05 - DGCA ITS No 6701 RISK MITIGATION PROCEDURES REV. 1 (49slides)

ITS course Number : 6701
Course duration : 24 Hours
INITIAL
SAFETY MANAGEMENT SYSTEMS (SMS)
Module 6 – RISK MITIGATION PROCEDURES
MINISTRY OF TRANSPORTATION
DIRECTORATE GENERAL OF CIVIL AVIATION
DIRECTORATE OR AIRWORTHINESS AND AIRCRAFT OPERATION
erlanadgca@gmail.com
Safety Management System Modul 5
Module 06
OBJECTIVE
At the end of this module, participants will be able to apply
the fundamentals of risk management through a case
study.
erlanadgca@gmail.com Slide 2
Module 06
OUTLINE
 Definition of risk
 First fundamental – Risk management
 Second fundamental – Risk probability
 Third fundamental – Risk severity
 Fourth fundamental - Risk assessment and tolerability
 Fifth fundamental – Risk control/mitigation
 Risk management warm-up exercises
 Questions and answers
 Points to remember
Module 06
DEFINITION OF RISK
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 risk.
Module 06
FIRST FUNDAMENTAL – RISK MANAGEMENT

What is it?
The identification, analysis and elimination, and/or
mitigation to an acceptable level of risks that threaten
the capabilities of an organization.
What is the objective?
Aims at a balanced allocation of resources to address
all risks and viable risk control and mitigation.
Why is it important?
A key component of safety management systems.
Data-driven approach to safety resources allocation,
thus defensible and easier to explain.
Module 06
RISK MANAGEMENT
The risk is
Intolerable region unacceptable
at any level
As The risk is
acceptable based
Low on
As Tolerable region .
mitigation
Cost benefit
Reasonably analysis
Practicable is required.
Acceptable
region The risk is
acceptable as it
currently
stands
Module 06
Second fundamental - Risk probability
Definition(s)
Probability – The likelihood that an unsafe event or

condition might occur.
Module 06
Questions for assessing the probability of an occurrence:
Is there a history of occurrences like the one being

assessed, or is the occurrence an isolated event?
What other equipment, or similar type components,

might have similar defects?
Module 06
… questions such as:
What number of operating or maintenance personnel

must follow the procedure (s) in question?
How frequently is the equipment or procedure under

assessment used?
Module 06

Probability of occurrence
Qualitative
Meaning Value
definition
Frequent Likely to occur many times (has occurred frequently)

5
Occasional Likely to occur some times (has occurred infrequently)
4
Remote Unlikely, but possible to occur (has occurred rarely)
3
Improbable Very unlikely to occur (not known to have occurred) 2
Extremely
Almost inconceivable that the event will occur
improbable 1
Module 06
Third fundamental – Risk severity
Definition(s)
Severity – The possible consequences of an unsafe

event or condition, taking as reference the worst
foreseeable situation.
Module 06
Define the severity in terms of consequences for:

Property
Finance
Liability
People
Environment
Image
Public confidence
Module 06
Questions for assessing the severity of an occurrence:

How many lives may be lost?
Employees
Passengers
Bystanders
General public
What is the environmental impact?
Spill of fuel or other hazardous product
Physical disruption of natural habitat
Module 06

… questions such as:
What is the severity of the property or financial
damage?
Direct operator property loss
Damage to aviation infrastructure
Third party damage
Financial impact and economic impact for the State
Are there organizational, management or regulatory
implications that might generate larger threats to public
safety?
What are the likely political implications and/or media
interest?
Module 06

Severity of occurrences
Aviation definition 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
Hazardous perform their tasks accurately or completely. B
Serious injury.
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 increase in workload, or as a result
Major of conditions impairing their efficiency. C
Serious incident.
Injury to persons.
Nuisance.
Minor Operating limitations.
Use of emergency procedures. D
Minor incident.
Negligible Little consequences E
Module 06
Fourth fundamental – Risk assessment
Risk severity
Risk Catastrophic Hazardous Major Minor Negligible
probability A B C D E
Frequent 5 5A 5B 5C 5D 5E
Occasional 4 4A 4B 4C 4D 4E
Remote 3 3A 3B 3C 3D 3E
Improbable 2 2A 2B 2C 2D 2E
Extremely
improbable 1 1A 1B 1C 1D 2E
Module 06
Fourth fundamental – Risk tolerability
Assessment risk
Risk management Suggested criteria
index
Intolerable region
5A, 5B, 5C, 4A, Unacceptable under the
4B, 3A existing circumstances
5D, 5E, 4C, 4D, 4E, Acceptable based on risk

Tolerable region 3B, 3C, 3D, 2A, 2B, mitigation. It might require
management decision
2C
Acceptable
region 3E, 2D, 2E, 1A, 1B
Acceptable
,1C, 1D, 1E
Module 06
Fifth fundamental – Risk control/mitigation
Definition(s)
Mitigation – Measures to address the potential hazard
or to reduce the risk probability or severity.
Risk mitigation = Risk control
(Mitigate – To make milder, less severe or less harsh)
Module 06
Strategies
Avoidance – The operation or activity is cancelled
because risks exceed the benefits of continuing the
operation or activity.
Operations into an aerodrome surrounded by
complex geography and without the necessary aids
are cancelled.
Module 06
Strategies
Reduction –The frequency of the operation or activity is
reduced, or action is taken to reduce the magnitude of
the consequences of the accepted risks.
complex geography and without the necessary aids
are limited to day-time, visual conditions.
Module 06
Strategies
Segregation of exposure – Action is taken to isolate
the effects of the consequences of the hazard or build-in
redundancy to protect against it.
complex geography are limited to aircraft with
specific/performance navigation capabilities.
Non RVSM equipped aircraft not allowed to operate
into RVSM airspace.
Slide 21
Module 06
Safety risk management at a glance

Hazard
Equipment, procedures, organization, etc.
identification
Analyse the likelihood of the consequence Risk analysis

occurring
Probability
Evaluate the seriousness of the consequence if it Risk analysis
does occur
Severity
Is the assessed risk(s) acceptable and within the Risk assessment
organization’s safety performance criteria and tolerability
No, take action to Risk control

Yes, accept the risk(s) reduce the risk(s) to
an acceptable level /mitigation
Module 06
Risk mitigation – Defences
Recalling the three basic defences in aviation:
Technology
Training
Regulations
Module 06
Risk mitigation – Defences
As part of the risk mitigation, determine:

Do defences to protect against such risk (s) exist?
Do defences function as intended?
Are the defences practical for use under actual working
conditions?
Is staff involved aware of the risks and the defences in
place?
Are additional risk mitigation measures required?
Module 06
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
different mitigation
Tolerable region
warranted?
R R R R Do the mitigation
Acceptable
strategies
region generates
Each Risk additional risk(s)
Feedback (Safety assurance)
Module 06
As a reminder
 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” (ALARP)
 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.
Module 06
Hazards and risks – Closing the loop

 Hazard – Condition, object or activity with the potential of causing
injuries to personnel, damage to equipment or structures, loss of
material, or reduction of ability to perform a prescribed function.
 Consequence – Potential outcome(s) of the hazard.
 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 risk.
Module 06
Risk management process at a glance

Feedback and
record the hazard A safety concern is perceived
identification and
assessment and Identify hazards/consequences
risk mitigation and assess risks
Define the level Define the level
of probability of severity
Define the level of risk
Take action
and continue YES Is the risk level acceptable? NO
the operation
Take action
and continue YES Can the risk be eliminated? NO
the operation
YES Can the risk be mitigated?
Take action Can the residual risk be

and continue Cancel the
YES accepted? (if any) NO operation
the operation
Module 06
Risks
RISK MANAGEMENT WARM-UP

EXERCISES
Module 06
Warm-up exercise N° 05/01
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.
Module 06
Warm-up exercise N°05/01 – results
Hazard
Risk probability Remote
Fuel spill
Risk severity Hazardous
Consequence(s)
Risk index 3B
1. Fire
2. Contamination
Acceptable based on
3. Sliding vehicle risk mitigation. It
Risk tolerability might require
management decision
Module 06
Warm-up exercise N°05/02
Scenario:
It was observed that airline baggage handling personnel
generates FO(D) on the aerodrome apron area .
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.
Module 06
Warm-up exercise N°05/02– results
Hazard
Foreign object
Risk severity Hazardous
Consequence(s) Risk index 3B

1. Engine ingestion
2. Property damage
3. Tire damage Acceptable based on
risk mitigation. It
management decision
Module 06
Scenario:
A parked aircraft shows damage in the left wing root
near the fuselage. Such damage was caused by a
maintenance stair hitting the aircraft as a consequence
of the wind, apparently because the stair was not
properly restrained.
In conditions of strong winds it is essential that all
equipment around aircraft is properly restrained and
locked, thus preventing the possibility of aircraft
damage.
Module 06
Warm-up exercise N° 05/03 – results
Hazard
Risk probability Occasional
Unsecured equipment
Risk severity Minor
Consequence(s) Risk index 4D

1. Damage to aircraft
2. Injury to persons
Acceptable based on
risk mitigation. It
management decision
Module 06
Scenario:
The vehicle and ramp equipment parking area behind
the fingers shows a large amount of FO(D) (food, trays,
plastics, pillows, etc.) left behind by an airline.
The presence of decomposed food and others
dangerous material was informed to the airline, since in
addition to FO(D), this presents a bacteriological danger
for people who operate in this sector, also attracting
animals to the operative apron.
Module 06
Hazard
Risk probability Occasional
Foreign object
Risk severity Major
Consequence(s) Risk index 4C

1. Attract wildlife
2. Vehicle accident Acceptable based on
3. Bacteriological risk mitigation. It
management decision
Module 06
Scenario:
A loose wheel, apparently from a baggage cart, was
observed in the handling area. The driver apparently did
not notice what happened. The wheel rolled at high
speed through the area, hitting the fence accessing the
fuel zone.
This could have caused injuries to ramp personnel in
addition to material damage to equipment and/or
aerodrome facilities. We have insisted in the past on the
periodic verification of all equipment and vehicles that
operate in the aerodrome apron area.
Module 06
Hazard
Unsecured wheel
Risk severity Major

2. Damage to property
Acceptable based on
risk mitigation. It
management decision
Module 06
Scenario:
The absence of airline personnel attending the stairs
was observed in three occasions, in flights from different
companies. The presence of airline personnel is
necessary to guide passengers when embarking and
disembarking.
This is a risk for passengers, since they should access
the apron to board aircraft in an orderly manner under
the guidance of airline personnel.
Module 06
Hazard
Unaccompanied
passengers in the
ramp
Risk severity Major

2. Damage to equipment
3. Interruption of Acceptable based on
risk mitigation. It might
operations Risk tolerability require management
decision
Module 06
Table 05/01 – Hazard identification and risk

management
Type of Specific Existing defences Further action to
operation Generic components Hazard-related to control risk(s) reduce risk(s) and
Nº hazard consequences
or activity of the hazard and risk index resulting risk index
1 Risk index: Risk index:

Risk tolerability: Risk tolerability:




Slide 42
Module 06
Risks
QUESTIONS AND ANSWERS
Module 06
Questions and answers
Q: Define risk management.

A:
The identification, analysis and elimination, and/or
mitigation of risks that threaten the capabilities of an
organization to an acceptable level.
Slide number: 6
Module 06
Q: What are the five designations for risk probability?

A:
Frequent
Occasional
Remote
Improbable
Extremely
improbable
Slide number: 13
Module 06
Q: What are the five designations for risk severity?

A:
Catastrophic
Hazardous
Major
Minor
Negligible
Slide number: 18
Module 06
Q: Describe the three basic risk mitigation strategies.

A:
Avoidance – The operation or activity is cancelled
because risks exceed the benefits of continuing the
operation or activity.
Reduction –The frequency of the operation or activity is
reduced, or action is taken to reduce the magnitude of
the consequences of the accepted risks.
Segregation of exposure – Action is taken to isolate
the effects of the consequences of the hazard or build-in
redundancy to protect against it.
Slide number: 22, 23 and 24
Module 06
Points to remember
1. The risk assessment matrix.

2. The risk assessment criteria table.
3. Risk mitigation: avoid, reduce, segregate.
ITS course Number : 6701
Course duration : 24 Hours
INITIAL
SAFETY MANAGEMENT SYSTEMS (SMS)
Module 2 – REPUBLIC OF INDONESIA LEGISLATION
AND DGCA CASRs THAT PERTAIN TO THIS SUBJECT
MINISTRY OF TRANSPORTATION
DIRECTORATE GENERAL OF CIVIL AVIATION
DIRECTORATE OR AIRWORTHINESS AND AIRCRAFT OPERATION
erlanadgca@gmail.com

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05 - DGCA ITS No 6701 RISK MITIGATION PROCEDURES REV. 1 (49slides)

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ITS course Number : 6701

Course duration : 24 Hours

At the end of this module, participants will be able to apply

the fundamentals of risk management through a case

FIRST FUNDAMENTAL – RISK MANAGEMENT

Second fundamental - Risk probability

Probability – The likelihood that an unsafe event or

Second fundamental - Risk probability

Questions for assessing the probability of an occurrence:

Is there a history of occurrences like the one being

What other equipment, or similar type components,

Second fundamental - Risk probability

… questions such as:

What number of operating or maintenance personnel

How frequently is the equipment or procedure under

Second fundamental - Risk probability

Frequent Likely to occur many times (has occurred frequently)

Third fundamental – Risk severity

Severity – The possible consequences of an unsafe

Third fundamental – Risk severity

Define the severity in terms of consequences for:

Third fundamental – Risk severity

Questions for assessing the severity of an occurrence:

Third fundamental – Risk severity

Third fundamental – Risk severity

Fourth fundamental – Risk assessment

Fourth fundamental – Risk tolerability

5D, 5E, 4C, 4D, 4E, Acceptable based on risk

Fifth fundamental – Risk control/mitigation

(Mitigate – To make milder, less severe or less harsh)

Fifth fundamental – Risk control/mitigation

Fifth fundamental – Risk control/mitigation

Fifth fundamental – Risk control/mitigation

Safety risk management at a glance

Analyse the likelihood of the consequence Risk analysis

No, take action to Risk control

Risk mitigation – Defences

Recalling the three basic defences in aviation:

Risk mitigation – Defences

As part of the risk mitigation, determine:

Risk mitigation at a glance

H H H H Does it address the

Feedback (Safety assurance)

Hazards and risks – Closing the loop

Risk management process at a glance

YES Can the risk be mitigated?

Take action Can the residual risk be

RISK MANAGEMENT WARM-UP

Warm-up exercise N° 05/01

Warm-up exercise N°05/01 – results

Risk severity Hazardous

Warm-up exercise N°05/02

Warm-up exercise N°05/02– results

Risk severity Hazardous

Consequence(s) Risk index 3B

Warm-up exercise N° 05/03

Warm-up exercise N° 05/03 – results

Risk severity Minor

Consequence(s) Risk index 4D