New Risk Management Techniques The Way Forward EDUARDO DUERI JLT Aerospace Latam MAY 2017

Transcription

1 New Risk Management Techniques The Way Forward EDUARDO DUERI JLT Aerospace Latam MAY 2017

2 SETTING THE RECORD BASIC CONCEPTS 2

3 Hazard? 3

4 Hazards Hazard - A condition or an object with the potential to cause death, injuries to personnel, damage to equipment or structures, loss of material, or reduction of the ability to perform a prescribed function Hazard identification is a prerequisite to the safety risk management process Any incorrect differentiation between hazards and safety risks can be a source of confusion 4

5 What is a Consequence? A consequence is defined as the possible outcome (or outcomes) of a hazard The damaging potential of a hazard materialises through one or more consequences 5

6 Hazards and their Consequences 6

7 What is Risk? Definition of Safety Risk - The projected likelihood and severity of the consequence or outcome from an existing hazard or situation Safety Risk Probability - Likelihood or frequency that a safety consequence or outcome might occur Safety Risk Severity - The extent of harm that might reasonably occur as a consequence or outcome of the identified hazard 7

8 Risk Components All risks have two main variables: Severity (impact) How bad is it when it does happen? Likelihood (frequency / probability) How likely is it? How often does it happen? Risk = Severity X Likelihood 8

9 ICAO Severity Table SEVERITY MEANING VALUE Catastrophic Hazardous Major Minor Negligible Equipment destroyed Multiple deaths Greater than $5m Large reduction in safety margins Physical distress Major equipment damage Serious injury or death to number of people Between $1m and $5m Significant reduction in safety margins Serious incident Injury to persons Between $ and $1m Nuisance Operating limitations Use of emergency procedures Minor incident and/or injury Up to $ No injuries or adverse outcome Cost negligible A B C D E 9

10 Safety Risk Management 10

11 ICAO Risk Management Process 11

12 The Reason Model Accidents require the coming together of a number of enabling factors, each one necessary, but in itself not sufficient to breach system defences Major equipment failures, or operational personnel errors, are seldom the sole cause of breaches in safety defences Often breakdowns are the consequence of human failures in decision-making The breakdowns may involve active failures at the operational level, or they may involve latent conditions conducive to facilitating a breach of the system s inherent safety defences Most accidents include both active and latent failures 12

13 Accident Causation Model James Reason/ICAO 13

14 A Concept of Accident Causation 14

15 Hidden Cost of Accidents and Incidents 15

16 Indirect Costs of Accidents & Incidents Non-company employees at the site External experts and investigators Employee overtime Supervisor s time working on the accident Lost productivity Cost of new hire and training Increased insurance excess Uninsured damage costs Cost of recovery equipment Loss of spare parts inventory Legal fees Government citations Liability claims Government operating restrictions Loss of brand value and corporate reputation Increased insurance premiums 16

17 Technical/ Operational Delay Costs 17

18 Concept of Safety Within the context of aviation, safety is the state in which the possibility of harm to persons or of property damage is reduced to, and maintained at or below, an acceptable level through a continuing process of hazard identification and safety risk management 18

19 Safety Space 19

20 Safety Management Strategies 20

21 SAFETY MANAGEMENT SYSTEM 21

22 Safety Management Strategies Reactive (Past) Proactive (Present) Predictive (Future) Responds to events that have already happened, such as incidents and accidents Actively seeks the identification of hazardous conditions through the analysis of the organisation s processes Analyses system processes and environment to identify potential future problems 22

23 What is SMS? SMS is a dynamic risk management system based on quality management system (QMS) principles in a structure scaled appropriately to the operational risk, applied in a safety culture environment. Source: Safety Management Systems in Aviation Stolzer, Halford, Goglia A systemic approach to managing safety, including the necessary organisational structures, accountabilities, policies and procedures Source: ICAO A safety management system is a series of defined, organisation-wide processes that provide for effective riskbased decision-making related to your daily business Source: UK CAA 23

24 SMS What it is and What it is not What it is NOT A substitute for compliance A substitute for oversight What it is Compliance is integral to safety management An effective interface for safety management A replacement for system safety A requirement for new department SMS completes the system approach A set of decision making processes for senior and line management 24

25 Components and Elements of SMS Safety Policies and Objectives Management Commitment and Responsibility Safety Accountabilities Appointment of Key Safety Personnel Coordination of Emergency Response Planning SMS Documentation Safety Risk Management Hazard Identification Safety Risk Assessment and Mitigation Safety Assurance Safety Performance Monitoring and Measurement The Management of Change Continuous Improvement of the SMS Safety Promotion Training and Education Safety Communication 25

26 Safety Management - Eight Building Blocks 1. Senior management s commitment to the management of safety 2. Effective safety reporting 3. Continuous monitoring through systems to collect, analyse, and share safety-related data arising from normal operations 4. The investigation of safety occurrences with the objective of identifying systemic safety deficiencies rather than assigning blame 26

27 Safety Management - Eight Building Blocks 5. The sharing safety lessons learned and best practices through the active exchange of safety information 6. The integration of safety training for operational personnel 7. Effective implementation of Standard Operating Procedures (SOPs), including the use of checklists and briefings 8. The continuous improvement of the overall level of safety The result of implementing the eight building blocks: An organisational culture that fosters safe practices, encourages effective safety communication, and actively manages safety with the same attention to results as financial management 27

28 Integrated Aviation Management Systems iams 28

29 QMS vs. SMS 29

30 BOW-TIE METHODOLOGY 30

31 Bow Tie Methodology Increasingly popular Both commercial and government organisations accept the Bow Tie Methodology Number of operators and managers using Bow Tie increasing day by day Regulators are enabled to audit effectively Bow Tie Characteristics Simple and elegant way of assessing risk Easy to understand at all levels of an organisation A Bow Tie diagram summarises large documents Provides a structured thinking Picture paints a thousand words Bow Tie is commonly used for major risks 31

32 Why is it call Bow-tie? 32

33 Bow Tie Explained Hazard The potential to cause harm, including injury, damage to property, products or the environment, production losses or increased liabilities Top Event The release of the hazard. The initial consequence. What happens when control is lost 33

34 Bow Tie Explained Threat A possible cause that will potentially release a hazard and produce a Top Event Some examples: Electrical High voltage Human factor incompetence Environmental condition poor visibility Thermal High temperature 34

35 Bow Tie Explained Consequence An event or chain of events that potentially results from the release of hazard Examples Reputational damage Financial damage Property damage Production loss Injuries/fatalities Unemployment Complaints 35

36 Bow Tie Explained Threats and consequences need to be controlled 36

37 Bow Tie Explained Threat barriers and recovery measures control the release of hazard or reduce/ prevent the consequences 37

38 Bow Tie Explained Escalation Factors Conditions that lead to increased risk by defeating or overriding barriers or recovery preparedness measures Examples: Environmental variations - Extreme weather Loss of services - Hydraulics, Electrical Power Escalation Factor Controls Controls put in place to manage conditions that lead to increased risk due to loss of barriers or loss of recovery preparedness measures How do we maintain the controls so they do not fail? 38

39 Bow Tie Explained Bow Tie makes it possible to highlight what is risk critical within your organisation 39

40 SAFETY CULTURE 40

41 Culture Culture binds people together as members of groups and provides clues as to how to behave in both normal and unusual situations Culture influences the values, beliefs and behaviours that people share with other members of various social groups 41

42 Culture National Culture Organisational Culture Professional Culture Safety Culture 42

43 Organisational/ Corporate Culture 43

44 Three Possible Organisational Cultures 44

45 Safety Culture 45