AIRBORNE LAW ENFORCEMENT ASSOCIATION

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AIRBORNE LAW ENFORCEMENT ASSOCIATION

• Safety Management System
• Workshop
• -----------------------------------------------
  ----------
  
• Keith Johnson
• Safety Program Manager

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IHSS

• Safety is most important
• Need to collect data
• Collect flight hours
• Collect Serious Incident Information
• ALEA Incident Reporting System Proposal
• Expedite Accident Reporting
• Increased training
• Reduce Accidents by 80 over 10-years
• Focus on Leadership
• Non-punitive reporting
• Accountability
• Accidents can be eliminated
• ALEA on International Helicopter Safety Team

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The topic of the day
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SAFETY

• It holds the key to our future
• It affects everything we do (SMS)
• Every accident affects everyone

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SAFETY PRIORITIES

• SAFETY has the highest priority
• MISSION has a lower priority
• Each person is critical to eliminating accidents
• Inclusive communications chain

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SAFETY PRINCIPLES

• Always operate in the safest manner possible
• Never take unnecessary risks
• Safe does not mean risk free
• Key to safety is the i.d. and management of risk
• An absence of accidents does not necessarily
  equate to safety
  
• Familiarity and prolonged exposure without an
  incident leads to a loss of appreciation of risk
  
• How does this apply flying patrol?

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Safety Goals

• Zero accidents
• Zero injuries
• Zero harm to environment
• Improve public perception of law enforcement
  aviation

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• An effective Safety Management System is
  essential to achieving sustaining a zero
  accident.

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ELEMENTS OF THE ORGANIZATION

• Flight Operations
• Ground Operations
• Maintenance
• Training
• Safety
• Safety Management System is all inclusive

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ACCIDENT ELIMINATION

• Must be proactive Reached plateau
• Pilots focus on flying aircraft
• Two person crews
• Focus on risk management
• Adverse Trends
• Identify and eliminate adverse trends
• Incidents - Investigate disseminate findings
• Factory emergency procedures training
• Dont reinvent the wheel
• No new causes of accidents
• Copy successful organizations
• Accreditation Platinum Program

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JUDGMENT ACTION ERRORS

• Failure to manage known risks
• Mission urgency risk taking
• Will to succeed
• Flight profile unsafe
• Crew Qualifications
• Aircraft Suitability
• Mission Requirements
• Environment
• Judgment errors committed
• Failure to follow procedures
• Poor CRM
• Poor Aircraft Control
• Over confidence
• Loss of situational awareness

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What is an SMS?

• Coordinated, comprehensive set of processes
  designed to direct and control resources to
  optimally manage safety.
  
• Makes safety management an integral part of the
  overall operations/business plan.
  
• Based on leadership and accountability.

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What Does Having an SMS Give?

• We will now concentrate on describing the three
  key processes generically
  
• Once you understand these, the rest becomes more
  readily apparent
  
• But first some more definitions

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Why is Having an SMS Important?

• Widely recognized as best practice
• Eliminates accidents
• Reduces costs
• Limits exposure (reduces total risk)
• Reduces probability of having an accident
• Reduces severity of risks
• Reduces exposure to risk
• Increases likelihood of completing the mission

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1. Safety Management Plan

• Description of SMS components
• Definition of fundamental approach to safety
• Philosophical approach Vision, Mission, Values
• Safety policy SMS policy statement
• Business and department goals set/reviewed
  annually
  
• Clearly defined roles and responsibilities
• a) Openly documented and briefed
• Top leadership involvement
• a) Safety is an agenda item, resource allocation,
  openness, involved in daily activities, promoting
  awareness
  

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What should it look like?
A Framework for Safety Management
Worksheets
Checklist
Security
Policy
Maint
.
Alcohol
Schedule
Drugs
HSE Policy
QA
Policy
Audit
Safety
Training
FAA
Drills
Plan
Audits
Regs
.
Task / Check Feedback - Action
ERPs
CRM
STRUCTURE
No Structure
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Safety Management Training Requirements

• Safety orientation for all new personnel
• Document competency requirements
• Document training requirements
• Have regularly scheduled safety meetings
• Key personnel educated on safety management best
  practices

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JHSAT ACCIDENT CAUSATION JUDGMENT ACTION ERRORS

• Fail to manage known risks
• Mission urgency
• Risk taking
• Failure to follow standards
• Unsafe flight profile
• Crew qualifications
• Aircraft suitability
• Mission requirements
• Environment
• Aircraft control deficiencies

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JHSAT STUDY RESULTS

• Three themes came from JHSAT study
• Better training
• Operational oversight
• Safety Management

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JHSAT Initial Recommendations

• First of the seven initial JHSAT recommendations
  was implementing SMS
  
• JHSIT prioritized the recommendations, agreed
  that SMS was the foundation for all subsequent
  IHST implementations
  
• JHSIT focused its work to issue this Toolkit at
  IHSS 2007
  
• SMS Committee
• Feedback

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• SAFETY RECOMMENDATIONS
• More consistent comprehensive NTSB involvement
  and investigation
  
• Collect worldwide fleet hour data as previously
  performed by FAA
  
• 3. Promote the Safety Management Systems
• 4. Establish safety website to disseminate
  information
  
• 5. Use proximity detection equipment on
  aircraft
  
• 6. Use flight recording devices and cockpit
  image recording systems
  
• 7. Develop strategy to improve ADM

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JHSAT L/E RECOMMENDATIONS

• Develop regulations requiring compliance with
  same regulations as operators of civil aircraft
  
• Mission planning/Preflight procedures
• Autorotations
• CFI performance
• Aircraft performance
• Inadvertent IMC
• Risk assessment
• Emergency procedures
• LTE dynamic rollover
• Simulators

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Results of full year 2000 dataset
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(No Transcript)
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Introduction to the Toolkit

• The Toolkit contains SMS guidance material and a
  sample SMS Manual
  
• The Toolkit provides a foundation for your own
  system
  
• The issued IHST SMS Toolkit is Version 1.0
• Feedback

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Resulting Actions

• Fire the PIC, 30 day suspension for SIC
• Stuff happens! Get over it!
• Seek restitution someone pays!
• Do these actions prevent future events of this
  type?
  
• Is there an alternative?

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Just Culture

• A blame culture undermines open reporting
• A no-blame culture is also flawed as it
  undermines accountability responsibility
  
• If other personnel could make the same error
  occasionally then we must change the controls not
  discipline the personnel
  
• Holding people accountable through a disciplinary
  process is only relevant for
  
• Gross negligence
• Persistent sub-standard performance
• Wilful recklessness

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Just Culture Process
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Management of Changes

• Operational procedures
• Location, equipment or operating conditions
• Maintenance and Operations Manuals
• Personnel made aware and understand changes
• Level of management authority to approve changes

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Performance Based SMS

• Rather than specify an organizational
  configuration or architecture, the SMS Toolkit
  deals with SMS Attributes.
  
• These attributes describe the performance of a
  successful SMS.
  
• Meeting the performance standard is what is
  critical the configuration or architecture is
  dependent on the size and scope of the operation.

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Attributes of a SMS

• SMS Management Plan
• Safety Promotion
• Data information management
• Hazard identification and risk management
• Hazard reporting
• Occurrence investigation and analysis
• Safety oversight programs
• Safety training requirements
• Management of change
• Emergency preparedness and response
• Performance measurement improvement

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The Attributes of an SMS

• 1) SMS Management Plan
• Policies, objectives
• Organizational structure and key individuals
• Elements defined
• Expectations described
• Commitment to compliance with safety and
  regulatory requirements
  

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The Attributes of an SMS

• Safety Promotion
• Safety Policy
• Messages, memos from management
• Posters, flyers, website
• Safety training
• Recognition program
• Just Culture process in place

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The Attributes of an SMS

• Document and Data Information Management
• Safety policies, regulations, objectives and SMS
  requirements publicized
  
• Change control system in place for applicable
  documents training
  
• Periodic review of documents

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The Attributes of an SMS

• Hazard Identification and Risk Management
• Proactively identify potential hazards
• Hazards are considered when making changes
• Risk Assessment
• Identified hazards are tracked for closure

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The Attributes of an SMS

• Occurrence and Hazard Reporting
• Corrective actions monitored for effectiveness,
  employees receive feedback
  
• A non-punitive disciplinary policy in place for
  reporting hazards (Just Culture process)
  
• Safety data analyzed, hazards are monitored to
  identify trends
  
• Anonymous submittals of hazards

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The Attributes of an SMS

• Occurrence Investigation and analysis with
  technically qualified investigators
  
• Investigations conducted to determine root
  causes, and identify what can be done to prevent
  future occurrences
  
• Identify causal factors and the contributory
  factors, including organizational factors
  
• Acts of omission and commission identified
• Reports provided to manager that has
  accountability and authority
  

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The Attributes of an SMS

• Safety Assurance Oversight Programs
• Internal assessments at regularly scheduled
  intervals, including contractors
  
• Utilizing checklists tailored to the
  organizations operations when conducting safety
  evaluations
  
• Independent assessment of evaluators processes
• Sharing the results and corrective actions with
  all personnel
  
• Utilizing available technology such as Health
  Usage Monitoring Systems (HUMS) to supplement
  quality and maintenance programs as well as
  supporting programs to monitor and evaluate
  aircrew operations

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The Attributes of an SMS

• Occurrence Investigation and Analysis
• Technically qualified investigators
• Investigations conducted to determine root
  causes, and identify what can be done to prevent
  future occurrences
  
• Identify causal factors and the contributory
  factors, including organizational factors
  
• Acts of omission and commission identified
• Reports provided to manager that has
  accountability and authority
  

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The Attributes of an SMS

• Safety Management Training Requirements
• Include a safety orientation for all new
  personnel, stressing the organizations
  commitment to safety and everyones roll in the
  SMS
• Document competency requirements for personnel
• Have a system to track training requirements
• Make effective use of conferences, workshops,
  literature and trade journals
  

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The Attributes of an SMS

• 9) Management of Changes
• Identify required changes in training,
  documentation or equipment
  
• Changes in location, equipment or operating
  conditions analyzed for any potential hazards
  
• Screen, review, approve, implement

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The Attributes of an SMS

• 10) Emergency Preparedness and Response
• Be readily available at the work stations of
  those that may be the first to be notified or
  required to respond
  
• Be relevant and useful to people on duty
• Be exercised periodically to ensure the adequacy
  of the plan and the readiness of the people who
  must make it work
  
• Be updated when contact information changes
• Be briefed to all personnel along with their
  responsibilities
  
• Should be practiced so personnel receive training
  in emergency response procedures

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The Attributes of an SMS

• 11) Performance Measurement and Continuous
  Improvement
  
• Safety performance monitoring used as feedback to
  improve the system
  
• Address individual areas (preflight, FOD,
  fueling)
  
• Are SMART (Specific, Measurable, Achievable,
  Results Oriented, Timely)
  
• Linked to the organizations operations/business
  performance measures
  

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Using an SMS - What Would We Have Done Differently

• Investigate the Occurrence
• Technically qualified investigators
• Determine the root causes, and identify what can
  be done to prevent future occurrences
  
• Identify causal and the contributory factors,
  including organizational factors
  
• Acts of omission and commission identified
• Provide a report to manager that has
  accountability and authority
  
• Identify and Assess the Hazards
• Share results with all affected
  organizations/agencies
  

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Actions as a Result of the Investigation

• Using the findings, apply the Just Culture
  model to the crew, the management structure, and
  the organization
  
• Identify changes required
• Personnel
• Training
• Preflight and Operational Procedures
• Facilities Management
• Maintenance
• Apply MOC process to changes in training,
  operations, maintenance, etc.
  
• Safety Assurance Oversight Program share the
  information with all affected employees
  
• Track the identified hazards

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LEADERSHIP SAFETY STANDARDS

• Managements role responsibilities
• Intentional non-compliance
• Know procedures produce known outcomes
• Standards produce repeatable results
• Bad rules produce bad results
• Standards are mechanisms for changing bad rules

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STANDARDS

• Standards increase likelihood of repeatable
  results
  
• Known procedures produce known results
• Bad rules produce produce bad results
• Enhance conflict resolution
• Airlines cover almost every situation and the
  proper response in writing Why?
  
• Just follow the rules and eliminate majority of
  accidents
  

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DEVIATION FROM STANDARDS

• Behavior is a function of consequences
• Run a red light, you get a ticket
• I.D. correct immediately
• Be consistent No freebees
• Be fair
• Counsel, train, discipline, ground and remove

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BREAKING RULES

• Breaking the rules usually does not always
  result in an accident, however
  
• It always results in a greater risk for the
  operation!
  
• Never take UNNECESSARY RISKS!

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NON-COMPLIANCE

• Non-compliance rarely results in an accident
  or incident, however
  
• It always results in greater risk for the
  operation!

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Intentional Non-Compliance

• Research Shows Once you start deviating
  from the rules, you are almost twice as likely to
  commit an error with potentially serious
  consequences!
• We could eliminate 70-80 of the accidents
  just by following the rules.
  
• NOTE Read the NTSB accident reports on the
  HAI website. Should be a requirement for all
  personnel
  
• Honest mistakes vs. intentional non-compliance

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Why is Insight Important for Safety Leaders?

• With this insight
• You will understand the hazards risks you face
• You will understand how to control them
• You will know how these controls are working in
  service
  
• You will learn from when controls fail
• You can drive improvements to take us towards
  achieving sustaining a zero accident rate
  
• Your Culture of Safety needs to be a culture
  that
  
• Embraces the concept of an SMS as a means to the
  a zero rate end
  
• Drives continuous improvement

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Are We Rewarding the Right People?

• Supervisors know who will wont break the
  rules
  
• Rule breakers are often rewarded for mission
  accomplishment
  
• Reward systems are often upside down. We should
  reward the normal, positive performance that
  complies with organization standards.
  
• What you reward today will get done tomorrow

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Success Solutions

• Reinforced bad behavior breeds continued bad
  behavior
  
• Rationalization of the gravity of the situation
  seems to lessen the risk in our minds, but in
  reality does not
  
• Habitual rule breaking is often condoned by
  management when they look the other way
  
• Does complacency play a role in this issue?

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How the Processes Gives Insight
Insight
Risk Management (e.g. hazard identification, ri
sk assessment
Foresight
Monitoring (e.g. supervision, Inspections, au
dits,
HUMS Oversight
Safety Reporting Investigation Hindsig
ht

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How the Processes Interact
Feedback / Feed-forward
Risk Management Proactive Planning
Monitoring Proactive Checking
Safety Reporting Investigation Reactive Checki
ng

But all three processes are also there to Act to
introduce improvements
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PDCA Putting the Processes in Context

• Plan Do Check Act Cycle
• Plan what we are going to do
• Do it
• Check performance
• Act to improve
• Q So where would you put the three process?

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ATTITUDE

• What lies behind us and what lies before us
  are tiny matters compared to what lies within
  us.
  
• Ralph Waldo Emerson

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• The hardest thing to do, and the right thing to
  do are usually the same thing.

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COMMUNICATION BARRIERS

• Position/Rank
• Age
• Gender
• Organization culture
• Predispositions (attitude)
• Assumptions

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Summary

• The guiding principle of risk management is
  elimination of accidents
  
• Safetys role is the maximization of
  effectiveness and efficiency
  
• A Safety Management System aims to establish and
  maintain this control
  
• Reduce loss (people, production, assets,
  environment)
  
• Strengthen Management performance and
  organizational culture
  
• Advance the Technology and knowledge base
• Demonstrate Compliance
• Provide a performance advantage