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SCANDINAVIAN AVIATION EDUCATION PROGRAM Risk Management Course Stockholm 5 – 6 February 2008
Transcript

SCANDINAVIAN AVIATION EDUCATION PROGRAM

Risk Management Course

Stockholm

5 – 6 February 2008

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

[email protected]

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

CCCC

SSSS

MMMM

OOOO

PPPP

CCCC

LLLL

IIII

NNNN

EEEE

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RRRR

EEEE

PPPP

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RRRR

TTTT

AAAA

UUUU

DDDD

IIII

TTTT

AAAA

CCCC

MMMM

SSSS

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

FFFF14141414

FFFF20202020

FFFF22222222 FFFF21212121

FFFF16161616

FFFF22222222 FFFF11111111FFFF2222

FFFF9999FFFF21212121FFFF14141414

FFFF3333

FFFF8888

FFFF4444FFFF10101010 FFFF25252525 FFFF21212121FFFF7777 FFFF6666 FFFF2222FFFF1111

FFFF1111

FFFF1111

ICEBERG

FFFF21212121FFFF17171717

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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IIII

TTTT

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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

03.02.2008

7

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:

03.02.2008

8

� 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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9

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

03.02.2008

11

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

03.02.2008

12

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


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