Of the four pillars1 of a safety management system (SMS), safety risk management is perhaps the most practical and progressive, as it represents precisely the response that will be given to the identified hazards to which an organization is subjected.
Managing risks is a never-ending process that challenges an organization to constantly search for possible sources of hazards, and to devise often innovative ways to reduce the risks associated with them. However, risk management also entails constant reassessment, since implemented barriers may become additional sources of hazards, and organizations may undergo changes that can render previously adopted risk-mitigating actions obsolete or ineﬀective. Finally, risk management cannot succeed in a vacuum. This means that risk management tasks must not be detached from a company’s business objectives, and, as much as possible, they must help the company achieve its financial goals without allowing safety to be neglected.
According to aviation human factors expert Daniel Maurino and others in the 1995 book Beyond Aviation Human Factors, “Pursuing safety and eﬀectiveness in aviation is an endless quest, which allows for no time to rest over accomplishments.”2
Risk management follows the same philosophy, given that, in an eﬀective SMS, there should never be a sense of satisfaction. Instead, there should be a desire to not only try to identify as many hazards as possible and to bring their associated risks to a level that is as low as practicable, but also to look back at implemented barriers and think about whether they have introduced new sources of risk. A prime example is the advent of bulletproof cockpit doors with advanced locking mechanisms: These were introduced following the Sept. 11, 2001, terrorist attacks in the United States to prevent individuals who planned to inflict harm from entering aircraft flight decks; however, 14 years later, they allowed a Germanwings co-pilot struggling with mental health issues to lock his captain outside the cockpit and fly an Airbus A320 with 150 occupants into the ground in the French Alps.
Essentially, all changes must be well managed and monitored into the future. Carefully planning the implementation of these barriers and diligently assessing possibly negative consequences does not mean that they will indefinitely be suitable for their originally intended purpose. With time, organizations change: New procedures are introduced, new equipment is incorporated, and new people are recruited. All of this signifies that actions adopted in the past to mitigate risks may be rendered ineﬀective following certain organizational changes. For this reason, changes must not be underestimated and, from time to time, risk mitigations have to be re- assessed through a process of change management.
Although, in the safety realm, people often associate “being creative” with bad conduct, such as creating more dangerous ways to carry out a task or simply not following procedures, creativity is actually a desirable trait in managing risks. Balancing production and protection is often about thinking outside the box and devising ways to reduce exposure to hazards while also ensuring that excessive resources are not required to do so. For this to be achieved, though, the people who provide input on the mitigation measures should come from diverse backgrounds and have varied experiences. Additionally, those who will closely engage with the end product of a risk management process (for example, pilots, mechanics and air traﬃc controllers) must be involved, since this may be an easy way to learn from the beginning which measures will work and which will not.
Lastly, risk management must not occur in a vacuum. That is, the company’s financial objectives must be taken into consideration. Think about how ineﬀective it would be to have very low overall exposure to risks but not enough revenue to maintain the business. The International Civil Aviation Organization (ICAO) establishes in its Safety Management Manual (Doc 9859) that a cost-benefit analysis should be conducted during safety risk mitigation activities whenever a significant financial impact is expected. This allows organizations to make sounder decisions about the best course of action when aiming to mitigate certain risks.
For example, in the past, the rotorcraft industry has discussed the possibility of mandating the installation of crash-resistant fuel systems (CRFS) in all helicopters to prevent post-crash fires. However, these systems are not simple to install, may require extensive design modifications and, consequently, may present a prohibitive cost to many operators. Therefore, while helicopters equipped with CRFS are safer, many companies simply cannot aﬀord them. This results in operators either accepting the risk of post-crash fires or devising alternate, less costly mitigation strategies, such as procuring fire-resistant flight suits for crewmembers.
Mitigating risks requires continuously searching for hazards and for opportunities to further mitigate their associated risks, as well as being suﬃciently creative to develop innovative mitigation strategies while being sensible enough to ensure that the production-versus-protection scale remains balanced.
Image: © EtiAmmos | iStockphoto
Lucca Carrasco Filippo is a safety training and promotion specialist at a large European business aviation company and a former commercial helicopter pilot. He holds a degree in aeronautical sciences and multiple qualifications in safety management systems, human factors and incident investigation.
- The four pillars, as set forth by the International Civil Aviation Organization, are safety policy, safety risk management, safety assurance and safety promotion.
- Maurino, Daniel E.; Reason, James; Johnston, Neil; Lee, Rob B. Beyond Aviation Human Factors. Farnham, Surrey, U.K.: Ashgate Publishing, 1995.