Project Report on Safety Management System

Description
Safety management system (SMS) is a term used to refer to a comprehensive business management system designed to manage safety elements in the workplace.

Safety Management System (SMS) – Advocating A Software Prototype for the U.S. FAA FAR 139 Airports

Submitted by Chien-tsung Lu Department of Aviation Technology Purdue University 1401 Aviation Dr. W. Lafayette, IN 47907 & Mark Sherman Department of Aviation Farmingdale State University Lupton Hall, Route 110 Farmingdale, NY 11735

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Dr. Chien-tsung Lu Associate Professor, Purdue University Dr. Mark Sherman Associate Professor, Farmingdale State University ABSTRACT Most aviation accidents are human-error related. To change a worker’s behavior and therefore improve safety culture, the International Civil Aviation Organization (ICAO) had started to promote Safety Management System (SMS) to his signatory nations since 2003. In 2006, the U.S. Federal Aviation Administration (FAA) introduced SMS to aviation community in order to improve aviation safety including airports. The SMS is a scientific and comprehensive safety management model helping the airlines, airports and aircraft manufacturers create or reform a safety culture. However our most current study about SMS in 2008 shows that the interviewed FAA FAR Part 139 airports and Part 121 air carriers do not have a clear picture about the SMS. As a result, most airports and airlines have chosen to wait for the final SMS manual to be unveiled by the FAA and are continuing their existing safety programs. The research finding also indicates that technology should be adopted to facilitate the future mandatory SMS in a cost-effective fashion. People could argue that if airports/airlines do not prepare ahead, the sudden initiation of SMS may encounter problems and need urgent assistance from the government. Consequently, the FAA may suffer from manpower shortage in training, instruction, education, system design, implementation, etc. In fact, a userfriendly computerized SMS would help reduce workload, documentation management, data processing time, and provide timely safety alerts to safety managers. To help aviation industry and, therefore, to be more proactive in promoting safety from academia, this study advocates the utilization of technology to create an computerized prototype of SMS for the needed aviation workers based on the standards of FAA AC 150/5200-37, AC 120-92, ICAO SMM, and Lu-Bos-Caldwell SMS model published on the FAA’s International Journal of Applied Aviation Studies (IJAAS) in 2007. It would be extremely beneficial to the aviation industry if a computerized SMS is available to them to effectively and efficiently manage potential hazards. Background The National Commission on Terrorist Attacks (the 9/11 Commission) has recommended a redundant safety system (2004) for the national airspace system. However, the System Safety’s philosophy of “redundancy” or a multi-layered “safety net” has enlightened U.S. government to generate a better aviation safety program since 1996 (Bos & Lu, 2007; Ericson, 2005; Lu, 2008; Lu, Wetmore, & Przetak, 2006; Peterson, 1988; Vincolli, 1993). Any additional layer of defense will increase the safety quality of a given transportation system. Originally, from the FAA, the Office of System Safety (OSS) was empowered to lead Aviation System Safety research, promote findings, and train application through

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Administrative Order 8040-1. The Administrative Order 8040-1 requires the Office of System Safety to: 1) incorporate a risk management process for all high-consequence decisions including airlines and airports, and 2) provide a handbook/manual of System Risk management and to recommend tools of System Safety to all US-based airlines. To accommodate this requirement, the FAA had published Advisory Circular (AC) 120-92 Introduction to safety management systems for air operators in 2006 and 150/5200-37 Introduction to Safety Management System for Airport Operators in 2007. Interestingly, as Lu and Asfoor (2008) discovered, most airports do not structure safety programs in a recommended SMS fashion. It is because designing a new SMS may cost more than expected on the tops of existing safety initiatives. In particular, implementing SMS has not been mandatory yet. Our Safety Concern The current airport industry embraces FAA FAR 139 requirements as its safety benchmark. Previous survey findings showed: 1) airport authorities are waiting for the FAA to provide a final official copy of guideline for implementing SMS, 2) GA airports need assistances in the area of a more comprehensive system for safety operation and 3) FAR 139 and related ACs are documents adopted by airports but a comprehensive or cohesive safety management model is lacking (Lu & Asfoor, 2008). Further, airport authorities would like to see a user-friendly and cost-effect system that allows employees to easily get access to whenever and wherever the system is needed. A Solution to the Industry While MITRE (a consulting group) is working on the completion of the first SMS manual/handbook for the industry funded by the Transportation Research Board (TRB), we envision problems that aviation industry would encounter and advocate an advanced study to provide a proactive safety management model in a user-friendly, computerized format tangible to airport workers with the highest efficiency and lowest possible cost. However, without a regulatory enforcement, the adoption of SMS could be less popular. In this regard, the FAA has proposed a new Notice of Proposed Rulemaking (NPRM) of SMS on July 23, 2009 and Congress has proposed a new bill HR 3371 Airline Safety and Pilot Training Improvement Act 2009 on July 29, 2009. In other words, this project will benefit the airports willing to incorporate SMS to their safety operation. We hope to reduce both risk probability and severity associated within their daily operation. Ultimately, a positive safety culture can be formed to eliminate or reduce unwanted events, unforeseen accidents, and un-needed financial waste. A Computerized SMS Model As showed in Figure 1, the research team had proposed a SMS model in 2007, which is a comprehensive management mechanism. However, the model is still manual in nature. The SMS software or an online management system will play a significant role for SMS users to receive needed assistance in the following areas:

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• • • • • • • • • •

Collecting daily hazard reports; Providing an automatic system alert to managers and employees; Enacting safety information distribution and informing mechanism; Disseminating announcement of educational (workshops, seminars, etc.) events; Supervising quality assurance activities and outcome measurement; Facilitating online safety forums for safety communication; Providing automatic calculation of risks and suggesting controls; Building and measuring safety culture and worker behavior; Reducing workload from safety specialists and management personnel; & Increasing overall performance safety.

Figure 1 Lu-Bos-Caldwell Aviation SMS Model

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Data collection. Hazardous data can be retrieved from the current ongoing reporting programs such as ASAP, Wildlife Hazard, ATOS, ASRS, internal voluntary report programs, etc. through an automatic system. The data collection process can be: 1) reported by employees, 2) downloaded from existing databases, or 3) a documentary review. A suggestion of this data collection phase is that the data reporting mechanism should be open to all workers allowing safety project managers to collect sufficient information from specialists in the filed. This collection must meet several requirements in order to encourage contributions: 1) penalty-free, 2) anonymous, 3) confidential, 4) easy-to-report, 5) maintaining an open-door policy, and 6) promising solutions. Hazard identification. The purpose of hazard identification is twofold: 1) hazard definition and 2) data categorization. The criticality of hazard identification focuses on the review of hazard reports from line experts or safety committee to recognize if it is a reportable hazard or requires further analysis. In addition, collected data should be categorized and prepared for a prompt analysis and immediate hazard study. Data analysis. This is the first analytical output of review focused on identifying and reporting hazard prioritization associated with a quick solution or immediate safety alert. Data analysis should contain but not be limited to some basic hazardous information such as trend study, hazard ranking, and preliminary accident and/or incident rates during a specific time and locations. Risk matrix calculation and response. During this phase of system safety management model, the formation of a Risk Index can be flexible as long as a precise risk indication can be generated. An example shown in Table 1, the Risk Index embraces addition (sum) numbers instead of multiplication which can provide an easier way of risk calculation and interpretation ranging between 2 and 10, the higher the better. Of course, this matrix can be revised based on the operational nature of the users. Table 1 SMS Risk Index (SMSRI) Mishap Severity Catastrophic 1 Critical 2 Marginal 3 Negligible 4 Index note: Impossible Improbable 6 5 7 8 9 10
2~4

Mishap Remote 4 5 6 7 8
5~7

Probability Occasional Probable 3 2 4 5 6 7
Cautious

Frequent 1 2 3 4 5
Supervisory

6 7 8 9
Emergency

3 4 5 6
8 ~ 10

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Meanwhile, a color-coded numerical index indicates the risk level of a reported situation. In this proposed model, the risk index (2~4) is qualitatively defined as an Emergency case that needs an immediate response or solution. The risk index (5 ~7) indicates a Cautious situation needing a fast review and resolution which more information and analysis may be needed to determine the level of risk eroding the entire operational system. Lastly, the risk index (8 ~10) represents a Supervisory case and the reported hazard needs a continuous measurement in the future. In the above matrix for the aviation industry, although the mishap probability is extremely low (Impossible 6), any fatality (Catastrophe 1) is unacceptable thus it is categorized as Cautious instead of Supervisory. Meanwhile, Frequent (1) mishap probability with Negligible (4) hazard severity is also unacceptable because the hazard could be immediately mitigated with a very low cost (i.e., tool misplacement) otherwise hazard accumulation (i.e., complacency) may lead to a larger scale of damage. System safety tools implementation and regulatory compliance. This phase processes the information/reports and receives the hazard probability from previous processing stage. The accident case of “Federal Express Flight 1478” was selected using FTA (See Appendix A) and O&SHA for a conceptual demonstration (See Appendix B). The genuine value of this phase is to apply System Safety tools to conduct a detailed hazard-accident-incident analysis and provide counter-measures. The reports and documentations are good for new employee orientations, routine safety education, recurrent trainings, and accident-prevention courses based on regulatory requirements. This stage of process could also identify safety loopholes within the operational system. Reports and feedback. The purpose of accident investigation is to identify the problems, provide safety measures, and prevent similar problems from happening again. With this in mind, the analytical reports will be sent to a safety committee for a review if the calculation of Risk Index indicates a need. Also, the result and resolution needs to be distributed to the submitters, if known. Otherwise, the summarized synopsis should be posted on a service bulletin board or to a monitoring system for a public information sharing. A hazard tracking system is equally important for two counts: 1) it will help the safety manager identify the status of a hazard report and 2) it will show submitters the importance of their contribution and further motivate their participation. Real-time system safety alert. Qualitative risk alert index of this proposed electronic/automatic system provides a visionary image to safety managers or system users who need up-to-date information for prompt safety awareness. The research team suggests a color-coded (red, yellow, green) information distribution design for quick informative hazard identification. Information distribution. This process should inform all employees about the ongoing safety status. It can be accomplished by utilizing several formats such as Email, automatic voicemail, internal circulation channel, flight crew briefings, ground crew discussions, maintenance safety notices, and recurrent and routine meeting and trainings.

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Problem-solving meeting. Members of safety committee receive routine, at least daily, hazard analysis and provide comments and recommendation to upper management for further decision-making reviews (action or non-action). Line managers or worker representatives should be invited to meetings and suggest possible trainings or resolutions if deemed necessary. Program Methods and Progress Monitoring As the research team approach to the design, implementation, and program review process, Action Research methodology will be applied throughout the study. It is because that Action Research (AR) methodology is a scientific approach available for the researchers to merge themselves in a research setting for evident discovery, researchers experience the first-hand challenges, process cognition and available knowledge, and implement selected strategies. The AR procedures or the “Look-Think-Act” loop has been utilized as an acronym in the qualitative research discipline for decades (Chalmers, 2005; Reason, 2003; Stringer, 1996). A flow-chart provided below indicates how research team will implement research procedures:
SMS model reviews (“Look”) Source availability reviews (“Look”) Group meetings (“Think”) SMS Computer Prototype Design (“Think-Act”)

Software finalization & report User verification (“Look-Think”) Objective evaluations (“Look-Think”) Result review (“Look-Think”) Pilot-testing (“Act”)

The outcome distributions and needed workforces are scheduled as the following table: Inputs (necessity) Implementations Hazard reports, data, safety comments, existing database, etc. Throughputs (activity) System design and brainstorming, computer algorithms, inter-departmental communications and meetings, aviation regulatory reviews, calculations and computations, etc. Providing expertise, 7 Outputs (products) Online SMS system, automatic risk alert, information sharing and distribution, training updates, safety enhancement, etc.

Staffs

2 Researchers, 3

User-friendly system,

consultants, 5 student assistants, several airport experts, etc.

knowledge, consultation, supervision, advices, trouble-shooting, revisions, etc.

Procurements

A work station, PC, software franchise, printer and related supplies, etc.

Necessary FAA supplies and supports

bias-free working environment, collaborative efforts, synergized team-work, effective leadership, efficient management, productive communication, etc. Systems, supplies and supports to the industry

Conclusion While the aviation industry prefers an effective and efficient computerized system to manage their daily activities in the air and on the ground, this project will help ease tension and pressure related to the future mandatory SMS. There are several challenges in front of the promotion of a computerized SMS. First, worker’s willingness to report identified hazards or suspicious events is critical. A memorandum of understanding (MOU) between management people and workers should be done to ensure a nonpunitive SMS. Worker’s education in relation to the usage of the system is equally important. Second, a long-term training to information management personnel is essential as a confidential database management is also a key to a successful SMS. Third, false alerts could result in a massive amount of financial loss as the reaction to a fake emergency issue could be expensive. The reliability and creditability of the system must reach at an acceptable level before a full implementation. Lastly, a computerized SMS cannot cover all aspects of hazard reports. There is a need to form a safety committee as some reports may be in narrative format which need interpretation. Technology is plausible and is widely used by air transportation system such as airport navigation aids, GPS, traffic control, onboard warning, aircraft control, etc. Using a computerized hazard reporting, analysis, and alert system would contribute equivalent value as to that of aeronautical engineering innovations.

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Reference Bos, P. & Lu, C-t. (August/September, 2007). Safety management systems: A primer. AAAE Airport Magazine, 44-48. Chalmers, Colvin (2005).Addressing environmental inequalities in UK policy: An action research perspective. Environment Policy, 10(4), 333-360. Ericson, C. A., II (2005). Hazard analysis techniques for system safety. Hoboken, NJ: John Wiley & Sons. FAA. (2006). Advisory Circular 120-92 (AC120-92). Introduction to safety management systems for air operators. (NTIS No. DOT/FAA/AC120-92) Washington DC: U.S. Government Printing Office. FAA. (2007). Advisory Circular 150/5200-37. Introduction to safety management systems (sms) for airport operators. (NTIS No. DOT/FAA/AC150-5200-37) Washington DC: U.S. Government Printing Office. Lu, C-t. (June, 2008). Aviation Security Management Model, Aviation Security Management (A. R. Thomas, eds.). University of Akron. Lu, C-t, & Asfoor, M. (2008). Validating an airport Safety management system. Paper presented to 2008 NASA Airport Safety Competition. Lu, C-t., Bos, P., & Caldwell, W. (2007). System safety application: Constructing a comprehensive aviation system safety management model (ASSMM). International Journal of Applied Aviation Studies, 7(1), 28-45. Lu, C-t., Wetmore, M., & Przetak, R, (Oct., 2006). A new approach to enhance airline safety: Using system safety techniques. Journal of Air Transportation, 11(2), 113139. National Commission on Terrorist Attacks. (2004). The 9/11 commission report. NY: W. W. Norton & Company. Peterson, D. (1988). Safety management: A human approach. (2ND ed.). Goshen, NY: Aloray, Inc. Reason, P. (2003) Choice and quality in action research practice. Bath, University of Bath. Stringer, E. T. (1996). Action research: A handbook for practitioners. Thousand Oaks, CA: Sage. Vincoli, J. W. (1993). Basic guide to system safety. New York: Van Nostrand Reinhold.

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Appendix A

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Appendix B

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