Module 5

Safety Risk Assessment and

Mitigation
 SMS Course Outline

Module Z
Module 6 SMS
SMS Implementation Course
Summary

Module 5
Module 4
Safety Risk
Hazard
Assessment and
Identification
Mitigation

Module 2
Module A Module 1 Introduction to Module 3
SMS Course Basic Safety Safety SMS Framework
Introduction Concepts Management

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PPT 5.2
 End-of-Module Objective

Condition In the classroom, having completed this module

delivery, the participants will be able to:

Performance to apply the fundamentals of safety risk assessment

and mitigation;

through a case study in accordance with ICAO Annex 19

Standards (Safety Management) and ICAO Document 9859 Safety
Management Manual.

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PPT 5.3
 Intermediate Objective

1 Define the safety risk management component of SMS

Define the safety risk assessment and mitigation element of SRM

2
component of an SMS

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PPT 5.4
Module Outline

Recall SMS Framework: Safety Risk

Management
Risk Assessment and Mitigation
Hazards and Consequences
Human Factors and Safety Risk
Management
Cost Benefit Analysis
 Safety Risk Management

Service providers should Safety Risk Management

ensure that they are includes
managing the safety risks
they are faced with.

This process is known as

safety risk
management.

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PPT 5.6
 Risk Assessment and Mitigation

• The second part of the safety risk

management component is to
complete a safety risk assessment
for each potential consequence of
the identified hazard and if
necessary, decide on appropriate
mitigation.
• The objective of the mitigation is
to reduce the risk of the hazard to
a tolerable level by either
reducing the likelihood of the
potential consequences or by
reducing the severity, taking into
consideration all foreseeable
scenarios.

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PPT 5.7
 Safety Risk Management
When to carry out a risk assessment

When a hazard has been identified (safety reporting)

A safety event has occurred (incident or accident)

Safety issues identified (e.g., Pandemic)

Changes (Operational, organizational, technical)

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PPT 5.8
 Risk Assessment and Mitigation

A basic safety risk

assessment and mitigation
process may start with
determining the
potential consequences
of identified hazards
within an operation.

Next, the probability and

severity of the
consequence are
determined.

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PPT 5.9
 Risk Assessment and Mitigation

It is important to determine
what defenses are already
in place and how effective
they might or might not be.
The conclusion should
determine the safety risk
and reveal whether that risk
is acceptable – this is known
as safety risk tolerability.

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PPT 5.10
 Risk Assessment and Mitigation

If the risk is unacceptable,

mitigation, probably in the
form of additional or
improved defenses, are
needed.

Integrated risks
considerations should be
included in this process

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PPT 5.11
 Definition of Safety Risk

Safety Risk
- The assessment, expressed in terms of predicted probability and
severity, of the consequence(s) of a hazard taking as reference the worst
foreseeable situation.

A wind of 15 knots blowing directly across the runway is a hazard.

The potential that a pilot may not be able to control the aircraft during
takeoff or landing is one of the consequences of the hazard

The assessment of the consequences of the potential loss of control of

the aircraft by the pilot expressed in terms of probability and severity is
the safety risk.

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PPT 5.12
 Safety Risk Assessment

Safety Risk Index

• Combination of the level of:
➢ Safety risk probability
➢ Safety risk severity

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PPT 5.13
 Safety Risk Assessment

Safety Risk Probability

What to ask in assessing the probability of
• the likelihood that an unsafe event
an occurrence:
or condition might occur • Is there a history of occurrences like the
• Any factors underlying these one being assessed, or is the occurrence
questions will help in assessing the an isolated event?
likelihood that a hazard may exist, • What other equipment, or similar type
components, might have similar defects?
taking into consideration all • What number of operating or
potentially valid scenarios. maintenance personnel must follow the
• The determination of likelihood procedure (s) in question?
can then be used to assist in • How frequently is the equipment or
procedure under assessment used?
determining safety risk probability.

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PPT 5.14
 Safety Risk Assessment

Safety Risk Probability

• includes 5 categories to
denote the probability
related to an unsafe event
or condition, the
description of each
category, and an
assignment of a value to
each category.

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PPT 5.15
 Safety Risk Assessment
Safety Risk Severity
What to ask for in assessing the severity of an occurrence:
• is defined as the extent of • How many lives may be lost?
harm that might reasonably ➢ Employees
➢ Passengers
occur as a consequence or ➢ Bystanders
outcome of the identified ➢ General public
• What is the environmental impact?
hazard ➢ Spill of fuel or other hazardous product
• severity assessment should ➢ Physical disruption of natural habitat
• What is the severity of the property or financial damage?
consider all possible ➢ Direct operator property loss
consequences related to an ➢ Damage to aviation infrastructure
➢ Third party damage
unsafe condition or object, ➢ Financial impact and economic impact for the State
taking into account the • Are there organizational, management or regulatory implications
worst foreseeable that might generate larger threats to public safety?
• What are the likely political implications and/or media interest?
outcome.

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PPT 5.16
 Safety Risk Assessment
Safety Risk Severity
• includes 5 categories to
denote the level of
severity, the description
of each category, and
the assignment of, in
this case, a letter value
to each category

Each organization should

define the number of levels
of safety risk probability and
severity to suit their own
environment.

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PPT 5.17
 Safety Risk Assessment

Safety Risk Severity

• The severity assessment can be Severity defined in terms of
based upon: consequences for:
➢ Fatalities/injury.
• Property
• Finance
How many lives may be lost
• Liability
(employees, passengers, bystanders
• People
and the general public)
• Environment
➢ Damage.
• Image
What is the likely extent of aircraft, • Public confidence
property or equipment damage?

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PPT 5.18
 Safety Risk Assessment

Safety Risk Assessment risk

Risk management Suggested criteria
Tolerability Matrix index
The decision-making
process involves the 5A, 5B, 5C, 4A, Unacceptable under the
Intolerable region
use of a risk 4B, 3A existing circumstances

categorization that may

be in the form of an 5D, 5E, 4C, 4D, 4E, Acceptable based on risk
assessment matrix. 3B, 3C, 3D, 2A, 2B, mitigation. It might require
Tolerable region management decision
The aim is to reduce the 2C, 1A
safety risk tolerability
level downwards. Acceptable
region 3E, 2D, 2E, 1B, The safety risk is
acceptable as it stands
1C, 1D, 1E

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PPT 5.19
 Safety Risk Assessment

Alternate Risk Tolerability Matrix

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PPT 5.20
 Safety Risk Assessment

As an example, the
criterion for safety risk
assessed as 4B falls in the
unacceptable under the
existing circumstance
category.

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PPT 5.21
 Safety Risk Assessment

The goal is to identify the most cost

effective mitigation or combination
of mitigations that will reduce the
risk to an acceptable level.

The practicable nature refers not

only to physical factors but also
financial implications of putting the
mitigation in place.

The recommended risk control

actions should take into
consideration the associated
financial implications.

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PPT 5.22
 Human Factors and Safety Risk Management

• Given that mature SSPs and SMSs target both human and
organizational factors, a specific analysis process is a
component of any mature, effective risk management
system.

• In the course of any hazard identification and risk mitigation

exercise involving human elements, it is necessary to assure
that existing or recommended defenses have taken human
factors (HF) into consideration.

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PPT 5.23
 SRM – Cost Benefit Analysis

Direct costs
• The obvious costs, which are easily determined. The high
costs of exposure of hazards can be reduced by insurance
coverage.
• Purchasing insurance only transfers monetary risk, does not
address the safety hazard
Indirect costs
• The uninsured costs. An understanding of uninsured costs (or
indirect costs) is fundamental to understand the economics
of safety.

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PPT 5.24
 SRM – Cost Benefit Analysis

Indirect costs may amount to more than the

direct costs resulting from exposure to
hazards:
• Loss of business
• Damage to the reputation
• Loss of use of equipment
• Loss of staff productivity
• Legal actions and claims
• Fines and citations
• Insurance deductibles

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PPT 5.25
 SRM Worksheet Illustration

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PPT 5.26
 Knowledge Check

•Q: The safety risk management process systematically :

•A:
a. Identifies hazards that exist within the context of the delivery of its products or
services
b. Analyzes and assesses the safety risks associated with those identified
hazards
c. Implements appropriate risk controls to mitigate the risks
d. All of the above
?
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PPT 5.27
 Knowledge Check

• Q: What are the five designations for risk probability?

• A: Probability of Occurrence
Likelihood Meaning/Description Value
Likely to occur many times
Frequent 5
(has occurred frequently)
Likely to occur some times
Occasion 4
(has occurred infrequently)
Unlikely to occur, but possible
Remote 3
(has occurred rarely)

? Improbable

Extremely
Very unlikely to occur
(not known to have occurred)
2

Almost inconceivable that the event will occur 1

improbable

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PPT 5.28
 Knowledge Check
• Q: What are the five designations for risk severity?
• A: SEVERITY ASSESSMENT
Severity Meaning Value
▪ Equipment destroyed.
Catastrophic ▪ Multiple deaths. A

▪ A large reduction in safety margins, physical distress or a workload

such that the operators cannot be relied upon to perform their tasks
accurately or completely
Hazardous ▪ Serious injury B
▪ Major equipment damage

▪ A significant reduction in safety margins, a reduction in the ability of

the operators to cope with adverse operating conditions as a result of
an increase in workload or as a result of conditions impairing their
Major efficiency C
▪ Serious incident
▪ Injury to persons

? Minor
▪
▪
▪
▪
Nuisance
Operating limitations
Use of emergency procedures
Minor incident
D

Negligible ▪ Few consequences E

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PPT 5.29
 Knowledge Check
• Q: How is the safety risk tolerability determined?
• A:
Risk severity
To determine safety risk tolerability: Risk probability
Catastrophi Hazardous Major Minor Negligible
1. Obtain the indices in the safety risk Ac B C D E
assessment matrix.
2. The index obtained from the safety 5
risk assessment matrix may then
Frequent 5A 5B 5C 5D 5E
be exported to a safety risk
Occasional 4 4A 4B
tolerability matrix that describes 4C 4D 4E
the tolerability criteria for the
particular organization. 3
Remote 3A 3B 3C 3D 3E

?
Improbable 2 2A 2B 2C 2D 2E
Extremely 1
improbable 1A 1B 1C 1D 1E

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PPT 5.30
 Knowledge Check
• Scenario:
• Airport YYY has 25,000 movements in a month with 225,000 passengers.
• They had 3 bird strike events that resulted in damage to aircraft wing
leading edges.
• They had 1 runway incursion in the last 12 months to a loss of
situational awareness by a foreign flight crew that missed the correct
runway exit taxiway and in backtracking ended up on the incorrect
taxiway and crossed the stop bars before being halted by Air Traffic.
• There have been 18 occurrences reported of vehicles causing damage to
parked aircraft and one occurrence where the aircraft had to stop
suddenly due to a vehicle crossing the taxiway.

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PPT 5.31
 Knowledge Check
Identified Associated Existing Current Further Residual Accountable
Hazard Risk Mitigation Level of Risk Mitigation Risk
(Consequence) Measures Measures
in Place

L S Score L S Score

Bird Bird strike Bird strike

Acceptable (3C) based on

activity at reports

require mgmt decision

airport

risk mitigation; may

Damage to
aircraft

Remote (3)
Major (C)

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PPT 5.32
 Knowledge Check

Identified Associated Existing Current Level of Further Residual Accountable

Risk
Hazard Risk Mitigation Mitigation Risk
(Consequence) Measures L S Score Measures L S Score
in Place
Flight crew Runway Airport
loss of incursion signage

Intolerable (3A)
Catastrophic (A)
situational
awareness Operation

Remote (3)
on the of stop
ground bars in low
visibility
conditions

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PPT 5.33
 Knowledge Check
Identified Associated Existing Current Level Further Residual Accountable
Hazard Risk Mitigation of Risk Mitigation Risk
(Consequence) Measures Measures
in Place L S Score L S Score

Ground Runway Airport

Frequent (5) Improbable (2)

vehicle incursion signage

mitigation; may
Acceptable (2C)
driver loss

require mgmt
based on risk
Major (C)
of Training as

decision
situational requireme
awareness nt for
on the driving
Ground
ground permit
collision with

Intolerable
Major (C)
an aircraft

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PPT 5.34
 Mitigation Strategies

Risks should be managed to

an acceptable level by
mitigating the risk through
the application of
appropriate risk controls.

This should be balanced

against time, cost and
difficulty of taking action to
reduce or eliminate the risk.

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PPT 5.35
 Mitigation Strategies

Mitigation
• Measures to address the
potential hazard or to reduce
the risk probability or severity

The level of risk can be lowered by

reducing the severity of the
potential consequences, reducing
the likelihood of occurrence or by
reducing exposure to that risk.

It is more common to reduce the

likelihood than it is to reduce the
severity.

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PPT 5.36
 Mitigation Strategies

Typical mitigation strategies include:

Eliminate or remove the hazard altogether (and hence its

Eliminate
potential consequences)

Avoiding the hazard (hence its consequences) altogether

Avoid by modifying, suspending or cancelling the operational
activity or relevant portion of it

Mitigate against the hazard’s consequence by reducing the

Mitigate magnitude of the consequences of the safety risk

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PPT 5.37
 Mitigation Strategies

Typical mitigation strategies include:

Eliminate or remove the hazard altogether (and hence its

Eliminate
potential consequences)

• Possible only if hazard can indeed be totally

eliminated or removed by conventional corrective
actions
• For hazards deemed to be temporary, transient or
isolated in nature and which do not necessitate
resolution through a safety risk mitigation protocol

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PPT 5.38
 Mitigation Strategies

Typical mitigation strategies include:

Avoiding the hazard (hence its consequences) altogether
Avoid by modifying, suspending or cancelling the operational
activity or relevant portion of it

• Likely the result of a safety risk level which

remains highly intolerable/unacceptable in spite
of all possible (or economically viable) defenses
being considered.

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PPT 5.39
 Mitigation Strategies

Typical mitigation strategies include:

Mitigate against the hazard’s consequence by reducing the

Mitigate magnitude of the consequences of the safety risk

• Achieved through incorporation of new defenses

or enhancement of existing defenses
• Usual for hazards which are of a permanent or
recurring nature, and which cannot be
eliminated

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PPT 5.40
 Mitigation Strategies

Risk Mitigation - Defenses

• As part of the risk mitigation, determine:
• Do defenses to protect against such risk (s)
The three basic defences exist?
in aviation: • Do defenses function as intended?
• Technology • Are the defenses practical for use under
• Training actual working conditions?
• Regulations • Is staff involved aware of the risks and the
defenses in place?
• Are additional risk mitigation measures
required?

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PPT 5.41
 Risk Mitigation at a Glance
Hazard/consequence Assessment of the Control and Accepting the
identification defences within the mitigation of the mitigation of the
and risk assessment safety system risk(s) risk(s)

H H H H ➢ Does it address the

risk(s)?
Intolerable region
➢ Is it effective?
Each ➢ Is it appropriate?
consequence ➢ Is additional or
Tolerable different mitigation
region
warranted?
R R R R ➢ Do the mitigation
Acceptable
strategies generates
region additional risk(s)
Each Risk

Feedback (Safety assurance)

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PPT 5.42
 Reminders
There is no such thing as absolute safety.
➢ In aviation it is not possible to eliminate all risks.
• Risks can be managed to a level “as low as reasonably practicable”
(acceptable level of safety performance)
• Risk mitigation must be balanced against:
➢ time
➢ cost
➢ difficulty of taking measures to reduce or eliminate the risk (i.e.
managed).
• Effective risk management seeks to maximize the benefits of
accepting a risk (a reduction in time and cost) while minimizing
the risk itself.
• Communicate the rationale for risk decisions to gain acceptance by
stakeholders affected by them.

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PPT 5.43
 Risk Mitigation Considerations

• Effectiveness • Durability
• Cost/Benefit • Residual safety
• Practicality risk
• Acceptability • Unintended
• Enforceability consequence
• Time

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PPT 5.44
 Risk Mitigation Documentation

Safety risk management output

should be documented, including:
• Hazard and any consequences
• Any risk control action
These are often captured in a
register so that they can be tracked
and monitored.
It may be necessary to use IT tools
to facilitate the documentation
process

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PPT 5.45
 Risk Mitigation Documentation

This safety risk management

documentation:
• Becomes a resource of safety
knowledge to be used as reference in
organizational safety decision-
making processes
• Provides material for safety trend
analyses as well as for safety training
and communications
• Can be useful information for the
internal audit activities to assess
whether risk controls and actions
have been taken

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PPT 5.46
In summary, the
following actions
should be taken in
order to safely manage
risk. The safety risk
management process
decision aid is as
shown:

H5.1
 Knowledge Check

•Q: Describe the three basic risk mitigation strategies.

•A:
(1) Eliminate
(2) Avoid
(3) Mitigate

?
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PPT 5.48
 Knowledge Check
• Scenario:
• Airport YYY has 25,000 movements in a month with 225,000 passengers.
• They had 3 bird strike events that resulted in damage to aircraft wing
leading edges.
• They had 1 runway incursion in the last 12 months to a loss of
situational awareness by a foreign flight crew that missed the correct
runway exit taxiway and in backtracking ended up on the incorrect
taxiway and crossed the stop bars before being halted by Air Traffic.
• There have been 18 occurrences reported of vehicles causing damage to
parked aircraft and one occurrence where the aircraft had to stop
suddenly due to a vehicle crossing the taxiway.

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PPT 5.49
 Knowledge Check
Identified Associated Existing Current Further Residual Accountable
Hazard Risk Mitigation Level of Risk Mitigation Risk
(Consequence) Measures Measures
in Place

L S Score L S Score

Bird Bird strike Bird strike Personnel training Airport Manager

Acceptable (3C) based on

activity at reports on wildlife control

require mgmt decision

mitigation; may require mgmt

Acceptable (2C) based on risk
airport

risk mitigation; may

Cover all trash and
garbage receptacles
Damage to
aircraft Support zoning of

Improbable (2)
Remote (3)
areas near airports

Major (C)
to reduce

Major (C)

decision
attractants to
wildlife

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PPT 5.50
 Knowledge Check

Identified Associated Existing Current Level of Further Residual Accountable

Risk
Hazard Risk Mitigation Mitigation Risk
(Consequence) Measures L S Score Measures L S Score
in Place
Flight crew Runway Airport Stop bars in use Airport
loss of incursion signage 24/7 Manager

Extremely Improbable (1)

Acceptable (1A)
Intolerable (3A)
Catastrophic (A)

Catastrophic (A)
situational
awareness Operation Ground

Remote (3)
on the of stop surveillance radar
ground bars in low installed
visibility
conditions

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PPT 5.51
 Knowledge Check
Identified Associated Existing Current Level Further Residual Accountable
Hazard Risk Mitigation of Risk Mitigation Risk
(Consequence) Measures Measures
in Place L S Score L S Score

Ground Runway Airport Vehicle tracking Airport

Extremely Improbable
Frequent (5) Improbable (2)
devices required on
vehicle incursion signage Manager

Acceptable (1C)
all airside vehicle

Acceptable (2C)
driver loss

mitigation; may
require mgmt
based on risk
Major (C)
of Training as Airport layout chart

Major (C)
requirement mandatory in all
situational

decision
for driving airside vehicles
awareness
permit

(1)
on the
Ground Airport layout chart Airport

mitigation; may require

ground mandatory in all
collision with Manager

Improbable (2)
Intolerable
airside vehicles

Acceptable (2C)
Major (C)
an aircraft

mgmt decision
based on risk
Major (C)
Additional person to
guide driver when

(5C)
close to aircraft

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PPT 5.52
 Warm-up exercise 1

•Scenario:
• Fuel spill on the apron area surface of approximately 25 m (75 ft)
length and 5 m (15 ft) width, produced by an A310 ready to
pushback and taxi for departure.

•Report by the apron responsible person:

• After the A310 pushback the spill was contained and the apron
area was decontaminated.

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PPT 5.53
 Warm-up exercise 1 - Results

Identifie Associated Existing Current Level Further Mitigation Residual Risk Accountabl
d Risk Mitigation of Risk Measures e
Hazard (Consequenc Measures in
e) Place
L S Score L S Score

Fuel Spill Fire Spill Establish airside Airport

risk mitigation; may require

safety committee Manager

the existing circumstance

containment

Acceptable (3C) based on

Unacceptable (4B) under
and
Establish standard
decontaminati fueling procedures
Contamination on procedures and require

Occassional (4)

mgmt decision
Hazardous (B)
stakeholders to

Remote (3)
undergo training

Major(C)
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PPT 5.54
 Warm-up exercise 2

•Scenario:
• It was observed that airline baggage handling personnel generates
FO(D) on the aerodrome apron area .

•Report by the apron responsible person:

• It should be noted that airline baggage handling personnel are not
complying with safety standards as set in the aerodrome operating
manual. This is considered a hazard that can produce incident or
accident in the movement area.

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PPT 5.55
 Warm-up exercise 2 - Results

Identified Associated Existing Current Level Further Residual Accountable

Hazard Risk Mitigation of Risk Mitigation Risk
(Consequence) Measures L S Score Measures L S Score
in Place
Foreign Object Engine ingestion Regular apron FOD posters Airport Manager

Acceptable (3C) based

require mgmt. decision

on risk mitigation; may
Debris (FOD) sweeping FOD bins at all parking
stands

Acceptable (2D)
Property Damage

Improbable (2)
Safety training/

Remote (3)
briefing to airport users

Minor (D)
Major (C)
Tire Damage
FOD inspection and
audits

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PPT 5.56
 Practical Exercise
Group activity
•A facilitator, who will coordinate the discussion, will be
appointed
•A summary of the discussion will be written on MSWord file
and a member of the group will brief on their findings in a
plenary session

Scenario
•Continental Express Flight 2574 Crash (H5.2)

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PPT 5.57
 Practical Exercise
Continental Express Flight
2574 Crash (H4.1)

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PPT 5.58
 Practical Exercise
Your task:

Using the output from the Practical Exercise from Module 4 where
you identified the generic hazard(s), the specific components of
the hazard(s), the unsafe events and the hazard-related
consequences and assess the risk(s), perform the following :
• assess existing defences to control the risk(s) and resulting safety
risk index.
• Propose further action to reduce the risk(s) and resulting risk
index.
• Complete the attached log (H5.2 Risk Management Template).

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PPT 5.59
 Practical Exercise

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PPT 5.60
 Practical Exercise

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PPT 5.61
 Practical Exercise

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PPT 5.62
 Practical Exercise

Recommendations / Proposed Solutions Must…

• Support the purpose
• Be reasonable

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PPT 5.63
 Practical Exercise

Useful tips:
• Elect a facilitator
• Start with a general discussion on the objective of the task and the
material available for this exercise (no more than 10 minutes)
• Select one of the participants of the group for preparing the final
report on the laptop
• Be prepared to deliver the results of the exercises (in a pen drive) to
the course instructor at least five minutes before the time allocated

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PPT 5.64
 Your Questions

?
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PPT 5.65
Summary
The following topics Recall SMS Framework: Safety Risk
were covered in this Management
module:
Risk Assessment and Mitigation
Hazards and Consequences
Human Factors and Safety Risk
Management
Cost Benefit Analysis
THANK YOU