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effects on safety-critical activities.
c) A formal system for safety oversight. This is needed to confirm the organization’s continuing
fulfilment of its corporate safety policy, objectives, goals and standards. The term safety oversight
Accident
Defences-in-depth
Gaps or
weaknesses
in the
defences
Trajectory
Chapter 5. Basics of Safety Management 5-5
refers specifically to the activities of the State as part of its safety programme. For an operator or
service provider, the term safety performance monitoring is often used to cover these activities
under its safety management system (SMS).
5.3.2 A more detailed examination of each of these cornerstones is provided in Appendix 1 to this
chapter.
Strategies for safety management
5.3.3 The strategy that an organization adopts for its SMS will reflect its corporate safety culture and
may range from purely reactive, responding only to accidents, through to strategies that are highly proactive
in their search for safety problems. The traditional or reactive process is dominated by retrospective repairs
(i.e. fixing the stable door after the horse has bolted). Under the more modern or proactive approach,
prospective reform plays the leading part (i.e. making a stable from which no horse could run away or even
want to). Depending on the strategy adopted, different methods and tools need to be employed.
Reactive safety strategy: Investigate accidents and reportable incidents
5.3.4 This strategy is useful for situations involving failures in technology, or unusual events. The utility
of the reactive approach for safety management purposes depends on the extent to which the investigation
goes beyond determining the causes to include an examination of all the contributory factors. The reactive
approach tends to be marked by the following characteristics:
a) Management’s safety focus is on compliance with minimum requirements.
b) Safety measurement is based on reportable accidents and incidents with such limitations in value
as:
1) any analysis is limited to examining actual failures;
2) insufficient data is available to accurately determine trends, especially those attributable to
human error; and
3) little insight is available into the “root causes” and latent unsafe conditions, which facilitate
human error.
c) Constant “catching up” is required to match human inventiveness for new types of errors.
Proactive safety strategy: Aggressively seeking information from a variety of sources which may be
indicative of emerging safety problems
5.3.5 Organizations pursuing a proactive strategy for safety management believe that the risk of
accidents can be minimized by identifying vulnerabilities before they fail and by taking the necessary actions
to reduce those risks. Consequently, they actively seek systemic unsafe conditions using such tools as:
a) hazard and incident reporting systems that promote the identification of latent unsafe conditions;
b) safety surveys to elicit feedback from front-line personnel about areas of dissatisfaction and
unsatisfactory conditions that may have accident potential;
5-6 Safety Management Manual (SMM)
c) flight data recorder analysis for identifying operational exceedances and confirming normal
operating procedures;
d) operational inspections or audits of all aspects of operations to identify vulnerable areas before
accidents, incidents or minor safety events confirm a problem exists; and
e) a policy for consideration and embodiment of manufacturers’ service bulletins.
Key safety management activities
5.3.6 Those organizations which manage safety most successfully practice several common activities.
Some of those specific activities are outlined below:
a) Organization. They are organized to establish a safety culture and to reduce their accidental
losses. Organizations will normally have a formal SMS as outlined in Chapters 12 to 15.
b) Safety assessments. They systematically analyse proposed changes to equipment or procedures
to identify and mitigate weaknesses before change is implemented.
c) Occurrence reporting. They have established formal procedures for reporting safety occurrences
and other unsafe conditions.
d) Hazard identification schemes. They employ both reactive and proactive schemes for identifying
safety hazards throughout their organization, such as voluntary incident reporting, safety surveys,
operational safety audits, and safety assessments. Chapters 16 and 17 outline several safety
processes that are effective in the identification of safety hazards, for example, Flight Data Analysis
(FDA), Line Operations Safety Audit (LOSA) and Normal Operations Safety Survey (NOSS).
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Safety Management Manual (SMM) 安全管理手册(40)
