1. Modelled Risk Scenarios for an Aviation SMS Shell Aircraft International Aviation Hazard Management Ltd International Federation of Airworthiness

2. ICAO - SMS mandatory from 2009 UK Oil Industry - SMS mandated since 1992 Piper Alpha Disaster - Cullen Report ‘it was irresponsible to operate a business without understanding the risks and managing the hazards that existed within that business’

3. Aim: to produce a Transportable Hazard Analysis SAI - Facilities, tools & models UKFSC - expertise (pilots & engineers) Hazard Analysis Team

4. HEMP Hazard and Effects Management Programme - Identify (the hazard, and hazardous events) - Assess (the Risks)

6. HEMP Hazard and Effects Management Programme - Identify (the hazard, and hazardous events) - Assess (the Risks) - Control (the threats that might release the hazard that leads to the hazardous event) - Recover (from the hazardous event, if possible before incurring an unwanted consequence)

7. Hazardous Event HAZARDSHAZARDS MITIGATIONMITIGATION THREATTHREAT CONSEQUENCESCONSEQUENCES CONTROLCONTROL CONTROLCONTROL ESCALATIONESCALATION ESCALATIONESCALATION CONTROLCONTROL RECOVERRECOVER Manage / Control The causes Minimize The results The Bow-Tie Analysis Tool www.bowtie.com

8. Bow-Tie Shape

9. Risk Scenarios Team identified 450 potential events unmanagable number for detailed analysis by generic grouping, combining threats & threat controls reduced list of 35 separate Risk Scenarios

10. Example of Bow-TieXP as an analysis tool

11. Who does What, Why and How?

17. Human Error Release of an Unairworthy Aircraft to Service

19. Hazard Modelling Using HEMP the team focused on Hazardous Events Hazardous Event ‘Potential hazardous events are what need to be risk assessed, rather than the hazard itself’ Test needed to check for gaps

21. Locations Location A - Aircraft on the ground in preparation for or recovery from service Location B - Aircraft in motion - on the ground Location C - Aircraft in Motion - Airborne Location D - Aircraft Undergoing Maintenance Location E - Offices and Facilities

22. Hazardous Events - Example of coding HE 18ACD - Loss of Containment - Dangerous Goods HE = Hazardous Event 18 = sequential by discipline (except 1 & 2) ACD = Locations Disciplines - Operational, Maintenance, HSE related, Organisational & Management

23. HE 1CDeviation from intended safe flight path ‘Situations causing a signicant departure from a safe, intended heading, altitude, speed, flight level and or track’. GENERIC PRIMARY OPERATIONAL HAZARDOUS EVENTS HE 2ADRelease of an unairworthy aircraft to service ‘Situations resulting in the inadvertent release of an aircraft following maintenance, or servicing actions, which is not fully airworthy’.

24. Operational HE 4BC - Aircraft major system failures including dynamic failure of components Maintenance HE 19D - Lost of containment fluid or gas under pressure HSE Related HE 22 AD - Encountering adverse weather conditions Organisation & Management HE 30E - Contracted corporate commitments at variance to company resources

25. These generic analyses can be customised for use by any aircraft operator