Risk Management Course
Introduction: The course is conducted by Scandinavian Aviation. Morten Kjellesvig is
program manager for the course and he has the primary response for the course.
Purpose: To assist individuals responsible for managing Risk Management.
Knowledge: After the course you will understand the principles of Risk Management and be
able to able to develop, implement, and manage Risk Management as a comprehensive part of
the Safety Management System in order to:
� Identify Threats
� Analyze the findings
� Perform Risk Management on the basis of Probability Severity and Exposure
� Implement Risk Management in own organization
� Enhance the mission/job effectiveness of the organization
Safety Philosophy: Communicate for Safety
Critiques: Each participant is expected to submit a course critique.
Certificate: At the completion of the course each student will receive a certificate of
completion for his/hers records.
Morten Kjellesvig
www.scandiavia.net
Telephone +4791184182
Name: Morten Kjellesvig MSc Air Safety Management Title: First Officer, SAS Managing Director ScandiAvia
Morten Kjellesvig is an airline pilot flying the Airbus 340 for Scandinavian Airlines. He has attended several courses in safety management and accident investigation and has extensive experience in aviation safety, management and accident / incident investigation. In the Royal Norwegian Air Force he flew fighter aircraft and held several management positions as safety manager, and held several courses for safety employees. He also attended 10 accident investigations, three as chairman. In Scandinavian Airlines Morten has held several management positions including Head of Flight Safety and Quality Support administering SAS quality system and been a part of SAS Company Investigation Team. Morten is managing director of ScandiAvia and he has taught quality and safety management in several Norwegian businesses and at different classes at SAS Flight Academy, at the University of Southern California and at City University in London. Morten finished his master project in January 2008 on Risk Management completing his Master of Science MSc in Air Safety Management at City University in London.
1
WELCOME TO THE
RISK MANAGEMENT COURSE 5-6FEB08
Morten KjellesvigMorten KjellesvigMorten KjellesvigMorten Kjellesvig
RISK MANAGEMENT COURSE 5-6 FEB08
Morten KjellesvigMScMScMScMSc in Air Safety Management atin Air Safety Management atin Air Safety Management atin Air Safety Management at
City University in LondonCity University in LondonCity University in LondonCity University in London
Lecture USC & City: Lecture USC & City: Lecture USC & City: Lecture USC & City:
Safety Management & Accident Inv.Safety Management & Accident Inv.Safety Management & Accident Inv.Safety Management & Accident Inv.
Admin positions Air Force & SAS
Accident investigator (10)Accident investigator (10)Accident investigator (10)Accident investigator (10)
Head of Flight Safety & QualityHead of Flight Safety & QualityHead of Flight Safety & QualityHead of Flight Safety & Quality
Editor Scandinavian Air SafetyEditor Scandinavian Air SafetyEditor Scandinavian Air SafetyEditor Scandinavian Air Safety
Fly AFly AFly AFly A----340 for Scandinavian Airlines340 for Scandinavian Airlines340 for Scandinavian Airlines340 for Scandinavian Airlines
Air Force pilot 1981 Air Force pilot 1981 Air Force pilot 1981 Air Force pilot 1981 ----1996199619961996
RISK MANAGEMENT COURSE 5-6 FEB08
INTRODUCTION
� Name & Company
� Current Position
� Previous ”Risk” experience
2
RISK MANAGEMENT COURSE 5-6 FEB08
JAROPS 1.037 ACCIDENT PREVENTION
AND FLIGHT SAFETY PROGRAMME
� An operator shall establish an accident
prevention and flight safety programme, which
may be integrated with the Quality System,
including:
� Programmes to achieve and maintain risk
awareness by all persons involved in operations
� No mentioning of Risk Management!
RISK MANAGEMENT COURSE 5-6 FEB08
DOC 9859 SAFETY MANAGEMENT MANUAL
� Criteria are established for assessing risks.
� Risks are analysed and ranked by competent personnel (including experienced staff representatives).
� Viable risk control measures are evaluated.
� Management takes action to reduce, eliminate or avoid the risks.
� Staff are aware of the actions taken to avoid or eliminate identified hazards.
� Procedures are in place to confirm that the actions taken are working as intended.
RISK MANAGEMENT COURSE 5-6 FEB08
A QUALITY SYSTEM
� Contains all we do to assure that our processes
run smoothly and that they continously improve
� Main processes in Flight operations can be:
� Preparation of Flights
� Production of Flights
� Evaluation, Follow Up and Improvements
� To control and improve theses processes
we need a Management System
3
RISK MANAGEMENT COURSE 5-6 FEB08
FAA DEFINED FOUR CORE COMPONENTS IN SMS
� Safety Policy
� Comprehensive Risk Management
� A Safety Assurance Process and
� Safety Promotion
MonitorMonitor
DocumentDocument
Plan & ImplementPlan & Implement
DevelopDevelop
CountermeasuresCountermeasures
Action!Action!
AnalysingAnalysing
DataData
InformationInformation
CollectionCollection
SMS COMPONENTS
RISK MANAGEMENT COURSE 5-6 FEB08
Supporting Sub SystemsSupporting Sub SystemsSupporting Sub SystemsSupporting Sub Systems
Safety reporting of Safety reporting of Safety reporting of Safety reporting of
events and concernsevents and concernsevents and concernsevents and concerns
Cabin Safety MonitoringCabin Safety MonitoringCabin Safety MonitoringCabin Safety Monitoring
Safety and quality auditsSafety and quality auditsSafety and quality auditsSafety and quality audits
Line check (LOSA)Line check (LOSA)Line check (LOSA)Line check (LOSA)
Flight Data MonitoringFlight Data MonitoringFlight Data MonitoringFlight Data Monitoring
Safety orientation and trainingSafety orientation and trainingSafety orientation and trainingSafety orientation and trainingCrisis management, Accident responseCrisis management, Accident responseCrisis management, Accident responseCrisis management, Accident response
External informationExternal informationExternal informationExternal information
Incident InvestigationIncident InvestigationIncident InvestigationIncident Investigation
Proficiency checkProficiency checkProficiency checkProficiency check
AuditAuditAuditAudit
Risk ManagementRisk ManagementRisk ManagementRisk Management
SMS COMPONENTS
4
ASR PROCESS
ASR?Type
Inv.? Invest?
Assess-
mentAction?Effect?
ReportTelex
E-mailYUrgent?
Y
Reqister
Init. Risk
N
Other ?
N
N
Invest.
report
Y
Implem-
entationYY
N
File &
Distr.
N
ManagementManagementManagementManagement
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Maintenance
GroundFlight Deck
THREE DOMAINS FOR COLLECTION
5
RISK MANAGEMENT COURSE 5-6 FEB08
THREE STEPS
“You don’t know what you don’t know”
“If you don’t know, How can you fix it?”
“If you can’t fix it, you’ve got a real
problem!”
RISK MANAGEMENT COURSE 5-6 FEB08
EFFECTIVE INCIDENT REPORTING
� Trust
� Non-punitive
� Inclusive reporting data base
� Independence
� Ease of reporting
� Acknowledgement
� Promotion / Feed Back
AccidentAccidentAccidentAccidentAccidentAccidentAccidentAccident
Serious incidentSerious incidentSerious incidentSerious incidentSerious incidentSerious incidentSerious incidentSerious incident
IncidentsIncidentsIncidentsIncidentsIncidentsIncidentsIncidentsIncidents
FFFF7777 FFFF6666
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FFFF20202020
FFFF22222222 FFFF21212121
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FFFF9999FFFF21212121FFFF14141414
FFFF3333
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FFFF4444FFFF10101010 FFFF25252525 FFFF21212121FFFF7777 FFFF6666 FFFF2222FFFF1111
FFFF1111
FFFF1111
ICEBERG
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6
RISK MANAGEMENT COURSE 5-6 FEB08
DOMINO – POOL – FLYING
RISK MANAGEMENT COURSE 5-6 FEB08
HELIOS HELIOS HELIOS HELIOS 522522522522, 14 AUG05 ATHENS B737, 14 AUG05 ATHENS B737, 14 AUG05 ATHENS B737, 14 AUG05 ATHENS B737
� Fatalities: 121:121
� Year of Delivery: 1998
� Cyprus to Athens
� Crew reported problem with the air conditioning packs
� Maintenance night before – left pressurisation off
� Check list
� 10.000’ alarm mistaken for T/O warning
� 14.000’ masks fell down - master caution
� Language problem
DOMINODOMINODOMINODOMINO
C
A
B
A
L
E
R
T
O
2
M
A
S
K
T
E
C
H.
K
N
O
W
L
L
A
U
N
G
U
A
G
E
P
R
E
T/
O
C
H
K
A
F
T
R
T/
O
C
H
K
P
R
E
S
S
V
A
L
V
E
O
P
E
N
7
DOMINO
LAUNGUAGE
Accident
DOMINODOMINODOMINODOMINO
T
E
C
H.
K
N
O
W
L
L
A
U
N
G
U
A
G
E
Normal &safe operation
=CABALERT
HELIOS HELIOS HELIOS HELIOS 522522522522, 14 AUG05 ATHENS B737, 14 AUG05 ATHENS B737, 14 AUG05 ATHENS B737, 14 AUG05 ATHENS B737
� Boeing shortly after the accident:� "Confusion between the cabin altitude warning horn and the takeoff
configuration warning horn can be resolved if the crew remembers that
the takeoff configuration warning horn is only armed when the airplane
is on the ground," the notice said. "If this horn is activated in flight, it
indicates that the cabin altitude has reached 10,000 feet."
8
RISK MANAGEMENT COURSE 5-6 FEB08
AIR SAFETY REPORT
� Your organisation receive the following Safety Report from a B757 crew:
� On the approach to 19 at SKCL (Cali) we selected the NDB 274R but the aircraft turned about 90 degrees off track. We reverted to HDG select, turned back towards R and the rest of the approach was uneventful.
RISK MANAGEMENT COURSE 5-6 FEB08
RISK BASED APPROACH
� Problem solving or risk control for regulatory
agency needs the following capacities:
� To Identify
� To Analyze
� To prioritize risk or problem areas in order:
� To ascertain the justifiable intensity of regulatory safety
oversight
� To fix and control the problem or risks
RISK MANAGEMENT COURSE 5-6 FEB08
RISK ANALYSIS
Define RiskIdentify Risk
involved
Assess
Risk factor
Risk analysis
Risk Analysis is about developingRisk Analysis is about developingRisk Analysis is about developingRisk Analysis is about developing
and understanding of the risk.and understanding of the risk.and understanding of the risk.and understanding of the risk.
9
RISK MANAGEMENT COURSE 5-6 FEB08
DEFINE RISK
� RiskRiskRiskRisk: The chance of Harm, in terms of
Probability and Severity i.e. (how often x how
bad) considered with the element of exposure
to risk.
� HazardHazardHazardHazard: Something that can cause significant
Harm
� ThreatThreatThreatThreat: Cause the release of Hazard
RISK MANAGEMENT COURSE 5-6 FEB08
IDENTIFY RISK INVOLVED
� Quality system to detect the threats
� Reporting system, Audits, Interviews
� Management review,
� Brainstorming
� Workshops
� Look through of procedures and checklists
� Training records
� Other operators
RISK MANAGEMENT COURSE 5-6 FEB08
ASSESS RISK FACTOR
� All threats need to be assessed in order to
prioritize what to fix “first” or focus on.
� Assessments can result in a number, a
description of the threat or a color code system
(red, orange or green).
� In order to identify the Risk factor, Probability,
Severity and Threat exposure needs to be
examined.
10
RISK MANAGEMENT COURSE 5-6 FEB08
RISK ASSESSMENT
Define RiskIdentify Risk
involved
Assess
Risk factor
Risk analysis
Risk assessment
Make control
decisions
RISK MANAGEMENT COURSE 5-6 FEB08
MAKE CONTROL DECISIONS
� Now the organization must decide upon
action(s) to control, eliminate, mitigate or
reduce the risk.
� Management must always balance between
risk versus cost and even sometimes risk
against opportunities.
� When the sum of the benefits exceeds the cost,
risk should normally be accepted.
RISK MANAGEMENT COURSE 5-6 FEB08
OUTCOMES OF ANALYSIS
� Design for minimum hazard
� Safety devices
� Warning devices
� Procedures and training
11
RISK MANAGEMENT COURSE 5-6 FEB08
RISK MANAGEMENT
Define RiskIdentify Risk
involved
Assess
Risk factor
Action to
control Risk
Monitor &
Evaluate
Risk analysis
Risk assessment
Risk Management
Make control
decisions
RISK MANAGEMENT COURSE 5-6 FEB08
ACTION TO CONTROL RISK
� The important task is to look at and determine
action to take in order to eliminate or reduce
the risk.
� Whenever there is an improvement in place
there should be an owner to the solution in
order to assure that actions and timeline is
followed.
RISK MANAGEMENT COURSE 5-6 FEB08
ACTION TO CONTROL RISK
� Who does what
� Timeline
� Follow up
12
RISK MANAGEMENT COURSE 5-6 FEB08
MONITOR AND EVALUATE
� After the RM is complete there is a need to
monitor and evaluate the result.
� Did the action taken have the needed effect,
did it have a side effect or unwanted effect.
� A review or follow up is important in order to
see if the action had the needed effect or any
side effect.
INCIDENT REPORT
Three red and three green lights in landing gear
Define RiskIdentify Risk
involved
Assess
Risk factor
Action to
control Risk
Monitor &
Evaluate
Make control
decisions
INCIDENT REPORT
Three red and three green lights in landing gear
Identify Risk
involved
Assess
Risk factor
Action to
control Risk
Monitor &
Evaluate
Make control
decisions
13
RISK MANAGEMENT COURSE 5-6 FEB08 EXTRACT OF COMMANDERS REPORT
� When selecting gear down, we got three red
and three green lights.
� After recycling the landing gear we got a normal
three green indication.
� Landing uneventful.
Identify Risk
involved
ManagementManagementManagementManagement
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Identify Risk
involved
RISK MANAGEMENT COURSE 5-6 FEB08
QUALITY SYSTEM – REPORTING SYSTEM
� Crew reported and the problem was identified
� Investigation revealed:� Similar occurrences has happened before with this A/C
� Illumination of the 3 green landing gear indicator lights confirms "Gear down & locked".
� The 3 red gear indicator lights indicate a disagreement between the gear lever and a gear position.
� With the red lights illuminated a GPWS aural/visual alert will be activated ("TOO LOW, GEAR" and "PULL UP", respectively) if the approach is continued with this indication.
Identify Risk
involved
14
RISK MANAGEMENT COURSE 5-6 FEB08
INVESTIGATION
� The gear lever was not in down detent or pushed
fully down at the first gear down selection.
� The crew made the correct decision to recycle the
gear.
� The second gear down selection gave normal
indication and a normal landing was performed.
� When selecting gear down, high gear lever friction
or a gentle lever handling could cause the 3 red
lights to remain illuminated.
Identify Risk
involved
RISK MANAGEMENT COURSE 5-6 FEB08
SEVERITY PROBABILITY & EXPOSURE
Assess
Risk factor
RISK MANAGEMENT COURSE 5-6 FEB08
� Adjust the target to the proximity switch
� Inspect the rest of the fleet
Make control
decisions
15
RISK MANAGEMENT COURSE 5-6 FEB08
� Who does what
� Timeline
� Follow up
� Adjust the target to the proximity switch
� Inspect the rest of the fleet
Action to
control Risk
RISK MANAGEMENT COURSE 5-6 FEB08
QUALITY SYSTEMMonitor &
Evaluate
ManagementManagementManagementManagement
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AAAA
UUUU
DDDD
IIII
TTTT
AAAA
CCCC
MMMM
SSSS
RISK MANAGEMENT COURSE 5-6 FEB08
RISK MANAGEMENT
Define RiskIdentify Risk
involved
Assess
Risk factor
Action to
control Risk
Monitor &
Evaluate
Risk analysis
Risk assessment
Risk Management
Make control
decisions
16
RISK MANAGEMENT COURSE 5-6 FEB08
RATIONALE FOR RISK MANAGEMENT
� Every situation has threats
� No one knows all the threats
� Threats are not equally consequential
� All situations require a balance (Risk vs. Benefit)
� Limited resources available to identify, eliminate, and control threats
� All serious threats should be eliminated or controlled
RISK MANAGEMENT COURSE 5-6 FEB08
RISK MANAGEMENT RULES
� No unnecessary risk should ever be accepted
� Risk decisions must be made at the
appropriate level
RISK MANAGEMENT COURSE 5-6 FEB08
ADVANTAGES OF RISK MANAGEMENT
� Detect risk before loss
� Quantify risk
� Provide risk control alternatives
� Greater integration of safety
� Increased mission capability
17
RISK MANAGEMENT COURSE 5-6 FEB08
HOW TO DETECT THREATS
� Analysis of data
� Observation of near mishaps
� Safety surveys
� Review of company plans, policies, procedures,
and instructions
� Two types of Risk
� Informed risk
� Uninformed risk
ThreatsThreatsThreatsThreats
RISK MANAGEMENT COURSE 5-6 FEB08
NECESSARY RISK
� Some risks are necessary since risk come with
every activity, but how much is acceptable?
� Do we have an answer?
� Is it different in different organisations?
RISK MANAGEMENT COURSE 5-6 FEB08
NECESSARY RISK
� ..an organisation is safe enough when the
leaders seeks modern safety processes, and
makes the effort to identify every possible
hazard, and then strives to eliminate, control or
reduce the associated risks through training,
procedures and technology to the point that
operations do not accept unnecessary risks.
Greg Alston 2003Greg Alston 2003Greg Alston 2003Greg Alston 2003
18
EvaluateEvaluate !!
IdentifyIdentifyThreatsThreats
DetermineDetermineRiskRisk
Acceptable ?Acceptable ?
YesYes
Cancel !!!Cancel !!!NONO
YesYes
NONO EliminateEliminateRiskRisk
ReduceReduceRiskRisk
NONO
YesYes
Continue operationContinue operation
RISK MANAGEMENT COURSE 5-6 FEB08
Event
AwarenessAwarenessAwarenessAwareness
TimeTimeTimeTime
XXXX
OverOverOverOver----reactionreactionreactionreaction
UnderUnderUnderUnder----reactionreactionreactionreaction
OptimalOptimalOptimalOptimal
SAFETY AWARENESS
RISK MANAGEMENT COURSE 5-6 FEB08
RISK ASSESSMENT
� Probability
� Severity
� Exposure to Risk
19
RISK MANAGEMENT COURSE 5-6 FEB08
CHANGE PROBABILITIES
What is the Probability of getting:2
3
4
5
6
7
8
9
10
11
12
RISK MANAGEMENT COURSE 5-6 FEB08
Probability (Frequency)
Low (2)
Sev
erit
y (C
on
seq
uen
ces)
10101010 15151515 20202020 25252525
8 12 16 20
6 9 12 15
4 6 8 10
2 3 4 5
5
4
3
2
1
Low (1) Medium (3) High (4) High (5)
High (5)
High (4)
Medium (3)
Low (2)
Lov (1)
RISK MANAGEMENT COURSE 5-6 FEB08
RISK ACCEPTANCE CRITERIA
1111----6666May be acceptable, however, review May be acceptable, however, review May be acceptable, however, review May be acceptable, however, review
task to see if risk can be reduced task to see if risk can be reduced task to see if risk can be reduced task to see if risk can be reduced
furtherfurtherfurtherfurther
7777----14141414
Task should only proceed with appropriate management Task should only proceed with appropriate management Task should only proceed with appropriate management Task should only proceed with appropriate management
authorisation. Where possible the task should be authorisation. Where possible the task should be authorisation. Where possible the task should be authorisation. Where possible the task should be
redefined to take account of the redefined to take account of the redefined to take account of the redefined to take account of the threats threats threats threats involved or the involved or the involved or the involved or the
risk should be reduced further prior to task risk should be reduced further prior to task risk should be reduced further prior to task risk should be reduced further prior to task
commencement.commencement.commencement.commencement.
15151515----25252525Task must not proceed. It should be redifined or further Task must not proceed. It should be redifined or further Task must not proceed. It should be redifined or further Task must not proceed. It should be redifined or further
control measures put in place to reduce risk. The control measures put in place to reduce risk. The control measures put in place to reduce risk. The control measures put in place to reduce risk. The
controls should be reassessed for adequacy prior to controls should be reassessed for adequacy prior to controls should be reassessed for adequacy prior to controls should be reassessed for adequacy prior to
task commencement.task commencement.task commencement.task commencement.
20
RISK MANAGEMENT COURSE 5-6 FEB08 � An aircraft lands just after taking off due An aircraft lands just after taking off due An aircraft lands just after taking off due An aircraft lands just after taking off due
to fire/smoke in the cabin. to fire/smoke in the cabin. to fire/smoke in the cabin. to fire/smoke in the cabin.
The investigation revealed that it was due The investigation revealed that it was due The investigation revealed that it was due The investigation revealed that it was due
to moist in the cables and couplings and to moist in the cables and couplings and to moist in the cables and couplings and to moist in the cables and couplings and
the air condition system had been the air condition system had been the air condition system had been the air condition system had been
operating only partly for the last month.operating only partly for the last month.operating only partly for the last month.operating only partly for the last month.
HOW DO WE REDUCE THE PROBABILITY?
An aircraft lands just after taking off due to fire/smoke in
the cabin.
The investigation revealed that it was due to moist in the
cables and couplings and the air condition system had
been operating only partly for the last month.
HOW DO WE REDUCE THE SEVERITY?
RISK MANAGEMENT COURSE 5-6 FEB08
RISK
� Acceptable
� Unacceptable
21
Morten KjellesvigMorten KjellesvigMorten KjellesvigMorten Kjellesvig
Risk Management Course 2008Risk Management Course 2008Risk Management Course 2008Risk Management Course 2008
Break
03.02.2008
1
RISK MANAGEMENT COURSE DAY 2
Morten KjellesvigMorten KjellesvigMorten KjellesvigMorten Kjellesvig
WHAT IS RISK
� “The chance of Harm, in terms of Probability
and Severity i.e. (how often x how bad)
considered with the element of exposure to
risk”.
� What is uncertainty?
�North Pole
� Risk is linked to objectives
SEVERITY - PROBABILITY - EXPOSURE
� Remember we look for a positive change we
want to increase the chances of a good
outcome
�Reduce the Probability of something happening
�Reduce the Severity if it happens
� See what exposure does to the operation
03.02.2008
2
CASE: TUNNEL
� How do we reduce the
� Probability
� Severity
� Exposure
MonitorMonitor
DocumentDocument
Plan & ImplementPlan & Implement
DevelopDevelop
CountermeasuresCountermeasures
Action!Action!
AnalysingAnalysing
DataData
InformationInformation
CollectionCollection
THE “MANAGEMENT” IN RISK MANAGEMENT
PROBABILITY
Designation Description
Low (1),
Improbable
Not credible or almost improbable, not heard of or seen before
and can be assumed that it never happens
Low (2),
Remote
Low probability and would require multiple failures but can
eventually happen
Medium (3),
Occasional
Probably that it happens sometimes and can lead to an accident
High (4),
Probable
Could lead to an accident, and similar incident have occurred
before
High (5),
Frequent
Probably that it happens and likely to lead to an accident,
similar incidents have lead to accidents in the past
03.02.2008
3
SEVERITYPersonnel Material Damage Cost
Very low (1),
Insignificant
Negligible, no injury Negligible or no
damage
Less than 10.000 $
Low (2), Marginal Minor / Light injury
requiring first aid
treatment on site.
Damage requiring
minor repair
Up to 1 mill $
Medium (3),
Marginal to
Critical
Event leading to a
minor injury
where personnel
can no longer
continue duty.
Damage requiring
extensive repair
and or loss of
production /
function.
1 – 10 mill $
High (4), Critical Involving severe
injury
Severe damage
requiring
extensive repair
and or loss of
production /
function
10 – 25 mill $
High (5),
Catastrophic
Involving death Hull loss, material loss More than 25 mill $
DOMINO THEORY
ManagementManagementManagementManagement
•Latent ConditionsLatent ConditionsLatent ConditionsLatent Conditions
UnderlyingUnderlyingUnderlyingUnderlying
CauseCauseCauseCause
BasicBasicBasicBasic
CauseCauseCauseCause
SystemSystemSystemSystem
•Latent ConditionsLatent ConditionsLatent ConditionsLatent Conditions
ImmediateImmediateImmediateImmediate
CauseCauseCauseCause
IndividualIndividualIndividualIndividual
•Active FailuresActive FailuresActive FailuresActive Failures
SafetySafetySafetySafety
DefensesDefensesDefensesDefenses
Safety NetSafety NetSafety NetSafety Net
•CountermeasuresCountermeasuresCountermeasuresCountermeasures
ConsequencesConsequencesConsequencesConsequences
ResultResultResultResult
•Close CallsClose CallsClose CallsClose Calls
•IncidentsIncidentsIncidentsIncidents
•AccidentsAccidentsAccidentsAccidents
LATENT CONDITIONS - COMET
� Explosive decompression of the pressure cabin. Explosive decompression of the pressure cabin. Explosive decompression of the pressure cabin. Explosive decompression of the pressure cabin. They
had no reason to suspect the primary structure of the
cabin itself.
� Their main concern, however, was the window panels,
where they thought it necessary to consider possible
defects which might cause weakness not revealed in
the tests made during design at de Havillands.
03.02.2008
4
LATENT CONDITIONS - COMET
� Corrective action was modification of
windows to oval / round edge on pressurised
aircraft
DOMINO 3, ACTIVE FAILURE
ImmediateImmediateImmediateImmediate
CauseCauseCauseCause
IndividualIndividualIndividualIndividual
•Active FailuresActive FailuresActive FailuresActive Failures
�Refers to Immediate
Causes or Symptoms
and includes:
�Substandard Practices
�Substandard Conditions
� Individual errors
DOMINO 3, ACTIVE FAILURE
1. Didn’t follow instructions
2. Blundered ahead without knowing how to do the job
3. Bypassed or ignored a rule, regulation, or procedure to save time
4. Failed to use protective equipment
5. Didn’t think ahead
6. Used wrong equipment to do the job
03.02.2008
5
DOMINO 3, ACTIVE FAILURE
7. Used equipment that needed repair or
replacement
8. Didn’t look
9. Didn’t listen
10. Didn’t recognize physical limitations
11. Failed to use safeguards or protective devices
12. Didn’t pay attention
MANAGEMENT MUST
PAY ATTENTION TO
PAYING ATTENTION!
DOMINO 4, SAFETY DEFENSES
SafetySafetySafetySafety
DefensesDefensesDefensesDefenses
Safety NetSafety NetSafety NetSafety Net
•CountermeasuresCountermeasuresCountermeasuresCountermeasures
� Target of safety defenses
�Management
�Systems
� Individual
�Consequences
03.02.2008
6
CONCORDE GROUNDED
� Single failure, tirecomponents puncturing the
wing
DOMINO 5, RESPONSIBILITIES
� Management
� Set standards
�Hold individuals accountable
� Just culture
� Each Individual
�Know standards
� Follow standards
ConsequencesConsequencesConsequencesConsequences
ResultResultResultResult
•Close CallsClose CallsClose CallsClose Calls
•IncidentsIncidentsIncidentsIncidents
•AccidentsAccidentsAccidentsAccidents
DOMINO 5, CONTROLLING ERROR
� Do not introduce latent conditions
� Support operator
� Motivate individuals
� Design safety measures to trap error
ConsequencesConsequencesConsequencesConsequences
ResultResultResultResult
•Close CallsClose CallsClose CallsClose Calls
•IncidentsIncidentsIncidentsIncidents
•AccidentsAccidentsAccidentsAccidents
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RAMP ACCIDENTS FREQUENCY:
The Frequency is 0,67 per 1000 departures The Frequency is 0,67 per 1000 departures The Frequency is 0,67 per 1000 departures The Frequency is 0,67 per 1000 departures
Departures 29.500.000 x 0,67 = 19765Departures 29.500.000 x 0,67 = 19765Departures 29.500.000 x 0,67 = 19765Departures 29.500.000 x 0,67 = 19765
20
RAMP ACCIDENT COST US $
1 Accident / Damage direct cost = 185001 Accident / Damage direct cost = 185001 Accident / Damage direct cost = 185001 Accident / Damage direct cost = 18500
Indirect cost = 18500 x 4 = 74000Indirect cost = 18500 x 4 = 74000Indirect cost = 18500 x 4 = 74000Indirect cost = 18500 x 4 = 74000
Total = 74000 x 19765Total = 74000 x 19765Total = 74000 x 19765Total = 74000 x 19765
= = = =
USD 1.462.610.000USD 1.462.610.000USD 1.462.610.000USD 1.462.610.000
21
US$ 1.462.610.000 EQUALS 48 NEW:
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� Active Failures
� Individual Error
� Effects seen immediately
�But when we have an accident we did not see it….
ERROR TYPES
Failure toFailure toFailure toFailure to
crosscheckcrosscheckcrosscheckcrosscheck
MANAGEMENT EVALUATION JAR 1.035
� 2.2.3 The Accountable Manager will have
overall responsibility for the AOC holders Quality
System including the frequency, format and
structure of the internal management
evaluation activities as prescribed in paragraph
4.9 below.
JAR OPS 1 SUB PART B AMC OPS 1.035
�4.9 Management Evaluation� A management evaluation is a comprehensive, systematic, documented review by themanagement of the quality system, operational policies and procedures, and should consider:
�a. The results of quality inspections, audits and any other indicators;
�b. The overall effectiveness of the management organisation in achieving stated objectives.
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JAR OPS 1 SUB PART B AMC OPS 1.035
�4.9 Management Evaluation cont.� A management evaluation should identify and correct trends, and prevent, where possible, futurenon-conformities. Conclusions and recommendations made as a result of an evaluation should be submitted in writing to the responsible manager for action. The responsible manager should be an individual who has the authority to resolve issues and take action.
�4.9.3 The Accountable Manager should decide upon the frequency, format, and structure of internal management evaluation activities.
VIRGIN
� Fuel computer
� No 1 engine flameout
� Fuel empty in feed tank
� Continue to Heathrow on three engines
� No 4 engine power began fluctuating
� Fuel empty in feed tank
� Crossfeed valves on, and No 4 engine recovers
� Land AMS
MANAGEMENT EVALUATION (REVIEW)
� Management Evaluation (Review)
� Observation of near mishaps, Safety surveys, Review of company plans, policies, procedures, and instructions
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MANAGEMENT EVALUATION – TASK:
� Your Accountable Manager want’s to know
what are the greatest risk the company faces.
(What type of accident would we have)
MURPHY WAS WRONG:
What can go wrong
usually goes right.
USEFUL WEBSITE
�www.scandiavia.net/web.htm
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Communicate for Safety!
SAFETY PHILOSOPHY
SAFETY TRAINING
� Safety Management course
� Accident Investigation course
� Threat and Error Management course
� Commander Candidate course
� Safety Awareness
� Top Management course
� Airworthiness
� Air Law
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SPREAD THE WORD.......
SPREAD THE WORD
Thanks forThanks for YOUR YOUR attention!attention!
Morten KjellesvigMorten KjellesvigMorten KjellesvigMorten Kjellesvig
[email protected]@[email protected]@scandiavia.net
www.scandiavia.netwww.scandiavia.netwww.scandiavia.netwww.scandiavia.net