ARMS - The enabler to understanding risk (CHIRP Mar12).ppt · Microsoft PowerPoint - ARMS - The...

3/27/2012

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ARMS

CHIRP Maintenance Meeting

28th March 2012

Andrew Rose – Llanbury Consulting

The enabler to

understanding Risk

Llanbury Consulting‘RISK’ – The big picture

ARMS – Aviation Risk Management

Solutions working group

The Mission of the ARMS Working Group is to

produce useful and cohesive Operational Risk

Assessment methods for airlines and other aviation

organisations and to clarify the related Risk

Management processes.

Formed in 2007 (Jari Nisula – Airbus, Andrew Rose – British Airways)

Llanbury Consulting‘RISK’ – The Big Picture

ARMS Background

Jun 07 – Oct 09 Safety practitioners from over 20 aviation organisations

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ARMS Participants

ARMS Working Group 2009

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Investigations

Data Analysis-Frequencies

-Trends

-Identification of Safety

Issues

Hazard

Analysis

Safety

Performance

Monitoring

All collected

safety data

-Categorized

-ERC values

Safety Issue Risk

Assessment“SIRA”

Safety

Issues

Actions to

reduce risk

Safety

Assessments

Event Risk Classification (ERC)

All Data

Safety

Events

Safety

Issues

Scenarios

The ARMS Concept


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What’s in it for me?

Effective risk management requires us to

monitor the performance of our system

ARMS techniques enable the best use of

the data and knowledge to enable the

optimum risk management decisions

Possibilities…


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G-VXLA G-VXLB G-VXLC G-VXLD

G-VXLE G-VXLF G-VXLG G-VXLH

G-VXLG


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Investigations


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Issues

Hazard

Analysis

Safety

Performance

Monitoring

All collected

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-Categorized

-ERC values

Safety Issue Risk


Safety

Issues

Actions to

reduce risk

Safety

Assessments


All Data

Safety

Events

Safety

Issues

Scenarios

The ARMS Concept



Event Risk Classification

This activity is about measuring performance and

risk in the system based on historical events:

Risk classification – NOT Risk Assessment

Severity of the

potential accident

outcome

Probability of the

event resulting in that

outcome*+

= Risk

* Probability of occurrence is derived from the data

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Catastrophic accident with multiple fatalities >8

1-8 fatalities, multiple serious injuries, major

damage/loss to the aircraft

Minor injuries, minor damage to aircraft

No potential damage or injury could occur

If this event had escalated into an accident, what would have been the most credible

accident outcome?

ARMS Event Risk Classification (ERC) Framework

What is the probability of this event progressing to that credible accident outcome?


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accident outcome?

The shared Aviation Risk Space

What is the probability of this event progressing to that credible accident outcome?


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ERC – Severity Question

The severity question has to be based on the

credible accident outcome and not some

intermediary point.Why?

Because this is a measurement exercise for

risk across the aviation system so you have

to measure to the same point

Intermediary outcomes (such as

‘unairworthy aircraft’) are only separated

from accidents by probabilities and these

are accounted for in the next question


ERC – Probability Question

It is very subjective based on our personal

experience so the ARMS approach suggested

adopting a barrier principle:

Probability is a difficult question for us

What was the effectiveness of the remaining barriers

between this event and the accident scenario?Effective / Limited / Minimal / Not Effective

Barriers are an easier concept for us to

judge but this approach is still subjective

and perhaps over simplistic with regards to

the effectiveness of barriers.So …

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ERC – Structured Barrier Models

Significant work is on-going with the UK CAA

(involving airlines, EASA, FAA, EC, etc.) to

develop a structured barrier model approach to

answer the probability question:

What barriers stopped this event progressing?

What other barriers could also have stopped

this event progressing?

How reliable are those barriers?

It is a whole presentation on its own but in brief it is

evaluating standardised approaches to developing and

using models for different scenarios to determine:

Common Risk Classification Framework

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Common Risk Classification Framework

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What are the barriers in this scenario?How important is each barrier?What is the status of the barriers in this case?


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Framework approach to the ERC

It makes the semi-automated risk classification of

masses of system generated data a possibility…

- Reporting data is a rich source but narrow in its scope

- System generated data lacks detail but has wide coverage

- Combined they become a powerful source

of system performance knowledge

As an aviation system we over rely on employee reporting

data as our key (and separate) window on performance

"The whole is greater

than the sum of its

parts." - Aristotle


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Investigations


-Trends


Issues

Hazard

Analysis

Safety

Performance

Monitoring

All collected

safety data

-Categorized

-ERC values

Safety Issue Risk


Safety

Issues

Actions to

reduce risk

Safety

Assessments


All Data

Safety

Events

Safety

Issues

Scenarios

The ARMS Concept


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2009 Page 19

Undesirable

operational

stateTriggering EVENT

Maintenance

error

Flight ops hazard

Hazard on

ground

ATC hazard

Weather

hazard

ACCIDENT OUTCOME

Catastrophic

accident (e.g.

mid air collision)

Major accident

(e.g. overrun)

Minor safety

occurrence (e.g.

turbulence

bruises)

Negligible

PREVENTPREVENT AVOIDAVOID RECOVERRECOVER((MINIMISEMINIMISE

LOSSES)LOSSES)

1. FREQUENCY

OF Triggering EVENT

2. EFFECTIVENESS

OF AVOIDANCE

BARRIERS

3. EFFECTIVENESS

OF RECOVERY

BARRIERS

4. ACCIDENT

SEVERITY

Safety Issue Risk Assessment

Technical

hazard

Undesirable

operational

state

Triggering EVENT

ACCIDENT OUTCOME

Unrecoverable engine failures resulting in catastrophic accident

Loss of control due ash damage to airframe or sensors

Midair collision as a result of ash avoidance and recovery maneuvers

Injuries & damage sustained during emergency diversion & landing

Example SIRA for operations into areas

of forecast volcanic ash

Flight into area of forecast volcanic ash

Inadvertent encounter with higher than

expected density of volcanic ashPredict

Plan

Operate

MEL ATC

Engine mgmt

Flt Crew SOPs

Recover

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Expanded Volcanic Ash Model- One off encounter

KLM UK example

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ARMS - Jari Nisula 2010

ARMS SIRA Excel application

• Analysing the

risk factors

and barriers

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3.1 Triggering event 3.2 Undesirable Operational State 3.3 Accident Outcome

4 Describe the barriers

4.1 To avoid the UOS 4.2 To recover before the Accident

5 Risk Assessment

The estimated frequency of

the triggering event (per

flight sectors) is:

The barriers will fail in AVOIDING

the UOS...

The barriers will fail in

RECOVERING the situation before

the ACCIDENT...

The accident severity would be...

About every 100000 sectors Once every 10 times Once every 10 times Major

1.E-05 1.E-01 1.E-01

UOS frequency: Mean Accident frequency:

1.E-06 1.E-07

6 Result 1.E+00

6.1 Resulting risk class Secure 1.E+00

Comments on actions:

Secure

Analysis of potential Accident Scenario

• Needed figures can be obtained

from the event

database or

estimated


Conclusion

ARMS offers powerful tools in the cohesive

understanding of risk across the aviation

system:

ERC and its associated barrier framework provides a

basis for the common measurement of risk

performance across aviation

So reach for the possibilities of a cohesive

picture of risk performance for maintenance

within the whole aviation context…

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Questions

Contact:

Andrew Rose – [email protected]

Questions and Further Information

?


ARMS link –

http://www.skybrary.aero/index.php/ARMS_Methodology_for_Risk_Assessment

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