1 joint helicopter safety implementation team (jhsit) sms presentation june 6, 2007 sao paulo,...
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JOINT HELICOPTER SAFETY
IMPLEMENTATION TEAM (JHSIT)
SMS Presentation
June 6, 2007
Sao Paulo, Brasil
Greg WyghtVice President Safety & QualityCHC Helicopter CorporationCo- Chair, [email protected]
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• 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.
Introduction
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• 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:• People• Training• Hardware & Software• Policy & Procedures• etc
• It is not some kind of giant IT ‘system’ you can buy off the shelf
What is a Safety Management System (SMS)
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SafetyAchievement
Finance Plan
Targets & Objectives
Budget
Accountabilities
Levels of Authority
Procedures
Safety Plan
Targets & Objectives
Budget
Line Management Authorities
Accountabilities
Procedures
Financial Management System Safety Management System
AccountantsAuditPlan
Checks and Balances
AuditsBalanceSheets
Audits
Monitoring/Line Checks
Audit PlanSafety
Committee
Financial Management vs. Safety Management
Comparing Two “Systems”
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CRM
Audits
ChecklistWorksheets
Training
Plan
Alcohol& Drugs
Policy
Audit
Maint .Schedule
Safety
Drills
Policy
FAA
Regs .
No Structure STRUCTURE
ERPs
Process /Do
Policy /PlanHSE
Policy
Security
QA
Ops Manual
Plans
Task /Check – Feedback - Action
A Framework for Safety Management
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ManagementSystems
Technologyand standards
ImprovedcultureIn
cid
ent
rate
Time
“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.”
Goal: The Reduction of Accidents
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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?
Some Elements of an SMS
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Proactive Risk Management
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“SMS Tools” that will be Available
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1. It makes good business sense for long term growth2. Widely recognized as best practice3. A contractual requirement for many of your
customers4. Increasingly becoming a regulatory requirement, for
example:• 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
Why is Having an SMS Important?
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• Before we commence an activity where we are implementing a change we need to proactively:• 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.
3 Main Processes: #1) Risk Management
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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) $ 0
Cost of Parts (2 per year) $20,000
Annual Cost, if nothing changed $20,000+
Cost of the “Intervention” $-10,000
Total savings in the first year $10,000
Basic Cost Benefit AnalysisData-Driven Safety Initiatives
3 Main Processes: #1) Risk Management
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• 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:• 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)
3 Main Processes: #2) Monitoring
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3 Main Processes: #2) Monitoring
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• 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.
3 Main Processes: #3) Safety Reporting
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3 Main Processes: #3) Safety Reporting
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• 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
Managing Human Error must be part of an SMS
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“HFACS” Analysis ToolHuman Factors Analysis and Classification System
OrganizationalInfluences
Resource Management
OrganizationalClimate
OrganizationalProcess
UnsafeSupervision
Level ofSupervision
PlannedActivities
Rules & Regulations
ProblemCorrection
OrganizationalInfluences
UnsafeSupervision
PreconditionsFor Unsafe Acts
Unsafe Acts
PreconditionsFor Unsafe Acts
Conditionsof Personnel
Working Condition
s
Practices of
Personnel
Unsafe Acts &Conditions
Errors Violations
DecisionBased
TechniqueBased
RoutineViolation
Exceptional Violation
Attention/Memory
KnowledgeBased
PerceptualError
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• 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
An SMS only works within a “Just Culture”
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Was the Job understood?
Sabotage or Malevolent Act
Were the results as intended?
Were the actions as intended?
Knowingly violating Procedures?
Pass Substitution Test?
Defective Training orSelection Experience?
Negligent Error
History of Violating Procedures?
No Blame Error
Yes
Yes
Yes
No
No
No
Yes
Are Procedures Clear and Workable?
Reckless Violation
* **No No
No
No
Yes
Yes
YesYes
*No * *
Repeated Incidents with Similar Root Causes
Increasing Individual Culpability / Diminishing Individual Culpability
Severe Sanctions
Final Warning and Negative Performance Appraisal
First Written WarningCoaching / Greater SupervisionUntil Behavior is Corrected
Documented for thePurpose of PreventionAwareness and Training will Suffice
Start Here
QACheck
“Just Culture” ModelRules of Fair Play for Managers
*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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Risk Management(e.g.: hazard identification,risk assessment,JSA, safety cases etc)
Foresight
Monitoring(e.g.: supervision, CRM, Inspections, audits, HUMS, HOMP, Behavioural Based Program etc)
Oversight
Safety Reporting& Investigation
Hindsight
Insight
3 Process Lead to Insight
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• JHSIT’s goal is to deliver simple tools for these three processes, allowing small operators to:• 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
Why is Insight Important to Leaders?
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Obrigado!
SMS Team Lead
Ray WallDirector Quality & SafetyBristow Group, Western [email protected]
Hooper HarrisUS DOT/FAA Commuter, On Demand, & Training Center Branch202-267-3437 (USA)[email protected]
Gregory F. WyghtVice President, Safety & Quality CHC Helicopter Corporation 604-232-7428 (Canada)[email protected]
International JHSIT Co-Chairs