Glossary of Terms

Glossary of Terms
The following terms are used within this course of SMS Training
Accident an unplanned event or series of events that results in death, injury, occupational illness, damage to or loss of equipment or property, or damage to the environment. Accident / Incident (Ground) An occurrence associated with the operation of an aircraft involved in an emergency situation in which the aircraft or an person has been exposed to undue risk resulting in an emergency evacuation of passengers/crew by emergency slides, injuries to persons involved, and/or damage to the aircraft. An aircraft accident in which there are no serious injuries or deaths may also be classified as an aircraft-ground incident if there is major damage to the aircraft. Accident Prevention The detection and elimination or avoidance of hazards to prevent accidents, thus improving public confidence in air safety; saving lives, property and money; and reducing suffering. Active Failure see Unsafe Acts Aircraft Accident An occurrence associated with the operation of an aircraft which takes place between the time any person boards the aircraft with the intention of flight until such time as all such persons have disembarked, in which: a) a person is fatally or seriously injured as a result of: being in the aircraft, or having direct contact with any part of the aircraft, including parts which have become detached from the aircraft, or direct exposure to jet blast b) the aircraft sustains damage of structural damage, which adversely affects the structural strength, performance or flight characteristics of the aircraft, and would normally require major repair or replacement of the affected component c) the aircraft is missing or is completely inaccessible
Aircraft Incident means an occurrence other than an accident, associated with the operation of an aircraft, which affects or could affect the safety of operations. Analysis the process of identifying a question or issue to be addressed, modeling the issue, investigating model results, interpreting the results, and possibly making a recommendation. Analysis may involve using scientific or mathematical methods for evaluation. As Low As Reasonably Practicable (ALARP) means a risk is low enough that any further risk reduction is either not practical, or grossly outweighed by the cost. Assessment process of measuring or judging the value or level of something. Risk Assessment a quantifiable measurement of risk based on variables of exposure, severity and likelihood. System Assessment a safety assurance process in which the performance of safety-related functions of operational processes area assessed against the objectives and expectations of those processes, and in which the performance of the SMS is assessed against its objectives and expectations. External Assessment refers to an external audit by an oversight organization (e.g., CAA).
2010 - 2012 Omni Air Group, Inc.
Revision: 01 Date: 25 July 2012
Glossary of Terms Page 1
Glossary of Terms
Attributes (System Safety) System Safety Attributes, or System Attributes, are design criteria for written guidance, intended to ensure process outcomes. They form the basis for many SMS expectations: Responsibility who is accountable for management and overall quality of a process (planning, organizing, directing, controlling) and its ultimate accomplishment. Authority who can direct, control, or change the process, as well as who can make key decisions such as risk acceptance. This attribute also includes fiscal authority and the concept of empowerment. Procedures documented activities to accomplish various processes. ISO-9000-2000 defines procedure as a specified way to carry out an activity or a process. Procedures translate the what in goals and objectives into how in practical activities (things people do). Controls checks and restraints designed into a process to ensure a desired result. Safety assurance activities of continuous monitoring, internal audits, internal evaluations, and management reviews, are examples of SMS controls. Other practices such as documentation, process reviews, and data tracking are also considered controls with respect to specific elements and processes. Process Measures quantitative or qualitative measurements of process outputs, for the purpose of measuring the effectiveness of such processes. With regard to SMS, internal evaluations (which measure SMS process outputs) and management reviews are good examples of process measures. Interfaces input-output relationships between the activities of various processes, which include procedures, documentation, and flows of authority / responsibility / communication. These interfaces may involve lines of authority between departments, interactions between employees, different departments and contractors, and consistency of procedures within written guidance. With regard to SMS activities, interfaces are the Inputs and Outputs of a process.
Audit Systematic and independent examination to determine whether safety and quality activities and related results meet requirements based on documentation, procedures, and work instructions and whether procedures are implemented effectively and are suitable to achieve desired objectives. Internal audit an audit conducted internally, by the organization being audited. Internal audits are also referred to as departmental audits, wherein departments (e.g., flight operations, maintenance) audit themselves internally for regulatory compliance and other criteria. External audit an audit conducted by an entity outside of the organization being audited. External audits by oversight organizations such as CAA are referred to as an assessment. Vendor audit an audit performed to assure the quality of products and services received from a vendor or contractor. Follow-up a brief and informal audit performed to determine conformance with design and the effectiveness of a risk control or corrective action that has been implemented.
Aviation system the functional operation/production system used by an organization to produce a product or service. A system includes equipment, technology, personnel, managers and the working environment. Causes - causes may be natural or man-made, active or passive, initiating or permitting, obvious or hidden. Those causes that lead immediately to an effect or outcome are often called direct causes. Direct causes often result from another set of causes, which could be called intermediate causes, and these may be the result of still other causes. When a chain of cause and effect is followed from a known effect or outcome, back to an origin or starting point, Root Causes are found. The process used to find root causes is called Root Cause Analysis. Change Analysis: The methodical comparison of a current operation (or segment) with a previous known operation, wherein differences are noted, and to which hazard identification tools are then applied.
Glossary of Terms
Communications (Lateral / Upward) Information conveyed between same-level employees or between departments, opposite the normal direction of communications from management to staff. Lateral Communications regarding hazards, problems, and poor-quality process outputs which employees share with each other, and supervisors and managers share between departments. Upward Communications regarding hazards, problems, and poor-quality process outputs, shared from front-line employees to supervisors, or from supervisors to managers.
Complete nothing has been omitted and the attributes stated are essential and appropriate to the level of detail. Conditions (front-line operators) see Preconditions for Unsafe Acts Conformity fulfillment of a requirement (ref. ISO 9000-2000). This includes but is not limited to compliance with regulations. It also includes company requirements, requirements of company-developed risk controls or company-specified policies and procedures. Consequence the potential outcome (or outcomes) of a hazard. Continual improvement implementation of carefully analyzed corrective actions, and process measurement of those actions to ensure satisfactory process outputs; communication of lessons learned and further application of corrective actions to further improve processes and their outputs. Continuous monitoring uninterrupted watchfulness over the system. Contributing Factors any number of latent conditions and/or active failures which are determined to be instrumental in the causal chain of events leading to an incident, accident, or other unwanted event. Controls are checks and restraints designed into a process to ensure a desired result. Correct accurately reflects the item with an absence of ambiguity or error in its attributes. Corrective Action Remedial action intended to correct or improve an existing risk control that is not performing as desired, or to correct/improve/overcome any defect or non-conformity in documentation, procedures, or implementation. Corrective Action Plan (CAP) one or more risk controls, developed in response to an identified hazard, and designed to reduce risk to an acceptable level. Criteria an accepted standard used in making a decision or judgment about something. Defences see System Defences Documentation information or meaningful data and its supporting medium (e.g., paper, electronic, etc.). In this context it is distinct from records because it includes the written description of policies, processes, procedures, objectives, requirements, authorities, responsibilities, or work instructions. Emergency A state of sudden, pressing necessity requiring immediate response.
Glossary of Terms
Emergency Evacuation The urgent and rapid disembarkation of occupants from the aircraft due to imminent danger to the aircraft and its occupants. Error Management Strategies Controls designed into processes and systems, intended to prevent errors from occurring, or minimize the consequences of errors when they occur. Error reduction strategies intervene at the source of the error by reducing or eliminating contributing factors. These strategies include Ergonomic designs, application of technology, and training. Error capturing strategies intervene once the error has already been made, capturing the error before it generates adverse consequences. Error tolerance strategies intervene to increase the ability of a system to accept errors without serious consequence.
Evaluation a functionally independent review of policies, procedures, and systems. The term is synonymous with assessment. If accomplished by the company itself (internal evaluation), the evaluation should be done by an element of the company other than the one performing the function being evaluated. With regard to this SMS Manual and supporting programs, internal evaluations are performed by the Director of Safety on operational departments, in order to measure the quality of SMS process outputs. The evaluation process builds on the concepts of auditing and inspection. An evaluation is an anticipatory process, and is designed to identify and correct potential findings before they occur. See: Audit. Event An accident, incident, mishap, irregularity, near-accident, near-miss, act, error, or other occurrence. Executive Management The highest level of THAI Management including the President, Senior Executive Vice Presidents, Executive Vice Presidents, and Managing Directors of Business Units. Expectations are what an SMS component, element, or process is expected to accomplish or produce. This includes performance objectives, system outcomes, and process outputs. Performance Objectives represent the objective outcomes of a particular element or process. Process Expectations are the outputs a particular process is expected to produce, such as completed forms, data, records, etc.
Exposure - The amount of time, number of cycles, number of people involved, and/or amount of equipment involved in a given event, expressed in time, proximity, volume, or repetition. Finding a conclusion reached after examination or investigation. As applied to audits and evaluations, evidence of non-compliance with policy, standards, regulations, and/or contractual requirements. Hazard Any object, condition, behavior, event, or circumstance that could lead to or contribute to an unplanned or undesired event (e.g., an injury, incident, or accident). HFACS Framework (Human Factors Analysis and Classification System) A framework of causal human factors that can lead to an accident. HFACS uses levels of: organizational influences, unsafe supervision, preconditions for unsafe acts and unsafe acts. Within each level of HFACS, causal categories identify the active and latent failures that can occur which lead up to an adverse event, such as an incident or accident. Human Factors Factors dependent on individual human judgment or response which could contribute to the possibility of the occurrence of an incident or accident.
Glossary of Terms
Incident a near-miss or minor-damage episode with minor consequences that could have resulted in greater loss; an unplanned event that could have resulted in an accident, or did result in minor damage, and indicates the existence of (though may not define) a hazard or hazardous condition(s). Incident, Aircraft means an occurrence other than an accident, associated with the operation of an aircraft, which affects or could affect the safety of operations. Injury, Fatal means any injury which results in death within 30 days of the accident. Interfaces are the relationships and interactions between the components of a system. These components include Software, Hardware, Liveware, and the Environment. Investigation a structured, detailed and systematic inquiry and examination into an event (such as an accident, incident or injury) that attempts to reveal causes and contributing factors, including organizational or systemic deficiencies, which are also known as latent conditions. Key Performance Indicator (KPI) Aspects of performance with major impact on customer satisfaction and business activities which are measured on a regular basis to track performance for continual improvement in safety and quality. Latent conditions Weaknesses or deficiencies in a system that can contribute to an incident or accident but that will not, by themselves, cause an incident or accident to occur. Lessons learned knowledge or understanding gained by experience, which may be positive, such as a successful test or mission, or negative, such as a mishap or failure. Lessons learned should be developed from information obtained from within, as well as outside of, the organization and/or industry. Likelihood the estimated probability or frequency, in quantitative or qualitative terms, of an occurrence related to the hazard. Line management management structure that operates the aviation system. Minor occurrence Minor aircraft damage or a minor injury that should be reported to management, but does not require reporting to regulatory authorities. Minor injury Minor cuts or bruises, minor first degree burns over less than 5% of the body, or minor fractures of fingers, toes or nose. Minor aircraft damage Includes engine failure or damage limited to an engine if only one engine fails or is damaged, bent cowling or fairing, dented skin, small puncture holes in the skin, ground damage to propeller blades, damage to the landing gear, wheels, tires, flaps, engine accessories, brakes, or wingtips.
Mishap An undesirable event that includes an aircraft accident / incident, personal injury, or damage to facilities, assets or other equipment. Missing aircraft An aircraft is considered to be missing when its position is unknown, and with the supply of fuel normally carried, can no longer be airborne. Monitoring Keeping regular watch over activities to track performance. Near-accident A narrow escape from an actual accident; as used in the context of this manual, an event or situation which could have become an incident or accident that was narrowly averted.
Glossary of Terms
Nonconformance any deviation from or failure to comply with established policy, procedures, documentation, or work instructions. Normalized Deviation occurs when personnel routinely violate company policy or procedures to accomplish a task, due to poor system design, improper procedures, inoperative equipment, lack of resources, or other changes in operating conditions. Over time, the violation becomes commonplace and normalized. Objective the desired state or performance target of a process. An objective is usually the final state of a process and contains the results and outputs used to obtain the objective (see also Safety objectives). Operational context the conditions within which people perform their jobs and interact with software (policies, procedures, manuals, computer programs), hardware (machines, equipment, tools), and the environment (weather, workplace conditions, available resources, operating pressures, corporate climate, safety culture, etc.) Operational life cycle period of time from implementation of a product/service until it is no longer in use. Operational processes are separate and distinct parts of an organizations aviation activities, such as flight operations; operational control (dispatch/flight following); maintenance and inspection; cabin safety; ground handling and servicing; cargo handling; training; and supervisory activities. Organizational Influences The policies, communications, actions, or omissions of upper-level management which directly or indirectly affect supervisory practices, conditions or actions of the organization, and result in system failure, human error or an unsafe (latent) condition. The three types of organizational influences are: Organizational Climate (OC): Prevailing atmosphere/vision within the organization including such things as policies, command structure, and culture. Operational Process (OP): Formal processes by which the vision / mission of the company is carried out, such as flight operations, maintenance, training, inflight service, cabin safety, catering, aircraft servicing, weight & balance, cargo handling, etc. Resource Management (RM): This category describes how human, monetary, and equipment resources necessary to carry out the vision are managed.
Outputs The product of an SMS process, which is capable of being recorded, monitored, measured, and analyzed. Outputs are the minimum expectation for the content of each process area and the input for the next process in succession. Each of the outputs of a process should have a method of measurement specified by the service provider. Measures need not be quantitative where this is not practical, however some method of providing objective evidence of the attainment of the expectation is expected. The individual outputs of a process are the content of the measures. Overdue aircraft - An aircraft is considered to be overdue when an ATC agency reports it as such, or when no information about the aircraft has been received by ATC or the company (1) for 30 minutes after its last notified estimated time of arrival (ETA); (2) for 5 minutes after the estimated time of landing, after having landing clearance; or within 10 minutes after takeoff. Oversight a function that ensures the effective promulgation and implementation of the safety-related standards, requirements, regulations, and associated procedures. Safety oversight also ensures that the acceptable level of safety risk is not exceeded in the air transportation system. Safety oversight is conducted by an outside regulatory agency, such as the local Civil Aviation Authority (CAA). Practical Drift The difference between how a system or process was designed to perform, and how it actually performs in practice; hence the name, practical drift. Without clearly defined and followed policies and procedures, a system or process may drift in practice to the point where it is operating outside of design and safety parameters, and an accident may occur.
Glossary of Terms
Practices (of frontline people) See Preconditions for Unsafe Acts Preconditions for Unsafe Acts are the substandard conditions and practices of front-line operators which can set up accident potential. They are divided into two major sub-divisions: Substandard Practices and Substandard Conditions. Substandard Conditions of Operators: (front-line people): Adverse Mental States (AMS): Acute psychological and/or mental conditions that negatively affect performance such as mental fatigue, pernicious attitudes, and misplaced motivation. Adverse Physiological States (APS): Acute medical and/or physiological conditions that preclude safe operations such as illness, intoxication, and the myriad of pharmacological and medical abnormalities known to affect performance. Physical/Mental Limitations (PML): Permanent physical/mental disabilities that may adversely impact performance such as poor vision, lack of physical strength, mental aptitude, general knowledge, and a variety of other chronic mental illnesses. Personnel Factors Communication, Coordination, & Planning (CC): Includes a variety of communication, coordination, and teamwork issues that impact performance. Fitness for Duty (PR): Off-duty activities required to perform optimally on the job such as adhering to crew rest requirements, alcohol restrictions, and other off-duty mandates. Substandard Practices of Operators (front-line people): Interpersonal (Crew) Resource Mismanagement Poor crew / team coordination and use of available resources, particularly during non-routine / abnormal operations or when unexpected operational difficulties are encountered. Personal Readiness - Readiness violations which refer to the disregard for rules, regulations, and instructions that govern an individuals readiness to perform, such as violating crew rest requirements and alcohol restrictions.
Preferred Order of Controls System Safety technology and practice has provided a preferred order of control actions that range from most to least effective. The order of controls is shown here, from most effective to least effective: Plan or design for minimum risk: Design the system to eliminate hazards. Without a hazard there is no exposure, likelihood or severity. Incorporate safety devices: Reduce risk through the use of design features or devices. These devices usually do not affect likelihood but reduce severity: Use of shoulder harnesses wont prevent an accident but reduces the severity of injuries. Provide warning devices: Warning devices may be used to detect an undesirable condition and alert personnel. This could be in the form of a warning light, warning in an operations manual, safety bulletin, advisory or signals of the hazard. Develop procedures and training: Where it is impractical to eliminate hazards through design selection or adequately reduce the associated risk with safety and warning devices, procedures should be developed and published, and training should be administered.
Preventive Action Any action or measure intended to prevent hazards from developing which could otherwise result in accidents. Proactive See Safety Risk Management, Proactive Probability The likelihood an event will occur.
Glossary of Terms
Procedure specified way to carry out an activity or a process. Process A series of steps, actions, or measures which take an input and modify it to produce an output Process Measures see Attributes (Process Measures). Process Outputs The expectations of a particular process in terms of measurable criteria. Product The final output, outcome, or commodity resulting from a particular process. Product / Service Provider any entity that offers or sells a product/service to satisfy a want or need in the air transportation system. Examples of product/service providers include: aircraft and aircraft parts manufacturers; aircraft operators; providers of fueling and de-icing services; maintainers of aircraft, avionics, and air traffic control equipment; educators in the air transportation system; etc. Quality Degree to which a set of inherent characteristics fulfils requirements. Quality Escape any process output that does not conform (or contains a non-conformity), to specified standards. Quality escapes are typically identified through continuous monitoring and/or audits, but may also be identified by front-line employees at any time during the course of an operational process. Quality Assurance A function which monitors and ensures the quality of work performed within a particular department in compliance with requirements. RMR Risk Management Record: a record created in the companys SMS database. Records evidence of results achieved or activities performed. In this context it is distinct from documentation because records are the documentation of SMS outputs. Redundancy the presence of more than one independent means for accomplishing a given function. Each means of accomplishing the function need not be identical. Risk The consequences of accepting a hazard, expressed in terms of probability and severity. Risk Assessment - The systematic process of evaluating various risk levels for specific hazards identified with a particular task or operation, in terms of exposure, severity and likelihood. Risk Control / Mitigation Steps taken to eliminate hazards or to mitigate their effects by reducing severity, likelihood or exposure of risk associated with those hazards. Risk Control / Mitigation Strategies - Strategies used to control the risks associated with hazards and their consequences. These strategies include: Risk Avoidance - means avoiding the hazard and the associated risk, thereby avoiding the consequences of an injury or loss, if an unwanted event were to occur. Risk Reduction application of risk controls designed to reduce either the likelihood or the probability of the consequence(s) of a hazard being realized, or the magnitude and impact of the consequences. This is the most commonly applied risk control and mitigation measure. Segregation of Exposure - controls risk by limiting the exposure of certain groups, assets, and operations to known hazards and their consequences.
Risk Level The composite of predicted exposure, severity and likelihood of the potential effect of a hazard in the worst credible system state. Measured as High (unacceptable), Moderate (may be acceptable if mitigated), and Low (acceptable).
Glossary of Terms
Risk, Residual the remaining safety risk that exists after all control techniques have been implemented or exhausted, and all controls have been verified. Only verified controls can be used for the assessment of residual safety risk. Root cause(s) (see causes) one or more basic initiating cause(s) which, either individually or combined, can lead to an undesirable outcome (such as a poor quality process output or an incident or accident). Root cause analysis (RCA) is an event investigation technique aimed at identifying the underlying factors that contributed to an undesired or harmful event, such as an incident or accident. The purpose of RCA is to identify what behaviors, actions, inactions, or conditions need to be changed to prevent recurrence of similar harmful outcomes. Safety Freedom from harm, danger, injury, damage, or threat resulting from either intention or un-intention. Safety Assurance processes within the SMS which include activities of continuous monitoring, internal audits, internal evaluations, external audits, data analysis, system assessment and management review, together which systematically provide confidence that organizational products/services meet or exceed safety requirements. Safety Attributes see Attributes Safety Culture the product of individual and group values, attitudes, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, the organization's management of safety. Organizations with a positive safety culture are characterized by communications founded on mutual trust, by shared perceptions of the importance of safety, and by confidence in the efficacy of preventive measures. Safety Management System (SMS) the formal, top-down business-like approach to managing safety risk. It includes systematic procedures, practices, and policies for the management of safety (as described in this document) as well as support services, safety assurance and safety promotion). Product/Service Provider Safety Management System (SMS-P) the SMS owned and operated by a product/service provider; in other words, this companys Safety Management System. Oversight Safety Management System (SMS-O) the SMS owned and operated by an oversight entity, such as the local CAA.
SMS Manual written guidance containing policies, procedures, roles, responsibilities, sub-programs and forms necessary for the formalized application of the Safety Management System. Safety Objectives something sought or aimed for, related to safety. Safety objectives are generally based on the organizations safety policy. Safety objectives are generally specified for relevant functions and levels in the organization.
Safety planning part of safety management focused on setting safety objectives and specifying necessary operational processes and related resources to fulfill quality objectives (i.e., assure the quality of operational process outputs). Safety risk the composite of predicted exposure, severity and likelihood of the potential effect of a hazard. Safety risk control anything that reduces or mitigates the safety risk of a hazard. Safety risk controls must be measurable and monitored to ensure effectiveness.
Glossary of Terms
Safety Risk Management (SRM) Time-critical / Deliberate - A continuous, systematic process of identifying and controlling risks in all activities by personal application of techniques, methods, and appropriate management policies and procedures. This process includes hazard awareness, detecting hazards, assessing and analyzing risks, and implementing and monitoring risk controls to support effective, risk-based decisionmaking. Safety Risk Management (SRM) A formal SMS process - Describing and analyzing a system or task, identifying hazards, and assessing, analyzing, and controlling risk. Resulting risk controls are then embedded in the operational processes used to provide the product/service. Reactive SRM The reactive method responds to events that have already happened, such as incidents and accidents Proactive SRM The proactive method looks actively for the identification of safety risks through analysis of the organizations activities Predictive SRM The predictive method captures system performance as it happens in real-time normal operations to identify potential future problems
Safety-Risk Profile also known as a Significant Safety Issue List, or SIL, the safety-risk profile lists the top ten or twelve potential hazards to which an organization is exposed. These areas of higher risk require increased vigilance and risk controls to ensure an accident, incident or injury does not occur. Safety Promotion a combination of safety culture, training, and data sharing activities that support the implementation and operation of an SMS in an organization. Serious Injury means any injury which; (1) requires hospitalization for more than 48 hours, commencing within 7 days from the date the injury was received; (2) results in a fracture of any bone (except simple fractures of fingers, toes, or nose); (3) causes severe hemorrhages, nerve, muscle, or tendon damage; (4) involves any internal organ; or (5) involves second or third degree bums, or any bums affecting more than 5 percent of the body surface. Service - Work performed to benefit another individual, company, or organization. Set-up Factors (see Latent conditions) Those factors that set the stage for an accident or other undesirable outcome to occur. Severity - the consequence or impact of a hazard or event, in terms of degree of damage, injury, loss or harm. Significant Event An event where one or more fatal or serious injuries occurs, an aircraft receives substantial damage, or facilities / property are substantially damaged. Substantial Damage means damage or failure which adversely affects the structural strength, performance or flight characteristics of the aircraft, and which would normally require major repair or replacement of the affected component. Engine failure or damage limited to an engine if only one engine fails or is damaged, bent fairings or cowling, dented skin, small punctured holes in the skin or fabric, ground damage to rotor or propeller blades, and damage to landing gear, wheels, tires, flaps, engine accessories, brakes, or wingtips are not considered substantial damage for the purpose of this part. Substitute Risk Risk unintentionally created as a consequence of safety risk control(s). Supplier A person, company, or organization who/which has agreed to provide products or services for the benefit of another
Glossary of Terms
System an integrated set of constituent elements that are combined in an operational or support environment to accomplish a defined objective. These elements include people, hardware, software, firmware, information, procedures, facilities, services, and other support facets. System Description and Task Analysis The process of creating a written description of a system, and then analyzing various tasks in order to identify hazards. The analysis need only be as extensive as needed to understand the processes in enough detail to develop procedures, design appropriate training curricula, identify hazards, and measure performance. System Defences System defences are resources which are designed and built into the system to protect against the safety risks that organizations involved in production activities generate and must control. Typically, defences in aviation can be grouped under three large headings: technology, training and regulations. System Safety Attributes see Attributes Senior management see Top management. Top management (ref. ISO 9000-2000 definition 3.2.7) the person or group of people who direct(s) and control(s) an organization. See Executive Management Triggering Event Events which must act upon a latent condition, or vulnerable situation, for a consequence or undesirable outcome to occur. For example, oil spilled on the floor is a latent condition, but an injury will not occur without a triggering event, such as foot traffic in the area. Unsafe Acts also known as active failures, these are the actions, inactions, or omissions of personnel which, when combined with latent conditions, can sometimes breach system defences and cause an accident. They are grouped into two categories: Errors: Decision Errors (DE): These thinking errors represent conscious, goal-intended behavior that proceeds as designed, yet the plan proves inadequate or inappropriate for the situation. These errors typically manifest as poorly executed procedures, improper choices, or simply the misinterpretation and/or misuse of relevant information. Skill-based Errors (SBE): Highly practiced behavior that occurs with little or no conscious thought. These doing errors frequently appear as breakdown in visual scan patterns, inadvertent activation/deactivation of switches, forgotten intentions, and omitted items in checklists often appear. Even the manner or technique with which one performs a task is included. Perceptual Errors (PE): These errors arise when sensory input is degraded as is often the case when flying at night, in poor weather, or in otherwise visually impoverished environments. Faced with acting on imperfect or incomplete information, aircrew run the risk of misjudging distances, altitude, and decent rates, as well as responding incorrectly to a variety of visual/vestibular illusions. Violations: Routine Violations (RV): Often referred to as bending the rules this type of violation tends to be habitual by nature and is often enabled by a system of supervision and management that tolerates such departures from the rules. Exceptional Violations (EV): Isolated departures from authority, neither typical of the individual nor condoned by management.
Glossary of Terms
Unsafe Supervision Inadequate Supervision (IS): Oversight and management of personnel and resources including training, professional guidance, and operational leadership among other aspects. Planned Inappropriate Operations (PIO): Management and assignment of work including aspects of risk management, crew pairing, operational tempo, etc. Failed to Correct Known Problems (FCP): Those instances when deficiencies among individuals, equipment, training, or other related safety areas are known to the supervisor, yet are allowed to continue uncorrected. Supervisory Violations (SV): The willful disregard for existing rules, regulations, instructions, or standard operating procedures by management during the course of their duties.
Workaround a shortcut or other violation of policy or procedures, in order to accomplish a task. Most workarounds typically stem from a genuine desire to do a good job; seldom are they acts of negligence. They are developed by operational personnel because the organization has failed to provide the necessary resources and / or realistic procedures to accomplish the task.

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2010 - 2012 Omni Air Group, Inc.

Revision: 01 Date: 25 July 2012