hazard management ihst/ehest safety workshop -london 25 …ihsf.aero/sms/sheffield_risk.pdf ·...
TRANSCRIPT
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Hazard Management
IHST/EHEST Safety Workshop - London
25 September2013
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• Already have an SMS?
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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.
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Session Plan
• Discussion• Exercises
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• 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
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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
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Indentify and Mitigate Key Hazards
• Brainstorm • Assess• Mitigate
– Barriers
– Controls– Recovery Measures
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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
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Hazard/Risk Management Process
SCOPE OF ACTIVITY
IDENTIFY AND RECORD HAZARDS
RISK ANALYSIS
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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.
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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
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• Too vague and open to different interpretation.
• Detailed definition required for likelihood and severity.
Typical RAM
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Detailed RAM
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Detailed RAM
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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
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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
Vs
The safety benefit realised from the control
While it is proportional, continue.When it gets disproportional, stop.
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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
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Step 4 – Controls for Specific Hazards
• Effective
• Costs proportional to benefits
• Practical
• Acceptable
• Enforceable
• Sustainable
• Doesn’t create new hazards
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Step 4 – Controls for Specific Hazards
1.01 Weather
CFIT:
Inadvertent Entry to IMC
How do we preventthis from happening?
Add controls/barriers to the process
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1.01 Weather
CFIT:
Company Weather Operating Limits
Inadvertent Entry to IMC
Now start asking questions “How can that control fail?”“What if…….”
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1.01 Weather
CFIT:
Company Weather Operating Limits
Inadvertent Entry to IMC
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
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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
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Basic Hazard Register ExampleTask Description/Location
Onshore seismic support Reference No. Date last reviewed
HS - 017 Sept 12
Hazard Description: Inadvertent entry to IMC RAM Score
Initial Current
Barriers, Controls & Recovery Measures Reference Owner Status
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.
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1.01 Weather
CFIT:
Company Weather Operating Limits
Inadvertent Entry to IMC
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
Do I need another control?Is the one I have fully effective?
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1.01 Weather
CFIT:
Aircraft Equipped for Basic IMC flight
Company Weather Operating Limits
Inadvertent Entry to IMC
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
What if……?
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1.01 Weather
CFIT:
Aircraft Equipped for Basic IMC flight
Company Weather Operating Limits
Inadvertent Entry to IMC
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
Simulator Training including IFR
procedures
Annual Instrument Flight Check
Pilot Instrument Rated
PIlot Instrument Flying Competency
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1.01 Weather
CFIT:
All Aircraft Equipted with TAWS
Aircraft Equipped for Basic IMC flight
Company Weather Operating Limits
Inadvertent Entry to IMC
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
Simulator Training including IFR
procedures
Annual Instrument Flight Check
Pilot Instrument Rated
PIlot Instrument Flying Competency
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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
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.
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Task 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
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
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1.01 Weather
CFIT:
All Aircraft Equipted with TAWS
Aircraft Equipped for Basic IMC flight
Company Weather Operating Limits
Inadvertent Entry to IMC
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
Simulator Training including IFR
procedures
Annual Instrument Flight Check
Pilot Instrument Rated
PIlot Instrument Flying Competency
Now consider the hazard consequences and how to mitigate them.
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1.01 Weather
CFIT:
All Aircraft Equipted with TAWS
Aircraft Equipped for Basic IMC flight
Company Weather Operating Limits
Inadvertent Entry to IMC
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
Simulator Training including IFR
procedures
Annual Instrument Flight Check
Pilot Instrument Rated
PIlot Instrument Flying Competency
Unknown Aircraft Location
Inadequate ER
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1.01 Weather
CFIT:
All Aircraft Equipted with TAWS
Aircraft Equipped for Basic IMC flight
Company Weather Operating Limits
Inadvertent Entry to IMC
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
Simulator Training including IFR
procedures
Annual Instrument Flight Check
Pilot Instrument Rated
PIlot Instrument Flying Competency
Satelite Flight Tracking
Unknown Aircraft Location
ERP in Place and Exercised Annually
Inadequate ER
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Task 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
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. Min 30 min
Inadvertent IFR procedures trained and checked during annual simulator training.
All aircraft equipped with TAWS
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Task 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
Minimum company weather limits for VFR operations
Accurate daily forecasts available for operation
Weather limits agreed with client
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
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Hazard Management ProcessSCOPE OF ACTIVITY
IDENTIFY AND RECORD HAZARDS
RISK ANALYSIS
IDENTIFY CONTROLS FOR SPECIFIC HAZARDS
REFERENCE DOCUMENTS AND
RESPONSIBLE POSTS
CONTROL EXISTS
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Task 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
Minimum company weather limits for VFR operations
Accurate daily forecasts available for operation
Weather limits agreed with client
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
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Task 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
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
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Hazard Management ProcessSCOPE OF ACTIVITY
IDENTIFY AND RECORD HAZARDS
RISK ANALYSIS
IDENTIFY CONTROLS FOR SPECIFIC HAZARDS
REFERENCE DOCUMENTS AND
RESPONSIBLE POSTS
REMEDIAL ACTION PLAN
CONTROL EXISTS NEW CONTROL REQUIRED
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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.
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Task 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
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 to 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 currency and competence. Min 30 min
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
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Task 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
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 to changes in weather.
RAP Item 16 Director Operations
Due 31 Dec 13
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 currency and competence. Min 30 min
Training Man 6.4 Chief Pilot In force
Inadvertent IFR procedures trained and checked during annual simulator training.
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
Emergency response plan in place & exercised annually with client
ERP 5.6 and Standard
Head of Safety & QA
In force
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Step 6 – Remedial Action Plan
• Re-assess risk
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Task 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
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 to changes in weather.
RAP Item 16 Director Operations
Due 31 Dec 13
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 currency and competence. Min 30 min
Training Man 6.4 Chief Pilot In force
Inadvertent IFR procedures trained and checked during annual simulator training.
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
Emergency response plan in place & exercised annually with client
ERP 5.6 and Standard
Head of Safety & QA
In force
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Task 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
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 to changes in weather.
RAP Item 16 Director Operations
Due 31 Dec 13
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 currency and competence. Min 30 min
Training Man 6.4 Chief Pilot In force
Inadvertent IFR procedures trained and checked during annual simulator training.
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
Emergency response plan in place & exercised annually with client
ERP 5.6 and Standard
Head of Safety & QA
In force
Operator assessed that untilSim training, TAWS and the
EOC were in place, risk remained medium.
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Hazard Management ProcessSCOPE OF ACTIVITY
IDENTIFY AND RECORD HAZARDS
RISK ANALYSIS
IDENTIFY CONTROLS FOR SPECIFIC HAZARDS
REFERENCE DOCUMENTS AND
RESPONSIBLE POSTS
REMEDIAL ACTION PLAN
CONTROL EXISTS NEW CONTROL REQUIRED
CONTROL DEVELOPED
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Step 7 – Interface with Quality
The quality management system must be integrated with the hazard management system.
Wasted effort alert
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SCOPE OF ACTIVITY
IDENTIFY AND RECORD HAZARDS
RISK ANALYSIS
IDENTIFY CONTROLS FOR SPECIFIC HAZARDS
REFERENCE DOCUMENTS AND
RESPONSIBLE POSTS
REMEDIAL ACTION PLAN
CONTROL EXISTS NEW CONTROL REQUIRED
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.
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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
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SCOPE OF ACTIVITY
IDENTIFY AND RECORD HAZARDS
RISK ANALYSIS
IDENTIFY CONTROLS FOR SPECIFIC HAZARDS
REFERENCE DOCUMENTS AND
RESPONSIBLE POSTS
REMEDIAL ACTION PLAN
CONTROL EXISTS NEW CONTROL REQUIRED
CONTROL DEVELOPED
QUALITY SYSTEM –UPDATE
CHECKLISTS
INTERNAL AUDIT TO CONFIRM
IMPLEMENTATION & EFFECTIVENESSOF CONTROLS
SAFETY REPORTING &
INVESTIGATION
SAFETY REPOPTING & INVESTIGATION PROCESS LINKED DIRECTLY TO THE
HAZARD MANAGEMENT
PROCESS.
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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.
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• 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.
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Task 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
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 to changes in weather.
RAP Item 16 Director Operations
Due 31 Dec 13
Aircraft equipped for IFR flight (Designate minimum avionic equipment)
Ops Man 8.3.1 Maintenance Director
In force
Pilots instrument rated Ops Man 3.4 Chief Pilot In force
Annual inadvertent IFR flight check to ensure currency and competence.
Training Man 6.4 Chief Pilot In force
Inadvertent IFR procedures trained and checked during annual simulator training.
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 Maintenance
DirectorIn force
Emergency response plan in place & exercised annually with client
ERP 5.6 and Standard contract clause 10.1
Head of Safety & QA
In force
����
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Task 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
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 to changes in weather.
RAP Item 16 Director Operations
Due 31 Dec 13
Aircraft equipped for IFR flight (Designate minimum avionic equipment)
Ops Man 8.3.1 Maintenance Director
In force
Pilots instrument rated Ops Man 3.4 Chief Pilot In force
Annual inadvertent IFR flight check to ensure currency and competence.
Training Man 6.4 Chief Pilot In force
Inadvertent IFR procedures trained and checked during annual simulator training.
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 Maintenance
DirectorIn force
Emergency response plan in place & exercised annually with client
ERP 5.6 and Standard contract clause 10.1
Head of Safety & QA
In force
����
����
����
����
����
Amend contractrequirements
Accelerateintroduction
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Task 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 Referece Owner Status
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 to changes in weather.
RAP Item 16 Director Operations
Due 31 Dec 13
Aircraft equipped for IFR flight (Designate minimum avionic equipment)
Ops Man 8.3.1 Maintenance Director
In force
Pilots instrument rated Ops Man 3.4 Chief Pilot In force
Annual inadvertent IFR flight check to ensure currency and competence.
Training Man 6.4 Chief Pilot In force
Wx limits and EOC requirements included in Pilot annual ground training syllabus
Training Man 6.12
Chief Pilot
Inadvertent IFR procedures trained and checked during annual simulator training.
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 Maintenance
DirectorIn force
Emergency response plan in place & exercised annually with client
ERP 5.6 and Standard contract clause 10.1
Head of Safety & QA
In force
����
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Add and record a further control
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1.01 Weather
CFIT:
All Aircraft Equipted with TAWS
Aircraft Equipped for Basic IMC flight
Company Weather Operating Limits
Inadvertent Entry to IMC
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
Simulator Training including IFR
procedures
Annual Instrument Flight Check
Pilot Instrument Rated
PIlot Instrument Flying Competency
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1.01 Weather
CFIT:
All Aircraft Equipted with TAWS
Aircraft Equipped for Basic IMC flight
Company Weather Operating Limits
Inadvertent Entry to IMC
Acurate Daily WX Forecast
Unknown WX forecast
WX limits held by client site supervisor
WX limits agreed with client
Client unaware of Company WX limits
EOC & WX limits in pilots annual ground
training syllabus
Enhanced Operational Control (EOC)
procedure in place
Client pressure to fly
Simulator Training including IFR
procedures
Annual Instrument Flight Check
Pilot Instrument Rated
PIlot Instrument Flying Competency
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SCOPE OF ACTIVITY
IDENTIFY AND RECORD HAZARDS
RISK ANALYSIS
IDENTIFY CONTROLS FOR SPECIFIC HAZARDS
REFERENCE DOCUMENTS AND
RESPONSIBLE POSTS
REMEDIAL ACTION PLAN
CONTROL EXISTS NEW CONTROL REQUIRED
CONTROL DEVELOPED
QUALITY SYSTEM –UPDATE
CHECKLISTS
INTERNAL AUDIT TO CONFIRM
IMPLEMENTATION & EFFECTIVENESSOF CONTROLS
SAFETY REPORTING &
INVESTIGATION
VALIDATE EXISTING CONTROLS OR DEVELOP
NEW CONTROLS
PROCESS NEW HAZARDS
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SCOPE OF ACTIVITY
IDENTIFY AND RECORD HAZARDS
RISK ANALYSIS
IDENTIFY CONTROLS FOR SPECIFIC HAZARDS
REFERENCE DOCUMENTS AND
RESPONSIBLE POSTS
REMEDIAL ACTION PLAN
CONTROL EXISTS NEW CONTROL REQUIRED
CONTROL DEVELOPED
QUALITY SYSTEM –UPDATE
CHECKLISTS
INTERNAL AUDIT TO CONFIRM
IMPLEMENTATION & EFFECTIVENESSOF CONTROLS
SAFETY REPORTING &
INVESTIGATION
VALIDATE EXISTING CONTROLS OR DEVELOP
NEW CONTROLS
PROCESS NEW HAZARDS
MANAGEMENT OF CHANGE PROCESS
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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…?
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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.
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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.
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Scope of Change
Ref #
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
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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 __________
Department/location Responsible Hazard Register Reviewed/Updated
Signature
Summary of Actions Arising Responsible Due Date & Signature
Statement of Completion/Fitness Accountable Manager Date & Signature
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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 __________
Department/location Responsible Hazard Register Reviewed/Updated
Signature
Maintenance DepartmentTraining DepartmentFlight Operations DepartmentSafety & Quality DepartmentEdmonton Base
Calgary Base
Summary of Actions Arising Responsible Due Date & Signature
Statement of Completion/Fitness Accountable Manager Date & Signature
List all stakeholders
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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 __________
Department/location Responsible Hazard Register Reviewed/Updated
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
Summary of Actions Arising Responsible Due Date & Signature
Statement of Completion/Fitness Accountable Manager Date & Signature
Once a department has completed its review of the
Hazard Register, the responsible party will
sign for completion
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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 __________
Department/location Responsible Hazard Register Reviewed/Updated
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
Summary of Actions Arising Responsible Due Date & Signature
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.
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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 __________
Department/location Responsible Hazard Register Reviewed/Updated
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
Summary of Actions Arising Responsible Due Date & Signature
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
Statement of Completion/Fitness Accountable Manager Date & Signature
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
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VALIDATE EXISTING CONTROLS OR DEVELOP
NEW CONTROLS
SCOPE OF ACTIVITY
IDENTIFY AND RECORD HAZARDS
RISK ANALYSIS
IDENTIFY CONTROLS FOR SPECIFIC HAZARDS
REFERENCE DOCUMENTS AND
RESPONSIBLE POSTS
REMEDIAL ACTION PLAN
CONTROL EXISTS NEW CONTROL REQUIRED
CONTROL DEVELOPED
QUALITY SYSTEM –UPDATE
CHECKLISTS
INTERNAL AUDIT TO CONFIRM
IMPLEMENTATION & EFFECTIVENESSOF CONTROLS
SAFETY REPORTING &
INVESTIGATION
PROCESS NEW HAZARDS
MANAGEMENT OF CHANGE PROCESS
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SCOPE OF ACTIVITY
IDENTIFY AND RECORD HAZARDS
RISK ANALYSIS
IDENTIFY CONTROLS FOR SPECIFIC HAZARDS
REFERENCE DOCUMENTS AND
RESPONSIBLE POSTS
REMEDIAL ACTION PLAN
CONTROL EXISTS NEW CONTROL REQUIRED
CONTROL DEVELOPED
QUALITY SYSTEM –UPDATE
CHECKLISTS
INTERNAL AUDIT TO CONFIRM
IMPLEMENTATION & EFFECTIVENESSOF CONTROLS
SAFETY REPORTING &
INVESTIGATION
PROCESS NEW HAZARDS
MANAGEMENT OF CHANGE PROCESS
MANAGEMENT REVIEW
VALIDATE EXISTING CONTROLS OR DEVELOP
NEW CONTROLS
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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
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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
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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.”
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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