ihst - helicopter hazard management

Hazard Management

IHST/EHEST Safety Workshop - London

25 September2013

• Already have an SMS?

Goal for this Session

Help you make your SMS “live” in the hangar and in your helicopters rather than

sit in a book on a shelf.

Session Plan

• Discussion• Exercises

• Your potential goals:– Comply with regulations– Prevent accidents– Prevent “losses”– Manage risks– Sleep better at night

• Let’s assume you want to achieve all these goals.

• Where should be start?

Step 1 – Set Goals

Goal & Policy Statement• The goal

– Manage all significant risks to ALARP

– No harm to people, property or the environment

– “Goal Zero” or “Target Zero”

• Supporting policy statement– Sets out the company leaders’ commitment

– References a plan with • specific objectives,

• organisational structure,

• processes and accountabilities,

• and specific targets.

– Describes the desired safety culture and contains a “Just Culture”statement

Indentify and Mitigate Key Hazards

• Brainstorm • Assess• Mitigate

– Barriers

– Controls– Recovery Measures

Step 2 – Identify & Record Hazards

Networking, blogs

Safety reporting system

QA findings

Flight Data Monitoring

Incident investigations

Safety Observation Process

Trend analysis

Accidents reports for own A/C types

Training feedback

Recordable occurrences

Brainstorming

Information exchange

Industry Bodies/committees/forums

Generic Hazard Lists

Accident reports for ownregion/country/location

Accident reports for own role

Hazard/Risk Management Process

SCOPE OF ACTIVITY

IDENTIFY AND RECORD HAZARDS

RISK ANALYSIS

Step 3 – Risk Analysis• Assess risk associated with each hazard to:

– Determine if action is required

– Prioritise first efforts

• Use a Risk Assessment Matrix (RAM) to give an objective score to a subjective topic

– Standardise across the organisation.

– Make risk assessments visual.

• Red is difficult to ignore and loosens budget strings.

Example:

• Loss of control of a passenger on an offshore helideck. Entered helideck via incorrect stairwell that was in the vicinity of the tail rotor.

• Not happened in your company before, happened previous year in offshore industry & a number of examples in the wider helicopterindustry. Normally results in death.

Typical RAM

• Too vague and open to different interpretation.

• Detailed definition required for likelihood and severity.

Typical RAM

Detailed RAM

Step 4 – Controls for Specific Hazards• Methods for identifying controls

– Brainstorming

– Bow Tie analysis

– Tripod

• Goal is to manage each hazard to ALARP– Barriers, controls & recovery measures proportional to

risks.

– Humans require backup

ALARP – As Low As Reasonably Practicable

What does that mean?

How far should you go in developing controls?

ALARP is a trade off between:The cost/effort/ operational impact of implementing the control

The safety benefit realised from the control

While it is proportional, continue.When it gets disproportional, stop.

Step 4 –Controls for Specific Hazards• Challenge existing procedures and controls.

• Begin by ignoring financial and resource constraints.

– “Blue sky thinking”

– Impractical controls can be discounted later in the process

• Engage stakeholders from all levels within the company.

– Line pilots and mechanics as well as supervisors and safety staff.

• Look outside your own organisation.

Wasted effort alert

Step 4 – Controls for Specific Hazards

• Effective

• Costs proportional to benefits

• Practical

• Acceptable

• Enforceable

• Sustainable

• Doesn’t create new hazards

Step 4 – Controls for Specific Hazards

1.01 Weather

Inadvertent Entry to IMC

How do we preventthis from happening?

Add controls/barriers to the process

1.01 Weather

Company Weather Operating Limits

Now start asking questions “How can that control fail?”“What if…….”

1.01 Weather

Acurate Daily WX Forecast

Unknown WX forecast

WX limits agreed with client

Client unaware of Company WX limits

Enhanced Operational Control (EOC)

procedure in place

Client pressure to fly

Record controls in the hazard register

Basic Hazard Register ExampleTask Description/Location

Onshore seismic support Reference No. Date last reviewed

HS - 017 Sept 11

Hazard Description: Inadvertent entry to IMC RAM Score

Initial Current

Barriers, Controls & Recovery Measures Reference Owner Status

HS - 017 Sept 12

Initial Current

Minimum company weather limits for VFR operations

Accurate daily forecasts available for operation Weather limits agreed with clientEnhanced Operational Controls in place to respond to changes in weather.

1.01 Weather

Unknown WX forecast

procedure in place

Do I need another control?Is the one I have fully effective?

1.01 Weather

Aircraft Equipped for Basic IMC flight

Unknown WX forecast

procedure in place

What if……?

1.01 Weather

Unknown WX forecast

procedure in place

Simulator Training including IFR

procedures

Annual Instrument Flight Check

Pilot Instrument Rated

PIlot Instrument Flying Competency

1.01 Weather

All Aircraft Equipted with TAWS

Unknown WX forecast

procedure in place

procedures

HS - 017 Sept 11

Initial Current

Accurate daily forecasts available for operation Weather limits agreed with clientEnhanced Operational Controls in place to respond to changes in weather.

Task Description/Location

HS - 017 Sept 11

Initial Current

Minimum company weather limits for VFR operationsAccurate daily forecasts available for operation

Weather limits agreed with client

Enhanced Operational Controls in place to respond to changes in weather.Aircraft equipped for IFR flight (Designate minimum avionic equipment)Pilots instrument rated

Annual inadvertent IFR flight check to ensure currency and competence. Inadvertent IFR procedures trained and checked during annual simulator training.

All aircraft equipped with TAWS

1.01 Weather

Unknown WX forecast

procedure in place

procedures

Now consider the hazard consequences and how to mitigate them.

1.01 Weather

Unknown WX forecast

procedure in place

procedures

Unknown Aircraft Location

Inadequate ER

1.01 Weather

Unknown WX forecast

procedure in place

procedures

Satelite Flight Tracking

Unknown Aircraft Location

ERP in Place and Exercised Annually

Inadequate ER

HS - 017 Sept 11

Initial Current

Minimum company weather limits for VFR operationsAccurate daily forecasts available for operation

Enhanced Operational Controls in place to respond to changes in weather.Aircraft equipped for IFR flight (Designate minimum avionic equipment)Pilots instrument rated

Annual inadvertent IFR flight check to ensure currency and competence. Min 30 min

Inadvertent IFR procedures trained and checked during annual simulator training.

All aircraft equipped with TAWS

HS - 017 Sept 11

Initial Current

Accurate daily forecasts available for operation

Enhanced Operational Controls in place to respond t o changes in weather.Aircraft equipped for IFR flight (Designate minimum avionic equipment)Pilots instrument rated

Annual inadvertent IFR flight check to ensure curre ncy and competence. Min 30 minInadvertent IFR procedures trained and checked duri ng annual simulator training.All aircraft equipped with TAWS

All aircraft equipped with satellite flight trackin g

Emergency response plan in place & exercised annual ly

Hazard Management ProcessSCOPE OF ACTIVITY

RISK ANALYSIS

IDENTIFY CONTROLS FOR SPECIFIC HAZARDS

REFERENCE DOCUMENTS AND

RESPONSIBLE POSTS

CONTROL EXISTS

HS - 017 Sept 11

Initial Current

Accurate daily forecasts available for operation

Enhanced Operational Controls in place to respond t o changes in weather.Aircraft equipped for IFR flight (Designate minimum avionic equipment)Pilots instrument rated

Annual inadvertent IFR flight check to ensure curre ncy and competence. Min 30 minInadvertent IFR procedures trained and checked duri ng annual simulator training.All aircraft equipped with TAWS

All aircraft equipped with satellite flight trackin g

Emergency response plan in place & exercised annual ly with client

HS - 017 Sept 11

Initial Current

Minimum company weather limits for VFR operations Ops Man 4.2.3 Chief Pilot In force

Accurate daily forecasts available for operation Ops Man 4.2.4 Chief Pilot In force

Weather limits agreed with client Standard contract clause 9.2

Director Operations

In force

Enhanced Operational Controls in place to respond t o changes in weather.Aircraft equipped for IFR flight (Designate minimum avionic equipment)

Ops Man 8.3.1 Director of Maintenance

In force

Pilots instrument rated Ops Man 3.4 Chief Pilot In force

Annual inadvertent IFR flight check to ensure curre ncy and competence. Min 30 min

Training Man 6.4

Chief Pilot In force

Inadvertent IFR procedures trained and checked duri ng annual simulator training.All aircraft equipped with TAWS

All aircraft equipped with satellite flight trackin g Ops Man 8.3.4 Director of Maintenance

In force

Emergency response plan in place & exercised annual ly with client

ERP 5.6 and Standard contract clause

Head of Safety & QA

In force

RISK ANALYSIS

RESPONSIBLE POSTS

REMEDIAL ACTION PLAN

CONTROL EXISTS NEW CONTROL REQUIRED

Step 6 – Remedial Action Plan• Lists actions required to address key hazard

management gaps.

• Presents senior management with complete overview.

• Fit-for-purpose recording & tracking.

• Hazard Register should reflect the status of the remedial action plan.

HS - 017 Sept 11

Initial Current

Ops Man 4.2.3 Chief Pilot In force

Director Operations

In force

Enhanced Operational Controls in place to respond to changes in weather.Aircraft equipped for IFR flight (Designate minimum avionic equipment)

In force

Training Man 6.4 Chief Pilot In force

Inadvertent IFR procedures trained and checked during annual simulator training.All aircraft equipped with TAWS

All aircraft equipped with satellite flight trackin g Ops Man 8.3.4 Director of Maintenance

In force

Emergency response plan in place & exercised annually with client

ERP 5.6 and Standard

Head of Safety & QA

In force

HS - 017 Sept 11

Initial Current

Director Operations

In force

Enhanced Operational Controls in place to respond to changes in weather.

RAP Item 16 Director Operations

Due 31 Dec 13

Aircraft equipped for IFR flight (Designate minimum avionic equipment)

In force

RAP Item 23 Chief Pilot Awaiting sim availabilityAll aircraft equipped with TAWS RAP Item 15 Maintenance

DirectorDue complete Apr 2014All aircraft equipped with satellite flight trackin g Ops Man 8.3.4 Director of

MaintenanceIn force

Head of Safety & QA

In force

Step 6 – Remedial Action Plan

• Re-assess risk

HS - 017 Sept 11

Initial Current

Director Operations

In force

Due 31 Dec 13

In force

MaintenanceIn force

Head of Safety & QA

In force

HS - 017 Sept 11

Initial Current

Director Operations

In force

Due 31 Dec 13

In force

MaintenanceIn force

Head of Safety & QA

In force

Operator assessed that untilSim training, TAWS and the

EOC were in place, risk remained medium.

RISK ANALYSIS

RESPONSIBLE POSTS

CONTROL DEVELOPED

Step 7 – Interface with Quality

The quality management system must be integrated with the hazard management system.

Wasted effort alert

SCOPE OF ACTIVITY

RISK ANALYSIS

RESPONSIBLE POSTS

CONTROL DEVELOPED

QUALITY SYSTEM –UPDATE

CHECKLISTS

INTERNAL AUDIT TO CONFIRM

IMPLEMENTATION & EFFECTIVENESSOF CONTROLS

Steps 3 – 7 should now be repeated for

each hazard identified in Step 2.

Your hazard management process should be saving money and attracting clients.

It must be kept alive to prevent it from being a dusty book on the shelf, only brought out when

auditors arrive.

Wasted effort alert

SCOPE OF ACTIVITY

RISK ANALYSIS

RESPONSIBLE POSTS

CONTROL DEVELOPED

CHECKLISTS

SAFETY REPORTING &

INVESTIGATION

SAFETY REPOPTING & INVESTIGATION PROCESS LINKED DIRECTLY TO THE

HAZARD MANAGEMENT

PROCESS.

Step 8 – Safety Reporting and Investigation• All incident reports should prompt a review the hazard

register.

• Identifying new hazards leads to Step 2 (Hazard Identification).

• Incidents with hazards already identified should result in a review of the existing and potential mitigations.

– Those that worked, thus preventing an accident,

– Those that were ineffective, and

– Potential mitigations that were missing.

• A pilot reports inadvertently entering IMC during a seismic support flight. After some maneuvering he was able to recover and regain VMC, but had some worried passengers.

• After interview with the pilot it appears he pressed on with the task, in deteriorating weather conditions, under client pressure to complete the last flight of the day.

• The client’s on site supervisor claims that he was unaware of the operators more restrictive weather limits.

HS - 017 Sept 11

Initial Current

Director Operations

In force

Due 31 Dec 13

Ops Man 8.3.1 Maintenance Director

In force

Annual inadvertent IFR flight check to ensure currency and competence.

DirectorDue complete Apr 2014All aircraft equipped with satellite flight trackin g Ops Man 8.3.4 Maintenance

DirectorIn force

ERP 5.6 and Standard contract clause 10.1

Head of Safety & QA

In force

��

HS - 017 Sept 11

Initial Current

Director Operations

In force

Due 31 Dec 13

In force

DirectorIn force

Head of Safety & QA

In force

��

Amend contractrequirements

Accelerateintroduction

HS - 017 Sept 11

Initial Current

Barriers, Controls & Recovery Measures Referece Owner Status

Director Operations

In force

Due 31 Dec 13

In force

Wx limits and EOC requirements included in Pilot annual ground training syllabus

Training Man 6.12

Chief Pilot

DirectorIn force

Head of Safety & QA

In force

��

Add and record a further control

1.01 Weather

Unknown WX forecast

procedure in place

procedures

1.01 Weather

Unknown WX forecast

WX limits held by client site supervisor

EOC & WX limits in pilots annual ground

training syllabus

procedure in place

procedures

SCOPE OF ACTIVITY

RISK ANALYSIS

RESPONSIBLE POSTS

CONTROL DEVELOPED

CHECKLISTS

SAFETY REPORTING &

INVESTIGATION

VALIDATE EXISTING CONTROLS OR DEVELOP

NEW CONTROLS

PROCESS NEW HAZARDS

SCOPE OF ACTIVITY

RISK ANALYSIS

RESPONSIBLE POSTS

CONTROL DEVELOPED

CHECKLISTS

SAFETY REPORTING &

INVESTIGATION

NEW CONTROLS

PROCESS NEW HAZARDS

MANAGEMENT OF CHANGE PROCESS

Step 9 – Management of Change• Required element of the SMS

• Process to include:

– Review the relevant sections of the hazard register.

– Planned or potential effects on existing controls

– Potential for introduction of new hazards.

• New hazards should be run through the whole process.

• What should prompt the MOC process…?

Step 9 – Management of Change• The SMS manual should describe the process for

management of change (MOC).

• The MOC process should be used ahead of the following events:

– Introduction of new aircraft type

– New contract/operation

– Opening a new base

– Major change in key personnel or the organisation

• MOC risk assessments and mitigation steps should be documented.

Step 9 – Management of Change

• The MOC process documentation should summarise:

– what will change,

– areas/departments affected,

– hazards identified,

– risk assessments, and

– actions to be taken to manage risks.

Scope of Change

Accountable ManagerType of change Permanent Temporary: From ________ to __________

Department/location Responsible Hazard Register Reviewed/Updated

Signature

Summary of Actions Arising Responsible Due Date & Signature

Statement of Completion/Fitness Accountable Manager Date & Signature

Scope of Change

Introduction of AW139 from Aug 2013

Ref # MOC 02/2013

Accountable Manager

Director of Operations J. C. Van Damm

Type of change Permanent �� Temporary: From ________ to __________

Signature

Scope of Change

Ref # MOC 02/2013

Accountable Manager

Signature

Maintenance DepartmentTraining DepartmentFlight Operations DepartmentSafety & Quality DepartmentEdmonton Base

Calgary Base

List all stakeholders

Scope of Change

Ref # MOC 02/2013

Accountable Manager

Signature

Maintenance Department

Director Maintenance 13 Apr 2013

Training Department

Training Manager 1 Apr 2013

Flight Operations Department

Director Operations 22 Mar 2013

Safety & Quality Department

Director Safety & Quality 10 Apr 2013

Edmonton Base Base Manager 5 Mar 2013

Calgary Base Base Manger 15 Mar 2013

Once a department has completed its review of the

Hazard Register, the responsible party will

sign for completion

Scope of Change

Ref # MOC 02/2013

Accountable Manager

Signature

Training Department

Training Manager 1 Apr 2013

Pilot and mechanic training syllabus developed and documented

Training Manager 1 May 2013Factory training completed for Pilots and

Maintenance SupervisorsTraining Manager 1 Aug

2013Maintenance work stands designed and manufactured

Director Maintenance

1 Jul 2013Additional Hangar space at Edmonton to

be acquired or builtBase Manager 1 Jul

2013Maintenance documentation developed for B429.

Maintenance QA Lead

1 Jul 2013Statement of Completion/Fitness Accountable Manager Date & Signature

Each department will developa detailed action plan.

Scope of Change

Ref # MOC 02/2013

Accountable Manager

Signature

Training Department Training Manager 1 Apr 2013

Pilot and mechanic training syllabus developed and documented

Training Manager 1 May 2013

Factory training completed for Pilots and Maintenance Supervisors

Training Manager 1 Aug 2013

Maintenance work stands designed and manufactured

Director Maintenance 1 Jul 2013

Additional Hangar space at Edmonton to be acquired or built

Base Manager 1 Jul 2013

Maintenance documentation developed for B429.

Maintenance QA Lead 1 Jul 2013

MOC process for introduction of AW139 completed . All appropriate sections of the hazard register reviewed and updated. Risk

Director of Operations

J.C. Van Damm 15 Jun 2013

NEW CONTROLS

SCOPE OF ACTIVITY

RISK ANALYSIS

RESPONSIBLE POSTS

CONTROL DEVELOPED

CHECKLISTS

SAFETY REPORTING &

INVESTIGATION

PROCESS NEW HAZARDS

SCOPE OF ACTIVITY

RISK ANALYSIS

RESPONSIBLE POSTS

CONTROL DEVELOPED

CHECKLISTS

SAFETY REPORTING &

INVESTIGATION

PROCESS NEW HAZARDS

MANAGEMENT REVIEW

NEW CONTROLS

Step 10 – Management Review

Unless your senior management supports, is actively involved in the process and uses the process as a

management tool, it will be an academic exercise with limited impact on the business.

Applied effectively the Hazard Management process can be a key factor in influencing the financial decisions

within the company.

Wasted effort alert

Check ICAO Doc 9859 Section 8.2: The Components and Elements of an SMS

•Safety policy and objectives– Management commitment and responsibility– Safety accountabilities– Appointment of key safety personnel– Coordination of emergency response planning, and– SMS documentation

•Safety risk management– Hazard identification, and– Risk assessment and mitigation

•Safety assurance– Safety performance monitoring and measurement– Management of change, and– Continuous improvement of the SMS

•Safety promotion– Training and education, and – Safety communication

References

“Safety risk management. A formal system of hazard identification and safety risk management is essential in controlling risk to acceptable levels. The safety risk management component of the SMS is based upon the system safety process model that is used in the system safety training course that is

taught at the FAA Academy.”

“Risk management is a proactive activity that looks at the risks associated with identified hazardsand assists in selecting actions to maintain an appropriate level of safety when faced with these

hazards.”

Safety Risk Management“A formal system of hazard identification and management is fundamental in controlling an acceptable

level of risk. A well-designed risk management system describes operational processes across department and organizational boundaries, identifies key hazards and measures them, methodically assesses risk, and

implements controls to mitigate risk.”

“Hazard identification and safety risk management are the core processes involved in the management ofsafety. They are neither new, nor have they been developed as a consequence of recent interest in safety

managementand, in particular, safety management systems (SMS). Hazard identification and safety risk management

are dogmaticcomponents that underlie the overarching concept of system safety. This is an all-encompassing,

engineering-basedapproach that contributes to system design and which was developed more that forty years ago.”

Other References:• International Standard for Business Aircraft

Operations – helicopter revision will be delivered soon – SMS guidance is already robust

• International Helicopter Safety Team’s SMS Toolkit available at www.ihst.org\

• EASA• FAA

• HAI video at http://www.rotor.org/Safety/DevelopingaSafetyManagementSystem.aspx

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