Airport Incident Reporting Practices (2019)

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72 A P P E N D I X B Terms and Definitions The following terms and definitions are presented to illustrate the variability within the industry as to what a particular term may mean. They are also presented as alternative selections for an airport organization to choose from that would best meet the application at its airport. Accident: An unplanned event or series of events that results in death, injury, or damage to, or loss of, equipment or property. (FAA Order 8040.4B. https://www.faa.gov/documentLibrary/media/Order/FAA_Order_8040.4B.pdf). At-risk behaviors: Any activity that is not consistent with safety programs or training. (WIT Transactions on The Built Environment, Vol 134, p. 261. https://webcache.googleusercontent.com/search?q=cache:uHqnbwjikgoJ:https://www.witpress.com/ elibrary/wit-transactions-on-the-built-environment+&cd=1&hl=en&ct=clnk&gl=us&client=firefox-b-ab). Audit: A systematic and documented review of the effectiveness of implementation of processes, programs, and procedures based on general process criteria set by the organization. (The Anglo American Safety Way. http://www.angloamerican.com/~/media/Files/A/ Anglo-American-PLC-V2/documents/approach-and-policies/safety-and-health/the-anglo-american-safety-way-final.pdf). Business continuity (BC): The capability of the organization to continue delivery of products or services at acceptable predefined levels following a disruptive incident. (ISO 22301:2012. http://www.thebci.org/index.php/resources/what-is-business-continuity). Business continuity management (BCM): A holistic management process that identifies potential threats to an organization and the impacts to business operations those threats, if realized, might cause, and which provides a framework for building organizational resilience with the capability of an effective response that safeguards the interests of its key stakeholders, reputation, brand, and value-creating activities. (ISO 22301:2012. http://www.thebci.org/index.php/resources/what-is-business-continuity). Climate: Employees’ perceptions of workplace events and the expectations that the organization has of workplace behaviors, attitudes, and norms. [Ostroff, C., Kinicki, A. J., & Tamkins, M. M. 2003. Organiza tional culture and climate. In W. C. Borman, D. R. Ilgen, & R. J. Klimoski (Eds.), Handbook of psychology. Industrial and organizational psychology, Vol. 12 (pp. 565–593). Hoboken: Wiley]. Climate: The measurable components of the safety culture such as the management behaviors, the safety systems, and the employee perceptions of safety. (Guldenmund F., The nature of safety culture: a review of theory and research. Saf Sci. 2000;34:215–257.) Climate: Describes employees’ perceptions (as opposed to attitudes and beliefs) about risk and safety, providing a “snapshot” of the current state of safety. (Mearns, K., Yule, S., 2009. The role of national culture in determining safety performance. Challenges for the global oil and gas industry. Safety Science 47, 777–785.) Climate: An “artifact” of the deeper cultural level and the visible behavior of its members. Artifacts include organizational processes which render certain behaviors routine. The term “safety climate” is often heard alongside that of culture. (A literature review on safety performance indicators supporting the control of major hazards National Institute for Public Health and the Environment Dutch Ministry of Health, Welfare, and Sport, Netherlands RIVM Report 620089001/2012 L.J. Bellamy | V.M. Sol). Consequence: The negative effect of an event, incident, or occurrence. (GAO-16-632 Aviation Security. https://www.gao.gov/assets/680/677586.pdf). Culture: The ability and willingness of the organization to understand safety, hazards and means of preventing them, as well as ability and willingness to act safely, prevent hazards from actualizing, and promote safety. (Reiman, T., E. Pietikäinen. “Leading indicators of system safety – Monitoring and driving the organizational safety potential.” Safety Science, Vol. 50, 2012. pp. 1993–2000). Culture: The product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that can determine the commitment to and the style and proficiency of an organization’s safety management system. [The Advisory Committee on the Safety of Nuclear Installations (ACSNI). www.hse.gov.uk/humanfactors/topics/common4.pdf].

Terms and Definitions 73 Culture: The ability and willingness of the organization to understand safety, hazards and means of preventing them, as well as ability and willingness to act safely, prevent hazards from actualizing, and promote safety. Safety culture refers to a dynamic and adaptive state. It can be viewed as a multilevel phenomenon of organizational dimensions, social processes, and psychological states of the personnel. [Reiman, T. & Oedewald, P. (2009). Evaluating safety critical organizations. Focus on the nuclear industry. Swedish Radiation Safety Authority, Research Report 2009:12]. Culture: The set of enduring values and attitudes regarding safety issues, shared among the members of the group. It refers to the extent to which the members of the group are positively committed to safety; consistently evaluate safety-related behavior; are willing to communicate safety issues; are aware of the known risks and unknown hazards induced by their activities; are willing and able to adapt themselves when facing safety issues; and are continuously behaving so as to preserve and enhance safety. [Montijn, C. and Balk, A.D. (2010), ASC-IT Aviation Safety Culture Inquiry Tool: Development from theory to practical tool, NLR Technical Report 2009-241, January 2010]. Enterprise risk management (ERM): A process, effected by an entity’s board of directors, management, and other personnel, applied in a strategy setting and across the enterprise, designed to identify potential events that may affect the entity, and manage risks to be within its risk appetite, to provide reasonable assurance regarding the achievement of entity objectives. [Committee of Sponsoring Organizations of the Treadway Commission (COSO), 2004. https://erm.ncsu.edu/library/article/coso-erm-framework]. Enterprise risk management: A discipline that addresses the full spectrum of an organization’s risks, including challenges and opportunities, and integrates them into an enterprise-wide, strategically aligned portfolio view. ERM contributes to improved decision-making and supports the achievement of an organization’s mission, goals, and objectives. (OMB Circular No. A-123: Management’s Responsibility for Enterprise Risk Management and Internal Control Association for Federal Enterprise Risk Managers November 7, 2016. https://www.whitehouse.gov/sites/whitehouse.gov/files/omb/.../2016/m-16-17.pdf). Enterprise risk management: A holistic approach and process to identify, prioritize, mitigate, manage, and monitor current and emerging risks in an integrated way across the breadth of the enterprise (ACRP Report 74: Application of Enterprise Risk Management at Airports, 2012. URL: http://www.trb.org/Publications/Blurbs/167515.aspx). Enterprise risk management: A systematic approach to risk management across the entire organization for identifying, assessing, deciding on responses to, and reporting on opportunities and threats that affect the achievement of its objectives. (Institute of Internal Auditors, 2009. http://www.uvm.edu/~erm/RiskAssessmentGuide.pdf). Enterprise risk management framework: A series of key components that collectively provide the ERM principles, concepts, processes, terminology, and direction for the delivery of effective ERM to enable the achievement of key strategic/operational objectives. (ACRP Report 74: Application of Enterprise Risk Management at Airports, 2012. URL: http://www.trb.org/Publications/Blurbs/167515.aspx). Error: A generic term to encompass all those occasions in which a planned sequence of mental or physical activities fails to achieve its intended outcome, and when these failures cannot be attributed to the intervention of some chance agency. (Reason, J. Human Error 1990. Cambridge University Press. Manchester, UK 1990.) Error: Includes two types of failures. Either the plan developed by the operator is adequate, but the actions deviate from the plan; or the actions may follow the plan, but the plan is not appropriate for achieving its desired ends. The first type of failure is considered a slip or a lapse and is a failure in executing a plan, while the second type of failure is considered a mistake and is a failure in formulating a plan. (Maurino, et al. Beyond Aviation Human Factors. Avebury Aviation, Hants, UK 1995). Event: The occurrence or change of a particular set of circumstances. (ANSI-ASSE Z690.1 2011, http://www.asse.org/ansi/ asse-z690-1-2011-vocabulary-for-risk-management-national-adoption-of-iso-guide-73-2009-/) Event: Occurrence of a particular set of circumstances. The event can be certain or uncertain. The event can be a single occurrence or a series of occurrences. (URL: https://www.enisa.europa.eu/topics/threat-risk-management/risk-management/current-risk/risk- management-inventory/glossary). Fault tree analysis (FTA): Used to examine an extremely complex system involving various targets such as skills, quality, equipment, facility, operators, finance, management, reputation, or property within the domain of operation. [Malasky, S. W. (1982). System safety: Technology and application (2nd ed.). New York: Garland STPM Press]. Hazard: A condition, object or activity with the potential for causing damage, loss, or injury. (FAA AC 150/5200-37, 2007. https://www.faa.gov/documentLibrary/media/.../150-5200-37/150_5200_37.pdf). Culture: The enduring value and priority placed on worker and public safety by everyone in every group at every level of an organization. It refers to the extent to which individuals and groups will commit to personal responsibility for safety; act to preserve, enhance, and communicate safety concerns; strive to actively learn, adapt, and modify (both individual and organizational) behavior based on lessons learned from mistakes; and be rewarded in a manner consistent with these values. [Wiegmann, D.A.; Zhang, H.; von Thaden, T.; Sharma, G.; Mitchell, A. Safety culture: A review. (Technical Report no. ARL-02-3/FAA-02-2). Atlantic City, New Jersey: FAA, 2002.] Culture: The values, beliefs, and norms that govern how people act and behave with respect to safety. (Stolzer, A.J.; Halford, C.D.; Goglia, J.J. Implementing safety management systems in aviation. Burlington, Vermont: Ashgate, 2011).

74 Airport Incident Reporting Practices Hazard: A source of potential harm or a situation with a potential to cause loss. (ACRP Report 74: Application of Enterprise Risk Management at Airports, 2012. URL: http://www.trb.org/Publications/Blurbs/167515.aspx). Hazard: A present condition, event, object, or circumstance that could lead to or contribute to an unplanned or undesired event such as an accident. [Risk Management Handbook (FAA-H-8083-2) 2009. https://www.faa.gov/regulations_policies/handbooks_manuals/.../faa-h-8083-2.pdf]. Hazard: An undesirable condition or situation that may lead to unsafe event(s) or occurrence(s). Sometimes the term “threat” (e.g., TEM) is used instead of “hazard.” [ICAO. Doc 9859 - Safety Management Manual (SMM). International Civil Aviation Organization. 3nd ed, pp. 1-284. Montreal, Canada. 2013.] Hazard: An inherent property of a substance, agent, source of energy or situation having the potential of causing undesirable consequences. (OECD. 2008. Guidance on Developing Safety Performance Indicators Related to Chemical Accident Prevention, Preparedness and Response: Guidance for Industry. https://www.oecd.org/env/ehs/chemical-accidents/48356891.pdf). Hazard: A hazard is any existing or potential condition that can lead to injury, illness, or death to people; damage to or loss of a system, equipment, or property; or damage to the environment. A hazard is a condition that might cause (is a prerequisite to) an accident or incident. FAA, 2015. https://www.faa.gov/regulations_policies/advisory_circulars/index.cfm/go/document.information/documentID/1026670. Incident: An occurrence other than an accident that affects or could affect the safety of operations. (FAA Order 8040.4B. https://www.faa.gov/documentLibrary/media/Order/FAA_Order_8040.4B.pdf). Incident: An event of sufficient severity to be reported. No general agreement on what counts as “sufficient.” (Reason, J.T., The Human Contribution: Unsafe Acts, Accidents and Heroic Recoveries. Ashgate. 2008). Incident: An event that could lead to loss of, or disruption to, an organization’s operations, services, or functions. (Glossary of Terms, The Business Continuity Institute Good Practice Guidelines 2010 Global Edition. URL: http://www.thebci.org/glossary.pdf). Incident: Work-related events or emergencies (including accidents which give rise to injury, ill health or fatality) that have resulted in, or have the potential to result in (i.e., a near hit), adverse consequences to people, the environment, property, reputation or a combination of these. Significant deviations from standard operating procedures are also classed as incidents. Ongoing conditions that have the potential to result in adverse consequences are considered to be incidents. (The Anglo American Safety Way. http://www.angloamerican.com/~/media/Files/A/Anglo-American-PLC-V2/documents/approach-and-policies/safety-and-health/ the-anglo-american-safety-way-final.pdf). Incident (serious): An incident involving circumstances indicating that there was a high probability of an accident. (ICAO, Annex 13. 2010, p. 21–22. https://www.icao.int/safety/airnavigation/AIG/Pages/Documents.aspx). Incident management (IcM): A term describing the activities of an organization to identify, analyze, and correct hazards to prevent a future re-occurrence. These incidents within a structured organization are normally dealt with by either an incident response team (IRT), or an incident management team (IMT). Similar to an IRT or IMT is an Incident Command System (ICS). (URL: https://en.wikipedia.org/wiki/Incident_management). Indicator: A statistic that is used to quantify a current or past observable condition or to provide future insight into changes affecting the condition. [Øien, K, Massaiu, S, Tinmannsvik, R.K., Størseth, F. (2010). Proceedings of the 10th International Probabilistic Safety Assessment and Management Conference (PSAM), Seattle, USA. http://www.proceedings.com/16555.html]. Indicator: Observable measures that provide insights into a concept—safety—that is difficult to measure directly. This Guidance includes two types of safety performance indicators: “outcome indicators” and “activities indicators.” (OECD. 2008. Guidance on Developing Safety Performance Indicators Related to Chemical Accident Prevention, Preparedness and Response: Guidance for Industry. https://www.oecd.org/env/ehs/chemical-accidents/48356891.pdf). Indicator: An algorithm or formula that expresses the qualitative or quantitative relationship between two or more variables and that serves to measure to what extent has the target been achieved. (ICAO Acceptable Level of Safety Performance ALoSP. https://www.icao.int/SAM/Documents/2017.../Módulo%209%20-%20ALoSP_en.pdf). Just culture: A culture that balances the need for discipline when warranted, with rewards when earned. People clearly understand acceptable and unacceptable behaviors. There’s a sense of fairness in how business is conducted for everyone. In a Just Culture, those in authority do not “shoot the messenger” for bringing up safety concerns. (NASA. https://sma.nasa.gov/sma-disciplines/ safety-culture). Hazard: The potential for harm (physical or mental). In practical terms, a hazard often is associated with a condition or activity that, if left uncontrolled, can result in an injury or illness. (OSHA. https://www.osha.gov/dte/grant_materials/fy10/sh...10/ hazard_id_facilitatorguide.pdf). Hazard: Any existing or potential condition that can lead to injury, illness, or death to people; damage to or loss of a system, equipment, or property; or damage to the environment. A hazard is a condition that is a prerequisite to an accident or incident. (FAA AC 150/5200-37, 2007. https://www.faa.gov/documentLibrary/media/.../150-5200-37/150_5200_37.pdf).

Terms and Definitions 75 Key performance indicators (KPIs): Measures that monitor the performance of key result areas of business activities. KPIs represent a set of measures focusing on those aspects of organizational performance that are the most critical for the success of an organization. (A literature review on safety performance indicators supporting the control of major hazards National Institute for Public Health and the Environment Dutch Ministry of Health, Welfare, and Sport, Netherlands RIVM Report 620089001/2012 L.J. Bellamy | V.M. Sol). Key performance indicators (KPIs): A metric that embeds performance targets so organizations can chart progress toward goals. [The Data Warehousing Institute (TDWI) Deploying Dashboards and Scorecards, July 2006 Wayne W. Eckerson ©2006 1105 Media, Inc., based in Chatsworth, CA]. Lagging indicator: Metrics that measure safety events that have already occurred including those unwanted safety events you are trying to prevent. (Safety Management International Collaboration Group SMICG. https://www.skybrary.aero/bookshelf/ books/2395.pdf). Lagging indicators: Also known as outcome, trailing, down-stream and after-the-fact indicators. (Broadbent, D. and Arnold, I. 2011. Leading the Way Towards Optimal Safety and Health Performance: Lagging and Leading Indicator Characteristics. London: ICMM). Lagging indicators: Metrics that measure the extent of harm that has occurred—past performance. Reactive, tells you whether you have achieved a desired result (or when a desired safety result has failed) and provide historical information about health and safety performance (OECD. 2008. Guidance on Developing Safety Performance Indicators Related to Chemical Accident Prevention, Preparedness and Response: Guidance for Industry. https://www.oecd.org/env/ehs/chemical-accidents/48356891.pdf). Lagging indicators: Measures of a system taken after events to assess outcomes and occurrences, such as accident and injury rates, operational incidents, and dollar costs. (Guidance Notes on Safety Culture and Leading Indicators of Safety American Bureau of Shipping, February 2014. https://ww2.eagle.org/content/dam/...safety/leading_indicators_gn_e-feb14.pdf). Leading indicators: Metrics that provide information on the current situation that may affect future performance (Safety Management International Collaboration Group SMICG. https://www.skybrary.aero/bookshelf/books/2395.pdf). Leading indicators: Conditions, events or measures that precede an undesirable event and that have some value in predicting the arrival of the event, whether it is an accident, incident, near miss or undesirable safety state. Leading indicators are associated with proactive activities that identify hazards and assess, eliminate, minimize and control risk. [Grabowski, M., Ayyalasomayajula, P., Merrick, J., Harrald, J. R., & Roberts, K. (2007). Leading indicators of safety in virtual organizations. Safety Science, 45(10), 1013-1043]. Leading indicators: Provide information about developing or changing conditions and factors that tend to influence future human performance. Leading indicators are viewed as measures or signs of changing vulnerabilities. Effective leading indicators provide a basis for predicting or forecasting situations in which the potential exists for a change in human performance, either for better or worse. (Electric Power Research Institute EPRI. https://www.epri.com/#/pages/product/1003033/). Leading indicators: Conditions, events, and sequences that precede and lead up to accidents. (National Academy of Engineering (NAE) (2004). Accident Precursor Analysis and Management: Reducing Technological Risk Through Diligence. Washington, D.C.: The National Academies Press.) Leading indicators: Conditions, events or measures that precede an undesirable event, and have some value in predicting the arrival of the event, whether it is an accident, incident, near miss, or undesirable safety state. (Toellner, J., “Improving safety and health performance. Identifying and measuring leading indicators.” Professional Safety Vol. 46, No. 9, 2001. pp. 42–47). Leading indicators: Safety metrics that are associated with, and precede, an undesirable/unexpected consequence such as an operational incident, near miss or personal injury. (Human Factors in Ship Design and Operation, 16–17 November 2011, London. http://www.rina.org.uk/hres/human%20factors%20web1.pdf). Leading indicators: The factors that provide measures of the performance of key work processes, culture and behaviors before an unwanted outcome occurs. (Dyreborg, J. 2009. The causal relation between lead and lag indicators. Safety Science, 47, 474-475). Metric: A system of measurement used to quantify safety performance for outcome and/or activities indicators. (OECD. 2008. Guidance on Developing Safety Performance Indicators Related to Chemical Accident Prevention, Preparedness and Response: Guidance for Industry. https://www.oecd.org/env/ehs/chemical-accidents/48356891.pdf). Just culture: A culture in which front-line operators or other persons are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training, but in which gross negligence, willful violations and destructive acts are not tolerated, and in which personnel are encouraged to report such information for improvements of the organization’s safety (performance). (European Commission Regulation No. 376/2014. http://www.eurocontrol.int/articles/just-culture). Key performance indicators (KPIs): A set of measures focusing on those aspects of organizational performance that are the most critical for the current and future success of the organization. [Parmenter, David (2007) “Key performance indicators: develo implementing, and using winning KPIs,” New Jersey: John Wiley & Sons, Inc.]. ping,

76 Airport Incident Reporting Practices Near hit: A near hit is any occurrence or situation which had the potential for adverse consequences to people, the environment, property or reputation, or a combination of these. (The Anglo American Safety Way. http://www.angloamerican.com/~/media/Files/A/ Anglo-American-PLC-V2/documents/approach-and-policies/safety-and-health/the-anglo-american-safety-way-final.pdf). Near miss: An incident in which no property was damaged and no personal injury was sustained, but where, given a slight shift in time or position, damage or injury easily could have occurred. (URL: http://www.coopertsmith.com/nearmiss-explained). Near miss: An opportunity to improve reliability, safety, security, health, and the environment of an operation based on an abnormal event having the potential for a more serious consequence. [Phimister JR, Oktem U, Kleindorfer PR, Kunreuther H. Near-miss incident management in the chemical process industry. Risk Anal. 23 (2003); 445-459.] Near miss: An event, a sequence of events, or an observation of unusual occurrences that possesses the potential of improving a system’s operability by reducing the risk of upsets, some of which could eventually cause serious damage. (Mürmann, A. Oktem, U. The Near-Miss Management of Operational Risk July 23, 2002. https://riskcenter.wharton.upenn.edu/wp-content/uploads/.../02-02- MO-published.pdf). Near miss: An undesired event that under slightly different circumstances could have resulted in harm to people; damage to property, equipment or environment; or loss of process. (CCPS Process Safety Metrics “You don’t improve what you don’t measure” Center for Chemical Process Safety (CCPS) New York, p. 35. https://www.aiche.org/ccps/resources/tools/process-safety-metrics). Near miss: A sequence of events and/or conditions that could have resulted in loss. This loss was prevented only by a fortuitous break in the chain of events and/or conditions. The potential loss could be human injury, environmental damage, or negative business impact (e.g., repair or replacement costs, scheduling delays, contract violations, loss of reputation). [International Maritime Organization (IMO). http://www.vta.ee/public/MSC-MEPC.7-Circ.7_-_Guidance_On_Near-Miss_Reporting.pdf]. Near miss: One in which no property was damaged and no personal injury was sustained, but where, given a slight shift in time or position, damage or injury easily could have occurred. [OSHA National Safety Council (NSC). www.nsc.org/WorkplaceTrainingDocuments/Near-Miss-Reporting-Systems.pdf]. Occurrence: The term used to embrace all events which have, or could have significance in the context of aviation safety, ranging from accidents and serious incidents, through incidents or events that must be reported, to occurrences of lesser severity which, in the opinion of the reporter could have safety significance. (URL: http://www.skybrary.aero/index.php/Safety_Occurrence_Reporting). Operational drifts: Deviations from the correct state when everything is running as it should, all procedures are followed and the system behaves under the proposed overall condition. (The Role of Taxonomies for the Safety Indicators definition, Plos, V., V. NEMEC, S. SZABO, Proceedings of the 20th World Multi-Conference on Systemics, Cybernetics and Informatics. WMSCI 2016. http://www.iiis.org/CDs2016/CD2016Summer/papers/RA563CO.pdf). Operational risk: The risk of loss resulting from inadequate or failed internal processes, people and systems, or from external events. The definition includes legal risk, which is the risk of loss resulting from failure to comply with laws as well as prudent ethical standards and contractual obligations. It also includes the exposure to litigation from all aspects of an institution’s activities. The definition does not include strategic or reputational risks. (Supervisory Guidance on Operational Risk Advanced Measurement Approaches for Regulatory Capital, July 2, 2003. https://www.fdic.gov/regulations/laws/publiccomments/basel/oprisk.pdf). Operational risk: The risk of loss resulting from inadequate or failed internal processes, people and systems or from external events [Basel Committee on Banking Supervision (BCBS), “The New Basel Capital Accord” 2001. The Near-Miss Management of Operational Risk. https://www.bis.org/publ/bcbs196.pdf]. Precursor: Any event or group of events that must occur for an accident to occur in a given scenario. They are conditions, events, and sequences that precede and lead up to accidents. (The National Academy of Engineering. https://www.nap.edu/read/11061/chapter/12). Precursor: An event or situation that, if a small set of behaviors or conditions had been slightly different, would have led to a consequential adverse event. (National Academies of Sciences. https://www.nap.edu/read/11061/chapter/6). Precursor: An anomaly that signals the potential for more severe consequences that may occur in the future, due to causes that are discernible from its occurrence today. (NASA Accident Precursor Analysis Handbook. http://www.islinc.com/wp- content/uploads/2016/03/NASA_SP-2011-3423.pdf) Model: A representation of something else, of a phenomenon or event such an accident or of a system such as an organization. (Revisiting the “Swiss Cheese” Model of Accidents. EEC Note No. 13/06. 2006. European Organisation for the Safety of Air Navigation. http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.80.5369&rep=rep1&type=pdf). Model: Two types: (1) Retrospective model is the basis for explaining or understanding something, (2) Prospective model is the basis for predicting something, including measurements of present states as an indicator of possible future states. (Herrera, I.A. 2012. Proactive safety performance indicators. Doctoral thesis Norwegian University of Science and Technology 2012:151. Trondheim, Norway. https://brage.bibsys.no/xmlui/handle/11250/240805).

Terms and Definitions 77 Resilience: The intrinsic ability of a system to adjust its functioning prior to, during, or following changes and disturbances, so that it can sustain required operations under both expected and unexpected conditions. (Hollnagel et al., 2011.) Resilience: The capacity of an organization to accommodate failures and disturbances without producing serious accidents. (R. Rosness, G.Guttormsen, T. Steiro, R.K. Tinmannsvik and I.A. Herrera, Organisational accidents and resilient organisations: Five perspectives, SINTEF Industrial Management, Trondheim, 2004.) Resilience engineering: Addresses socio-technical systems ability and capability to adjust and to continue operations in presence of continuous disturbances. (Herrera, I.A. 2012. Proactive safety performance indicators. Doctoral thesis Norwegian University of Science and Technology 2012:151. Trondheim, Norway. https://brage.bibsys.no/xmlui/handle/11250/240805). Risk: The chance of loss or injury measured in terms of severity and probability. (FAA AC 150/5200-37, 2007. https://www.faa.gov/documentLibrary/media/.../150-5200-37/150_5200_37.pdf) Risk: The effect of uncertainty on objectives with the potential for either a negative outcome or a positive outcome or opportunity. (GAO-17-63, Enterprise Risk Management: Selected Agencies’ Experiences Illustrate Good Practices in Managing Risk. https://www.gao.gov/products/GAO-17-63). Risk: The effect of uncertainty on objectives. It is typically addressed within functional, programmatic, or organizational silos. (OMB Circular No. A-123: Management’s Responsibility for Enterprise Risk Management and Internal Control Association for Federal Enterprise Risk Managers November 7, 2016. https://www.whitehouse.gov/sites/whitehouse.gov/files/omb/.../2016/ m-16-17.pdf). Risk: The effect of uncertainty on objectives with the potential for either a negative outcome or a positive outcome or opportunity. (GAO-17-63, Enterprise Risk Management: Selected Agencies’ Experiences Illustrate Good Practices in Managing Risk. https://www.gao.gov/products/GAO-17-63). Risk: Risks are uncertain future events that may influence an organization’s ability to achieve its objectives. The term “risk” can be used in three distinct applications: • Risk as exposure: The most common definition of the term. Most people refer to potential negative events such as financial loss, fraud, lawsuits, or threats to meeting objectives as “risks.” In this context, risk management means reducing the probability of a negative event without incurring excessive costs. • Risk as uncertainty: The distribution of all possible outcomes, both positive and negative. In this context, risk management seeks to reduce the variance between anticipated outcomes and actual results. • Risk as opportunity: This is implicit in the concept that a relationship exists between risk and return. The greater the risk, the greater the potential return, and, necessarily, the greater the potential for loss. In this context, managing risk means using techniques to maximize the upside of uncertainty within the constraints of a current operating environment. (ACRP Report 74: Application of Enterprise Risk Management at Airports, 2012. URL: http://www.trb.org/Publications/Blurbs/167515.aspx). Risk: The potential for an unwanted outcome resulting from an incident, event, or occurrence, as determined by its likelihood and the associated consequences. Extended Definition: Potential for an adverse outcome assessed as a function of threats, vulnerabilities and consequences associated with an incident, event or occurrence. (U.S. Department of Homeland Security. https://www.dhs.gov/xlibrary/assets/dhs_risk_lexicon.pdf). Risk management: A continuing process to identify, analyze, evaluate, and treat loss exposures and monitor risk control and financial resources to mitigate the adverse effects of loss. (URL: http://www.marquette.edu/riskunit/riskmanagement/whatis.shtml). Risk Management: The identification, analysis, assessment, control, and avoidance, minimization, or elimination of unacceptable risks. An organization may use risk assumption, risk avoidance, risk retention, risk transfer, or any other strategy (or combination of strategies) in proper management of future events. (URL: www.businessdictionary.com/definition/risk-management.html). Safety: Freedom from those conditions that can cause death, injury, occupational illness, damage to or loss of equipment or property, or damage to the environment. In a risk-informed context, safety is an overall mission and program condition that provides sufficient assurance that accidents will not result from the mission execution or program implementation, or, if they occur, their consequences will be mitigated. This assurance is established by means of the satisfaction of a combination of deterministic criteria and risk criteria. The term “safety” broadly includes human safety (public and workforce), environmental safety, and asset safety. (NASA. https://nodis3.gsfc.nasa.gov/npg_img/N..._/N_PR_8715_0007__AppendixA.pdf). Resilience: The ability of individuals, teams and organizations to continually recognize, adapt to and absorb variations, disturbances, disruptions and surprises in order to maintain safe functioning. [Hollnagel E, Woods DD and Leveson N (eds.) engineering. Concepts and precepts. Aldershot, Hants: Ashgate Publishing; 2006]. Resilience Precursors: Events, conditions, circumstances or factors that precede a desired or undesired outcome, and to which it is linked through a causal chain. Also known as antecedents. (Overview of leading indicators for occupational health and safety in mining, International Council on Mining & Metals, November 2012. https://www.icmm.com/website/publications/pdfs/health-and-safety/4800.pdf).

78 Airport Incident Reporting Practices Safety: A learning and adjustment process whereby the process safety indicator metrics provide feedback for controlling actions that ensure the technical systems remains within the safe envelope of the design. (Bellamy, L.J., Sol, V.M., A literature review on safety performance indicators supporting the control of major hazards, RIVM Report 620089001/2012, National Institute for Public Health and the Environment Dutch Ministry of Health, Welfare, and Sport, Netherlands. URL: www.rivm.nl/bibliotheek/rapporten/620089001.pdf). Safety: The state in which the possibility of damage is reduced and maintained below an acceptable level through a continuous process of hazard identification and safety risk management. [ICAO. “Doc 9859 - Safety Management Manual (SMM).” International Civil Aviation Organization. 3nd ed, pp. 1–284. Montreal, Canada. 2013.] Safety: The freedom of unacceptable risk, were risk is a combination of the probability of occurrence of harm and the severity of the harm. (ISO, 1999. Safety aspects – guidelines for their inclusion in standards, ISO/IEC guide 51:2014, International Organisation for Standardisation, Geneva, Switzerland. https://www.iso.org/standard/53940.html). Safety assessment: A multidiscipline review and documentation often conducted by a panel of experts, of a preliminary safety analysis of a system or proposed system change. [FAA Order 5200.11 CHG 3, 2014. FAA Airports (ARP) Safety Management System, Appendix A. https://www.faa.gov/documentLibrary/media/Order/order5200_11Chg3.pdf]. Safety assurance: Processes within the SMS that function systematically to ensure the performance and effectiveness of safety risk controls and that the organization meets or exceeds its safety objectives through the collection, analysis, and assessment of information. (FAA Order 8040.4B. https://www.faa.gov/documentLibrary/media/Order/FAA_Order_8040.4B.pdf). Safety barrier: An obstacle, an obstruction, or a hindrance that may either (1) prevent an event from taking place, or (2) thwart or lessen the impact of the consequences if it happens nonetheless. (Hollnagel E., Barriers and accident prevention. Ashgate, Aldershot, England, 2004. p. 68) Safety barrier: An administrative or technical constraint at operator level which will prevent an inappropriate human action, or absorb the effect of such an action, thus making the system “error tolerant” or forgiving. We use the terms “weak” and “strong” for safety barriers, where we claim that administrative barriers generally are weaker than technical barriers. (International Journal for Quality in Health Care, Volume 17, Number 1: pp–9, 2005.). 1 Safety indicators: The precursors for hazards and risks based on routine monitoring of operational processes according to the latest trends in building the SMS. [ICAO. “Doc 9859 - Safety Management Manual (SMM).” International Civil Aviation Organization. 3nd ed., pp. 1–284. Montreal, Canada. 2013.] Safety indicators: An observable characteristic of an operational unit, presumed to bear a positive correlation with the safety of the system. (Herrera, I.A. 2012. Proactive safety performance indicators. Doctoral thesis Norwegian University of Science and Technology 2012:151. Trondheim, Norway. https://brage.bibsys.no/xmlui/handle/11250/240805). Safety indicators: The measurable process variables that can be used to describe the larger phenomenon or part of reality. (Plos, V., Methodology for Risk-based Indicators Implementation, 2016. https://ojs.cvut.cz/ojs/index.php/mad/article/download/3586/3513). Safety performance: A state or a service provider’s safety achievement as defined by its safety performance targets and safety performance indicators. (ICAO Annex 19, 2013. https://www.casa.gov.au/file/157236/download?token=uZzL-kPo ). Safety performance indicator (SPI): 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. (ACRP Report 1, Vol. 2. 2007. http://www.trb.org/Publications/Blurbs/162491.aspx). Safety performance indicator (SPI): A data-based safety parameter used for monitoring and assessing performance. (ICAO Annex 19, 2013. https://www.casa.gov.au/file/157236/download?token=uZzL-kPo). Safety performance measurement: The process of measuring and monitoring safety-related outcomes associated with a given operational system or organization. (ICAO: https://www.icao.int/APAC/Meetings/.../07%20-%20SIN_SPM%20Presentation.pdf). Safety performance measures: Indicators that focus on the differences between actual safety performance and what has been defined as acceptable, i.e., measuring the gap. (Janicak, C. 2003. Safety Metrics: Tools and Techniques for Measuring Safety Performance. Lanham: Government Institutes. In Overview of leading indicators for occupational health and safety in mining, International Council on Mining & Metals, November 2012). Safety performance target: A measurable goal used to verify the predicted residual safety risk of a hazard’s effect. (FAA Order 8040.4B. https://www.faa.gov/documentLibrary/media/Order/FAA_Order_8040.4B.pdf). Safety: The state in which the risk of harm to persons or property damage is acceptable. (FAA Order 8040.4B. https://www.faa.gov/documentLibrary/media/Order/FAA_Order_8040.4B.pdf). Safety: The system property or quality that is necessary and sufficient to ensure that the number of events that could be harmful to workers, the public, or the environment is acceptably low. [Besnard, D. and Hollnagel. E., I want to believe: some myths about the management of industrial safety. Cognition, Technology and Work, Springer Verlag, 2014, 16 (1), pp.13 https://www.researchgate.net/publication/257480355_I_want_to_believe_Some_myths_about_the_management_of_industrial_safety]. –23.

Terms and Definitions 79 Safety risk assessment (SRA): Assessment of a system or component, often by a panel of system subject matter experts (SMEs) and stakeholders, to compare an achieved risk level with the tolerable risk level. (ACRP Synthesis 71: Airport Safety Risk Management Panel Activities and Outcomes. http://www.trb.org/Publications/Blurbs/174359.aspx). Safety reporting: The filing of reports and collection of information on actual or potential safety deficiencies. (http://www.skybrary.aero/index.php/Safety_Occurrence_Reporting). System: An integrated set of constituent elements that are combined in an operational or support environment to accomplish a defined objective. These elements include people, hardware, software, firmware, information, procedures, facilities, services, and other support facets. (FAA Order 8040.4B. https://www.faa.gov/documentLibrary/media/Order/FAA_Order_8040.4B.pdf). System safety: Mechanisms aiming to control the risks that may affect the safety of the stakeholders while ensuring compliance with relevant legislation. (J. Santos-Reyes and A.N. Beard. “Assessing safety management systems.” Journal of Loss Prevention in the Process Industries. Vol. 15, Issue 2, pp. 77–95. 2002.) System safety: The state or objective of striving to sustainably ensure accident prevention through actions on multiple safety levers, be they technical, organizational, or regulatory. (System safety principles: A multidisciplinary engineering perspective J.H. Saleh 284 et al. / Journal of Loss Prevention in the Process Industries 29 (2014) 283–294). Triggers: The requirements, precursors, or organizational plans that lead to initiation of the SRA process. (ACRP Synthesis 71: Airport Safety Risk Management Panel Activities and Outcomes. http://www.trb.org/Publications/Blurbs/174359.aspx). Safety performance target: The planned or intended objective for safety performance indicator(s) over a given period. [Doc 9859 - Safety Management Manual (SMM). International Civil Aviation Organization. 3nd ed, pp. 1–284. Montreal, Canada. 2013].