SCANDINAVIAN AVIATION EDUCATION PROGRAM. Risk Management Course

Transcription

1 SCANDINAVIAN AVIATION EDUCATION PROGRAM Risk Management Course Stockholm 5 6 February 2008

2 Risk Management Course Introduction: The course is conducted by Scandinavian Aviation. Morten Kjellesvig is program manager for the course and he has the primary response for the course. Purpose: To assist individuals responsible for managing Risk Management. Knowledge: After the course you will understand the principles of Risk Management and be able to able to develop, implement, and manage Risk Management as a comprehensive part of the Safety Management System in order to: Identify Threats Analyze the findings Perform Risk Management on the basis of Probability Severity and Exposure Implement Risk Management in own organization Enhance the mission/job effectiveness of the organization Safety Philosophy: Communicate for Safety Critiques: Each participant is expected to submit a course critique. Certificate: At the completion of the course each student will receive a certificate of completion for his/hers records. Morten Kjellesvig morten@scandiavia.net Telephone

3 Name: Morten Kjellesvig MSc Air Safety Management Title: First Officer, SAS Managing Director ScandiAvia Morten Kjellesvig is an airline pilot flying the Airbus 340 for Scandinavian Airlines. He has attended several courses in safety management and accident investigation and has extensive experience in aviation safety, management and accident / incident investigation. In the Royal Norwegian Air Force he flew fighter aircraft and held several management positions as safety manager, and held several courses for safety employees. He also attended 10 accident investigations, three as chairman. In Scandinavian Airlines Morten has held several management positions including Head of Flight Safety and Quality Support administering SAS quality system and been a part of SAS Company Investigation Team. Morten is managing director of ScandiAvia and he has taught quality and safety management in several Norwegian businesses and at different classes at SAS Flight Academy, at the University of Southern California and at City University in London. Morten finished his master project in January 2008 on Risk Management completing his Master of Science MSc in Air Safety Management at City University in London.

4 WELCOME TO THE RISK MANAGEMENT COURSE 5-6FEB08 Morten Kjellesvig Morten Kjellesvig MSc in Air Safety Management at City University in London Lecture USC & City: Safety Management & Accident Inv. Admin positions Air Force & SAS Accident investigator (10) Head of Flight Safety & Quality Editor Scandinavian Air Safety Fly A-340 A for Scandinavian Airlines Air Force pilot INTRODUCTION Name & Company Current Position Previous Risk experience 1

5 JAROPS ACCIDENT PREVENTION AND FLIGHT SAFETY PROGRAMME An operator shall establish an accident prevention and flight safety programme, which may be integrated with the Quality System, including: Programmes to achieve and maintain risk awareness by all persons involved in operations No mentioning of Risk Management! DOC 9859 SAFETY MANAGEMENT MANUAL Criteria are established for assessing risks. Risks are analysed and ranked by competent personnel (including experienced staff representatives). Viable risk control measures are evaluated. Management takes action to reduce, eliminate or avoid the risks. Staff are aware of the actions taken to avoid or eliminate identified hazards. Procedures are in place to confirm that the actions taken are working as intended. A QUALITY SYSTEM Contains all we do to assure that our processes run smoothly and that they continously improve Main processes in Flight operations can be: Preparation of Flights Production of Flights Evaluation, Follow Up and Improvements To control and improve theses processes we need a Management System 2

6 FAA DEFINED FOUR CORE COMPONENTS IN SMS Safety Policy Comprehensive Risk Management A Safety Assurance Process and Safety Promotion SMS COMPONENTS Monitor Information Collection Document Plan & Implement Develop Countermeasures Action! Analysing Data SMS COMPONENTS Flight Data Monitoring Line check (LOSA) Proficiency check Safety orientation and training Supporting Sub Systems Safety reporting of events and concerns Incident Investigation Audit Risk Management Cabin Safety Monitoring Safety and quality audits External information Crisis management, Accident response 3

7 ASR PROCESS Other? N N Report ASR? Y Urgent? Y Telex Type Inv.? Reqister Init. Risk Invest? Y N N File & Distr. Y Effect? Assessment Implementation Y Action? Invest. report N Management C S M O P C L I N E R E P O R T A U D I T A C M S THREE DOMAINS FOR COLLECTION Flight Deck Ground Maintenance 4

8 THREE STEPS You don t know what you don t know If you don t know, How can you fix it? If you can t fix it, you ve got a real problem! EFFECTIVE INCIDENT REPORTING Trust Non-punitive Inclusive reporting data base Independence Ease of reporting Acknowledgement Promotion / Feed Back ICEBERG F 7 F 6 F 1 F 14 Accident F 20 F 16 F 8 F 1 F 22 F 21 F 22 F 2 F 11 F 9 F 3 F 14 F 21 Serious incident F 10 F 4 F 1 F 25 F 7 F 21 F 17 F 21 F 6 F 2 Incidents 5

9 DOMINO POOL FLYING HELIOS 522,, 14 AUG05 ATHENS B737 Fatalities: 121:121 Year of Delivery: 1998 Cyprus to Athens Crew reported problem with the air conditioning packs Maintenance night before left pressurisation off Check list alarm mistaken for T/O warning masks fell down - master caution Language problem DOMINO P V R A E L S V S E O P E N P R E T/ O C H K A F T R T/ O C H K C A B A L E R T O 2 M A S K T E C H. K N O W L L A U N G U A G E 6

10 DOMINO Accident L A U N G U A G E DOMINO A L E R T C A B T E C H. K N O W L L A U N G U A G E = Normal & safe operation HELIOS 522,, 14 AUG05 ATHENS B737 Boeing shortly after the accident: "Confusion between the cabin altitude warning horn and the takeoff configuration warning horn can be resolved if the crew remembers that the takeoff configuration warning horn is only armed when the airplane is on the ground," the notice said. "If this horn is activated in flight, it indicates that the cabin altitude has reached 10,000 feet." 7

11 AIR SAFETY REPORT Your organisation receive the following Safety Report from a B757 crew: On the approach to 19 at SKCL (Cali) we selected the NDB 274R but the aircraft turned about 90 degrees off track. We reverted to HDG select, turned back towards R and the rest of the approach was uneventful. RISK BASED APPROACH Problem solving or risk control for regulatory agency needs the following capacities: To Identify To Analyze To prioritize risk or problem areas in order: To ascertain the justifiable intensity of regulatory safety oversight To fix and control the problem or risks RISK ANALYSIS Define Risk Identify Risk involved Risk analysis Assess Risk factor Risk Analysis is about developing and understanding of the risk. 8

12 DEFINE RISK Risk: The chance of Harm, in terms of Probability and Severity i.e. (how often x how bad) considered with the element of exposure to risk. Hazard: Something that can cause significant Harm Threat: Cause the release of Hazard IDENTIFY RISK INVOLVED Quality system to detect the threats Reporting system, Audits, Interviews Management review, Brainstorming Workshops Look through of procedures and checklists Training records Other operators ASSESS RISK FACTOR All threats need to be assessed in order to prioritize what to fix first or focus on. Assessments can result in a number, a description of the threat or a color code system (red, orange or green). In order to identify the Risk factor, Probability, Severity and Threat exposure needs to be examined. 9

13 RISK ASSESSMENT Define Risk Identify Risk involved Risk analysis Risk assessment Assess Risk factor Make control decisions MAKE CONTROL DECISIONS Now the organization must decide upon action(s) to control, eliminate, mitigate or reduce the risk. Management must always balance between risk versus cost and even sometimes risk against opportunities. When the sum of the benefits exceeds the cost, risk should normally be accepted. OUTCOMES OF ANALYSIS Design for minimum hazard Safety devices Warning devices Procedures and training 10

14 RISK MANAGEMENT Define Risk Identify Risk involved Risk analysis Risk assessment Assess Risk factor Risk Management Make control decisions Action to control Risk Monitor & Evaluate ACTION TO CONTROL RISK The important task is to look at and determine action to take in order to eliminate or reduce the risk. Whenever there is an improvement in place there should be an owner to the solution in order to assure that actions and timeline is followed. ACTION TO CONTROL RISK Who does what Timeline Follow up 11

15 MONITOR AND EVALUATE After the RM is complete there is a need to monitor and evaluate the result. Did the action taken have the needed effect, did it have a side effect or unwanted effect. A review or follow up is important in order to see if the action had the needed effect or any side effect. Define Risk Identify Risk involved Assess Risk factor Make control decisions Action to control Risk Monitor & Evaluate Three red and three green lights in landing gear INCIDENT REPORT Identify Risk involved Assess Risk factor Make control decisions Action to control Risk Monitor & Evaluate Three red and three green lights in landing gear INCIDENT REPORT 12

16 Identify Risk involved EXTRACT OF COMMANDERS REPORT When selecting gear down, we got three red and three green lights. After recycling the landing gear we got a normal three green indication. Landing uneventful. Identify Risk involved Management C S M O P C L I N E R E P O R T A U D I T A C M S Identify Risk involved QUALITY SYSTEM REPORTING SYSTEM Crew reported and the problem was identified Investigation revealed: Similar occurrences has happened before with this A/C Illumination of the 3 green landing gear indicator lights confirms "Gear down & locked". The 3 red gear indicator lights indicate a disagreement between the gear lever and a gear position. With the red lights illuminated a GPWS aural/visual alert will be activated ("TOO LOW, GEAR" and "PULL UP", respectively) if the approach is continued with this indication. 13

17 Identify Risk involved INVESTIGATION The gear lever was not in down detent or pushed fully down at the first gear down selection. The crew made the correct decision to recycle the gear. The second gear down selection gave normal indication and a normal landing was performed. When selecting gear down, high gear lever friction or a gentle lever handling could cause the 3 red lights to remain illuminated. Assess Risk factor SEVERITY PROBABILITY & EXPOSURE Make control decisions Adjust the target to the proximity switch Inspect the rest of the fleet 14

18 Action to control Risk Who does what Timeline Follow up Adjust the target to the proximity switch Inspect the rest of the fleet QUALITY SYSTEM Monitor & Evaluate C S M O P C Management L I N E R E P O R T A U D I T A C M S RISK MANAGEMENT Define Risk Identify Risk involved Risk analysis Risk assessment Assess Risk factor Risk Management Make control decisions Action to control Risk Monitor & Evaluate 15

19 RATIONALE FOR RISK MANAGEMENT Every situation has threats No one knows all the threats Threats are not equally consequential All situations require a balance (Risk vs. Benefit) Limited resources available to identify, eliminate, and control threats All serious threats should be eliminated or controlled RISK MANAGEMENT RULES No unnecessary risk should ever be accepted Risk decisions must be made at the appropriate level ADVANTAGES OF RISK MANAGEMENT Detect risk before loss Quantify risk Provide risk control alternatives Greater integration of safety Increased mission capability 16

20 HOW TO DETECT THREATS Analysis of data Observation of near mishaps Safety surveys Review of company plans, policies, procedures, and instructions Two types of Risk Informed risk Threats Uninformed risk NECESSARY RISK Some risks are necessary since risk come with every activity, but how much is acceptable? Do we have an answer? Is it different in different organisations? NECESSARY RISK..an organisation is safe enough when the leaders seeks modern safety processes, and makes the effort to identify every possible hazard, and then strives to eliminate, control or reduce the associated risks through training, procedures and technology to the point that operations do not accept unnecessary risks. Greg Alston

21 Identify Threats Determine Risk Acceptable? NO Eliminate Risk NO Reduce Risk NO Cancel!!! Yes Yes Yes Continue operation Evaluate! SAFETY AWARENESS Awareness Over-reaction reaction X Event Optimal Under-reaction reaction Time RISK ASSESSMENT Probability Severity Exposure to Risk 18

22 CHANGE PROBABILITIES What is the Probability of getting: Probability (Frequency) Low (1) Low (2) Medium (3) High (4) High (5) Severity (Consequences) High (5) High (4) Medium (3) Low (2) Lov (1) RISK ACCEPTANCE CRITERIA May be acceptable, however, review task to see if risk can be reduced further Task should only proceed with appropriate management authorisation. Where possible the task should be redefined to take account of the threats involved or the risk should be reduced further prior to task commencement. Task must not proceed. It should be redifined or further control measures put in place to reduce risk. The controls should be reassessed for adequacy prior to task commencement. 19

23 An aircraft lands just after taking off due to fire/smoke in the cabin. The investigation revealed that it was due to moist in the cables and couplings and the air condition system had been operating only partly for the last month. An aircraft lands just after taking off due to fire/smoke in the cabin. The investigation revealed that it was due to moist in the cables and couplings and the air condition system had been operating only partly for the last month. HOW DO WE REDUCE THE PROBABILITY? HOW DO WE REDUCE THE SEVERITY? RISK Acceptable Unacceptable 20

24 Break Morten Kjellesvig Risk Management Course

25 RISK MANAGEMENT COURSE DAY 2 Morten Kjellesvig WHAT IS RISK The chance of Harm, in terms of Probability and Severity i.e. (how often x how bad) considered with the element of exposure to risk. What is uncertainty? North Pole Risk is linked to objectives SEVERITY - PROBABILITY - EXPOSURE Remember we look for a positive change we want to increase the chances of a good outcome Reduce the Probability of something happening Reduce the Severity if it happens See what exposure does to the operation 1

26 CASE: TUNNEL How do we reduce the Probability Severity Exposure THE MANAGEMENT IN RISK MANAGEMENT Monitor Information Collection Document Plan & Implement Develop Countermeasures Action! Analysing Data PROBABILITY Designation Description Low (1), Improbable Not credible or almost improbable, not heard of or seen before and can be assumed that it never happens Low (2), Remote Medium (3), Occasional High (4), Probable High (5), Frequent Low probability and would require multiple failures but can eventually happen Probably that it happens sometimes and can lead to an accident Could lead to an accident, and similar incident have occurred before Probably that it happens and likely to lead to an accident, similar incidents have lead to accidents in the past 2

27 SEVERITY Personnel Material Damage Cost Very low (1), Insignificant Low (2), Marginal Medium (3), Marginal to Critical High (4), Critical High (5), Catastrophic Negligible, no injury Minor / Light injury requiring first aid treatment on site. Event leading to a minor injury where personnel can no longer continue duty. Involving severe injury Negligible or no damage Damage requiring minor repair Damage requiring extensive repair and or loss of production / function. Severe damage requiring extensive repair and or loss of production / function Less than $ Up to 1 mill $ 1 10 mill $ mill $ Involving death Hull loss, material loss More than 25 mill $ DOMINO THEORY Underlying Cause Basic Cause Immediate Cause Safety Defenses Consequences Management System Individual Safety Net Result Latent Conditions Latent Conditions Active Failures Countermeasures Close Calls Incidents Accidents LATENT CONDITIONS - COMET Explosive decompression of the pressure cabin. They had no reason to suspect the primary structure of the cabin itself. Their main concern, however, was the window panels, where they thought it necessary to consider possible defects which might cause weakness not revealed in the tests made during design at de Havillands. 3

28 LATENT CONDITIONS - COMET Corrective action was modification of windows to oval / round edge on pressurised aircraft DOMINO 3, ACTIVE FAILURE Immediate Cause Refers to Immediate Causes or Symptoms and includes: Substandard Practices Substandard Conditions Individual errors Individual Active Failures DOMINO 3, ACTIVE FAILURE 1. Didn t follow instructions 2. Blundered ahead without knowing how to do the job 3. Bypassed or ignored a rule, regulation, or procedure to save time 4. Failed to use protective equipment 5. Didn t think ahead 6. Used wrong equipment to do the job 4

29 DOMINO 3, ACTIVE FAILURE 7. Used equipment that needed repair or replacement 8. Didn t look 9. Didn t listen 10. Didn t recognize physical limitations 11. Failed to use safeguards or protective devices 12. Didn t pay attention MANAGEMENT MUST PAY ATTENTION TO PAYING ATTENTION! DOMINO 4, SAFETY DEFENSES Target of safety defenses Management Systems Individual Consequences Safety Defenses Safety Net Countermeasures 5

30 CONCORDE GROUNDED Single failure, tirecomponents puncturing the wing DOMINO 5, RESPONSIBILITIES Management Set standards Hold individuals accountable Just culture Each Individual Know standards Follow standards Consequences Result Close Calls Incidents Accidents DOMINO 5, CONTROLLING ERROR Do not introduce latent conditions Support operator Motivate individuals Design safety measures to trap error Consequences Result Close Calls Incidents Accidents 6

31 RAMP ACCIDENTS FREQUENCY: The Frequency is 0,67 per 1000 departures Departures x 0,67 = RAMP ACCIDENT COST US $ 1 Accident / Damage direct cost = Indirect cost = x 4 = Total = x = USD US$ EQUALS 48 NEW: 21 7

32 ERROR TYPES Active Failures Individual Error Effects seen immediately But when we have an accident we did not see it. Failure to crosscheck MANAGEMENT EVALUATION JAR The Accountable Manager will have overall responsibility for the AOC holders Quality System including the frequency, format and structure of the internal management evaluation activities as prescribed in paragraph 4.9 below. JAR OPS 1 SUB PART B AMC OPS Management Evaluation A management evaluation is a comprehensive, systematic, documented review by the management of the quality system, operational policies and procedures, and should consider: a. The results of quality inspections, audits and any other indicators; b. The overall effectiveness of the management organisation in achieving stated objectives. 8

33 JAR OPS 1 SUB PART B AMC OPS Management Evaluation cont. A management evaluation should identify and correct trends, and prevent, where possible, future non-conformities. Conclusions and recommendations made as a result of an evaluation should be submitted in writing to the responsible manager for action. The responsible manager should be an individual who has the authority to resolve issues and take action The Accountable Manager should decide upon the frequency, format, and structure of internal management evaluation activities. VIRGIN Fuel computer No 1 engine flameout Fuel empty in feed tank Continue to Heathrow on three engines No 4 engine power began fluctuating Fuel empty in feed tank Crossfeed valves on, and No 4 engine recovers Land AMS MANAGEMENT EVALUATION (REVIEW) Management Evaluation (Review) Observation of near mishaps, Safety surveys, Review of company plans, policies, procedures, and instructions 9

34 MANAGEMENT EVALUATION TASK: Your Accountable Manager want s to know what are the greatest risk the company faces. (What type of accident would we have) MURPHY WAS WRONG: What can go wrong usually goes right. USEFUL WEBSITE 10

35 SAFETY PHILOSOPHY Communicate for Safety! SAFETY TRAINING Safety Management course Accident Investigation course Threat and Error Management course Commander Candidate course Safety Awareness Top Management course Airworthiness Air Law 11

36 SPREAD THE WORD... SPREAD THE WORD Thanks for YOUR attention! Morten Kjellesvig 12