Small Fleet and Private Operators - International Helicopter ...

Safety Management Systems

Safety Management Systems

Small Fleet and Private OperatorsSmall Fleet and Private Operators

forfor

Bryan Smith

ALEA Safety Program Manager

Seminole County Sheriff’s Office

C

Aviation PoemOne day, a long, long time ago…there was a

pilot…

B

FLIGHT PLAN… 1. WHY SMS?

2. SETTING UP POLICY3. HAZARD ID AND

ANALYSIS4. RISK ANALYSIS5. RISK CONTROLS6. ASSURANCE

B

If you had one superpower, what would it be?

How much time and money did you spend on training or safety stuff last year?

Are you safer for it?How do you know?What is ‘safer’?

80-90% of ‘safety events’ are caused by system issues*

Individual eventsvs

‘System’ events

* University of Illinois study, Goh and Wiegmann, 2001B

“Insanity is doing the same thing over and over again, and expecting different results.”

~Albert Einstein

Why SMS?

1. Hazard ID only

2. Tracks lag data (final link)

3. Assumption of risk

4. Assumption of performance

5. Isolated

Traditional Safety Program…

1. Hazard ID + Hazard and Risk Assessment

2. Lead and lag (entire chain)

3. Quantification and Prioritization

4. Quantified tracking (assurance)

5. Integrated with Ops and Training

Safety Management System…

• SMS: The formal, top-down approach to managing safety risk. It includes systematic procedures, practices, and policies for the management of safety.

1. Hazard ID + Hazard and Risk Assessment

2. Lead and lag (entire chain)

3. Quantification and Prioritization

4. Quantified tracking (assurance)

5. Integrated with Ops and Training

1. Cost savings

2. Increased efficiency

3. Industry standard

4. Legal ramifications

5. It WORKS = lives saved

Why SMS?• SMS: The formal, top-down approach

to managing safety risk. It includes systematic procedures, practices, and policies for the management of safety.

C

FLIGHT PLAN…

1. WHY SMS?2. SETTING UP POLICY3. HAZARD ID AND


2. SETTING UP POLICY

B

Phase 1Setting the Foundation

SMS Checklist:GAP Analysis

FAA: http://www.faa.gov/about/initiatives/sms/specifics_by_aviation_industry_type/air_operators/media/SMS_Gap_Analysis_Tool_MRO_7-31-14.xls

Email me…

C

What is your Vne?

What is your Max Gross Weight?

How long can you pull your torque into the yellow?

How could a new pilot figure these out without being told?

What are your safety limits?

SETTING UP POLICY

Why put it in writing?People believe written promises more than spoken onesIt provides rational, thought out perspective when there a question or issuePersonal limits kept only in the mind are easily manipulated by desire!Cut away the fat - use an analytical process

B

IHST SMS Toolkit p. 7, 9, 15

Required Elements…Safety Statement from ManagementEstablishment of Just CultureSet up Reporting System and DocumentsEstablish Safety Related Positions (& Committee)P.A.V.E. Operations LimitsEmergency Response PlanTraining Requirements and PlanningGoals and Objectives

…

SETTING UP POLICY

Safety Manual

OpsManual

OpsManual

Operational Limits

16

• Persons – Experience, training, fatigue, illness, [I’M SAFE checklist]

• Aircraft – Known maintenance issues, performance limitations, fuel status, avionics updates.

• enVironment – Weather (present and forecast), flight (mission) type, ATC, obstructions, time of day, other air traffic

• External Pressures - Recent changes in personnel, management insistence, difficult customers, consequences of canceling flight.

SETTING UP POLICY

C

Why put it in writing?People believe written promises more than spoken onesWhen the time comes to apply a policy the situation may distort the proper mindset needed to make a safe decisionIt provides rational, thought out perspective when there a question or issuePersonal limits kept only in the mind are easily manipulated by desire!Cut away the fat - use an analytical process


0

2

3

5

6

8

Fatigue ExampleSETTING UP POLICY

Safety StatementSETTING UP POLICY

C


Just Culture must be codified in policy so it can be universally implemented

Without a written commitment it is unlikely that employees will have faith in it.

Just CultureSETTING UP POLICY

B

Safety Committee

✓ Management✓ Training✓ Safety✓ Maintenance✓ Other Line Level Employee Groups

✓ Flight Instructor✓ Flying colleagues✓ Flying clubs✓ Other operators on the field✓ Your mechanic

✓ At least Quarterly✓ Does not have to be in person

SETTING UP POLICY

C

It’s fine to have a ‘vision’ statement…”Zero accidents…Safe Operations…”

You need intermediate, measurable objectives to define the path and verify progress.

Safety is a vision… What are you going to do to get

there?IHST SMS Toolkit p. 7, 9, 15

TipsSETTING UP POLICY

B

Emergency Response Plan

Emergency Response Plans:

Weak Points:

• When to initiate• Poor tracking system• Location of plan• Contact list outdated• Organization family

contact slower than media

• Survivor/Responder mental health care

SETTING UP POLICY

B


PRIVATE OPERATOR POLICY EXAMPLE…

My Personal Limits:Daytime local flight - 1000 feet, 4 miles vis.*Night or Daytime cross country flight - 1500 feet, 5 miles vis.Forecast minimum wx from departure to 1 hr. after arrivalIf I did not sleep X hrs the night before, I will ground myselfPersonal currency requirements

– 3 takeoff/landings every 30 days- 1 safety class or seminar every 60 days

…

Private Operator PolicySETTING UP POLICY

C

Cutting the Safety FAT Tips:1. Leave excessive risk management ‘theory’ discussion out of the

policy manual. Utilize appendixes.

C

SMS Checklist:GAP AnalysisPolicy

Safety Statement from ManagementSafety Goals and ObjectivesEstablishment of Just CultureSet up Reporting System and DocumentsEstablish Safety Related PositionsP.A.V.E. Operations LimitsEmergency Response PlanTraining Requirements and PlanningSafety Committee Structure and Functions

B

FLIGHT PLAN…

1. WHY SMS?2. SETTING UP POLICY3. HAZARD ID AND



C

SMSHAZARD ID

RISK ANALYSIS

RISK CONTROL

ASSURANCE

B

• Hazard - The ability to cause an unfavorable event

• Risk - Probability and Severity of that event

• Lag Information - Event already happened (or nearly so)

• Lead Information - Latent factors that contribute to an event

1. HAZARD ID

SMS

Ye ol’ Safety Program

1. HAZARD ID

Ye ol’ Safety Program

Opi

nion

Ass

umpt

ion

Bes

t Gue

ss

Airl

ine

Safe

ty

Context:Does the info apply to you…today?

Traditional Sources Accident Reports Annual Reports, Statistics and StudiesWar StoriesFRATAudits and Inspections (GAP)SurveysHazard Analysis (Root Cause)Accident ReportsStudiesClasses…..

IHST SMS Toolkit p. 7, 27

Hazard ID Forms Keep them simple Make them easy to fill outFollow up can be done later

1. HAZARD ID

C

Traditional Sources Accident Reports Annual Reports, Statistics and StudiesWar Stories

IHST SMS Toolkit p. 7, 27

INTERNAL info… small fleet or private operator

Safety/Hazard Reports - self assessment of flightsSurvey …FRAT stay tunedInternal Audits and Inspections - Use local flying community, instructors, friendsRoot Cause Analysis stay tuned

1. HAZARD ID

SMS

INTERNAL VS EXTERNAL1. HAZARD ID

INFORMATION

You need both

Compare the information to validate risk

stay tuned

What is a significant hazard at your operation ?

B

SMSHAZARD ID

RISK ANALYSIS

RISK CONTROL

ASSURANCE

B

Should we address all of the hazards we identify???

NO!

Should we address all of the hazards we identify???

NO!

B

Accidents

10 (8)

8

6

23

18

Fatalities

18

3

10

2

0

• LOC (IIMC)

• LTE

• Wire Strike• Training

Autos 16Hydraulics 4

• Mechanical Failure

Cutting the Safety FAT Tips:1. Leave excessive risk management ‘theory’ discussion

out of the policy manual.

2. Use Risk Assessment to address only higher risk hazards

C

SMS Checklist:GAP AnalysisPolicyHazard ID FormsSurveyRisk Assessment Matrix

C

SMSHAZARD ID

RISK ANALYSIS

RISK CONTROL

ASSURANCE

B

Risk Management: Interventions, Mitigations, Controls

• Training• Procedures and Policies• Environmental Controls• Education (directed at

hazard)

Target specific hazard elements

“Be Safe”

RISK CONTROLRISK CONTROL

B


Design Interventions to lower Likelihood and/or SeverityThis will allow you to track the change in risk


RISK CONTROL

B

RISK CONTROL -DESIGN

These tasks are best done in the Safety Committee:

Verify your Risk and Hazard Analysis

Design Risk Control as a group

Better IdeasBetter Buy-in from everyone

Access to Training and Policy Authority

=T

T

T

C

The helicopter landed hard during a forced landing.

The student pilot’s delayed throttle application during the practice autorotation and the flight instructor’s lack of immediate remedial action

The pilot’s failure to maintain clearance with a telephone pole during a low-level maneuver.

RISK CONTROL - HAZARD ANALYSIS

C

1. “Why did Thunder Pig hit the side of the hangar with the tailboom?”“He lost control during a landing.”

2. “Why did he lose control?”“He put the tail in the wind (downwind hover) when heavy and got into LTE.”

3. “Why did he not put in enough control input more quickly or hover into the wind?”“He had not flown in those conditions for several months and was ‘rusty’.”

4. “Why had he not flown in unit SOP approved wind conditions in several months?”“He set personal minimums that were below the conditions on the day of the accident and turned down flights if the winds exceeded those.”

5. “Why did he take a flight in conditions that exceeded those personal limits on the day of the accident?”“The call was for a missing 2 year-old and he felt compelled to go.”

Rule of “5-Why’s”

Landing area proximity to hangar

Operational procedures for landing during high winds.

Possible training deficiency. Possible conflict in proficiency and wx limitations

- Personal wx minimums not applied when needed - Input of mission specifics negatively influenced pilot decision making

Pilot skills possibly not maintained to standards between training/check rides.

RISK CONTROL - HAZARD ANALYSIS

B

“MAN – A creature that was created at the end of the week when God was very tired.”

~Mark Twain

“MAN – A creature that was created at the end of the week when God was very tired.”

~Mark Twain

RISK CONTROL -DESIGN

Analytical Decision Making

1. Fast2. Simple3. Memory based 4. Work with limited information5. Option chosen probably OK, but not optimal

1. Clear goal or outcome2. Plenty of time3. All conditions, factors are known4. Provides the best answers

Intuitive Methods

Use this process to create effective RISK CONTROLS.

Analytical decision making ability is limited in the cockpit or under the tress of a mission scramble

Build Risk Controls so they can be utilizedin an intuitive manner.

They will be ineffective without consistent training

RISK CONTROL - DESIGN

Sources: Dave Huntzinger & Fred Brisbois

Naturalistic Decision Making (Intuitive DM process)

Potential Solutions:

1. Rule based – single, memory based solution (experience, training, EP drills, etc.)

2. Choice based – Multiple Options 3. Creative – No obvious choice, must use substitute experiences

Our SMS Interventions must help employees survive using these three

choices

Choice based – Multiple Options



choicesChoice based – Multiple Options

Hicks’s Law

hen the number of possible choices increases - reaction time increases

Increase of 1 possible choice to 2 = 58% increase in response time


Sources: Dave Huntzinger & Fred Brisbois

Naturalistic Decision Making (Intuitive DM process)

Potential Solutions:

1. Rule based – single, memory based solution


choices

TRAINING(experience, training, EP drills, etc.)


Recommended solutions

Reading a situationPerforming the correct procedure

Recommended solutions

ExperienceEducation

Training

B

RISK CONTROL - DESIGN & ENVIRONMENTAL SOLUTIONS

C

When analyzing risk factors for an activity we consider them individually

The interaction of the factors on overall risk is difficult to do in our heads

Personal desire to complete a mission has subliminal influence on this process

Just prior to launch the pace of operations will start shifting our decision making from analytical to intuitive

Take care of the analytical process independent of these influences

“The program does not employ any policy guidance to aid the pilot in making risk managed decisions with respect to flight scheduling decision making..”

~Excerpt from a NTSB report of a fatal law enforcement IIMC/CFIT accident

RISK CONTROL - DESIGN & FLIGHT RISK ASSESSMENT (FRAT)

C

• In an emergency if it is not ‘on’ you, you will likely not have it available to you • Helmets protect from impact, birds, glass and can assist in flotation • Gloves (exposed wrists – F-4 example)

• Survival vest

• HEEDS

• Cutting Tools

• Personal Location Devices

• Mirror

• Quick-clot

• Lighter

• Firearm?

• Police Radio

• Water

• ‘Go To Hell’ Bag

Aircrew had to tred water waiting for rescue – life jackets hanging on hooks in the cockpit, could not get them out in time. Bird Strike - Pilot hit in the face – serious injury, blood in eyes, almost lost consciousness

Emergency landing while doing alligator survey for wildlife commission. Aircraft immediately sank and they had to get out and spend the night on the roof of the aircraft. Unable to retrieve survival kit before sinking.

RISK CONTROL - DESIGN & PROTECTIVE EQUIPMENT

B

RISK CONTROL - DESIGN & CRM

B

Address each Risk Control with considerations for:

RISK CONTROL -IMPLEMENTATION

Policy / Procedure Training

B


Don’t just tell them to do it, they won’t


Assign TasksRISK CONTROL -IMPLEMENTATION

Use Numbers to Define ChangeAssign Follow Up Dates

C

Safety Education should be based on the same hazards you are addressing…


Continuing Education and Training

Bulletin Boards

Safety Standdown Meetings

C

SMSHAZARD ID

RISK ANALYSIS

RISK CONTROL

ASSURANCE

B

Normalized deviation:Policy Normal Procedure

Are we “Safer” after implementing a new

intervention?

Assumption vs Knowledge:

Be in love with the results, not the policy

4. ASSURANCE

B

Assurance&

Performance

1. Operational drift

2. Normalized deviation

3. Performance vs Plan

4. Unintended consequences

5. Unanticipated challenges

6. Additional hazard data

Did it work?

C

31% Reduction in safety hazards

84% IIMC training complete

65% of Pinch Hitter training complete

Egress training nearly complete

75% FRATs completed

7 Safety reports made*

B

What is ‘safer’?

A definable (documented, measurable) decrease of:

the Likelihood and/or Severity

in the risk

of specific hazards

affecting your operation

B

SMS Checklist:GAP AnalysisPolicyHazard ID FormsSurveyRisk Assessment Chart Hazard Analysis (Root Cause) Form (i.e. 5 Whys)Risk Control (Mitigation) Form includes Training and Policy/Procedure elementsSafety Committee Formed for Risk Control planningMeans of tracking Risk Controls (Tracking Spreadsheet)Means of documenting performance for planning purposesDo What You Say; Say What You Do

C

Cutting the Safety FAT Tips:1. Leave excessive risk management ‘theory’ discussion

out of the policy manual.

2. Use Risk Assessment to address only higher risk hazards

3. Analyze Hazard for weak spots in Probability or Severity - 5 Whys

C

Cutting the Safety FAT Tips:4. Target Probability and/or Severity so you can track

performance

5. Evaluate performance of risk controls so you only keep spending time and money on what is actually working

B

There are no new ways to crash an aircraft…

…but there are new ways to keep people from crashing them…

1. Use various sources to identify HAZARDS

2. Uncover contributing factors through HAZARD ANALYSIS

3. Respond to RISK, not raw hazard information

4. Attach numbers to RISK and goals

5. Use risk controls to lower PROBABILITY or SEVERITY of risk

6. Use numbers to TRACK performance and direct changes

Bryan [email protected]

407-222-8644

Bryan [email protected]

407-222-8644

Chris [email protected]

203-767-8564

SMS Installation

Hazard ID -

Risk Analysis -

Hazard Analysis -

Intervention Design -

Implementation -

Assurance -

Five Why’s

Latent Factors

Select Hazard Element(s)

Individual risk factor

Ability to attack risk (money, time, law of nature?)

Quantify it somehow (how often, how close to threshold, etc.)

Target Severity or Likelihood

Policy/Procedure

Training

Measure change in Likelihood or Severity

Respond to results (continue, change, stop)

Feed results back into Promotion efforts

Date post:	31-Jan-2023
Category:	Documents
Upload:	khangminh22
View:	0 times
Download:	0 times