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? 1. 2. 3. 4. 5. 6. 7. Widely recognized as best practice Reduces number of accidents Reduces costs Reduces probability of occurrences Reduces severity of occurrences Reduces exposure to risk
Increases 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 change Phase-1 SMS
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 Approach to to safety Safety Organizational Effective Organisation structure for for of & ownership 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 apparent 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 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 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 & elimination of the Ground Duties Maintenance Results of full year 2000 dataset Ground personnel 20 23
74 16 Commercial Operator 101 100 12 145 150 Emergency Medical Service 28 Aerial Application 0 27
200 Personal / Private 37 50 Instructional / Training Frequency SPS & Accident Count by Primary Mission 250 Accident 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: Gross negligence Persistent sub-standard performance Wilful recklessness Just Culture Process Start No* Knowingly violated procedures? Was the job understood? Yes Was the action as intended? No Are the procedures clear? Yes* Pass substitution test? No
Yes Yes Were the results as intended? No* No* Yes Defective training or selection experience? No Yes* Yes* No Blame Error No
No Reckless Violation History of violating procedures? Negligent Error Repeated Incident With Similar Root Cause Yes Sabotage or Malevolent Act First written warning; Final warning and negative performance appraisal Coaching / Increased Supervision until behavior is corrected. Documented for the
purpose of accident prevention awareness and training will suffice. Severe Sanctions * Indicates a System induced error. Manager/supervisor must evaluate what part of the system failed and what corrective and preventative action is required. Corrective and preventative action shall be documented for management review. The Attributes of an SMS 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 11) 12) Safety Policy
SMS Management Plan Safety Promotion Document and Data Information Management Hazard Identification and Risk Management Occurrence and Hazard Reporting Occurrence Investigation and Analysis Safety Assurance Oversight Programs Safety Management Training Requirements Management of Changes Emergency Preparedness and Response 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
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