Safety Management Systems (SMS) Course

Module N° 5 – Safety Risks

Revision N° 11 ICAO Safety Management Systems (SMS) Course 01/01/08

 Objective

 At the end of this module, participants will be able to apply

the fundamentals of safety risk management through a

case study.

Module N° 5 ICAO Safety Management Systems (SMS) Course 2

 Outline

 Definition of risk
 First fundamental – Safety Risk management
 Second fundamental – Safety Risk probability
 Third fundamental – Safety Risk severity
 Fourth fundamental – Safety Risk assessment and tolerability
 Fifth fundamental – Safety Risk control/mitigation
 Safety Risk management warm-up exercises
 Questions and answers
 Points to remember
 Exercise 05/01 – Accident of a Boeing B-747 at an International
Airport (See Handout N° 4)

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 Definition of Safety Risk
 Safety Risk –
- The assessment, expressed in terms of predicted probability and
severity, of the consequence(s) of a hazard taking as reference the
worst foreseeable situation.

o A wind of 15 knots blowing directly across the runway is a hazard.

o The potential that a pilot may not be able to control the aircraft
during takeoff or landing is one of the consequences of the hazard

 The assessment of the consequences of the potential loss of

control of the aircraft by the pilot expressed in terms of probability
and severity is the safety risk.

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 Safety Risk management
 What is safety risk management?
The identification, analysis and elimination, and/or
mitigation to an acceptable level of risks that threaten
the capabilities of an organization.
 What is the objective?
Aims at a balanced allocation of resources to address all
risks and viable risk control and mitigation.
 Why is it important?
A key component of safety management systems.
Data-driven approach to safety resources allocation,
thus defensible and easier to explain.
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 SRM - Safety Risk Probability

 Definition(s)

Probability – The likelihood that an unsafe event or

condition might occur.

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 SRM – Safety Risk Probability
 What to ask in assessing the probability of an occurrence:
 Is there a history of occurrences like the one being assessed, or is the
occurrence an isolated event?

 What other equipment, or similar type components, might have similar

defects?

 What number of operating or maintenance personnel must follow the

procedure (s) in question?

 How frequently is the equipment or procedure under assessment

used?
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 SRM - Safety Risk Probability

 Any factors underlying these questions will help in

assessing the likelihood that a hazard may exist,
taking into consideration all potentially valid
scenarios.

 The determination of likelihood can then be used

to assist in determining safety risk probability.

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 SRM – Safety Risk probability

Probability of occurrence
Qualitative
Meaning Value
definition

Frequent Likely to occur many times (has occurred frequently) 5

Occasional Likely to occur some times (has occurred infrequently) 4

Remote Unlikely, but possible to occur (has occurred rarely) 3

Improbable Very unlikely to occur (not known to have occurred) 2

Extremely
Almost inconceivable that the event will occur 1
improbable

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 SRM – Safety Risk severity

 Definition(s)
Safety Risk Severity – is defined as the extent of harm
that might reasonably occur as a consequence or
outcome of the identified hazard.

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 SRM – Safety Risk severity

The severity assessment can be based upon:

a) Fatalities/injury. How many lives may be lost
(employees, passengers, bystanders and the general
public)
b) Damage. What is the likely extent of aircraft, property
or equipment damage?

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 SRM – Safety Risk severity

 Severity defined in terms of consequences for:

 Property
 Finance
 Liability
 People
 Environment
 Image
 Public confidence

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 SRM – Safety Risk Severity
 What to ask for in assessing the severity of an occurrence:
How many lives may be lost?
 Employees
 Passengers
 Bystanders
 General public
What is the environmental impact?
 Spill of fuel or other hazardous product
 Physical disruption of natural habitat

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 SRM – Safety Risk severity
…
What is the severity of the property or financial damage?
 Direct operator property loss
 Damage to aviation infrastructure
 Third party damage
 Financial impact and economic impact for the State
Are there organizational, management or regulatory
implications that might generate larger threats to public
safety?
What are the likely political implications and/or media
interest?

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 SRM – Safety Risk severity
Severity of occurrences
Aviation definition Meaning Value
Multiple deaths.
Catastrophic Equipment destroyed. A
A large reduction in safety margins, physical distress or a
workload such that the operators cannot be relied upon to
Hazardous perform their tasks accurately or completely. B
Serious injury.
Major equipment damage.
A significant reduction in safety margins, a reduction in the
ability of the operators to cope with adverse operating
conditions as a result of increase in workload, or as a result C
Major of conditions impairing their efficiency.
Serious incident.
Injury to persons.
Nuisance.
Minor Operating limitations.
Use of emergency procedures. D
Minor incident.
Negligible Little consequences E
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 SRM – Safety Risk Assessment

Risk severity
Risk
Catastrophic Hazardous Major Minor Negligible
probability
A B C D E
Frequent 5 5A 5B 5C 5D 5E
Occasional 4 4A 4B 4C 4D 4E
Remote 3 3A 3B 3C 3D 3E
Improbable 2 2A 2B 2C 2D 2E
Extremely
improbable 1 1A 1B 1C 1D 1E
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 SRM– Safety Risk tolerability

Assessment risk index

Risk management Suggested criteria

Intolerable region
5A, 5B, 5C, Unacceptable under the
4A, 4B, 3A existing circumstances

5D, 5E, 4C, 4D, Acceptable based on risk

Tolerable region 4E, 3B, 3C, 3D, mitigation. It might require
management decision
2A, 2B, 2C
Acceptable
region 3E, 2D, 2E, 1A,
Acceptable
1B ,1C, 1D, 1E

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 Alternate Risk Tolerability Matrix
RISK INDEX RANGE DESCRIPTION RECOMMENDED ACTION

5A, 5B, 5C, HIGH Risk Cease or cut back operation promptly
if necessary. Perform priority risk
4A, 4B, 3A mitigation to ensure that additional or
enhanced preventive controls are put
in place to bring down the risk index to
the MODERATE or LOW range.

5D, 5E, 4C, 4D, MODERATE Risk Schedule for performance of safety
assessment to bring down the risk
4E, 3B, 3C, 3D, index to the LOW range if viable.
2A, 2B, 2C, 1A

3E, 2D, 2E, 1B, LOW Risk Acceptable as is. No further risk
mitigation required.
1C, 1D, 1E
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 Human Factors and Safety Risk Management

 Given that mature SSPs and SMSs target both human

and organizational factors, a specific analysis process
is a component of any mature, effective risk
management system.

 In the course of any hazard identification and risk

mitigation exercise involving human elements, it is
necessary to assure that existing or recommended
defences have taken human factors (HF) into
consideration.

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 Human Factors and SRM

 Where necessary, a supplementary HF analysis

may be conducted to support that particular risk
mitigation exercise/team.

 An HF analysis provides an understanding of the

impact of human error on the situation and
ultimately contributes to the development of more
comprehensive and effective mitigation/corrective
actions.

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 SRM - Cost-benefit analysis
 Direct costs
The obvious costs, which are easily determined. The
high costs of exposure of hazards can be reduced by
insurance coverage.
 Purchasing insurance only transfers monetary risk,
does not address the safety hazard
 Indirect costs
The uninsured costs. An understanding of uninsured
costs (or indirect costs) is fundamental to understand
the economics of safety.

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 SRM - Cost-benefit analysis
 Indirect costs may amount to
more than the direct costs
resulting from exposure to
hazards:
Loss of business
Damage to the reputation
Loss of use of equipment
Loss of staff productivity
Legal actions and claims
Fines and citations
Insurance deductibles
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 Safety Risk Mitigation Worksheet (Illustration)

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 RISK MITIGATION TABLE

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 RISK MITIGATION TABLE

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Module N° 1 ICAO Safety Management Systems (SMS) Course 26
 BASIC SEVERITY TABLE

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 ALTERNATE SEVERITY TABLE

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 LIKELIHOOD TABLE

Risk index matrix (severity × likelihood)

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 Risk acceptability (tolerability) table

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 SRM – Safety Risk control/mitigation

 Definition
Mitigation – Measures to address the potential hazard or
to reduce the risk probability or severity.

 Risk mitigation = Risk control

(Mitigate – To make milder, less severe or less harsh)

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 SRM –Safety Risk control/mitigation

 Strategies:

(1) Avoidance

(2) Reduction

(3) Segregation of exposure

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 SRM –Safety Risk control/mitigation

 Avoidance –
- The operation or activity is cancelled because risks
exceed the benefits of continuing the operation or
activity.

 Operations into an aerodrome surrounded by

complex geography and without the necessary
aids:
- CANCEL OPERATIONS

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 SRM – Risk control/mitigation

Reduction –
The frequency of the operation or activity is reduced, or
action is taken to reduce the magnitude of the
consequences of the accepted risks.

Operations into an aerodrome surrounded by complex

geography and without the necessary aids:
- LIMIT OPERATIONS to day-time, visual conditions

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 SRM– Safety Risk control/mitigation

 Segregation of exposure –
- Action is taken to isolate the effects of the
consequences of the hazard or build-in redundancy to
protect against it.

Operations into an aerodrome surrounded by complex

geography are limited to aircraft with specific /
performance navigation capabilities:
- DO NOT ALLOW Non-RVSM equipped aircraft to
allowed to operate into RVSM airspace

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 Safety risk management: at a glance

Equipment, procedures, organization, etc. Hazard

Identification

Analyse the likelihood of the consequence Risk analysis

occurring Probability

Evaluate the seriousness of the consequence if Risk analysis

it does occur Severity

Is the assessed risk(s) acceptable and within the Risk assessment

organization’s safety performance criteria and tolerability

No, take action to Risk control

Yes, accept the risk(s) reduce the risk(s) to an
acceptable level /mitigation
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 Risk mitigation – Defences

 Recalling the three basic defences in aviation:

Technology
Training
Regulations

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 Risk mitigation – Defences

 As part of the risk mitigation, determine:

Do defences to protect against such risk (s) exist?
Do defences function as intended?
Are the defences practical for use under actual working
conditions?
Is staff involved aware of the risks and the defences in
place?
Are additional risk mitigation measures required?

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 Risk mitigation at a glance
Hazard/consequence Assessment of the
Control and mitigation Accepting the
identification defences within the
of the risk(s) mitigation of the risk(s)
and risk assessment safety system

H H H H Intolerable region
 Does it address the
risk(s)?
 Is it effective?
Each
consequence  Is it appropriate?
 Is additional or
Tolerable region different mitigation
warranted?
R R R R  Do the mitigation
Acceptable
region
strategies generates
additional risk(s)
Each Risk

Feedback (Safety assurance)

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 Reminders…
 There is no such thing as absolute safety.
– In aviation it is not possible to eliminate all risks.
 Risks can be managed to a level “as low as reasonably practicable”
(acceptable level of safety performance)
 Risk mitigation must be balanced against:
 time
 cost
 difficulty of taking measures to reduce or eliminate the risk (i.e.
managed).
 Effective risk management seeks to maximize the benefits of
accepting a risk (a reduction in time and cost) while minimizing the
risk itself.
 Communicate the rationale for risk decisions to gain acceptance by
stakeholders affected by them.
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 Risk management process: at a glance
Feedback and
record the hazard A safety concern is perceived
identification and
assessment and Identify hazards/consequences and
risk mitigation assess risks
Define the level of Define the level of
probability severity
Define the level of risk

Take action
and continue YES Is the risk level acceptable? NO
the operation

Take action
and continue YES Can the risk be eliminated? NO
the operation

YES Can the risk be mitigated?

Take action Cancel the

Can the residual risk be accepted?
and continue YES (if any) NO operation
the operation
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 Risks

Risk management warm-up exercises

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 Warm-up exercise N° 05/01

 Scenario:
Fuel spill on the apron area surface of approximately 25
m (75 ft) length and 5 m (15 ft) width, produced by an
A320 ready to pushback and taxi for departure.

 Report by the apron responsible person:

After the A320 pushback the spill was contained and the
apron area was decontaminated.

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 Warm-up exercise N°05/01 – results

Hazard
Risk probability

Risk severity

Risk(s) Risk index

Risk tolerability

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 Warm-up exercise N°05/02
 Scenario:
It was observed that airline baggage handling personnel
generates FO(D) on the aerodrome apron area .

 Report by the apron responsible person:

It should be noted that airline baggage handling
personnel are not complying with safety standards as
set in the aerodrome operating manual. This is
considered a hazard that can produce incident or
accident in the movement area.

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 Warm-up exercise N°05/02– results

Hazard
Risk probability

Risk severity

Risk(s) Risk index

Risk tolerability

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 Warm-up exercise N° 05/03
 Scenario:
A parked aircraft shows damage in the left wing root
near the fuselage. Such damage was caused by a
maintenance staircase hitting the aircraft as a
consequence of the wind, apparently because the
staircase was not properly restrained.
 Report by the apron responsible person:
In conditions of strong winds it is essential that all
equipment around aircraft are properly restrained and
locked, thus preventing the possibility of aircraft
damage.
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 Warm-up exercise N° 05/03 – results

Hazard
Risk probability

Risk severity

Risk(s) Risk index

Risk tolerability

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 Warm-up exercise N° 05/04
 Scenario:
The vehicle and ramp equipment parking area shows a
large amount of FO(D) (food, trays, plastics, pillows,
etc.) left behind by an airline.
 Report by the apron responsible person:
The presence of decomposed food and others
dangerous material was informed to the airline, since in
addition to FO(D), this presents a bacteriological danger
for people who operate in this sector, also attracting
animals to the operative apron.

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 Warm-up exercise N° 05/04 – results

Hazard
Risk probability

Risk severity

Risk(s) Risk index

Risk tolerability

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 Warm-up exercise N° 05/05
 Scenario:
A loose wheel, apparently from a baggage cart, was
observed in the handling area. The driver apparently did
not notice what happened. The wheel rolled at high
speed through the area, hitting the fence accessing the
fuel zone.
 Report by the apron responsible person:
This could have caused injuries to ramp personnel in
addition to material damage to equipment and/or
aerodrome facilities. We have insisted in the past on the
periodic verification of all equipment and vehicles that
operate in the aerodrome apron area.
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 Warm-up exercise N° 05/05 – results

Hazard
Risk probability

Risk severity

Risk(s) Risk index

Risk tolerability

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 Warm-up exercise N° 05/06
 Scenario:
The absence of airline personnel attending the stairs
was observed in three occasions, in flights from different
companies. The presence of airline personnel is
necessary to guide passengers when embarking and
disembarking.
 Report by the apron responsible person:
This is a risk for passengers, since they should access
the apron to board aircraft in an orderly manner under
the guidance of airline personnel.

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 Warm-up exercise N° 05/06 – results

Hazard
Risk probability

Risk severity

Risk(s) Risk index

Risk tolerability

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 Risks

Questions and answers

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 Questions and answers

 Q: Define risk management.

 A: ?

Slide number:
Module N° 5 ICAO Safety Management Systems (SMS) Course 56
 First fundamental – Safety Risk management
 What is safety risk management?
The identification, analysis and elimination, and/or
mitigation to an acceptable level of risks that threaten
the capabilities of an organization.
 What is the objective?
Aims at a balanced allocation of resources to address all
risks and viable risk control and mitigation.
 Why is it important?
A key component of safety management systems.
Data-driven approach to safety resources allocation,
thus defensible and easier to explain.
Module N° 5 ICAO Safety Management Systems (SMS) Course 57
 Questions and answers

 Q: What are the five designations for risk probability?

 A: ?

Slide number:
Module N° 5 ICAO Safety Management Systems (SMS) Course 58
 Second Fundamental – Safety Risk probability

Probability of occurrence
Qualitative
Meaning Value
definition

Frequent Likely to occur many times (has occurred frequently) 5

Occasional Likely to occur some times (has occurred infrequently) 4

Remote Unlikely, but possible to occur (has occurred rarely) 3

Improbable Very unlikely to occur (not known to have occurred) 2

Extremely
Almost inconceivable that the event will occur 1
improbable

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 Questions and answers

 Q: What are the five designations for risk severity?

 A: ?

Slide number:
Module N° 5 ICAO Safety Management Systems (SMS) Course 60
 Third fundamental – Safety Risk severity
Severity of occurrences
Aviation definition Meaning Value
Multiple deaths.
Catastrophic Equipment destroyed. A
A large reduction in safety margins, physical distress or a
workload such that the operators cannot be relied upon to
Hazardous perform their tasks accurately or completely. B
Serious injury.
Major equipment damage.
A significant reduction in safety margins, a reduction in the
ability of the operators to cope with adverse operating
conditions as a result of increase in workload, or as a result C
Major of conditions impairing their efficiency.
Serious incident.
Injury to persons.
Nuisance.
Minor Operating limitations.
Use of emergency procedures. D
Minor incident.
Negligible Little consequences E

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 Questions and answers
 Q: Describe the three basic risk mitigation strategies.
 A: ?

Slides number:
Module N° 5 ICAO Safety Management Systems (SMS) Course 62
 Fifth fundamental –Safety Risk control/mitigation

 Strategies:

(1) Avoidance

(2) Reduction

(3) Segregation of exposure

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 Hazards and risks:
Closing the loop

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 Hazards and risks: Closing the loop

 Hazard – Condition, object or activity with the potential of causing injuries to

personnel, damage to equipment or structures, loss of material, or reduction
of ability to perform a prescribed function.
 Consequence – Potential outcome(s) of the hazard.
 Risk – The assessment, expressed in terms of predicted probability and
severity, of the consequence(s) of a hazard taking as reference the worst
foreseeable situation.
 A wind of 15 knots blowing directly across the runway is a hazard.
 The potential that a pilot may not be able to control the aircraft during
takeoff or landing is one of the consequences of the hazard.
 The assessment of the consequences of the potential loss of control of
the aircraft by the pilot expressed in terms of probability and severity is the
risk.
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 Points to remember

1. The risk assessment matrix

2. The risk assessment criteria table
3. Risk mitigation: avoid, reduce, segregate

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 Table 05/01 – Hazard identification and risk
management
Type of Specific Hazard-related Existing defences Further action to
operation Generic components of to control risk(s) reduce risk(s) and
Nº hazard consequences
or activity the hazard and risk index resulting risk index

1 Risk index: Risk index:

Risk tolerability: Risk tolerability:

2 Risk index: Risk index:

Risk tolerability: Risk tolerability:

3 Risk index: Risk index:

Risk tolerability: Risk tolerability:

4 Risk index: Risk index:

Risk tolerability: Risk tolerability:

5 Risk index: Risk index:

Risk tolerability: Risk tolerability:

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 Safety Management Systems (SMS) Course

Module N° 5 – Risks

Revision N° 11 ICAO Safety Management Systems (SMS) Course 01/01/08