Presentation on theme: "Airborne Law Enforcement Association CHC Safety Summit Safety Management Systems -------------------------------------------------------- Keith Johnson."— Presentation transcript:
Airborne Law Enforcement Association CHC Safety Summit Safety Management Systems Keith Johnson Safety Program Manager
The topic of the day Whose job is it?
Start Points ?
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 Don’t reinvent the wheel No new causes of accidents Copy successful organizations “Flying to a higher standard” Accreditation
“It’s 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. Widely recognized as best practice 2. Reduces number of accidents 3. Reduces costs 4. Reduces probability of occurrences 5. Reduces severity of occurrences 6. Reduces exposure to risk 7. Increases likelihood of completing the mission
SMS IMPLEMENTATION Organization CEO’s role – The Accountable Executive (ICAO, TC, FAA) – The “Champion” – Define Objectives – Promotion – Policy – Budget – Training – Empowerment – Monitoring – Feedback – Identify every organization that implements – Insurance rewards
THE CHAMPION Pre-requisite for implementing SMS Person that will lead the implementation effort (disciple) Must be empowered with the authority to transform the organization – Over-through managers long-held beliefs about responsibility, accountability, punitive vs. Just Culture Requires re-engineering the systems and processes in the organization
DISCIPLINE Disciplinary action vs. accountability Change core value SMS by nature is Non-Punitive Champion’s greatest challenge
DEVIATION FROM STANDARDS Behavior is a function of consequences – Run a red light, you get a ticket I.D. & correct immediately Be consistent – No freebees Be fair Counsel, train, discipline, ground and remove Only reward desired performance
SMS & ACCOUNTABLE EXECUTIVE Is the agent for cultural change Minister of TC is the accountable executive ICAO concurs with TC
COMPLACENCY Familiarity & prolonged exposure without a mishap leads to a loss of appreciation of risk. Why?
IHST SMS DELIVERABLES SMS Toolkit & Exemplars SMS Mentoring Program SMS Promotion – 30 Safety Industry-wide articles on SMS – SMS Power Point presentations on IHST website – 23 Industry-wide SMS presentations Computer SMS Training Program Return on Investment Training Testified at NTSB HEMS hearing HAI/IHST SMS video
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 Anchor new approaches in the 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
EMS ACCIDENT STUDY Bad weather increases risk 8-times 68% of crashes occurred at night Crashes at night 8-times more likely fatal 77% IIMC conditions fatal
What Does Having an SMS Give? We will now concentrate on describing the three key processes generically Once you understand these, the rest becomes more readily apparent But first some more definitions…
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 You must take care of yourself – Al Haynes
TRAINING SOLUTIONS Higher standards for certification Higher standards for CFI’s Enforcement of standards for flight examiners
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 (technology)
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 organization
JHSAT STUDY RESULTS Three themes came from JHSAT study: 1. Better training 2. Better Operational Oversight 3. Implementation Safety Management System
Results of full year 2000 dataset
Introduction to the SMS Toolkit Contains SMS guidance material Sample SMS Manual Provides a foundation for implementing SMS IHST needs feedback Compliant FAA AC
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 behavior 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 Willful recklessness
Just Culture Process
EFFECTS OF ATTITUDE The rose colored glasses of performance Decision-making Compliance with standards Proficiency Teamwork Effectiveness & efficiency Bottom line SAFETY
“What lies behind us and what lies before us are tiny matters compared to what lies within us.” Ralph Waldo Emerson
ENFORCEMENT OF STANDARDS Research Shows – Once you start deviating from the rules, you are almost twice as likely to commit an error with potentially serious consequences! We could eliminate 70-80% of the accidents just by following the rules. * NOTE: Read the NTSB accident reports on the ALEA website. Should be a requirement for all personnel Honest mistakes vs. intentional non-compliance
NON-COMPLIANCE Non-compliance rarely results in an accident or incident, however: It always results in greater risk for the operation!
DEVIATION FROM STANDARDS Behavior is a function of consequences – Run a red light, you get a ticket I.D. & correct immediately Be consistent – No freebees Be fair Counsel, train, discipline, ground and remove
DECISION TO ABORT We must change the perception that the mission is the most important no matter the risk. *
“ The hardest thing to do, and the right thing to do are usually the same thing.”
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?
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
PDCA: Putting the Processes in Context Plan Do Check Act Cycle – Plan what we are going to do – Do it – Check performance – Act to improve Q: So where would you put the three process? Risk Management MonitoringSafety Reporting & Investigation All 3 can result in Action
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
FINAL THOUGHTS Can achieve our objective Industry is mobilized Only one chance to achieve objective Requires everyone’s commitment