Transcript Document

HeliStat™
An Automated Risk Assessment Tool for
Helicopter Safety Management Systems
Alex Richman
AlgoPlus Consulting Limited
Halifax NS Canada
[email protected]
Leonard MacLean
Dalhousie University
Halifax NS Canada
T SEPT 28
Copyright©2005 AlgoPlus Consulting
Abstract
Safety Management System (SMS)
developers have challenges in:
Becoming proactive
Assessing risks systematically
Prioritizing
This presentation describes HeliStat™, a
computerized system which automatically
performs these functions for mechanical
malfunctions (SDR and MMIR) and
operational incidents (CADORS)
The Evolution of Safety Culture
(and Safety Management Systems)
Systematic knowledge
about operation of
system as a whole.
5. GENERATIVE
safety is how we do business
round here
4. PROACTIVE
we work on the problems that
we still find
3. CALCULATIVE
we have systems in place to
manage all hazards
2. REACTIVE
Safety is important, we do a lot
every time we have an accident
1. PATHOLOGICAL
who cares as long as we’re not
caught
Increasing
vigilance for
potential
hazards
Adapted from Hudson , Leiden Univ, 2004
SMS requires Data
SMS Implementation
There are multiple approaches to SMS
Transport Canada’s Guide is more detailed than
others in specifying the process (TP14343)
Phase 1: Plans and procedures
Phase 2: Reactive system (3.1)
Capture internal data
Monitor/analyze trends
Phase 3- Proactive hazard identification from
external sources(3.2)
Risk assessment (3.4)
Advantages of
Proactive Analysis
1. Because of their larger size, systemwide databases are far more likely to
yield information about events which
might occur later in a smaller fleet
2. Larger data bases are more likely to
reveal trends
3. Benchmark comparisons are possible
Reactive/ Proactive Dichotomy
Reactive
Post facto
“Tombstone mentality”
Investigation of event
Microscopic
“Smoking gun”
Forensic cause
Proactive
Identify potential hazards
Wariness
 General analysis of
system
Macroscopic
Chain of risk factors
Probabilistic
Richman & Murphy 2005
Sources for Proactively
Identifying Potential Hazards
•Company experience: reports, minutes
•Managers’ perceptions
•Workforce opinions
•Audit reports
•Previous hazard analyses
•Hazards identified by other organizations
Safety and reliability data recording systems:
CADORS, BASIS
SDR, MMIR
TC TP 1381E
SDR and MMIR Reports:
Mechanical and Maintenance
Service Difficulty Reports:
•Federal Aviation Administration and Transport
Canada
•Mandated
•“Mechanical problems, defects, malfunctions
affecting safety”
Mechanical Malfunction Information Reports:
•Helicopter Association International
•Voluntary
•Broad definition
Web sites are useful for locating specific reports but are
less useful for risk assessment and trend assessment
Questions about SafetySignificant Events (SSE)
• Are there significant increases over time?
• Are SSEs “consistent” over time (SPC)?
• Which SSEs are more severe and more likely to
occur (risk assessment)?
• Are SSEs more likely in one model or operator?
• Are there historically unusual SSEs?
• Which SSEs should have more priority for further
attention?
• How can we identify SSE precursors ?
GAIN Initial Survey of
15 Safety Officers
– Too much time spent on routine tasks
– Little time for proactive safety efforts
– Follow-up is not always well tracked
– Need outside benchmarking
– Need better analytical tools
– Clear safety strategy infrequent (1/15)
Problems in SMS Analyses
•Complexity of data preparation and updating
•Difficulties in integrating data and software
into IT infrastructure
•Need for computer proficiency
•Acquiring analytic skills
•Lack of time
Lots to Do: Too Little Analysis
SMS Software Requirements
• Easy to use
• Contain proactive data bases
• Identify hazards and assess risks
(Likelihood, severity, trends)
• Indicate priorities
• Generate documentation
• Monitor system continually
Continuous Monitoring and
Automated Analysis
• (Morningstar is a financial example)
– Continuous monitoring of updated databases
– Near-real-time reporting of updates to benchmarks,
trends, rankings, priorities
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– “Pushes” analytic results to user
– Very user-friendly for SMEs
HeliStat™ uses this model
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What is HeliStat™?
A subscription service
for web-based analyses
of mechanical malfunctions
reported to the FAA- Service Difficulty Reports
and to Helicopter Association International’s
Mechanical Malfunction Information Reports
HeliStat™ is Designed for
Aviation Specialists Without
Data Analytic Skills
TM
HeliStat™
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Incorporates multiple databases SDR/MMIR
Near-real-time data
Uses census denominators
Compares models/operators with industry wide
benchmarks
Model specific
Source data accompanies analyses
Prioritizes problems
Shares and tracks reports
HeliStat™ is a System
1 E-mail list for
model by JASC
2
Threat
Matrix
3
Source
report
4 Share Report
5 Out mail list
Priority ALERTS in E-mail
A
B
C
D
A. Risk assessment traffic light summarizes Threat
Matrix
B. Prioritized
C. Recent reports, past 5 weeks
D. Reports not yet viewed
Systematically Defined
Risk Matrix
Significantly above
average
Relative
Likelihood
Below average
Minimal
Hazard
Increased
Reliable and Objective
Risk Matrix Calculation:
•Relative likelihood of occurrence:
Rate in the specified model
Benchmark rate for all the other models
•Hazard is derived from the FAA Severity score
for specific ATA/JASC codes and the Flight
Safety Foundation’s CARE project for classifying
“Nature of Condition” and “Precautionary
Procedures” in SDRs
3 Graphs Combined to Show
Time Trends
Time Trends in One
Risk Assessment Matrix
Risk Matrix Summarized in
Traffic Lights
•Relative likelihood
•Hazard level
•Time Trends
•Recent Increase
Risk Matrices for
Individual Parts
• No limit on number of parts
Individual Narrative Reports
for 6 Months
Historically Unusual Events:
Unique, First, Rare, Cluster
HeliStat™ Overcomes Many Pitfalls
in Risk Assessment
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Objective, quantitative assessment
Specified time span
Indicates trends over time - trajectory
States nature of the hazard
Shows source narratives
Automated without specialist assessment
Sensitive to short-term changes
Continuous monitoring
HeliStat™ System for
Sharing Reports
The user can e-mail the
JASC threat matrix to others
within the organization.
The recipient has full
access to all linked data
for this JASC only
HeliStat™
Share Message
The sender can
state why s/he is
sending this
report, ask a
specific question
or request a
general
comment.
HeliStat™ Maintains Out-Mail List and
Tracks Recipients’ Opening Dates
ALERT keeps track for the sender:
•Recipient
•ATA/JASC code
•Model
•Date sent
Unopened link
•Date opened
HeliStat™ Enables Early
Decision Making
1. For the model and each ATA/JASC component
HeliStat™ gives the user :
• Priority traffic light
• Risk assessment matrix
• Time trends
• Historically unusual occurrences
• Source narratives
2. Users have more time to target their activity
and to explore source data
HeliStat™ Analyses Give
More Time for SMEs
to Use Expertise
Possible Reactions to
HeliStat™ Information
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Problem already known and taken care of
Check fleet now/soon
Consider preventive suggestion
Modify procedure: installation/inspection
Modify inspection: method or frequency
Recommend as audit topic
Place on MEL
Await further information, tickle
HeliStat™- Features
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Point and click – no programming required
Push technology- subscriber specifies model,
frequency of reports
Mechanical problems affecting safety in 2 data
bases(SDR, MMIR)
Near real time- reports daily, weekly, monthly
E-mail for newly reported events,
Risk matrices for ATA/JASC system – 488 codes
Trajectory: likelihood and severity over 3 time periods
Likelihood rates compared to system-wide benchmarks
Likelihood and hazards quantified
Past history since 1/1/1996
Narratives of reports for past 182 days
HeliStat™ Helps a
Safety Culture Evolve Faster
SMS becomes more effective when HeliStat™
overcomes SMS challenges for :
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Becoming proactive
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Risk assessment
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Prioritization
Making SMS more effective helps move the
organization towards achieving a safety culture
HeliStat™ References
1. Rotor magazine (Winter 2004-2005, 42-43
2. Air Beat (January-February 2005), 42-43
3. Aviation Maintenance, December 2004, 34
4. Air Safety Week, September 27, 2004
5. www.helistat.com
Questions ?
AlgoPlus Consulting Limited
Suite 308
5670 Spring Garden Road
Halifax, NS, Canada B3J 1H6
http://www.helistat.com
telephone: 1-902-423-5155
1-888-ALGOPLUS
fax:
1-902-484-7061
email:
[email protected]