Transcript Portland Safety Seminar

NATIONAL HELICOPTER
INDUSTRY WORKSHOP
Portland, OR 23 March 2011
Fred Brisbois
Sikorsky Aircraft Corporation
CO-CHAIR US JHSIT
[email protected]
Industry Workshop, Portland, OR
March 23, 2011
1
IHST GOAL
• Reduce the worldwide helicopter accident
rate by 80% by 2016!
• 2011-2016 are critical to achieving
success
• Reduce accidents…save lives!!!
Industry Workshop, Portland, OR
March 23, 2011
2
Accident Rates Vary by Region of the World
Civil registered helicopter accidents and flight hours from IHST data
Pre-IHST (2001-2005) accident rates vs. 2011 thru February accident rates
North
America
Pre: 9.3
2011: 3.0
World
Pre: 9.4
Europe
Pre: 7.1
2011: 2.7
2011 Feb: 4.2
Asia
Pre: 9.4
2011: 5.5
Accidents per
100K flt hrs
Africa
Pre: 12.9
2011: 5.6
Note: Few accidents
in Jan/Feb 2011.
Lowered rates except
in South America.
4 March 2011
South
America
Pre: 9.7
2011: 16.6
Oceania
Pre: 17.5
2011: 10.1
Accuracy of flight hour exposure estimate improves every year.
Industry Workshop, Portland, OR
March 23, 2011
3
IHST - Regional Process Tracking
IHSS
Formed
US
Europe
Excom
Formed
1
2
2011
2010
3
5
2
6
7
8
3
1
E
4
3
2
1
4
5
3
2
3
6 7 8 9
Metrics
4
5 6
5
6 4
7
4
7
7
P
P
Japan
E
1
2
3
P
E
4 JHSAT Report Complete
Regional Kickoff Meeting
5 JHSIT Formed
JHSAT Team Formed
Accident Dataset Established 6 JHSIT Process Refined
March 23, 2011
Metrics
P
3
Industry Workshop, Portland, OR
9
5 6
2
3
8
4
1
2
Metrics
P
E
1
7
4 5
Mid East
Key:
6
9
P
2
1
E
4
P
2
India
Australia
4
3
1
Canada
Russia
2012
Program staffing, marketing, management, communications, international outreach
1
Brazil
2009
2008
Today
2007
2006
(03 2011)
5 6
5
6
E
4
1
7
7
2 3
8
9
8
9
Metrics
8
9
Metrics
8
9
Metrics
8
9
Metrics
4
5
Metrics
6
7
8
9
7 JHSIT SEs complete
8 JHSIT DIPs complete
P
Prelim Report/Data
9 JHIMDAT Formed
E
“Exploratory” Mtg
4
Heli-Expo 2010 and IHSS 2010
In a ringing endorsement of the IHST safety initiative, the CEO’s of
AgustaWestland, Bell Helicopter Textron, Eurocopter and Sikorsky
Aircraft signed a joint letters captioned “A Call for Action by Helicopter
Owners.” and “Ten Major Offshore Operators” signed a joint letter of
commitment captioned
“Call to Action by and for Offshore Helicopter 0perators”
•
The letter calls upon “all those who
operate our products to implement the
safety enhancements recommended by
the International Helicopter Safety Team
(IHST).”
•
The areas cited in the letters are the
adoption of:
–
–
–
Safety Management Systems (SMS)
Improved Training
Use of advanced systems/equipment
•
•
–
Use of mission-specific equipment
•
•
–
–
–
Flight data monitoring systems (FDM)
Health monitoring systems (HUMS)
Night vision goggles
Avionics to avoid controlled flight into terrain
Strict compliance with manufacturer’s
maintenance program
Cultural/Behavioural Change, and
Crew Resource Management (CRM) Program
Industry Workshop, Portland, OR
March 23, 2011
5
523 ACCIDENTS ANALYZED
176 pages
197 Accidents
210 pages
174 Accidents
37 Instructional /
Training
29 Instructional /
Training
184 pages
152 Accidents
28 Instructional /
Training
Industry Workshop, Portland, OR
March 23, 2011
6
IHST TOOLKITS
MAINTENANCE TOOLKIT
MARCH 2011
Industry Workshop, Portland, OR
March 23, 2011
7
IS IT MONDAY?…..
Industry Workshop, Portland, OR
March 23, 2011
8
TOPIC OF THE DAY
Industry Workshop, Portland, OR
March 23, 2011
9
Industry Workshop, Portland, OR
March 23, 2011
10
SAFETY
 Is the key to our future
 It affects everything we do (SMS)
 Every accident affects everyone
Industry Workshop, Portland, OR
March 23, 2011
11
PRIMARY CAUSE
FACTORS
ACCIDENT CAUSES
HUMAN
MACHINE
TIME
Industry Workshop, Portland, OR
March 23, 2011
13
WE ARE ONLY HUMAN!
“Human beings by their very nature make mistakes;
therefore, it is unreasonable to expect error-free human
performance.”
Shappell & Wiegmann, 1997
Industry Workshop, Portland, OR
March 23, 2011
14
CAUSES OF HUMAN ERRORS
•
•
•
•
Not following a procedure (violation)
Follow an incorrect process.
Forget to complete a procedure
Skills and training related errors
Industry Workshop, Portland, OR
March 23, 2011
15
COMMON MAINTENANCE ERRORS*
•
•
•
•
Omission—forget a step, a part, etc. 56%
Incorrect installation 30%
Wrong part 8%
Other (ground handling, etc.) 6%
* Ref.: ICAO Human Factors Circular 12 Human Factors in Aircraft Maintenance Digest
Industry Workshop, Portland, OR
March 23, 2011
16
JHSAT YEAR 2000 ANALYSIS
• 57 recommendations to prevent accidents
derived from analysis of data for 197 accidents
• 42% of the recommendations pertain to Safety
Management Systems
Industry Workshop, Portland, OR
March 23, 2011
17
SOLUTIONS
Must be tailored to the operations
Industry Workshop, Portland, OR
March 23, 2011
18
SOLUTIONS
Must be data driven
• Know what you know
• Know what you don’t know
• Studies must generate
‘actionable’ information
• Plans must be executable
Benefits
Industry Workshop, Portland, OR
March 23, 2011
Resources
19
SAFETY PRINCIPLES
1.
2.
3.
4.
Always operate in the safest manner possible
Never take unnecessary risks
Safe does not mean risk free
Key to safety is the identification and management
of risk
5. An absence of accidents does not necessarily
equate to safety
6. Familiarity and prolonged exposure without an
incident leads to a loss of appreciation of risk
SMS EMBODIES ALL THESE PRINCIPLES
ACROSS THE ENTIRE BUSINESS !
Industry Workshop, Portland, OR
March 23, 2011
20
REDUCING THE ACCIDENT RATE 80%
USING SMS TO IMPROVE PERFORMANCE
Perfect
Real
Good
Good
Okay
Not So
Bad
Awful
Catastrophic
Outcomes
Industry Workshop, Portland, OR
March 23, 2011
21
SAEFTY MANAGEMENT SYSTEMS (SMS)
Industry Workshop, Portland, OR
March 23, 2011
22
SMS DEFINED
• A system that enables the systematic management of
safety throughout an organization
• A business-like approach to safety
• A systematic, explicit and comprehensive process for
managing risks and
• Provides for goal-setting, planning and measuring
performance.
Industry Workshop, Portland, OR
March 23, 2011
23
BEWARE…ALLWAYS
Industry Workshop, Portland, OR
March 23, 2011
24
A NEW & MODERN CULTURE
X
Industry Workshop, Portland, OR
March 23, 2011
25
THE PARADIGM
“Safety people have their hearts in the right place but
seldom understand true business objectives”
• Safety has the high moral ground

No one can publicly disagree with what we represent
• But Safety people are seldom seen as true business partners


Our requests are compared with competing business objectives
We’re never seen as balancing Safety objectives with business reality
• We seldom make a credible business case
Industry Workshop, Portland, OR
March 23, 2011
26
WHAT LANGUAGE DO YOU SPEAK?
PROBABILITY FREQUENT PROBABLE OCCASIONAL REMOTE IMPROBABLE
SEVERITY 
I - CATASTROPHIC
II - CRITICAL
III - MARGINAL
IV - NEGLIGIBLE
A
B
C
D
E
1
3
7
13
2
5
9
16
4
6
11
18
8
10
14
19
12
15
17
20
-OR-
Industry Workshop, Portland, OR
March 23, 2011
27
METRICS USED BY CFO’s
Metric
•
•
•
•
•
•
Internal Rate of Return
Net Present Value
Payback Period
Discounted Payback Period
Account Rate of Return
Profitability Index
% Time Used
75.6%
74.9%
56.7%
29.5%
30.3%
11.9%
Source: Graham, John R. and Harvey R. Campbell, “The Theory and Practice of Corporate Finance:
Evidence from the Field”, Journal of Financial Economics 2001
Industry Workshop, Portland, OR
March 23, 2011
28
FINANCIAL METRICS
The financial metrics are built around the concept
of the:
$ Time Value of Money $
That is, a dollar today is worth more than a dollar
tomorrow.
Industry Workshop, Portland, OR
March 23, 2011
29
INFLATION AND DISCOUNTING
An investment can be viewed in two
ways—its future value or its present value.
Inflation
Present
Value
Industry Workshop, Portland, OR
March 23, 2011
Discounting
Future
Value
30
ROI – WHAT IS SAFETY’s PAYBACK?
ROI =
Net Present Value
Present Value of
Project Cost
Industry Workshop, Portland, OR
March 23, 2011
31
MANAGEMENT SYSTEM = SAFETY SYSTEM
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
Achievement
Industry Workshop, Portland, OR
March 23, 2011
32
WHAT DOES A SAFETY GUY KNOW
ABOUT FINANCE?
Return on Investment (ROI): This is calculated by dividing the net present value by the present
value of the project costs. The net present value is calculated by subtracting the present value of
project costs from the present value of project benefits. The model calculates ROI based on
costs, benefits, and the discount rate that are entered by the user.
é( B - C )(1+ n)i ù
ê i i
ú
i
ê
ú
(1+ r)
i=1 ë
û
ROI=
=
iù
t é
C (1+ n)
ê i
ú
i
i=1 ê
ë (1+ r) úû
t
å
å
Industry Workshop, Portland, OR
March 23, 2011
é B (1+ n)i ù t éC (1+ n)i ù
ê i
ú- ê i
ú
i
i
i=1 ê
ë (1+ r) úû i=1 êë (1+ r) úû
i
t é
Ci (1+ n) ù
ê
ú
i
i=1 ê
ë (1+ r) úû
t
å
å
å
33
ROHSEI
One Way To Change The Paradigm.
Return on Health,
Safety and
Environmental
Investment
(ROHSEI)
Industry Workshop, Portland, OR
March 23, 2011
34
BRIDGING FINANCE & SAFETY
BUSINESS TALK
SAFETY TALK
Finance/Operations
Safety/Industrial Hygiene
Earnings/EPS
Accident rates
ROI
Property loss
Payback
Insurance premiums
PVRR
Fines and citations
Internal Rate of Return
No. of people trained
Production rates
Exposure Assessments
Earnings/employee
Net Present Value
Cost Benefit
Industry Workshop, Portland, OR
March 23, 2011
ROHSEI
Bridges
the Gap
Near misses
Behavioral Observations
Audit findings
35
ROHSEI APPLIED TO SMS
2. Double the
cost to implement
for aircaft valued
50% less
Industry Workshop, Portland, OR
March 23, 2011
36
FAA Order
VS 8000.367
FAA Advisory
Circular 120-92
ICAO
DOC 9859
AN/460
34 Pages
40 Pages
290 Pages
Industry Workshop, Portland, OR
March 23, 2011
37
The SMS Table (Top View)
External
Audit
Are risk mitigations
effective? When not, is
the risk re-introduced
into SRM for
re-analysis?
External
Audit
Are data sources
accurate, complete
and timely?
External
Audit
Are policies,
procedures,
and organizations
appropriate?
External
Audit
Are risk
mitigation
strategies
appropriate?
External
Audit
Is there a safety
culture? Is there
adequate training &
communication?
External
Audit
Is there a
Voluntary
Reporting
System?
External
Audit
Are all
hazards
identified?
External
Audit
Are identified
hazards analyzed
© 2006 The MITRE Corporation. All Rights Reserved.
correctly?
Approved for Public Release; Distribution Unlimited 06-1
A ‘JUST’ CULTURE
PROCESS
(EXAMPLE)
‘Just’ Culture
Process
Start
No *
Knowingly violated
procedures?
Was the job understood?
Yes
Was the action as
intended?
No
Are the procedures clear,
concise and workable?
Pass substitution test?
Yes *
No
Yes
Yes
Were the results as
intended?
No *
No *
Yes
Def ective training or
selection experience?
No
Yes *
Yes *
No Blame Error
No
No
Reckless Violation
History of violating
procedures?
Negligent Error
Repeated Incident With
Similar Root Cause
Yes
Sabotage or Malevolent
Act
First written warning;
Final warning and
negative performance
appraisal
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.
Industry Workshop, Portland, OR
March 23, 2011
39
IHST.ORG
Industry Workshop, Portland, OR
March 23, 2011
40
SMS TOOLKIT – CHAPTER 1
Organization & Human Requirements
• Guidelines for using policies and procedures to
achieve desired level of safety
Policies
Procedures
Individual responsibilities
Authority
• Safety Planning Exercise/Template
Industry Workshop, Portland, OR
March 23, 2011
41
SMS TOOLKIT – CHAPTER 1
SMS Planning Exercise
Industry Workshop, Portland, OR
March 23, 2011
42
SMS TOOLKIT – CHAPTER 2
Safety Management System Elements
Theories and philosophy behind core SMS elements in designing an
effective SMS plan.
Internal Evaluation tables from FAA SMS Program Office Assurance
guide
Safety culture assessment (adapted from Dr. James Reason)
Industry Workshop, Portland, OR
March 23, 2011
43
SMS TOOLKIT – CHAPTER 2
FAA SMS Program Office Assurance Guide
Industry Workshop, Portland, OR
March 23, 2011
44
SMS TOOLKIT – CHAPTER 2
Safety Culture Assessment
Industry Workshop, Portland, OR
March 23, 2011
45
SMS TOOLKIT – CHAPTER 3
Guidelines To SMS Implementation
Systematic guidelines to implement an SMS
Checklist for SMS elements
Phased implementation guidelines
Planning & organization
Reactive processes
Proactive processes
Industry Workshop, Portland, OR
March 23, 2011
46
SMS TOOLKIT – CHAPTER 3
SMS Implementation Checklist
Industry Workshop, Portland, OR
March 23, 2011
47
SMS TOOLKIT – CHAPTER 3
SMS Development Chart
Industry Workshop, Portland, OR
March 23, 2011
48
SMS TOOLKIT – CHAPTER 4
Resources for SMS Implementation
Definition of terms
Sample SMS program
CD
Industry Workshop, Portland, OR
March 23, 2011
49
SEEKING THE RIGHT BALANCE
Industry Workshop, Portland, OR
March 23, 2011
50
THE VISION
80% REDUCTION OF HELICOPTER
ACCIDENT RATE BY 2016
12
10
8
6
4
2
0
2006
2008
2010
2012
2014
2016
…CAN BECOME A REALITY !!!!
Industry Workshop, Portland, OR
March 23, 2011
51
GIT-R-DONE !!!!
BE LIKE THE RABBIT
NOT THE SNAKE!!
Industry Workshop, Portland, OR
March 23, 2011
52
CONTACT INFO:
ANALYSIS DATA:
Scott T. Tyrrell
FAA
Co-Chair – Analysis Team
[email protected]
817-222-5121
IMPLEMENTATION:
Larry Buehler
FAA
Co-Chair Implementation Team
[email protected]
202-267-3370
Industry Workshop, Portland, OR
March 23, 2011
Fred Brisbois
Sikorsky Aircraft Corporation
Co Chair Implementation Team
[email protected]
203-605-7747
53