IHST - Helicopter Hazard Management
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IHST - Helicopter Hazard Management

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Helicopter Hazard Management Safety Workshop

Helicopter Hazard Management Safety Workshop

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IHST - Helicopter Hazard Management IHST - Helicopter Hazard Management Presentation Transcript

  • Hazard Management IHST/EHEST Safety Workshop - London 25 September2013
  • • Already have an SMS?
  • Goal for this Session Help you make your SMS “live” in the hangar and in your helicopters rather than sit in a book on a shelf.
  • Session Plan • Discussion • Exercises
  • Step 1 – Set Goals • Your potential goals: – – – – – Comply with regulations Prevent accidents Prevent “losses” Manage risks Sleep better at night • Let’s assume you want to achieve all these goals. • Where should be start?
  • Goal & Policy Statement • The goal – Manage all significant risks to ALARP – No harm to people, property or the environment – “Goal Zero” or “Target Zero” • Supporting policy statement – Sets out the company leaders’ commitment – References a plan with • specific objectives, • organisational structure, • processes and accountabilities, • and specific targets. – Describes the desired safety culture and contains a “Just Culture” statement
  • Indentify and Mitigate Key Hazards • Brainstorm • Assess • Mitigate – Barriers – Controls – Recovery Measures
  • Step 2 – Identify & Record Hazards Accident reports for own role Recordable occurrences Networking, blogs Brainstorming Accidents reports for own A/C types Industry Bodies/committees/forums QA findings Safety reporting system Safety Observation Process Information exchange Incident investigations Accident reports for own region/country/location Flight Data Monitoring Training feedback Trend analysis Generic Hazard Lists
  • Hazard/Risk Management Process SCOPE OF ACTIVITY IDENTIFY AND RECORD HAZARDS RISK ANALYSIS
  • Step 3 – Risk Analysis • Assess risk associated with each hazard to: – Determine if action is required – Prioritise first efforts • Use a Risk Assessment Matrix (RAM) to give an objective score to a subjective topic – Standardise across the organisation. – Make risk assessments visual. • Red is difficult to ignore and loosens budget strings.
  • Typical RAM Example: • Loss of control of a passenger on an offshore helideck. Entered helideck via incorrect stairwell that was in the vicinity of the tail rotor. • Not happened in your company before, happened previous year in offshore industry & a number of examples in the wider helicopter industry. Normally results in death.
  • Typical RAM • Too vague and open to different interpretation. • Detailed definition required for likelihood and severity.
  • Detailed RAM
  • Detailed RAM
  • Step 4 – Controls for Specific Hazards • Methods for identifying controls – Brainstorming – Bow Tie analysis – Tripod • Goal is to manage each hazard to ALARP – Barriers, controls & recovery measures proportional to risks. – Humans require backup
  • ALARP – As Low As Reasonably Practicable What does that mean? How far should you go in developing controls? ALARP is a trade off between: The cost/effort/ operational impact of implementing the control Vs The safety benefit realised from the control While it is proportional, continue. When it gets disproportional, stop.
  • Wasted effort alert Step 4 –Controls for Specific Hazards • Challenge existing procedures and controls. • Begin by ignoring financial and resource constraints. – “Blue sky thinking” – Impractical controls can be discounted later in the process • Engage stakeholders from all levels within the company. – Line pilots and mechanics as well as supervisors and safety staff. • Look outside your own organisation.
  • Step 4 – Controls for Specific Hazards • Effective • Costs proportional to benefits • Practical • Acceptable • Enforceable • Sustainable • Doesn’t create new hazards
  • Step 4 – Controls for Specific Hazards 1.01 Weather How do we prevent this from happening? CFIT: Inadvertent Entry to IMC Add controls/barriers to the process
  • 1.01 Weather CFIT: Inadvertent Entry to IMC Company Weather Operating Limits Now start asking questions “How can that control fail?” “What if…….”
  • 1.01 Weather Inadvertent Entry to IMC Company Weather Operating Limits Unknown WX forecast Acurate Daily WX Forecast Client unaware of Company WX limits WX limits agreed with client Client pressure to fly Enhanced Operational Control (EOC) procedure in place Record controls in the hazard register CFIT:
  • Basic Hazard Register Example Task Description /Location Onshore seismic support Hazard Description: Reference No. HS - 017 Reference Sept 11 RAM Score Inadvertent entry to IMC Barriers, Controls & Recovery Measures Date last reviewed Initial Owner Current Status
  • Basic Hazard Register Example Task Descripti on /Location Onshore seismic support Hazard Description: Reference No. HS - 017 RAM Score Inadvertent entry to IMC Barriers, Controls & Recovery Measures Minimum company weather limits for VFR operations Accurate daily forecasts availablelimits agreed with Weather for operation client Enhanced Operational Controls in place to respond to changes in weather. Reference Date last reviewed Sept 12 Initial Owner Current Status
  • 1.01 Weather Inadvertent Entry to IMC Company Weather Operating Limits Unknown WX forecast Acurate Daily WX Forecast CFIT: Client unaware of Company WX limits WX limits agreed with client Client pressure to fly Enhanced Operational Control (EOC) procedure in place Do I need another control? Is the one I have fully effective?
  • 1.01 Weather Inadvertent Entry to IMC Company Weather Operating Limits Aircraft Equipped for Basic IMC flight Unknown WX forecast Acurate Daily WX Forecast CFIT: Client unaware of Company WX limits WX limits agreed with client Client pressure to fly Enhanced Operational Control (EOC) procedure in place What if……?
  • 1.01 Weather Inadvertent Entry to IMC Company Weather Operating Limits Aircraft Equipped for Basic IMC flight Unknown WX forecast Acurate Daily WX Forecast CFIT: Client unaware of Company WX limits WX limits agreed with client Client pressure to fly Enhanced Operational Control (EOC) procedure in place PIlot Instrument Flying Competency Pilot Instrument Rated Annual Instrument Flight Check Simulator Training including IFR procedures
  • 1.01 Weather Inadvertent Entry to IMC Company Weather Operating Limits Aircraft Equipped for Basic IMC flight All Aircraft Equipted with TAWS Unknown WX forecast Acurate Daily WX Forecast CFIT: Client unaware of Company WX limits WX limits agreed with client Client pressure to fly Enhanced Operational Control (EOC) procedure in place PIlot Instrument Flying Competency Pilot Instrument Rated Annual Instrument Flight Check Simulator Training including IFR procedures
  • Basic Hazard Register Example Task Description /Location Onshore seismic support Hazard Description: Reference No. HS - 017 Date last reviewed Sept 11 RAM Score Inadvertent entry to IMC Initial Barriers, Controls & Recovery Measures Minimum company weather limits for VFR operations Accurate daily forecasts availablelimits agreed with Weather for operation client Enhanced Operational Controls in place to respond to changes in weather. Reference Owner Current Status
  • Task Description /Location Hazard Description: Onshore seismic support Reference No. HS - 017 Minimum company weather limits for VFR operations Accurate daily forecasts available for operation Weather limits agreed with client Enhanced Operational Controls in place to respond to changes in weather. Aircraft equipped for IFR flight (Designate minimum avionic equipment) Pilots instrument rated Annual inadvertent IFR flight check to ensure currency and competence. trained and checked Inadvertent IFR procedures during annual simulator training. All aircraft equipped with TAWS Sept 11 RAM Score Inadvertent entry to IMC Barriers, Controls & Recovery Measures Date last reviewed Initial Reference Owner Status Current
  • 1.01 Weather Inadvertent Entry to IMC Company Weather Operating Limits Aircraft Equipped for Basic IMC flight All Aircraft Equipted with TAWS Unknown WX forecast Acurate Daily WX Forecast CFIT: Client unaware of Company WX limits WX limits agreed with client Client pressure to fly Enhanced Operational Control (EOC) procedure in place PIlot Instrument Flying Competency Pilot Instrument Rated Annual Instrument Flight Check Simulator Training including IFR procedures Now consider the hazard consequences and how to mitigate them.
  • 1.01 Weather Inadvertent Entry to IMC Company Weather Operating Limits Aircraft Equipped for Basic IMC flight All Aircraft Equipted with TAWS Unknown WX forecast Acurate Daily WX Forecast Unknown Aircraft Location CFIT: Client unaware of Company WX limits WX limits agreed with client Inadequate ER Client pressure to fly Enhanced Operational Control (EOC) procedure in place PIlot Instrument Flying Competency Pilot Instrument Rated Annual Instrument Flight Check Simulator Training including IFR procedures
  • 1.01 Weather Inadvertent Entry to IMC Company Weather Operating Limits Aircraft Equipped for Basic IMC flight All Aircraft Equipted with TAWS Unknown WX forecast Acurate Daily WX Forecast Unknown Aircraft Location CFIT: Client unaware of Company WX limits Satelite Flight Tracking WX limits agreed with client Inadequate ER ERP in Place and Exercised Annually Client pressure to fly Enhanced Operational Control (EOC) procedure in place PIlot Instrument Flying Competency Pilot Instrument Rated Annual Instrument Flight Check Simulator Training including IFR procedures
  • Task Description /Location Hazard Description: Onshore seismic support Reference No. HS - 017 Minimum company weather limits for VFR operations Accurate daily forecasts available for operation Weather limits agreed with client Enhanced Operational Controls in place to respond to changes in weather. Aircraft equipped for IFR flight (Designate minimum avionic equipment) Pilots instrument rated Annual inadvertent IFR flight check to ensure currency and competence. Min 30 min Inadvertent IFR procedures trained and checked during annual simulator training. All aircraft equipped with TAWS Sept 11 RAM Score Inadvertent entry to IMC Barriers, Controls & Recovery Measures Date last reviewed Initial Reference Owner Current Status
  • Task Description /Location Hazard Description: Onshore seismic support Reference No. HS - 017 Minimum company weather limits for VFR operations Accurate daily forecasts available for operation Weather limits agreed with client Enhanced Operational Controls in place to respond to changes in weather. Aircraft equipped for IFR flight (Designate minimum avionic equipment) Pilots instrument rated Annual inadvertent IFR flight check to ensure currency and competence. Min 30 min Inadvertent IFR procedures trained and checked during annual simulator training. All aircraft equipped with TAWS All aircraft equipped with satellite flight tracking Emergency response plan in place & exercised annually Sept 11 RAM Score Inadvertent entry to IMC Barriers, Controls & Recovery Measures Date last reviewed Initial Reference Owner Current Status
  • Hazard Management Process SCOPE OF ACTIVITY IDENTIFY AND RECORD HAZARDS RISK ANALYSIS IDENTIFY CONTROLS FOR SPECIFIC HAZARDS CONTROL EXISTS REFERENCE DOCUMENTS AND RESPONSIBLE POSTS
  • Task Description /Location Hazard Description: Onshore seismic support Reference No. HS - 017 Minimum company weather limits for VFR operations Accurate daily forecasts available for operation Weather limits agreed with client Enhanced Operational Controls in place to respond to changes in weather. Aircraft equipped for IFR flight (Designate minimum avionic equipment) Pilots instrument rated Annual inadvertent IFR flight check to ensure currency and competence. Min 30 min Inadvertent IFR procedures trained and checked during annual simulator training. All aircraft equipped with TAWS All aircraft equipped with satellite flight tracking Emergency response plan in place & exercised annually with client Sept 11 RAM Score Inadvertent entry to IMC Barriers, Controls & Recovery Measures Date last reviewed Initial Reference Owner Current Status
  • Task Description /Location Hazard Description: Onshore seismic support Reference No. Date last reviewed HS - 017 Sept 11 RAM Score Inadvertent entry to IMC Initial Current Barriers, Controls & Recovery Measures Reference Owner Status Minimum company weather limits for VFR operations Ops Man 4.2.3 Chief Pilot In force Accurate daily forecasts available for operation Ops Man 4.2.4 Chief Pilot In force Weather limits agreed with client Standard contract clause 9.2 Director Operations In force Ops Man 8.3.1 Director of Maintenance Chief Pilot In force Enhanced Operational Controls in place to respond to changes in weather. Aircraft equipped for IFR flight (Designate minimum avionic equipment) Pilots instrument rated Ops Man 3.4 In force Annual inadvertent IFR flight check to ensure currency and competence. Min 30 min Inadvertent IFR procedures trained and checked during annual simulator training. All aircraft equipped with TAWS Training Man 6.4 Chief Pilot In force All aircraft equipped with satellite flight tracking Ops Man 8.3.4 In force Emergency response plan in place & exercised annually with client ERP 5.6 and Standard contract clause Director of Maintenance Head of Safety & QA In force
  • Hazard Management Process SCOPE OF ACTIVITY IDENTIFY AND RECORD HAZARDS RISK ANALYSIS IDENTIFY CONTROLS FOR SPECIFIC HAZARDS CONTROL EXISTS REFERENCE DOCUMENTS AND RESPONSIBLE POSTS NEW CONTROL REQUIRED REMEDIAL ACTION PLAN
  • Step 6 – Remedial Action Plan • Lists actions required to address key hazard management gaps. • Presents senior management with complete overview. • Fit-for-purpose recording & tracking. • Hazard Register should reflect the status of the remedial action plan.
  • Task Description /Location Hazard Description: Onshore seismic support Reference No. Date last reviewed HS - 017 Sept 11 RAM Score Inadvertent entry to IMC Initial Barriers, Controls & Recovery Measures Reference Owner Status Minimum company weather limits for VFR operations Accurate daily forecasts available for operation Ops Man 4.2.3 Chief Pilot In force Ops Man 4.2.4 Chief Pilot In force Standard contract clause Enhanced Operational Controls in place to respond 9.2 to changes in weather. Aircraft equipped for IFR flight (Designate minimum Ops Man 8.3.1 avionic equipment) Director Operations In force Director of Maintenance In force Pilots instrument rated Ops Man 3.4 Chief Pilot In force Annual inadvertent IFR flight check to ensure currency and competence. Min 30 min Training Man 6.4 Chief Pilot In force All aircraft equipped with satellite flight tracking Ops Man 8.3.4 Director of Maintenance In force Emergency response plan in place & exercised annually with client ERP 5.6 and Standard Head of Safety & QA In force Weather limits agreed with client Inadvertent IFR procedures trained and checked during annual simulator training. All aircraft equipped with TAWS Current
  • Task Description /Location Hazard Description: Onshore seismic support Reference No. Date last reviewed HS - 017 Sept 11 RAM Score Inadvertent entry to IMC Initial Current Barriers, Controls & Recovery Measures Reference Owner Status Minimum company weather limits for VFR operations Accurate daily forecasts available for operation Ops Man 4.2.3 Chief Pilot In force Ops Man 4.2.4 Chief Pilot In force Standard contract clause Enhanced Operational Controls in place to respond RAP Item 16 9.2 to changes in weather. Aircraft equipped for IFR flight (Designate minimum Ops Man 8.3.1 avionic equipment) Director Operations Director Operations Director of Maintenance In force Pilots instrument rated Ops Man 3.4 Chief Pilot In force Annual inadvertent IFR flight check to ensure currency and competence. Min 30 min Training Man 6.4 Chief Pilot In force Inadvertent IFR procedures trained and checked during annual simulator training. All aircraft equipped with TAWS RAP Item 23 Chief Pilot RAP Item 15 All aircraft equipped with satellite flight tracking Ops Man 8.3.4 Maintenance Director Director of Maintenance Awaiting sim availability Due complete Apr 2014 In force Emergency response plan in place & exercised annually with client ERP 5.6 and Standard Head of Safety & QA Weather limits agreed with client Due 31 Dec 13 In force In force
  • Step 6 – Remedial Action Plan • Re-assess risk
  • Task Description /Location Hazard Description: Onshore seismic support Reference No. Date last reviewed HS - 017 Sept 11 RAM Score Inadvertent entry to IMC Initial Current Barriers, Controls & Recovery Measures Reference Owner Status Minimum company weather limits for VFR operations Accurate daily forecasts available for operation Ops Man 4.2.3 Chief Pilot In force Ops Man 4.2.4 Chief Pilot In force Standard contract clause Enhanced Operational Controls in place to respond RAP Item 16 9.2 to changes in weather. Aircraft equipped for IFR flight (Designate minimum Ops Man 8.3.1 avionic equipment) Director Operations Director Operations Director of Maintenance In force Pilots instrument rated Ops Man 3.4 Chief Pilot In force Annual inadvertent IFR flight check to ensure currency and competence. Min 30 min Training Man 6.4 Chief Pilot In force Inadvertent IFR procedures trained and checked during annual simulator training. All aircraft equipped with TAWS RAP Item 23 Chief Pilot RAP Item 15 All aircraft equipped with satellite flight tracking Ops Man 8.3.4 Maintenance Director Director of Maintenance Awaiting sim availability Due complete Apr 2014 In force Emergency response plan in place & exercised annually with client ERP 5.6 and Standard Head of Safety & QA Weather limits agreed with client Due 31 Dec 13 In force In force
  • Task Description /Location Hazard Description: Onshore seismic support Inadvertent Reference No. Operator assessed that until Sim training, entry to IMC TAWS and the EOC were in place, risk remained medium. Date last reviewed HS - 017 Sept 11 RAM Score Initial Current Barriers, Controls & Recovery Measures Reference Owner Status Minimum company weather limits for VFR operations Accurate daily forecasts available for operation Ops Man 4.2.3 Chief Pilot In force Ops Man 4.2.4 Chief Pilot In force Standard contract clause Enhanced Operational Controls in place to respond RAP Item 16 9.2 to changes in weather. Aircraft equipped for IFR flight (Designate minimum Ops Man 8.3.1 avionic equipment) Director Operations Director Operations Director of Maintenance In force Pilots instrument rated Ops Man 3.4 Chief Pilot In force Annual inadvertent IFR flight check to ensure currency and competence. Min 30 min Training Man 6.4 Chief Pilot In force Inadvertent IFR procedures trained and checked during annual simulator training. All aircraft equipped with TAWS RAP Item 23 Chief Pilot RAP Item 15 All aircraft equipped with satellite flight tracking Ops Man 8.3.4 Maintenance Director Director of Maintenance Awaiting sim availability Due complete Apr 2014 In force Emergency response plan in place & exercised annually with client ERP 5.6 and Standard Head of Safety & QA Weather limits agreed with client Due 31 Dec 13 In force In force
  • Hazard Management Process SCOPE OF ACTIVITY IDENTIFY AND RECORD HAZARDS RISK ANALYSIS IDENTIFY CONTROLS FOR SPECIFIC HAZARDS CONTROL EXISTS REFERENCE DOCUMENTS AND RESPONSIBLE POSTS NEW CONTROL REQUIRED CONTROL DEVELOPED REMEDIAL ACTION PLAN
  • Step 7 – Interface with Quality Wasted effort alert The quality management system must be integrated with the hazard management system.
  • SCOPE OF ACTIVITY IDENTIFY AND RECORD HAZARDS INTERNAL AUDIT TO CONFIRM IMPLEMENTATION & EFFECTIVENESS OF CONTROLS RISK ANALYSIS IDENTIFY CONTROLS FOR SPECIFIC HAZARDS CONTROL EXISTS QUALITY SYSTEM – UPDATE CHECKLISTS Steps 3 – 7 should now be repeated for each hazard identified in Step 2. REFERENCE DOCUMENTS AND RESPONSIBLE POSTS NEW CONTROL REQUIRED CONTROL DEVELOPED REMEDIAL ACTION PLAN
  • Wasted effort alert Your hazard management process should be saving money and attracting clients. It must be kept alive to prevent it from being a dusty book on the shelf, only brought out when auditors arrive.
  • SCOPE OF ACTIVITY IDENTIFY AND RECORD HAZARDS INTERNAL AUDIT TO CONFIRM IMPLEMENTATION & EFFECTIVENESS OF CONTROLS RISK ANALYSIS IDENTIFY CONTROLS FOR SPECIFIC HAZARDS CONTROL EXISTS QUALITY SYSTEM – UPDATE CHECKLISTS REFERENCE DOCUMENTS AND RESPONSIBLE POSTS SAFETY REPOPTING & INVESTIGATION PROCESS LINKED DIRECTLY TO THE HAZARD MANAGEMENT PROCESS. NEW CONTROL REQUIRED CONTROL DEVELOPED REMEDIAL ACTION PLAN SAFETY REPORTING & INVESTIGATION
  • Step 8 – Safety Reporting and Investigation • All incident reports should prompt a review the hazard register. • Identifying new hazards leads to Step 2 (Hazard Identification). • Incidents with hazards already identified should result in a review of the existing and potential mitigations. – Those that worked, thus preventing an accident, – Those that were ineffective, and – Potential mitigations that were missing.
  • • A pilot reports inadvertently entering IMC during a seismic support flight. After some maneuvering he was able to recover and regain VMC, but had some worried passengers. • After interview with the pilot it appears he pressed on with the task, in deteriorating weather conditions, under client pressure to complete the last flight of the day. • The client’s on site supervisor claims that he was unaware of the operators more restrictive weather limits.
  • Task Description /Location Hazard Description: Onshore seismic support Reference No. Date last reviewed HS - 017 Sept 11 RAM Score Inadvertent entry to IMC Initial Barriers, Controls & Recovery Measures Reference Owner Status Minimum company weather limits for VFR operations Accurate daily forecasts available for operation Ops Man 4.2.3 Chief Pilot In force Ops Man 4.2.4 Chief Pilot In force Director Operations Director Operations Maintenance Director Chief Pilot Current In force Weather limits agreed with client Standard contract clause Enhanced Operational Controls in place to respond RAP Item 16 9.2 to changes in weather. Aircraft equipped for IFR flight (Designate minimum Ops Man 8.3.1 avionic equipment) Pilots instrument rated Ops Man 3.4 Due 31 Dec 13 In force In force Annual inadvertent IFR flight check to ensure currency and competence. Inadvertent IFR procedures trained and checked during annual simulator training. All aircraft equipped with TAWS Training Man 6.4 Chief Pilot In force RAP Item 23 Chief Pilot RAP Item 15 All aircraft equipped with satellite flight tracking Ops Man 8.3.4 Emergency response plan in place & exercised annually with client ERP 5.6 and Standard contract clause 10.1 Maintenance Director Maintenance Director Head of Safety & QA Awaiting sim availability Due complete Apr 2014 In force In force
  • Task Description /Location Hazard Description: Onshore seismic support Reference No. HS - 017 Minimum company weather limits for VFR operations Accurate daily forecasts available for operation Reference Ops contract AmendMan 4.2.3 requirements Ops Man 4.2.4 Weather limits agreed with client Standard contract clause Enhanced Operational Controls in place to respond RAP Item 16 9.2 to changes in weather. Aircraft equipped for IFR flight (Designate minimum Ops Accelerate Man 8.3.1 avionic equipment) Pilots instrument rated Opsintroduction Man 3.4 Sept 11 RAM Score Inadvertent entry to IMC Barriers, Controls & Recovery Measures Date last reviewed Initial Owner Status Chief Pilot In force Chief Pilot In force Director Operations Director Operations Maintenance Director Chief Pilot Current In force Due 31 Dec 13 In force In force Annual inadvertent IFR flight check to ensure currency and competence. Inadvertent IFR procedures trained and checked during annual simulator training. All aircraft equipped with TAWS Training Man 6.4 Chief Pilot In force RAP Item 23 Chief Pilot RAP Item 15 All aircraft equipped with satellite flight tracking Ops Man 8.3.4 Emergency response plan in place & exercised annually with client ERP 5.6 and Standard contract clause 10.1 Maintenance Director Maintenance Director Head of Safety & QA Awaiting sim availability Due complete Apr 2014 In force In force
  • Task Description /Location Hazard Description: Onshore seismic support Reference No. Date last reviewed HS - 017 Sept 11 RAM Score Inadvertent entry to IMC Initial Barriers, Controls & Recovery Measures Referece Owner Status Minimum company weather limits for VFR operations Accurate daily forecasts available for operation Ops Man 4.2.3 Chief Pilot In force Ops Man 4.2.4 Chief Pilot In force Director Operations Director Operations Maintenance Director Chief Pilot Current In force Weather limits agreed with client Standard contract clause Enhanced Operational Controls in place to respond RAP Item 16 9.2 to changes in weather. Aircraft equipped for IFR flight (Designate minimum Ops Man 8.3.1 avionic equipment) Pilots instrument rated Ops Man 3.4 Annual inadvertent IFR flight check to ensure currency and competence. Wx limits and EOC requirements included in Pilot annual ground training syllabus Inadvertent IFR procedures trained and checked during annual simulator training. All aircraft equipped with TAWS All aircraft equipped with satellite flight tracking Emergency response plan in place & exercised annually with client Training Man 6.4 Chief Pilot Training Man 6.12 RAP Item 23 RAP Item 15 Due 31 Dec 13 In force In force In force Chief Pilot Chief Pilot Maintenance Director Ops Man 8.3.4 Maintenance Add and record Director a 5.6 and ERP further control Head of Standard Safety & QA contract clause 10.1 Awaiting sim availability Due complete Apr 2014 In force In force
  • 1.01 Weather Inadvertent Entry to IMC Company Weather Operating Limits Aircraft Equipped for Basic IMC flight All Aircraft Equipted with TAWS Unknown WX forecast Acurate Daily WX Forecast CFIT: Client unaware of Company WX limits WX limits agreed with client Client pressure to fly Enhanced Operational Control (EOC) procedure in place PIlot Instrument Flying Competency Pilot Instrument Rated Annual Instrument Flight Check Simulator Training including IFR procedures
  • 1.01 Weather Inadvertent Entry to IMC Company Weather Operating Limits Aircraft Equipped for Basic IMC flight All Aircraft Equipted with TAWS Unknown WX forecast Acurate Daily WX Forecast CFIT: Client unaware of Company WX limits WX limits agreed with client WX limits held by client site supervisor Enhanced Operational Control (EOC) procedure in place EOC & WX limits in pilots annual ground training syllabus Pilot Instrument Rated Annual Instrument Flight Check Client pressure to fly PIlot Instrument Flying Competency Simulator Training including IFR procedures
  • SCOPE OF ACTIVITY IDENTIFY AND RECORD HAZARDS INTERNAL AUDIT TO CONFIRM IMPLEMENTATION & EFFECTIVENESS OF CONTROLS RISK ANALYSIS VALIDATE EXISTING CONTROLS OR DEVELOP NEW CONTROLS IDENTIFY CONTROLS FOR SPECIFIC HAZARDS CONTROL EXISTS QUALITY SYSTEM – UPDATE CHECKLISTS PROCESS NEW HAZARDS REFERENCE DOCUMENTS AND RESPONSIBLE POSTS NEW CONTROL REQUIRED CONTROL DEVELOPED REMEDIAL ACTION PLAN SAFETY REPORTING & INVESTIGATION
  • MANAGEMENT OF CHANGE PROCESS SCOPE OF ACTIVITY IDENTIFY AND RECORD HAZARDS INTERNAL AUDIT TO CONFIRM IMPLEMENTATION & EFFECTIVENESS OF CONTROLS RISK ANALYSIS VALIDATE EXISTING CONTROLS OR DEVELOP NEW CONTROLS IDENTIFY CONTROLS FOR SPECIFIC HAZARDS CONTROL EXISTS QUALITY SYSTEM – UPDATE CHECKLISTS PROCESS NEW HAZARDS REFERENCE DOCUMENTS AND RESPONSIBLE POSTS NEW CONTROL REQUIRED CONTROL DEVELOPED REMEDIAL ACTION PLAN SAFETY REPORTING & INVESTIGATION
  • Step 9 – Management of Change • Required element of the SMS • Process to include: – Review the relevant sections of the hazard register. – Planned or potential effects on existing controls – Potential for introduction of new hazards. • New hazards should be run through the whole process. • What should prompt the MOC process…?
  • Step 9 – Management of Change • The SMS manual should describe the process for management of change (MOC). • The MOC process should be used ahead of the following events: – – – – Introduction of new aircraft type New contract/operation Opening a new base Major change in key personnel or the organisation • MOC risk assessments and mitigation steps should be documented.
  • Step 9 – Management of Change • The MOC process documentation should summarise: – what will change, – areas/departments affected, – hazards identified, – risk assessments, and – actions to be taken to manage risks.
  • Ref # Scope of Change Accountable Manager Type of change Permanent Department/location Responsible Summary of Actions Arising Statement of Completion/Fitness Temporary: From ________ to __________ Hazard Register Reviewed/Updated Responsible Signature Due Accountable Manager Date & Signature Date & Signature
  • Scope of Change Accountable Manager Type of change Department/location Introduction of AW139 from Aug 2013 of Operations J. C. Van Damm Director Permanent Responsible Summary of Actions Arising Statement of Completion/Fitness Ref # MOC 02/2013 Temporary: From ________ to __________ Hazard Register Reviewed/Updated Responsible Signature Due Accountable Manager Date & Signature Date & Signature
  • Scope of Change Accountable Manager Type of change Department/location Introduction of AW139 from Aug 2013 of Operations J. C. Van Damm Director Permanent Responsible Ref # MOC 02/2013 Temporary: From ________ to __________ Hazard Register Reviewed/Updated Signature Maintenance Department Training Department Flight Operations Department Safety & Quality Department Edmonton Base Calgary Base Summary of Actions Arising Responsible Due Date & Signature List all stakeholders Statement of Completion/Fitness Accountable Manager Date & Signature
  • Scope of Change Accountable Manager Type of change Introduction of AW139 from Aug 2013 of Operations J. C. Van Damm Director Ref # MOC 02/2013 Temporary: From ________ to __________ Permanent Department/location Responsible Hazard Register Reviewed/Updated Maintenance Department Training Department Flight Operations Department Safety & Quality Department Edmonton Base Director Maintenance 13 Apr 2013 Training Manager 1 Apr 2013 Director Operations 22 Mar 2013 Director Safety & Quality 10 Apr 2013 Base Manager 5 Mar 2013 Calgary Base Base Manger 15 Mar 2013 Summary of Actions Arising Statement of Completion/Fitness Responsible Signature Due Once a department has completed its review of the Hazard Register, the responsible party will Accountable Manager sign for completion Date & Signature Date & Signature
  • Scope of Change Accountable Manager Type of change Introduction of AW139 from Aug 2013 of Operations J. C. Van Damm Director Permanent Ref # MOC 02/2013 Temporary: From ________ to __________ Department/location Responsible Hazard Register Reviewed/Updated Maintenance Department Training Department Flight Operations Department Safety & Quality Department Edmonton Base Director Maintenance 13 Apr 2013 Training Manager Director Operations 1 Apr 2013department will develop Each 22 Mar 2013 a detailed action plan. Director Safety & Quality 10 Apr 2013 Base Manager 5 Mar 2013 Calgary Base Base Manger 15 Mar 2013 Summary of Actions Arising Responsible Pilot and mechanic training syllabus developed and documented Factory training completed for Pilots and Maintenance Supervisors Maintenance work stands designed and manufactured Additional Hangar space at Edmonton to be acquired or built Maintenance documentation developed for B429. of Completion/Fitness Statement Training Manager Signature Due Date & Signature 1 May 2013 Training Manager 1 Aug 2013 Director 1 Jul Maintenance 2013 Base Manager 1 Jul 2013 Maintenance QA 1 Jul Lead 2013 Date & Signature Accountable Manager
  • Scope of Change Accountable Manager Type of change Introduction of AW139 from Aug 2013 of Operations J. C. Van Damm Director Permanent Ref # MOC 02/2013 Temporary: From ________ to __________ Department/location Responsible Maintenance Department Training Department Director Maintenance Hazard Register Reviewed/Updated 13 Apr 2013 Training Manager 1 Apr 2013 Flight Operations Department Safety & Quality Department Edmonton Base Director Operations 22 Mar 2013 Director Safety & Quality 10 Apr 2013 Base Manager 5 Mar 2013 Calgary Base Base Manger Signature 15 Mar 2013 Summary of Actions Arising Responsible Due Pilot and mechanic training syllabus developed and documented Factory training completed for Pilots and Maintenance Supervisors Maintenance work stands designed and manufactured Additional Hangar space at Edmonton to be acquired or built Maintenance documentation developed for B429. Statement of Completion/Fitness Training Manager 1 May 2013 Training Manager 1 Aug 2013 Director Maintenance 1 Jul 2013 Base Manager 1 Jul 2013 Maintenance QA Lead 1 Jul 2013 MOC process for introduction of AW139 completed . All appropriate sections of the hazard register reviewed and updated. Risk Date & Signature Accountable Manager Date & Signature Director of Operations J.C. Van Damm 15 Jun 2013
  • MANAGEMENT OF CHANGE PROCESS SCOPE OF ACTIVITY IDENTIFY AND RECORD HAZARDS INTERNAL AUDIT TO CONFIRM IMPLEMENTATION & EFFECTIVENESS OF CONTROLS RISK ANALYSIS VALIDATE EXISTING CONTROLS OR DEVELOP NEW CONTROLS IDENTIFY CONTROLS FOR SPECIFIC HAZARDS CONTROL EXISTS QUALITY SYSTEM – UPDATE CHECKLISTS PROCESS NEW HAZARDS REFERENCE DOCUMENTS AND RESPONSIBLE POSTS NEW CONTROL REQUIRED CONTROL DEVELOPED REMEDIAL ACTION PLAN SAFETY REPORTING & INVESTIGATION
  • MANAGEMENT OF CHANGE PROCESS SCOPE OF ACTIVITY IDENTIFY AND RECORD HAZARDS INTERNAL AUDIT TO CONFIRM IMPLEMENTATION & EFFECTIVENESS OF CONTROLS RISK ANALYSIS VALIDATE EXISTING CONTROLS OR DEVELOP NEW CONTROLS IDENTIFY CONTROLS FOR SPECIFIC HAZARDS CONTROL EXISTS QUALITY SYSTEM – UPDATE CHECKLISTS PROCESS NEW HAZARDS NEW CONTROL REQUIRED REFERENCE DOCUMENTS AND RESPONSIBLE POSTS CONTROL DEVELOPED MANAGEMENT REVIEW REMEDIAL ACTION PLAN SAFETY REPORTING & INVESTIGATION
  • Step 10 – Management Review Wasted effort alert Unless your senior management supports, is actively involved in the process and uses the process as a management tool, it will be an academic exercise with limited impact on the business. Applied effectively the Hazard Management process can be a key factor in influencing the financial decisions within the company.
  • Check ICAO Doc 9859 Section 8.2: The Components and Elements of an SMS •Safety policy and objectives – – – – – Management commitment and responsibility Safety accountabilities Appointment of key safety personnel Coordination of emergency response planning, and SMS documentation •Safety risk management – Hazard identification, and – Risk assessment and mitigation •Safety assurance – Safety performance monitoring and measurement – Management of change, and – Continuous improvement of the SMS •Safety promotion – Training and education, and – Safety communication
  • References Safety Risk Management “Hazard identification and safety risk management are the core processes involved in the management of “A formal system of hazard nor have they been developed is a consequence of recent an acceptable safety. They are neither new, identification and managementas fundamental in controllinginterest in safety level “Risk management is a proactive activity that looks at the risks associated with identified hazards of risk. A well-designed risk managementmanagement system describes operational processes across department and“Safety risk management. identifies system (SMS). Hazard identificationsafety risk management isand organizational boundaries, A formal key hazards and identification safety when faced with these and, and assists insafety management systems of hazard measures them, methodically risk management in particular, selecting actions to maintain an appropriate level of and and safety assesses risk, implementsare dogmatic controls to mitigate risk.” essential in controlling risk to acceptable levels. The safety risk management component of the SMS is hazards.” components that underlie the overarching concept used in the system safety training course that based upon the system safety process model that is of system safety. This is an all-encompassing,is engineering-based taught at the FAA Academy.” approach that contributes to system design and which was developed more that forty years ago.”
  • Other References: • International Standard for Business Aircraft Operations – helicopter revision will be delivered soon – SMS guidance is already robust • International Helicopter Safety Team’s SMS Toolkit available at www.ihst.org • EASA • FAA • HAI video at http://www.rotor.org/Safety/DevelopingaSafetyM anagementSystem.aspx