Shell Aircraft International Our GOAL is your SAFETY
A Simplified Process for Hazard Management Tony Cramp Shell Aircraft International
Scope • Not a presentation about or justifying SMS. • Not an academic review of hazard management. • It is a distillation of observed best practice.
2
2
Scope • Identify the interactions of Hazard Management within the SMS. • Detail the procedural steps of the Hazard Management process. • Suggest documentation requirements. • Emphasise how to keep the process live and delivering real benefit to the organisation.
References
Safety Risk Management “Hazard identification and safety risk management are the core processes involved in the management of “A formal system of hazard identification and management is fundamental in controlling an acceptable of risk. safety. They are neither new, nor have they been developed as a consequence of recent interest inlevel safety A well-designed risk management systemactivity describes operational across with department and organizational management “Risk management is a proactive that looks at theprocesses risks associated identified hazards boundaries, identifies key management hazards and measures them, methodically assesses risk, and implements controls and, inand particular, safety systems (SMS). Hazard identification and safety risk management areto “Safety risk management. A formal system of hazard identification and risk management is essential in assists in selecting actions to maintain an appropriate level ofsafety safety when faced with these mitigate risk.” dogmatic controlling risk to acceptable levels. The safety risk management component of the SMS is based upon the system hazards.” components that underlie overarching concept of system safety. This is an engineering-based safety process modelthe that is used in the system safety training course thatall-encompassing, is taught at the FAA Academy.” approach that contributes to system design and which was developed more that forty years ago.”
Hazard/Risk Management Process SCOPE OF ACTIVITY
IDENTIFY AND RECORD HAZARDS
MANAGEMENT OF CHANGE PROCESS PROCESS NEW HAZARDS
SAFETY REPOPTING & INVESTIGATION PROCESS LINKED DIRECTLY TO THE SAFETY CASE.
RISK ANALYSIS INTERNAL AUDIT TO CONFIRM IMPLEMENTATION & EFFECTIVENESS OF CONTROLS
IDENTIFY CONTROLS FOR SPECIFIC HAZARDS
NEW CONTROL REQD
CONTROL EXISTS
REFERENCE CONTROLS AND RESPONSIBLE POSTS
QA SYSTEM – UPDATE CHECKLIST S
VALIDATE EXISTING CONTROLS OR DEVELOP NEW CONTROLS
CONTROL DEVELOPED
REMEDIA L ACTION PLAN
MANAGEMEN T REVIEW
SAFETY REPORTING & INVESTIGATION
SMS ELEMENTS & RELATIONSHIPS LEADERSHI P
RESOURCES
POLICY, OBJECTIVES & KPI’S
PROCEDURES
MANAGEMEN T OF CHANGE PROCESS
QUALITY ASSURANCE
COMMUNICATION (TO WORKFORCE)
SAFETY REPORTING & INVESTIGATIO N
HAZARD & RISK MANAGEMENT. (SAFETY CASE)
REGULAR SENIOR MANAGEMENT REVIEW & ACTIVE INVOLVEMENT
SMS ELEMENTS & RELATIONSHIPS LEADERSHI P
RESOURCES
POLICY, OBJECTIVES & KPI’S
PROCEDURES
MANAGEMEN T OF CHANGE PROCESS
QUALITY ASSURANCE
COMMUNICATION (TO WORKFORCE)
SAFETY REPORTING & INVESTIGATIO N
HAZARD & RISK MANAGEMENT. (SAFETY CASE)
REGULAR SENIOR MANAGEMENT REVIEW & ACTIVE INVOLVEMENT
Wasted effort alert
Keep it manageable and if necessary start small
Hazard/Risk Management Process SCOPE OF ACTIVITY
Step 1 - Define the scope
•
Determine what range of activities, locations or aircraft the process will cover. ¾ Smaller operators – May cover the whole operation. ¾ Larger operators – May split the process by 9 Location/base 9 Aircraft type 9 Operational role (e.g. offshore, HEMS, heliski-ing)
•
Start where you feel the greatest risk or exposure lies within your operation. ¾ Hazard or incident reports may give the indication. ¾ Staff and managers normally know what their risk areas are. ¾ This may also be influenced by customers and regulators!
Hazard/Risk Management Process SCOPE OF ACTIVITY
IDENTIFY AND RECORD HAZARDS
Step 2 – Identify & Record Hazards
•
This stage should be a continuous process.
•
Definition of a Hazard can cause debate amongst learned safety professionals. ¾ Generic hazards – Wind, IMC, aircraft components. ¾ Specific hazards – Crosswind exceeding limits, inadvertent entry into IMC, incorrectly fitted aircraft components. ¾ Hazardous consequences – loss of control, disorientation, aircraft system failure.
•
While you can list each definition/level in your hazard register, recommend focus on specific hazards at this stage.
Step 2 – Identify & Record Hazards
Where to start?
Step 2 – Identify & Record Hazards Networking, blogs
Recordable occurrences QA findings Brainstorming
Accident reports for own role
Safety reporting system Industry Bodies/committees/forums Accidents reports for own A/C types Safety Observation Process Incident investigations
Flight Data Monitoring
Information exchange Trend analysis
Accident reports for own region/country/location Training feedback
Generic Hazard Lists
Step 2 – Identify & Record Hazards Networking, blogs
Recordable occurrences QA findings Brainstorming
Accident reports for own role
Safety reporting system Industry Bodies/committees/forums Accidents reports for own A/C types Safety Observation Process Incident investigations
Flight Data Monitoring
Information exchange Trend analysis
Accident reports for own region/country/location Training feedback
Generic Hazard Lists
Step 2 – Identify & Record Hazards
Step 2 – Identify & Record Hazards External Information sources: •
State Accident Investigation bodies report data bases 9 NTSB 9 AAIB 9 Transport Canada 9 BEA
•
Flight safety Foundation “Basic Aviation Risk Standard – Resource sector” 9 Gives both generic and role specific hazards and lists a number of possible controls for each hazard.
Identified hazards should be recorded in a Hazard Register ¾ Various formats. ¾ Web based, excel tables, access data bases, hand written!
Hazard Register • Minimum Content ¾Hazard ¾RAM Score ¾Controls ¾Control references to procedure manuals (Ops, Maintenance, Training etc) ¾Responsible person – control owner
Basic Hazard Register example Reference No.
Task Description /Location Hazard Description:
Date last reviewed
RAM Score Initial
Controls
Reference
Owner
Status
Current
Basic Hazard Register example Task Description /Location Hazard Description:
Controls
Reference No.
Onshore seismic support
HS - 017
Date last reviewed Sept 09 RAM Score
Inadvertent entry to IMC
Initial
Reference
Owner
Status
Current
Hazard/Risk Management Process SCOPE OF ACTIVITY
IDENTIFY AND RECORD HAZARDS
RISK ANALYSIS
Step 3 – Risk Analysis •
Having identified hazards, assess the level of risk associated with each to: ¾ Determine if further action is required ¾ Prioritise where effort needs to be directed first
•
Use a Risk Assessment Matrix (RAM) to give an objective score to a subjective topic ¾ This enables standardisation across the organisation. ¾ It reduces dispute and argument ¾ Gives a very visual and clear indication of risk for management review. 9 Red is difficult to ignore and loosens budget strings.
Typical RAM
•
Too vague and open to different interpretation.
•
Detailed definition required for likelihood and severity.
Detailed RAM
•
Detailed definition of Likelihood.
•
More detail can be added to consequences i.e. actual $ values to asset levels.
•
Consequences should be applied as the actual consequences that happened in previous cases of the event.
Detailed RAM
Inadvertent Entry to IMC hazard example. •
This company had a fatal CFIT following inadvertent IMC entry 3 years ago.
•
Within the country there were 4 CFIT on VFR aircraft in last 12 months, 2 fatal, with 8 fatalities.
Basic Hazard Register example Task Description /Location Hazard Description:
Controls
Reference No.
Onshore seismic support
HS - 017
Date last reviewed Sept 09 RAM Score
Inadvertent entry to IMC
Initial
Reference
Owner
Current
Status
Basic Hazard Register example Task Description /Location Hazard Description:
Controls
Reference No.
Onshore seismic support
Date last reviewed
HS - 017
Sept 09 RAM Score
Inadvertent entry to IMC
Initial
Reference
Owner
Current
Status
Hazard/Risk Management Process SCOPE OF ACTIVITY
IDENTIFY AND RECORD HAZARDS
RISK ANALYSIS
IDENTIFY CONTROLS FOR SPECIFIC HAZARDS
Step 4 – Identify controls for specific hazards •
A number of methods for identifying controls ¾ Brainstorming ¾ Bow Tie analysis ¾ Tripod (Investigation tool, but can be reverse engineered)
•
Regardless of method, this step requires that appropriate controls are identified to manage each hazard to ALARP ¾ The higher the risk, the more effective the controls have to be and potentially more layers of controls required.
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.
Step 4 – Identify controls for specific hazards •
A number of methods for identifying controls ¾ Brainstorming ¾ Bow Tie analysis ¾ Tripod (Investigation tool, but can be reverse engineered)
•
Regardless of method, this step requires that appropriate controls are identified to manage each hazard to ALARP ¾ The higher the risk, the more effective the controls have to be and potentially more layers of controls required.
Quote from ICAO SMS Manual “The most effective mitigations are hard mitigations. Because hard mitigations are often expensive, organizations frequently resort to soft mitigations (such as training). In such cases, the organization is more often than not relinquishing to subordinates responsibility for safety risk management.”
Step 4 – Identify controls for specific hazards Wasted effort alert
•
Don’t just use this as an exercise to justify existing procedures and controls. ¾ You will have added no benefit from the process.
•
Try and look at the hazard isolated from financial and resource constraints in the first place. ¾ “Blue sky thinking” ¾ Impractical controls can be discounted later in the process
•
Use a range of personnel from within the company at this stage. ¾ Line pilots and mechanics as well as supervisors and safety staff.
•
Look outside your own organisation at how others in the broader aviation industry have managed this hazard. ¾ Especially those areas with better safety records e.g. airlines, offshore. ¾ Can those controls be replicated at a local level?
Step 4 – Identify controls for specific hazards
• Each control needs to meet the following criteria: ¾ Effective ¾ Cost/benefit ¾ Practical ¾ Acceptable ¾ Enforceable ¾ Durable ¾ Doesn’t create new hazards
Basic Hazard Register example Task Description /Location Hazard Description:
Controls
Reference No.
Onshore seismic support
Date last reviewed
HS - 017
Sept 09 RAM Score
Inadvertent entry to IMC
Initial
Reference
Owner
Current
Status
Basic Hazard Register example Task Description /Location Hazard Description:
Reference No.
Onshore seismic support
Date last reviewed
HS - 017
RAM Score
Inadvertent entry to IMC
Controls 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 to changes in weather.
Sept 09
Initial
Reference
Owner
Current
Status
Basic Hazard Register example Task Description /Location Hazard Description:
Reference No.
Onshore seismic support
Date last reviewed
HS - 017
RAM Score
Inadvertent entry to IMC
Controls 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 to changes in weather. Aircraft equipped for IFR flight (Designate minimum avionic equipment) Pilots instrument rated Annual inadvertant IFR flight check to ensure currency and competence. Min 30 min Inadvertant IFR procedures trained and checked during annual simulator training. All aircraft equipped with TAWS
Sept 09
Initial
Reference
Owner
Current
Status
Basic Hazard Register example Task Description /Location Hazard Description:
Reference No.
Onshore seismic support
Date last reviewed
HS - 017
RAM Score
Inadvertent entry to IMC
Controls 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 to changes in weather. Aircraft equipped for IFR flight (Designate minimum avionic equipment) Pilots instrument rated Annual inadvertant IFR flight check to ensure currency and competence. Min 30 min Inadvertant IFR procedures trained and checked during annual simulator training. All aircraft equipped with TAWS All aircraft equipped with satellite flight tracking Emergency response plan in place & exercised annually with client
Sept 09
Initial
Reference
Owner
Current
Status
Hazard/Risk Management Process SCOPE OF ACTIVITY
IDENTIFY AND RECORD HAZARDS
RISK ANALYSIS
IDENTIFY CONTROLS FOR SPECIFIC HAZARDS CONTROL EXISTS
REFERENCE CONTROLS AND RESPONSIBLE POSTS
Basic Hazard Register example Task Description /Location Hazard Description:
Reference No.
Onshore seismic support
Date last reviewed
HS - 017
RAM Score
Inadvertent entry to IMC
Controls 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 to changes in weather. Aircraft equipped for IFR flight (Designate minimum avionic equipment) Pilots instrument rated Annual inadvertant IFR flight check to ensure currency and competence. Min 30 min Inadvertant IFR procedures trained and checked during annual simulator training. All aircraft equipped with TAWS All aircraft equipped with satellite flight tracking Emergency response plan in place & exercised annually with client
Sept 09
Initial
Reference
Owner
Current
Status
Basic Hazard Register example Task Description /Location Hazard Description:
Reference No.
Onshore seismic support
Date last reviewed
HS - 017
Sept 09 RAM Score
Inadvertent entry to IMC
Initial
Current
Controls
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
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
All aircraft equipped with satellite flight tracking
Ops Man 8.3.4
Director of Maintenance
In 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
Enhanced Operational Controls in place to respond to changes in weather.
Inadvertent IFR procedures trained and checked during annual simulator training. All aircraft equipped with TAWS
Hazard/Risk Management Process SCOPE OF ACTIVITY
IDENTIFY AND RECORD HAZARDS
RISK ANALYSIS
IDENTIFY CONTROLS FOR SPECIFIC HAZARDS CONTROL EXISTS
REFERENCE CONTROLS AND RESPONSIBLE POSTS
NEW CONTROL REQD
REMEDIA L ACTION PLAN
Step 6 – Remedial Action Plan •
Ideally an organisation should have just one remedial action plan, containing all the actions arising from the hazard management process, safety reporting, QA audits etc.
•
This presents senior management with one complete overview and allows departmental requirements to be compared and addressed on a priority basis using the RAM score. ¾ For larger global organisations, local plans may be required.
•
Remedial action plans can be recorded on simple excel sheets or in complex integrated databases such as Qpulse or Impact Safety.
•
The Hazard Register should reflect the status of the remedial action plan.
Basic Hazard Register example Task Description /Location Hazard Description:
Reference No.
Onshore seismic support
Date last reviewed
HS - 017
Sept 09 RAM Score
Inadvertent entry to IMC
Initial
Current
Controls
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
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
All aircraft equipped with satellite flight tracking
Ops Man 8.3.4
Director of Maintenance
In 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
Enhanced Operational Controls in place to respond to changes in weather.
Inadvertent IFR procedures trained and checked during annual simulator training. All aircraft equipped with TAWS
Basic Hazard Register example Task Description /Location Hazard Description:
Reference No.
Onshore seismic support
Date last reviewed
HS - 017
Sept 09 RAM Score
Inadvertent entry to IMC
Initial
Current
Controls
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 Jun 10
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 availability of sim for type
All aircraft equipped with TAWS
RAP Item 15
Director of Maintenance
Due complete Apr 2011
All aircraft equipped with satellite flight tracking
Ops Man 8.3.4
Director of Maintenance
In 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
Step 6 – Remedial Action Plan
•
Having completed and referenced the RAP, the current risk score for that hazard can be re-assessed, taking into account the mitigations and controls that the company has in place.
Basic Hazard Register example Task Description /Location Hazard Description:
Reference No.
Onshore seismic support
Date last reviewed
HS - 017
Sept 09 RAM Score
Inadvertent entry to IMC
Initial
Current
Controls
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 Jun 10
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 availability of sim for type
All aircraft equipped with TAWS
RAP Item 15
Director of Maintenance
Due complete Apr 2011
All aircraft equipped with satellite flight tracking
Ops Man 8.3.4
Director of Maintenance
In 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
Basic Hazard Register example Task Description /Location Hazard Description:
Reference No.
Onshore seismic support
Date last reviewed
HS - 017
Inadvertent entry to IMC
Operator assessed that until Sim training, TAWS and the EOC were in place, risk remained medium
Sept 09 RAM Score Initial
Current
Controls
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 Jun 10
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 availability of sim for type
All aircraft equipped with TAWS
RAP Item 15
Director of Maintenance
Due complete Apr 2011
All aircraft equipped with satellite flight tracking
Ops Man 8.3.4
Director of Maintenance
In 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
Hazard/Risk Management Process SCOPE OF ACTIVITY
IDENTIFY AND RECORD HAZARDS
RISK ANALYSIS
IDENTIFY CONTROLS FOR SPECIFIC HAZARDS NEW CONTROL REQD
CONTROL EXISTS
REFERENCE CONTROLS AND RESPONSIBLE POSTS
CONTROL DEVELOPED
REMEDIA L ACTION PLAN
Step 7 – Interface with QA system
Wasted effort alert
Your QA system needs to know what your Hazard Management Process has developed.
Hazard/Risk Management Process SCOPE OF ACTIVITY
IDENTIFY AND RECORD HAZARDS
RISK ANALYSIS INTERNAL AUDIT TO CONFIRM IMPLEMENTATION & EFFECTIVENESS OF CONTROLS
IDENTIFY CONTROLS FOR SPECIFIC HAZARDS NEW CONTROL REQD
CONTROL EXISTS
REFERENCE CONTROLS AND RESPONSIBLE POSTS
QA SYSTEM – UPDATE CHECKLIST S
CONTROL DEVELOPED
REMEDIA L ACTION PLAN
Having documented controls to manage hazards, some existing and some new, QA checklists must be updated to ensure that auditors assess those controls for compliance and effectiveness. Ineffective controls need to be reassessed at Step 4.
Hazard/Risk Management Process SCOPE OF ACTIVITY
IDENTIFY AND RECORD HAZARDS
RISK ANALYSIS INTERNAL AUDIT TO CONFIRM IMPLEMENTATION & EFFECTIVENESS OF CONTROLS
Steps 3 – 7 should now be repeated for each hazard identified in step 2.
IDENTIFY CONTROLS FOR SPECIFIC HAZARDS NEW CONTROL REQD
CONTROL EXISTS
REFERENCE CONTROLS AND RESPONSIBLE POSTS
QA SYSTEM – UPDATE CHECKLIST S
CONTROL DEVELOPED
REMEDIA L ACTION PLAN
Wasted effort alert
How to keep it a live process and prevent the hazard register from being a dusty book on the shelf, only brought out when auditors arrive. This process should also be saving money and attracting clients
Keeping it alive – Part I
Hazard/Risk Management Process SCOPE OF ACTIVITY
IDENTIFY AND RECORD HAZARDS SAFETY REPOPTING & INVESTIGATION PROCESS LINKED DIRECTLY TO THE HAZARD MANAGEMENT PROCESS.
RISK ANALYSIS INTERNAL AUDIT TO CONFIRM IMPLEMENTATION & EFFECTIVENESS OF CONTROLS
IDENTIFY CONTROLS FOR SPECIFIC HAZARDS NEW CONTROL REQD
CONTROL EXISTS
REFERENCE CONTROLS AND RESPONSIBLE POSTS
QA SYSTEM – UPDATE CHECKLIST S
CONTROL DEVELOPED
REMEDIA L ACTION PLAN
SAFETY REPORTING & INVESTIGATION
Step 8 – Interface with Safety Reporting and Investigation •
All company accident/incident/hazard/near miss report forms should have a step that requires the safety manager or investigator to refer to the hazard register as part of the investigation process. ¾ Suggest this be for all Medium and High RAM assessed events.
•
If a new hazard is identified this should lead to Step 2 (Haz ID).
•
If the hazard has already been analysed and documented, the process should result in the existing controls being reviewed for effectiveness. ¾ They may all have worked, thus preventing an accident. ¾ Some may have proved ineffective though and the incident may have been too close, requiring additional controls.
Example Hazard report received that a pilot inadvertently entered IMC during seismic support tasking. 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.
Basic Hazard Register example Task Description /Location Hazard Description:
2 2 3 3 3
Reference No.
Onshore seismic support
Date last reviewed
HS - 017
Sept 09 RAM Score
Inadvertent entry to IMC
Initial
Current
Controls
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 Jun 10
Aircraft equipped for basic 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 availability of sim for type
All aircraft equipped with TAWS
RAP Item 15
Director of Maintenance
Due complete Apr 2011
All aircraft equipped with satellite flight tracking
Ops Man 8.3.4
Director of Maintenance
In 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
Basic Hazard Register example Task Description /Location Hazard Description:
3 3
Sept 09 RAM Score
Inadvertent entry to IMC
Minimum company weather limits for VFR operations
3
Date last reviewed
HS - 017
Controls
2 2
Reference No.
Onshore seismic support
Initial
Reference
Amend contract Ops Man 4.2.3 requirements
Current
Owner
Status
Chief Pilot
In force
Accurate daily forecasts available for operation
Ops Man 4.2.4
Chief Pilot
In force
Weather limits agreed with client and communicated to site supervisor
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 Jun 10
Aircraft equipped for basic IFR flight (Designate minimum avionic equipment)
Accelerate Ops Man 8.3.1 Director of introductionMaintenance
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 availability of sim for type
All aircraft equipped with TAWS
RAP Item 15
Director of Maintenance
Due complete Apr 2011
All aircraft equipped with satellite flight tracking
Ops Man 8.3.4
Director of Maintenance
In 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
In force
Basic Hazard Register example Task Description /Location Hazard Description:
2 2 3 3 3
Reference No.
Onshore seismic support
Date last reviewed
HS - 017
Sept 09 RAM Score
Inadvertent entry to IMC
Initial
Current
Controls
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 and communicated to site supervisor
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 Jun 10
Aircraft equipped for basic 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
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 Add and training.
RAP Item 23
Chief Pilot
Awaiting availability of sim for type
All aircraft equipped with TAWS
RAP Item 15
Director of Maintenance
Due complete Apr 2011
All aircraft equipped with satellite flight tracking
Ops Man 8.3.4
Director of Maintenance
In force
Emergency response plan in place & exercised annually with client
ERP 5.6 and Standard contract
Head of Safety & QA
In force
record a further control
Hazard/Risk Management Process SCOPE OF ACTIVITY
IDENTIFY AND RECORD HAZARDS
PROCESS NEW HAZARDS
SAFETY REPOPTING & INVESTIGATION PROCESS LINKED DIRECTLY TO THE HAZARD MANAGEMENT PROCESS.
RISK ANALYSIS INTERNAL AUDIT TO CONFIRM IMPLEMENTATION & EFFECTIVENESS OF CONTROLS
IDENTIFY CONTROLS FOR SPECIFIC HAZARDS
NEW CONTROL REQD
CONTROL EXISTS
REFERENCE CONTROLS AND RESPONSIBLE POSTS
QA SYSTEM – UPDATE CHECKLIST S
VALIDATE EXISTING CONTROLS OR DEVELOP NEW CONTROLS
CONTROL DEVELOPED
REMEDIA L ACTION PLAN
SAFETY REPORTING & INVESTIGATION
Keeping it alive – Part II
Hazard/Risk Management Process SCOPE OF ACTIVITY
IDENTIFY AND RECORD HAZARDS
MANAGEMENT OF CHANGE PROCESS PROCESS NEW HAZARDS
SAFETY REPOPTING & INVESTIGATION PROCESS LINKED DIRECTLY TO THE HAZARD MANAGEMENT PROCESS
RISK ANALYSIS INTERNAL AUDIT TO CONFIRM IMPLEMENTATION & EFFECTIVENESS OF CONTROLS
IDENTIFY CONTROLS FOR SPECIFIC HAZARDS
NEW CONTROL REQD
CONTROL EXISTS
REFERENCE CONTROLS AND RESPONSIBLE POSTS
QA SYSTEM – UPDATE CHECKLIST S
VALIDATE EXISTING CONTROLS OR DEVELOP NEW CONTROLS
CONTROL DEVELOPED
REMEDIA L ACTION PLAN
SAFETY REPORTING & INVESTIGATION
Step 9 – Management of Change •
Required element of the SMS
•
Process to include: ¾ Review the relevant sections of the hazard register. ¾ How does the change effect existing controls ¾ What new hazards may be introduced.
•
New hazards should be run through the whole process.
•
What should prompt the MOC process…?
Step 9 – Management of Change •
The MOC process should be triggered and the hazard register should be formally reviewed ahead of the following occasions: ¾ Introduction of new aircraft type ¾ New contract/operation ¾ Opening a new base ¾ Major change in key personnel or organisation change ¾ If none of the above occur, then every 2 years.
•
This wording can form the basis of the Change Management section in the SMS manual.
•
The TC SMS Guidelines call for a Safety Case to be developed as a minimum on the occasions listed above.
Step 9 – Management of Change •
However – if you have a live, active and comprehensive Hazard Management Process in place, this “Safety Case” could be limited to a 2-3 page document.
•
It would summarise: ¾ What has changed ¾ Which areas/departments have been affected ¾ Which hazards have been reviewed or new hazards identified. ¾ What actions have been taken to manage risk.
Suggested MOC Summary Doc/(”Safety Case”) Scope of Change
Introduction of B 429 from Aug 2010
Accountable Manager
Director of Operations
J. C. Van Damm
Ref # MOC 02/2010
Suggested MOC Summary Doc/(”Safety Case”) Scope of Change
Introduction of B 429 from Aug 2010
Accountable Manager
Director of Operations
Type of change
Permanent
3
Ref # MOC 02/2010
J. C. Van Damm
Temporary: From ________ to __________
Suggested MOC Summary Doc/(”Safety Case”) Scope of Change
Introduction of B 429 from Aug 2010
Accountable Manager
Director of Operations
Type of change
Permanent
Department/location
Responsible
3
Maintenance Department Training Department Flight Operations Department Safety & Quality Department Edmonton Base Calgary Base Other departments could be added dependant on the type of change
Ref # MOC 02/2010
J. C. Van Damm
Temporary: From ________ to __________ Hazard Register Reviewed/Updated
Signature
Suggested MOC Summary Doc/(”Safety Case”) Scope of Change
Introduction of B 429 from Aug 2010
Accountable Manager
Director of Operations
Type of change
Permanent
Department/location
Responsible
Hazard Register Reviewed/Updated
Maintenance Department
Dir Maintenance
13 Apr 2010
Training Department
Training Manager
1 Apr 2010
Flight Operations Department
Dir Operations
22 Mar 2010
Safety & Quality Department
Dir Safety & Quality
10 Apr 2010
Edmonton Base
Base Manager
5 Mar 2010
Calgary Base
Base Manger
15 Mar 2010
3
Ref # MOC 02/2010
J. C. Van Damm
Temporary: From ________ to __________ Signature
Once a department has completed its Review of the hazard Register, the HOD will sign for completion
Suggested MOC Summary Doc/(”Safety Case”) Ref # MOC 02/2010
Scope of Change
Introduction of B 429 from Aug 2010
Accountable Manager
Director of Operations
Type of change
Permanent
Department/location
Responsible
Hazard Register Reviewed/Updated
Maintenance Department
Dir Maintenance
13 Apr 2010
Training Department
Training Manager
1 Apr 2010
Flight Operations Department
Dir Operations
Safety & Quality Department
Dir Safety & Quality
22 Mar 2010 Each department will have developed a detailed action 10 Apr 2010 list, for its own internal use.
Edmonton Base
Base Manager
5 Mar 2010
Calgary Base
Base Manger
15 Mar 2010
3
J. C. Van Damm
Temporary: From ________ to __________ Signature
Summary of Actions Arising
Responsible
Due
Pilot and mechanic training syllabus developed and documented
Training Manager
1 May 2010
Factory training completed for Pilots and Maintenance Supervisors
Training Manager
1 Aug 2010
Maintenance work stands designed and manufactured
Dir Maintenance
1 Jul 2010
Additional Hangar space at Edmonton to be acquired or built
Edm Base Manager
1 Jul 2010
Maintenance documentation developed for B429.
Maintenance QA Lead
1 Jul 2010
Date & Signature
Suggested MOC Summary Doc/(”Safety Case”) Scope of Change
Introduction of B 429 from Aug 2010
Accountable Manager
Director of Operations
Type of change
Permanent
Department/location
Responsible
Hazard Register Reviewed/Updated
Maintenance Department
Dir Maintenance
13 Apr 2010
Training Department
Training Manager
1 Apr 2010
Flight Operations Department
Dir Operations
22 Mar 2010
Safety & Quality Department
Dir Safety & Quality
10 Apr 2010
Edmonton Base
Base Manager
5 Mar 2010
Calgary Base
Base Manger
15 Mar 2010
3
Ref # MOC 02/2010
J. C. Van Damm
Temporary: From ________ to __________ Signature
Summary of Actions Arising
Responsible
Due
Date & Signature
Pilot and mechanic training syllabus developed and documented
Training Manager
1 May 2010
Factory training completed for Pilots and Maintenance Supervisors
Training Manager
1 Aug 2010
Maintenance work stands designed and manufactured
Dir Maintenance
1 Jul 2010
Additional Hangar space at Edm acquired or built
Edm Base Manager
1 Jul 2010
Maintenance documentation developed for B429.
Maintenance QA Lead
1 Jul 2010
Statement of Completion/Fitness
Accountable Manager
Date & Signature
MOC process for introduction of B429 completed . All appropriate sections of the hazard register reviewed and updated. Risk considered managed to ALARP
Director of Operations
J.C. Van Damm 15 Jun 2010
Step 9 – Management of Change
The same process could be applied to a new contract or operation and the MOC Summary could be presented to the client prior to the start of operations as part of their assurance that all hazards have been assessed and that risk is being managed to ALARP.
Hazard/Risk Management Process SCOPE OF ACTIVITY
IDENTIFY AND RECORD HAZARDS
MANAGEMENT OF CHANGE PROCESS PROCESS NEW HAZARDS
SAFETY REPOPTING & INVESTIGATION PROCESS LINKED DIRECTLY TO THE HAZARD MANAGEMENT PROCESS
RISK ANALYSIS INTERNAL AUDIT TO CONFIRM IMPLEMENTATION & EFFECTIVENESS OF CONTROLS
IDENTIFY CONTROLS FOR SPECIFIC HAZARDS
NEW CONTROL REQD
CONTROL EXISTS
REFERENCE CONTROLS AND RESPONSIBLE POSTS
QA SYSTEM – UPDATE CHECKLIST S
VALIDATE EXISTING CONTROLS OR DEVELOP NEW CONTROLS
CONTROL DEVELOPED
REMEDIA L ACTION PLAN
SAFETY REPORTING & INVESTIGATION
Keeping it alive – Part III
Hazard/Risk Management Process SCOPE OF ACTIVITY
IDENTIFY AND RECORD HAZARDS
MANAGEMENT OF CHANGE PROCESS PROCESS NEW HAZARDS
SAFETY REPOPTING & INVESTIGATION PROCESS LINKED DIRECTLY TO THE SAFETY CASE.
RISK ANALYSIS INTERNAL AUDIT TO CONFIRM IMPLEMENTATION & EFFECTIVENESS OF CONTROLS
IDENTIFY CONTROLS FOR SPECIFIC HAZARDS
NEW CONTROL REQD
CONTROL EXISTS
REFERENCE CONTROLS AND RESPONSIBLE POSTS
QA SYSTEM – UPDATE CHECKLIST S
VALIDATE EXISTING CONTROLS OR DEVELOP NEW CONTROLS
CONTROL DEVELOPED
REMEDIA L ACTION PLAN
MANAGEMEN T REVIEW
SAFETY REPORTING & INVESTIGATION
Step 10 – Management Review
Wasted effort alert
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.
Hazard/Risk Management Process SCOPE OF ACTIVITY
IDENTIFY AND RECORD HAZARDS
MANAGEMENT OF CHANGE PROCESS PROCESS NEW HAZARDS
SAFETY REPOPTING & INVESTIGATION PROCESS LINKED DIRECTLY TO THE SAFETY CASE.
RISK ANALYSIS INTERNAL AUDIT TO CONFIRM IMPLEMENTATION & EFFECTIVENESS OF CONTROLS
IDENTIFY CONTROLS FOR SPECIFIC HAZARDS
NEW CONTROL REQD
CONTROL EXISTS
REFERENCE CONTROLS AND RESPONSIBLE POSTS
QA SYSTEM – UPDATE CHECKLIST S
VALIDATE EXISTING CONTROLS OR DEVELOP NEW CONTROLS
CONTROL DEVELOPED
REMEDIA L ACTION PLAN
MANAGEMEN T REVIEW
SAFETY REPORTING & INVESTIGATION
Each of these steps in the process can be a separate agenda item at the regular Senior Management Review meetings
Hazard/Risk Management Process SCOPE OF ACTIVITY
IDENTIFY AND RECORD HAZARDS
MANAGEMENT OF CHANGE PROCESS PROCESS NEW HAZARDS
SAFETY REPOPTING & INVESTIGATION PROCESS LINKED DIRECTLY TO THE SAFETY CASE.
RISK ANALYSIS INTERNAL AUDIT TO CONFIRM IMPLEMENTATION & EFFECTIVENESS OF CONTROLS
IDENTIFY CONTROLS FOR SPECIFIC HAZARDS
NEW CONTROL REQD
CONTROL EXISTS
REFERENCE CONTROLS AND RESPONSIBLE POSTS
QA SYSTEM – UPDATE CHECKLIST S
VALIDATE EXISTING CONTROLS OR DEVELOP NEW CONTROLS
CONTROL DEVELOPED
REMEDIA L ACTION PLAN
MANAGEMEN T REVIEW
SAFETY REPORTING & INVESTIGATION
Legal Footnote Does having this process documented open me to legal or regulatory action in the event of an accident? • Not having a Hazard Management Process and not having assessed the risks that others in the industry have, may well give you exposure. • A comprehensive, well documented Hazard Management Process, even one that lists controls that have not yet reasonably been put in place for financial or other reasons, represents “Best Endeavour”, which is legally defensible. • Your hazard register and remedial action plan are not State “approved” documents, but internal management tools.
Summary • Keep it manageable and focus first on your known areas of risk. • Look outside your company for global industry best practice. • Assess the risks honestly and openly within your company. • Consider all reasonable controls. • Keep the process live and adding value.
Scope • Identify the interactions of Hazard Management within the SMS. • Detail the procedural steps of the Hazard Management process. • Suggest documentation requirements. • Emphasise how to keep the process live and delivering real benefit to the organisation.
Shell Aircraft International Our GOAL is your SAFETY
QUESTIONS
