysis
Documentation of Hazards
Safety Risk Management
A. Safety Policy and Objectives
• Management commitment and responsibility
• Safety accountabilities
• Appointment of key safety personnel
• Coordination of emergency response planning
• SMS documentation
B. Safety Risk Management
• Hazard identification
• Safety risk assessment and mitigation
C. Safety Assurance
• Safety performance monitoring and
measurement
• The management of change
• Continuous improvement of the SMS
D. Safety Promotion
• Training and education
• Safety communication
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PPT 4.6
Safety Risk Management
Service providers should Safety Risk Management
ensure that they are includes
managing the safety risks
they are faced with.
This process is known as
safety risk
management.
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PPT 4.7
Safety Risk Management
The safety risk management process
systematically:
• Identifies hazards that exist within
the context of the delivery of its
products or services;
• Analyzes and assesses the safety
risks associated with those
identified hazards; and
• Implements appropriate risk
controls to mitigate the risks.
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PPT 4.8
Safety Risk Management
Safety risk management is a
continuous activity as some
hazards, the assessment of
the associated risks and the
effectiveness of any risk
mitigations may change over
time.
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PPT 4.9
First fundamental - Understanding Hazards and Consequences
A hazard is:
• Something that, in case of failure, can lead to a negative outcome
• A normal and identifiable system component (part of normal
business), whose effects are usually manageable
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PPT 4.10
First fundamental - Understanding Hazards and Consequences
A condition or an object with the potential to cause or contribute to an aircraft
incident or accident (Annex 19, Amendment 1, 16th July 2016)
An undesirable condition or situation which may lead to unsafe events or
Hazard consequences (SMI Website 2.4 Hazard Identification Risk Mitigation Worksheet)
Condition: Something that exists for a period of time rather than occurs at a specific
point in time. It is a state, situation or circumstance (ATSB, Safety Investigation Guidelines for
Analysis, 2011).
A hazard can be considered as a dormant potential for harm which is present in one form or another within
the system or its environment (SMM2.5.1.1).
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PPT 4.11
First fundamental - Understanding Hazards and Consequences
Unsafe State
• The stage in the escalation of an accident
scenario where the accident will occur, unless
an active recovery measure is available and is
successfully used.
(Ref: ECAST Guidance on Hazard Identification)
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PPT 4.12
First fundamental - Understanding Hazards and Consequences
Ultimate Consequence
• The most credible outcome, ultimate event or accident (SMI Hazard
Identification Risk Mitigation worksheet)
• The severity of injuries to personnel, damage to equipment or
structures, loss of material, or reduction of ability to perform a
prescribed function arising from an outcome. Consequences have a
magnitude (ECAST Guidance on Hazard Identification)
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PPT 4.13
First fundamental - Understanding Hazards and Consequences
Ultimate Consequence
Recommendations:
• Consequences are what we ultimately want to prevent.
• can be expressed generically as losses, damages and/or injuries/fatalities
directly
• Although those descriptions are valid, their added value is limited. To know
how we got to that generic loss or damage, try to describe events based in type
of accidents or serious incidents including scenario related details.
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PPT 4.14
First fundamental - Understanding Hazards and Consequences
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PPT 4.15
First fundamental - Understanding Hazards and Consequences
Hazards in ATM
• Loss of communication
• Loss of aircraft separation
• Improper flight handover
• Improper clearance
• Use of wrong call sign
• Adverse weather conditions
• Diversion of multiple aircraft
• Loss of transponder transmission
…
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PPT 4.16
First fundamental - Understanding Hazards and Consequences
Release of Hazards
Ultimate
Hazard Unsafe State
Consequence
Hazard: Condition or Unsafe State: A possible Ultimate Consequence:
object that could cause intermediate event Ultimate event or
or contribute to an before any ultimate accident. Worst credible
aircraft incident or consequence or accident consequence (SMI Hazard
(SMI Hazard Identification Identification Risk Mitigation
accident (Annex19)
Risk Mitigation worksheet) worksheet)
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PPT 4.17
First fundamental - Understanding Hazards and Consequences
Example of Hazard Release
Ultimate
Hazard Unsafe State
Consequence
Controlled
Loss of Control Consequence
Condition
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PPT 4.18
First fundamental - Understanding Hazards and Consequences
• There is a natural tendency to describe hazards as their
consequence(s).
➢ “Unclear aerodrome signage” vs. “runway incursion”
• Stating a hazard as consequence(s)
➢ disguises the nature of the hazard
➢ interferes with identifying other important consequences.
• Well-named hazards
➢ allow to infer the sources or mechanisms of the hazard
➢ allow to evaluate the loss outcome(s).
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PPT 4.19
First fundamental - Understanding Hazards and Consequences
Types of Hazards
ENVIRONMENTAL TECHNICAL ORGANIZATIONAL HUMAN
• Severe weather or Deficiencies regarding: • Economics • Medical
climatic events • Aircraft systems and (Growth/Recession) • Psychological
• Adverse weather related equipment • Operational Policies • Cognitive
conditions • an organization’s and Procedures
• Physical limitation
• Geophysical events facilities, tools, and • Materials/Equipment
• Geographical related equipment acquisition
conditions • facilities, systems, and • Organizational Culture
• Environmental events related equipment
• Public health events external to the
organization
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PPT 4.20
Second Fundamental - Hazard Identification
Hazard identification is a prerequisite
to the safety risk management
process.
For personnel
involved in the safety
risk management
process, a clear
understanding of
hazards and their
related consequences
is essential to the
implementation of
sound safety risk
management.
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PPT 4.21
Second Fundamental - Hazard Identification
THIS WILL BE HELPED BY HAVING A DETAILED SYSTEM
DESCRIPTION THAT DEFINES THE SYSTEM AND ITS
INTERFACES
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PPT 4.22
Second Fundamental - Hazard Identification
Hazards may be
introduced through
interfaces with external
organizations that may
or may not have their
own SMS.
LDR v1.0 March 2024
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PPT 4.23
Second Fundamental - Hazard Identification
The following should be considered during
the hazard identification process:
• Organization’s system description
• Design factors
• Human performance limitations
• Procedures and operating practices
➢ includes documentation and checklists and
their validation under actual operating
conditions
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PPT 4.24
Second Fundamental - Hazard Identification
The following should be considered during the
hazard identification process:
• Communication factors
➢ including media, terminology and language
• Organizational factors
➢ Such as those related to recruitment, training and
retention of personnel, the compatibility of
production and safety goals, the allocation of
resources, operating pressures and the corporate
safety culture
• Factors related to the operational environment of the
aviation system
➢ Such as ambient noise and vibration, temperature
and lighting
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PPT 4.25
Second Fundamental - Hazard Identification
The following should be considered during the
hazard identification process:
• Regulatory oversight factors
➢ Includes applicability and enforceability of
regulations and the certification of equipment,
personnel and procedures
• Performance monitoring systems
➢ Can detect practical drift, operational deviations
or a deterioration of product reliability
• Human-machine interface factors
• Factors related to the SMS/SSP interfaces
with other organizations.
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PPT 4.26
Second Fundamental - Hazard Identification
There are 2 main methodologies for identifying hazards:
• involves analysis of past outcomes or events.
• Hazards are identified through investigation of safety occurrences.
Reactive • Incidents and accidents are clear indicators of system deficiencies and
therefore can be used to determine the hazards that contributed to the
event.
• involves collecting data of lower consequence events or process
performance and analyzing the safety information or frequency of
Proactive occurrence to determine if a hazard could lead to an incident or accident.
• The safety information for proactive hazard identification primarily comes
from flight data analysis (FDA) programmes, safety reporting systems and
the safety assurance function, including internal audits
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PPT 4.27
Second Fundamental - Hazard Identification
Hazard Taxonomy
• Consists of the following components:
Generic Term Specific Term
HAZARD TAXONOMY PRECISE DEFINITION CONTEXT
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PPT 4.28
Second Fundamental - Hazard Identification
• Severe Weather or Climatic Events (Hurricanes, Typhoons, etc.)
Generic term: • Adverse Weather (Fog, Ice, Low Visibility, etc.)
Hazard Taxonomy ENVIRONMENTAL • Geographical Events (Volcanos, Earthquakes, etc.)
(CICTT) (ENV) • Geography (Terrain, Altitudes, etc.)
• Natural events (Wildlife, Fires, etc.)
The generic • Public Health (Epidemics, etc.)
component allows • Aircraft (systems, subsystems, components & associated eqpt.)
TECHNICAL
users to capture • Organizational (tools, hangars, workshops, etc.)
• External (facilities and systems external to the operation)
the nature of a (TECH)
• Physical (human characteristics associated to physical activities of operations)
hazard with a view • Economics (Growth/Recession)
to aid in ORGANIZATIONAL • Operational (Policies and Procedures)
identification, (ORG) • Materials/Equipment acquisition
• Organizational Culture
analysis and • Medical
coding • Psychological
HUMAN (HUM) • Cognitive
• Physical Limitation
See Reference: CICTT Hazard Taxonomy
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PPT 4.29
Second Fundamental - Hazard Identification
Specific component
• Adds precision to the hazard definition and context
• enables more detailed risk management processing
• The following criteria may be helpful when formulating hazard
definitions:
• Clearly identifiable
• Identified in a commonly accepted terminology
• Described in the desired (controlled) state
• Described with no judgmental adjectives (e.g., poor, deficient) nor negative
meanings or descriptions of absence (e.g., lack)
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PPT 4.30
Second Fundamental - Hazard Identification
Phase of Operation Procedure Item
Specific component: Context
• Hazard to be linked to a
context to enable further
processes and better
understanding
System/Component Facility
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PPT 4.31
Second Fundamental - Hazard Identification
Hazard Taxonomy
• Consequence Coding
Recommendation: to classify operational consequences in terms of the ADREP Aviation
Occurrence Categories
Definition
Usage notes
See Reference: CICTT Occurrence Category
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PPT 4.32
Second Fundamental - Hazard Identification
Hazard Taxonomy
• Examples
Hazard
Ultimate
(Generic and Unsafe event
consequence
specific term)
ENV. Adverse Weather
Loss of Terrain Aircraft Collision into
Aircraft descending Separation terrain (CIFT)
under IMC
TECH. Aircraft Inability to stop Aircraft Overrun
Aircraft landing in within landing RWY Excursion
short RWY distance (RE)
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PPT 4.33
Second Fundamental - Hazard Identification
Hazard Log
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PPT 4.34
Data Resources
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PPT 4.35
Data Resources
Normal operation monitoring Automated monitoring
– This uses observational systems – This uses automated
Aviation accident reports –
techniques to monitor the day- recording systems to monitor State mandatory and
Reviewing accident reports can
to-day operations and activities parameters that can be voluntary reporting systems –
be a useful resource for hazard
(e.g. Line Orientated Safety analyzed such as Flight Data Some States provide
data. This may be related to
Audits) Monitoring. summaries of the safety reports
accidents in the same State or
they receive from service
to a similar aircraft type, region,
providers
Audits – These can be used to or operational environment.
Voluntary and mandatory
reporting systems – This identify hazards in the task or
provides everyone including staff process being audited. These
working in external organizations should also be coordinated with
with the opportunity to report organizational changes to
hazards and other safety issues identify hazards related to the
to the organization implementation of the change State oversight audits and
third-party audits – External Trade association and
audits can sometimes identify information exchange
hazards. These may be systems – Many trade
Feedback from training – Safety investigations –
documented clearly as an associations and industry
Where training is interactive Hazards identified in internal
unidentified hazard or captured groups are able to share safety
(two way) this can facilitate the safety investigation and follow-
less obviously within an audit data that may include hazards
identification of new hazards up reports on
finding
from the training participants accidents/incidents
SMS v1.0 May 2024
PPT 4.36
Data Resources
Normal operation monitoring Automated monitoring
– This uses observational systems – This uses automated
Aviation accident reports –
techniques to monitor the day- recording systems to monitor State mandatory and
Reviewing accident reports can
to-day operations and activities parameters that can be voluntary reporting systems –
be a useful resource for hazard
(e.g. Line Orientated Safety analyzed such as Flight Data Some States provide
data. This may be related to
Audits) Monitoring. summaries of the safety reports
accidents in the same State or
they receive from service
to a similar aircraft type, region,
providers
Audits – These can be used to or operational environment.
Voluntary and mandatory
reporting systems – This identify hazards in the task or
provides everyone including staff process being audited. These
working in external organizations should also be coordinated with
with the opportunity to report organizational changes to
hazards and other safety issues identify hazards related to the
to the organization implementation of the change State oversight audits and
third-party audits – External Trade association and
audits can sometimes identify information exchange
hazards. These may be systems – Many trade
Feedback from training – Safety investigations –
documented clearly as an associations and industry
Where training is interactive Hazards identified in internal
unidentified hazard or captured groups are able to share safety
(two way) this can facilitate the safety investigation and follow-
less obviously within an audit data that may include hazards
identification of new hazards up reports on
finding
from the training participants accidents/incidents
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PPT 4.36
Hazard Prioritization Procedure
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PPT 4.37
Hazard Prioritization Procedure
Prioritization of a hazard, for follow-
up risk mitigation purposes, should
be based on the risk level of its
projected consequence.
A simple approach is to use the
occurrence category:
• Accident
• Serious incident
• Incident
to define the projected
consequence’s risk level
SMS v1.0 May 2024
PPT 4.38
Third Fundamental - Hazard Analysis
The ABC of hazard analysis
B – Identify specific C – Naturally leading
A – State the generic
components of the to a specific
hazard
hazard consequence (s)
Adds precision to the hazard
definition and context
Allows users to Recommendation:
Helpful criteria:
capture the nature to classify
• Clearly identifiable
of a hazard with a • Identified in a commonly accepted consequences in
view to aid in terminology
• Described in the desired (controlled)
terms of the ADREP
identification, state Aviation Occurrence
analysis and coding • No judgmental adjectives (e.g. poor,
deficient)
Categories
• Nor negative meanings or description
(e.g. lack)
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PPT 4.39
Third Fundamental - Hazard Analysis
• Efficient and safe operations or provision of service require a
constant balance between production goals and safety
goals…
➢maintaining regular aerodrome operations during a runway
construction project (production)
➢maintaining existing margins of safety in aerodrome operations
during runway construction project (protection)
• Aviation workplaces may contain hazards which may not be
cost-effective to address even when operations must continue.
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PPT 4.40
Fourth Fundamental – Documentation of Hazards
• Appropriate documentation management is
important:
• a formal procedure to translate operational safety data into
hazard-related information.
• Documentation becomes the “safety library” of an
organization.
• Tracking and analysis of hazards is facilitated by
standardizing:
• Definitions
• Understanding
• Validation
• Reporting
• Measurement
• Management
SMS v1.0 May 2024
PPT 4.41
Knowledge Check
Q: Define the concept of hazard
Hazard – a condition or an object with the potential to cause death,
injuries to personnel, damage to equipment or structures, loss of
material, or reduction of the ability to perform a prescribed function.
?
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PPT 4.42
Knowledge Check
Q: Provide three examples of areas/factors to consider when
identifying hazards.
A:
• Organization’s system description
• Design factors
• Human performance limitations
• Procedures and operating practices
• Communication factors
• Organizational factors
• Factors related to the operational environment of the aviation system
• Regulatory oversight factors
?
• Performance monitoring systems
• Human-machine interface factors
• Factors related to the SMS/SSP interfaces with other organizations.
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PPT 4.43
Practical Exercise
Group activity
•A facilitator, who will coordinate the discussion, will be
appointed
•A summary of the discussion will be written on MSWord file
and a member of the group will brief on their findings in a
plenary session
Scenario
•Continental Express Flight 2574 Crash (H4.1)
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PPT 4.44
Practical Exercise
Continental Express Flight
2574 Crash (H4.1)
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PPT 4.45
Practical Exercise
Identify hazards
Your task
• Identify the hazards using brainstorming techniques
• brainstorm a list of possible hazards, their components and their
related consequences.
• Complete the H4.1 Hazard Identification Template as follows
• list type of operation or activity
• state the generic hazard (hazard statement)
• identify specific components of the hazard
• list the unsafe event/s
• list hazard-related consequences
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PPT 4.46
Practical Exercise
Hazard Identification Table (Table 04/01)
Operation/ Hazard Hazard Taxonomy Ultimate Consequence
System No. Unsafe Event
Generic Specific Component ADREP Consequences
Component
Choose an
Choose an item
item
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PPT 4.47
Hazard Identification Summary
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PPT 4.48
Hazard Identification Summary
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PPT 4.48
Your Questions
?
SMS v1.0 May 2024
PPT 4.49
Summary
The following topics Recall SMS Framework: Safety Risk
were covered in this Management
module:
Understanding Hazards and
Consequences
Hazard Identification
Hazard Analysis
Documentation of Hazards
THANK YOU