SMS 25 6 Mugridge AirCanada

8/3/2019 SMS 25 6 Mugridge AirCanada

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SMS in Practice- Information Gathering and RiskManagementSMS Seminar & WorkshopOctober 25/26 2007Tokyo, Japan

Michael Mugridge, BCommManager, Quality ServicesAir [email protected]


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Background: Air Canada Legacy Systems

British Airways Safety Information System(BASIS): only used by Flight Operations, Flight

Safety SurPass Audit Software:

only used by Maintenance

Parklane Injury system only used for reporting of personal injuries

for claims purposes

Discrete systems which did not communicate


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Decision made by the Executive toconsolidate:

Document Control; Audits; Safety Reporting; and

into a single Information Managementtool

Background: Air Canada Legacy Systems


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Benefits of Integration

help meet Transport Canada SMS andIOSA requirements

one taxonomy model

one risk model

efficiencies with respect to operations andmaintenance of a single it system

standardization of functionality across the

business units easier Corporate reporting


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The Software Solution:


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EtQ Reliance Web-based, enterprise system for Quality

Management.

Flexible Workflow Engine, it allows: workflows

forms fields,

reports

to be configured without programming. In other words build your system


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Reliance Notifications E-mail notifications can be used to:

Notify users that they have a task to perform e.g.

> Approve a document> Complete an audit checklist> Do a risk assessment

Notify users when they are late

Provides hyperlink directly to document.


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Three Principle Modules Implementation

at Air Canada

small grouptrials

Safety Reporting

ImplementedAudit and

Corrective/Preventive Action

ImplementedDocument Management

and Control


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Document Control


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Document Management and Control For company policy and procedure documents

Provides control over source documents (e.g.Microsoft Word)

Automates: creation of draft copy;

review and comment; approval (includes Transport Canada approval);

etc.

Provides a central repository for current; and archived documents


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Document Control FeaturesApproved documents areseparated from Drafts

(Pending)


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Document Control Features (contd)

Draft (Pending) documents travel through a

workflow for all value-added work: review and comment, approvals; translation;

printing, distribution, uploading; etc

Draft

Review &

Comment

Internal

Approval Approved

Regulatory

Approval

PENDING

APPROVED


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Document Control Features (contd)

Approved

ARCHIVED OBSOLETE

[automatic]

Manual Archive

Superseded documents are automaticallyarchived

Obsolete documents may be manually archived


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Document Control Features (contd)Reliance can monitor a documents date and

warn (via e-mail) of potentially outdated

content


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Reliance screen

E-mail


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Audit and Corrective & Preventive Action

(CAPA)


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Question Bank (question profiles) Each audit question only exists once.

If question is revised, all checklists using that

question are updated. Questions are revision controlled

Old versions are archived.


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Audit Templates Checklist templates points to questions in

question bank

Audit template point to checklists


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Question Bank

Audit Templates

Audit type 1

Audit type 2 QuestionQuestionQuestion

Checklist 3

Question

QuestionQuestionChecklist 2

QuestionQuestionQuestion

Checklist 1


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Audit Records Creating an audit of a certain type

copies the template contents intorecords.

Templates remain untouched.


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Audit Document (Record)


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Checklist Document (Record)


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Question Document (Record)


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Audit Record Workflows

Lead auditor can manage the audit record and assignchecklists to individual auditors for completion

Draft Scheduled In Progress Accomplished Closed

Audit Record

Draft Assigned Completed

Checklist Document

Draft Completed

Question Document


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Audit Corrective Action

LinksCAPA are automatically linked to the Audit Report


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Audit Corrective Action

Links Audit question contains link to CAPA


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CAPA Document Workflow

DraftCorrective

Action Plan

CAP

Approval

ImplementationVerification &

Effectiveness *Completed

Auditor

Auditee


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Fields - Draft


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Fields Draft (contd)


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Root Cause Analysis

Uses HFACS model which will be covered inthe Safety Module


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Fields - Corrective Action Plan


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Fields - Implementation


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Fields Verification and Validation


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Output Reports Audit

WebFocus: Web-based reporting tool


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Sample Report

Pdf but can be other format


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Safety Reporting


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Safety Reporting

Provides a single, platform for reporting safetyevents and hazards / concerns

Used by several different Branches andBusiness Units

Uses intuitive Risk Assessment Model (IRAM)

and root cause analysis/causal factors model(HFACS)


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Occurrence Form

Contains approximately 200 fields

Shows / hides sections/fields depending on

user entries e.g. Disruptive passenger

Environment

Injury Turbulence

Equipment damage

Fuel dump

O W kfl


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Occurrence Workflow

Draft Investigate

Review

WithManagement

Finalize

Report Finished

Risk

Assessment

Low risk

High risk


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Phase - Draft

Employee checks box to determine type of report

Ph D ft G l S ti


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Phase Draft: General Sections

Ph D ft G l S ti


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Phase - Draft: General Sections


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Phase - Draft: Context Specific Sections

plus context specific sections

Occurrence Workflow


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Occurrence Workflow

Draft Investigate

Review

WithManagement

Finalize

Report Finished

Risk

Assessment

Low risk

High risk

Risk

Assessment


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Risk Assessment

Air Canada has developed an intuitive RiskAssessment Matrix

Provides guidance words to front-line staff tomake quick assessments without statistics

User chooses:

Probability of occurrence Severity of outcome

The matrix provides a direction letter AD


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Guidance Words

Exist for the following possible incidentoutcomes:

Injury Illness

Aircraft damage

Equipment / facility damage

Safety of flight

Environmental

Regulatory

Security

Sample Guidance Words for Severity for


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Sample Guidance Words for Severity forSafety of Flight

Low; activation of a safety system or safety procedure with correct crew response an avoidance maneuver that is deemed not to have been required loss of single primary system with redundant system available. smoke, smell, or fire/spark that was brief, identifiable, and extinguished

Medium; activation of a safety system or safety procedure followed by an incorrect crew

response, which however did not result in an increased safety threat an avoidance maneuver that is deemed to have been required loss of multiple primary systems with redundant systems available an un-commanded flight control input that is easily counter controlled.

smoke, smell, or fire that was prolonged and identifiable, but contained orextinguished. High;

activation of a safety system or safety procedure with incorrect response whichdid result in an increased safety threat

an avoidance maneuver that is deemed to have been aggressive or prolonged loss of a primary system with no redundant system available

an un-commanded flight control input that is difficult to counter control smoke, smell, or fire that was prolonged and not identifiable, or not contained,

or not extinguishable. Critical;

hull loss


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Risk Assessment The Challenge

How to make all the guidance wordsavailable via the software?


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Phases Risk Assessment


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Selecting the Appropriate Severity


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Phases Risk Assessment

The overall risk for an incident is the highestrisk for any one outcome

The employee is also provided with direction


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Risk Assessment - Example

Occurrence Workflow


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Draft Investigate

Review

WithManagement

Finalize

Report Finished

Risk

Assessment

Low risk

High risk

Investigate


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Phases Investigation and Recommendation

Investigate: Supervisor or trained investigatorperforms investigation: Executive Summary of Occurrence Factual Information of Occurrence Analysis of Occurrence Findings

Recommendations (Corrective and PreventativeActions)

Categorizes the incident various ways HFACS

Immediate Effect Incident Category

I id t R t


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Incident Report

I ti ti D t il


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Investigation Details

Occurrence Causal Factors is the HFACS field

Human Factors Accident ClassificationS t (HFACS) I l t ti


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System (HFACS) Implementation

User can choose asmany as needed

Human Factors Accident ClassificationSystem (HFACS) Implementation


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System (HFACS) Implementation

Entire tree structure is captured to facilitate roll-up analysis

Occurrence Workflow


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Draft Investigate

Review

WithManagement

Finalize

Report Finished

Risk

Assessment

Low risk

High risk

Review

WithManagement

Finalize

Report

Review and Finalize Phases


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Review and Finalize Phases

Review Review with responsible management to agree with

Corrective Actions Finalize Report

Investigator:

> creates Corrective Action documents (same as

Audit module)> Finishes report.

Output Reports WebFocus


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Output Reports - WebFocus

Reports for Safety (accident, incident, concern)are being developed.

Questions?


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Questions?

Documents

SMS 25 6 Mugridge AirCanada