Auditoria Interna
e
Gestão de Risco Operacional
Experiência em Empresa Não-Financeira
IPAI 2009
Management and Control
 The Operator shall commit to the
implementation of Enterprise Risk
Management
Source: IATA AMS 2007
IPAI/2009
2
Enterprise Risk (ERM)
 Strategic risk (market dynamics, resource
allocation, etc.)
 Financial risk (capital structure, liquidity, credit,
etc.)
 Operational risk (assets, people, technology, etc)
 Compliance risk (legal, regulatory, best practices,
etc.)
 Environmental risk (petroleum products,
hazardous materials, etc.)
 Corporate citizen/image/reputation risk
 Project risk
Source: IATA AMS 2007
IPAI/2009
3
Enterprise Risk Management
(ERM) System
 Perhaps the most significant limitation to
ERM is the absence of multi-variant
mathematical models that are needed to
support both operational and enterprise
risk management efforts.
Source: IATA AMS 2007
IPAI/2009
4
Enterprise Risk Management
(ERM) System
 Enterprise Risk Management (ERM) is typically
an activity of the senior management team, i.e.,
an assessment and analysis of all risks in an
organization. It is important to note that this
activity is not typically of interest to the State
CAA;
however, the regulatory authority will be
interested in the operational risk
management system.
Source: IATA AMS 2007
IPAI/2009
5
Operational Risk
Operational risk in an airline is a component
of the entity's overall risk, i.e., enterprise
risk.
Regulatory agencies and the majority of the
airline employee groups are primarily
concerned with operational risk.
Source: IATA AMS 2007
IPAI/2009
6
Operations Risk Management
The air carrier needs to have a SMS risk analysis
process that provides for:
 Identification of operational hazards;
 Qualitative or quantitative analysis to determine risk
acceptability;
 Development of corrective action that eliminates or
mitigates unacceptable risks;
 Implementation of corrective action in appropriate
operational areas; and
 Evaluation of corrective action to determine
effectiveness
Source: IATA AMS 2007
IPAI/2009
7
SMS/QMS/ESMS/SEMS
An Evolution of Continuous Improvement
Implement change & re-evaluate
AIRLINE OPERATIONS
AUDITING
SAFETY REPORTS
DATA
FOQA / FDA/ FDM
Safety Statistics
RISK ANALYSIS
Everyone sees safety status
Management
Adjust / Change
Regulators
Employees/Unions
Operational Risk Analysis output
to ERM model
Source: IATA AMS 2007
IPAI/2009
8
COSO MODEL
Source: Manual de Risco TAP
IPAI/2009
9
The evolution of safety thinking
Source: ICAO SMM MANUAL 2009
IPAI/2009
10
A concept of accident causation
Source: ICAO SMM MANUAL 2009
IPAI/2009
11
The management dilemma
Management levels
IPAI/2009
Resources
Resources
Protection
Production
12
The management dilemma
Protection
Production
Catastrophe
Source: ICAO SMM MANUAL 2009
IPAI/2009
13
The management dilemma
Production
Protection
Bankruptcy
Source: ICAO SMM MANUAL 2009
IPAI/2009
14
Safety space
Protection
Bankruptcy
Catastrophe
Source: James Reason
IPAI/2009
Production
15
Source: ICAO SMM MANUAL 2009
SOURCE: ARMS WORKING GROUP
IPAI/2009
16
Safety
The state in which the possibility 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 identification and safety
risk management.
Source: ICAO SMM MANUAL 2009
IPAI/2009
17
SOURCE: ARMS WORKING GROUP
IPAI/2009
18
Reactive Risk Management
 Minor events, irregularities and occurrences
occur often during normal operations, many
times without noticeable consequences.
Identifying and investigating certain irregular
operational occurrences can reveal system
weaknesses or deficiencies that, if left
unchecked, could eventually lead to an accident
or serious incident. These types of events are
referred to as accident precursors.
Source: IATA AMS 2007
IPAI/2009
19
Proactive Risk Management
It is preferable to conduct a risk
assessment prior to introducing a
significant change in the operation and
then taking appropriate action to alleviate
(or mitigate) important problems prior to
implementation of the change rather
than proceeding immediately to the
implementation phase and then await
potential negative outcomes
Source: IATA AMS 2007
IPAI/2009
20
SOURCE: ARMS WORKING GROUP
IPAI/2009
21
SOURCE: ARMS WORKING GROUP
IPAI/2009
22
Formal risk
 Formal risk management is a systematic
and disciplined method of accident
prevention. The programme may appear
complex, but experience has shown that
familiarity and proficiency is gained with
practice.
IPAI/2009
23
Safety Risk
Safety risk is defined as the assessment,
expressed in terms of predicted probability
and severity, of the consequences of a
hazard, taking as reference the worst
foreseeable situation.
Source: ICAO SMM MANUAL 2009
IPAI/2009
24
Safety risk probability table
Source: ICAO SMM MANUAL 2009
IPAI/2009
25
Safety risk severity table
Source: ICAO SMM MANUAL 2009
IPAI/2009
26
Safety risk assessment matrix
Source: ICAO SMM MANUAL 2009
IPAI/2009
27
Safety risk tolerability matrix
Source: ICAO SMM MANUAL 2009
IPAI/2009
28
Safety Risk Management
Source: ICAO SMM MANUAL 2009
IPAI/2009
29
The safety risk mitigation process
Source: ICAO SMM MANUAL 2009
IPAI/2009
30
The safety risk management process
Source: ICAO SMM MANUAL 2009
IPAI/2009
31
Hazard identification
and risk mitigation
IPAI/2009
32
The five fundamentals of
safety risk management
 There is no such thing as absolute safety
in aviation it is not possible to eliminate all
safety risks.
 Safety risks must be managed to a level
“as low as reasonably practicable”
(ALARP).
IPAI/2009
33
The five fundamentals of
safety risk management
 Safety risk mitigation must be balanced
against:
1) time;
2) cost; and
3) the difficulty of taking measures to
reduce or eliminate the safety risk (i.e.
managed).
IPAI/2009
34
The five fundamentals of
safety risk management
 Effective safety risk management seeks to
maximize the benefits of accepting a
safety risk (most frequently, a reduction in
either time and/or cost in the delivery of
the service) while minimizing the safety
risk itself.
IPAI/2009
35
The five fundamentals of
safety risk management
 The rationale for safety risk decisions must
be communicated to the stakeholders
affected by them, to gain their acceptance.
IPAI/2009
36
Safety Risk Management
The safety risk management function of an
SMS provides for initial identification of
hazards and
assessment of safety risks. Organizational
safety risk controls are developed, and once
they are determined to be capable of
bringing the safety risk to ALARP, they are
employed in daily operations.
Source: ICAO SMM MANUAL 2009
IPAI/2009
37
Safety Risk Management
The safety assurance function takes over
at this point to ensure that the safety risk
controls are being practised as intended
and that they continue to achieve their
intended objectives. The safety assurance
function also provides for the identification
of the need for new safety risk controls
because of changes in the operational
environment.
IPAI/2009
38
Safety Risk Management
Safety risk management requires
feedback on safety performance to
complete the safety management cycle.
Through monitoring and feedback, SMS
performance can be evaluated and any
necessary changes to the system effected.
In addition, safety assurance provides
stakeholders an indication of the level
of safety performance of the system.
Source: ICAO SMM MANUAL 2009
IPAI/2009
39
Safety Risk Management
Once safety risk controls are developed
and implemented, it is the organization’s
responsibility to assure that they continue
to be in place and that they work as
intended.
Source: ICAO SMM MANUAL 2009
IPAI/2009
40
AUDIT
INAC
EASA
INTERNAL AUDITS
EXTERNAL AUDITS
FAA
ICAO
IOSA
Safety Risk Management
INTERNAL AUDIT
 Confirm that Safety Risk Management
complies with regulation
 Guarantee the process integrety
IPAI/2009
42
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pela
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