safety management systems (sms) and decision making

Heli-Expo 2013

International Helicopter Safety Team

SMS Committee

WHO’S THIS GUY?

Bryan SmithAirborne Law Enforcement

Association Safety Program Manager

Lee County Sheriff’s Office (FL)

IHST SMS Committee Chair

[email protected]

• Many of these slides have only speaker’s notes I use during class.

• I have also removed many of the videos in order to make the file sizes more manageable.

• In these online versions I have added some additional information to the bottom of many slides. This additional info should help to explain the main points of the slide.

• If you still have questions or would like to see the videos that have been removed, please contact me.

• Many of the charts can be found in the 2011 JSHAT report: http://www.ihst.org/portals/54/US_JSHAT_Compendium_Report1.pdf

• Page numbers at the bottom of some slides refer to the FREE ALEA SMS Toolkit (2nd edition), which can be downloaded here… https://www.alea.org/assets/cms/files/safety/SMS-Toolkit.pdf

• If you are still looking at this in the ‘edit’ mode – hit [F5] or go to ‘Slide Show’ on the menu bar and click ‘From Current Slide’ second from the left.

-Bryan

http://www.ihst.org/portals/54/US_JSHAT_Compendium_Report1.pdf

https://www.alea.org/assets/cms/files/safety/SMS-Toolkit.pdf

SETTING THE GAUGES

• Who is with us today?

• Who currently works with an established SMS?

• Who is working on establishing an SMS?

• Who is with us today?

• Who currently works with an established SMS?

• Who is working on establishing an SMS?

Another Safety Class?

Safety classes and programs have a bad reputation of being boring and limiting to operations, especially those operations that are regarded as necessary ones to ‘get the job done’ or, frankly, the ‘fun stuff’. We need to start with an understanding that safety programs can actually increase productivity, profit and ensure a long career in a fun job

Is this how SMS is seen at your operation?This is the reality…

FLIGHT PLAN…1. Brief Review of SMS

2. In depth look at key components

3. SMS and Decision Making

4. Open Workshop Discussion

1. Brief Review of SMS


3. SMS and Decision Making


1. BRIEF REVIEW OF SMS

“Insanity is doing the same thing over and over again, and expecting different results.”

~Albert Einstein

WHY DO WE NEED SMS?

• Industry-wide Helicopter Stats:Industry-wide Helicopter Stats:

• 41% Loss of Control41% Loss of Control

• 32% Autorotation32% Autorotation

• 3% CFIT3% CFIT

• Average total time 4000 hours Average total time 4000 hours

• 237 less than 500hrs in make and model (45%)237 less than 500hrs in make and model (45%)

• *August 2011 JHSAT report

• Industry-wide Helicopter Stats:Industry-wide Helicopter Stats:

• 41% Loss of Control41% Loss of Control

• 32% Autorotation32% Autorotation

• 3% CFIT3% CFIT

• Average total time 4000 hours Average total time 4000 hours

• 237 less than 500hrs in make and model (45%)237 less than 500hrs in make and model (45%)

• *August 2011 JHSAT report

It is little surprise for most of us to see what is causing accidents. The usual suspects. A couple surprising points come out of the data, such as the high rate of accidents during repositioning and RTB phases of flight. Also the high average total time for accident pilots was striking. The low number of hours in make/model in those same pilots is also important to note. We will revisit these points a little later on. But what we are left with is a general plateau in the accident rate. So we have a choice, write off the remaining rate as an unavoidable cost of doing business, or do something else.

“They were convinced, without study, that nothing could be done about

such an emergency. The intellectual curiosity and skepticism that a

solid safety culture requires was almost entirely absent” the report

further stated that such a culture was, “incompatible with an

organization that deals with high-risk technology”-Space Shuttle Columbia Accident Review Board

“They were convinced, without study, that nothing could be done about

such an emergency. The intellectual curiosity and skepticism that a

solid safety culture requires was almost entirely absent” the report

further stated that such a culture was, “incompatible with an

organization that deals with high-risk technology”-Space Shuttle Columbia Accident Review Board

"One thing we learned from this accident is that if safety is not the highest organizational priority, an organization may accomplish more missions, but there can be a high price to pay for that success,"

The Board also identified a number of safety-related deficiencies in the NMSP's aviation policies. Some of these deficiencies included the lack of a requirement for a risk assessment at any point during a mission; the lack of an effective fatigue management program for pilots

As a result of this accident investigation, the NTSB issued recommendations addressing pilot decision-making, safety management system programs and risk assessments,

The recommendations were issued to the Governor of New Mexico, the Airborne Law Enforcement Association, the International Association of Chiefs of Police, and the National Association of State Aviation Officials.

"One thing we learned from this accident is that if safety is not the highest organizational priority, an organization may accomplish more missions, but there can be a high price to pay for that success,"

The Board also identified a number of safety-related deficiencies in the NMSP's aviation policies. Some of these deficiencies included the lack of a requirement for a risk assessment at any point during a mission; the lack of an effective fatigue management program for pilots

As a result of this accident investigation, the NTSB issued recommendations addressing pilot decision-making, safety management system programs and risk assessments,

The recommendations were issued to the Governor of New Mexico, the Airborne Law Enforcement Association, the International Association of Chiefs of Police, and the National Association of State Aviation Officials.

Recent Landmark Cases in Aviation Risk Management:

•Carson Helicopters S-61 ‘Iron 44’

•New Mexico State Police

• In the 1970’s Occupational Risk Management was implemented to shift safety management from government oversight to individual professions.

• Risk Management brought into public sector in late 1980’s – legal, injury based. Mostly reactive policy changes. Spearheaded by military, EPA, etc.

• Gradual shift to more ‘complete’ management of system wide risk in 1990’s (Swiss Cheese, etc.). Management Training (little emphasis on employee inclusion)

• Sept 11, 2001 – no more excuses. Cannot write anything off as unmanageable because of the ‘nature’ of the business. Complete cultural changes still being implemented. All risk can be mitigated… we are accountable for everything.

• FAA SMS Program implementation 2006

SHIFT IN DEFINITION OF WHAT ‘RISK’ IS

Sources: Gander et al, 2009; O’Hara, 2005; Archbold, 2005

“The program does not employ any policy guidance to aid the pilot in making risk managed decisions with respect to flight scheduling decision making..”

~Excerpt from a NTSB report of a fatal law enforcement IIMC/CFIT accident

“The program does not employ any policy guidance to aid the pilot in making risk managed decisions with respect to flight scheduling decision making..”

~Excerpt from a NTSB report of a fatal law enforcement IIMC/CFIT accident

Actually, we don’t really have a choice anymore. There has been a shift in the definition of risk. Risk is defined - by society, not us - as an acceptable probability of an unfavorable outcome. What used to be acceptable, no longer is. What we used to write of as ‘the cost of doing business’ is no longer acceptable, as seen in accident responses and litigation over the last ten years.

“If you had one superpower, what would it be?”

“Luck.”

Since we do not have this superpower either…we need something better than the traditional safety program.

LIMITS OF TRADITIONAL SAFETY PROGRAMS…• Limited understanding exactly what the threats are

• No analysis of the nature (prioritization) of the risks that create accidents

• System of ‘educated guesses’ based on personal experiences

• No method of tracking safety implementations (for ROI and Effectiveness)

LTE

Training

Weather

Maintenance

Fatigue

Mid-a

irPilot Error

Historically the biggest challenge to safety was simply a failure to get a handle on the endless number of possible risks to our business. Typically we would deal with each one as they came up. The problem was they first needed to ‘come up’ which was often too late. It also led to a lot of wasted time and effort as we guessed at which threats needed to be dealt with. There area million threats out there. We either deal with it by being the ‘Chicken Little’ pointing out every possible danger we can think up or the “Maverick’ and just ignore them all expecting our personal ‘awesome’ness to pull us through.

THE TRADITIONAL SAFETY PROGRAM…

• The limits of a traditional Safety Program: • Reactionary• Focus on last couple links in the chain of errors direct or only those factors

directly related factors• ‘What’ not ‘Why’• Often uses only information from external sources• No prioritization

• Covers for unknown factors by limiting operations and applying across the board caution

• No method of tracking results of safety efforts

LEAD VS. LAG

• What is the aim of risk management?

LAGLEAD

What is the aim of risk management? It is not to prevent accidents…that is a byproduct. It is not simply identify all possible risks either. It is to identify the main ingredients in the witches brew that allows an accident to happen, understanding how they interact, and find a way of removing as many components as possible, even if it is just one. In this video ( http://www.youtube.com/watch?v=-eKsDwU7kdo ) we see there was no lag information generated – accident or incident. But is the witches brew complete? Yes. SMS can deal with this before his luck runs out. Look at the video. The challenging aspect of this from a safety point of view is the unsafe act did not generate any lag info. The fact that it did not also fueled the unsafe mentality for the pilot and anyone who saw it. Inexperienced pilots may mistake the lack of an accident for pilot skill and perceive it as a low risk maneuver. If we rely only on lag info, we will not keep this pilot, or others from having an accident.

http://www.youtube.com/watch?v=-eKsDwU7kdo

Safety Management Systems

Full SpectrumRisk AnalysisFull SpectrumRisk Analysis

InterventionRecommendations

InterventionRecommendations

PrioritizedImplementation

planning

PrioritizedImplementation

planning

WORKING TOWARDS A SOLUTION…

LTE

Training

Weather

Maintenance

Fatigue

Mid-a

ir

Pilot Error

SMS

• The pillars of a Safety Management System:

•Policy

•Risk Management

•Assurance

•Promotion

“Incomprehensible jargon is the hallmark of a profession.”

~Kingman Brewster Jr.

COMMON GROUND…

IHST SMS Toolkit p.6, 96

• Definition of SMS: The formal, top-down approach to managing safety risk. It includes systematic procedures, practices, and policies for the management of safety.

Safety: Policy• “What” is to be done, as opposed to ‘How”

objectives, safety commitment, etc.

• “Who” Authority, Responsibility, Roles• Set by management• Documentation and Records• Emergency Preparedness

IHST SMS Toolkit p. 6, 9, 15

FOUR PILLARS OF SMS

POLICY – RISK MANAGEMENT – ASSURANCE - PROMOTION

All operations conducted at Bob’s Helicopter Service will be done in the safest manner possible. No mission or customer is so important as to require deviation from safety policies, procedures, industry standards, or the prudent judgment of our employees. Safe operations are always the priority in every task we undertake.

Safety: Policy

IHST SMS Toolkit p. 14-16

FOUR PILLARS OF SMS


Safety Policy and Operations Policy should be the same document, not two separate ones. The organization’s policy should start with a safety statement. That statement should be more specific than ‘be safe’ or ‘safety first’. It should include a commitment to a Just Culture. It should also be signed by the chief administrator every year.

Safety: Risk Management• Risk Assessment and Control (Mitigation)

1. Context (scope of inquiry, limits of risk, POLICY)

2. ID Hazards (reports, audits, lag data, observation)

3. Analyze Risk (likelihood vs. consequence)

4. Evaluate Risk (Prioritize, compare to accepted risk limits)

5. Treat the Risks (policy/procedure, training, equipment, also under PROMOTION)

6. Monitor and Review (Safety ASSURANCE)

IHST SMS Toolkit p. 7, 27

FOUR PILLARS OF SMS


Risk Assessment and Control is mainly under the RM pillar, but it requires input from the other pillars to get the job done. Info used to ID hazards can also come from Assurance and Promotion Pillars. Interventions deigned in the RM process are trained for in the Promotion Pillar and documented in the Policy Pillar. Don’t get hung up on the idea that particular functions are only conducted under one pillar. They all work together.

The limits of what risks are acceptable are outlined in policy. This is the first step in setting your context. Then break the operations down into sections: training, normal ops, maintenance, scheduling, etc. This will allow you to focus your efforts instead of taking on every possible risk at once. Once context is defined…start looking for hazards…


FOUR PILLARS OF SMS


Bob County Sheriff’s Office Aviation Unit

Saf et y Sur vey 1. What are your biggest three safety concerns?

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. What suggestions do you have for addressing these safety concerns?

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3. How safe do you feel reporting safety hazards to the Safety Officer?

Very safe Neutral Not Safe

1 2 3 4 5 6 7

There are many methods of identifying hazards. Here are a couple examples. The Hazard ID form is in the toolkit (p.52). I also recommend using Lead Indicator Identification techniques (look for my presentation on that topic). Once the hazards are identified, one of the great strengths of an SMS is to then prioritize those risk using measurable labels. This chart is a easy to use method of doing just that (p.37 of toolkit). Another method will be discussed later.

IHST SMS Toolkit p.

FOUR PILLARS OF SMS

POLICY – RISK MANAGEMENT – ASSURANCE - PROMOTIONIHST SMS Toolkit p. 37, 87, 93

Safety: Assurance

• Policy and procedure (Intervention) performance monitoring.

• Management of change (impact of new factors, including safety interventions)

• Return on Investment (ROI) tracking• Requires use of metrics (quantification) to be

successful.

IHST SMS Toolkit p. 7, 28, 54, 61

FOUR PILLARS OF SMS


Safety Assurance is a component completely missing from most traditional Safety Programs. It is key to making sure efforts are being directed to the right places, policy and procedures are effective and that the benefits of the program are being tracked in order to keep employees invested and management supportive.

Safety: Assurance

Source: Dave Huntzinger

FOUR PILLARS OF SMS


0

10

20

30

40

50

60

70

80

Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09

Ops Normal

Waiver, Mitigate

STOP WORK

Let’s say you decide to use a preflight risk assessment in order to mitigate risk you’ve identified. Assurance can be obtained by tracking the assessments so you can see if they are having a positive impact on safety, failing to mitigate the targeted risk, or just wasting time.

Safety: Promotion•Training and Education

Initial, recurrent, general and specific Establish proficiency and currency requirements

•Communications SMS program performance, status Management’s commitment to the program Safety related information

IHST SMS Toolkit p. 68

FOUR PILLARS OF SMS




3. How SMS and Decision Making are connected


The quote describes the same rule that applies to having a Safety Program on the shelf that is either not used, or is ineffective.

• Safety Climate - The support and emphasis given to a safety program by administrators.

• Safety Knowledge – Actual safety information an employee has on how they should perform their work, and why

• Safety Culture - Actual safety practices and attitudes generally covering operations.

FOUR PILLARS OF SMS – A CLOSER LOOK


Source: Vinodkumar & Bhasi, 2010

These three components must be strong in each of the four pillars of an SMS, or one will fall and bring the others with it.

• It is likely that your program already has this component • Make this Safety Policy part of your operation’s SOP, not a

separate document• Is Safety ‘First’?? No, it is the product of doing business a

certain way• Set by management, but must include input from line level

staff• Scheduled updates with big-picture vision statements and

MEASURABLE intermediate objectives to pave the way.

IHST SMS Toolkit p.9, 15



Safety: Policy

Safety: Policy

FOUR PILLARS OF SMS

1. the intentional understatement of the helicopter's empty weight

2. the alteration of the power available chart to exaggerate the helicopter's lift capability

3. the practice of using unapproved above-minimum specification torque in performance calculations that, collectively, resulted in the pilots relying on performance calculations that significantly overestimated the helicopter's load-carrying capacity and did not provide an adequate performance margin for a successful takeoff

1. the intentional understatement of the helicopter's empty weight

2. the alteration of the power available chart to exaggerate the helicopter's lift capability

3. the practice of using unapproved above-minimum specification torque in performance calculations that, collectively, resulted in the pilots relying on performance calculations that significantly overestimated the helicopter's load-carrying capacity and did not provide an adequate performance margin for a successful takeoff


Look over these items from a landmark case. How many of them could have been addressed with a simple policy statement guiding all operations? Do you think one was written in a book somewhere? Probably. Why didn’t it work?

Policy and Risk Management-Hazard Identification requires input from everyone

-That input depends on Just Culture being written into policy



This picture shows blade damage that occurred after the pilot did his preflight. Fortunately the crewmember who caused the damage, while nobody was looking, trusted the just culture at the operation and reported the incident. If he had not, the pilot would have flown without seeing it. It was a case of normalized deviation that was occurring throughout the entire operation so it could have happened to anyone.


Safety: Risk Management• Risk can also be defined as:

R = I x T x V [ I,T,V value 1-4 ]

Impact – Level of damage and/or costThreat – Capability of risk to inflict estimated impactVulnerability – Of the person or resource to risk

Source – FBI; Lee, 2005



Bird Strike

I = 4

T = 1-4 (depends on bird size most often encountered in your area)

V= 1-4 (depends on altitudes, flight paths, safety equipment)

IIMC/CFIT

I = 4

T = 2-4 (Can very with policy on wx minimums, avionics, flight area)

V= 1-4 (depends on training, culture, experience)

Risk was earlier shown on a consequence vs. likelihood chart. Risk can also be defined this way…this formula gives you the opportunity to address either the environmental factor (T) or the human factor (V). This formula is used by the FBI to deal with security threats that have never happened, thus no lag info is available. This would be useful in operations that have not recently had an incident, to deal with management of change (avionics, mission, etc.) or a newly identified hazard. This formula could also be used to show the impact of an SMS driven Intervention (Control) or other variables. For example, the threat level (T) could change with a change in seasons, mission parameters, or equipment. The (V) Vulnerability factor could be changed with training, improved safety culture, etc.

Safety: Risk Management

•Need to develop policy AND procedures AND recommend training – normalized deviance



Failing to provide a suitable procedure and training to support a new policy can lead to normalized deviation. This is when a policy says one thing, but its understood that everybody does something against that policy as a general rule. Fatigue rules are a prime example of this. For example, a policy may say that crews get 8 hours of sleep. But if you have a 12 hour shift with a 45 minute drive each way and family at home it is unlikely that you will often get a full 8 hours. If you do not, or if you are ill, is there a procedure to allow crews to adhere to the policy (i.e. ability to have someone cover the shift, leave the shift open, etc.)? If not, the policy is just there as an administrative checkmark to cover liability for the organization, the policy does not improve safety.


Safety: Risk Management – Hazard Identification

•Don’t limit yourself to just looking at the direct factors in identified hazards or lag data •Search for Latent Factors as well•These can be used to develop LEAD INDICATORS •Swiss Cheese, 5-Why’s, etc




Safety: Risk Management – Latent Factors


1. “Why did Thunder Pig hit the side of the hangar with the tailboom?” “He lost control during a landing.”

2. “Why did he lose control?” “He put the tail in the wind (downwind hover) when heavy and got into LTE.”

3. “Why did he not put in enough control input more quickly or hover into the wind?”“He had not flown in those conditions for several months and was ‘rusty’.”

4. “Why had he not flown in unit SOP approved wind conditions in several months?”“He set personal minimums that were below the conditions on the day of the accident and turned down flights if the winds exceeded those.”

5. “Why did he take a flight in conditions that exceeded those personal limits on the day of the accident?”“The call was for a missing 2 year-old and he felt compelled to go.”

Tell me where you think a traditional accident investigation would end. Be honest. For more information on this process and LEAD INDICATORS, please look for my presentation on this topic.

CHECKLISTS

• Use SMS generated lead indicators (interventions) in your checklists

• Develop preflight (post-preflight) and mission checklists

• Stop Checklist at major objective and start new one

• Consider the ‘flow’ of the checklist

• Alternating colors

• Larger print at bottom of list

Safety: Assurance• Feedback – Anything

without feedback is a guess…at best an educated guess

• Traditionally, safety implementations were unquestionable once made into policy

• Love the results, not the policy or procedure


POLICY – RISK MANAGEMENT – ASSURANCE - PROMOTIONIHST SMS Toolkit p. 28, 39, 44

Safety: Promotion

•Training and Testing must be separated by definitive lines. i.e. If every flight with an Instructor seems like a test, the pilot will never be comfortable asking for instruction on something they are not 100% sure about. •Safety Management and Training cannot operate independently of each other.




Training and Aviation Safety

Often the suggested answer to dealing with shrinking budgets and the high number of training accidents is to simply cut training. As we can see here, the number one method of stopping accidents is through training! We cannot improve safety by cutting training. All SMS efforts end in a control or intervention that cannot be put into place without some sort of training. Training is vital to safety, without it SMS collects information, but does not have an avenue for actually affecting safety.

4. SMS AND DECISION MAKING4. SMS AND DECISION MAKING

“MAN – A creature that was created at the end of the week when God was very tired.”

~Mark Twain

DECISION MAKING THEORY

Analytical Decision MakingIdeal for the following conditions:

• Clear goal or outcome• Plenty of time• All conditions, factors are known

From this, the decision maker can:

• Develop wide range of options• Evaluate and compare options• Choose the optimal path

Source: Dave Huntzinger & Fred Brisbois - IHST 2012 Heli-Expo SMS Presentation

Analytical Method Characteristics• Structured• Time consuming• Process breaks down with stress, limited time

Analytical MethodsDeliberate & thoughtful; best suited for:

• Aircraft design• Flight planning• Aircraft purchasing• And………


Safety Management System Implementations, Policies, Procedures,

Training, Communications, Education….


The analytical decision making processes are structured, deliberate and thoughtful. They are ideal for planning stages and lend themselves to flight planning, aircraft purchasing or design. These work the best in a group environment with access to loads of information. Can you see where this is going? What we have come to learn is that these methods are not well suited for decision making while flying. Up there, we have exactly the opposite situation; all factors are not known, there are very likely competing goals (safety, customer satisfaction, contract requirements, financials, etc.) and time is extremely tight.

We don’t need to cast these theories out because they don’t work well in the aircraft. Use analytical methods to develop good procedures and policy while on the ground. Use this method to understand the issues as best as possible and develop safety tools that can be used in the aircraft with the following decision making theories in mind.

Intuitive Methods• Fast

• Simple

• Memory based

• Work with limited information

• Option chosen probably OK, but not optimal

Better suited to real time decision making (flying) and other dynamic, fast paced situations: car driving, sports, combat



There is a name for the decision making processes we use while flying. They are called intuitive decision making processes. These are fast, simple and memory based. They work reasonably well with limited information and can expect to produce a solution that has a chance of being successful (or not). This process is better suited to fast paced, dynamic situations such as car driving, sports and combat.As you can see, SMS plugs into this nicely. Memory based items are developed through SMS influenced training materials and methods. When working with limited information – use SMS to understand problem and help prepare pilot for what information they need to seek out

Naturalistic Decision Making (Intuitive DM process)

Used in complex, fast paced situations• Based on environmental input

• Conditions constantly changing, both independently and as result of your actions

• Real time decision making (not planning)

• Goals not well defined

• Could be competing goals (safety vs …)

• Decision maker is: knowledgeable, experienced & professional

(Peter Simpson)



One intuitive method in particular is called Naturalistic Decision making. It takes this name from its dependence on environmental cues, clues and feedback. In this case, the decisions are sequential and interdependent. That is, one decision affects the next one. And other things could be changing in the middle of everything (such as weather, time, system status, people, etc.).

Naturalistic Decision Making Not so much a method as the way we actually do things…

Step 1: Situation Assessment (SA)1. Problem definition: Identify -

• Problem• Goal(s)• Information sources needed to succeed • Prioritize incoming information

2. Risk assessment• severity• probability

3. Time available


Naturalistic decision making has two important parts. The first is Situation Assessment. You identify the problem and resources needed to get the job done and how much time you have. Then run a risk assessment. What is the worst credible outcome and the likelihood this will work or not? SMS can drive the knowledge and training needed to help aircrews seek out the info needed and prioritize the info coming in. It can allow them to regain Situational Awareness faster. It can also allow for faster severity vs. probability decisions.


Naturalistic Decision Making

Step 2: Course of Action (CoA)1. Potential Solutions Considered

• Rule based – single, memory based solution (experience, training, EP drills, etc.)

• Choice based – Multiple Options • Creative – No obvious choice, must use substitute

experiences 2. Simulation

• Mental test of potential solutions3. Act

The second half is Course of Action. We have three basic programs we can use. One is rule based; if this, then that. These are memory based and come from experience and training. Emergency procedures fall into this category. The second option is a choice. I can go either here or there for fuel. The last one is creativity. This is where you have to respond to a situation where neither the first nor the second choices mentioned above apply. You can only try to draw parallels from some other experience. An airframe vibration is a good example. There are no procedures and what choices do you have? To understand or solve the problem you may have to experiment. From that set of potential solutions you create a course of action and act.


Common Errors - Two basic areasSituation Assessment errors

• Poor understanding of situation

• Poor risk assessment

• Misjudge time available

Course of Action errors

• Right rule, wrong time

• Right rule, poor application

• Choose wrong procedure or option



DIRECTING FIRE INTERVENTIONS AND DECISION MAKING

• Consider these Decision Making factors when developing Interventions

• Checklists – Consider flow and critical tasks

• ADM – Combine with SA information. Make specific to your profession

• CRM – Teach crew to recognize ‘triggers’ based on lead indicators

• Training – Not the same thing every time. Direct training accordingly

• Environment - Cannot program out all human error. Minimize error and build in protective environmental layers

Once you use your SMS to ID hazards, analyze them, and prioritize them, you need to start looking at ways to control them through Interventions (Controls). Consider the decision making process that the people you are trying to help will be using when facing each risk. Here are a few areas where you can use decision making theory and SMS data to create an Intervention that will be useful in the cockpit.

Remember, human error cannot be programmed completely out. When you can, put in a non-human control for the risk. In the picture at the end, I could ‘train’ my daughter not to draw on the wall…or I could move the markers away from the wall so the temptation is removed.


The top chart shows the mental state of a fatigued person. The bars indicate the speed the person needs to respond to a certain task. You can see that fatigue is not uniform, it goes up and down. The bottom chart is made up tasking for a flight – again, not uniform because some tasks require more work from the pilot than others. We often evaluate our own level of fatigue during those phases when our brains are not running as slow, and we do not recognize the high peaks. During a flight luck keeps the peaks apart, not skill. When luck runs out high flight tasking occurs during a high fatigue peak. A fatigued person not able to evaluate themself any more than a drunk person can. Environmental intervention is needed to control risk (policy in this case).

The top chart shows the mental state of a fatigued person. The bars indicate the speed the person needs to respond to a certain task. You can see that fatigue is not uniform, it goes up and down. The bottom chart is made up tasking for a flight – again, not uniform because some tasks require more work from the pilot than others. We often evaluate our own level of fatigue during those phases when our brains are not running as slow, and we do not recognize the high peaks. During a flight luck keeps the peaks apart, not skill. When luck runs out high flight tasking occurs during a high fatigue peak. A fatigued person not able to evaluate themself any more than a drunk person can. Environmental intervention is needed to control risk (policy in this case).

ADM AND CRM

• Once your most significant risks are identified (prioritized), develop ADM type triggers and responses.

• Aeronautical Decision Making – Hazardous Attitudes

• Invulnerability “It won’t happen to me”

• “The best crews have fallen victim to the simplest of errors”

• Two different sources of mission information are conflicting

• Hold on, attempt to verify both

• “If the ceiling drops another 100 feet, we’re out of here”

• If I (you) are saying that, it is already time to go home.


1) Contributing to the accident was the failure of the flight crewmembers to address the fact that the helicopter had approached its maximum performance capability on their two prior departures from the accident site because they were accustomed to operating at the limit of the helicopter’s performance.

1) Contributing to the accident was the failure of the flight crewmembers to address the fact that the helicopter had approached its maximum performance capability on their two prior departures from the accident site because they were accustomed to operating at the limit of the helicopter’s performance.



“The pilot advised the SAR personnel to load quick, as he had no intentions of spending the night there...they lost sight of the helicopter about 50 feet agl. They continued to hear the helicopter to the time of a collision sound, followed by the sound of an avalanche.”

~Excerpt from a NTSB report of a law enforcement IIMC/CFIT accident with multiple fatalities

“The pilot advised the SAR personnel to load quick, as he had no intentions of spending the night there...they lost sight of the helicopter about 50 feet agl. They continued to hear the helicopter to the time of a collision sound, followed by the sound of an avalanche.”

~Excerpt from a NTSB report of a law enforcement IIMC/CFIT accident with multiple fatalities

5. WORKSHOP DISCUSSION

• Who is with us today• Who currently works with an established SMS?

• What were your biggest challenges?• How did you overcome them?

• Who is working on establishing an SMS?• What is your biggest challenge?• What would you ask the SMS genie to create out

of this air in order to help facilitate your effort?


There are no new ways to crash an aircraft…

…but there are new ways to keep people from crashing them…

Bryan [email protected]

239-938-6144www.ihst.orgwww.alea.org

http://www.ihst.org/

http://www.alea.org/

safety management systems (sms) and decision making

Business

dave huntzinger

state aviation officials

high fatigue peak

traditional safety program

ihst sms toolkit

decision making

high peaks

id hazards