Implementing a Safety Management System

at Bell Helicopter’sMirabel facility

ByMichel Roby

Why did BHTCL choose to implement its SMS as of 2001?

• We have been crash-free since our operations started up in 1986 but…

• There have been a few near-misses• No system to document and investigate incidents• Assembly errors have been detected in Preflight• Our quality system should have detected and corrected

them during the manufacturing process• BHTCL wants to be a leader in Flight Safety

BHTCL has two licenses

• Manufacturer and AMO

• A SMS is currently required by Transport Canada, but for AMO only

• A question was raised: Should SMS be applied only to AMO or should it apply to the entire organization?

• BHTCL has chosen to apply its SMS to the entire organization because our AMO and Production activities share several common services, including manpower.

Applying the SMS

These important steps were followed

• Policy signed by the President

• Definition of roles and responsibilities

• Programming of an online reporting system

• Training given to the Flight Safety Committee

• Communication to employees

Roles and responsibilities

• Coordinator– Manages program on daily basis– Handles investigations further to observations– Sees to corrective action follow-up

• Flight Safety Committee– Makes sure the program runs smoothly– Provides monthly review of received observations– Takes part in some investigations– Makes recommendations to management

Final report write-up and closure

Processing by coordinator

Lost objectTool found

FO

Corrective action followup and closure

Final reportValidation

Write-up and distribution

Processing by team

Flight mishapsIncident

Potential hazardFOD

How the processing is handled

Validation

Preliminary report

How an observation is processed

Preliminary reportObserver creates report (preliminary)

Potential hazard, incident and FOD reports are automatically distributed to the coordinator, to his manager and to Flight Safety preliminary report readers

Preliminary report is automatically recorded as is (not modifiable)

How an observation is processed

Final report write-up and closure

Processing by coordinator

Lost objectTool found

FO

Corrective action followup and closure

Final reportValidation

Write-up and distribution

Processing by team

Flight mishapsIncident

Potential hazardFOD

How the processing is handled

Validation

Preliminary report

Validation

Coordinator validates the content of the preliminary report with the observer

Coordinator produces the official observation

report

Choice of processing channel

Final report write-up and closure

Processing by coordinator

Lost objectTool found

FO

Corrective action followup and closure

Final reportValidation

Write-up and distribution

Processing by team

Flight mishapsIncident

Potential hazardFOD

How the processing is handled

Validation

Preliminary report

Processed by the coordinator

Coordinator:

• Issues a search notice if object is suspected to be lost on aircraft. The search notice must be closed only by production and QC supervisors

• Investigates contributing factors

• Helps identifying root causes

• Ensures proper corrective actions are put in place and validates implementation.

How an observation is processed

Final report write-up and closure

Processing by coordinator

Lost objectTool found

FO

Corrective action followup and closure

Final reportValidation

Write-up and distribution

Processing by team

Flight mishapsIncident

Potential hazardFOD

How the processing is handled

Validation

Preliminary report

Final report

The Coordinator draws up the final report and sends it to the individual responsible of corrective actions.

Case closed

Choice of processing channel

Final report write-up and closure

Processing by coordinator

Lost objectTool found

FO

Corrective action followup and closure

Final reportValidation

Write-up and distribution

Processing by team

Flight mishapsIncident

Potential hazardFOD

How the processing is handled

Validation

Preliminary report

When processed by teamCoordinator distributes report to observer, to FSFRs (Flight Safety First Responders) , to Managers and Supervisors of departments involved (with voting button)

FSFRs and Managers / Supervisors show interest using voting button

Coordinator investigates contributingfactors

Task force establishes root causes and corrective actions

Coordinator proposes final report

Does task force validatefinal report ?

No

How an observation is processed

Final report write-up and closure

Processing by coordinator

Lost objectTool found

FO

Corrective action followup and closure

Final reportValidation

Write-up and distribution

Processing by team

Flight mishapsIncident

Potential hazardFOD

How the processing is handled

Validation

Preliminary report

The coordinator distributes the report to the observer, the Flight Safety First Responders, to task force, to Managers/Supervisors of the departments involved and to those in charge of implementing corrective action.

Final report validation, write-upand distribution

The Coordinator draws up final report

How an observation is processed

Final report write-up and closure

Processing by coordinator

Lost objectTool found

FO

Corrective action followup and closure

Final reportValidation

Write-up and distribution

Processing by team

Flight mishapsIncident

Potential hazardFOD

How the processing is handled

Validation

Preliminary report

Corrective action follow-up

The coordinator verifies whether corrective actions have been implemented.

Case closed

Received observation reports

• Per 2000 work hours (2001 six months)

Incidents history

• Per 2000 work hours (2001 six months)

Major leaks during ground runs

• Per 2000 work hours 2001 six months

Lessons learned

• Communication is a vital element for success

• Corrective action follow-up is a demanding but essential process if tangible results are to be obtained.

Our SMS is a driver that helps…

• Reduce incident and accident risks• Stabilize and reinforce the manufacturing

processes• Lower non-quality related costs