Transcript UNITED NATIONS MISSION FOR THE REFERENDUM IN WESTERN SAHARA

UNITED NATIONS MISSION FOR THE
REFERENDUM IN WESTERN SAHARA
AVIATION ORM IN MINURSO
BRINDISI
APRIL 2009
AREAS OF OPERATION
Bonifacio “BONI” Bonavente
Philippines
MINURSO Avn Safety Unit
(a.k.a. Ramesh’ sidekick)
ex-Philippine Air Force Attack Heli Pilot
4 yrs MONUC Air Operations
HOW WE WENT ABOUT IT
ANY RISK IS MANAGEABLE
PRELIMINARIES
Safety
Management
System
Module10
Module10
Phased
Phased approach
approach to
to SMS
SMS
implementation
implementation
Module
Module 88
SMS
SMS planning
planning
Module
Module 55
Risks
Risks
Module
Module 11
SMS
SMS course
course introduction
introduction
Module
Module 99
SMS
SMS operation
operation
Module
Module 66
SMS
SMS regulation
regulation
Module
Module 22
Basic
Basic safety
safety concepts
concepts
Module
Module 77
Introduction
Introduction to
to SMS
SMS
Module
Module 33
Introduction
Introduction to
to safety
safety
management
management
Module
Module 44
Hazards
Hazards
A CONCEPT OF
ACCIDENT CAUSATION
Organization
Workplace
People
Management
decisions and
organizational
processes
Working
conditions
Errors
and
violations
Source: James Reason
Latent conditions trajectory
Defenses A
c
c
i
d
e
n
t
THE ORGANIZATIONAL
ACCIDENT
Organizational processes
Improve
Monitor
Latent
conditions
Reinforce
Contain
Workplace
conditions
Active
failures
Identify
Defences
ORM TERMS

Hazard - A condition with the potential to cause
personal injury or death, property damage, or
mission degradation.

Risk - An expression of possible loss in terms of
severity and probability.

Risk Assessment - The process of detecting hazards
and assessing associated risks.

Operational Risk Management (ORM) - The process
of dealing with risk associated with operations or
activities, which includes risk assessment, risk
decision making, and implementation of effective
risk controls.
ORM PROCESS
Identify Hazards
Assess Hazards
Make Risk Decisions
Implement Controls
Supervise
ORM PRINCIPLES
 Accept
risk when benefits outweigh the
cost.



Accept no unnecessary risk.
Anticipate and manage risk by
planning.
Make risk decisions at the right level.
Ask yourself three crucial
questions:
 What
can go wrong?
 What
am I going to do about it?
 If
I can’t do anything, who do I tell?
Core Values and ORM Principles
Principles
1. Accept risk when
benefits outweigh the
cost.
Values
Accountable for our actions. . .
2. Accept no unnecessary
risk .
‘Work smart’ avoid
shortcuts/steps that may cause
injury or damage…
Minimize risk taking …
3. Anticipate and manage
risk by planning.
Plan ahead. . .
Take time to plan…
Ask yourself the right questions.
4. Make risk decisions at
the right level.
Support the chain of command. .
Know that you have choices…
Do the right thing. . .right…
Process of Aviation hazard
Identification
• Policy directive Aviation Operational Risk Management (ORM)
• Through a brainstorming session with CAVO, Air Ops Officer, Tech
Compliance Officer and MASO
• List of Aviation Hazards applicable at MINURSO
• Subjected to Matrix of Severity, Probability & Exposure Time
• Refined and a Risk Level for each Hazard was derived
• Each hazard at the risk level was subjected to mitigating factors
• A fresh risk level was derived by matrix application & a state of
applicable hazards are as projected
• The recommendations could be ambitious but possible and
achievable
ORM MATRIX
PROBABILITY
Frequent Occasional Remote
S
E
V
E
R
I
T
Y
Catastrophic 5
Improbable
Extremely
improbable
5
4
3
2
1
25
20
15
10
5
Hazardous
4
2
16
12
8
4
Major
3
15
12
9
6
3
Minor
2
10
8
6
4
2
Negligible
1
5
4
3
2
1
RISK LEVELS
WEATHER RELATED
HAZARDS
SAND STORMS
Low Visibility
3x3= 9
Avoid flying during the Acceptable
Undesirable occurrence,
timely
weather reports from
Team Sites.
Sand
accumulation
and
undulation of
landing strips
Engine
De-gradation
2x2=4
Stop flying for the Acceptable
Acceptable duration
of
the
occurrence,
early
airstrip clearance
2x1=2
Avoid flying during Acceptable
Acceptable sandstorm,
Precautionary
measures of covering
and blanketing vital
parts of engine and
airframe.
TORRENTIAL RAINS
Low Visibility.
1x1 =1
Acceptable
Avoid flying, flying only Acceptable
as per pilot rating, if
encountered
not
committed to landing.
Use of helicopters.
Landing
Strip 2 x 4 = 8
Flooding, Damage to Undesirable
landing strip.
Stop flying, early repairs, Acceptable
improvised surfacing of
airstrips to allow rain
water drainage. Use of
helicopters
Uneven wet patches 2 x 4 = 8
on landing strip
Undesirable
Stop flying, early repairs. Acceptable
Use of helicopters.
ADVECTION FOG
Frequent Advection 2 x 4 = 8
Fog Conditions.
Undesirable
Avoid flying during the Acceptable
occurrence,
timely
weather reports from
Team Sites. flying only
as per pilot rating
HIGH TEMPERATURES
Engine
Limitations
4 x 3=12
Close monitoring of temperature Acceptable
Unacceptable variance
and
adjusting
operations schedule (summer
schedule)
Crew
Fatigue
3x3 = 9
Undesirable
Facilitation of
accommodation,
adjustments etc.
comfortable Acceptable
schedule
Aircraft
3x3 = 9
Performance Undesirable
Payload restrictions
operations
manual,
schedule
In-flight
Turbulence
Precautionary briefing to crew Acceptable
and passengers, Aviation Safety
Awareness
briefing,
strict
adherence to cargo lashing.
2x2 = 4
Acceptable
as per Acceptable
summer
Landing
& 3 x 4=12
Avoid operations during out of Acceptable
Take-off
Unacceptable limit
temperatures,
payload
conditions.
restricted
operations,
longer
landing
strips.
Use
of
INFRASTRUCTURE
RELATED HAZARDS
UNMANNED AIR STRIPS/ HELI LANDING SITES
No two way 5 x 3 = 15
communications Unacceptable
.
Equip ATOs with hand
held air band radios for
landing clearance, ATO
training,
proposal
for
recruitment of airfield
manager local staff at all
unmanned air strips.
Undesirable
(recruitment of
airfield
manager)
No
ground 5 x 2 = 10
clearance
for Unacceptable
landing or takeoff.
Equip ATOs with hand
held air band radios for
landing clearance, ATO
training,
proposal
for
recruitment of airfield
manager local staff at all
unmanned air strips.
Undesirable
(recruitment of
airfield
manager)
FIRE FIGHTING AND SAFETY EQUIPMENTS AT TS
Inadequate
5 x 4 = 20
equipment and Unacceptable
trained
personnel
Deployment
of Unacceptable
serviceable existing fire
fighting equipment, ATO
training on fire fighting,
recruitment of qualified
fire
safety
officer,
proposal for procurement
of medium duty fire/crash
tenders for unmanned
airstrips.,
No crash, fire & 5 x 4 = 20
rescue facility
Unacceptable
ATO training on crash Unacceptable
drills,
proposal
for
positioning
of
crash
emergency kits, proposal
for
procurement
of
medium duty fire/crash
tenders for unmanned
airstrips, ERP exercises.
Liason
with
local
authorities.
LANDING STRIP CONDITIONS
Compact
Soil 4 x 3 = 12
airstrip
with Unacceptable
frequent
degradation.
Regular
resurfacing, Undesirable
compacting, proposal for
use of Marston Matting.
Additional
budget
allocation.
Additional take off 2 x 2 = 4
and landing roll Acceptable
due lose surface.
Additional
available Acceptable
length of landing strips
Susceptible to tire 2 x 4 = 8
bursts.
Undesirable
Controlled
long
float Undesirable
touch
down
landing
technique.
Foreign
Damage
ATO training, inspection Undesirable
of landing strip before
landing and take off.
Object 3 x 4 = 12
Unacceptable
REFUELING FACILITIES FOR HELICOPTERS
Fuel Contamination
Fuel pilferage
Fuel Coagulation
Early degradation of
equipment
due
inclement weather
No
effective
fire
fighting capabilities
No
fuel
security
station
Unmanned
station.
fuel
2 x 5 = 10
Undergoing upUnacceptable gradation of fuel
facilities at team
2x4= 8
Un desirable sites to international
standards.
2 x 5 = 10
Proposal for
Unacceptable procurement of
medium duty
4 x 3 = 12
Unacceptable crash/fire tenders.
Proposal for fencing,
CCTV, security
5 x 5 = 25
lighting etc.
Unacceptable
Periodic servicing of
equipment, ATO
training, refueling by
5 x 3 = 15
Unacceptable trained aircrew only,
crew training for
refueling.
5 x 2 = 10
Unacceptable
Acceptable
On completion
of the proposed
up-gradation
SEARCH AND RESCUE FACILITIES
No
dedicated 3 x 4 = 12
search
and Unacceptable
rescue in the
eastern side of
Berm
No infrastructure 3 x 4 = 12
for
effective Unacceptable
response
to
accidents.
No
immediate 3 x 4 = 12
medical facilities Unacceptable
at Team Sites.
Effective ERP, regular Undesirable
updating of ERP, Up
gradation of infrastructure
for
crash
emergency
relief, Training of UNMOs
for first aid, crash drills.
Proposal for positioning of
emergency crash kits at
unmanned air strips.
AGEING FLEET
Degradation in 2 x 2 = 4
aircraft
and Acceptable
equipment
performance
Regular monitoring of aircraft Acceptable
performance for ageing factors,
regular aircraft inspections.
METEOROLOGICAL SERVICES
No
qualified 2 x 3 = 6
meteorological Undesirable
services
available
at
Team Sites.
Employment
of
automated Acceptable
weather monitoring devices.
Positioning of adequate wind
socks,
ATO
training
for
weather
monitoring.
AIR TRAFFIC SERVICES
1.Uncontrolled
2x2 = 4
airspace
with Acceptable
only information
services
Effective flight following by Acceptable
aviation
section,
strict
adherence
to
aircraft
reporting procedure, best
use of area control available,
1.Insufficient
Navigational
aids
Proposal for installation of
low range portable NDB,
Delineating airstrip markings
and painting of threshold
after laying of Marston
Matting. Regular updating of
Jeppesen for currently used
on board GPS equipment.
3x3 = 9
Undesirable
1.Restricted
4 x 4 = 16
night
flying Unacceptable
capability
and
infrastructure
Acceptable
Only
with
installation of
short range
NDBs
ATO training, crew training, Undesirable
up gradation of night flying
infrastructure, employment
of night sun on helicopters.
MINES & UXOS
Contaminated
4 x 5 = 20
area of mines Un acceptable
causing concern
for
emergency
landings
and
reconnaissance
for new landing
sites.
Establishment
of
GIS Acceptable
section in mission for
mapping and plotting and in
coordination
with
Mine
Action Cell mark areas of
suspected mine activity,
regular
liaison
with
Moroccan Army on updating
of mine activity, making
these maps available to the
crew for regular flying.
AVIATION SECURITY
No
existing 2 x 4 = 8
infrastructure and Undesirable
manning to cater
for
aviation
security at un
manned airstrips
and Heli- landing
sites.
Airstrip inspection by ATOs Undesirable
before and after operations, (recruitment
of
regular
inspection
by airfield manager)
Technical Compliance and
Aviation Safety.
HUMAN RELATED
HAZARDS
CREW FATIGUE
Crew Fatigue due surroundings 2 x 2 = 4
and high temperature
Acceptable
Long intervals between crew 2 x 2 = 4
rotations (Air Urga)
Acceptable
Lack of recreation facilities.
2x2 = 4
Acceptable
Additional Responsibility of
ground
clearance
and 2 x 3 = 6
assessment of meteorological Undesirable
conditions
Preventive scheduling Acceptable
of flights, up gradation
of recreational facilities,
proposal for reduction
in crew rotation period,
training,
motivation
exercises,
equipping
and training ATOs for
ground clearance and
weather watch
MANNING
Non availability of trained 4 x 4 = 16
manpower at team sites for air Unacceptable
operations
and
aviation
requirement
Continuous
and Unacceptable
repetitive training for
ATOs, proposal for
recruitment of local
Moroccan
aviation
qualified staff as Air
Field
Manager
at
Mahbas, Oum Drega
and Asward airstrips
Mission Approach
AVIATION ORM
Implementation Task Group (ITG) formed in
MINURSO on 05 Jun 08 and is headed by
Chief Technical Services (CTS). Other
members are:
• CAVO,
• MASO,
• Air Operations Officer,
• Technical Compliance Assistant and
• ALO from Military component.
Cont…Mission
Approach
The ITG will carry out:
• Determination of risk level for all aviation
activities and all types of flights on a Risk
Matrix;
• Review of these risk levels at prescribed
regular basis or when changes occur in
mission mandate, objectives, and type of
operations or assets
• Update on the effects of the measures
adopted in mitigation and review of the
conditions for ORM
Implementation Process and
Control by Air Operations
• AOO to brief aircrew members of any risks
inherent in the operation or mission;
• AOO will follow up conditions during the
mission and conduct an after mission action
review to ensure that all went according to
plan;
• AOO will re-evaluate the plan or make
adjustments as required to accommodate
unforeseen issues and incorporating lessons
learned for future use.
Implementation Process and
Control by Contractor PIC
• The Pilot-in-Command (PIC) of each aircraft shall
sign the Aviation Risk Management Check List
acknowledging that he was briefed, is fully prepared
and capable of performing the mission.
• To identify, control and reduce hazards to flight, a
risk assessment must be performed before each
flight by the aircrew during mission preparation. The
CAVO will be directly involved and should there be
undue pressure for a mission with an unacceptable
risk, the CMS will be notified.
Risk Management Authority and
Leadership
•Aviation risk management is already a part of DPKO/ DFS
standard operating procedures and defined in Chapter 3,
Annex F of the DPKO/ DFS Aviation Manual published in May
2005.
•The standard for risk management is leadership at the
appropriate level of authority SRSG, CMS, CTS and CAVO
making informed decisions to control hazards or accept risks.
•The degree of risk determines the level of acceptance by the
decision authority (SRSG, CMS, CTS and CAVO).
Feedback
•
•
•
•
Aviation Risk Management Checklist
Aircraft Technical Report
After Mission Report
Periodic Inspection Report produced
by Aviation and Aviation Safety
personnel
• Aviation Observed Hazard Report
Application of Risk Management
• CAVO will ensure that the Risk Management process
is integrated into all planning phases of operations.
• No unnecessary risk will be accepted
• SRSG, CMS, CTS and CAVO have the authority to
accept risks but also have the responsibility to
protect personnel from unnecessary risk.
• SRSG, CMS, CTS and CAVO must understand risks
and be prepared to take risks to accomplish their
mission.
Aviation ORM has been integrated into
the MINURSO Aviation SOP….
Problems Encountered
• Initial Apprehension
– ORM already in AV Manual
– What is new?
– Reluctance to change
• Compilation of SOP
– Who to compile?
– What format?
– How to make it effective?
Lessons Learned
• The policy directive issuance
• Familiarization on SMS to Senior
Management
• ORM as a budget justification tool
• Regular proactive measures in pursuing
ORM
• Adapted by other sections
• Acceptance by the Mission Management
Achievements by ORM Policy
•
•
•
•
•
•
•
•
•
Refueling Infrastructure
Fire Fighting Capability at Airstrips
Repair of Airstrips
Repair of HLS
Identification Emergency Landing Sites
Night Flying to Team Sites
100% Aviation Safety Awareness
Well prepared ERP
Adaptation of ORM process by other
Sections
TS Mahbas Desert Runway
Nearing Completion
ERODED FIRE EXTINGUISHER HOSES
TS MAHBAS
FIRE FIGHTING CAPABILITY
UPGRADE FOR THE TS
EQUIPMENT & FUEL SUSCEPTIBLE
TO CONTAMINATION & DAMAGE
FUEL HOSES EMBEDDED IN HOT &
COLD DESERT SAND
TS AVN FUEL EQUIPMENT
BEFORE MODIFICATION
Modified Protection of Refueling
Equipment in TS Awsard
ERP Stores Preparation/Inspection
“Complacency or a false sense of
security should not be allowed to
develop as a result of long periods
without an accident or serious
incident. An organization with a good
safety record is not necessarily a
safe organization.”
-International Civil Aviation Organization (ICAO)
Accident Prevention Manual, 1984
ORM is a proven
successful tool for
operational use, but it has
equal application to many
types of activities where
there is risk associated.
ORM Alternate Definition
DON’T FALL PREY TO……
Occasional Risk
Mismanagement
ORM in Real Life:
Why They Have Safety Observers
Should the nose be that close to the ground?
Yes, if someone forgot to install the gear pins...
and someone else raised the gear handle.
The air bags are going to raise the airplane.
It looks like those air bags work real good!
Hmm… maybe they work too good.
Uh oh... somebody forgot to use those air bags in the back.
Hey! Who left that tail stand under the right elevator?
Ouch!
ORM is a process…
not a program!
It must become an inherent
way of doing business