Safety Management Systems (SMS)

AVSC 403
The Theory of Risk and Risk
Management Process SMS

Prepared by Dr. Ali Abu Odeh

 WHAT IS RISK IN AVIATION?
• Definition of Risk: The combination of the likelihood of an event and its
consequences or severity (ICAO, Annex 19).
• Types of Risks in Aviation:
• Operational risks (e.g., pilot error, mechanical failure).
• Organizational risks (e.g., inadequate training, resource allocation).
• External risks (e.g., weather, bird strikes).
• Importance of Risk Management: Ensures the safety of passengers, crew, and
assets while maintaining operational efficiency.

Original Author: JTS Slide No. 2

 RISK MANAGEMENT PROCESS IN AVIATION SMS
• 4-Step Risk Management Process (ICAO, FAA):
• Hazard Identification: Recognizing potential sources of harm (e.g., runway
incursions, maintenance errors).
• Risk Assessment: Evaluating the likelihood and severity of identified hazards.
• Risk Mitigation: Implementing controls to reduce risk (e.g., training,
procedural changes, technology).
• Monitoring and Review: Continuously assessing the effectiveness of risk
controls.

Original Author: JTS Slide No. 3

 4-STEP RISK MANAGEMENT PROCESS

Hazard
Identification

Monitoring and Risk

Review Assessment

Risk Mitigation

Original Author: JTS Slide No. 4

 HAZARD IDENTIFICATION
Hazard Identification is the first and most critical step in the Risk Management
Process within an aviation Safety Management System (SMS). It involves
systematically identifying potential sources of harm or situations that could lead to
accidents, incidents, or other safety-related events. Effective hazard identification
ensures that risks are proactively managed before they result in adverse outcomes.

Original Author: JTS Slide No. 5

 PURPOSE OF HAZARD IDENTIFICATION
The primary goal of hazard identification is to:
1. Prevent Accidents: Identify potential hazards before they lead to incidents or
accidents.
2. Improve Safety: Enhance safety by addressing vulnerabilities in operations,
equipment, and procedures.
3. Comply with Regulations: Meet regulatory requirements for risk management in
aviation SMS (e.g., ICAO Annex 19, FAA AC 120-92B).
4. Support Decision-Making: Provide data for informed decision-making and
resource allocation.

Original Author: JTS Slide No. 6

 Methods for Hazard Identification
❑ Hazard identification is an ongoing process that involves multiple methods and
data sources. Below are the most common techniques used in aviation:
1. Reactive Methods
2. Proactive Methods
3. Predictive Methods
4. Collaborative Methods

Original Author: JTS Slide No. 7

 PREDICTIVE METHODS
• Data Analysis: Use historical data and trends to predict potential hazards (e.g.,
analyzing bird strike data to identify high-risk airports).
• Scenario Analysis: Simulate potential scenarios (e.g., engine failure during
takeoff) to identify hazards and their consequences.
• Safety Risk Modeling: Use predictive models to assess the likelihood and impact
of hazards.

Original Author: JTS Slide No. 8

 COLLABORATIVE METHODS
• Safety Committees: Involve cross-functional teams in hazard identification and
risk assessment.
• Workshops and Brainstorming Sessions: Engage employees at all levels to
identify hazards and share insights.
• External Expertise: Consult with industry experts, regulators, or other
organizations to identify emerging hazards.

Original Author: JTS Slide No. 9

 STEPS IN HAZARD IDENTIFICATION
1. Define the Scope: Determine the area of focus (e.g., flight operations,
maintenance, ground handling).
2. Gather Data: Collect information from various sources, such as incident reports,
safety audits, and employee feedback.
3. Identify Hazards: Use appropriate methods (e.g., JHA, scenario analysis) to
identify potential hazards.
4. Document Hazards: Record identified hazards in a hazard register or database for
further analysis.
5. Communicate Findings: Share the results of hazard identification with relevant
stakeholders, including management and employees.

Original Author: JTS Slide No. 10

 CHALLENGES IN HAZARD IDENTIFICATION
• Underreporting: Employees may hesitate to report hazards due to fear of blame or
reprisal.
• Complexity: Aviation operations are highly complex, making it difficult to identify
all potential hazards.
• Dynamic Environment: Hazards can change rapidly due to factors like weather,
technology, or operational changes.
• Resource Constraints: Limited time, personnel, or tools can hinder effective
hazard identification.

Original Author: JTS Slide No. 11

 BEST PRACTICES FOR EFFECTIVE HAZARD IDENTIFICATION
1. Promote a Just Culture: Encourage open reporting of hazards without fear of
punishment.
2. Use Multiple Methods: Combine reactive, proactive, and predictive methods for
comprehensive hazard identification.
3. Involve Employees: Engage frontline staff, as they often have firsthand knowledge
of potential hazards.
4. Leverage Technology: Use data analytics, predictive modeling, and digital tools to
enhance hazard identification.
5. Regular Reviews: Continuously update the hazard register and review processes to
address new or emerging hazards.

Original Author: JTS Slide No. 12

 RISK ASSESSMENT
Risk Assessment is the second step in the Risk Management Process within an
aviation Safety Management System (SMS). It follows Hazard Identification and
involves evaluating the likelihood and consequences of identified hazards to
determine the level of risk they pose. The goal of risk assessment is to prioritize risks
and decide on appropriate mitigation strategies.

Original Author: JTS Slide No. 13

 RISK ASSESSMENT TOOLS AND TECHNIQUES

1. Risk Matrix
Shows the relationship between Likelihood and Consequences. This is a common
tool used in aviation safety management systems (SMS) to assess and prioritize risks.
2. Bowtie Analysis
A visual tool that identifies causes, preventive controls, and mitigation measures for a
hazard.
3. Fault Tree Analysis (FTA)
A top-down approach to identify root causes of a hazard.
4. Event Tree Analysis (ETA)
A forward-looking approach to assess the potential outcomes of a hazard.

Original Author: JTS Slide No. 14

 RISK MATRIX DIAGRAM

Likelihood
Almost Certain
Rare (1) Unlikely (2) Possible (3) Likely (4)
(5)
Severity
Catastrophic (5) Medium (5) High (10) High (15) Extreme (20) Extreme (25)
Major (4) Low (4) Medium (8) High (12) High (16) Extreme (20)
Moderate (3) Low (3) Low (6) Medium (9) High (12) High (15)
Minor (2) Low (2) Low (4) Low (6) Medium (8) Medium (10)
Insignificant (1) Low (1) Low (2) Low (3) Low (4) Medium (5)

Original Author: JTS Slide No. 15

 EXPLANATION OF THE DIAGRAM
1. Likelihood (X-axis): The probability of an event occurring, ranging
from Rare to Almost Certain.
2. Consequences (Y-axis): The severity of the event's impact, ranging
from Insignificant to Catastrophic.
3. Risk Levels:
1. Low (Green): Acceptable risk; no immediate action required.
2. Medium (Yellow): Moderate risk; action may be needed to reduce likelihood or
consequences.
3. High (Orange): Significant risk; immediate action required to mitigate.
4. Extreme (Red): Unacceptable risk; activity must be stopped until risk is reduced.

Original Author: JTS Slide No. 16

 HOW TO USE THE RISK MATRIX
1. Identify Hazards: Determine potential hazards in aviation operations (e.g., bird
strikes, runway incursions).
2. Assess Likelihood: Estimate how likely the hazard is to occur (e.g., Rare,
Unlikely, Possible, Likely, Almost Certain).
3. Assess Consequences: Estimate the severity of the consequences if the hazard
occurs (e.g., Insignificant, Minor, Moderate, Major, Catastrophic).
4. Determine Risk Level: Use the matrix to find the intersection of likelihood and
consequences, which will indicate the risk level (Low, Medium, High, Extreme).
5. Prioritize Actions: Focus on mitigating risks with higher levels (High or Extreme).

Original Author: JTS Slide No. 17

 EXAMPLES OF RISK ASSESSMENT IN AVIATION
❑ Example 1: Runway Incursion
• Hazard: Aircraft or vehicle entering the runway without clearance.
• Likelihood: Possible (based on historical data and operational complexity).
• Consequences: Major (potential for collision, injuries, or fatalities).
• Risk Level: High.
• Mitigation: Enhanced air traffic control procedures, runway lighting, and pilot training.
❑ Example 2: Engine Failure
• Hazard: Mechanical failure of an aircraft engine.
• Likelihood: Unlikely (due to rigorous maintenance schedules).
• Consequences: Catastrophic (potential for crash and loss of life).
• Risk Level: High.
• Mitigation: Regular engine inspections, redundancy in engine design, and pilot training for engine failure scenarios.
Original Author: JTS Slide No. 18
 CHALLENGES IN RISK ASSESSMENT

• Subjectivity: Likelihood and consequence assessments can be subjective and vary

between individuals.
• Data Limitations: Lack of historical data or incomplete reporting can hinder
accurate risk assessment.
• Dynamic Environment: Risks can change rapidly due to factors like weather,
technology, or operational changes.
• Complex Interactions: Hazards often interact in complex ways, making it difficult
to assess their combined impact.

Original Author: JTS Slide No. 19

 BEST PRACTICES FOR EFFECTIVE RISK ASSESSMENT
1. Use Multiple Methods: Combine qualitative and quantitative approaches for a
comprehensive assessment.
2. Involve Experts: Engage subject matter experts (e.g., pilots, engineers, safety
officers) in the assessment process.
3. Leverage Data: Use historical data, incident reports, and predictive analytics to
inform risk assessments.
4. Regular Reviews: Continuously update risk assessments to reflect changes in
operations, technology, or the environment.
5. Communicate Results: Share risk assessment findings with stakeholders to ensure
informed decision-making.

Original Author: JTS Slide No. 20

 RISK MITIGATION
❑ Hierarchy of Risk Controls (ICAO, FAA):
• Elimination: Removing the hazard entirely (e.g., redesigning a runway to
prevent incursions).
• Substitution: Replacing a hazardous process with a safer one (e.g., using safer
materials).
• Engineering Controls: Physical changes to equipment or procedures (e.g.,
installing collision avoidance systems).
• Administrative Controls: Policies, training, and procedures (e.g., crew
resource management training).
• Personal Protective Equipment (PPE): Last line of defense (e.g., helmets,
fire-resistant clothing).
Original Author: JTS Slide No. 21
 EXAMPLES OF MITIGATION IN AVIATION
• Enhanced pilot training programs.
• Implementation of Safety Management Systems (SMS).
• Use of advanced technology (e.g., TCAS, EGPWS).

❑ Visuals:
• Diagram of the hierarchy of risk controls.
• Examples of risk mitigation in aviation (e.g., TCAS system, pilot training).

Original Author: JTS Slide No. 22

 DIAGRAM OF THE HIERARCHY OF RISK CONTROLS.

Original Author: JTS Slide No. 23

 1. Elimination
- Most effective control.
- Completely remove the hazard from aviation operations.
- Example: Discontinuing the use of a faulty aircraft model or ceasing operations
in extremely hazardous weather conditions.
2. Substitution
- Replace a hazardous element with a safer alternative.
- Example: Using a less flammable hydraulic fluid or replacing an outdated
navigation system with a more reliable one.

Original Author: JTS Slide No. 24

 3. Engineering Controls
- Isolate people from the hazard through design or technology.
- Example: Installing enhanced ground proximity warning systems (EGPWS) to prevent controlled
flight into terrain (CFIT) or designing aircraft with redundant systems for critical functions.
4. Administrative Controls
- Change procedures or policies to reduce exposure to hazards.
- Example: Implementing strict maintenance schedules, crew rest requirements, or air traffic
management protocols to minimize risks.
5. Personal Protective Equipment (PPE)
- Least effective control.
- Protect individuals with equipment designed to mitigate specific risks.
- Example: Providing pilots with noise-canceling headsets, flight crew with fire-resistant uniforms,
or ground crew with high-visibility vests and helmets.
Original Author: JTS Slide No. 25
 MONITORING AND REVIEW
• Safety Culture: A shared commitment to safety at all levels of the organization.
• Encourages reporting of hazards and incidents without fear of retribution.
• Promotes open communication and teamwork.
• Continuous Improvement:
• Regular safety audits and performance reviews.
• Learning from incidents and near-misses to prevent recurrence.
• Updating risk management processes based on new data and technology.
• Role of Safety Performance Indicators (SPIs): Metrics used to measure the
effectiveness of risk controls and overall safety performance.

Original Author: JTS Slide No. 26

 ❑ Visuals:
• Diagram of the safety culture pyramid (e.g., reporting, learning, just culture).
• Examples of SPIs (e.g., number of reported incidents, audit findings).

Original Author: JTS Slide No. 27

 DIAGRAM OF THE SAFETY CULTURE PYRAMID
1. Informed Culture (Base)
- It refers to an organization's ability to collect, analyze, and understand safety-related
data.
- In aviation, this includes data from flight operations such as flight data recorders
(FDRs) and cockpit voice recorders (CVRs) , maintenance reports, incident
investigations, and safety audits.
2. Learning Culture
- Building on the informed culture, this level focuses on using the collected data to learn
and improve.
- It involves identifying root causes of incidents, sharing lessons learned, and
implementing changes to prevent recurrence such as conducting thorough investigations
after near-misses or accidents and updating training programs based on findings.
Original Author: JTS Slide No. 28
 3. Reporting Culture
- This level emphasizes creating an environment where employees feel safe to report
safety concerns without fear of punishment.
- Example: Encouraging pilots, cabin crew, and ground staff to report safety issues
through confidential reporting systems like Aviation Safety Reporting Systems (ASRS).
4. Just Culture (Top)
- The pinnacle of the pyramid, a just culture balances accountability and fairness.
- It ensures that individuals are not punished for honest mistakes but are held accountable
for reckless or intentional violations.
- Example: Differentiating between a pilot making an unintentional error due to fatigue
and a pilot deliberately ignoring safety protocols.

Original Author: JTS Slide No. 29

 REFERENCES
• ICAO Annex 19: Safety Management
• ICAO Document 9859: Safety Management Manual (SMM)
• FAA AC 120-92B: Safety Management Systems for Aviation Service Providers
• Federal Aviation Administration (FAA)
• European Union Aviation Safety Agency (EASA)
• International Air Transport Association (IATA)
• Civil Aviation Authority (CAA)

Original Author: JTS Slide No. 30