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Introduction 3 1.3 Definitions The following terms are used throughout this report: Accident: An unplanned event or series of events resulting in death, injury, or damage to, or loss of, equipment or property. Audit: Formal reviews and verifications to evaluate conformity with policy, standards, and contractual requirements. -- Internal Audit: An audit conducted by, or on behalf of, the organization being audited. -- External Audit: An audit conducted by an entity outside the organization being audited. Beliefs: The conviction (real or perceived) that certain facts and/or actions will entail specific consequences; how people think things work. An example is the belief, "I will not get penalized if I delay the job for safety reasons." There are beliefs that promote a strong safety culture and others that undermine it. Beliefs that may promote or undermine safety Promote Undermine My supervisor is really committed to Sometimes it is necessary to take safety chances to get a job done Most accidents are caused by human Sometimes it is necessary to turn a blind factors eye when safety rules are broken Incidents are valuable learning My manager says "safety first" but experiences and should be reported doesn't really mean it Consequence: Potential outcome(s) of a hazard. Corrective Action: Action to eliminate or mitigate the cause or reduce the effects of a detected nonconformity or other undesirable situation. Culture: Workplace culture is the set of shared values and beliefs of people in an organization. Culture encourages certain behaviors and discourages others. Documentation: Information or meaningful data and supporting medium (e.g., paper, electronic). In this context, it is distinct from records because it is the written description of policies, processes, procedures, objectives, requirements, authorities, responsibilities, or work instructions. Errors: In the present context, an error is an "honest mistake" that is unintentional, not out of "Human error is a symptom, not a cause." malicious intent, and not a result of gross negli- (James Reason(5)) gence. There are legal definitions of the term "gross negligence," but it is not the intent of this guide- book to debate this issue. Gap Analysis: Identification of existing safety pillars compared with SMS program require- ments. Gap analysis provides an airport operator an initial SMS development plan. Hazard: Any existing or potential condition that can lead to injury, illness, or death to peo- ple; damage to or loss of a system, equipment, or property; or damage to the environment. A hazard is a prerequisite to an accident or incident.

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4 Safety Management Systems for Airports A runway contaminated with ice is a hazard. The potential that the pilot may not be able to control the aircraft during the operation and veer off or overrun the runway, causing hull loss and multiple fatalities is the risk. Incident: A near miss episode, malfunction, or failure without accident-level consequences that has a significant chance of resulting in accident-level consequences. Investigation: A process conducted for the purpose of accident prevention which includes the gathering and analysis of information, the drawing of conclusions, including the determination of causes and, when appropriate, the making of safety recommendations. Latent Conditions: existent conditions in the system that can be triggered by an event or a set of events(3) or "latent errors, whose adverse consequences may lie dormant within the system for a long time."(4) Likelihood: The estimated probability or frequency, in quantitative or qualitative terms, of a hazard's effect. Line Management: Management structure that operates the production/operational system. Near Miss: "Any event that could have had bad consequences, but did not."(31) Nonconformity: Non-fulfillment of a requirement. This includes but is not limited to non- compliance with federal regulations. It also includes an organization's requirements, policies, and procedures, as well as requirements of safety risk controls developed by the organization. Oversight: A function that ensures the effective promulgation and implementation of safety standards, requirements, regulations, and associated procedures. Safety oversight also ensures that the acceptable level of safety risk is not exceeded in the air transportation system. Procedure: A specified way to carry out an activity or a process. Process: A set of interrelated or interacting activities that transforms inputs into outputs. Proximate Cause: A cause that, in a natural and continuous sequence, unbroken by new and independent causes, produces the injury. Records: Evidence of results achieved or activities performed. In this context, it is distinct from documentation because records are the documentation of SMS outputs. Risk Assessment: Assessment of the system or pillar to compare the achieved risk level with the tolerable risk level. Root Cause: A factor (event, condition, organizational) that contributed to or created the proximate cause and subsequent undesired outcome and, if eliminated or modified, would have prevented the undesired outcome. Typically, multiple root causes contribute to an undesired outcome. Safety: The state in which the risk of harm to persons or of property damage is reduced to, and maintained at or below, an acceptable level through a continuing process of hazard identi- fication and risk management. Safety Assessment: A systematic, comprehensive evaluation of an implemented system. Safety Assurance: SMS process management functions that systematically provide confidence that organizational products/services meet or exceed safety requirements.

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Introduction 5 Safety Climate: The manifestation of safety culture in the behavior and expressed attitude of employees. Safety Culture: The product of individual and group values, attitudes, competencies, and pat- terns of behavior that determine the commitment to, and the style and proficiency of, the orga- nization's management of safety. Organizations with a positive safety culture are characterized by communications founded on mutual trust, by shared perceptions of the importance of safety, and by confidence in the efficacy of preventive measures. Safety Management System: The formal, top-down business-like approach to managing safety risk. It includes systematic procedures, practices, and policies for the management of safety (including safety risk management, safety policy, safety assurance, and safety promotion). Safety Objective: Safety goals or desired outcomes, which typically are measurable. Safety Performance Indicator: Any measurable parameter used to point out how well any activity related to safety is performing over time, and to assess the overall SMS health indirectly. Safety Policy: Defines the fundamental approach to managing safety that is to be adopted within an organization. Safety policy further defines the organization's commitment to safety and overall safety vision. Safety Promotion: A combination of safety culture, training, and information sharing activ- ities that supports the implementation and operation of an SMS in an organization. Safety Risk: The composite of the likelihood (i.e., probability) of the potential effect of a haz- ard and predicted severity of that effect. As an example, an overshoot by an aircraft landing on an icy runway would be considered a safety risk of the hazard. The hazard is "icy runway," and the risk is "an overshoot." Safety Risk Control: Anything that mitigates the safety risk of a hazard. Safety risk controls necessary to mitigate an unacceptable risk should be mandatory, measurable, and monitored for effectiveness. Safety Risk Management: A formal process within the SMS composed of describing the sys- tem, identifying the hazards and assessing, analyzing, and controlling the risk. The SRM process is embedded in the operational system; it is not a separate process. Severity: The consequence or impact of a hazard in terms of degree of loss or harm. System: An integrated set of elements that are combined in an operational or support envi- ronment to accomplish a defined objective. These elements include people, hardware, software, firmware, information, procedures, facilities, services, and environment. Top Management: The person or group of people who direct and control an organization. This group is sometimes referred to as Senior Management. Unsafe Behavior: A behavior that is more likely to lead to incidents or accidents. An unsafe behavior may be unintentional or intentional. In 2005, a ground baggage handler grazed an MD-83 aircraft with a tug while attempting to depart the vicinity of the airplane. The incident was triggered by improper operation (the unsafe behavior) and was not reported (an amplification factor also indicative of an unsafe behavior). The damage to the aircraft was substantial. The result was the aircraft's in-flight depressurization. Post landing examination of the fuselage revealed a 12 by 6-inch hole on the right side of the airplane (source: NTSB SEA06LA033).