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Shell Aircraft InternationalOur 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.
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. A formal system of hazard identification and safety risk management is essential in controlling risk to acceptable levels. The safety risk management component of the SMS is based upon the system
safety process model that is used in the system safety training course that is taught at the FAA Academy.”
“Risk management is a proactive activity that looks at the risks associated with identified hazardsand assists in selecting actions to maintain an appropriate level of safety when faced with these
hazards.”
Safety Risk Management“A formal system of hazard identification and management is fundamental in controlling an acceptable level of risk. A well-designed risk management system describes operational processes across department and organizational boundaries, identifies key hazards and measures them, methodically assesses risk, and implements controls to
mitigate risk.”
“Hazard identification and safety risk management are the core processes involved in the management ofsafety. They are neither new, nor have they been developed as a consequence of recent interest in safety
managementand, in particular, safety management systems (SMS). Hazard identification and safety risk management are
dogmaticcomponents that underlie the overarching concept of system safety. This is an all-encompassing, engineering-based
approach that contributes to system design and which was developed more that forty years ago.”
Hazard/Risk Management ProcessSCOPE OF ACTIVITY
IDENTIFY AND RECORD HAZARDS
RISK ANALYSIS
IDENTIFY CONTROLS FOR SPECIFIC HAZARDS
REFERENCE CONTROLS AND RESPONSIBLE
POSTS
REMEDIAL ACTION
PLAN
QA SYSTEM – UPDATE
CHECKLISTS
SAFETY REPORTING &
INVESTIGATION
INTERNAL AUDIT TO CONFIRMIMPLEMENTATION & EFFECTIVENESSOF CONTROLS
MANAGEMENT REVIEW
MANAGEMENT OF CHANGE PROCESS
SAFETY REPOPTING & INVESTIGATION PROCESS LINKED DIRECTLY TO THE SAFETY CASE.
VALIDATE EXISTING CONTROLS OR DEVELOP NEW CONTROLS
PROCESS NEW HAZARDS
CONTROL EXISTS NEW CONTROL REQD
CONTROL DEVELOPED
SMS ELEMENTS & RELATIONSHIPSLEADERSHI
P
POLICY, OBJECTIVES &
KPI’S
PROCEDURES
RESOURCES
SAFETY REPORTING & INVESTIGATIO
N
COMMUNICATION (TO WORKFORCE)
MANAGEMENT OF CHANGE
PROCESS
QUALITY ASSURANCE
HAZARD & RISK MANAGEMENT. (SAFETY CASE)
REGULAR SENIOR
MANAGEMENT REVIEW &
ACTIVE INVOLVEMENT
SMS ELEMENTS & RELATIONSHIPSLEADERSHI
P
POLICY, OBJECTIVES &
KPI’S
PROCEDURES
RESOURCES
SAFETY REPORTING & INVESTIGATIO
N
COMMUNICATION (TO WORKFORCE)
MANAGEMENT OF CHANGE
PROCESS HAZARD & RISK MANAGEMENT. (SAFETY CASE)
QUALITY ASSURANCE
REGULAR SENIOR
MANAGEMENT REVIEW &
ACTIVE INVOLVEMENT
Keep it manageableand if necessary
start small
Wasted effort alert
Hazard/Risk Management ProcessSCOPE OF ACTIVITY
Step 1 - Define the scope
• Determine what range of activities, locations or aircraft the process will cover.Smaller operators – May cover the whole operation.Larger operators – May split the process by
Location/baseAircraft typeOperational role (e.g. offshore, HEMS, heliski-ing)
• Start where you feel the greatest risk or exposure lies within your operation.Hazard or incident reports may give the indication.Staff and managers normally know what their risk areas are.This may also be influenced by customers and regulators!
Hazard/Risk Management ProcessSCOPE 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.
Generic hazards – Wind, IMC, aircraft components.
Specific hazards – Crosswind exceeding limits, inadvertent entry into IMC, incorrectly fitted aircraft components.
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
Safety reporting system
QA findings
Flight Data Monitoring
Incident investigations
Safety Observation Process
Trend analysis
Accidents reports for own A/C types
Accident reports for ownregion/country/location
Accident reports for own role
Training feedback
Recordable occurrences
Brainstorming
Information exchange
Industry Bodies/committees/forums
Generic Hazard Lists
Step 2 – Identify & Record Hazards
Networking, blogs
Safety reporting system
QA findings
Flight Data Monitoring
Incident investigations
Safety Observation Process
Trend analysis
Accidents reports for own A/C types
Accident reports for ownregion/country/location
Accident reports for own role
Training feedback
Recordable occurrences
Brainstorming
Information exchange
Industry Bodies/committees/forums
Generic Hazard Lists
Step 2 – Identify & Record Hazards
Step 2 – Identify & Record Hazards
External Information sources:
• State Accident Investigation bodies report data basesNTSB
AAIB
Transport Canada
BEA
• Flight safety Foundation “Basic Aviation Risk Standard – Resource sector”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
Various formats.
Web based, excel tables, access data bases, hand written!
Hazard Register
• Minimum ContentHazardRAM ScoreControlsControl references to procedure manuals (Ops, Maintenance, Training etc) Responsible person – control owner
Basic Hazard Register example
Task Description/Location
Reference No. Date last reviewed
Hazard Description: RAM Score
Initial Current
Controls Reference Owner Status
Basic Hazard Register example
Task Description/Location
Onshore seismic support Reference No. Date last reviewed
HS - 017 Sept 09
Hazard Description: Inadvertent entry to IMC RAM Score
Initial Current
Controls Reference Owner Status
Hazard/Risk Management ProcessSCOPE OF ACTIVITY
IDENTIFY AND RECORD HAZARDS
RISK ANALYSIS
Step 3 – Risk Analysis
• Having identified hazards, assess the level of risk associated with each to:Determine if further action is requiredPrioritise where effort needs to be directed first
• Use a Risk Assessment Matrix (RAM) to give an objective score to a subjective topic
This enables standardisation across the organisation.It reduces dispute and argumentGives a very visual and clear indication of risk for management review.
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
Onshore seismic support Reference No. Date last reviewed
HS - 017 Sept 09
Hazard Description: Inadvertent entry to IMC RAM Score
Initial Current
Controls Reference Owner Status
Basic Hazard Register example
Task Description/Location
Onshore seismic support Reference No. Date last reviewed
HS - 017 Sept 09
Hazard Description: Inadvertent entry to IMC RAM Score
Initial Current
Controls Reference Owner Status
Hazard/Risk Management ProcessSCOPE 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 controlsBrainstormingBow Tie analysisTripod (Investigation tool, but can be reverse engineered)
• Regardless of method, this step requires that appropriate controls are identified to manage each hazard to ALARP
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 controlVs
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 controlsBrainstormingBow Tie analysisTripod (Investigation tool, but can be reverse engineered)
• Regardless of method, this step requires that appropriate controls are identified to manage each hazard to ALARP
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
• Don’t just use this as an exercise to justify existing procedures and controls.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.
“Blue sky thinking”Impractical controls can be discounted later in the process
• Use a range of personnel from within the company at this stage.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.
Especially those areas with better safety records e.g. airlines, offshore.Can those controls be replicated at a local level?
Wasted effort alert
Step 4 – Identify controls for specific hazards
• Each control needs to meet the following criteria:EffectiveCost/benefitPracticalAcceptableEnforceableDurableDoesn’t create new hazards
Basic Hazard Register example
Task Description/Location
Onshore seismic support Reference No. Date last reviewed
HS - 017 Sept 09
Hazard Description: Inadvertent entry to IMC RAM Score
Initial Current
Controls Reference Owner Status
Basic Hazard Register example
Task Description/Location
Onshore seismic support Reference No. Date last reviewed
HS - 017 Sept 09
Hazard Description: Inadvertent entry to IMC RAM Score
Initial Current
Controls Reference Owner Status
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.
Basic Hazard Register example
Task Description/Location
Onshore seismic support Reference No. Date last reviewed
HS - 017 Sept 09
Hazard Description: Inadvertent entry to IMC RAM Score
Initial Current
Controls Reference Owner Status
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
Basic Hazard Register example
Task Description/Location
Onshore seismic support Reference No. Date last reviewed
HS - 017 Sept 09
Hazard Description: Inadvertent entry to IMC RAM Score
Initial Current
Controls Reference Owner Status
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
Hazard/Risk Management ProcessSCOPE OF ACTIVITY
IDENTIFY AND RECORD HAZARDS
RISK ANALYSIS
IDENTIFY CONTROLS FOR SPECIFIC HAZARDS
REFERENCE CONTROLS AND RESPONSIBLE
POSTS
CONTROL EXISTS
Basic Hazard Register example
Task Description/Location
Onshore seismic support Reference No. Date last reviewed
HS - 017 Sept 09
Hazard Description: Inadvertent entry to IMC RAM Score
Initial Current
Controls Reference Owner Status
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
Basic Hazard Register example
Task Description/Location
Onshore seismic support Reference No. Date last reviewed
HS - 017 Sept 09
Hazard Description: Inadvertent entry to IMC 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.
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.
All aircraft equipped with TAWS
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 ProcessSCOPE OF ACTIVITY
IDENTIFY AND RECORD HAZARDS
RISK ANALYSIS
IDENTIFY CONTROLS FOR SPECIFIC HAZARDS
REFERENCE CONTROLS AND RESPONSIBLE
POSTS
REMEDIAL ACTION
PLAN
CONTROL EXISTS NEW CONTROL REQD
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.
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
Onshore seismic support Reference No. Date last reviewed
HS - 017 Sept 09
Hazard Description: Inadvertent entry to IMC 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.
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.
All aircraft equipped with TAWS
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 exampleTask Description/Location
Onshore seismic support Reference No. Date last reviewed
HS - 017 Sept 09
Hazard Description: Inadvertent entry to IMC 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
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 exampleTask Description/Location
Onshore seismic support Reference No. Date last reviewed
HS - 017 Sept 09
Hazard Description: Inadvertent entry to IMC 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
Basic Hazard Register exampleTask Description/Location
Onshore seismic support Reference No. Date last reviewed
HS - 017 Sept 09
Hazard Description: Inadvertent entry to IMC 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
Operator assessed that untilSim training, TAWS and theEOC were in place, risk remained medium
Hazard/Risk Management ProcessSCOPE OF ACTIVITY
IDENTIFY AND RECORD HAZARDS
RISK ANALYSIS
IDENTIFY CONTROLS FOR SPECIFIC HAZARDS
REFERENCE CONTROLS AND RESPONSIBLE
POSTS
REMEDIAL ACTION
PLAN
CONTROL EXISTS NEW CONTROL REQD
CONTROL DEVELOPED
Step 7 – Interface with QA system
Your QA system needs to know what your Hazard Management Process has developed.
Wasted effort alert
Hazard/Risk Management ProcessSCOPE OF ACTIVITY
IDENTIFY AND RECORD HAZARDS
RISK ANALYSIS
IDENTIFY CONTROLS FOR SPECIFIC HAZARDS
REFERENCE CONTROLS AND RESPONSIBLE
POSTS
REMEDIAL ACTION
PLAN
QA SYSTEM – UPDATE
CHECKLISTS
INTERNAL AUDIT TO CONFIRMIMPLEMENTATION & EFFECTIVENESSOF CONTROLS
CONTROL EXISTS NEW CONTROL REQD
CONTROL DEVELOPED
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 ProcessSCOPE OF ACTIVITY
IDENTIFY AND RECORD HAZARDS
RISK ANALYSIS
IDENTIFY CONTROLS FOR SPECIFIC HAZARDS
REFERENCE CONTROLS AND RESPONSIBLE
POSTS
REMEDIAL ACTION
PLAN
QA SYSTEM – UPDATE
CHECKLISTS
INTERNAL AUDIT TO CONFIRMIMPLEMENTATION & EFFECTIVENESSOF CONTROLS
CONTROL EXISTS NEW CONTROL REQD
CONTROL DEVELOPED
Steps 3 – 7 should now be repeated for each hazard identified in step 2.
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
Wasted effort alert
Keeping it alive – Part I
Hazard/Risk Management ProcessSCOPE OF ACTIVITY
IDENTIFY AND RECORD HAZARDS
RISK ANALYSIS
IDENTIFY CONTROLS FOR SPECIFIC HAZARDS
REFERENCE CONTROLS AND RESPONSIBLE
POSTS
REMEDIAL ACTION
PLAN
QA SYSTEM – UPDATE
CHECKLISTS
SAFETY REPORTING &
INVESTIGATION
INTERNAL AUDIT TO CONFIRMIMPLEMENTATION & EFFECTIVENESSOF CONTROLS
SAFETY REPOPTING & INVESTIGATION PROCESS LINKED DIRECTLY TO THE HAZARD MANAGEMENT PROCESS.
CONTROL EXISTS NEW CONTROL REQD
CONTROL DEVELOPED
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.
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.They may all have worked, thus preventing an accident.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 exampleTask Description/Location
Onshore seismic support Reference No. Date last reviewed
HS - 017 Sept 09
Hazard Description: Inadvertent entry to IMC 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 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 exampleTask Description/Location
Onshore seismic support Reference No. Date last reviewed
HS - 017 Sept 09
Hazard Description: Inadvertent entry to IMC 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 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
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
Amend contractrequirements
Accelerateintroduction
Basic Hazard Register exampleTask Description/Location
Onshore seismic support Reference No. Date last reviewed
HS - 017 Sept 09
Hazard Description: Inadvertent entry to IMC 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 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 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
Add and record a further control
Hazard/Risk Management ProcessSCOPE OF ACTIVITY
IDENTIFY AND RECORD HAZARDS
RISK ANALYSIS
IDENTIFY CONTROLS FOR SPECIFIC HAZARDS
REFERENCE CONTROLS AND RESPONSIBLE
POSTS
REMEDIAL ACTION
PLAN
QA SYSTEM – UPDATE
CHECKLISTS
SAFETY REPORTING &
INVESTIGATION
INTERNAL AUDIT TO CONFIRMIMPLEMENTATION & EFFECTIVENESSOF CONTROLS
SAFETY REPOPTING & INVESTIGATION PROCESS LINKED DIRECTLY TO THE HAZARD MANAGEMENT PROCESS.
VALIDATE EXISTING CONTROLS OR DEVELOP NEW CONTROLS
PROCESS NEW HAZARDS
CONTROL EXISTS NEW CONTROL REQD
CONTROL DEVELOPED
Keeping it alive – Part II
Hazard/Risk Management ProcessSCOPE OF ACTIVITY
IDENTIFY AND RECORD HAZARDS
RISK ANALYSIS
IDENTIFY CONTROLS FOR SPECIFIC HAZARDS
REFERENCE CONTROLS AND RESPONSIBLE
POSTS
REMEDIAL ACTION
PLAN
QA SYSTEM – UPDATE
CHECKLISTS
SAFETY REPORTING &
INVESTIGATION
INTERNAL AUDIT TO CONFIRMIMPLEMENTATION & EFFECTIVENESSOF CONTROLS
MANAGEMENT OF CHANGE PROCESS
SAFETY REPOPTING & INVESTIGATION PROCESS LINKED DIRECTLY TO THE HAZARD MANAGEMENT PROCESS
VALIDATE EXISTING CONTROLS OR DEVELOP NEW CONTROLS
PROCESS NEW HAZARDS
CONTROL EXISTS NEW CONTROL REQD
CONTROL DEVELOPED
Step 9 – Management of Change
• Required element of the SMS
• Process to include:
Review the relevant sections of the hazard register.
How does the change effect existing controls
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:
Introduction of new aircraft type
New contract/operation
Opening a new base
Major change in key personnel or organisation change
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:
What has changed
Which areas/departments have been affected
Which hazards have been reviewed or new hazards identified.
What actions have been taken to manage risk.
Suggested MOC Summary Doc/(”Safety Case”)
Scope of Change Introduction of B 429 from Aug 2010 Ref # MOC 02/2010
Accountable Manager
Director of Operations J. C. Van Damm
Suggested MOC Summary Doc/(”Safety Case”)
Scope of Change Introduction of B 429 from Aug 2010 Ref # MOC 02/2010
Accountable Manager
Director of Operations J. C. Van Damm
Type of change Permanent Temporary: From ________ to __________
Suggested MOC Summary Doc/(”Safety Case”)
Scope of Change Introduction of B 429 from Aug 2010 Ref # MOC 02/2010
Accountable Manager
Director of Operations J. C. Van Damm
Type of change Permanent Temporary: From ________ to __________
Department/location Responsible Hazard Register Reviewed/Updated
Signature
Maintenance Department
Training Department
Flight Operations Department
Safety & Quality Department
Edmonton Base
Calgary Base
Other departments could be added dependant on thetype of change
Suggested MOC Summary Doc/(”Safety Case”)
Scope of Change Introduction of B 429 from Aug 2010 Ref # MOC 02/2010
Accountable Manager
Director of Operations J. C. Van Damm
Type of change Permanent Temporary: From ________ to __________
Department/location Responsible Hazard Register Reviewed/Updated
Signature
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
Once a department has completed its Review of the hazard Register, the HOD will sign for completion
Suggested MOC Summary Doc/(”Safety Case”)
Scope of Change Introduction of B 429 from Aug 2010 Ref # MOC 02/2010
Accountable Manager
Director of Operations J. C. Van Damm
Type of change Permanent Temporary: From ________ to __________
Department/location Responsible Hazard Register Reviewed/Updated
Signature
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
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 Edmonton to be acquired or built Edm Base Manager 1 Jul 2010
Maintenance documentation developed for B429. Maintenance QA Lead 1 Jul 2010
Each department will havedeveloped a detailed actionlist, for its own internal use.
Suggested MOC Summary Doc/(”Safety Case”)
Scope of Change Introduction of B 429 from Aug 2010 Ref # MOC 02/2010
Accountable Manager
Director of Operations J. C. Van Damm
Type of change Permanent Temporary: From ________ to __________
Department/location Responsible Hazard Register Reviewed/Updated
Signature
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
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 & SignatureMOC 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 ProcessSCOPE OF ACTIVITY
IDENTIFY AND RECORD HAZARDS
RISK ANALYSIS
IDENTIFY CONTROLS FOR SPECIFIC HAZARDS
REFERENCE CONTROLS AND RESPONSIBLE
POSTS
REMEDIAL ACTION
PLAN
QA SYSTEM – UPDATE
CHECKLISTS
SAFETY REPORTING &
INVESTIGATION
INTERNAL AUDIT TO CONFIRMIMPLEMENTATION & EFFECTIVENESSOF CONTROLS
MANAGEMENT OF CHANGE PROCESS
SAFETY REPOPTING & INVESTIGATION PROCESS LINKED DIRECTLY TO THE HAZARD MANAGEMENT PROCESS
VALIDATE EXISTING CONTROLS OR DEVELOP NEW CONTROLS
PROCESS NEW HAZARDS
CONTROL EXISTS NEW CONTROL REQD
CONTROL DEVELOPED
Keeping it alive – Part III
Hazard/Risk Management ProcessSCOPE OF ACTIVITY
IDENTIFY AND RECORD HAZARDS
RISK ANALYSIS
IDENTIFY CONTROLS FOR SPECIFIC HAZARDS
REFERENCE CONTROLS AND RESPONSIBLE
POSTS
REMEDIAL ACTION
PLAN
QA SYSTEM – UPDATE
CHECKLISTS
SAFETY REPORTING &
INVESTIGATION
INTERNAL AUDIT TO CONFIRMIMPLEMENTATION & EFFECTIVENESSOF CONTROLS
MANAGEMENT REVIEW
MANAGEMENT OF CHANGE PROCESS
SAFETY REPOPTING & INVESTIGATION PROCESS LINKED DIRECTLY TO THE SAFETY CASE.
VALIDATE EXISTING CONTROLS OR DEVELOP NEW CONTROLS
PROCESS NEW HAZARDS
CONTROL EXISTS NEW CONTROL REQD
CONTROL DEVELOPED
Step 10 – Management Review
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.
Wasted effort alert
Hazard/Risk Management ProcessSCOPE OF ACTIVITY
IDENTIFY AND RECORD HAZARDS
RISK ANALYSIS
IDENTIFY CONTROLS FOR SPECIFIC HAZARDS
REFERENCE CONTROLS AND RESPONSIBLE
POSTS
REMEDIAL ACTION
PLAN
QA SYSTEM – UPDATE
CHECKLISTS
SAFETY REPORTING &
INVESTIGATION
INTERNAL AUDIT TO CONFIRMIMPLEMENTATION & EFFECTIVENESSOF CONTROLS
MANAGEMENT REVIEW
MANAGEMENT OF CHANGE PROCESS
SAFETY REPOPTING & INVESTIGATION PROCESS LINKED DIRECTLY TO THE SAFETY CASE.
VALIDATE EXISTING CONTROLS OR DEVELOP NEW CONTROLS
PROCESS NEW HAZARDS
CONTROL EXISTS NEW CONTROL REQD
CONTROL DEVELOPED
Each of these steps in the processcan be a separate agenda itemat the regular Senior ManagementReview meetings
Hazard/Risk Management ProcessSCOPE OF ACTIVITY
IDENTIFY AND RECORD HAZARDS
RISK ANALYSIS
IDENTIFY CONTROLS FOR SPECIFIC HAZARDS
REFERENCE CONTROLS AND RESPONSIBLE
POSTS
REMEDIAL ACTION
PLAN
QA SYSTEM – UPDATE
CHECKLISTS
SAFETY REPORTING &
INVESTIGATION
INTERNAL AUDIT TO CONFIRMIMPLEMENTATION & EFFECTIVENESSOF CONTROLS
MANAGEMENT REVIEW
MANAGEMENT OF CHANGE PROCESS
SAFETY REPOPTING & INVESTIGATION PROCESS LINKED DIRECTLY TO THE SAFETY CASE.
VALIDATE EXISTING CONTROLS OR DEVELOP NEW CONTROLS
PROCESS NEW HAZARDS
CONTROL EXISTS NEW CONTROL REQD
CONTROL DEVELOPED
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 InternationalOur GOAL is your SAFETY
QUESTIONS