Transcript Safety Update

JOINT
HELICOPTER SAFETY
IMPLEMENTATION TEAM (JHSIT)
SMS Presentation
June 6, 2007
Sao Paulo, Brasil
Greg Wyght
Vice President Safety & Quality
CHC Helicopter Corporation
Co- Chair, JHSIT
[email protected]
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Introduction
• An effective Safety Management
System is essential to achieving &
sustaining a zero accident rate along
with other quality programs
• The following briefing will discuss the
key elements of the SMS Tool that the
JHSIT is developing for delivery in the
IHSS conference, September 2007
Montreal.
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What is a Safety Management System (SMS)
• Management is: the art of “controlling or directing resources to
achieve objectives”
• A System is: “a coordinated & comprehensive set of processes”
• A Process is: “a systematic series of actions”
• An SMS is: a comprehensive set of processes designed to
control and direct resources to achieve (safety) objectives. An
SMS will need to consider:
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People
Training
Hardware & Software
Policy & Procedures
etc
• It is not some kind of giant IT ‘system’ you can buy off the shelf
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Financial Management vs. Safety Management
Comparing Two “Systems”
Financial Management System
Safety Management System
Finance Plan
Safety Plan
Targets & Objectives
Targets & Objectives
Budget
Budget
Accountabilities
Accountabilities
Levels of Authority
Line Management
Authorities
Procedures
Procedures
Checks and Balances
Monitoring/Line Checks
Audit
Plan
Accountants
Audit Plan
Safety
Committee
Audits
Balance
Sheets
Audits
Safety
4Achievement
A Framework for Safety Management
Checklist
Security
Policy
Maint.
Schedule
Ops
Manual
QA
Worksheets
Alcohol
& Drugs
Policy
HSE
Policy
Policy /
Plan
Audit
Plans
Training
Plan
Safety
FAA
Regs
Drills
.
Process /
Do
Audits
ERPs
CRM
No Structure
Task /
Check – Feedback - Action
STRUCTURE
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Goal: The Reduction of Accidents
Incident rate
Technology
and standards
Management
Systems
“A company’s culture is derived
from the management’s actions,
not its words and unfortunately
is usually fear driven.
The culture should be “Just”
and “Learning” and actively
lived by all the staff.
Culture it is about Shared
beliefs and perceptions of the
Company.”
Improved
culture
Time
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Some Elements of an SMS
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Leadership and Accountability (including Top Level Policies)
Risk Assessment and Hazard Management
Standard Procedures (SOP’s) & Safe Work Practices
Information and Document Control
Training and Competency (Realistic, Comprehensive, but Simple)
Systems for Reporting Hazards, Occurrences, Incidents & Accidents
Systems for collecting, analyzing, and storing data (root cause, etc.)
Corrective action strategies and procedures for tracking closeout.
Auditing and ongoing Compliance Monitoring (QA of system)
Crisis Management and Emergency Response
An SMS must:
a) address factors that contribute to an event, rather than just the event itself
or the people involved.
b) be Reactive & Proactive – Hazard/Deficiency Reports, Audits, Safety
meetings, Aviation Safety Report reviews, Safety Cases, Suggestion box, Flight
Data Monitoring (FDM) and Health Usage Monitoring (HUMS).
c) consider Latent & Active failures - Are we training a way that leads to events
on the flight line later? Is there a system defect?
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Proactive Risk Management
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“SMS Tools” that will be Available
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Why is Having an SMS Important?
1.
2.
3.
It makes good business sense for long term growth
Widely recognized as best practice
A contractual requirement for many of your
customers
Increasingly becoming a regulatory requirement, for
example:
4.
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The International Civil Aviation Organisation made having
requirements for an SMS a recommended practice last
year
It will become an ICAO standard in 2009
So our aviation regulators will need to implement SMS
rules by 2009
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3 Main Processes: #1) Risk Management
• Before we commence an activity where we are implementing a
change we need to proactively:
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Understand the associated hazards
Understand the risks they pose
Cost Benefit Analysis
Put controls in place to ensure the risk is acceptable
• These controls need to include controls for emergencies situations too
• The JHSIT plans to deliver risk management tools &
techniques to make this process easier for small operators
• Simplified tools and techniques for conducting a Job Safety
Analyses, Hazard Identification, Risk Assessments etc.
• Simple Cost Benefit model.
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3 Main Processes: #1) Risk Management
Basic Cost Benefit Analysis
Data-Driven Safety Initiatives
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Identify the Hazard - Audit, Occurrence Review or HAZID
Assess the Impact the Hazard may have on Operation quantify the impact in a language managers understand.
Brain Storm Possible Controls – Staff Participation!!
Develop a “Business Case” for Implementation!
(What’s the cost of implementing vs. not implementing?)
E.g. #1 – S76 Blade Tip: Loss of Revenue (no penalty)
Cost of Parts (2 per year)
Annual Cost, if nothing changed
Cost of the “Intervention”
Total savings in the first year
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$
0
$20,000
$20,000+
$-10,000
$10,000
3 Main Processes: #2) Monitoring
• During an activity we need to proactively monitor that
risk is being managed acceptably
• When they are not that’s when safety leaders intervene
• The JHSIT plans to demonstrate examples of
monitoring tools & techniques to help simplify
this process.
• Tools & techniques will include:
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Safety surveys
Behavioural based safety observations
Crew Resource Management
Simple and inexpensive helicopter flight data monitoring
program for light aircraft (known as HOMP, FOQA or FDM)
• Helicopter Health & Usage Monitoring Systems (HUMS)
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3 Main Processes: #2) Monitoring
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3 Main Processes: #3) Safety Reporting
• When problems occur you need a means for safety concerns to
be raised:
• Accidents, incidents, near misses, new hazards, errors, deficiencies
etc
• You then need to investigate independently to a level
appropriate to their significance
• The focus is on learning, improving & prevention
• The JHSIT plans to demonstrate some simple and
inexpensive reporting tools and techniques.
• Tools such as HAI’s Occurrence and Defecting Reporting tools
etc.
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3 Main Processes: #3) Safety Reporting
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Managing Human Error must be part of an SMS
• We must recognise that humans can and do
make errors!
• We must recognise that errors & at-risk
behaviour are often provoked by system
problems
• i.e. flawed, missing or inconsistent controls
• Tackling these controls is a powerful means of
improvement
• So we need to encourage safety reports in order
to learn & improve
• A human error or at-risk behaviour is thus a
starting point not a finishing point
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“HFACS” Analysis Tool
Human Factors Analysis and Classification System
Organizational
Influences
Resource
Management
Organizational
Influences
Organizational
Climate
Organizational
Process
Unsafe
Supervision
Level of
Supervision
Unsafe
Supervision
Problem
Correction
Planned
Activities
Rules &
Regulations
Preconditions
For Unsafe Acts
Conditions
of Personnel
Preconditions
For Unsafe Acts
Working
Conditions
Practices of
Personnel
Unsafe Acts &
Conditions
Unsafe Acts
Errors
Decision
Based
Technique
Based
Attention/
Memory
Violations
Knowledge
Based
Routine
Violation
Perceptual
Error
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Exceptional
Violation
An SMS only works within a “Just Culture”
• A ‘blame culture’ undermines open reporting
• A ‘no-blame culture’ is also flawed as it
undermines accountability & responsibility
• 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:
• Wilful recklessness or malicious intent
• Gross negligence
• Persistent sub-standard performance
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“Just Culture” Model
Rules of Fair Play for Managers
Start Here
No *
Was the Job understood?
Yes
Knowingly violating
Procedures?
No *
Yes
No
Are Procedures Clear
and Workable?
Were the actions as intended?
Yes
No
Were the results as intended?
Yes
No *
Yes*
Pass Substitution Test?
No
*
Yes
Defective Training or
Selection Experience?
History of Violating
Procedures?
No
Yes*
No Blame Error
No
Reckless Violation
Negligent Error
Final Warning and
Negative Performance
Appraisal
First Written Warning
Coaching / Greater Supervision
Until Behavior is Corrected
Repeated Incidents with
Similar Root Causes
QA
Check
Yes
Sabotage or Malevolent Act
Severe Sanctions
Documented for the
Purpose of Prevention
Awareness and
Training will Suffice
*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 recorded on the appropriate form for management review (either the NCR form or the Incident
Report as applicable).
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3 Process Lead to Insight
Insight
Risk Management Monitoring
(e.g.: hazard identification,
risk assessment,
JSA, safety cases etc)
(e.g.: supervision, CRM,
Inspections, audits,
HUMS, HOMP,
Behavioural Based Program etc)
Foresight
Oversight
Safety Reporting
& Investigation
Hindsight
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Why is Insight Important to Leaders?
• JHSIT’s goal is to deliver simple tools for these
three processes, allowing small operators to:
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understand the hazards & risks they face
determine a cost effective way to control those risks
know how effective these controls are in their operation
be informed when controls fail
drive continuous improvements to take us towards
achieving & sustaining a zero accident rate
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Obrigado!
SMS Team Lead
Ray Wall
Director Quality & Safety
Bristow Group, Western Hemisphere
337-365-6771
[email protected]
International JHSIT Co-Chairs
Hooper Harris
US DOT/FAA
Commuter, On Demand, & Training Center Branch
202-267-3437 (USA)
[email protected]
Gregory F. Wyght
Vice President, Safety & Quality
CHC Helicopter Corporation
604-232-7428 (Canada)
[email protected]
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