Transcript Document

Airborne Law Enforcement
Association
FAA FAAST Conference
Kansas City, Missouri
Safety Management System
-------------------------------------------------------Keith Johnson
Safety Program Manager
The topic of the day
Whose job is it?
IHSS
Safety is most important
 Need to collect data

– Collect flight hours
– Collect Serious Incident Information
– Expedite Accident Reporting

Increased training
– Scaled check-rides based upon experience





Reduce accidents by 80% over 10-years
Focus on leadership
Non-punitive reporting
Accountability
Accidents can be eliminated
“SAFETY” Management
 It
holds the key to our future
 It
affects everything we do (SMS)
 Every
accident affects everyone
ACCIDENT ELIMINATION

Must be proactive – Reached plateau
– Pilots focus on flying aircraft
– Two person crews
– Focus on risk management

Adverse Trends
– Identify and eliminate adverse trends
– Incidents - Investigate & disseminate findings
– Factory emergency procedures training





Don’t reinvent the wheel
No new causes of accidents
Copy successful organizations
Accreditation
Flying to higher standard
“It’s insane to think that
doing the same thing over &
over will have a different
result.”
Why do we continue to make
the same mistakes?
IHST SMS Industry
Working Group







Don Arendt, PhD – FAA SMS Program Mgr.
Gordon Dupont – CEO System Safety
J. Heffernan – HAI Director of Safety
David Huntzinger PhD – AeroSSQQ
Peter Gardiner PhD. – CEO So. Cal. Safety Inst.
Denise Uhlin – Bristow Group
Keith Johnson – ALEA Safety Program Manager
Why is having an SMS important?
1.
2.
3.
4.
5.
6.
7.
Widely recognized as best practice
Reduces number of accidents
Reduces costs
Reduces probability of occurrences
Reduces severity of occurrences
Reduces exposure to risk
Increases likelihood of completing the
mission
IHST SMS DELIVERABLES



SMS Toolkit & Exemplars
SMS Mentoring Program
SMS Promotion
– 30 Safety Industry-wide articles on SMS
– SMS PPT on IHST website
– 21 Industry-wide SMS presentations




Computer SMS Training Program
Return on Investment Training
Testified at NTSB HEMS hearing
Meetings with NTSB on accident investigation
SMS Process

Need “sense of urgency” at top of every
organization
– ICAO, FAA, IHST, HAI, ALEA, AAMS, Operators
– Everyone is in the same boat




Create the “Guiding Coalition” - IHST
Develop a Vision and Strategy
Communicate Change Vision
Broad-Based Action
– SAFETY, TRAINING, MAINTENANCE INFRASTRUCTURE


Consolidate gains to produce more change
Anchor new approaches in the Culture
Phase-1 SMS










Safety & Quality Policy
Safety Planning
Organization Structure & Responsibilities
Compliance with legal & other requirements
Develop procedures & controls
Safety Promotion
Safety Culture
Communication & Awareness
Competence
Training
PHASE-2 SMS





Emergency Preparedness & Response
Documentation & Records Management
Safety Risk Management
Identify Hazards
Analyze, assess & control Safety Risk
Safety Assurance & Internal
Evaluation





Information Acquisition
Analysis of data
System Assessment
Preventive/corrective action
Management Reviews
Safety Promotion








Safety Culture
Personnel requirements (competence)
Training
Recognition & Awards
Safety Bulletins, posters, hazard reports
Feedback
Lessons learned
Meetings and events
RISK MANAGEMENT
• Mission
• Standards
• Training
• Equipment
• Supervision
• Assessment
• Accountability
•Open reporting
• Feedback
•Just Culture
JUDGMENT & ACTION ERRORS
Failure to manage known risks
 Mission urgency & risk taking

– Will to succeed

Flight profile unsafe
–
–
–
–
Crew Qualifications
Aircraft Suitability
Mission Requirements
Environment
Judgment errors committed
 Failure to follow procedures
 Poor CRM
 Poor Aircraft Control

– Over confidence
– Loss of situational awareness
What Does Having an SMS
Give?
Comprehensive
Comprehensive
approach
Corporate
Approach to
to safety
Safety
Organizational
Effective
Organisation
structure
for
for of &
ownership
Delivering Safety
accountability
for
safety



Robust
effective
Robust &
Systems
safety
for
management
Assuring Safety
processes
We will now concentrate on describing the three key processes generically
Once you understand these, the rest becomes more readily apparent
But first some more definitions…
Safety Culture




The essential human component of
organizations
You are rated, you are trained, but are you
COMFORTABLE?
Consists of values, beliefs, norms, legends
rituals, mission goals, performance
measures and a sense of responsibility to its
employees, customers and the community.
You cannot turn SAFETY on & off
Positive Safety Culture








Generated from top down (set the stage)
Words & actions
Safety in decision-making
Safety as a core value
I.D. its activities as high risk & high consequence
Trust permeates the organization
Trust is essential ingredient in safety
management
Employees supported making decisions in the
interest of safety
Positive Safety Culture







Hazards & risks actively sought
No shooting the messenger
Everyone vigilant about activities
People trained to recognize & respond
When I.D. Investigate and mitigate
Responsibility for safety is shared
High performance standards established
and monitored (technology)
TRAINING



Training is the only substitute for experience
SMS training is mandatory
What are the consequences of lack of
training?
– Lack of knowledge & skill
– Poor decision making
– Accidents
– Incidents
– Loss of support and funding & elimination of the
organization
Results of full year 2000 dataset
23
20
Regulatory
Aircraft Design
Ground
personnel
1
10
24
Mission Risk
Infrastructure
24
Communications
0
26
50
Post-crash
survival
Part/system
failure
Pilot situation
awareness
66
87
98
100
Ground Duties
154
112
150
Maintenance
Data issues
173
200
Safety Culture
400
401
450
Pilot judgment &
actions
Frequency
SPS Frequency by Primary Category
350
300
250
50
0
53
51
48
47
44
32
30
8
9
6
10
6
4
4
External Load
siness - Company owns A/C
Firefighting
Air Tour
Sightseeing
Electronic News Gathering
tilities Patrol and Construction
Logging
Aerial Observation / Patrol
3 17
145
170
210
SPS
Count
5 24
68
9
Offshore
Law Enforcement
74
92
13
16
Commercial Operator
101
100
12
28
Aerial Application
150
Emergency Medical Service
27
200
Personal / Private
37
250
Instructional / Training
Frequency
SPS & Accident Count by Primary Mission
Accident
Count
Introduction to the Toolkit





Contains SMS guidance material
Sample SMS Manual
Provides a foundation for implementing SMS
IHST needs feedback
Compliant FAA AC 120-92
Just Culture
A ‘blame culture’ undermines open reporting
 A ‘no-blame culture can undermine
accountability & responsibility
 Defines clear lines of what is and is not
acceptable behaviour
 If other personnel could make the same error
occasionally then we must change the controls
not discipline the personnel

– Holding people accountable through a disciplinary
process is only relevant for:
 Gross negligence
 Persistent sub-standard performance
 Wilful recklessness
Just Culture Process
Start
No*
Knowingly violated
procedures?
Was the job understood?
Yes
Was the action as
intended?
No
History of violating
procedures?
Pass substitution test?
No
Yes
Are the procedures
clear?
Yes
Were the results as
intended?
Yes*
No*
Yes*
Defective training or
selection experience?
No*
Yes
No
No Blame Error
Yes*
No
No
Reckless Violation
Repeated Incident With
Similar Root Cause
Negligent Error
Yes
Sabotage or Malevolent
Act
dua
divi
n
I
g
lity
abi
ulp
/
lpa
l Cu
hin
nis
i
m
Di
al C
gI
r
Inc
u
vid
ndi
in
eas
Final warning and
negative performance
appraisal
ty
bili
First written warning;
Coaching / Increased
Supervision until behavior
is corrected.
Documented for the
purpose of accident
prevention awareness
and training will
suffice.
Severe Sanctions
* 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.
The Attributes of an SMS
1) Safety Policy
2) SMS Management Plan
3) Safety Promotion
4) Document and Data Information Management
5) Hazard Identification and Risk Management
6) Occurrence and Hazard Reporting
7) Occurrence Investigation and Analysis
8) Safety Assurance Oversight Programs
9) Safety Management Training Requirements
10) Management of Changes
11) Emergency Preparedness and Response
12) Performance Measurement and Continuous
Improvement
Promotion of SMS

Safety must be a core value
– Procedures, practices, training & allocation of
resources

Mechanics
– Websites – ALEA, HAI, AAMS, PHPA, TOPS,
ICAO, AHS, FAA, Transport Canada

Benefits
– Reduced costs by eliminating accidents
– Insurance and performance based discounts
REWARDING SAFE BEHAVIOR






Timeliness – ASAP
Recipient – Focus on individuals
Presentation – Public presentation
Personalize – Name on the award
Possession – Keep and display
Value - $ not important
Success Solutions

Reinforced bad behavior breeds continued
bad behavior

Rationalization of the gravity of the situation
seems to lessen the risk in our minds, but in
reality does not

Habitual rule breaking is often condoned by
management when they look the other way

Does complacency play a role in this issue?
FINAL THOUGHTS
Can achieve our objective
 Industry is mobilized
 Only one chance to achieve
objective
 Requires everyone’s
commitment
