5. Step 1 – Set Goals
• 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?
6. 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
8. Step 2 – Identify & Record Hazards
Accident reports for own role
Recordable occurrences
Networking, blogs
Brainstorming
Accidents reports
for own A/C types
Industry Bodies/committees/forums
QA findings
Safety reporting system
Safety Observation Process
Information
exchange
Incident investigations
Accident reports for own
region/country/location
Flight Data Monitoring
Training feedback
Trend analysis
Generic Hazard
Lists
10. 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.
11. Typical RAM
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 helicopter
industry. Normally results in death.
12. Typical RAM
• Too vague and open to different interpretation.
• Detailed definition required for likelihood and severity.
15. 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
16. 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.
17. Wasted effort alert
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.
18. Step 4 – Controls for Specific Hazards
• Effective
• Costs proportional to benefits
• Practical
• Acceptable
• Enforceable
• Sustainable
• Doesn’t create new hazards
19. Step 4 – Controls for Specific Hazards
1.01 Weather
How do we prevent
this from happening?
CFIT:
Inadvertent Entry
to IMC
Add controls/barriers to the process
21. 1.01 Weather
Inadvertent Entry
to IMC
Company Weather
Operating Limits
Unknown WX
forecast
Acurate Daily WX
Forecast
Client unaware of
Company WX limits
WX limits agreed with
client
Client pressure to
fly
Enhanced Operational
Control (EOC)
procedure in place
Record controls in the hazard register
CFIT:
22. Basic Hazard Register Example
Task
Description
/Location
Onshore seismic support
Hazard Description:
Reference No.
HS - 017
Reference
Sept 11
RAM Score
Inadvertent entry to IMC
Barriers, Controls & Recovery Measures
Date last reviewed
Initial
Owner
Current
Status
23. Basic Hazard Register Example
Task
Descripti
on
/Location
Onshore seismic support
Hazard Description:
Reference No.
HS - 017
RAM Score
Inadvertent entry to IMC
Barriers, Controls & Recovery Measures
Minimum company weather
limits for VFR operations
Accurate daily forecasts
availablelimits agreed with
Weather for operation
client
Enhanced Operational
Controls in place to respond
to changes in weather.
Reference
Date last
reviewed
Sept 12
Initial
Owner
Current
Status
24. 1.01 Weather
Inadvertent Entry
to IMC
Company Weather
Operating Limits
Unknown WX
forecast
Acurate Daily WX
Forecast
CFIT:
Client unaware of
Company WX limits
WX limits agreed with
client
Client pressure to
fly
Enhanced Operational
Control (EOC)
procedure in place
Do I need another control?
Is the one I have fully effective?
25. 1.01 Weather
Inadvertent Entry
to IMC
Company Weather
Operating Limits
Aircraft Equipped for
Basic IMC flight
Unknown WX
forecast
Acurate Daily WX
Forecast
CFIT:
Client unaware of
Company WX limits
WX limits agreed with
client
Client pressure to
fly
Enhanced Operational
Control (EOC)
procedure in place
What if……?
26. 1.01 Weather
Inadvertent Entry
to IMC
Company Weather
Operating Limits
Aircraft Equipped for
Basic IMC flight
Unknown WX
forecast
Acurate Daily WX
Forecast
CFIT:
Client unaware of
Company WX limits
WX limits agreed with
client
Client pressure to
fly
Enhanced Operational
Control (EOC)
procedure in place
PIlot Instrument
Flying Competency
Pilot Instrument
Rated
Annual Instrument
Flight Check
Simulator Training
including IFR
procedures
27. 1.01 Weather
Inadvertent Entry
to IMC
Company Weather
Operating Limits
Aircraft Equipped for
Basic IMC flight
All Aircraft Equipted
with TAWS
Unknown WX
forecast
Acurate Daily WX
Forecast
CFIT:
Client unaware of
Company WX limits
WX limits agreed with
client
Client pressure to
fly
Enhanced Operational
Control (EOC)
procedure in place
PIlot Instrument
Flying Competency
Pilot Instrument
Rated
Annual Instrument
Flight Check
Simulator Training
including IFR
procedures
28. Basic Hazard Register Example
Task
Description
/Location
Onshore seismic support
Hazard Description:
Reference No.
HS - 017
Date last reviewed
Sept 11
RAM Score
Inadvertent entry to IMC
Initial
Barriers, Controls & Recovery Measures
Minimum company weather
limits for VFR operations
Accurate daily forecasts
availablelimits agreed with
Weather for operation
client
Enhanced Operational
Controls in place to respond
to changes in weather.
Reference
Owner
Current
Status
29. Task
Description
/Location
Hazard Description:
Onshore seismic support
Reference No.
HS - 017
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 inadvertent IFR flight check to ensure
currency and competence. trained and checked
Inadvertent IFR procedures
during annual simulator training.
All aircraft equipped with TAWS
Sept 11
RAM Score
Inadvertent entry to IMC
Barriers, Controls & Recovery Measures
Date last reviewed
Initial
Reference
Owner
Status
Current
30. 1.01 Weather
Inadvertent Entry
to IMC
Company Weather
Operating Limits
Aircraft Equipped for
Basic IMC flight
All Aircraft Equipted
with TAWS
Unknown WX
forecast
Acurate Daily WX
Forecast
CFIT:
Client unaware of
Company WX limits
WX limits agreed with
client
Client pressure to
fly
Enhanced Operational
Control (EOC)
procedure in place
PIlot Instrument
Flying Competency
Pilot Instrument
Rated
Annual Instrument
Flight Check
Simulator Training
including IFR
procedures
Now consider the hazard
consequences and how to
mitigate them.
31. 1.01 Weather
Inadvertent Entry
to IMC
Company Weather
Operating Limits
Aircraft Equipped for
Basic IMC flight
All Aircraft Equipted
with TAWS
Unknown WX
forecast
Acurate Daily WX
Forecast
Unknown Aircraft
Location
CFIT:
Client unaware of
Company WX limits
WX limits agreed with
client
Inadequate ER
Client pressure to
fly
Enhanced Operational
Control (EOC)
procedure in place
PIlot Instrument
Flying Competency
Pilot Instrument
Rated
Annual Instrument
Flight Check
Simulator Training
including IFR
procedures
32. 1.01 Weather
Inadvertent Entry
to IMC
Company Weather
Operating Limits
Aircraft Equipped for
Basic IMC flight
All Aircraft Equipted
with TAWS
Unknown WX
forecast
Acurate Daily WX
Forecast
Unknown Aircraft
Location
CFIT:
Client unaware of
Company WX limits
Satelite Flight
Tracking
WX limits agreed with
client
Inadequate ER
ERP in Place and
Exercised Annually
Client pressure to
fly
Enhanced Operational
Control (EOC)
procedure in place
PIlot Instrument
Flying Competency
Pilot Instrument
Rated
Annual Instrument
Flight Check
Simulator Training
including IFR
procedures
33. Task
Description
/Location
Hazard Description:
Onshore seismic support
Reference No.
HS - 017
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 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
Sept 11
RAM Score
Inadvertent entry to IMC
Barriers, Controls & Recovery Measures
Date last reviewed
Initial
Reference
Owner
Current
Status
34. Task
Description
/Location
Hazard Description:
Onshore seismic support
Reference No.
HS - 017
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 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
All aircraft equipped with satellite flight tracking
Emergency response plan in place & exercised annually
Sept 11
RAM Score
Inadvertent entry to IMC
Barriers, Controls & Recovery Measures
Date last reviewed
Initial
Reference
Owner
Current
Status
35. Hazard Management Process
SCOPE OF ACTIVITY
IDENTIFY AND
RECORD HAZARDS
RISK ANALYSIS
IDENTIFY CONTROLS
FOR SPECIFIC HAZARDS
CONTROL EXISTS
REFERENCE
DOCUMENTS AND
RESPONSIBLE
POSTS
36. Task
Description
/Location
Hazard Description:
Onshore seismic support
Reference No.
HS - 017
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 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
All aircraft equipped with satellite flight tracking
Emergency response plan in place & exercised annually
with client
Sept 11
RAM Score
Inadvertent entry to IMC
Barriers, Controls & Recovery Measures
Date last reviewed
Initial
Reference
Owner
Current
Status
37. Task
Description
/Location
Hazard Description:
Onshore seismic support
Reference No.
Date last reviewed
HS - 017
Sept 11
RAM Score
Inadvertent entry to IMC
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
Ops Man 8.3.1
Director of
Maintenance
Chief Pilot
In force
Enhanced Operational Controls in place to respond to
changes in weather.
Aircraft equipped for IFR flight (Designate minimum
avionic equipment)
Pilots instrument rated
Ops Man 3.4
In force
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
Training Man
6.4
Chief Pilot
In force
All aircraft equipped with satellite flight tracking
Ops Man 8.3.4
In force
Emergency response plan in place & exercised annually
with client
ERP 5.6 and
Standard
contract clause
Director of
Maintenance
Head of Safety
& QA
In force
38. Hazard Management Process
SCOPE OF ACTIVITY
IDENTIFY AND
RECORD HAZARDS
RISK
ANALYSIS
IDENTIFY CONTROLS
FOR SPECIFIC HAZARDS
CONTROL EXISTS
REFERENCE
DOCUMENTS AND
RESPONSIBLE POSTS
NEW CONTROL REQUIRED
REMEDIAL
ACTION PLAN
39. 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.
40. Task
Description
/Location
Hazard Description:
Onshore seismic support
Reference No.
Date last reviewed
HS - 017
Sept 11
RAM Score
Inadvertent entry to IMC
Initial
Barriers, Controls & Recovery Measures
Reference
Owner
Status
Minimum company weather limits for VFR
operations
Accurate daily forecasts available for operation
Ops Man 4.2.3
Chief Pilot
In force
Ops Man 4.2.4
Chief Pilot
In force
Standard
contract clause
Enhanced Operational Controls in place to respond
9.2
to changes in weather.
Aircraft equipped for IFR flight (Designate minimum Ops Man 8.3.1
avionic equipment)
Director
Operations
In force
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
Head of
Safety & QA
In force
Weather limits agreed with client
Inadvertent IFR procedures trained and checked
during annual simulator training.
All aircraft equipped with TAWS
Current
41. Task
Description
/Location
Hazard Description:
Onshore seismic support
Reference No.
Date last reviewed
HS - 017
Sept 11
RAM Score
Inadvertent entry to IMC
Initial
Current
Barriers, Controls & Recovery Measures
Reference
Owner
Status
Minimum company weather limits for VFR
operations
Accurate daily forecasts available for operation
Ops Man 4.2.3
Chief Pilot
In force
Ops Man 4.2.4
Chief Pilot
In force
Standard
contract clause
Enhanced Operational Controls in place to respond RAP Item 16
9.2
to changes in weather.
Aircraft equipped for IFR flight (Designate minimum Ops Man 8.3.1
avionic equipment)
Director
Operations
Director
Operations
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
RAP Item 23
Chief Pilot
RAP Item 15
All aircraft equipped with satellite flight tracking
Ops Man 8.3.4
Maintenance
Director
Director of
Maintenance
Awaiting sim
availability
Due complete
Apr 2014
In force
Emergency response plan in place & exercised
annually with client
ERP 5.6 and
Standard
Head of
Safety & QA
Weather limits agreed with client
Due 31 Dec 13
In force
In force
42. Step 6 – Remedial Action Plan
• Re-assess risk
43. Task
Description
/Location
Hazard Description:
Onshore seismic support
Reference No.
Date last reviewed
HS - 017
Sept 11
RAM Score
Inadvertent entry to IMC
Initial
Current
Barriers, Controls & Recovery Measures
Reference
Owner
Status
Minimum company weather limits for VFR
operations
Accurate daily forecasts available for operation
Ops Man 4.2.3
Chief Pilot
In force
Ops Man 4.2.4
Chief Pilot
In force
Standard
contract clause
Enhanced Operational Controls in place to respond RAP Item 16
9.2
to changes in weather.
Aircraft equipped for IFR flight (Designate minimum Ops Man 8.3.1
avionic equipment)
Director
Operations
Director
Operations
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
RAP Item 23
Chief Pilot
RAP Item 15
All aircraft equipped with satellite flight tracking
Ops Man 8.3.4
Maintenance
Director
Director of
Maintenance
Awaiting sim
availability
Due complete
Apr 2014
In force
Emergency response plan in place & exercised
annually with client
ERP 5.6 and
Standard
Head of
Safety & QA
Weather limits agreed with client
Due 31 Dec 13
In force
In force
44. Task
Description
/Location
Hazard Description:
Onshore seismic support
Inadvertent
Reference No.
Operator assessed that until
Sim training,
entry to IMC TAWS and the
EOC were in place, risk
remained medium.
Date last reviewed
HS - 017
Sept 11
RAM Score
Initial
Current
Barriers, Controls & Recovery Measures
Reference
Owner
Status
Minimum company weather limits for VFR
operations
Accurate daily forecasts available for operation
Ops Man 4.2.3
Chief Pilot
In force
Ops Man 4.2.4
Chief Pilot
In force
Standard
contract clause
Enhanced Operational Controls in place to respond RAP Item 16
9.2
to changes in weather.
Aircraft equipped for IFR flight (Designate minimum Ops Man 8.3.1
avionic equipment)
Director
Operations
Director
Operations
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
RAP Item 23
Chief Pilot
RAP Item 15
All aircraft equipped with satellite flight tracking
Ops Man 8.3.4
Maintenance
Director
Director of
Maintenance
Awaiting sim
availability
Due complete
Apr 2014
In force
Emergency response plan in place & exercised
annually with client
ERP 5.6 and
Standard
Head of
Safety & QA
Weather limits agreed with client
Due 31 Dec 13
In force
In force
45. Hazard Management Process
SCOPE OF ACTIVITY
IDENTIFY AND
RECORD HAZARDS
RISK
ANALYSIS
IDENTIFY CONTROLS
FOR SPECIFIC HAZARDS
CONTROL EXISTS
REFERENCE
DOCUMENTS AND
RESPONSIBLE POSTS
NEW CONTROL REQUIRED
CONTROL
DEVELOPED
REMEDIAL
ACTION PLAN
46. Step 7 – Interface with Quality
Wasted effort alert
The quality management system must be integrated
with the hazard management system.
47. SCOPE OF ACTIVITY
IDENTIFY AND
RECORD HAZARDS
INTERNAL AUDIT TO
CONFIRM
IMPLEMENTATION &
EFFECTIVENESS
OF CONTROLS
RISK
ANALYSIS
IDENTIFY CONTROLS
FOR SPECIFIC HAZARDS
CONTROL EXISTS
QUALITY
SYSTEM –
UPDATE
CHECKLISTS
Steps 3 – 7 should
now be repeated for
each hazard identified
in Step 2.
REFERENCE
DOCUMENTS AND
RESPONSIBLE POSTS
NEW CONTROL REQUIRED
CONTROL
DEVELOPED
REMEDIAL
ACTION PLAN
48. Wasted effort alert
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.
49. SCOPE OF ACTIVITY
IDENTIFY AND
RECORD HAZARDS
INTERNAL AUDIT TO
CONFIRM
IMPLEMENTATION &
EFFECTIVENESS
OF CONTROLS
RISK
ANALYSIS
IDENTIFY CONTROLS
FOR SPECIFIC HAZARDS
CONTROL EXISTS
QUALITY
SYSTEM –
UPDATE
CHECKLISTS
REFERENCE
DOCUMENTS AND
RESPONSIBLE POSTS
SAFETY REPOPTING
& INVESTIGATION
PROCESS LINKED
DIRECTLY TO THE
HAZARD
MANAGEMENT
PROCESS.
NEW CONTROL REQUIRED
CONTROL
DEVELOPED
REMEDIAL
ACTION PLAN
SAFETY
REPORTING &
INVESTIGATION
50. 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.
51. • 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.
52. Task
Description
/Location
Hazard Description:
Onshore seismic support
Reference No.
Date last reviewed
HS - 017
Sept 11
RAM Score
Inadvertent entry to IMC
Initial
Barriers, Controls & Recovery Measures
Reference
Owner
Status
Minimum company weather limits for VFR
operations
Accurate daily forecasts available for operation
Ops Man 4.2.3
Chief Pilot
In force
Ops Man 4.2.4
Chief Pilot
In force
Director
Operations
Director
Operations
Maintenance
Director
Chief Pilot
Current
In force
Weather limits agreed with client
Standard
contract clause
Enhanced Operational Controls in place to respond RAP Item 16
9.2
to changes in weather.
Aircraft equipped for IFR flight (Designate minimum Ops Man 8.3.1
avionic equipment)
Pilots instrument rated
Ops Man 3.4
Due 31 Dec 13
In force
In force
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
Training Man 6.4 Chief Pilot
In force
RAP Item 23
Chief Pilot
RAP Item 15
All aircraft equipped with satellite flight tracking
Ops Man 8.3.4
Emergency response plan in place & exercised
annually with client
ERP 5.6 and
Standard
contract clause
10.1
Maintenance
Director
Maintenance
Director
Head of
Safety & QA
Awaiting sim
availability
Due complete
Apr 2014
In force
In force
53. Task
Description
/Location
Hazard Description:
Onshore seismic support
Reference No.
HS - 017
Minimum company weather limits for VFR
operations
Accurate daily forecasts available for operation
Reference
Ops contract
AmendMan 4.2.3
requirements
Ops Man 4.2.4
Weather limits agreed with client
Standard
contract clause
Enhanced Operational Controls in place to respond RAP Item 16
9.2
to changes in weather.
Aircraft equipped for IFR flight (Designate minimum Ops Accelerate
Man 8.3.1
avionic equipment)
Pilots instrument rated
Opsintroduction
Man 3.4
Sept 11
RAM Score
Inadvertent entry to IMC
Barriers, Controls & Recovery Measures
Date last reviewed
Initial
Owner
Status
Chief Pilot
In force
Chief Pilot
In force
Director
Operations
Director
Operations
Maintenance
Director
Chief Pilot
Current
In force
Due 31 Dec 13
In force
In force
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
Training Man 6.4 Chief Pilot
In force
RAP Item 23
Chief Pilot
RAP Item 15
All aircraft equipped with satellite flight tracking
Ops Man 8.3.4
Emergency response plan in place & exercised
annually with client
ERP 5.6 and
Standard
contract clause
10.1
Maintenance
Director
Maintenance
Director
Head of
Safety & QA
Awaiting sim
availability
Due complete
Apr 2014
In force
In force
54. Task
Description
/Location
Hazard Description:
Onshore seismic support
Reference No.
Date last reviewed
HS - 017
Sept 11
RAM Score
Inadvertent entry to IMC
Initial
Barriers, Controls & Recovery Measures
Referece
Owner
Status
Minimum company weather limits for VFR
operations
Accurate daily forecasts available for operation
Ops Man 4.2.3
Chief Pilot
In force
Ops Man 4.2.4
Chief Pilot
In force
Director
Operations
Director
Operations
Maintenance
Director
Chief Pilot
Current
In force
Weather limits agreed with client
Standard
contract clause
Enhanced Operational Controls in place to respond RAP Item 16
9.2
to changes in weather.
Aircraft equipped for IFR flight (Designate minimum Ops Man 8.3.1
avionic equipment)
Pilots instrument rated
Ops Man 3.4
Annual inadvertent IFR flight check to ensure
currency and competence.
Wx limits and EOC requirements included in Pilot
annual ground training syllabus
Inadvertent 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
Training Man 6.4 Chief Pilot
Training Man
6.12
RAP Item 23
RAP Item 15
Due 31 Dec 13
In force
In force
In force
Chief Pilot
Chief Pilot
Maintenance
Director
Ops Man 8.3.4
Maintenance
Add and record
Director
a 5.6 and
ERP further control
Head of
Standard
Safety & QA
contract clause
10.1
Awaiting sim
availability
Due complete
Apr 2014
In force
In force
55. 1.01 Weather
Inadvertent Entry
to IMC
Company Weather
Operating Limits
Aircraft Equipped for
Basic IMC flight
All Aircraft Equipted
with TAWS
Unknown WX
forecast
Acurate Daily WX
Forecast
CFIT:
Client unaware of
Company WX limits
WX limits agreed with
client
Client pressure to
fly
Enhanced Operational
Control (EOC)
procedure in place
PIlot Instrument
Flying Competency
Pilot Instrument
Rated
Annual Instrument
Flight Check
Simulator Training
including IFR
procedures
56. 1.01 Weather
Inadvertent Entry
to IMC
Company Weather
Operating Limits
Aircraft Equipped for
Basic IMC flight
All Aircraft Equipted
with TAWS
Unknown WX
forecast
Acurate Daily WX
Forecast
CFIT:
Client unaware of
Company WX limits
WX limits agreed with
client
WX limits held by
client site supervisor
Enhanced Operational
Control (EOC)
procedure in place
EOC & WX limits in
pilots annual ground
training syllabus
Pilot Instrument
Rated
Annual Instrument
Flight Check
Client pressure to
fly
PIlot Instrument
Flying Competency
Simulator Training
including IFR
procedures
57. SCOPE OF ACTIVITY
IDENTIFY AND
RECORD HAZARDS
INTERNAL AUDIT TO
CONFIRM
IMPLEMENTATION &
EFFECTIVENESS
OF CONTROLS
RISK
ANALYSIS
VALIDATE EXISTING
CONTROLS OR DEVELOP
NEW CONTROLS
IDENTIFY CONTROLS
FOR SPECIFIC HAZARDS
CONTROL EXISTS
QUALITY
SYSTEM –
UPDATE
CHECKLISTS
PROCESS NEW HAZARDS
REFERENCE
DOCUMENTS AND
RESPONSIBLE POSTS
NEW CONTROL REQUIRED
CONTROL
DEVELOPED
REMEDIAL
ACTION PLAN
SAFETY
REPORTING &
INVESTIGATION
58. MANAGEMENT
OF CHANGE
PROCESS
SCOPE OF ACTIVITY
IDENTIFY AND
RECORD HAZARDS
INTERNAL AUDIT TO
CONFIRM
IMPLEMENTATION &
EFFECTIVENESS
OF CONTROLS
RISK
ANALYSIS
VALIDATE EXISTING
CONTROLS OR DEVELOP
NEW CONTROLS
IDENTIFY CONTROLS
FOR SPECIFIC HAZARDS
CONTROL EXISTS
QUALITY
SYSTEM –
UPDATE
CHECKLISTS
PROCESS NEW HAZARDS
REFERENCE
DOCUMENTS AND
RESPONSIBLE POSTS
NEW CONTROL REQUIRED
CONTROL
DEVELOPED
REMEDIAL
ACTION PLAN
SAFETY
REPORTING &
INVESTIGATION
59. 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…?
60. 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.
61. 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.
62. Ref #
Scope of
Change
Accountable
Manager
Type of change
Permanent
Department/location
Responsible
Summary of Actions Arising
Statement of Completion/Fitness
Temporary: From ________ to __________
Hazard Register
Reviewed/Updated
Responsible
Signature
Due
Accountable Manager
Date & Signature
Date & Signature
63. Scope of
Change
Accountable
Manager
Type of change
Department/location
Introduction of AW139 from Aug
2013 of Operations J. C. Van Damm
Director
Permanent
Responsible
Summary of Actions Arising
Statement of Completion/Fitness
Ref # MOC 02/2013
Temporary: From ________ to __________
Hazard Register
Reviewed/Updated
Responsible
Signature
Due
Accountable Manager
Date & Signature
Date & Signature
64. Scope of
Change
Accountable
Manager
Type of change
Department/location
Introduction of AW139 from Aug
2013 of Operations J. C. Van Damm
Director
Permanent
Responsible
Ref # MOC 02/2013
Temporary: From ________ to __________
Hazard Register
Reviewed/Updated
Signature
Maintenance
Department
Training
Department
Flight Operations
Department
Safety & Quality
Department
Edmonton Base
Calgary Base
Summary of Actions Arising
Responsible
Due
Date & Signature
List all stakeholders
Statement of Completion/Fitness
Accountable Manager
Date & Signature
65. Scope of
Change
Accountable
Manager
Type of change
Introduction of AW139 from Aug
2013 of Operations J. C. Van Damm
Director
Ref # MOC 02/2013
Temporary: From ________ to __________
Permanent
Department/location
Responsible
Hazard Register
Reviewed/Updated
Maintenance
Department
Training
Department
Flight Operations
Department
Safety & Quality
Department
Edmonton Base
Director Maintenance
13 Apr 2013
Training Manager
1 Apr 2013
Director Operations
22 Mar 2013
Director Safety & Quality
10 Apr 2013
Base Manager
5 Mar 2013
Calgary Base
Base Manger
15 Mar 2013
Summary of Actions Arising
Statement of Completion/Fitness
Responsible
Signature
Due
Once a department has
completed its review of the
Hazard Register, the
responsible party will
Accountable Manager
sign for completion
Date & Signature
Date & Signature
66. Scope of
Change
Accountable
Manager
Type of change
Introduction of AW139 from Aug
2013 of Operations J. C. Van Damm
Director
Permanent
Ref # MOC 02/2013
Temporary: From ________ to __________
Department/location
Responsible
Hazard Register
Reviewed/Updated
Maintenance
Department
Training
Department
Flight Operations
Department
Safety & Quality
Department
Edmonton Base
Director Maintenance
13 Apr 2013
Training Manager
Director Operations
1 Apr 2013department will develop
Each
22 Mar 2013
a detailed action plan.
Director Safety & Quality
10 Apr 2013
Base Manager
5 Mar 2013
Calgary Base
Base Manger
15 Mar 2013
Summary of Actions Arising
Responsible
Pilot and mechanic training syllabus
developed and documented
Factory training completed for Pilots and
Maintenance Supervisors
Maintenance work stands designed and
manufactured
Additional Hangar space at Edmonton to
be acquired or built
Maintenance documentation developed
for B429. of Completion/Fitness
Statement
Training Manager
Signature
Due
Date & Signature
1 May
2013
Training Manager
1 Aug
2013
Director
1 Jul
Maintenance
2013
Base Manager
1 Jul
2013
Maintenance QA
1 Jul
Lead
2013 Date & Signature
Accountable Manager
67. Scope of
Change
Accountable
Manager
Type of change
Introduction of AW139 from Aug
2013 of Operations J. C. Van Damm
Director
Permanent
Ref # MOC 02/2013
Temporary: From ________ to __________
Department/location
Responsible
Maintenance
Department
Training Department
Director Maintenance
Hazard Register
Reviewed/Updated
13 Apr 2013
Training Manager
1 Apr 2013
Flight Operations
Department
Safety & Quality
Department
Edmonton Base
Director Operations
22 Mar 2013
Director Safety & Quality
10 Apr 2013
Base Manager
5 Mar 2013
Calgary Base
Base Manger
Signature
15 Mar 2013
Summary of Actions Arising
Responsible
Due
Pilot and mechanic training syllabus developed
and documented
Factory training completed for Pilots and
Maintenance Supervisors
Maintenance work stands designed and
manufactured
Additional Hangar space at Edmonton to be
acquired or built
Maintenance documentation developed for
B429.
Statement of Completion/Fitness
Training Manager
1 May 2013
Training Manager
1 Aug 2013
Director Maintenance
1 Jul 2013
Base Manager
1 Jul 2013
Maintenance QA Lead
1 Jul 2013
MOC process for introduction of AW139
completed . All appropriate sections of the
hazard register reviewed and updated. Risk
Date & Signature
Accountable Manager
Date & Signature
Director of
Operations
J.C. Van Damm 15
Jun 2013
68. MANAGEMENT
OF CHANGE
PROCESS
SCOPE OF ACTIVITY
IDENTIFY AND
RECORD HAZARDS
INTERNAL AUDIT TO
CONFIRM
IMPLEMENTATION &
EFFECTIVENESS
OF CONTROLS
RISK
ANALYSIS
VALIDATE EXISTING
CONTROLS OR DEVELOP
NEW CONTROLS
IDENTIFY CONTROLS
FOR SPECIFIC HAZARDS
CONTROL EXISTS
QUALITY
SYSTEM –
UPDATE
CHECKLISTS
PROCESS NEW HAZARDS
REFERENCE
DOCUMENTS AND
RESPONSIBLE POSTS
NEW CONTROL REQUIRED
CONTROL
DEVELOPED
REMEDIAL
ACTION PLAN
SAFETY
REPORTING &
INVESTIGATION
69. MANAGEMENT
OF CHANGE
PROCESS
SCOPE OF ACTIVITY
IDENTIFY AND
RECORD HAZARDS
INTERNAL AUDIT TO
CONFIRM
IMPLEMENTATION &
EFFECTIVENESS
OF CONTROLS
RISK
ANALYSIS
VALIDATE EXISTING
CONTROLS OR DEVELOP
NEW CONTROLS
IDENTIFY CONTROLS
FOR SPECIFIC HAZARDS
CONTROL EXISTS
QUALITY
SYSTEM –
UPDATE
CHECKLISTS
PROCESS NEW HAZARDS
NEW CONTROL REQUIRED
REFERENCE
DOCUMENTS AND
RESPONSIBLE POSTS
CONTROL
DEVELOPED
MANAGEMENT
REVIEW
REMEDIAL
ACTION PLAN
SAFETY
REPORTING &
INVESTIGATION
70. 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.
71. 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
72. References
Safety Risk Management
“Hazard identification and safety risk management are the core processes involved in the management of
“A formal system of hazard nor have they been developed is a consequence of recent an acceptable
safety. They are neither new, identification and managementas fundamental in controllinginterest in safety
level “Risk management is a proactive activity that looks at the risks associated with identified hazards
of risk. A well-designed risk managementmanagement
system describes operational processes across department
and“Safety risk management. identifies system (SMS). Hazard identificationsafety risk management isand
organizational boundaries, A formal key hazards and identification safety when faced with these
and, and assists insafety management systems of hazard measures them, methodically risk management
in particular, selecting actions to maintain an appropriate level of and and safety assesses risk,
implementsare dogmatic
controls to mitigate risk.”
essential in controlling risk to acceptable levels. The safety risk management component of the SMS is
hazards.”
components that underlie the overarching concept used in the system safety training course that
based upon the system safety process model that is of system safety. This is an all-encompassing,is
engineering-based
taught at the FAA Academy.”
approach that contributes to system design and which was developed more that forty years ago.”
73. 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/DevelopingaSafetyM
anagementSystem.aspx