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AIRBORNE LAW ENFORCEMENT AIRBORNE LAW ENFORCEMENT ASSOCIATIONASSOCIATION
Safety Management System Workshop
---------------------------------------------------------Keith JohnsonSafety Program Manager
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IHSSIHSS Safety is most important Need to collect data
– Collect flight hours– Collect Serious Incident Information– ALEA Incident Reporting System – Proposal– Expedite Accident Reporting
Increased training Reduce Accidents by 80% over 10-years Focus on Leadership Non-punitive reporting Accountability Accidents can be eliminated ALEA on International Helicopter Safety Team
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The topic of the dayThe topic of the day
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““SAFETY” SAFETY”
It holds the key to our future
It affects everything we do (SMS)
Every accident affects everyone
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SAFETY PRIORITIESSAFETY PRIORITIES SAFETY has the highest priority MISSION has a lower priority Each person is critical to
eliminating accidents Inclusive communications chain*
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SAFETY PRINCIPLESSAFETY PRINCIPLES1. Always operate in the safest manner possible2. Never take unnecessary risks3. Safe does not mean risk free4. Key to safety is the i.d. and management of risk5. An absence of accidents does not necessarily
equate to safety6. Familiarity and prolonged exposure without an
incident leads to a loss of appreciation of risk How does this apply flying patrol?
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Safety GoalsSafety Goals
Zero accidents Zero injuries Zero harm to environment Improve public perception of law
enforcement aviation
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An effective Safety Management System is essential to achieving & sustaining a zero accident.
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ELEMENTS OF THE ELEMENTS OF THE ORGANIZATIONORGANIZATION
Flight Operations Ground Operations Maintenance Training Safety Safety Management System is all
inclusive
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ACCIDENT ELIMINATIONACCIDENT ELIMINATION Must be proactive – Reached plateau
– Pilots focus on flying aircraft– Two person crews– Focus on risk management
Adverse Trends– Identify and eliminate adverse trends – Incidents - Investigate & disseminate findings– Factory emergency procedures training
Don’t reinvent the wheel No new causes of accidents Copy successful organizations Accreditation – Platinum Program
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JUDGMENT & ACTION ERRORSJUDGMENT & ACTION ERRORS Failure to manage known risks Mission urgency & risk taking
– Will to succeed Flight profile unsafe
– Crew Qualifications– Aircraft Suitability– Mission Requirements– Environment
Judgment errors committed Failure to follow procedures Poor CRM Poor Aircraft Control
– Over confidence– Loss of situational awareness
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What is an SMS?What is an SMS?
Coordinated, comprehensive set of processes designed to direct and control resources to optimally manage safety.
Makes safety management an integral part of the overall operations/business plan.
Based on leadership and accountability.
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What Does Having an SMS What Does Having an SMS Give?Give?
We will now concentrate on describing the three key processes generically Once you understand these, the rest becomes more readily apparent But first some more definitions…
Comprehensive
Corporate Approach to
Safety
Robust Systems
for
Assuring Safety
Effective Organisation
for
Delivering Safety
Comprehensive approach to safety
Robust & effective safety
management processes
Organizational structure for
ownership of & accountability for
safety
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Why is Having an SMS Why is Having an SMS Important?Important?
1. Widely recognized as best practice2. Eliminates accidents3. Reduces costs4. Limits exposure (reduces total risk)5. Reduces probability of having an
accident6. Reduces severity of risks7. Reduces exposure to risk8. Increases likelihood of completing the
mission
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1. Safety Management Plan1. Safety Management Plan
Description of SMS components:1. Definition of fundamental approach to
safetya) Philosophical approach – Vision, Mission, Valuesb) Safety policy – SMS policy statementc) Business and department goals – set/reviewed annually
2. Clearly defined roles and responsibilitiesa) Openly documented and briefed
3. Top leadership involvementa) Safety is an agenda item, resource allocation, openness, involved
in daily activities, promoting awareness
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What should it look like?What should it look like?A Framework for Safety Management
CRM
Audits
ChecklistWorksheets
TrainingPlan
Alcohol& Drugs
PolicyAudit
Maint.Schedule
SafetyDrills
Policy
FAA
Regs .
No Structure STRUCTURE
ERPs
Process /Do
Policy /PlanHSE
Policy
Security
QA
Ops Manual
Plans
Task /Check – Feedback - Action
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Safety Management Training Safety Management Training RequirementsRequirements
Safety orientation for all new personnel
Document competency requirements Document training requirements Have regularly scheduled safety
meetings Key personnel educated on safety
management best practices
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JHSAT ACCIDENT CAUSATION JHSAT ACCIDENT CAUSATION JUDGMENT & ACTION ERRORSJUDGMENT & ACTION ERRORS
Fail to manage known risks– Mission urgency– Risk taking– Failure to follow standards
Unsafe flight profile– Crew qualifications– Aircraft suitability– Mission requirements– Environment
Aircraft control deficiencies
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JHSAT STUDY RESULTSJHSAT STUDY RESULTS
Three themes came from JHSAT study:
1. Better training2. Operational oversight3. Safety Management
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SAFETY RECOMMENDATIONS
1. More consistent & comprehensive NTSB involvement and investigation
2. Collect worldwide fleet hour data as previously performed by FAA
3. Promote the Safety Management Systems
4. Establish safety website to disseminate information
5. Use proximity detection equipment on aircraft
6. Use flight recording devices and cockpit image recording systems
7. Develop strategy to improve ADM
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Results of full year 2000 dataset
SPS Frequency by Primary Category
401
173
154
112
98 87
66
26 24 24 23 20 10 1050
100150200250300350400450
Pilo
t jud
gmen
t &ac
tions
Saf
ety
Cul
ture
Dat
a is
sues
Mai
nten
ance
Gro
und
Dut
ies
Pilo
t situ
atio
naw
aren
ess
Par
t/sys
tem
failu
re
Pos
t-cra
shsu
rviv
al
Com
mun
icat
ions
Mis
sion
Ris
k
Reg
ulat
ory
Airc
raft
Des
ign
Infra
stru
ctur
e
Gro
und
pers
onne
l
Freq
uenc
y
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SPS & Accident Count by Primary Mission
210
170
145
101
92
74 68
53 51 48 47 44
32 30 24 17
37
27 28
12 16 13 9 8 9 6 10 6 4 4 5 3
0
50
100
150
200
250In
stru
ctio
nal /
Tra
inin
g
Pers
onal
/ Pr
ivat
e
Aeria
l App
licat
ion
Emer
genc
y M
edic
al S
ervi
ce
Com
mer
cial
Ope
rato
r
Law
Enf
orce
men
t
Offs
hore
Exte
rnal
Loa
d
Busi
ness
- C
ompa
ny o
wns
A/C
Fire
fight
ing
Aeria
l Obs
erva
tion
/ Pat
rol
Air T
our
Sigh
tsee
ing
Elec
troni
c N
ews
Gat
herin
g
Logg
ing
Utili
ties
Patro
l and
Con
stru
ctio
n
Freq
uenc
y
SPSCount
AccidentCount
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Introduction to the ToolkitIntroduction to the Toolkit
The Toolkit contains SMS guidance material and a sample SMS Manual
The Toolkit provides a foundation for your own system
The issued IHST SMS Toolkit is Version 1.0…
Feedback
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Resulting ActionsResulting Actions
Fire the PIC, 30 day suspension for SIC
Stuff happens! Get over it!
Seek restitution… someone pays!
Do these actions prevent future events of this type?
Is there an alternative?
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Just CultureJust Culture A ‘blame culture’ undermines open reporting A ‘no-blame culture’ is also flawed as it
undermines accountability & responsibility If other personnel could make the same
error occasionally then we must change the controls not discipline the personnel – Holding people accountable through a disciplinary process is
only relevant for: Gross negligence Persistent sub-standard performance Wilful recklessness
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Just Culture Process
Was the job understood? Knowingly violated procedures?
Was the action as intended?
Were the results as intended?
Are the procedures clear?
Pass substitution test?
Defective training or selection experience?
History of violating procedures?
Sabotage or Malevolent Act
Reckless Violation Repeated Incident With Similar Root CauseNegligent Error
No Blame Error
Yes*Yes
Yes
Yes
Yes
Yes
Yes*
Yes*
No*
No*
No
NoNo*
No
No
Start
Documented for the purpose of accident prevention awareness and training will suffice.
First written warning;
Coaching / Increased Supervision until behavior is corrected.
Final warning and negative performance appraisal
Severe Sanctions
* Indicates a ‘System’ induced error. Manager/supervisor must evaluate what part of the system failed and what corrective and preventative action is required. Corrective and preventative action shall be documented for management review.
No
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Management of ChangesManagement of Changes Operational procedures Location, equipment or operating
conditions Maintenance and Operations Manuals Personnel made aware and
understand changes Level of management & authority to
approve changes
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Performance Based SMSPerformance Based SMS
Rather than specify an organizational configuration or architecture, the SMS Toolkit deals with “SMS Attributes.”
These attributes describe the performance of a successful SMS.
Meeting the performance standard is what is critical… the configuration or architecture is dependent on the size and scope of the operation.
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Attributes of a SMSAttributes of a SMS SMS Management Plan Safety Promotion Data information management Hazard identification and risk management Hazard reporting Occurrence investigation and analysis Safety oversight programs Safety training requirements Management of change Emergency preparedness and response Performance measurement & improvement
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The Attributes of an SMSThe Attributes of an SMS
1) SMS Management Plan– Policies, objectives – Organizational structure and key individuals – Elements defined– Expectations described – Commitment to compliance with safety and
regulatory requirements
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The Attributes of an SMSThe Attributes of an SMS
2) Safety Promotion– Safety Policy– Messages, memos from management– Posters, flyers, website– Safety training– Recognition program– Just Culture process in place
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The Attributes of an SMSThe Attributes of an SMS
3) Document and Data Information Management
– Safety policies, regulations, objectives and SMS requirements publicized
– Change control system in place for applicable documents; training
– Periodic review of documents
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The Attributes of an SMSThe Attributes of an SMS
4) Hazard Identification and Risk Management
– Proactively identify potential hazards – Hazards are considered when making changes– Risk Assessment – Identified hazards are tracked for closure
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The Attributes of an SMSThe Attributes of an SMS
5) Occurrence and Hazard Reporting– Corrective actions monitored for effectiveness,
employees receive feedback – A non-punitive disciplinary policy in place for
reporting hazards (Just Culture process) – Safety data analyzed, hazards are monitored to
identify trends– Anonymous submittals of hazards
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The Attributes of an SMSThe Attributes of an SMS
6) Occurrence Investigation and analysis with technically qualified investigators
– Investigations conducted to determine root causes, and identify what can be done to prevent future occurrences
– Identify causal factors and the contributory factors, including organizational factors
– Acts of “omission” and “commission” identified– Reports provided to manager that has
accountability and authority
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The Attributes of an SMSThe Attributes of an SMS7) Safety Assurance Oversight Programs
– Internal assessments at regularly scheduled intervals, including contractors
– Utilizing checklists tailored to the organization’s operations when conducting safety evaluations
– Independent assessment of evaluator’s processes– Sharing the results and corrective actions with all
personnel– Utilizing available technology such as Health Usage
Monitoring Systems (HUMS) to supplement quality and maintenance programs as well as supporting programs to monitor and evaluate aircrew operations
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The Attributes of an SMSThe Attributes of an SMS
6) Occurrence Investigation and Analysis
– Technically qualified investigators – Investigations conducted to determine root
causes, and identify what can be done to prevent future occurrences
– Identify causal factors and the contributory factors, including organizational factors
– Acts of “omission” and “commission” identified– Reports provided to manager that has
accountability and authority
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The Attributes of an SMSThe Attributes of an SMS
8) Safety Management Training Requirements
– Include a safety orientation for all new personnel, stressing the organization’s commitment to safety and everyone’s roll in the SMS
– Document competency requirements for personnel
– Have a system to track training requirements – Make effective use of conferences, workshops,
literature and trade journals
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The Attributes of an SMSThe Attributes of an SMS
9) Management of Changes
– Identify required changes in training, documentation or equipment
– Changes in location, equipment or operating conditions analyzed for any potential hazards
– Screen, review, approve, implement
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The Attributes of an SMSThe Attributes of an SMS
10) Emergency Preparedness and Response
– Be readily available at the work stations of those that may be the first to be notified or required to respond
– Be relevant and useful to people on duty – Be exercised periodically to ensure the adequacy
of the plan and the readiness of the people who must make it work
– Be updated when contact information changes– Be briefed to all personnel along with their
responsibilities – Should be practiced so personnel receive training
in emergency response procedures
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The Attributes of an SMSThe Attributes of an SMS
11) Performance Measurement and Continuous Improvement
– Safety performance monitoring used as feedback to improve the system
– Address individual areas (preflight, FOD, fueling)– Are SMART (Specific, Measurable, Achievable,
Results Oriented, Timely)– Linked to the organization’s operations/business
performance measures
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LEADERSHIP SAFETY & LEADERSHIP SAFETY & STANDARDSSTANDARDS
Management’s role & responsibilities Intentional non-compliance Know procedures produce known outcomes Standards produce repeatable results Bad rules produce bad results Standards are mechanisms for changing
bad rules
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STANDARDSSTANDARDS Standards increase likelihood of
repeatable results Known procedures produce known results Bad rules produce produce bad results Enhance conflict resolution
– Airlines cover almost every situation and the proper response in writing – Why?
– Just follow the rules and eliminate majority of accidents
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DEVIATION FROM DEVIATION FROM STANDARDSSTANDARDS
Behavior is a function of consequences– Run a red light, you get a ticket
I.D. & correct immediately Be consistent – No freebees Be fair Counsel, train, discipline, ground and
remove
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BREAKING RULESBREAKING RULES
Breaking the rules usually does not always result in an accident, however:
It always results in a greater risk for the operation!
Never take UNNECESSARY RISKS!
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NON-COMPLIANCENON-COMPLIANCE
Non-compliance rarely results in an accident or incident, however:
It always results in greater risk for the operation!
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Intentional Non-ComplianceIntentional Non-Compliance Research Shows – Once you start deviating from
the rules, you are almost twice as likely to commit an error with potentially serious consequences!
We could eliminate 70-80% of the accidents just by following the rules. *
NOTE: Read the NTSB accident reports on the HAI website. Should be a requirement for all personnel
Honest mistakes vs. intentional non-compliance
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Why is Insight Important for Why is Insight Important for Safety Leaders?Safety Leaders?
With this insight:– You will understand the hazards & risks you face– You will understand how to control them– You will know how these controls are working in service– You will learn from when controls fail– You can drive improvements to take us towards
achieving & sustaining a zero accident rate Your “Culture of Safety” needs to be a
culture that:– Embraces the concept of an SMS as a means to the a
zero rate end – Drives continuous improvement
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Are We Rewarding the Right Are We Rewarding the Right People?People?
Supervisors know who will & won’t break the rules
Rule breakers are often rewarded for mission accomplishment
Reward systems are often upside down. We should reward the normal, positive performance that complies with organization standards.
What you reward today will get done tomorrow
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Success SolutionsSuccess Solutions Reinforced bad behavior breeds continued bad
behavior
Rationalization of the gravity of the situation seems to lessen the risk in our minds, but in reality does not
Habitual rule breaking is often condoned by management when they look the other way
Does complacency play a role in this issue?
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How the Processes Gives InsightHow the Processes Gives Insight
Risk Management(e.g.: hazard identification,risk assessment
Foresight
Monitoring(e.g.: supervision, Inspections, audits, HUMS
Oversight
Safety Reporting& Investigation
Hindsight
Insight
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How the Processes InteractHow the Processes Interact
Risk ManagementProactive Planning
MonitoringProactive Checking
Safety Reporting& InvestigationReactive Checking
Feedback / Feed-forward
But all three processes are also there to Act to introduce improvements…
Continuous Improvement
These improvements are vital if you are going to achieve & sustain a zero rate
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PDCA: Putting the Processes PDCA: Putting the Processes in Contextin Context
Plan Do Check Act Cycle– Plan what we are going
to do– Do it– Check performance– Act to improve
Q: So where would you put the three process?
Risk Management
MonitoringSafety Reporting & Investigation
All 3 can result in Action
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ATTITUDEATTITUDE
“What lies behind us and what lies before us are tiny matters compared to what lies within us.”
Ralph Waldo Emerson
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“The hardest thing to do, and the right thing to do are usually the same thing.”
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COMMUNICATION COMMUNICATION BARRIERSBARRIERS
Position/Rank Age Gender Organization culture Predispositions (attitude) Assumptions
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SummarySummary The guiding principle of risk management is
elimination of accidents “Safety’s” role is the maximization of
effectiveness and efficiency A Safety Management System aims to
establish and maintain this control1. Reduce loss (people, production, assets, environment)2. Strengthen Management performance and organizational
culture3. Advance the Technology and knowledge base4. Demonstrate Compliance5. Provide a performance advantage