Hazard Identification and risk management. Patrick PEZZATINI, EUROCOPTER Fleet Safety Dept SMS Manager

Hazard Identification and risk management Patrick PEZZATINI, EUROCOPTER Fleet Safety Dept SMS Manager

Agenda 1. Concepts 2. Hazard identification 3. Risk management 4. The importance of event report 5. Additional links

1. Concepts ICAO SMS framework 1Safety policy and objectives 1.1 Management commitment and responsibility 1.2 Safety accountabilities of managers 1.3 Appointment of key safety personnel 1.4 SMS implementation plan 1.5 Coordination of emergency response planning 1.6 Documentation 2 Safety risk management 2.1 Hazard identification process 2.2 Risk assessment and mitigation process 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 Source: ICAO

1. Concepts Hazard : any source of potential damage, harm or adverse health effects on something or someone under certain conditions at work.

1. Concepts

1. Concepts Examples of Hazards and Their Effects Workplace Hazard Example of Hazard Example of Harm Caused Thing Knife Cut Substance Benzene Leukemia Material Asbestos Mesothelioma Source of Energy Electricity Shock, electrocution Condition Wet floor Slips, falls

1. Concepts Undesirable Event Event Loss Loss of of control of of the the situation UE= UE= all all event event phase phase which which can can lead lead to to an an accident accident without without efficient efficient barriers barriers Controlled area UE Recovery phase Safety principles: Manage to stay in safety controlled area Safety Safety model model :: An An accident is is assimilated as as a loss loss of of control of of the the situation MITIGATION Accident If an UE occurs, react to hold it back and to return into controlled area Mitigation to reduce the consequences of an accident Source: Qualit Audit 7

1. Concepts 8

1. Concepts Prevention Training Ergonomy Procedure to open the Windows Control Recovery Reduction of conséquences Protection from outcomes

2. Hazard identification Hazard identification, risk assessment and mitigation process: 1. What am I the most afraid of in my activity? 2. How this event could happen? 3. What can be the consequences (for the company, for the others, on the environment )? 4. How can I reduce the probability of occurrence of this event (prevention)? 5. How can I reduce the consequences of this event (mitigation)? 6. What protective measures must be adopted and how can I put them in place to prevent this event?

2. Hazard identification Hazard identification, risk assessment and mitigation process: 1. What am I the most afraid of in my activity? 2. How this event could happen? 3. What can be the consequences (for the company, for the others, on the environment )? 4. How can I reduce the probability of occurrence of this event (prevention)? 5. How can I reduce the consequences of this event (mitigation)? 6. What protective measures shall be adopted and how can I put them in place to prevent this event?

2. Hazard identification CFIT, CFIW, antenna/wire strikes, main or rear rotor strike in obstacles? Long line in tail rotor? Inadvertent entry in IMC? Ground collision? Mid air collision?

2. Hazard identification EHSIT List of Undesirable Event in Commercial Air Transport Ref Description Ref Description UE 01 Unintended flight in IMC, unusual positions or loss of reference in flight UE 11 Incident related to icing or to de-icing procedures UE 02 UE 03 Inappropriate crew action, unsuitable use of aircraft systems, etc. Events related to work / maintenance / blocking on or in the vicinity of runways or utilities UE 12 UE 13 Incorrect weight/balance data and insertion of this data in the FMS, exceeded weight and balance limits adversely affecting aircraft handling Loss of separation in flight (IFR/IFR or IFR/VFR special) UE 04 Vehicle / aircraft / personnel / animal not scheduled in airport facilities UE 14 Deviation from flight path, obstacle unknown by the crew likely to interfere with the flight path UE 05 Events related to contaminated runway in service (FOD) UE 15 Aircraft system failure (other than one engine inoperative) UE 06 Bird strike hazard UE 16 One engine inoperative on multi-engine aircraft UE 07 Rotors striking obstacles UE 17 Engine failure on single-engine aircraft UE 08 Personnel struck by rotor blades UE 18 UE 09 Projection of debris or rubble by the rotor stream UE 19 UE 10 Hazardous phenomena (storms, strong winds, wind shears, hailstone, fog, etc.) Fire, smoke, malfunction of one or more systems, components or cargo elements leading to fire Failure of ground/aircraft interfaces, malfunction of communication sytem (ATC/aircraft, aircraft/ground team, etc.)

2. Hazard identification Hazard identification, risk assessment and mitigation process: 1. What am I the most afraid of in my activity? 2. How this event could happen? 3. What can be the consequences (for the company, for the others, on the environment )? 4. How can I reduce the probability of occurrence of this event (prevention)? 5. How can I reduce the consequences of this event (mitigation)? 6. What protective measures shall be adopted and how can I put them in place to prevent this event?

2. Hazard identification What can lead to an engine failure? Engine system failure Fuel system failure Fuel pollution or inadequate fuel Loss of engine power No more fuel available!!! Wrong management of fuel system Wrong management of engine system

2. Hazard identification Foreign Object Damage Failure of a component (design) Lack of maintenance check Errors, violations during maintenance task No anti-pollution test before refuelling No formal refuelling procedures Errors, violations during refuelling No cross check of fuel quantity delivered after refuelling Wrong calculation of Minimum Fuel Quantity before flight Unplanned diversion in flight Lack of knowledge Improper action of the crew Engine system failure Failure of fuel system Fuel pollution or inadequate fuel No more fuel available!!! Improper use of fuel system Improper use of engine system Loss of engine power

3. Risk management Hazard identification, risk assessment and mitigation process: 1. What am I the most afraid of in my activity? 2. How this event could happen? 3. What could be the consequences (for the company, for the others, on the environment )? 4. How can I reduce the probability of occurrence of this event (prevention)? 5. How can I reduce the consequences of this event (mitigation)? 6. What protective measures must be adopted and how can I put them in place to prevent this event?

3. Risk management Questions for assessing the severity of an occurrence: How many lives may be lost? Employees Passengers General public What is the environmental impact? Spill of fuel or other hazardous product Physical disruption of natural habitat

3. Risk management What is the severity of the property or financial damage? Direct operator property loss Damage to aviation infrastructure Third party damage Financial impact and economic impact for the company What are the likely media interest?

4 CATASTROPHIC CRITICAL MAJOR 5 SERIOUS MINOR Determination of initial Safety Risk: loss of power on multi engine helicopter NEGLIGEABLE No consequences IMPROBABLE RARE REMOTE PROBABLE FREQUENT Legend : ACCEPTABLE MEDIUM SERIOUS UNACCEPTABLE UNACCEPTABLE + 3 1 FREQUENCY IMPROBABLE RARE REMOTE PROBABLE FREQUENT Description: Never occurred in aviation world Already occurred in aviation world Already occurred one time in the company Occurs in the company less than 3 times by year Frequently occurs in the company (more than 3 times by year) SEVERITY Peoples Environment Assets Brand image 2 Direction / Référence / Date No consequences No injury No effect No damage No impact NEGLIGEABLE Damage < 10K MINOR Slight injuries Light impact Damage < 50K Limited impact MAJOR CRITICAL Major injuries One dead Important local No remediable Damage Damage effects effect < 250K < 1 M Important impact National impact CATASTROPHIC Superficial injuries Multiples deaths Negligeable effects Massive effects Damage > 1 M Light impact International Impact 21

3. Risk management Foreign Object Damage Failure of a component (design) Lack of maintenance check Errors, violations during maintenance task No anti-pollution test before refuelling No formal refuelling procedures Errors, violations during refuelling No cross check of fuel quantity delivered after refuelling Wrong calculation of Minimum Fuel Quantity before flight Unplanned diversion in flight Lack of knowledge Improper action of the crew Engine system failure Failure of fuel system Fuel pollution or inadequate fuel No more fuel available!!! Improper use of fuel system Improper use of engine system Loss of engine power

3. Stay in safety controlled area FOD policy Foreign Object Damage Failure of a component (design) Apply OEM directives HUMS Safety barriers Lack of maintenance check Safety and Quality policy visibly endorsed by CEO Adequate supervision Engine system failure Updated and cleared work documentation Technicians trained and rated Adequate tools, workshop, environment No misson/time pressure («hurry up syndrom») «just culture» Failure of fuel system Errors, violations during maintenance task

3. Recovery phase Crew fights to keep the control of flight Crew is trained and applies the appropriate procedure Safety barriers Engine system failure Crew is trained and applies the appropriate procedure In flight diversion to emergency airfield Failure of fuel system Loss of engine power Loss of control Calculation of new flight endurance Crew is trained and applies the appropriate procedure Safety barriers

3. Mitigation phase Pax: mandatory preflight safety briefing Crash absorber seats for crew and pax Lifevests, liferafts, survival kits, first aid kits Crew fights to keep the control of flight Crew: wear of helmets and all suitable protective suits (gloves, fireproof suits ) Loss of control IMPACT! Additional cabin extinguisher Passenger injuries Additional individual ELT for crew Aircraft damage GPS fleet tracking service Oversea flight: emergency floattation system Mitigation

CATASTROPHIC 4 CRITICAL MAJOR MINOR NEGLIGEABLE 5 MEDIUM Determination of resulting Safety Risk: loss of power on multi engine helicopter 1 No consequences 3 IMPROBABLE RARE REMOTE PROBABLE FREQUENT Legend : ACCEPTABLE MEDIUM SERIOUS UNACCEPTABLE UNACCEPTABLE + FREQUENCY Description: IMPROBABLE Never occurred in aviation world RARE Already occurred in aviation world REMOTE Already occurred one time in the company PROBABLE Occurs in the company less than 3 times by year FREQUENT Frequently occurs in the company (more than 3 times by year) SEVERITY Peoples Environment Assets Brand image 2 No consequences No injury No effect No damage No impact NEGLIGEABLE Damage < 10K MINOR Slight injuries Light impact Damage < 50K Limited impact MAJOR CRITICAL Major injuries One dead Important local No remediable Damage Damage effects effect < 250K < 1 M Important impact National impact CATASTROPHIC Superficial injuries Multiples deaths Negligeable effects Massive effects Damage > 1 M Light impact International Impact 27

3. Risk management Several solutions are possible Adopting new procedures is costly Conduct a cost/benefit analysis (business case) Could be very detailed (exact costs, benefits) Could use relative values (low, medium, high)

3. Risk management BENEFIT High Med Low COST Low 1 2 3 Med 2 3 4 High 3 4 5

3. Risk management Key role of risk continuous monitoring: Register your hazards and risks analyzis in a Database Reviews them periodically (set alarms) and when changes occur in your activity Use adequate risk management form (paper or electronic)

SERIOUS Current MEDIUM

3. Risk management Risk management form (cont d)

3. Risk management (to summarize) Hazard identification Risk analysis Probability Risk analysis Severity Risk assessment and tolerability Yes, accept the risk(s) Risk control /mitigation Source ICAO

4. The importance of event report SAFETY MANAGEMENT SYSTEM SAFETY CULTURE (People oriented) RISK MANAGEMENT (System oriented) Human Factors Safety Com «Just culture» Occurrence reports (and feedback!) Risk analysis Accident prevention program Hazard identification Incident/accident investigation Source : QualitAudit/Air France consulting 35

4. The importance of event report Just culture is a culture in which front line operators or others are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training, but where gross negligence, willful violations and destructive acts are not tolerated. (Regulation (EC) 691/2010 )

4. The importance of event report The vicious circle of taboo "Good professionals don't make errors" Errors become faults I hide my errors It's easier for errors to have serious consequences Errors remain invisible to all The system cannot put in place protective barriers

4. The importance of event report The "virtuous" circle of feedback "Man is intelligent, he makes mistakes" Now over to you! I talk to my colleagues It's much less likely that my mistake will have serious consequences I decide to give feedback The organization puts in place protective measures The organization processes my report

4. The importance of event report The reality? Yesterday, I made a real blunder... Does our method interest other teams? I talk to my team It is less likely that this mistake will have consequences I can see that this is not the first time It puts in place protective measures to prevent it The team reflects on the problem

4. The importance of event report Encourage people to report: The operational staff are the ones who know the real situation Implementation of a non punitive policy Obstacles to this reporting: It is difficult to "confess" to a mistake Fear of being punished No corrective actions following the declaration of an event

4. Day to day risk management New hazard 1 Risk analysis Scenario of accident 2 When an incident or accident occurs, analyze of dysfunctions Hazard identification Database Event reports Lessons learned 4 Analyzis of root causes and unexpected outcomes 3 Analyzis of barriers efficiency 41

5. Additional links Links: http://www.icao.int/anb/fls/icaosafety.html http://easa.europa.eu/essi/index.html http://www.ihst.org/ http://www.skybrary.aero/index.php/safety_culture http://www.tc.gc.ca/eng/civilaviation/opssvs/aviationsafet y menu.htm http://www.eurocopter.com/site/en/ref/safety_36.html http://www.eventreporting.org/

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