Upload
angel-floyd
View
219
Download
0
Tags:
Embed Size (px)
Citation preview
Supplier Qualification - RISQS
“Managed by the Industry for the Industry”
The Vision:-“Universally recognised as the most effective and efficient method and route for suppliers to engage with GB rail industry”
Objectives:-“Provide appropriate assurance regarding management systems and corporate legitimacy”“Act as a feed back tool to improve performance”
Standard NR/L2/CPR/302
The core criteria that affect me as a Contractor/Sentinel Sponsor:-
• 25 Pages which require systems, processes, procedures to enable me to operate safely
• Plus, controls and a reporting framework to enable/demonstrate consistent compliance
The Core Audit Module
Contents:-1. Management Systems2. Insurance Arrangements3. Policies4. Organisation and responsibilities5. Individual qualifications and experience of staff in key roles6. Provision of HSE advice7. Competence Management8. PTS and the Sentinel Scheme requirements
The Core Audit Module
Contents cont. –9. Employment medicals10. Alcohol and drugs arrangements11. Managing refusals to work on grounds of safety12. Managing fatigue13. Selection of safety critical products and plant14. Selection and management of Supplier’s services15. Control of bribery16. Reviewing changes to customer and regulatory requirements
The Core Audit Module
Contents cont. –18. Document management19. Internal and external communication arrangements20. Workforce involvement21. Risk assessment22. Co-operation and co-ordination23. Health, welfare and wellbeing24. First aid at work arrangements25. Close call, Near miss and Accident reporting and investigation
The Core Audit Module
Contents cont. –26. Site inspections27. Audit of management systems28. Monitoring and corporate safety and environmental performance
Just How Effective?
RISQS Objective:-• Provide appropriate assurance regarding management systems!
The Practice - Just one more time:-QUALIFICATION TENDER
Competence Management 10 detailed sections Describe in 600 words
Fatigue Management 13 detailed sections Describe in 600 words
Fatalities
Findings:-• Lack of clarity in managing near-miss incidents
• No effective performance regime for managing competence
• No comment at all on RISQS
Performance
• Would performance management help?
• How measured/shared?
• Not New!
• A Key Development Objective
Sentinel – Workforce “Competence”
• Perhaps expectations more easily identified
• Terminology, qualifications, skills, tickets, competences, competent
• Code of Conduct gets it right, competence management elsewhere!
Learning from Incidents• 70,000 shifts – 17 irregularities/incidents• No injuries but……• 5 High Risk
The key themes from these:-• Lack of familiarity• Over familiarity• Complacency• Disorientation• Communication
ACCIDENTAbsent or Failed Barriers
Human Involvement
Local Conditions
Organisational Factors
• Aircraft Overran runway after landing long
• No serious injuries (391 pax, 19 crew)
• Potential for more serious outcome
• Aircraft repair cost: $100,000,000 (?)
• Damage to company reputation
Landing procedure inappropriate
Absence of reverse thrust
during landing roll not notices,
reverse thrust not used
Crew Resource Management
deficient
Flight crew did not use an adequate risk management strategy for
approach and landing
Crew employed flaps 25/idle
reverse landing configuration
First Officer did not fly the
aircraft accurately during the
final approach
Captain did not order a go-
around earlier
Captain cancelled go-
around decision by retarding the
thrust levers
Very heavy rainfall, runway surface affected by water
Crew not aware of critical importance of reverse thrust as stopping force on
water-affected runways
Most pilots not fully aware about ‘aquaplaning’
Qantas B747s generally operated in good weather & to aerodromes with long, good quality runways
New 1996 approach/landing procedure inappropriate
Normal practice to use flaps 25/idle reverse
Recent crew experience using full reverse thrust lacking
Reduced visibility & distraction: rain and windscreen wipers
Captain & FO quite low levels of flying prior 30 days
FO awake for 19 hours at the time of the accident
Captain awake 21 hours at time of accident
High workload situation
No appropriately documented info, procedures re operations on water-affected runways
“Landing on Slippery Runways” (Boeing doc) not distributed in Qantas since 1977
Contaminated runway issues not covered during crew endorsement, promotion or
recurrent training in recent years
Document unclear (eg., key terms not well defined)
OC Mgt decisions informal, “intuitive”, “personality-driven”
No formal risk assessment conducted when changed landing procedure researched
Introduction of new landing procedure poor
No formal review of new procedures after ‘trail’ period
Cost-benefit analysis of new landing procedure was biased
No policies or procedures for maintenance of recency for management pilots
No policies, procedures on duty or work limits for pilots with flying & non-flying duties
ACCIDENTAbsent or Failed Barriers
Human Involvement
Local Conditions
Organisational Factors
Protection placed on the Up line not Down line – TES 2000, PSS
Communication between PSS/PICOP poor-sub-standard
PSS changed the SSWoP –
accessed from a
convenient point
PSS read off SSWoP when
reporting completion
PSS had attended his
brother’s funeral that
day
PSS relatively inexperienced -
not a factor
PSS had blocked at
same locations
7 hours between first and second task
PSS employed on a Zero Hour contract –financial pressure to work
TES had not specific HR procedure for bereavement-reported or otherwise
Too much detail in SSWoP