08 the operator point of view easyjet s.stewart 08 1002

7/28/2019 08 the Operator Point of View EasyJet S.stewart 08 1002

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Fatigue Risk Management integrated within a

Management System

Captain Simon Stewart

SMS Development Mgr

Deputy Director Safety & Security


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Some Facts

1 base

3 airports

2 routes

2 leased aircraft

Virtual airline!

20 bases103 airports26 countries398 routes165 aircraft

39 million pax7000 employees

1995 2008


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Safety through intelligent risk management

Safety is our business

4 Everyone committed to maintaining a safe and secure operationalenvironment for our customers, our staff, and our shareholders

4 Our goal is more that just regulatory compliance, our focus isproactive risk management, underpinning the needs of the business

in line with increased crew utilisation, the overall operating environment has

become significantly more complex, leading to an increase in levels of operational

risk.UK Civil Aviation Authority 2007


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EU Ops compliance is not enough


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easyJ et has continued to lead thefield in SMS

The Regulatory environment has

changed EASA has arrived

easyJ et is shaping the future ofsafety management in aviation

J ust Culture

Integrated management and

safety system

Domain of the SMS

Provides risk transparency tomanagement and the

regulator

Binary regulation. You areeither in compliance or youare not.

Domain of the qualitydepartment

Performance RegulationAdministrative Regulation

Total System Safety

Maintaining regulatory compliance and operating safely


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Management System Model

QA or Safety Management Systems

Simplest form - closed loop management system

Plan

Act

Check

Do

Plan to do something

Take actions

to improve

as required

Do the thing

you planned

Check what you did worked as planned

easyJ et


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Safety Management System Model

Active Safety Management

CommunicationCommunication

Corporate Strategy

Safety Performance

Measurement

Management

Review

Investigation

and Follow-up

Incident reports Risk Assessment

Line Management

of Operational tasks

Competence and

Accountability

Safety Plan

Safety

Objectives

Business Principles

& Safety Policy

CultureFeedback

Check

Do

PlanOperational Standards

Safety Monitoring Verification and Audit Risk Management

Review

Remedial Action


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We manage risks inherent in the system

Key risks:

4 Cultural differences

4 Operational environment

4 Crew experience gradients

4 Fatigue

SAFETY

ENGINE

easyJet

SAFETYRADAR

SIRA

StrategicDecisionMaking

SystemDefenceAnalysis Tactical

DecisionMaking

Organisa-tional

Learning

Self- Regulation

System Risk

Assessment &

Process Analysis


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Safety Culture policy

4 In order to develop organisational learning easyJet promotes a

just culture within which it is accepted that people who

undertake actions, make decisions or allow omissions, takinginto account their training and experience, are not punished

when the desired outcome is not achieved; but where gross

negligence, gross misconduct and destructive acts are not

tolerated.

4 I believe that in formulating this statement of easyJ et Safety Policy we build on andreflect our commitment to the Five Pillars of easyJ et Policy that our corporate goalsare best achieved through embodying the principles of :

4 Safety Teamwork Passionate Pioneering

Integrity


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Policy Implementation

easyJ et will maintain an evidence-based Safety ManagementSystem that proactively and continuously delivers safetyeffectiveness and operational integrity within a risk controlled

environment.

4 Effective reactive response to incidents;

4 Proactive risk analysis to maintain system integrity;

4 Risk trending that evaluates control strategies;

4 Explore system risks for future business strategy;

4 Real time knowledge of System Dynamic Risk;

4 Communicate dynamic risk state in standardised format;

4 All management levels have clearunderstanding of system risk.

This requires the establishment of an open framework of linkeddatabases


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Tactical and strategic risk oversight

Risk Management

Rostering

Environment

Route riskIndividual

differences

Hazardous

Event/s

Reactive

Proactive

ExploratoryEvaluative

Time cri tical

RiskCO

N

T

R

O

L

C

O

N

T

R

O

L

Risk

Precursor

examples

Detection Notify &

Inquire

Adjust

system

Sensory Network RiskAssessment


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Balancing

Hazards

Commercial

Objectives

Safety

Criteria

Operationa

l Criteria

Safety

Managem

ent System

Fatigue

Fatigue: Balancing Hazards againstOperational Criteria in Pursuit ofCommercial Objectives

Geneic Hazards

Airline Hazards

Balancing operational cri teria and performance cri teria in pursuit of commercial objectives


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Where does FRMS operate in the business

SIRA


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What You Can See You Can Avoid


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How do you measuredetect and investigate

fatigue?


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Incidents & SafetyPerformanceinformation

RiskThreshold

Events

Undesirableindications

Encode, Risk

Classification & notify

D

E D C C

E E E E

A A

B

E

C

D C

B

D

D

E

C

C B

B

D

Investigation

Data Analysis(Including sample data

extrapolation and

frequency consideration)

Feedback to

individual andorganisation

HAZID/OP AnalysisProactiveassessment ofSignificant changesto system oroperations

SignificantHazards

Risk Assessmentidentified hazards from

investigations and adversetrends

Risk Performance

Reporting(Historical trends and predictions)

Day to day and strategic risk trends

AllData

AllEvents

Risk MgtStakeholder decisionsagainst risk treatment

options

reactive

Organisational learning

ImplementationActions

Monitor, track &

evaluate actions

Hazardinvestigation

easyJ et SIRA-ECAST safety cycle 2008


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Fatigue Risk Detection


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Increasing

Trust/Accountability

EVENTS are risk triaged by the Safety Data Team

D 30 C 60

A 100

B 90C 60

B 85

Abnormal human

interventionProvidence

Defences that

avoided

consequences

Minor accident with

some injuries and

damage

E 1 E 5 E 10 D 15

E 8 E 10

Degradation of safety

margins but with littleconsequence

Normal InterventionNon-normal safety

nets

Limited accident

sceanario with limited

loss of life

Major accident with

significant loss of life

C 40D 12

D 15 C 50

Reasonable worst

case potential

consequences

Event Category and Risk Value


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Fatigue Indicators LT Trend 12 month chart April Prev month 3 month 12 month

Commute 8% 7% 5% 6%

Delay(s) 331% 21% 24% 27%

Early Start Time 38% 38% 22% 28%

Early to Late Transition 8% 21% 14% 10%

Health 8% 10% 8% 7%

Home Issues 38% 10% 12% 17%

Home Rest 331% 14% 23% 24%

Hotel Rest 38% 17% 20% 12%

Insufficient Rostered Rest Time31% 24% 28% 26%

Late Finish

38% 28% 32% 29%

Late to Early Transition 8% 0% 3% 4%

Long Duty Day

54% 55% 59% 54%

Long-Term Fatigue 23% 31% 20% 16%

Positioning 8% 21% 16% 9%

Roster Disrutpion38% 24% 26% 23%

APRIL CONTRIBUTORS TO FATIGUE

(AS % OF TOTAL FRFs RECEIVED FOR MONTH)

Crew citedcontributors to

fatigue

Fatigue Events: Example fatigue report form data representation


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Survey data is reviewed as part of data collection

SurveyDatacollectedandanalysed

Duration of naps

Crews comments and suggestionsFrequency of naps

CommuteRisk (severity x frequency)Duration of sleep

Morningness/eveningnessFrequency with which eachcontributor causes fatigue

Fatigue risk(severity x frequency)

Roster preferenceSeverity of fatigue causedby each contributor

Frequency of fatigue-relatedperformance impairment

Demographic data including age,base and experience

5 most influentialcontributors identified

Severity of fatigue

OtherContributors to fatigue

For each day of the roster


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EVENTS will be investigated, systemic causal factors analysed

Review AQD investigations &actions for risk keywords

per event category

Secure information:Data gathering, tabulation against scope

Event & conditional

factor analysis

SME triageClassification risk grading

& notification

Event detection

Sensory network

Define scope, context

& investigation team;Document risk keywords/event

Select investigation toolsfor investigation context

& apply

Document & rank

systematic causal factors &recomendationsfrom investigation

Is safety report accurate?

Case based reasoning:reuse (in context) similar event

investigation findingsin AQD?

Toolbox directory

ToolContextPeopleTask

output

SIRA Strategic & tactical decision process

against risk treatment options (cost and impact)

Allocate, communicate, implement, evaluate

SIRAInvestigation process

Y

Y

N

N

TU Delft, Lund, City Universities 2008


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Example tool: Control Change Analysis

NRI-TUDELFT


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Bowtie Model: Barriers and controls of fatigue risks are

examined

Hazardous or Top

Event

Hazard

Hazardous or Top

Event

Hazardous or Top

Event

Hazard

Identify assess

control recover


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Example Fatigue Investigation FindingsExample Fatigue Investigation Findings

Fatigue Investigation Results - Example

0 5 10 15 20 25

Night Stops

Health

Positioning of SIM duties

High Cumulative Hours

Hotel Rest

Home Issues

Roster Disruption

Sub-Optimal rest periods

Elongated Duties

Commute

Transition

Inadequate rest (FAID)

Operational Hassle Factors

Block Structure

ContributedtoSymptomsofFatigu

e


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How do you managefatigue risk?


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FRMS Team will allow management to assess options and rank risks for continuousimprovement

People, environment, assets, reputation

Consequence

Intolerable

Minor damage

Incorporate risk reduction measures

Frequency

A B C D E

Never heard of inindustry

Occurs frequentlyin company

Occurs several

times per year in

company

0

People Assets ReputationSeverity

Limited impact

Considerableimpact

Manage for continuous improvement

Environment

National Impact

No impact

Localised effect

Slight damage

No effect

Has occurred inindustry

Has occurred incompany

Internationalimpact

1

2

3

4

5

Slight impact

Extensive damage

Slight effect

Minor effect

No injury

Localised damage

Major damage

No damage

Major effect

Massive effect

Slight Injury

Minor injury

Major injury

1-3 fatalities

multiple fatalities


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We manage the risks inherent in the system

Board

Safety Review

Board

Airline Safety

Action Group

Departmental

Safety Action

Group

Chair: CEO

Chair: AOC

Accountable Manager

Chair: Post Holder

Director Safety and Security

RiskTransparency

J ust Culture


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Intolerable region

Acceptable

region

The risk is acceptable

as it currently stands

The risk is

unacceptable andrequires improvementaction

Tolerable regionIf the risk can be mitigated, it

is acceptable.

Risk reduction should besupported by a cost benefit

analysis.

Towards

As

LowAs

ReasonablyPracticable

ALARP

-Technical feasible

-Reasonable to do

-Affordable

Risk Management

The Risk Zone

The broader the triangle to bigger the risk


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Decision making process

Structured decision making process (after Failing et al., 2007)


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Complian

cewith

Regula

tions

CompanyStandards

Contracte

dRequirem

ent

BestPractice

A

steptoFar

Mandatory Level

Tolerability Level

Screening Level

Reducing Risk

Increasing Costs $$

Optimal PointALARP

Gold-plating Level

ALARP Model


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easyJets fatiguemanagement cycle


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Achieving commercial objectivesAchieving commercial objectives

OperationalPerformance Criteria

SafetyPerformance Criteria


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easyJet Key Performance Indicators

4 easyJ et operates 25,000 Flights per month and has a safety occurrence reportingrate of 45 per 1000 operated sectors against an industry standard of between 20-25/1000 sectors. Of this Fatigue reporting rate is between 50-60/month. This reflectsa strong safety cultural environment amongst our crew.

4 The safety department has 100% Flight Data Monitoring capture rate for systematicproactive operation oversight. FDM event traces support Fatigue event investigations.

4 easyJ et FRMS KPIs are linked to rostering and operational performance. They

include roster fatigue modeling risk rating, duty discretion, rostering violationreporting, roster stability, air safety reports (fatigue contributors), fatigue reportingrate, commute risk events (domestic & international), roster workload risk events,transition duty changes and crew error events (fatigue antecedent contributors)

4The airline reviews strategic safety performance against an overall computed riskvalue combined from Flight, Ground and Engineering operations. This is compared toa reference value so we can detect strategic practical drift and adverse tacticaltrends.


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Informing the decision making process

This system will enhance the CEO andexecutive teams ability to keep theirfinger on the risk pulse of the easyJ et

operation

SRB/AMB can make timely and better

informed decisions

We can target risk with laser accuracyand cost effectiveness, minimisingour risk signature


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Safety Protection & Cost Benefit

Indirect Cost

Benefits of Safety

Process optimisation with

evidenced safety

protection

Lean Initiative

Kaizen/6 sigma

Regulator fees

Linked to oversightRequirement of

business model

InsurancePremium linked

to risk signature

Self-governance with effective SMS capabil ity


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easyJet continuing to invest in safety

easyJ et strives to remain at the cutting edge of risk managementcapability to

meet easyJ et operational risk oversight and future regulatory requirement

4 Our strategic partners:

4 Regulators4 Rule Makers

4 EU HILAS programme

4 NASA

4 Academic Institutions

08 the operator point of view easyjet s.stewart 08 1002

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