9 - marcou+vernay from ssp to pbo

11Direction généralede l’Aviation civile

This image cannot currently be displayed.

Direction de la sécuritéde l’Aviation civile

EASA annual safety conference 2012

The DGAC approach

From State Safety Programme

to Risk Based Oversight

André VERNAY Bernard MARCOUHuman risks programme manager Manager, Airworthiness

and Operations Directorate





Abstracts

- SSP as a tool for Risk Based OversightI/ Safety measurement and integration method

II/ Non Compliant Approach : a good example of common incident overlook and fatalities exploration

III/ Authority and operators dialogue

- SSP as a tool for RBOI/ Building an oversight programme from SSP priorities

II/ Checking mitigation measures

III/ Lessons learnt





I / Safety measurement and integration

Established by the level of confidence between stakeholders at every step

- Statistics and classification- Risk prioritization via a driving committee - Risks portfolio

to establish the basis of the SSP via a Top-Down process

- Actors implication- Safety symposium conclusions- Guidance materials- Overview actions (training, flight checks…)

to build the action planvia a Bottom-Up process





Lines: Undesirable events

Columns:Accident types





II / Non compliant approaches (NCA)A stabilisation point on final leg is no more sufficient (operators dialogue and incidents overlook) to prevent :

- Hard landings,

- Bad quality of Going Around procedures after a renunciation

- Pilots’ low availability is responsible for risk transfer

- Within the last 25 years : 6 fatalities + 3 serious incidents with NCA in France and neigbourhood

- No fatality with CA in the same area





From safety data to risk coordination : a joint safety improvement between ATC and crews

Warning : non compliant approach mitigation procedure may inducea new threat, i.e. High Energy go around





III / Authority and operators dialogueFavored by a sharing policy and a feed back process

Despite a very low risk knowledge (few incidents or fatalities), an internal process can exist (reactive policy).

The SMS guide requires a preventive risk analysis (proactive policy)

Priorities and particularities have to be taken into account to ensure efficiency.

Reaching maturity requires time and an authority follow up policy to keep it « alive ».





State safety programme to Risk based oversight

Present situation:

•Each inspector has his own professional background and safety priorities.

•The safety impact of each piece of regulation w.r.g. to the risk matrix is not straightforward. Difficulty to classify severity of non compliance findings.

•Result is emphasis on formal compliance rather than on risk assessment






RulemakingComply

Check compliance

Correct findings

The Deming cycle closes on compliance to the rule and not on safety performance

Formal compliance to safety regulations through « quality control » checks is not sufficient alone to upgrade the operating safety to the desired level.

Available resources utilisation is not optimised for safety.






The acute feeling that compliance with the regulation alone may not be the proper course of action to mitigate all the risks has led ICAO to develop the Safety Management Systems.

The SMS approach requires the operators to:

1. Collect risks data

2. Classify threats according to operation exposure

3. Define and apply appropriate mitigation actions

And ask the States to do exactly the same thing at higher level to define their Strategic Safety Plans






SSP Risk portfolio

Do they match?

The DGAC is aware that a split between the safety objectives of the authority and that of the operator may exist.

Safety improvements can only be achieved through a collaborative effort of communication and data sharing with the operators and a continuing dialogue on selection, prioritisation and mitigation of risks.

Operators Risk portfolio






Summary of SMS implementation by the French operators as of to date.

• Effective from 1st January 2012

• Structures are mostly in place: SMS manager, incident reporting system, risk analysis procedures

• Risk matrix are much easier to define on scheduled operations or non scheduled on predefined areas of operations (operating conditions, destination and routes are known and predictable). Resources were available and the SMS is an evalution rather than a revolution of existing structures.

• Difficulties for on demand non scheduled operators due to lack of predictive data and time constraints on destinations. Market pressure results in missions being accepted and executed without any preliminary risk assessment.

• Strong demand of authority assistance by small operators on predefined risk assessment and mitigation measures.

• SMS oversight is not straightforward. Shall we focus on quality check of SMS procedures or shall we also assess the safety performance of the operator, i.e. the SMS efficiency ?






Our ambition is to close the Deming cycle on safety performance through the Risk Based Oversight

Operators to consider them in their SMS

Define prioritised risk mitigation actions

Check application through the SMS oversight programme

Revise action plan where necessary





What priorities: sometimes too much safety information, sometimes not enough depending on the kind of operations






Examples of current oversight priorities:

• Ground de-icing procedures (loss of control)• Adverse weather conditions: approach briefing (runway excursion)• Manual flying skills (loss of control)• High energy go around• Check of taxiing procedures (runway excursion)• Lithium batteries fire protection• Flight data insertion: crew crosscheck procedures (abnormal use, loading errors)






OVERSIGHT TOPICS

ORG ORG-SUP Organisation and operation supervision

ORG-SQ Quality System

ORG- DOC Documentation

SV SMS- Accident prevention and flight safety programme

PPV Flight preparation-Minimum, performance-Weight and balance-Fuel- Flight information

ESC Ground assistance Stopover

VOL Flight inspections

EQP Aircraft equipment

ENT Maintenance

PNT Technical crew training

PNC Cabin crew training

TVR Duty time and rest

SUR Security

MD Dangerous goods

ETP ETOPS

AH Helicopter special operations

DGAC has elected to integrate predefined safety checks in its bi-annual oversight programme






• DGAC internet website: Risk portfolio, safety symposiums proceedings, recommended good practices

• DGAC safety bulletins

• Annual Training recommended practices guide

• Operation manual inspectors review guide

• OPS inspectors manual

• EASA SIBs

Communication tools:






• Data collection1: Safety recommendations and good practices data base on large transport airplanes operations is huge and redundant.

• Data collection 2: data base on mid/small size aircraft operations is scarce.Effort is necessary to elaborate priorities and a consistent set of risk mitigation measures adapted to commuter operations.

• Priorities setting: the challenge to set up an action plan based on predefined risk priorities is to resist to the “last arrived, first served” syndrome. Do not change targets too often but know when it is time to change them. Visibility is the key word.

Challenges:






•Adapt to the real world and accept that some operators are less exposed to some categories of risks.

• Communication and knowledge. The national SSP risk matrix is public but who can say that it is actually taken into account by the operators? Action plan on risk mitigations measures should be known well in advance. Every year a guide of recommended practices on recurrent training is issued by the DGAC.

• There are several national SSPs risk portfolios in Europe: which one to choose?

• Inspectors training: capability to explain why an organisation is exposed to a given risk and why additional mitigation actions are necessary, is essential.

Challenges (cont’d):






Thank you for your attention !


9 - marcou+vernay from ssp to pbo

Documents

safety data

oversighti safety measurement

joint safety improvement

risk coordination

risk transfer

low risk knowledge

operators dialogue ssp

ssp prioritiesii