principles and elements of sms a review

April 2006 ICAO Seminar Baku

Principles and Elements of SMS

A ReviewPatrick Hudson

ICAO/Leiden University


StructureStructure

• Why SMS?• The principles• Shell’s experience• Implementation experience• Conclusion


Why Safety Management Why Safety Management Systems?Systems?

• Safety is a right for customers and staff

• Poor safety performance is a sensitive indicator of poor operations

• “If you can’t manage safety, how can you show you can manage anything else?”

• Safety management systems are about getting systematic about the problems


Safety Management Safety Management SystemSystem

A framework for Safety A framework for Safety Management Management

Alcohol& Drugs

PolicyAudit Plans

Road Safety Plan

Safety Drills

Security Policy

SafetyPolicy

No Structure Structure

Policy

Process

Task

ContinuousImprovement

Safety (HSE Cases)

Mgt.policy


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.


Early Safety ManagementEarly Safety Management• Early safety management was an unstructured mixture of ‘good things’

• Progress was based upon response to accidents• Measures were outcome based (crashes etc)• There were no process definitions (how to do it)

• Regulations prescribed exactly what to do (what to do)

• This works very well to start with, but expectations have been raised over the years, now everyone expects that every flight is safe


Types of CertificationTypes of Certification• There are three distinct ways of guaranteeing safety

• Type I - Classical ICAO/FAA/JAA certification

• Type II - Safety Cases and SMS• Type III - Safety Culture and Good Practice

• These different approaches are complementary, especially II and III

• Types I and II are Imagination Limited – Can people imagine what might go wrong– Type III involves doing The Right Thing anyway


Why have a Safety Why have a Safety Management System?Management System?

• A number of major disasters in the Petrochemical industry– Flixborough– Seveso– Bhopal

• Nuclear disasters– Three Mile Island– Chernobyl


FlixborougFlixboroughh1 June 19741 June 1974

•Modification Control

•Use suitably trained, educated and responsible people

•Know what you don’t know


SevesoSevesoJuly 1976July 1976

• Understanding safe state to leave reactions

• Multiple layers of protection

• Automated Reaction stop systems for exothermic systems


LongfordLongford25 September 199825 September 1998

Sale

Barry BeachMarine Terminal

Long Island PointFractionation Plant,Crude Oil Tank Farmand Liquids Jetty

LongfordGas & Oil Processing

PortPhillipBay

c

Melbourne

Altona

Monotower

Sub-sea Well Oil Platform

Gas Platform

Concrete Structure

Barracouta Marlin

Snapper

GoodingCompression (GTC)

c

c

• Training needs to impart and refresh knowledge.• Must identify other hazards and provide relevant training.•Corporate knowledge must be captured and kept alive


Piper AlphaPiper 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


Piper AlphaPiper Alpha

• Cost $1,500,000,000• 167 killed• Occidental UK went out of business in two years


The Cullen ReportThe Cullen Report• Cullen investigated the Piper Alpha disaster

• Report was published 1990• Requirement made for every offshore facility to have an SMS in place by November 1992

• Proof by submission of a safety case• If there was no acceptable safety case the operation would be shut down immediately


Shell International’s Shell International’s ApproachApproach

• Shell is the largest operator in the North Sea - SMS was made mandatory

• Shell decided to get in first rather than wait

• A considered approach was designed• The requirement for SMS was to be made world-wide for all Shell Group companies


Shell’s Approach - Shell’s Approach - don’t do everythingdon’t do everything

• Decision to operate in terms of hazards and a limited set of events to avoid

• Developed the Bow-tie model (next slides)

• Identification of safety critical activities to provide assurance

• Getting in first meant that they wouldn’t have to operate a system foreign to their culture


The Swiss cheese model The Swiss cheese model ofof

accident causation accident causation (Reason)(Reason)

Some holes dueSome holes dueto active failuresto active failures

Other holes Other holes due todue tolatent latent

conditionsconditions

Successive layers of defences, barriers, & safeguardsSuccessive layers of defences, barriers, & safeguards

HazardsHazards

LossesLosses


SAFETY MANAGEMENTSAFETY MANAGEMENTBased on the Reason Based on the Reason

ModelModel

Hazard/Risk

Undesirableoutcome

Work &Organisation

Barriersor Controls

World


Safety Management Safety Management CycleCycleLeadership and Commitment

Policy and Strategic Objectives

Management Review Corrective ActionAnd Improvement

Organisation, ResponsibilitiesResources, Standards & Documentation

Audit Corrective Actionand Improvement

Hazards and Effects Management

Planning and Procedures Corrective Action

Implementation Monitoring

PLAN

DO

CHECK

FEEDBACK


Hazard-based approachHazard-based approach• Construct a generic hazard register• Assess which are relevant for a particular operation

• Use a Business Process Model to identify safety critical processes that allow management of the hazards

• Construct Bow Ties for control and recovery


HEMPHEMP• HEMP - Hazard and Effects Management Process

• Identify - What are the hazards?• Assess - how big are those hazards?• Control - how do we control the hazards?

• Recover - what if it still goes wrong?


Bow-tie ConceptBow-tie ConceptEvents andEvents and

CircumstancesCircumstancesHarm to people and Harm to people and damage to assets damage to assets

or environmentor environment

HHAAZZAARRDD

CCOONNSSEEQQUUEENNCCEESS

BARRIERS

Undesirable event withUndesirable event withpotential for harm or damagepotential for harm or damage

Engineering activitiesMaintenance activitiesOperations activities


Bow-tie ConceptBow-tie Conceptfor a specific threatfor a specific threat

Events andEvents andCircumstancesCircumstances

Harm to people and Harm to people and damage to assets damage to assets

or environmentor environment

HHAAZZAARRDD

CCOONNSSEEQQUUEENNCCEESS

BARRIERS

Undesirable event withUndesirable event withpotential for harm or damagepotential for harm or damage

Engineering activitiesMaintenance activitiesOperations activities


RISK ASSESSMENT MATRIXPotential Consequence of the Incident Increasing Probability

Env'ment

0

2

3

4

5

Seriousinjury

Multiplefatality

Singlefatality

Minorinjury

Happened > 3 x in this location

Minordamage <US$ 50K

Localdamage <US$ 250K

Majordamage <US$ 1M

Extensivedamage >US$ 1M

MassiveEffect

Zerodamage

Localised Effect

MajorEffect

Minor Effect

1

Assets

Slightinjury

Slightdamage < US$ 10K

SlightEffect

ZeroEffect

B C D EA

Noinjury

Knownin aviation industry

Happened > 3 x in the Company

No Impact

InternationalI m p a c t

IndustryI m p a c t

N a t i o n a lI m p a c t

Slight Impact

Into

lerable

incorpora

te ri

sk

reductio

n

measure

Unknown but possible in the aviationindustry

Happenedin this company

LocalI m p a c t

ReputationPeopleRating

Manage Thro

ugh

Normal H

SE-MS

procedure

s


Hazard Management and Hazard Management and ControlControl

• Bow Ties describe the hazards and the relevant controls

• Controls are provided by elements in the business processes

• Top events are a restricted set of unwanted events, not the final outcomes


Bow Ties as StandardBow Ties as Standard

• The Bow Tie is now the standard for the FAA in the USA

• There are a number of computer packages for making and maintaining bow ties

• The information needed can be shared

• Local differences are easily accommodated


Shell’s HSE Shell’s HSE MANAGEMENTMANAGEMENT

putting it togetherputting it together

THESISRisk Assessment Matrix CONSEQUENCE INCREASING LIKELIHOOD ABCDE

SeverityPeopleAssetsEnvironmentReputationNeverheard ofin …..industryHeard ofin ….industryIncidenthasoccurredin ourCompanyHappensseveraltimes peryear inourCompanyHappensseveraltimes peryear in alocation0No healtheffect/injuryNo damageNo effectNo impact1Slight healtheffect/injurySlightdamageSlight effectSlight impact2Minor healtheffect/injuryMinordamageMinor effectLimitedimpactManage for continuousimprovement3Major healtheffect/injuryLocaliseddamageLocalisedeffectConsider-able impactIncorporate riskreduction4PTD or 1 to 3fatalitiesMajordamageMajor effectNationalimpactmeasures &demonstrate 5MultiplefatalitiesExtensivedamageMassiveeffectInternationalimpact ALARP Intolerable

Risk AssessmentMatrix

EP 95-0300

HAZOP/ HAZID EIA/SIA/HRA etc.

HSE MS

EP 95000Series

Technical advice

Minimum Expectations

Design standards

Group Guidance


HSE MS “in place”HSE MS “in place”

Job Hazard Analysi

s Workplans

Trends/benchmarking

ViolationSurvey

Hazardous SituationUnsafe Act reporting

AuditsReviews

Incident Investigation(Tripod Beta)

Incident Reporting

Contract/Contractor

Management

CompetencyProgrammes

Permit toWork System

HSE SelfAppraisal

Site Visits

Observationtechniques

HSE Standards& Procedures


Advantages of an SMSAdvantages of an SMS• The SMS provides a structure for measuring in system audits

• Bow ties provide a structure for operational audits– Are the barriers there?– Are the barriers intact and in operation– Is there sufficient defence- are there single point trajectories where everything relies on a single defence?

• The analysis of barriers and operations also provides a basis for incident investigation that is consistent with the Reason model


What does it take?What does it take?• Regulators can force implementation, but it is much easier if you want to do it anyway

• Top management has to be convinced that implementing an SMS is in their interest

• Shell had to implement in the North Sea, but decided to make SMS obligatory world-wide in view of the benefits to Shell group

• BP and ExxonMobil have taken exactly the same approach with GHSSER and OIMS

• You have to do it yourself – Hiring consultants can only be as support– An off-the-shelf SMS will soon fail


Conclusion Conclusion • Safety management systems turn safety into a systematic process

• Development can be done with sharing of information and experience - you don’t compete on safety

• SMS models can be used to unify management, audit and incident investigation

• SMS does not guarantee everything - to get ahead you need to develop a safety culture as well - tomorrow

principles and elements of sms a review

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