Airborne Law Enforcement Association
FAA FAAST Conference Kansas City, Missouri Safety Management System
-------------------------------------------------------
Keith Johnson Safety Program Manager
The topic of the day
SAFETY
Whose job is it?
IHSS
Safety is most important Need to collect data
Collect flight hours Collect Serious Incident Information Expedite Accident Reporting
Increased training
Scaled check-rides based upon experience
Reduce accidents by 80% over 10-years Focus on leadership Non-punitive reporting Accountability Accidents can be eliminated
SAFETY Management
It holds the key to our future
It affects everything we do (SMS)
Every accident affects everyone
ACCIDENT ELIMINATION
Must be proactive Reached plateau
Pilots focus on flying aircraft Two person crews Focus on risk management
Adverse Trends
Identify and eliminate adverse trends Incidents - Investigate & disseminate
findings Factory emergency procedures training
Dont reinvent the wheel No new causes of accidents Copy successful organizations Accreditation Flying to higher standard
Its insane to think that doing the same thing over & over will have a different result. Why do we continue to make the same mistakes?
IHST SMS Industry Working Group
Don Arendt, PhD FAA SMS Program Mgr. Gordon Dupont CEO System Safety J. Heffernan HAI Director of Safety David Huntzinger PhD AeroSSQQ Peter Gardiner PhD. CEO So. Cal. Safety Inst. Denise Uhlin Bristow Group Keith Johnson ALEA Safety Program Manager
Why is having an SMS important?
[Link] recognized as best practice [Link] number of accidents [Link] costs [Link] probability of occurrences [Link] severity of occurrences [Link] exposure to risk [Link] likelihood of completing the mission
IHST SMS DELIVERABLES
SMS Toolkit & Exemplars SMS Mentoring Program SMS Promotion
30 Safety Industry-wide articles on SMS SMS PPT on IHST website 21 Industry-wide SMS presentations
Computer SMS Training Program Return on Investment Training Testified at NTSB HEMS hearing Meetings with NTSB on accident
SMS Process
Need sense of urgency at top of every organization
ICAO, FAA, IHST, HAI, ALEA, AAMS,
Operators Everyone is in the same boat
Create the Guiding Coalition - IHST Develop a Vision and Strategy Communicate Change Vision Broad-Based Action
SAFETY, TRAINING, MAINTENANCE
INFRASTRUCTURE
Consolidate gains to produce more
Phase-1 SMS
Safety & Quality Policy Safety Planning Organization Structure & Responsibilities Compliance with legal & other requirements Develop procedures & controls Safety Promotion Safety Culture Communication & Awareness Competence
PHASE-2 SMS
Emergency Preparedness & Response Documentation & Records Management Safety Risk Management Identify Hazards Analyze, assess & control Safety Risk
Safety Assurance & Internal Evaluation
Information Acquisition Analysis of data System Assessment Preventive/corrective action Management Reviews
Safety Promotion
Safety Culture Personnel requirements (competence) Training Recognition & Awards Safety Bulletins, posters, hazard reports Feedback Lessons learned
RISK MANAGEMENT Mission Standards Training Equipment Supervision Assessment Accountability Open reporting Feedback Just Culture
JUDGMENT & ACTION ERRORS
Failure to manage known risks Mission urgency & risk taking
Will to succeed
Flight profile unsafe
Crew Qualifications Aircraft Suitability Mission Requirements Environment
Judgment errors committed Failure to follow procedures Poor CRM Poor Aircraft Control
Over confidence Loss of situational awareness
What Does Having an SMS Give?
Comprehensive Comprehensive approach Corporate safety to Approach to Safety
Organizational Effective Organisation structure for for ownership of & Delivering Safety accountability for safety
Robust & effective Robust Systems safety for management Assuring Safety processes
We will now concentrate on describing the three key processes generically Once you understand these, the rest becomes more readily
Safety Culture
The essential human component of organizations You are rated, you are trained, but are you COMFORTABLE? Consists of values, beliefs, norms, legends rituals, mission goals, performance measures and a sense of responsibility to its employees, customers and the community. You cannot turn SAFETY on & off
Positive Safety Culture
Generated from top down (set the stage) Words & actions Safety in decision-making Safety as a core value I.D. its activities as high risk & high consequence Trust permeates the organization Trust is essential ingredient in safety management Employees supported making decisions in the interest of safety
Positive Safety Culture
Hazards & risks actively sought No shooting the messenger Everyone vigilant about activities People trained to recognize & respond When I.D. Investigate and mitigate Responsibility for safety is shared High performance standards established and monitored
Safety Management Training Requirements
Safety orientation for all new personnel Document competency requirements Document training requirements Have regularly scheduled safety meetings Key personnel educated on safety
TRAINING
Training is the only substitute for experience SMS training is mandatory What are the consequences of lack of training?
Lack of knowledge & skill Poor decision making Accidents Incidents Loss of support and funding &
JHSAT STUDY RESULTS
Three themes came from JHSAT study:
1.
[Link] training [Link] Operational Oversight [Link] Safety Management System
Frequency 150 100
401 173 154 112 98 87 66 26 24 24 Mission Risk Regulatory Aircraft Design Infrastructure Ground personnel 23 20 10 1
200
250
350 300
400
450
50
0
Pilot judgment & actions Safety Culture Data issues Maintenance Ground Duties Pilot situation awareness Part/system failure Post-crash survival Communications
Results of full year 2000 dataset
S P S F r eq u en c y b y P r im a r y C at eg o r y
Frequency 100 150 200 250 50
210 170 145 101 92 74 68 53
0
Instructional / Training Personal / Private Aerial Application Emergency Medical Service Commercial Operator Law Enforcement Offshore External Load iness - Company owns A/C Firefighting Aerial Observation / Patrol Air Tour Sightseeing Electronic News Gathering Logging lities Patrol and Construction
37 27 28 12 16 13 9 8 9 6 10 6 4 4
51 48 47 44 32 30 SPS Count
5 24 3 17
S P S & A c c id e n t C o u n t b y P rim a ry M is s io n
A c c id e n t Count
Introduction to the Toolkit
Contains SMS guidance material Sample SMS Manual Provides a foundation for implementing SMS IHST needs feedback Compliant FAA AC 120-92
Just Culture
A blame culture undermines open reporting A no-blame culture can undermine accountability & responsibility Defines clear lines of what is and is not acceptable behaviour If other personnel could make the same error occasionally then we must change the controls not discipline the personnel
Holding people accountable through a
disciplinary process is only relevant for: l G ro ss n e g lig e n ce l P e rsiste n t su b - sta n d a rd p e rfo rm a n ce
Just Culture Process
Start
Performance Based SMS
Rather than specify an organizational configuration or architecture, the SMS Toolkit deals with SMS Attributes. These attributes describe the performance of a successful SMS. Meeting the performance standard is what is critical the configuration or architecture is dependent on the size and scope of the operation.
The Attributes of an SMS
1) Safety Policy 2) SMS Management Plan 3) Safety Promotion 4) Document and Data Information Management 5) Hazard Identification and Risk Management 6) Occurrence and Hazard Reporting 7) Occurrence Investigation and Analysis 8) Safety Assurance Oversight Programs 9) Safety Management Training Requirements 10) Management of Changes 11) Emergency Preparedness and Response 12) Performance Measurement and Continuous Improvement
Promotion of SMS
Safety must be a core value
Procedures, practices, training &
allocation of resources
Mechanics
Websites ALEA, HAI, AAMS, PHPA,
TOPS, ICAO, AHS, FAA, Transport Canada
Benefits
Reduced costs by eliminating
accidents Insurance and performance based discounts
REWARDING SAFE BEHAVIOR
Timeliness ASAP Recipient Focus on individuals Presentation Public presentation Personalize Name on the award Possession Keep and display Value - $ not important
Success Solutions
Reinforced bad behavior breeds continued bad behavior Rationalization of the gravity of the situation seems to lessen the risk in our minds, but in reality does not Habitual rule breaking is often condoned by management when they look the other way Does complacency play a role in this issue?
FINAL THOUGHTS Can achieve our objective Industry is mobilized Only one chance to achieve objective Requires everyones commitment
