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b) Administrative defences. These include procedures and practices that mitigate the probability of
an accident (for example, safety regulations, SOPs, supervision and inspection, and personal
proficiency).
6.4.6 Before selecting appropriate risk mitigation strategies, it is important to understand why the
existing system of defences was inadequate. The following line of questioning may pertain:
a) Were defences provided to protect against such hazards?
b) Did the defences function as intended?
c) Were the defences practical for use under actual working conditions?
d) Were affected staff aware of the risks and the defences in place?
e) Are additional risk mitigation measures required?
Risk mitigation strategies
6.4.7 There is a range of strategies available for risk mitigation, for example:
a) Exposure avoidance. The risky task, practice, operation or activity is avoided because the risk
exceeds the benefits.
b) Loss reduction. Activities are taken to reduce the frequency of the unsafe events or the magnitude
of the consequences.
c) Segregation of exposure (separation or duplication). Action is taken to isolate the effects of the
risk or build in redundancy to protect against the risks, i.e. reduce the severity of the risk (for
example, protecting against collateral damage in the event of a material failure, or providing back-up
systems to reduce the likelihood of total system failure).
Brainstorming
6.4.8 Generating the ideas necessary to create suitable risk mitigation measures poses a challenge.
Developing risk mitigation measures frequently requires creativity, ingenuity and, above all, an open mind to
consider all possible solutions. The thinking of those closest to the problem (usually with the most
experience) is often coloured by set ways and natural biases. Broad participation, including by
representatives of the various stakeholders, tends to help overcome rigid mindsets. Thinking “outside the
box” is essential to effective problem solving in a complex world. All new ideas should be weighed carefully
before rejecting any of them.
Evaluating risk mitigation options
6.4.9 In evaluating alternatives for risk mitigation, not all have the same potential for reducing risks.
The effectiveness of each option needs to be evaluated before a decision can be taken. It is important that
the full range of possible control measures be considered and that trade-offs between measures be
considered to find an optimal solution. Each proposed risk mitigation option should be examined from such
perspectives as:
6-10 Safety Management Manual (SMM)
a) Effectiveness. Will it reduce or eliminate the identified risks? To what extent do alternatives
mitigate the risks? Effectiveness can be viewed as being somewhere along a continuum, as follows:
1) Level One (Engineering actions): The safety action eliminates the risk, for example, by
providing interlocks to prevent thrust reverser activation in flight;
2) Level Two (Control actions): The safety action accepts the risk but adjusts the system to
mitigate the risk by reducing it to a manageable level, for example, by imposing more restrictive
operating conditions; and
3) Level Three (Personnel actions): The safety action taken accepts that the hazard can neither
be eliminated (Level One) nor controlled (Level Two), so personnel must be taught how to cope
with it, for example, by adding a warning, a revised checklist and extra training.
b) Cost/benefit. Do the perceived benefits of the option outweigh the costs? Will the potential gains be
proportional to the impact of the change required?
c) Practicality. Is it doable and appropriate in terms of available technology, financial feasibility,
administrative feasibility, governing legislation and regulations, political will, etc.?
d) Challenge. Can the risk mitigation measure withstand critical scrutiny from all stakeholders
(employees, managers, stockholders/State administrations, etc.)?
e) Acceptability to each stakeholder. How much buy-in (or resistance) from stakeholders can be
expected? (Discussions with stakeholders during the risk assessment phase may indicate their
preferred risk mitigation option.)
f) Enforceability. If new rules (SOPs, regulations, etc.) are implemented, are they enforceable?
g) Durability. Will the measure withstand the test of time? Will it be of temporary benefit or will it have
long-term utility?
h) Residual risks. After the risk mitigation measure is implemented, what will be the residual risks
relative to the original hazard? What is the ability to mitigate any residual risks?
i) New problems. What new problems or new (perhaps worse) risks will be introduced by the
proposed change?
6.4.10 Obviously, preference should be given to corrective actions that will completely eliminate the
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