AIRBORNE LAW ENFORCEMENT AIRBORNE LAW ENFORCEMENT ASSOCIATIONASSOCIATION

Safety Management System Workshop

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Keith JohnsonSafety Program Manager

IHSSIHSS Safety is most important Need to collect data

– Collect flight hours– Collect Serious Incident Information– ALEA Incident Reporting System – Proposal– Expedite Accident Reporting

Increased training Reduce Accidents by 80% over 10-years Focus on Leadership Non-punitive reporting Accountability Accidents can be eliminated ALEA on International Helicopter Safety Team

The topic of the dayThe topic of the day

““SAFETY” SAFETY”

It holds the key to our future

It affects everything we do (SMS)

Every accident affects everyone

SAFETY PRIORITIESSAFETY PRIORITIES

SAFETY has the highest priority MISSION has a lower priority Each person is critical to

eliminating accidents Inclusive communications chain*

SAFETY PRINCIPLESSAFETY PRINCIPLES

1. Always operate in the safest manner possible2. Never take unnecessary risks3. Safe does not mean risk free4. Key to safety is the i.d. and management of risk5. An absence of accidents does not necessarily

equate to safety6. Familiarity and prolonged exposure without an

incident leads to a loss of appreciation of risk How does this apply flying patrol?

Safety GoalsSafety Goals

Zero accidents Zero injuries Zero harm to environment Improve public perception of law

enforcement aviation

An effective Safety Management System is essential to achieving & sustaining a zero accident.

ELEMENTS OF THE ELEMENTS OF THE ORGANIZATIONORGANIZATION

Flight Operations Ground Operations Maintenance Training Safety Safety Management System is all

inclusive

ACCIDENT ELIMINATIONACCIDENT ELIMINATION Must be proactive – Reached plateau

– Pilots focus on flying aircraft– Two person crews– Focus on risk management

Adverse Trends– Identify and eliminate adverse trends – Incidents - Investigate & disseminate findings– Factory emergency procedures training

Don’t reinvent the wheel No new causes of accidents Copy successful organizations Accreditation – Platinum Program

JUDGMENT & ACTION ERRORSJUDGMENT & ACTION ERRORS Failure to manage known risks Mission urgency & risk taking

– Will to succeed

Flight profile unsafe– Crew Qualifications– Aircraft Suitability– Mission Requirements– Environment

Judgment errors committed Failure to follow procedures Poor CRM Poor Aircraft Control

– Over confidence– Loss of situational awareness

What is an SMS?What is an SMS?

Coordinated, comprehensive set of processes designed to direct and control resources to optimally manage safety.

Makes safety management an integral part of the overall operations/business plan.

Based on leadership and accountability.

What Does Having an SMS What Does Having an SMS Give?Give?

We will now concentrate on describing the three key processes generically Once you understand these, the rest becomes more readily apparent But first some more definitions…

Comprehensive

Corporate Approach to

Safety

Robust Systems

for

Assuring Safety

Effective Organisation

for

Delivering Safety

Comprehensive approach to safety

Robust & effective safety

management processes

Organizational structure for

ownership of & accountability for

safety

Why is Having an SMS Why is Having an SMS Important?Important?

1. Widely recognized as best practice2. Eliminates accidents3. Reduces costs4. Limits exposure (reduces total risk)5. Reduces probability of having an

accident6. Reduces severity of risks7. Reduces exposure to risk8. Increases likelihood of completing the

mission

1. Safety Management Plan1. Safety Management Plan

Description of SMS components:1. Definition of fundamental approach to

safetya) Philosophical approach – Vision, Mission, Values

b) Safety policy – SMS policy statement

c) Business and department goals – set/reviewed annually

2. Clearly defined roles and responsibilitiesa) Openly documented and briefed

3. Top leadership involvementa) Safety is an agenda item, resource allocation, openness, involved

in daily activities, promoting awareness

What should it look like?What should it look like?A Framework for Safety Management

CRM

Audits

ChecklistWorksheets

Training

Plan

Alcohol& Drugs

Policy

Audit

Maint.Schedule

Safety

Drills

Policy

FAA

Regs .

No Structure STRUCTURE

ERPs

Process /Do

Policy /PlanHSE

Policy

Security

QA

Ops Manual

Plans

Task /Check – Feedback - Action

Safety Management Training Safety Management Training RequirementsRequirements

Safety orientation for all new personnel

Document competency requirements Document training requirements Have regularly scheduled safety

meetings Key personnel educated on safety

management best practices

JHSAT ACCIDENT CAUSATION JHSAT ACCIDENT CAUSATION JUDGMENT & ACTION ERRORSJUDGMENT & ACTION ERRORS

Fail to manage known risks– Mission urgency– Risk taking– Failure to follow standards

Unsafe flight profile– Crew qualifications– Aircraft suitability– Mission requirements– Environment

Aircraft control deficiencies

JHSAT STUDY RESULTSJHSAT STUDY RESULTS

Three themes came from JHSAT study:

1. Better training

2. Operational oversight

3. Safety Management

SAFETY RECOMMENDATIONS

1. More consistent & comprehensive NTSB involvement and investigation

2. Collect worldwide fleet hour data as previously performed by FAA

3. Promote the Safety Management Systems

4. Establish safety website to disseminate information

5. Use proximity detection equipment on aircraft

6. Use flight recording devices and cockpit image recording systems

7. Develop strategy to improve ADM

Results of full year 2000 dataset

SPS Frequency by Primary Category

401

173

154

112

98 87

66

26 24 24 23 20 10 1

0

50

100

150

200

250

300

350

400

450Pi

lot j

udgm

ent &

actio

ns

Safe

ty C

ultu

re

Dat

a is

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Mai

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ance

Gro

und

Dut

ies

Pilo

t situ

atio

naw

aren

ess

Part/

syst

emfa

ilure

Post

-cra

shsu

rviv

al

Com

mun

icat

ions

Mis

sion

Ris

k

Reg

ulat

ory

Airc

raft

Des

ign

Infra

stru

ctur

e

Gro

und

pers

onne

l

Freq

uenc

y

SPS & Accident Count by Primary Mission

210

170

145

101

92

74 68

53 51 48 47 44

32 30 24 17

37

27 28

12 16 13 9 8 9 6 10 6 4 4 5 3

0

50

100

150

200

250In

stru

ctio

nal /

Tra

inin

g

Pers

onal

/ Pr

ivat

e

Aeria

l App

licat

ion

Emer

genc

y M

edic

al S

ervi

ce

Com

mer

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Ope

rato

r

Law

Enf

orce

men

t

Offs

hore

Exte

rnal

Loa

d

Busi

ness

- C

ompa

ny o

wns

A/C

Fire

fight

ing

Aeria

l Obs

erva

tion

/ Pat

rol

Air T

our

Sigh

tsee

ing

Elec

troni

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ews

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herin

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ing

Utili

ties

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Con

stru

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Freq

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SPSCount

AccidentCount

Introduction to the ToolkitIntroduction to the Toolkit

The Toolkit contains SMS guidance material and a sample SMS Manual

The Toolkit provides a foundation for your own system

The issued IHST SMS Toolkit is Version 1.0…

Feedback

Resulting ActionsResulting Actions

Fire the PIC, 30 day suspension for SIC

Stuff happens! Get over it!

Seek restitution… someone pays!

Do these actions prevent future events of this type?

Is there an alternative?

Just CultureJust Culture

A ‘blame culture’ undermines open reporting

A ‘no-blame culture’ is also flawed as it undermines accountability & responsibility

If other personnel could make the same error occasionally then we must change the controls not discipline the personnel – Holding people accountable through a disciplinary process is

only relevant for: Gross negligence Persistent sub-standard performance Wilful recklessness

Just Culture Process

Was the job understood?Knowingly violated

procedures?

Was the action as intended?

Were the results as intended?

Are the procedures clear?

Pass substitution test?

Defective training or selection experience?

History of violating procedures?

Sabotage or Malevolent Act

Reckless Violation Repeated Incident With

Similar Root CauseNegligent Error

No Blame Error

Yes*Yes

Yes

Yes

Yes

Yes

Yes*

Yes*

No*

No*

No

NoNo*

No

No

Start

Documented for the purpose of accident prevention awareness and training will suffice.

First written warning;

Coaching / Increased Supervision until behavior is corrected.

Final warning and negative performance appraisal

Severe Sanctions

* Indicates a ‘System’ induced error. Manager/supervisor must evaluate what part of the system failed and what corrective and preventative action is required. Corrective and preventative action shall be documented for management review.

No

Management of ChangesManagement of Changes

Operational procedures Location, equipment or operating

conditions Maintenance and Operations

Manuals Personnel made aware and

understand changes Level of management & authority to

approve changes

Performance Based SMSPerformance Based SMS

Rather than specify an organizational configuration or architecture, the SMS Toolkit deals with “SMS Attributes.”

These attributes describe the performance of a successful SMS.

Meeting the performance standard is what is critical… the configuration or architecture is dependent on the size and scope of the operation.

Attributes of a SMSAttributes of a SMS SMS Management Plan Safety Promotion Data information management Hazard identification and risk management Hazard reporting Occurrence investigation and analysis Safety oversight programs Safety training requirements Management of change Emergency preparedness and response Performance measurement & improvement

The Attributes of an SMSThe Attributes of an SMS

1) SMS Management Plan

– Policies, objectives – Organizational structure and key individuals – Elements defined– Expectations described – Commitment to compliance with safety and

regulatory requirements

The Attributes of an SMSThe Attributes of an SMS

2) Safety Promotion

– Safety Policy– Messages, memos from management– Posters, flyers, website– Safety training– Recognition program– Just Culture process in place

The Attributes of an SMSThe Attributes of an SMS

3) Document and Data Information Management

– Safety policies, regulations, objectives and SMS requirements publicized

– Change control system in place for applicable documents; training

– Periodic review of documents

The Attributes of an SMSThe Attributes of an SMS

4) Hazard Identification and Risk Management

– Proactively identify potential hazards – Hazards are considered when making changes– Risk Assessment – Identified hazards are tracked for closure

The Attributes of an SMSThe Attributes of an SMS

5) Occurrence and Hazard Reporting

– Corrective actions monitored for effectiveness, employees receive feedback

– A non-punitive disciplinary policy in place for reporting hazards (Just Culture process)

– Safety data analyzed, hazards are monitored to identify trends

– Anonymous submittals of hazards

The Attributes of an SMSThe Attributes of an SMS

6) Occurrence Investigation and analysis with technically qualified investigators

– Investigations conducted to determine root causes, and identify what can be done to prevent future occurrences

– Identify causal factors and the contributory factors, including organizational factors

– Acts of “omission” and “commission” identified– Reports provided to manager that has

accountability and authority

The Attributes of an SMSThe Attributes of an SMS

7) Safety Assurance Oversight Programs

– Internal assessments at regularly scheduled intervals, including contractors

– Utilizing checklists tailored to the organization’s operations when conducting safety evaluations

– Independent assessment of evaluator’s processes– Sharing the results and corrective actions with all

personnel– Utilizing available technology such as Health Usage

Monitoring Systems (HUMS) to supplement quality and maintenance programs as well as supporting programs to monitor and evaluate aircrew operations

The Attributes of an SMSThe Attributes of an SMS

6) Occurrence Investigation and Analysis

– Technically qualified investigators – Investigations conducted to determine root

causes, and identify what can be done to prevent future occurrences

– Identify causal factors and the contributory factors, including organizational factors

– Acts of “omission” and “commission” identified– Reports provided to manager that has

accountability and authority

The Attributes of an SMSThe Attributes of an SMS

8) Safety Management Training Requirements

– Include a safety orientation for all new personnel, stressing the organization’s commitment to safety and everyone’s roll in the SMS

– Document competency requirements for personnel

– Have a system to track training requirements – Make effective use of conferences, workshops,

literature and trade journals

The Attributes of an SMSThe Attributes of an SMS

9) Management of Changes

– Identify required changes in training, documentation or equipment

– Changes in location, equipment or operating conditions analyzed for any potential hazards

– Screen, review, approve, implement

The Attributes of an SMSThe Attributes of an SMS

10) Emergency Preparedness and Response

– Be readily available at the work stations of those that may be the first to be notified or required to respond

– Be relevant and useful to people on duty – Be exercised periodically to ensure the adequacy

of the plan and the readiness of the people who must make it work

– Be updated when contact information changes– Be briefed to all personnel along with their

responsibilities – Should be practiced so personnel receive training

in emergency response procedures

The Attributes of an SMSThe Attributes of an SMS

11) Performance Measurement and Continuous Improvement

– Safety performance monitoring used as feedback to improve the system

– Address individual areas (preflight, FOD, fueling)– Are SMART (Specific, Measurable, Achievable,

Results Oriented, Timely)– Linked to the organization’s operations/business

performance measures

LEADERSHIP SAFETY & LEADERSHIP SAFETY & STANDARDSSTANDARDS

Management’s role & responsibilities Intentional non-compliance Know procedures produce known outcomes Standards produce repeatable results Bad rules produce bad results Standards are mechanisms for changing

bad rules

STANDARDSSTANDARDS

Standards increase likelihood of repeatable results

Known procedures produce known results Bad rules produce produce bad results Enhance conflict resolution

– Airlines cover almost every situation and the proper response in writing – Why?

– Just follow the rules and eliminate majority of accidents

DEVIATION FROM DEVIATION FROM STANDARDSSTANDARDS

Behavior is a function of consequences– Run a red light, you get a ticket

I.D. & correct immediately Be consistent – No freebees Be fair Counsel, train, discipline, ground and

remove

BREAKING RULESBREAKING RULES

Breaking the rules usually does not always result in an accident, however:

It always results in a greater risk for the operation!

Never take UNNECESSARY RISKS!

NON-COMPLIANCENON-COMPLIANCE

Non-compliance rarely results in an accident or incident, however:

It always results in greater risk for the operation!

Intentional Non-ComplianceIntentional Non-Compliance

Research Shows – Once you start deviating from the rules, you are almost twice as likely to commit an error with potentially serious consequences!

We could eliminate 70-80% of the accidents just by following the rules. *

NOTE: Read the NTSB accident reports on the HAI website. Should be a requirement for all personnel

Honest mistakes vs. intentional non-compliance

Why is Insight Important for Why is Insight Important for Safety Leaders?Safety Leaders?

With this insight:– You will understand the hazards & risks you face– You will understand how to control them– You will know how these controls are working in service– You will learn from when controls fail– You can drive improvements to take us towards

achieving & sustaining a zero accident rate Your “Culture of Safety” needs to be a

culture that:– Embraces the concept of an SMS as a means to the a

zero rate end – Drives continuous improvement

Are We Rewarding the Right Are We Rewarding the Right People?People?

Supervisors know who will & won’t break the rules

Rule breakers are often rewarded for mission accomplishment

Reward systems are often upside down. We should reward the normal, positive performance that complies with organization standards.

What you reward today will get done tomorrow

Success SolutionsSuccess Solutions Reinforced bad behavior breeds continued bad

behavior

Rationalization of the gravity of the situation seems to lessen the risk in our minds, but in reality does not

Habitual rule breaking is often condoned by management when they look the other way

Does complacency play a role in this issue?

How the Processes Gives InsightHow the Processes Gives Insight

Risk Management(e.g.: hazard identification,risk assessment

Foresight

Monitoring(e.g.: supervision, Inspections, audits, HUMS

Oversight

Safety Reporting& Investigation

Hindsight

Insight

How the Processes InteractHow the Processes Interact

Risk ManagementProactive Planning

MonitoringProactive Checking

Safety Reporting& InvestigationReactive Checking

Feedback / Feed-forward

But all three processes are also there to Act to introduce improvements…

Continuous Improvement

These improvements are vital if you are going to achieve & sustain a zero rate

PDCA: Putting the Processes PDCA: Putting the Processes in Contextin Context

Plan Do Check Act Cycle– Plan what we are going

to do– Do it– Check performance– Act to improve

Q: So where would you put the three process?

Risk Management

Monitoring

Safety Reporting & InvestigationAll 3 can result in Action

ATTITUDEATTITUDE

“What lies behind us and what lies before us are tiny matters compared to what lies within us.”

Ralph Waldo Emerson

“The hardest thing to do, and the right thing to do are usually the same thing.”

COMMUNICATION COMMUNICATION BARRIERSBARRIERS

Position/Rank Age Gender Organization culture Predispositions (attitude) Assumptions

SummarySummary

The guiding principle of risk management is elimination of accidents

“Safety’s” role is the maximization of effectiveness and efficiency

A Safety Management System aims to establish and maintain this control

1. Reduce loss (people, production, assets, environment)2. Strengthen Management performance and organizational

culture3. Advance the Technology and knowledge base4. Demonstrate Compliance5. Provide a performance advantage