Outcome: CAA split into Air Services Australia and CASA after two further systemic investigations

Transcription

1 Outcome: CAA split into Air Services Australia and CASA after two further systemic investigations

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4 The catalyst for the inquiry was the report from the Bureau of Air Safety Investigation on the Monarch Airlines crash in June Since then the Civil Aviation Authority, its successor the Civil Aviation Safety Authority and air safety have been the subject of constant media attention. (p.xi)

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6 Session 15 The aircraft

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12 Figure 46: Individual actions, local conditions, risk controls, Transair organisational factors and CASA organisational factors

13 Safety Management Systems (SMS) - why they have become ICAO Standards In virtually all aviation accidents and serious incidents, the subsequent systemic investigation has shown that: The primary contributing factors were all present before the accident/incident. In many cases they were common knowledge, and had often been formally documented. In all cases, they could, and should, have been identified and rectified before the accident, if an integrated safety management system had been in place, operational, and effective..

14 Systems for managing safety versus Safety management systems For many years aviation has had in place systems for managing safety, and these have served us well However, with few exceptions, we have not had in place fully integrated safety management systems ISMS are a major step forward

15 The awful sameness of major accidents...

16 Systemic factors Hardware Training Organisation Communication Incompatible Goals Procedures Maintenance Management Design Housekeeping Defences/risk controls Safety culture Total factors contributing to accidents

17 The mandatory introduction of civil and military Safety Management Systems: The safety outcomes of the international adoption of a systemic approach to air safety investigation since 1994 have been the key drivers for the adoption of safety management systems in civil aviation. And for the same reasons, in the ADF

18 Annex 19 - Safety Management Annex 19 9 Safety Management On February 25 th 2013, after 30 years, the ICAO Council unanimously adopted a new Annex to the Chicago Convention, Annex 19 on Safety Management. Annex 19 is the first new ICAO Annex for 30 years

19 ICAO Annex 19 SMS Components and Elements 1. Safety policy and objectives 1.1 Management commitment and responsibility 1.2 Safety accountabilities 1.3 Appointment of key safety personnel 1.4 Coordination of emergency response planning 1.5 SMS documentation 2. Safety risk management 2.1 Hazard identification 2.2 Safety risk assessment and mitigation 3. Safety assurance 3.1 Safety performance monitoring and measurement 3.2 The management of change 3.3 Continuous improvement of the SMS 4. Safety promotion 4.1 Training and education 4.2 Safety communication

20 12 Elements of the ADF Aviation Safety Management System (ASMS) 1 Genuine command commitment 2 A generative aviation safety culture 3 A defined safety organisation structure 4 Communication 5 Documented aviation safety policy 6 Training and education 7 Risk management 8 Hazard reporting and tracking 9 Investigation 10 Emergency response 11 Survey and audit 12 ASMS review

21 The ICAO State Safety Program (SSP) Annex 19 includes the requirement for States to establish a State safety programme (SSP), in order to achieve an acceptable level of safety (ALoS) in civil aviation. An SSP is a management system for the management of safety by the State.

22 ICAO SSP definition (Annex 19): An SSP is defined as: An integrated set of regulations and activities established by a State aimed at managing civil aviation safety. It includes: specific safety activities that must be performed by the State regulations and directives promulgated by the State to support fulfilment of its responsibilities concerning safe and efficient delivery of aviation activities in the State. An SSP is an SMS at the national level

23 ICAO SMS Components and Elements: Service providers responsibilities airlines, MROs, ANSPs, etc. 1. Safety policy and objectives 1.1 Management commitment and responsibility 1.2 Safety accountabilities 1.3 Appointment of key safety personnel 1.4 Coordination of emergency response planning 1.5 SMS documentation 2. Safety risk management 2.1 Hazard identification 2.2 Safety risk assessment and mitigation 3. Safety assurance 3.1 Safety performance monitoring and measurement 3.2 The management of change 3.3 Continuous improvement of the SMS 4. Safety promotion 4.1 Training and education 4.2 Safety communication

24 ICAO SSP Components and Elements: States responsibilities 1. State s safety policy and objectives 1.1 State safety legislative framework 1.2 Safety responsibilities and accountabilities 1.3 Accident and incident investigation 1.4 Enforcement policy 2. State s safety risk management 2.1 Safety requirements for service providers SMS 2.2 Agreement on service providers safety performance 3. State s safety assurance 3.1 Safety oversight 3.2 Safety data collection, analysis and exchange 3.3 Safety data driven targeting of oversight on areas of greater concern or need 4. State s safety promotion 4.1 Internal training, communication and dissemination of safety information 4.2 External training, communication and dissemination of safety information

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26 Integrating the SMS: the greatest challenge

27 Consider an engine. All the necessary components may be present...

28 But, until the separate parts are properly assembled, fuelled and lubricated, you do not have a functioning engine

29 The assembled engine then needs to be installed in a vehicle, to have a functioning, integrated system at the organisational level. However, even a fully integrated system will fail if the design of the system itself, the engine, is fundamentally flawed.

30 If the SMS is not integrated, but standalone and fragmented, it will function independently of other management systems. This usually results in hazards, errors, violations, and safety deficiencies being overlooked, or not communicated throughout the organisation. The result is [an organisation] does not learn or improve its ability to manage the safety of its operations. (p308) The Honourable Peter McInerney, QC, Special Commission of Inquiry into the Waterfall Rail Accident, 2005

31 Where are we going? New thinking in safety management We need to adopt a fully integrated approach at the State level, and the service provider level Change our primary focus from the events to: the preventive controls that failed the recovery controls that worked The same sets of preventive and recovery controls are common to many generic categories of adverse operational events

32 We need to fully integrate risk management and safety investigation Both processes consider the same risk controls Risk management before the category of event Safety investigation after the event They are two sides of the same coin Effective safety management is the management of risk controls, not events

33 Risk management ORGANISATION organisational Deficiencies: latent conditions MANAGEMENT DECISIONS AND ORGANISATIONAL PROCESSES TASKING WORKPLACE local conditions ERROR- PRODUCING CONDITIONS VIOLATION- PRODUCING CONDITIONS OPERATIONS PERSON group/team ERRORS VIOLATIONS DEFENCES BARRIERS ACCIDENTS & SERIOUS INCIDENTS LATENT CONDITIONS Investigation

34 Basic Bow Tie Concept Preventive Controls Recovery Controls Events and Circumstances BARRIERS Harm to people and damage to assets or environment H A Z A R D T1 T2 T3 Top Event Undesirable event with potential for harm or damage C O N S E Q U E N C E S Engineering activities Maintenance activities Operations activities

35 HAZARD The Bow Tie in operational safety management TOP EVENT CONSEQUENCE Stick Shaker activates T1 Preventive Controls SOR1 Recovery Controls L O S S S T A L L T2 T3 SOR2 SOR3 SOR4 O F A I R C R A F T Engineering activities Maintenance activities Operations activities SOR = Safety Occurrence Report

36 The Bow Tie in operational safety management HAZARD TOP EVENT CONSEQUENCE A I R C R A F T T1 T2 T3 Preventive Controls Breakdown in separation SOR1 SOR2 SOR3 SOR4 Recovery Controls M I D A I R C O L L I S I O N Engineering activities Maintenance activities Operations activities

37 H A Z A R D T1 T2 T3 Escalation Factors Preventive Controls Escalation controls Incident Top Event Recovery Controls Escalation controls Undesirable event with potential for harm or damage Escalation Factors C O N S E Q U E N C E S Engineering activities Maintenance activities Operations activities

38 The ARMS Methodology for Operational Risk Assessment in Aviation Organisations Developed by the ARMS Working Group,

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41 UK CAA Significant Seven Bow Tie Templates (2014)

42 Service providers Many leading service providers are now structured so that within Group Safety departments the risk managers and investigators are the same people Risk management and investigation processes are fully integrated with each other, and with all the elements of the organisation's SMS

43 The Defence Aviation Safety Program (DASP) Modelled on the ICAO SSP concept In October 2011, DI(G) OPS 02-2 was reissued under the revised title of the Defence Aviation Safety Program (DASP) to reflect a single integrated policy that addresses both the Airworthiness Management System (AMS) and the Aviation Safety Management System (ASMS)

44 The need for major change: At the State level, is the current aviation safety structure compatible with the new ways of thinking about integrated safety management? We still have a basic structure which dates back to the 1980s Aviation has changed, and continues to change, in technical, social, commercial, economic and political dimensions Investigations keep coming up with the same systemic factors for generic categories of occurrence breakdowns in separation, runway incursions, approach and landing accidents, and so on We need to follow the lead of major aviation service providers and look at things differently Safety investigation organisations are by their very nature primarily reactive

45 We need to integrate the risk management and investigation processes in the one organisation, and link these to all the elements of the SSP We need to move from the traditional focus on investigation to focus on improved pro-active risk management and the improvement of our controls The SSP needs to incorporate these new ideas through improved and well informed policies in consultation with all stakeholders That requires the education of stakeholders, to change the traditional mind set.

46 Some final thoughts We need to adopt a new way of thinking about safety management In some areas we have made a good start The time has come to develop and adopt a fully integrated approach to risk management and safety investigation both at the State and service provider levels We need to adopt new structures and organistionsto achieve that end, supported by control based safety information systems Safety management should also be regarded as a dimension of enterprise risk management

47 Thank you