0
SAFETY MANAGEMENT SYSTEMS

FOR

SMALL FLEET 

AND 

PRIVATE OPERATORS
Bryan Smith
!
!
ALEA Safety Program Manager
!
Lee County Sheriff’s Office
!
IHST/USHST SMS Committee
Who’s	
  this	
  guy?
SETTING THE GAUGES
• Who is with us today?
!
• Who currently works with an
established SMS?
!
• Who is working on
establis...
• How about,
“Learning how to
minimize the risks
that hold you back
from doing our job
more…” class
Another Safety Class?
...
CHALLENGES TO IMPLEMENTATION
What do you feel are the biggest challenges to implementing SMS
for small fleet or private op...
CHALLENGES TO IMPLEMENTATION
!
• Scaling Traditional SMS systems down to an
administratively manageable level.
!
• Picking...
CHALLENGES TO IMPLEMENTATION
What do you feel are the biggest challenges to implementing SMS
for small fleet or private op...
1. SMS OVERVIEW
FLIGHT PLAN…
2. PRACTICAL APPLICATIONS
3. DECISION MAKING AND SMS
4. ROARING APPLAUSE
“The safety of the o...
“If you had one superpower, what would it be?”
“Luck.”
1. SMS OVERVIEW
!
2. PRACTICAL APPLICATIONS RISK MANAGEMENT
!
2. PRACTICAL APPLICATIONS RISK MANAGEMENT
How much time and money did you spend
on training or safety stuff last year?
A...
!
2. PRACTICAL APPLICATIONS RISK MANAGEMENT
How much time and money did you spend
on training or safety stuff last year?
A...
!
2. PRACTICAL APPLICATIONS RISK MANAGEMENT
How much time and money did you spend
on training or safety stuff last year?
A...
1. SMS OVERVIEW
“Insanity is doing the same
thing over and over again, and
expecting different results.”
!
~Albert Einstei...
1. SMS OVERVIEW
“Insanity is doing the same
thing over and over again, and
expecting different results.”
!
~Albert Einstei...
1. SMS OVERVIEW
“Insanity is doing the same
thing over and over again, and
expecting different results.”
!
~Albert Einstei...
1. SMS OVERVIEW
Why change?
1. Hazard ID + Hazard and Risk
Assessment
2. Lead and lag (entire chain)
3. Quantification and ...
1. SMS OVERVIEW
Why change?
1. Hazard ID + Hazard and Risk
Assessment
2. Lead and lag (entire chain)
3. Quantification and ...
1. SMS OVERVIEW
Why change?
1. SMS OVERVIEW
Why change?
"One thing we learned from this accident is that if safety is not the highest
organizational priority, an organization may...
!
!
Policy
!
• The pillars of a Safety Management System:
1. Policy
2. Risk Management
3. Assurance
4. Promotion
“Incompre...
First Step: SAFETY FIRST
Safety
Manual
Ops
Manual
!
2. PRACTICAL APPLICATIONS POLICY
!
Policy
First Step: SAFETY FIRST
Ops
Manual
!
2. PRACTICAL APPLICATIONS POLICY
• “What” is to be done, as opposed to ‘How”
objectives, safety commitment, etc.
• “Who” Authority, Responsibility, Roles
•...
Safety Statement
Just Culture
Weather minimums
Duty time and rest policy (include maintenance)
Designated roles and respon...
IHST SMS Toolkit p. 7, 9, 15 POLICY – RISK MANAGEMENT – ASSURANCE - PROMOTION
All operations conducted at Bob’s Helicopter...
IHST SMS Toolkit p. 7, 9, 15
PRIVATE OPERATOR POLICY EXAMPLE…
POLICY – RISK MANAGEMENT – ASSURANCE - PROMOTION
My Personal...
IHST SMS Toolkit p. 7, 9, 15 POLICY – RISK MANAGEMENT – ASSURANCE - PROMOTION
Why put it in writing?
People believe writte...
Fatigue - Need for Policy
Fatigue - Need for Policy
Fatigue - Need for Policy
0
2
3
5
6
Fatigue - Need for Policy
0
2
3
5
6
Fatigue - Need for Policy
0
2
3
5
6
Fatigue - Need for Policy
0
2
3
5
6
Fatigue - Need for Policy
When%we%are%tired%we%may%make%an%evaluation%of%our%ability%to%fly%during%a%low%
level%o...
IHST SMS Toolkit p. 7, 9, 15
!
2. PRACTICAL APPLICATIONS POLICY
c
Was the job understood?
Knowingly violated
procedures?
W...
IHST SMS Toolkit p. 7, 9, 15
!
2. PRACTICAL APPLICATIONS POLICY
Just Culture must be codified in policy so it can
be univer...
IHST SMS Toolkit p. 7, 9, 15
!
2. PRACTICAL APPLICATIONS POLICY
c
Was the job understood?
Knowingly violated
procedures?
W...
INCIDENT RESPONSE PLAN
!
2. PRACTICAL APPLICATIONS POLICY
INCIDENT RESPONSE PLAN
!
2. PRACTICAL APPLICATIONS POLICY
INCIDENT RESPONSE PLAN
!
2. PRACTICAL APPLICATIONS POLICY
!
• Hazard Identification
• Risk Assessment
• Risk Control (Mitigation)
• Assurance (Performance Tracking)
IHST SMS Toolki...
!
2. PRACTICAL APPLICATIONS RISK MANAGEMENT
IHST SMS Toolkit p. 7, 27
HAZARD IDENTIFICATION
!
2. PRACTICAL APPLICATIONS RISK MANAGEMENT
IHST SMS Toolkit p. 7, 27
HAZARD IDENTIFICATION!
!
Traditional Sources
Acciden...
!
2. PRACTICAL APPLICATIONS RISK MANAGEMENT
IHST SMS Toolkit p. 7, 27
HAZARD IDENTIFICATION
!
2. PRACTICAL APPLICATIONS RISK MANAGEMENT
IHST SMS Toolkit p. 7, 27
!
!
Hazard ID Forms
Keep them simple
Make them easy ...
!
2. PRACTICAL APPLICATIONS RISK MANAGEMENT
IHST SMS Toolkit p. 7, 27
!
!
Hazard ID Forms
Keep them simple
Make them easy ...
!
2. PRACTICAL APPLICATIONS RISK MANAGEMENT
!
Peer Audits (flying club, CFI)
FRAT
Audits and Inspections
Surveys
…..
IHST ...
!
2. PRACTICAL APPLICATIONS RISK MANAGEMENT
!
Peer Audits (flying club, CFI)
FRAT
Audits and Inspections
Surveys
…..
IHST ...
!
2. PRACTICAL APPLICATIONS RISK MANAGEMENT
!
Peer Audits (flying club, CFI)
FRAT
Audits and Inspections
Surveys
…..
IHST ...
!
2. PRACTICAL APPLICATIONS RISK MANAGEMENT
!
Peer Audits (flying club, CFI)
FRAT
Audits and Inspections
Surveys
…..
IHST ...
!
2. PRACTICAL APPLICATIONS RISK MANAGEMENT
!
What is a significant hazard at your operation ?
In class exercise was condu...
!
2. PRACTICAL APPLICATIONS RISK MANAGEMENT
!
1. Context (scope of inquiry, limits of risk, POLICY)
2. ID Hazards (reports...
!
2. PRACTICAL APPLICATIONS RISK MANAGEMENT
Now	
  we	
  have	
  identified	
  the	
  hazards	
  	
  
Do	
  we	
  want	
  ...
!
2. PRACTICAL APPLICATIONS RISK MANAGEMENT
Now	
  we	
  have	
  identified	
  the	
  hazards	
  	
  
Do	
  we	
  want	
  ...
!
2. PRACTICAL APPLICATIONS RISK MANAGEMENT
Now	
  we	
  have	
  identified	
  the	
  hazards	
  	
  
Do	
  we	
  want	
  ...
!
2. PRACTICAL APPLICATIONS RISK MANAGEMENT
!
2. PRACTICAL APPLICATIONS RISK MANAGEMENT
Spend limited resources where you will get the
biggest safety ‘bang for the bu...
!
2. PRACTICAL APPLICATIONS RISK MANAGEMENT
The helicopter landed hard during a forced landing.	

!
The student pilot’s de...
!
2. PRACTICAL APPLICATIONS RISK MANAGEMENT
The helicopter landed hard during a forced landing.	

!
The student pilot’s de...
!
2. PRACTICAL APPLICATIONS RISK MANAGEMENT
The helicopter landed hard during a forced landing.	

!
The student pilot’s de...
!
2. PRACTICAL APPLICATIONS RISK MANAGEMENT
1. “Why did Thunder Pig hit the side of the hangar with the tailboom?”
“He los...
!
2. PRACTICAL APPLICATIONS RISK MANAGEMENT
1. “Why did Thunder Pig hit the side of the hangar with the tailboom?”
“He los...
!
2. PRACTICAL APPLICATIONS RISK MANAGEMENT
Risk Management: Interventions
!
•Training
•Procedures and Policies
•Environme...
!
2. PRACTICAL APPLICATIONS RISK MANAGEMENT
Design Interventions to lower Likelihood and/or Severity
This will allow you t...
!
2. PRACTICAL APPLICATIONS RISK MANAGEMENT
1. Use a Flight Risk Assessment Tool (FRAT) with
specific wx information aimed at avoiding IMC
conditions. (forecast weath...
1. Use a Flight Risk Assessment Tool (FRAT) with
specific wx information aimed at avoiding IMC
conditions. (forecast weath...
!
2. PRACTICAL APPLICATIONS PROMOTION
Safety: Promotion
• Training and Education
✓ Initial, recurrent, general and specifi...
!
2. PRACTICAL APPLICATIONS PROMOTION
Safety: Promotion
• Training and Testing must be separated by
definitive lines. i.e....
Safety: Assurance
• Policy and procedure (Intervention) performance
monitoring.
• Management of change (impact of new fact...
!
2. PRACTICAL APPLICATIONS ASSURANCE
IHST SMS Toolkit p. 7, 28, 54, 61
Use the metrics set up at the beginning of the
pro...
!
2. PRACTICAL APPLICATIONS ASSURANCE
IHST SMS Toolkit p. 7, 28, 54, 61
Safety: Assurance
!
• Traditionally, safety interv...
!
2. PRACTICAL APPLICATIONS EXAMPLES
In class exercise was conducted at this point
!
2. PRACTICAL APPLICATIONS EXAMPLES
Hazard ID -
In class exercise was conducted at this point
!
2. PRACTICAL APPLICATIONS EXAMPLES
Hazard ID -
Risk Analysis -
In class exercise was conducted at this point
!
2. PRACTICAL APPLICATIONS EXAMPLES
Hazard ID -
Risk Analysis -
Hazard Analysis - Five Why’s
Latent Factors
In class exer...
!
2. PRACTICAL APPLICATIONS EXAMPLES
Hazard ID -
Risk Analysis -
Hazard Analysis -
Intervention Design -
Select Hazard Ele...
!
2. PRACTICAL APPLICATIONS EXAMPLES
Hazard ID -
Risk Analysis -
Hazard Analysis -
Intervention Design -
Implementation - ...
!
2. PRACTICAL APPLICATIONS EXAMPLES
Hazard ID -
Risk Analysis -
Hazard Analysis -
Intervention Design -
Implementation -
...
!
2. PRACTICAL APPLICATIONS EXAMPLES
Hazard ID -
Risk Analysis -
Hazard Analysis -
Intervention Design -
Implementation -
...
DISCUSSION?
POLICY – RISK MANAGEMENT – ASSURANCE - PROMOTION
SMS AND YOUR GOALS
SMS
UncertainRisksLimitingOperations
UncertainRisksLimitingOperations
Bryan Smith
safety@alea.org
239-938-6144
• There are no new ways to crash an aircraft…
Bryan Smith
safety@alea.org
239-938-6144
• There are no new ways to crash an aircraft…
• …but there are new ways to keep people from crashing them…
Bryan Smith
saf...
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IHST - SMS for Small Helicopter Fleets

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Helicopter Safety Management Systems for Small Fleet and Private Operators.

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Transcript of "IHST - SMS for Small Helicopter Fleets"

  1. 1. SAFETY MANAGEMENT SYSTEMS
 FOR
 SMALL FLEET 
 AND 
 PRIVATE OPERATORS
  2. 2. Bryan Smith ! ! ALEA Safety Program Manager ! Lee County Sheriff’s Office ! IHST/USHST SMS Committee Who’s  this  guy?
  3. 3. SETTING THE GAUGES • Who is with us today? ! • Who currently works with an established SMS? ! • Who is working on establishing an SMS? ! • Who just realized they were in the wrong class?
  4. 4. • How about, “Learning how to minimize the risks that hold you back from doing our job more…” class Another Safety Class? Concern for man himself and his fate must form the chief interest for all technical endeavors. Never forget this in the midst of your diagrams and equations ~ Albert Einstein Video removed for .pdf formatting
  5. 5. CHALLENGES TO IMPLEMENTATION What do you feel are the biggest challenges to implementing SMS for small fleet or private operators?
  6. 6. CHALLENGES TO IMPLEMENTATION ! • Scaling Traditional SMS systems down to an administratively manageable level. ! • Picking out the elements that are most beneficial to apply limited resources to. ! • Impact on bottom end: 1. Restriction of operational activity 2. Restriction on personnel availability 3. Cost of system 4. Liability concerns ! • Knowing how to do it What do you feel are the biggest challenges to implementing SMS for small fleet or private operators? SM SM
  7. 7. CHALLENGES TO IMPLEMENTATION What do you feel are the biggest challenges to implementing SMS for small fleet or private operators? SM SM The BIGGEST Challenge? ! Selling the idea that an SMS is even needed in the first place! ! !
  8. 8. 1. SMS OVERVIEW FLIGHT PLAN… 2. PRACTICAL APPLICATIONS 3. DECISION MAKING AND SMS 4. ROARING APPLAUSE “The safety of the operator is more important than any other point. Greater prudence is needed rather than greater skill. ! ~Wilbur Wright
  9. 9. “If you had one superpower, what would it be?” “Luck.” 1. SMS OVERVIEW
  10. 10. ! 2. PRACTICAL APPLICATIONS RISK MANAGEMENT
  11. 11. ! 2. PRACTICAL APPLICATIONS RISK MANAGEMENT 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’?
  12. 12. ! 2. PRACTICAL APPLICATIONS RISK MANAGEMENT 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’?
  13. 13. ! 2. PRACTICAL APPLICATIONS RISK MANAGEMENT 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’?
  14. 14. 1. SMS OVERVIEW “Insanity is doing the same thing over and over again, and expecting different results.” ! ~Albert Einstein Why change? Traditional Safety Program…
  15. 15. 1. SMS OVERVIEW “Insanity is doing the same thing over and over again, and expecting different results.” ! ~Albert Einstein Why change? 1. Hazard ID only 2. Tracks lag data (final link) 3. Assumption of risk 4. Assumption of performance 5. Isolated Traditional Safety Program…
  16. 16. 1. SMS OVERVIEW “Insanity is doing the same thing over and over again, and expecting different results.” ! ~Albert Einstein Why change? 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…
  17. 17. 1. SMS OVERVIEW Why change? 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
  18. 18. 1. SMS OVERVIEW Why change? 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
  19. 19. 1. SMS OVERVIEW Why change?
  20. 20. 1. SMS OVERVIEW Why change?
  21. 21. "One thing we learned from this accident is that if safety is not the highest organizational priority, an organization may accomplish more missions, but there can be a high price to pay for that success," ! The Board also identified a number of safety-related deficiencies in the NMSP's aviation policies. Some of these deficiencies included the lack of a requirement for a risk assessment at any point during a mission; the lack of an effective fatigue management program for pilots ! As a result of this accident investigation, the NTSB issued recommendations addressing pilot decision-making, safety management system programs and risk assessments, ! The recommendations were issued to the Governor of New Mexico, the Airborne Law Enforcement Association, the International Association of Chiefs of Police, and the National Association of State Aviation Officials. 1. SMS OVERVIEW
  22. 22. ! ! Policy ! • The pillars of a Safety Management System: 1. Policy 2. Risk Management 3. Assurance 4. Promotion “Incomprehensible jargon is the hallmark of a profession.” ! ~Kingman Brewster Jr. COMMON GROUND… IHST SMS Toolkit p.6, 96 • Definition of SMS: The formal, top-down approach to managing safety risk. It includes systematic procedures, practices, and policies for the management of safety. 1. SMS OVERVIEW 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
  23. 23. First Step: SAFETY FIRST Safety Manual Ops Manual ! 2. PRACTICAL APPLICATIONS POLICY
  24. 24. ! Policy First Step: SAFETY FIRST Ops Manual ! 2. PRACTICAL APPLICATIONS POLICY
  25. 25. • “What” is to be done, as opposed to ‘How” objectives, safety commitment, etc. • “Who” Authority, Responsibility, Roles • Documentation and Records • Emergency Preparedness IHST SMS Toolkit p. 7, 9, 15 POLICY – RISK MANAGEMENT – ASSURANCE - PROMOTION You likely already have this in place! For private operators – start with your personal limits An Emergency Plan does not need to be complicated ! 2. PRACTICAL APPLICATIONS POLICY
  26. 26. Safety Statement Just Culture Weather minimums Duty time and rest policy (include maintenance) Designated roles and responsibilities (safety, training, safety committee, etc.) Emergency Response Plan Documents (Hazard ID, Survey, Risk Management Form, Audit/Inspection, FRAT) IHST SMS Toolkit p. 7, 9, 15 POLICY – RISK MANAGEMENT – ASSURANCE - PROMOTION ! 2. PRACTICAL APPLICATIONS POLICY
  27. 27. IHST SMS Toolkit p. 7, 9, 15 POLICY – RISK MANAGEMENT – ASSURANCE - PROMOTION All operations conducted at Bob’s Helicopter Service will be done in the safest manner possible. No mission or customer is so important as to require deviation from safety policies, procedures, industry standards, or the prudent judgment of our employees. Safe operations are always the priority in every task we undertake. Just culture will be applied universally. The Boss 1/1/2014 ! 2. PRACTICAL APPLICATIONS POLICY
  28. 28. IHST SMS Toolkit p. 7, 9, 15 PRIVATE OPERATOR POLICY EXAMPLE… POLICY – RISK MANAGEMENT – ASSURANCE - PROMOTION 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 arrival ✓ If I did not sleep X hrs the night before, I will ground myself ✓ Personal currency requirements ✓ – 3 takeoff/landings every 30 days ✓ - 1 safety class or seminar every 60 days … ! ! ! 2. PRACTICAL APPLICATIONS POLICY
  29. 29. IHST SMS Toolkit p. 7, 9, 15 POLICY – RISK MANAGEMENT – ASSURANCE - PROMOTION Why put it in writing? People believe written promises more than spoken ones When the time comes to apply a policy the situation may distort the proper mindset needed to make a safe decision It provides rational, thought out perspective when there a question or issue Personal limits kept only in the mind are easily manipulated by desire! ! 2. PRACTICAL APPLICATIONS POLICY
  30. 30. Fatigue - Need for Policy
  31. 31. Fatigue - Need for Policy
  32. 32. Fatigue - Need for Policy
  33. 33. 0 2 3 5 6 Fatigue - Need for Policy
  34. 34. 0 2 3 5 6 Fatigue - Need for Policy
  35. 35. 0 2 3 5 6 Fatigue - Need for Policy
  36. 36. 0 2 3 5 6 Fatigue - Need for Policy When%we%are%tired%we%may%make%an%evaluation%of%our%ability%to%fly%during%a%low% level%on%the%top%chart%(higher%response%rate)%thinking%that%we%will%stay%at%that% level%throughout%the%flight.%If%our%response%time%happens%to%be%quick%(low%on% the%top%chart)%during%high%pilot%tasking,%we%are%fine%and%the%flight%goes%well.% This%reinforces%the%false%idea%that%we%can%monitor%our%own%performance%level% when%fatigued.%If%flight%tasking%gets%high%when%our%response%rate%is%high%as% well…things%may%not%end%up%so%great.%The%difference%is%only%a%matter%of%luck.% Here,%human%interventions%are%not%enough%to%keep%us%safe.%An%environmental% intervention,%such%as%strict%crew%rest%policy,%is%needed.%%%
  37. 37. IHST SMS Toolkit p. 7, 9, 15 ! 2. PRACTICAL APPLICATIONS POLICY c Was the job understood? Knowingly violated procedures? Was the action as intended? Were the results as intended? Are the procedures clear? Pass substitution test? Defective training or selection experience? History of violating procedures? Sabotage or Malevolent Act Reckless Violation Repeated Incident With Similar Root Cause Negligent Error No Blame Error Yes*Yes Yes Yes Yes Yes Yes* Yes* No* No* No No No* No No Start Documented for the purpose of accident prevention awareness and training will suffice. First written warning; Coaching / Increased Supervision until behavior is corrected. Final warning and negative performance appraisal Severe Sanctions Increasing Individual Culpability / Diminishing Individual Culpability * Indicates a ‘System’ induced error. Manager/supervisor must evaluate what part of the system failed and what corrective and preventative action is required. Corrective and preventative action shall be documented for management review. No
  38. 38. IHST SMS Toolkit p. 7, 9, 15 ! 2. PRACTICAL APPLICATIONS POLICY 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. c Was the job understood? Knowingly violated procedures? Was the action as intended? Were the results as intended? Are the procedures clear? Pass substitution test? Defective training or selection experience? History of violating procedures? Sabotage or Malevolent Act Reckless Violation Repeated Incident With Similar Root Cause Negligent Error No Blame Error Yes*Yes Yes Yes Yes Yes Yes* Yes* No* No* No No No* No No Start Documented for the purpose of accident prevention awareness and training will suffice. First written warning; Coaching / Increased Supervision until behavior is corrected. Final warning and negative performance appraisal Severe Sanctions Increasing Individual Culpability / Diminishing Individual Culpability * Indicates a ‘System’ induced error. Manager/supervisor must evaluate what part of the system failed and what corrective and preventative action is required. Corrective and preventative action shall be documented for management review. No
  39. 39. IHST SMS Toolkit p. 7, 9, 15 ! 2. PRACTICAL APPLICATIONS POLICY c Was the job understood? Knowingly violated procedures? Was the action as intended? Were the results as intended? Are the procedures clear? Pass substitution test? Defective training or selection experience? History of violating procedures? Sabotage or Malevolent Act Reckless Violation Repeated Incident With Similar Root Cause Negligent Error No Blame Error Yes*Yes Yes Yes Yes Yes Yes* Yes* No* No* No No No* No No Start Documented for the purpose of accident prevention awareness and training will suffice. First written warning; Coaching / Increased Supervision until behavior is corrected. Final warning and negative performance appraisal Severe Sanctions Increasing Individual Culpability / Diminishing Individual Culpability * Indicates a ‘System’ induced error. Manager/supervisor must evaluate what part of the system failed and what corrective and preventative action is required. Corrective and preventative action shall be documented for management review. No
  40. 40. INCIDENT RESPONSE PLAN ! 2. PRACTICAL APPLICATIONS POLICY
  41. 41. INCIDENT RESPONSE PLAN ! 2. PRACTICAL APPLICATIONS POLICY
  42. 42. INCIDENT RESPONSE PLAN ! 2. PRACTICAL APPLICATIONS POLICY
  43. 43. ! • Hazard Identification • Risk Assessment • Risk Control (Mitigation) • Assurance (Performance Tracking) IHST SMS Toolkit p. 7, 27 POLICY – RISK MANAGEMENT – ASSURANCE - PROMOTION Here is where we can identify all hazard factors Allows you to put your safety program in the correct context Prioritize your safety efforts to maximize efficiency of the program Begin to attach numbers so everything can be tracked ! 2. PRACTICAL APPLICATIONS Risk Management
  44. 44. ! 2. PRACTICAL APPLICATIONS RISK MANAGEMENT IHST SMS Toolkit p. 7, 27 HAZARD IDENTIFICATION
  45. 45. ! 2. PRACTICAL APPLICATIONS RISK MANAGEMENT IHST SMS Toolkit p. 7, 27 HAZARD IDENTIFICATION! ! Traditional Sources Accident Reports Annual Reports, Statistics and Studies War Stories
  46. 46. ! 2. PRACTICAL APPLICATIONS RISK MANAGEMENT IHST SMS Toolkit p. 7, 27 HAZARD IDENTIFICATION
  47. 47. ! 2. PRACTICAL APPLICATIONS RISK MANAGEMENT IHST SMS Toolkit p. 7, 27 ! ! Hazard ID Forms Keep them simple Make them easy to fill out Follow up can be done later HAZARD IDENTIFICATION
  48. 48. ! 2. PRACTICAL APPLICATIONS RISK MANAGEMENT IHST SMS Toolkit p. 7, 27 ! ! Hazard ID Forms Keep them simple Make them easy to fill out Follow up can be done later HAZARD IDENTIFICATION
  49. 49. ! 2. PRACTICAL APPLICATIONS RISK MANAGEMENT ! Peer Audits (flying club, CFI) FRAT Audits and Inspections Surveys ….. IHST SMS Toolkit p. 7, 27 ! ! Hazard ID Forms Keep them simple Make them easy to fill out Follow up can be done later HAZARD IDENTIFICATION
  50. 50. ! 2. PRACTICAL APPLICATIONS RISK MANAGEMENT ! Peer Audits (flying club, CFI) FRAT Audits and Inspections Surveys ….. IHST SMS Toolkit p. 7, 27 ! ! Hazard ID Forms Keep them simple Make them easy to fill out Follow up can be done later HAZARD IDENTIFICATION
  51. 51. ! 2. PRACTICAL APPLICATIONS RISK MANAGEMENT ! Peer Audits (flying club, CFI) FRAT Audits and Inspections Surveys ….. IHST SMS Toolkit p. 7, 27 ! ! Hazard ID Forms Keep them simple Make them easy to fill out Follow up can be done later HAZARD IDENTIFICATIONBob County Sheriff’s Office Aviation Unit Safety Survey 1.#What#are#your#biggest#three#safety#concerns?## _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________# 2.#What#suggestions#do#you#have#for#addressing#these#safety#concerns?# _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________# 3.#How#safe#do#you#feel#reporting#safety#hazards#to#the#Safety#Officer?# Very#safe# ########Neutral# # # Not#Safe# 1# 2# 3# 4# 5# 6# 7#
  52. 52. ! 2. PRACTICAL APPLICATIONS RISK MANAGEMENT ! Peer Audits (flying club, CFI) FRAT Audits and Inspections Surveys ….. IHST SMS Toolkit p. 7, 27 ! ! Hazard ID Forms Keep them simple Make them easy to fill out Follow up can be done later HAZARD IDENTIFICATION
  53. 53. ! 2. PRACTICAL APPLICATIONS RISK MANAGEMENT ! What is a significant hazard at your operation ? In class exercise was conducted at this point
  54. 54. ! 2. PRACTICAL APPLICATIONS RISK MANAGEMENT ! 1. Context (scope of inquiry, limits of risk, POLICY) 2. ID Hazards (reports, audits, lag data, observation) 3. Analyze Risk (likelihood vs. consequence) 4. Evaluate Risk (Prioritize, compare to accepted risk limits) 5. Treat the Risks (policy/procedure, training, equipment) 6. Monitor and Review IHST SMS Toolkit p. 7, 27 Risk Management 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
  55. 55. ! 2. PRACTICAL APPLICATIONS RISK MANAGEMENT Now  we  have  identified  the  hazards     Do  we  want  to  address  them  all?   No  !
  56. 56. ! 2. PRACTICAL APPLICATIONS RISK MANAGEMENT Now  we  have  identified  the  hazards     Do  we  want  to  address  them  all?   No  ! ! No  !   • Some  may  not  have  a  significant  influence  on  safety  at  our  operation  (i.e.   Risk  of  a  meteor  strike,  freezing  rain  in  Florida,  etc.)   • Some  may  have  a  more  significant  impact  than  others   • Some  may  be  difficult  or  impossible  to  mitigate   • What  is  the  RISK  of  this  HAZARD  causing  an  unfavorable  outcome?   • Addressing  Hazards  without  consideration  for  Risk  is  is  one  of  the  biggest   failures  of  safety  systems  in  our  world  
  57. 57. ! 2. PRACTICAL APPLICATIONS RISK MANAGEMENT Now  we  have  identified  the  hazards     Do  we  want  to  address  them  all?   No  ! ! No  !   • Some  may  not  have  a  significant  influence  on  safety  at  our  operation  (i.e.   Risk  of  a  meteor  strike,  freezing  rain  in  Florida,  etc.)   • Some  may  have  a  more  significant  impact  than  others   • Some  may  be  difficult  or  impossible  to  mitigate   • What  is  the  RISK  of  this  HAZARD  causing  an  unfavorable  outcome?   • Addressing  Hazards  without  consideration  for  Risk  is  is  one  of  the  biggest   failures  of  safety  systems  in  our  world  
  58. 58. ! 2. PRACTICAL APPLICATIONS RISK MANAGEMENT
  59. 59. ! 2. PRACTICAL APPLICATIONS RISK MANAGEMENT Spend limited resources where you will get the biggest safety ‘bang for the buck’ ! Respond to hazard reports that are warrantless ‘venting’ ! Allows you to track performance (initial values set)
  60. 60. ! 2. PRACTICAL APPLICATIONS RISK MANAGEMENT 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. Hazard Analysis (Root Cause, Latent Factors, Chain of Errors, etc.)
  61. 61. ! 2. PRACTICAL APPLICATIONS RISK MANAGEMENT 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. Hazard Analysis (Root Cause, Latent Factors, Chain of Errors, etc.)
  62. 62. ! 2. PRACTICAL APPLICATIONS RISK MANAGEMENT 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. Hazard Analysis (Root Cause, Latent Factors, Chain of Errors, etc.)
  63. 63. ! 2. PRACTICAL APPLICATIONS RISK MANAGEMENT 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”
  64. 64. ! 2. PRACTICAL APPLICATIONS RISK MANAGEMENT 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.
  65. 65. ! 2. PRACTICAL APPLICATIONS RISK MANAGEMENT Risk Management: Interventions ! •Training •Procedures and Policies •Environmental Controls •Education (directed at hazard) Target specific hazard elements “Be Safe”
  66. 66. ! 2. PRACTICAL APPLICATIONS RISK MANAGEMENT Design Interventions to lower Likelihood and/or Severity This will allow you to track the change in risk Target specific hazard elements
  67. 67. ! 2. PRACTICAL APPLICATIONS RISK MANAGEMENT
  68. 68. 1. Use a Flight Risk Assessment Tool (FRAT) with specific wx information aimed at avoiding IMC conditions. (forecast weather, temp/dew spread, etc.) https://easa.europa.eu/essi/ehest/2012/06/pre-departure-check-list/ ! 2. PRACTICAL APPLICATIONS RISK MANAGEMENT
  69. 69. 1. Use a Flight Risk Assessment Tool (FRAT) with specific wx information aimed at avoiding IMC conditions. (forecast weather, temp/dew spread, etc.) https://easa.europa.eu/essi/ehest/2012/06/pre-departure-check-list/ ! 2. PRACTICAL APPLICATIONS RISK MANAGEMENT This  FRAT  is  available  for  free  on  the  IHST   (ESEST)  website:  https://easa.europa.eu/essi/ ehest/2012/06/pre-­‐departure-­‐check-­‐list/  
  70. 70. ! 2. PRACTICAL APPLICATIONS PROMOTION Safety: Promotion • Training and Education ✓ Initial, recurrent, general and specific ✓ Establish proficiency and currency requirements ! • Communications ✓ SMS program performance, status ✓ Management’s commitment to the program ✓ Safety related information
  71. 71. ! 2. PRACTICAL APPLICATIONS PROMOTION Safety: Promotion • Training and Testing must be separated by definitive lines. i.e. If every flight with an IP seems like a test, the pilot will never be comfortable asking for instruction on something they are not 100% sure about. ! • Safety Management and Training cannot operate independently of each other.
  72. 72. Safety: Assurance • Policy and procedure (Intervention) performance monitoring. • Management of change (impact of new factors, including safety interventions) • Return on Investment (ROI) tracking • Requires use of metrics (quantification) to be successful. IHST SMS Toolkit p. 7, 28, 54, 61 FOUR PILLARS OF SMS POLICY – RISK MANAGEMENT – ASSURANCE - PROMOTION
  73. 73. ! 2. PRACTICAL APPLICATIONS ASSURANCE IHST SMS Toolkit p. 7, 28, 54, 61 Use the metrics set up at the beginning of the process to measure a change in risk.
  74. 74. ! 2. PRACTICAL APPLICATIONS ASSURANCE IHST SMS Toolkit p. 7, 28, 54, 61 Safety: Assurance ! • Traditionally, safety interventions are unquestionable once made into policy • Feedback – Anything without feedback is a guess…at best an educated guess • Justification: Return on Investment • Love the results, not the policy or procedure Use the metrics set up at the beginning of the process to measure a change in risk.
  75. 75. ! 2. PRACTICAL APPLICATIONS EXAMPLES In class exercise was conducted at this point
  76. 76. ! 2. PRACTICAL APPLICATIONS EXAMPLES Hazard ID - In class exercise was conducted at this point
  77. 77. ! 2. PRACTICAL APPLICATIONS EXAMPLES Hazard ID - Risk Analysis - In class exercise was conducted at this point
  78. 78. ! 2. PRACTICAL APPLICATIONS EXAMPLES Hazard ID - Risk Analysis - Hazard Analysis - Five Why’s Latent Factors In class exercise was conducted at this point
  79. 79. ! 2. PRACTICAL APPLICATIONS EXAMPLES Hazard ID - Risk Analysis - Hazard Analysis - Intervention Design - 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 In class exercise was conducted at this point
  80. 80. ! 2. PRACTICAL APPLICATIONS EXAMPLES Hazard ID - Risk Analysis - Hazard Analysis - Intervention Design - Implementation - Policy/Procedure Training In class exercise was conducted at this point
  81. 81. ! 2. PRACTICAL APPLICATIONS EXAMPLES Hazard ID - Risk Analysis - Hazard Analysis - Intervention Design - Implementation - Assurance - Measure change in Likelihood or Severity Respond to results (continue, change, stop) Feed results back into Promotion efforts In class exercise was conducted at this point
  82. 82. ! 2. PRACTICAL APPLICATIONS EXAMPLES Hazard ID - Risk Analysis - Hazard Analysis - Intervention Design - Implementation - Assurance - Measure change in Likelihood or Severity Respond to results (continue, change, stop) Feed results back into Promotion efforts In class exercise was conducted at this point
  83. 83. DISCUSSION? POLICY – RISK MANAGEMENT – ASSURANCE - PROMOTION
  84. 84. SMS AND YOUR GOALS SMS UncertainRisksLimitingOperations UncertainRisksLimitingOperations
  85. 85. Bryan Smith safety@alea.org 239-938-6144
  86. 86. • There are no new ways to crash an aircraft… Bryan Smith safety@alea.org 239-938-6144
  87. 87. • There are no new ways to crash an aircraft… • …but there are new ways to keep people from crashing them… Bryan Smith safety@alea.org 239-938-6144
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