Stages of Safety Events with FAA vs. Others
Regulatory oversight agencies in various countries/regions possess inconsistent definitions for:
- risks, and
- the stages of safety events.
Make no mistake, it’s extremely important how these safety elements are defined and conceptualized. It will determine how you practice risk management and safety assurance activities.
If your definitions don’t quite align with your oversight agency’s definitions, a keen auditor will notice disparities in your risk management documentation. The implications are:
- Your entire hazard register does not appropriately identify “hazards”;
- All hazard analysis documentation will be slightly misguided; and
- Risk controls may be controlling the wrong elements.
Related Aviation Risk Management Articles
- Difference between Hazards, Risks & Control Measures in Aviation SMS
- What Is Hazard Identification in Aviation SMS
- How to Identify Hazards and Assess Risks in Aviation SMS
Importance of Aligned Aviation SMS Definitions
A false understanding of core risk management definitions can throw off your entire aviation safety management system (SMS). In a real world scenario, this may or may not be catastrophic and only result in audit findings that will require attention from the accountable executive, upper-level management and the entire safety team. Otherwise,
- It could involve nothing more than the knowledge that your risk management practices are exposed to potential non-compliance audit findings; or
- It could involve an entire SMS manual revision that affects implemented risk management processes.
A lot depends on
- how far “off” your risk management program is;
- the maturity level of the aviation SMS; and
- the disposition of the aviation safety inspector.
We work with a lot of clients around the world. Everyday, we witness how different understandings of these core risk management definitions affect aviation SMS implementations. Sometimes an operator's misconceptions may pass undetected for years. Are these the lucky ones? It depends on your viewpoint.
Here are hazards, risks, and the stages of safety events as defined by the FAA.
Stage 1 – Root Causes ("Hazardous Sources")
The FAA defines root causes as “…initiating events, which started the adverse event flow…” The FAA acknowledges that “…accidents are the result of many contributors...” Hence why we refer to them as "root causes" and not simply "a root cause."
Root causes are an integral part of all safety events. Hence why the FAA has service providers conduct root cause analysis on all reported safety issues. The FAA does not attempt to define exactly what "initiating events" are, because initiating events can be just about anything.
The point is that in the first stage of a safety events, there are many factors and events that will conspire together to create a hazard. While the FAA doesn't say it expressly, the strongly implied intent is that root causes will always be "hazardous sources," which is one of the three hazard mechanisms as defined by the FAA.
An integral part of hazard identification is being able to identify hazardous sources.
Related Articles on Root Causes in Aviation SMS
- How to Conduct Root Cause Analysis in Aviation SMS
- 3 Methods for Root Cause Analysis in Aviation SMS
- Understanding "Root Cause Analysis" Charts in Aviation SMS Dashboards
Stage 2 – Initiating Mechanisms of Hazardous Sources
Hazard mechanisms are the interactions that create hazards. These are what transform hazardous sources (i.e., root causes) into a dangerous condition. Initiating mechanisms are often things like:
- Human Factors;
- Environmental change; or
- Lack of safety controls.
Initiating mechanisms and targets will be strongly influenced by the control measures that your company uses to control hazards and mitigate risk. Control measures should directly address initiating mechanisms and potential targets.
The FAA also considers targets as a part of hazard mechanisms. Targets are on who/what the hazard is targeting. The target could be:
- A person;
- A group of people;
- A machine; or
- An aircraft.
Control measures should be used to protect targets and mitigate the exposure of targets. One example of this is aircraft with specially reinforced windshields to protect against bird strikes. This makes aircraft less of a target. Similarly, employees might be required to wear safety gear.
Stage 3 – How FAA Defines Hazards
The FAA considers a hazard to be a dangerous condition that can lead to [injury, accident, damage]. The FAA defines a hazard as, “A condition that could foreseeably cause or contribute to an…accident…”
This is an extremely important point, because a constant misunderstanding by aviation safety professionals in the United States is that Hazards are a benign thing that have the potential to become dangerous. This is a different understanding of hazards, and is not the understanding that the FAA subscribes to (the FAA would call these "benign things" hazardous sources rather than "hazards").
In the stages of a safety event, a Hazard occurrence is the centerpiece of the event. It represents a similar stage to:
- Top Events, as seen in bowtie analysis;
- The "head" of fishbone diagrams; and
- Risk Events, as seen in a Shortfall Analysis.
Another way of thinking about this is that, in the eyes of the FAA, a hazard is a temporary situation of jeopardy that can lead to accidents if action is not taken to mitigate it.
Related Aviation Safety Hazard Articles
- What Is a Hazard in Safety Management Systems
- What Is Difference between Hazard and Risk in Aviation SMS
- How to Distinguish Hazard vs Risk Occurrence
Stage 3.1 – How FAA Defines Risk
It's also important that you understand how the FAA uses the following differently:
- "Risk" - the likelihood of occurrence and severity of damage for for "a risk", usually expressed in a risk matrix;
- "A risk" - a negative consequence/outcome that arises from a hazard, such as an accident, injury, etc.; and
- "Risks" - multiple negative consequence/outcome that arises from a hazard, such as accidents, injuries, etc..
The language used here can get a bit confusing, as you can say, "What is the 'risk' of 'a risk'?" A much better practice is to use words like "a consequence" or "an incidence" instead of "a risk." This helps avoid the confusion between likelihood/severity of an incident and the incident itself.
Stage 4 – Breakdown of Risk Control Measures
In order for a hazard to result in a consequence, there are intermediary events. The FAA places much value on mitigating risks (consequences) by creating risk controls to mediate between hazards and consequences. In doing so, the FAA implies that incidents happen due to a breakdown in the interceding control measures.
These SMS failures can happen for any number of reasons:
- Controls were inadequate;
- Controls were dated;
- There were no controls; or
- Controls were not used (such with a checklist).
As controls break down, the likelihood and/or severity of a safety event occurring ("a risk") increase.
Related Articles on Risk Controls in Aviation SMS
- What Is a Risk Control in Aviation SMS: Meaning, Purpose, Application
- How to Implement Effective Control Measures
- How to Evaluate and Justify a Risk Control in Aviation SMS
Stage 5 – Risks of Hazardous Condition (Accidents)
The final stage of safety events is the actualization of a risk (accident, incident, consequence, etc.). Risks can come in many forms:
- Loss of life;
- Damage to equipment;
- Damage/loss of aircraft;
- Reputation damage; and
- Loss of investor confidence.
A risk is simply a negative occurrence, which can be anything that harms your company. Personally, I like to think of risk as a "hazard related consequence."
Final Thoughts on Understanding Stages of Safety Events
The concepts of aviation safety management systems are not overly complicated. In short, aviation SMS is not rocket science. On the other hand, the terms and definitions used in aviation SMS are not always intuitive. In fact, I found my understanding of the terms "hazard" and "risk" to be wrong when I first became indoctrinated into the "SMS club."
The risk management processes and structure of your aviation SMS can be realistically applied outside the scope of aviation safety. Smart, young safety professionals have been extending their aviation SMS implementations to include operational and environmental issues.
What is important in every SMS is "the risk management process." However, we cannot forget that the aviation SMS structure (policy), coupled with repeated safety promotion efforts will ensure that your SMS is not a simple, "check-the-box SMS," but a bona-fide, functioning system that adds financial value to your organization.
For full coverage on FAA requirements, see our step by step guide walking through what the FAA really wants for SRM compliance.
When I think of Safety Assurance, I naturally think of oversight. How does your organization's SMS address safety assurance requirements? This short video may offer some inspiration.
Published March 2017. Last updated October 2019.