dca seminar hazard management 3

Air Safety, Safety Management Systems, Human Factors in Aviation Management, Continuing Airworthiness

AVIATION HAZARD MANAGEMENT

SMEP

Risk Assessment &Hazard Management

Cliff Edwards Aviation Safety Consultant

Aviation Hazard Management Ltd

Sponsored by Shell Malaysia Exploration & Production



SMEP

Risks and Hazards

• These are not new concepts to aviation, but have been dealt with covertly.

• The most significant change that SMS brings is that now the accountable manager must accept the risks of the organisation and demonstrably manage these to acceptable levels, or personally hold the liability for those risk.



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Hazards & Risks what are they?• A hazard is something with the potential to

cause harm, therefore, it must have energy in its own right.

• Risk in its simplest term is a calculation, it is the measure of how often something might happen and how bad it might be. (Frequency x Consequence).

• A third key term used in this process, is threat. Threats cause the release of hazards.



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Risk Assessment



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Risk Management• It is not possible to be free of risk, nor is it desirable.

• However, the risks should be understood and manageable.

• Assessment of risks requires a process that is measurable and can be reliably used repeatedly.

• In operation hazard do get released and a hazardous event occurs, you need to know what are the potential events and how they might effect your operations.

• It is essential for a company to be prepared to deal with the hazardous event and their potential consequences.

• In reality it is the hazardous events that are normally risk assessed, not the hazard itself.



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Risk Assessment• The purpose of risk assessment is to clearly establish

the dimensions of the risks faced, both :– To rank them in order of importance and. – To bring them to senior managements attention.

• Senior management are accountable for the risks and the provision of risk reducing measure to bring these to acceptable levels.

• Therefore, it is important that a reliable, repeatable process backed up with the best available data is used to do the risk assessment.



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Risk AssessmentTwo basic approaches to risk assessment:• Quantitative

• Systematic assessment using facts to accurately calculate the frequency of each potential outcome in terms of severity.

• Typically this is done during aircraft design and build to assess the potential failure rate of all critical parts.

• Qualitative • Assessment through expert opinion, informed by evidence

of past incidents/accidents and failure rates.• This is the preferred method for Risk Assessment in SMS

systems.



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Potential Consequence of the Incident Increasing Probability

Environ-

ment

0

2

3

4

5

Seriousinjury

Multiplefatality

Singlefatality

Minorinjury

Occurred more than 3

times in company

Minordamage <US$ 50K

Localdamage <US$ 250K

Majordamage <US$ 1M

Extensivedamage >US$ 1M

MassiveEffect

Zerodamage

Localised Effect

MajorEffect

Minor Effect

1

Assets

Slightinjury

Slightdamage < US$ 10K

SlightEffect

ZeroEffect

B C D EA

Noinjury

Occurred in your

company

No Impact

InternationalI m p a c t

ConsiderableI m p a c t

N a t i o n a lI m p a c t

Slight Impact

Intoler

able

Not Known in

the aviation

Industry

L i m i t e dI m p a c t

ReputationPeopleRating Known to have

occurred in aviation

Manage T

hrough

proce

dures

Normal H

SE-MS

incorp

orate

risk

reducti

on

measu

re

Occurred more than 3 times in 1 location

Risk Assessment Matrix

Assessment

C5



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Hazard Management



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Hazard Management

The concept of Risk or Hazard management is based on the following steps.

•Identify potential sources of harm (Hazards).

•Evaluate the worst case potentially of each hazard (Risk Assessment).

•Identify all undesirable events or circumstances associated with each hazard which could result in harm being caused (Threats).

•Develop or improve appropriate measures to prevent occurrence (Controls).

•If possible return the situation to “ops normal” or reduce the impact incurred (Mitigation Measures).



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How to Identify HazardsLearning from Incidents: Learning from incidents is helpful

but is not systematic and expensive, but when they occur you do need to learn.

Hazid: A Hazid (Hazard identification) is a facilitated brainstorming session with a team of subject matter experts (pilots or engineers).

Hazop: A Hazop (Hazard Operability) is a systematic review of all business processes (time consuming, but very systematic).

Generic Hazard Models: There are a small number of generic hazard models available and these can significantly reduce the manpower hours needed to do this work.



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HAZID ProcessScope

Scope the change define what the objective is intended to achieve

when the change is implemented.

Appoint

Appoint a team of subject matter experts, a trained facilitator and a

recorder for the brainstorming session.

Document

A Plan for the achievement of the actions identified in the brainstorming,

especially the critical paths.

Brainstorm

What could go wrong with the planned changes.

Action and Review

Allocated Action Parties act and report the achievement of the plan and measure

if the expected benefits are delivered.

Summarise

The brainstorming session and where possible what controls are needed to manage the perceived

problem areas. Identify the critical paths, milestones and targets.



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HEMP processes were developed by the Nuclear Industry, this is a four part process:

Are people, environment or assets exposed

to potential harm?

What are the causes and consequences?

How likely is loss of control?

What is the risk and is it ALARP?

Can the causes be eliminated?

What controls are needed?

How effective are the controls?

What recovery measures are needed?

Are recovery capabilities suitable and sufficient?

Can the potential consequences be mitigated?

Identify

Assess

Control

Recover

Hazard Management MethodologyHazard and Effects Management Process (HEMP)



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HAZARDSHAZARDS



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Classic Hazard Model Competencies

Procedures

Awareness

Training

Assurance

Accountability

Threat Threat

Th

reat

Th

reat

HAZARDSCFIT, Fuel

Human ErrorUnairworthy

AircraftPh

ysic

al

Barr

iers

Red

un

dan

tS

ystem

s



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Hazard Controls

• Procedures• Checklists • Challenge and Response• System Redundancy• Supervision• Training• Standards• Audits• Awareness• Management & leadership • Personal Protective Equipment

• Regulations• Briefings• Competency• Physical Barriers• Two crew operations• Maintenance• Effective planning• Housekeeping• Security• Team working• Medicals

Controls are typically those already used in aviation such as:



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Bow Tie Analysis Tool

Control

Hazard

Threat

Threat control

Escalation F

actor

Rec

over

y

Hazardous

Event

Proactive Reactive

HEMP Process Tool



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Simple Example of the Bow-Tie

Recovery

Escalation

Control

Consequence

Mitigation

Tiger Bites Keeper

TIGERCage Door Locking

SystemTwin Locks & Warning

Lights

Competent Keepers

Unserviceable System

Miss Tiger, or Tiger Evades Keeper

Effective Emergency Response Plan

Hazard

Threat

Control

Escalation

Control

Tiger out of the Cage

Shoot Tiger, or drive back in cage

Records & Maintenance



SMEP

Life Cycle Locations of an Aircraft Operation in Hazard Management Terms

MaintenanceTaxiing

Preparation for flight

All phases of flight

Taxiing

Head Office

Using the Bowtie approach it is the recovery measures that determine the need for a separate hazardous event analysis, and these are dependant on

the location.



SMEP

Aircraft Deviates

from Intended

Flight Path

Unairworthy

Aircraft Released

to Service

Interface with

Suppliers

Interface with

Maintenance

Contractors

Interface with

Air Charter

Carriers

Uncontrolled

proximity of

GSE to Aircraft

Proximity

to a Third

Party or

Obstacle

Loss of

Separation with

other Aircraft

Flammable

Materials

in proximity to a

source of ignition

Loss of

containment

of Dangerous

Goods

Encounter

with a potential

HSE occurrence

Exceedance of

Aircraft

Limitations

Encountering

Unexpected

External

Conditions

Deviation from

Intended Aircrew

Flight Training

Missions

Aircraft

Systems Failures

Inc. Dynamic

Failures

Deviation from

Intended

Aircraft Air-test

Missions

Encountering

Adverse Weather

Conditions

Loss of

containment

of fuel or oil

Static Out of

Balance

situations

Aircraft Deviates

from Intended

Ground Track

Loss of

containment

of fluid and gas

under pressure

Use of unsafe

lifting

equipment

Uncontrolled

people in close

proximity to an

Running engine

Hazardous Event Map



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EXAMPLE SMS MANAGEMENT

Compliant practicesalways used

Workplace culturesupportive

Engineer to carry out night maintenance task

Resource planningallocates enough time

Working time limitations regulated

Staff competencies checked against profiles

QA department does random night audits

Effective task cardsavailable

Worksheet completioninformative & correct

Handover of work isTell me Show me

Post maintenance checks always done

Night Shift SupervisorTo monitor task progress

•Management accountabilities clearly understood•Hazardous events identified•Risk assessments carried out and reported•Controls identified, tested and monitored •Systematic audit programme in place•Management reviews carried out routinely



SMEP

Using Bowtie Software

BowTieXPwww.bowtiexp.com



SMEP

“What happens when the hazard is released?”

“What happens when control is lost?”

“What are my hazards?”

“What causes the hazard to be released?”

“How can control be lost?”

“How can the event develop?”

“What are the potential outcomes?”

Hazardous or Top Event



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Hazardous or TopEvent

Hazard

“How do we prevent the hazard from being released?”

“How do we keep control?”

“How might controls fail?”

“How could their effectiveness be undermined?”

“How do we limit the severity of the event?”

“How do we minimise the effects?”

“How do we make sure controls do not

fail?”



SMEP

Hazard

Tasks

“What tasks do we do to make sure the control continues to work?”

Include design, operations, maintenance, management.

Management System

Hazardous or TopEvent

“How do we verify that the tasks have been done?”

Compliance

MonitoringAudit



SMEP

Aircraft deviates from intended safe

flight path



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Active Safety Management


flight path



SMEP


flight path

dca seminar hazard management 3

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