Académique Documents
Professionnel Documents
Culture Documents
SMS
A Review
Patrick Hudson
ICAO/Leiden University
Security
Policy
Safety Continuous
Road
Safety Alcohol Policy Policy Improvement
Plan & Drugs
Policy Mgt.
Audit
Plans policy
Safety Process
Drills Safety (HSE Cases)
Task
No Structure Structure
April 2006 ICAO Seminar Baku
A Pacific
Southwest Airlines
Boeing 727 as it
goes down over
San Diego,
California after a
mid-air collision
with a Cessna in
1978. One-
hundred-thirty-
seven people along
with 7 on the
ground were killed.
•Modification Control
•Use suitably trained,
educated and
responsible people
•Know what you don’t
April 2006 ICAO Seminar Baku
know
Seveso
July 1976
• Understanding safe
state to leave reactions
• Multiple layers of
protection
• Automated Reaction
stop systems for
exothermic systems
Longford
Gooding
Compression (GTC) Sale
Port c
Phillip
Bay Longford
25 September 1998 Gas & Oil Processing Snapper
Barracouta Marlin
Barry Beach
Marine Terminal
• Training needs to
impart and refresh
knowledge.
• Must identify other
hazards and provide
relevant training.
•Corporate
knowledge must be
captured and kept
alive
April 2006 ICAO Seminar Baku
Piper Alpha
• 1988 the Piper Alpha platform was destroyed
• The platform had just been audited by the
regulator
• Lord Cullen’s report set up a new regime
– Goal Setting
– ISO 9000 type management systems
– Safety Case to provide assurance - a documented proof
that the SMS is both in operation and effective
Undesirable
outcome
Implementation Monitoring
C
O
H N
S
A E
Z Q
U
A E
R N
C
D Undesirable event with E
potential for harm or damage S
Engineering activities
Maintenance activities
April 2006 ICAO Seminar
Operations Baku
activities
Bow-tie Concept
for a specific threat
Events and Harm to people and
Circumstances damage to assets
or environment
BARRIERS
C
O
H N
S
A E
Z Q
U
A E
R N
C
D Undesirable event with E
potential for harm or damage S
Engineering activities
Maintenance activities
April 2006 ICAO Seminar
Operations Baku
activities
RISK ASSESSMENT MATRIX
Potential Consequence of the Incident Increasing Probability
A B C D E
Rating People Env'ment Assets Reputation Unknown but Known Happened Happened Happened
possible in in aviation in this > 3 x in the > 3 x in this
the aviation industry company Company location
industry
0 No
injury
Zero
Effect
Zero
damage No Impact
Minor Minor
Minor Local
2 injury Effect
damage <
US$ 50K
Impact
Local
Serious Industry
3 injury
Localised
Effect
damage <
Impact
US$ 250K
Major
Single Major National
4 fatality Effect
damage <
US$ 1M
Impact
EP 95000
Series
Technical advice
Reputation
Assets
Group
effect/injury
Design
1 Slight health Slight Slight effect Slight impact
effect/injury damage
2 Minor health Minor Minor effect Limited Manage for continuous
effect/injury damage impact improvement
3 Major health Localised Localised Consider- Incorporate risk
effect/injury damage effect able impact
reduction
Guidance
4 PTD or 1 to 3 Major Major effect National measures &
fatalities damage impact
standards
demonstrate Intolerable
5 Multiple Extensive Massive International ALARP
fatalities damage effect impact
Observation
techniques
Violation
Site Visits Survey
Trends/
HSE Standards benchmarking
& Procedures
Incident Investigation
(Tripod Beta)
Competency
Programmes
Audits Incident Reporting
Reviews