sms sans frontières – presentation to asbaa shanghai and fsf bass san diego ir. roger lee...
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SMS Sans Frontières – presentation to AsBAA Shanghai and FSF BASS San Diego
Ir. Roger LeeDirector People, Safety and Quality
Metrojet April 2014
INTRODUCTION
Quick introduction of Metrojet’s CSQ TeamAsia’s Economic Development and Business Aviation growthImplementation of SMS – Metrojet’s experience in walking on the SMS frontièresOur commonality in safetyDelivering Safety san Frontiers as industry partners
2
GREETINGS FROM METROJET’S CSQ TEAM
3
THE CORPORATE SAFETY & QUALITY TEAM
Roger LeeDirector People, Safety
and Quality
TrainingCrisis Management
ERPEngineering
Cecilia LeeSenior Corporate Safety
& Quality Analyst
SecurityManagement Reporting
Ground Operational SafetyConfidential Reporting
System
Sue Ann LawCorporate Safety &
Quality Analyst
Occupational Safety and HealthEU-ETS
Safety PromotionsSafety and Quality Support
Operational World + Safety Officers
Hans von BlucherManager, Air Safety
Air SafetyFlight Data Monitoring
ONE AIRCRAFT DELIVERY TO ASIA PACIFIC EVERY THREE DAYS FOR THE NEXT 10 YEARS
5
870 aircraft currently , 2,845 expected by 2019
High growth rate of 16% per annum in China
Home to 6% of the worldwide business jet fleet
China - around 360 jets registered , 1000 business jets anticipated to arrive in the next 10 years
Fewer than 200 civil airports in China and many of them are not available to private aircrafts.
Business jets in Asia are more for personal use rather than corporate (9:1)
South Asia485 Business Jets
US$12.0bn
Oceania263 Business Jets
US$6.0bn
China635 Business Jets
US$21.0bn
Northeast Asia90 Business Jets
US$2.9bn
Southeast Asia
217 Business JetsUS$6.1bn
Source: Embraer Analysis – totals may differ due to rounding – sustained growth scenario
INFRASTRUCTURE TO SUPPORT BUSINESS AVIATION?
6
Circle Size indicates the number of aircrafts based at a location
• 360 Business Jets (Greater China)
• 190 public use airports
• Over 110 military only airports
• 1.6 airports per 100,000 km2 land
• Only 6 business jet MROs
China• 14’000 Business Jets• >5’000 public use
airports• >51 airports per
100,000 km2 land• 1.2 million jobs• 150 USD billion
economic output
USA
Sources: - US Figures: NBAA- China Figures: Asian Sky Group, Metrojet Research
METROJET 2013/14 FAST FACTS
7
34Aircraft in Fleet
2500Flight Legs
100,000Engineering Hours
7600Total Flight Hours
300Staff
22Nationalities
>100Pilots & FA
HK Home Carrier
17 yearsheritage in Hong Kong
>100Staff in Engineering
30%Market Share
650Charter Passengers
THE FLEET GROWS STEADILY
8
2010/11 2011/12 2012/13 2013/14
24 25 27
34
42%fleet
increase since 2010
METROJET’S AIRCRAFT MAINTENANCE FACILITIES IN ASIA
9
China – Hong Kong, SAR- Metrojet’s Headquarters - 300 staff with over 70 pilots and 110 maintenance professionals - Offer a complete range of aircraft management, aircraft charter, and aircraft maintenance service- Open since 1997
China – Zhuhai- Joint Venture with Hanxing Zhuhai General Aviation to form Metrojet Hanxing, located at Zhuhai airport- Over 15,000 ft2 of hangar space- Enhance the overall aircraft maintenance capability in China Philippines – Clark - Metrojet Engineering Clark (MEC) was established in 2012- Located at Diosdado Macapagal International Airport (DMIA) in the Clark Freeport Zone- A Maintenance, Repair and Overhaul facility catering to increasing demands in the SE Asia region- Over 13,000 ft2 of hangar space
India – Mumbai- Joint venture with Taj Air to form TajAir Metrojet Aviation- Aircraft maintenance capabilities
COMMON PERCEPTION IN BUSINESS AVIATION
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CROSSING THE FRONTIÈRES THROUGH 4 PILLARS OF SAFETY MANAGEMENT
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LEADING BUSINESS AVIATION COMPANY IN ASIA
Safety Policy and Objectives
Safety Assurance
Safety promotion Safety Risk
Management
Best People ◦ Highest Standards ◦ Operational & Service Excellence
1 Customer
2 Product
3 People
4 Operations
5 Finance
CHALLENGES – SMS PILLAR ONE
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Policies
“Plug and Play” policies, procedure and personnel?Complex regulatory environment evolved from commercial aviationSafety standard can potentially be used as commercial bargaining chip by clients
CHALLENGES – SMS PILLAR TWO
13
Risk Management
“Why do we need to risk assess? We have been flying this same route for so long?”“what is its value”“Secondary Duties” mentalityLack of skilled risk assessor – SME involvement crucialRetention of knowledge through a dynamic labour marketTime consuming
Tactical RA
Landscape RA
PDCA cycle
METROJET’S OPERATIONAL RISK PICTURE USING BOW TIE ANALYSIS
14
A
Root Cause, Precursor, or Triggering Event
B
Existing Controls or Avoidance Barriers
C
Undesirable Operational State (UOS)
D
Existing Controls or Recovery Barriers
E
Outcome
Risk
Lev
el
ALA
RP?
F
Additional Controls or Mitigation Required (feeds back into Column B)
Fina
l Ris
k
1. Circling approach
TAWS / EGPWS; Note to MLW: check MEL implications if EGPWS or any associated system is U/S.
Use of Global Navigation Satellite System (GNSS) based position feed to TAWS;
EGPWS database update protocols; Cockpit technology to assist situational
awareness (e.g. terrain overlay with certain aircraft);
Shared mental model and enhanced awareness through effective briefings;
Pilot awareness / training; Manual flying skills; Situational Awareness in relation to
proximity of terrain; Adherence to SOPs (task sharing, briefings,
use of checklists, standard calls and excessive-deviation callouts, mutual crosscheck and backup);
Cross-check of takeoff data: mass and balance, fuel distribution, wind component, runway conditions, flaps setting, V1/Vr speeds, and so on;
Adherence to sterile-cockpit rule; Compliance with the constant-angle non-
precision approach (CANPA) / constant descent final-approach (CDFA) concept;
Adequate use and supervision of automation;
Vertical and horizontal flight paths monitoring (situational and energy awareness);
Altimeter setting cross-check; Cross-checking cleared altitude versus
minimum safe altitude; Timely and adequate response to windshear
alert or warning; Timely go-around; Adherence to published missed-approach
procedure; Use of available aircraft technologies for
enhanced situation awareness (vertical situation display, head-up display, enhanced-vision, and so on);
Use of radio altimeter to improve situational awareness, provided that the flight crew are generally familiar with the terrain over which they are flying;
Awareness of: Minimum vectoring altitudes; Approach design criteria (PANS-OPS
versus TERPS); Relationship between track distance to
runway threshold and height (300 ft/nm rule-of-thumb);
Low-OAT correction to be added to minimum approach altitudes/heights;
Minimum safe radio-altimeter readings for each approach segment (IAF-IF, IF-FAF);
“Black-hole" or other visual illusions for prevailing approach / departure (e.g. Okinawa).
For Fatigue, see separate ‘Fatigue’ template.
Pre-CFIT condition: Loss of situational
(positional) awareness in relation to the proximity of terrain / surface;
Aircraft closing with terrain / surface – erosion of adequate safety margins.
Terrain Awareness Warning System TAWS (EGPWS) alert or warning;
Minimum Safe Altitude Warning (MSAW) warning – subsequent ATC intervention.
Timely and adequate flight crew response to EGPWS alert or warning - recovery of aircraft to a desirable operational state;
Land short (runway undershoot) event;
CFIT resulting in hull loss and fatalities.
2A*
1A*#
NO
Review and introduce to Company SOPs industry prevention strategies and best practices such as those produced by the FSF and Airbus (e.g. Flight Operations Briefing Notes – Operating Environment section: Enhancing Terrain Awareness);
Review SOPs and flight crew training to ensure compliance with the FSF ALAR Toolkit, the ALAR Risk Awareness Tool (RAT), the ALAR Risk Reduction Guide (RRG) and ALAR Briefing Notes;
Introduce aircraft / airport-specific Engine Out Standard Instrument Departure (EOSID) in case of engine failure after take-off at terrain limiting airports, using modern technology such as the subscription services of Guru or APG;
Provide additional flight crew training concerning the recognition of the precursors of CFIT, e.g. through awareness campaigns and through line training and testing – train the trainers accordingly;
CFIT awareness training (e.g. via simulator LOFT, using two Metrojet flight crew); Ensure that flight crew are properly training to carry out RNAV (GNSS)
approaches; Confirm the use the latest standard of EGPWS, fed with GPS-derived position
data; Ensure that adequate emergency escape routes exist in event of depressurisation
(e.g. over Iran); Ensure that QFE procedures are properly addressed in training; Develop and monitor Company SPIs to monitor significant events associated with
CFIT risk, e.g. from Safety Feedback Reports and through FDM: EGPWS warnings and alerts other than “pull up”; False / nuisance EGPWS warnings due to navigation or terrain database
errors; Incorrect flight crew response to EGPWS warnings; Unstable approaches continued to a landing (also as a proportion of all
unstable approaches); Significant deviations below glideslope (greater than x dots below yyy ft
AGL); Significant deviations about the localiser (greater than x dots below yyy ft
AGL); Altimeter setting errors.
Identify and analyse precursors through the examination of safety data from multiple reporting schemes, such as: Feedback from training (especially simulator) sessions; Pilots’ reports; FDM; Line observations; Survey and audit reports; Accident and incident investigations.
For Fatigue, see separate ‘Fatigue’ template.
2. Non-precision approach (especially premature descent to the next step-down altitude during a multiple-steps-down non-precision approach)
3. Unstable Approach, especially if slow and/or low (i.e. low energy state on approach) - flight below desired flight path during initial and/or final approach
4. Unclear / poor approach design and documentation / lack of familiarity with the approach or misreading of the approach plate, particularly where the approach features steps down from the IAF to the FAF
5. Failure to check navigation accuracy before approach
6. Lateral deviation during approach (STAR) 7. Incorrect or inappropriate radar vectoring by
ATC (i.e. below minimum vectoring altitude (MVA) and/or toward high terrain)
8. DME confusion (non-collocated DME versus ILS-DME), in identifying the final descent point
9. Premature descent to DA(H) before G/S intercept or premature descent to MDA(H) before final descent-point/FAF
10. Continued approach, when below DA(H) or MDA(H), after loss of visual references
11. QFE operations, especially if the EGPWS has to be turned off (e.g. Ordos in Inner Mongolia and Dalian)
12. Low altitude pattern following a go-around 13. Lack of effective flight path control during go-
around (e.g. go around in landing configuration with aircraft speed below VAPP resulting in significant loss of altitude)
14. Transition back to instrument flying during a go around
15. Failure to follow published missed-approach procedure
16. Failure to go-around 17. Descent / flight below segment or sector safe
altitude 18. Poor CRM (failure in cross checking /
coordination / monitoring) 19. Non-adherence to SOPs 20. ‘Press-on-itis’ 21. Fatigue 22. Inappropriate low altitude manoeuvring 23. Weather: rain, turbulence, and icing, may
increase flight crew workload and cause interference reducing the accuracy of radio navigation beacons / poor visibility and/or at night may lead to loss of situational awareness
24. Non- standard phraseology, leading to confusion and misunderstanding
25. Prolonged Loss of Communication (PLOC) 26. Low-on-fuel condition / fuel starvation 27. Low pitch attitude / shallow flight path /
altitude loss after lift-off 28. Flight below desired profile path during climb 29. Inability to make the prescribed minimum
climb gradient in event of engine failure after take-off at terrain limiting airports
30. Lateral deviation during climb (SID) 31. Altimeter setting error 32. Failure to revert to navaids raw data in case of
doubts about automation 33. Level Bust 34. “Black-hole" or other visual illusions 35. Late or inadequate response to windshear
warning
Root Cause, Contributing factors and initiating event
Existing defences
Undesirable state
Existing recovery barriers
Outcome
ALARP
METROJET’S RISK ASSESSMENT CRITERIA
15
Meaning in relation to People/life costs
Meaning in relation to financial/Property costs
Meaning in relation to reputational costs
Meaning in relation to Liability Cost
Meaning in relation to Environmental Cost
CHALLENGES – SMS PILLAR THREE
16
Safety Assurance
E-Audit and physical operational audit programme“What is business aviation?”Lack of designated FBOs and support facilities Lack of understanding in standardsHave to establish the level of compliance between our manuals and the “real world” – implementation of fleetwide Flight Data Analysis Programme – our biggest project so farInvestigation – 5’Ms, MEDA important
17
Incidents and Occurrences
a) Class A and B events in last reporting period b) Outstanding Insurance claims accumulated values
Headline Message: Sample: This reporting period, there have been 5 cases of
risk bearing events triggering the RED status
Trends
a) Reporting rate proportionality with ground
movement and flight ops exposure b) Rolling 3 months average of Class A and B
compared with last reporting period c) Class A and B personal injury events per 1000 staff
Headline Message: ……
Assurance
a) Level 1 and 2 regulatory audit findings b) Level 1 and 2 internal and external audit findings c) Outstanding actions and recommendations from
audits and investigation follow up d) Investigation recommendations follow up and
closure e) OHSE audit findings
Headline Message:
……
Safety Culture
a) SRB, SAG committee meetings held - schedule b) SRB, SAG committee meetings held - attendance c) SRB, SAG actions followed up and closed d) Regular review of the Safety and Quality Risk
Picture e) Corporate QMS and audits completed within
prescribed timescale f) Engineering internal audits completed within
prescribed timescale g) Number of anonymous safety reports h) Number of new reports from first time submitters
Headline Message:
……
METROJET’S SAFETY BALANCED SCORECARD
CHALLENGES – SMS PILLAR FOUR
18
Safety Promotion
Apprehensive - “trust” of the safety systemInfluence by “macro environment”International workforceTargeted communication with consideration of cultural and professional groups differencesApply to a mobile workforce who needs to access the information anytime, anywhereMultilingual Resource hungry if done properly!
PROMOTING SAFETY THROUGH GROWTH
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• Theme of the 2-months• Safety Digest• Making use of IT Platform• Safety Mascot Competition
2013-2014 SAFETY MASCOT COMPETITION
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THE CULTURAL CHALLENGES
21
TRAIN, TRAIN, TRAIN
22
SHARE SAFETY
Safety – we need to shareWithout information sharing, safety is dead
AS AN INDUSTRY, WHAT CAN WE DO?
24
Training– Clients– Staff– Regulators– Perspective staff
Sharing– Regional specific hazards and trends– Risk bearing occurrences– Global trends– Lessons learnt– Proactive data
Alignment– Alignment of safety standards and the “safety norm”
Understanding and declaring what the minimum standard is for Asia Business Aviation industryShare – lessons learnt, deidentified safety dataRisk based approachSafety Promotion ResourcesAsia Business Aviation safety forumSafety and ERP Industry Go team
CONCLUSION
With growth comes risks – which must be managed in a systematic and structured manner
Unfortunately, nothing called “plug and play” in aviation – having the policy, procedure or the hardware does not mean one is safe. These need to be continuously internalized.
Safety is one of the core functions of any aviation business, just like finance, marketing, engineering and flight operations which contribute towards the ROI, NPV and EBIT of an operator
Lets address safety as an industry team
25
FINALLY
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BUSINESS AV SAFETY
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