ASAP: A PROACTIVE APPROACH TO SAFETY RISK MANAGEMENT

BY RUSS LAWTON & BRYAN BURNSAIR CHARTER SAFETY FOUNDATION

Air Charter Safety Foundation (ACSF)

The Air Charter Safety Foundation is a 501(c)(3)non-profit organization, whose vision is to enable thehighest levels of safety in personal and businessaviation.

Where we’ve been: A brief history

Evolution of Safety

The Safety Eras: The Machine Period The Human Period The Organizational Period

From Mike Doiron, Moncton Flight College, New Brunswick

Evolution of Safety

Machine Period: 1920’s – 1960’s

Fly – Fix – Fly

Quick development of safety fixes

Improvements to engines, airframe, systems, design and airworthiness standards

Responded to high incidence of mechanical based accidents

“Blame and Train” philosophy

Evolution of Safety

Human Period: 1960’s – 1970’s

• Response to the 70-80% of “human factor” accidents

• Focus on human / machine interface

• Ergonomics, crew resource management, pilot decision making

• Emphasis on inter-relationships

• Improved selection, training

Evolution of Safety

Organizational Period: 1980’s – 1990’s

• Focus on organization and management

• Response to underlying factors which “set up” accident potential

• The Reason Model of organizational failure

• Attempt to explain why accidents continue to occur and identify organizational influences

Organizational Influences

James Reason’s “Swiss Cheese” Model

Decision-Makers

Organizational Preconditions, i.e., Company CultureLine Activities

Adapted from “Human Error: Models & Management,” Dr. James Reason, University of Manchester

We are Risk Managers

The Solution

SMS = Some More Systems

SMS: Four Components

1. Safety Policy

2. Safety Risk Management

3. Safety Assurance

4. Safety Promotion

SRM & Safety Assurance

2.Safety Risk Management (SRM): A formal system of hazard identification, analysis

and risk management is essential in controlling risk to acceptable levels.

3.Safety Assurance: Once controls are identified, the SMS must assure

they are continuously practiced and continue to be effective in a changing environment.

Aviation Safety Action Program (ASAP)

A confidential, voluntary safety event reporting system that provides a near consequence-free environment.

ASAP is part of robust SMS and fosters a positive safety culture.

Designed to identify critical incidents before they become potential accidents.

ASAP Philosophy

Fix the problem Don’t shoot the messenger

Why ASAP?

Enhancing and improving overall safety performance depends on:

• Data collection and analysis

• Collaboration of data to identify system failures and human errors that are precursors to accidents

• Identify & implement corrective actions in order to reduce the potential of a recurrence

Why ASAP?

Review patterns and trends

FOQA: What happened?

ASAP: Why did it happen?

Why ASAP?

• We can learn from the mistakes of others through publication of de-identified ASAP events

• Enhances and improves safety within our industry

• Has a proven track record

• Builds trust: Company, employees and FAA

ASAP History

1997: FAA launches demonstration ASAP program with Part 121 air carriers.

2000: FAA makes ASAP a continuing program and encourages all Part 121 air carriers to participate.

2005: Part 135 operators and 91K management companies allowed to participate in ASAP.

ASAP History

2005: Medallion Foundation approved by FAA as third-party ASAP program manager for Alaska operators.

2012: ACSF approved by FAA as third-party ASAP program manager.

2013: Part 91 operations join ASAP.

ACSF ASAP Partnership

Cooperative effort between: Company Participating employees (pilots, mechanics,

flight attendants, dispatchers, schedulers, etc.) FAA Air Charter Safety Foundation (ACSF)

Agreement between Company, ACSF and FAA is through a Memorandum of Understanding (MOU)

Current ACSF ASAP Participants

FAA Eastern, Great Lakes, Southern, Southwest & Western-Pacific Regions

13 Part 135 Operators

9 Part 91 Flight Departments

Partnership: Industry Perspective

An uneasy feeling

True partner-

ship

FAA: Here to

help

Partnership: Regulator Perspective

Fundamental Premise

Voluntary safety programs must incorporate incentives:

• The FAA must agree not to pursue legal enforcement action based on voluntarily submitted information.

• Companies must agree not to pursue disciplinary action based on voluntarily submitted information.

Fundamental Premise

Challenges:

• Culture− An organization's culture is a set of consistent beliefs, values, norms, attitudes, and practices among its employees.− Successful integration requires senior management to take ownership of the process and communicate that commitment throughout the organization.

• Education

Misconception

It’s important to understand that ASAP does not tolerate reckless workmanship or employees who take short cuts when performing their work.

How Does ASAP Work?

Four phases to ASAP:• Reporting• Research and Analysis• Event Review Committee• Follow-up and feedback

Reporting Process

Employee completes electronic ASAP form to report: An observed safety problem Violation or potential violation of CFRs or

company SOPs Any incident related to safety of flight

Report form is accessed on secure web portal

Must not involve any of the exclusionary items in accordance with the MOU:

“The Big 5”1. Criminal Act2. Substance Abuse3. Controlled Substance4. Alcohol5. Intentional Falsification

Or an Intentional Disregard for Safety

Reporting Process

Research and Analysis

All reports are researched for relevant information and prepared for review by the Event Review Committee (ERC).• Research

• Secure copies of charts, diagrams, flight plan, etc.• Gather additional information from submitter if

necessary.

• ERC Preparation• All reports are de-identified• All reports stored in secure database

Review Process

An Event Review Committee meets and is composed of: • Company Management • Employee Representative (pilots, mechanics,

dispatchers, etc.) • FAA Inspector assigned as ASAP Representative • ACSF ASAP Manager acts as facilitator

ERC Process

ERC consensus is required for all recommended corrective actions and report close-outs

The focus of the ERC is to determine root-cause and improve safety, NOT to punish individuals

Reports

Sole Source: The only information about the event comes from the pilot’s report(s). (Majority of ASAP reports.)

Non-Sole Source: Information obtained from a source, other than the ASAP report, that indicates a violation of the FARs has occurred, i.e., altitude deviation.

ERC Process

Report Acceptance:• Submitter working as an employee at time of event.

• Does not fall into “The Big 5” category

• Timeliness (except sole source)

• Inadvertent

• Does not involve intentional disregard for safety / reckless conduct

• Acceptance is reached by consensus (unanimous agreement) of the ERC.

Excluded Reports

Excluded Reports

Timeliness

The employee must submit the report in accordance with the time limits specified by the MOU.

Within a time period following the event, i.e., within 24 hours of the end of the duty day in which the event occurred.

Within 24 hours of having becoming aware of possible noncompliance with the CFRs.

• If a report is submitted later than the time period, the ERC will review all available information to determine whether it is appropriate in the best interest of safety to accept the untimely report.

Received ASAP Report

Was Submitter Acting as Employee

Criminal Substance

Abuse, Alcohol,Controlled Substance, Falsification

Meets MOU Timeliness

Criteria

Inadvertent & Not Intentional Disregard for

Safety

ERC Consensus on

Acceptance Requirements

INCLUDED REPORTS

EXCLUDED REPORTS

Refer Event to FAA for additional

Investigation

Refer Report to FAA Office

Refer to Regional Flight Surgeon. FAA

ERC Representatives

Follows FAA Flight Surgeon’s Advice

All Evidence of Violation Found

Through Report?

Lack of Qualification?

Sole SourceReport

Non-Sole Source Report

Sufficient Evidence?

FAA Administrative

Action

Corrective Action

Completed?

Yes No Yes Yes

Yes

No No

Yes

Yes

No

Aviation Safety Action ProgramEvent Review Committee

Operating Process

Yes

No

ACCEPTANCE

RESULT

DISPOSITION

ASAP REFERRALS

No

Process Owner: Manager ASAP Author: Randy McDonald File Number: 119032 Version: 1.0 Revised: 07/01/10

Lack of Medical Quaifiaction?

ERC Corrective Action?

EDP Matrix Risk Low?

Written or Oral Counseling

Yes

Yes

Yes

No

Yes

No

Yes

No

No

No

ERC Consensus on Corrective

Action?

FAA Member Decides

Was there a Violation?

No

No

No

Yes

Yes

FAA Letter of No Action

ERC Response

Yes

ERC Process

• Review and analyze reports• Determine if Sole or Non-Sole Source• Identify actual or potential problems identified

from report • Propose a corrective action for identified problems• Report close-out• Review of past corrective actions.

ERC Process

ERC consensus is required for all recommended corrective actions and report close-outs.

The focus of the ERC is to determine root-cause and improve safety, NOT to punish individuals.

ERC Process

Corrective Actions – Non-Sole Source

• Administrative Action:

• Letter of Warning – No ERC Corrective Action issued

• Letter of Correction – ERC Corrective Action issued

ERC Process

Administrative Action: Remains on local record for 2 years – at which

time it will be removed. Does not become permanent record. Is not discoverable through PRIA or FOIA.

ERC Process

Corrective Actions: Non-Sole-Source

• Informal Action• Oral Counseling: No ERC Corrective Action issued• Written Counseling: ERC Corrective Action issued

• Letter of No Action: ERC determines that there is insufficient evidence of a violation.

ERC Process

Corrective Actions: Sole Source:• ERC closure letter to the submitter – No Action

• Coaching / Mentoring from ERC

• Human Factors / CRM Training

• Altitude Awareness Program

• Aircraft Systems Training

• Technical Training

• Simulator

Follow-Up

• Recommendations and corrective actions are tracked to validate compliance.

• Feedback to the employees:

• Safety newsletter, bulletin, etc.

• Employee meetings/briefings

• Initial and Recurrent Training

• Awareness Items

• Classroom discussion of select events

• Simulator scenarios

Top Five Reported Categories/Events

Pilot: 1. Altitude deviation 2. Course deviation 3. Company procedure deviations 4. Maintenance operations 5. Manuals/logbook paperwork

Top Five Reported Categories/Events

Scheduler & Dispatcher: 1. Company procedure deviation 2. Dispatch operations 3. Load planning/ MX operations 4. Manuals/logbook paperwork 5. Weather

Top Five Reported Categories/Events

Maintenance: 1. Company procedure deviations 2. Manuals/logbook paperwork 3. Maintenance operations 4. FAR deviations 5. Ramp Safety

Top Causes

Communication: Pilots & ATC

Communication: Between Pilots

ATC Complications/Errors

Policies/Procedures Issues

Human Factors Issues

Corrective Actions

Checklist made or changed: 15%

Educational products developed: 21%

Recognition of existing or potential program/safety threats: 31%

Manual created or changed: 33%

ASAP Mitigates Risk

Identifies hazards & analyzes risks

Seeks corrective actions

Educates and increases employee awareness

Measures overall system performance

Ensures accountability

ASAP Final Thoughts

Fixes safety problems

Protection from FAA action

Proven history of improving & enhancing safety

Everybody wins: company, employees, passengers and regulatory authority

Safety Assurance

“However beautiful the strategy, you should occasionally look at the results."

-Winston Churchill