1. AIRBORNE LAW ENFORCEMENT ASSOCIATION Safety Management System Workshop --------------------------------------------------------- Keith Johnson Safety Program Manager

2. 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

3. The topic of the day

4. “SAFETY”  It holds the key to our future  It affects everything we do (SMS)  Every accident affects everyone

5. SAFETY PRIORITIES  SAFETY has the highest priority  MISSION has a lower priority  Each person is critical to eliminating accidents  Inclusive communications chain*

6. SAFETY PRINCIPLES 1. Always operate in the safest manner possible 2. Never take unnecessary risks 3. Safe does not mean risk free 4. Key to safety is the i.d. and management of risk 5. An absence of accidents does not necessarily equate to safety 6. Familiarity and prolonged exposure without an incident leads to a loss of appreciation of risk How does this apply flying patrol?

7. Safety Goals  Zero accidents  Zero injuries  Zero harm to environment  Improve public perception of law enforcement aviation

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

9. ELEMENTS OF THE ORGANIZATION  Flight Operations  Ground Operations  Maintenance  Training  Safety  Safety Management System is all inclusive

10. 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  Don’t reinvent the wheel  No new causes of accidents  Copy successful organizations  Accreditation – Platinum Program

11. 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

12. 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.

13. 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…

14. Why is Having an SMS Important? 1. Widely recognized as best practice 2. Eliminates accidents 3. Reduces costs 4. Limits exposure (reduces total risk) 5. Reduces probability of having an accident 6. Reduces severity of risks 7. Reduces exposure to risk 8. Increases likelihood of completing the mission

15. 1. Safety Management Plan Description of SMS components: 1. Definition of fundamental approach to safety a) Philosophical approach – Vision, Mission, ValuesVision, Mission, Values b) Safety policy – SMS policy statement SMS policy statement c) Business and department goals – set/reviewed annuallydepartment goals 2. Clearly defined roles and responsibilities a) Openly documented and briefed 3. Top leadership involvement a)Safety is an agenda item, resource allocation, openness, involved in daily activities, promoting awareness

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

17. 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

18. 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

19. JHSAT STUDY RESULTS Three themes came from JHSAT study: 1. Better training 2. Operational oversight 3. Safety Management

20. 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

21. SAFETY RECOMMENDATIONS 1.More consistent & comprehensive NTSB involvement and investigation 2.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

22. 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

23. Results of full year 2000 dataset

25. 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

26. 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?

27. 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

28. Just Culture Process

29. 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

30. 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.

31. 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

32. 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

33. The Attributes of an SMS 2) Safety Promotion – Safety Policy – Messages, memos from management – Posters, flyers, website – Safety training – Recognition program – Just Culture process in place

34. The Attributes of an SMS 3) 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

35. The Attributes of an SMS 4) Hazard Identification and Risk Management – Proactively identify potential hazards – Hazards are considered when making changes – Risk Assessment – Identified hazards are tracked for closure

36. The Attributes of an SMS 5) 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

37. The Attributes of an SMS 6) 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

38. The Attributes of an SMS 7) Safety Assurance Oversight Programs – Internal assessments at regularly scheduled intervals, including contractors – Utilizing checklists tailored to the organization’s operations when conducting safety evaluations – Independent assessment of evaluator’s 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

39. The Attributes of an SMS 6) 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

40. The Attributes of an SMS 8) Safety Management Training Requirements – Include a safety orientation for all new personnel, stressing the organization’s commitment to safety and everyone’s 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

41. 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

42. 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

43. 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 organization’s operations/business performance measures

44. 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

45. 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

46. LEADERSHIP SAFETY & STANDARDS  Management’s 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

47. 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

48. 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

49. 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!

50. NON-COMPLIANCE Non-compliance rarely results in an accident or incident, however: It always results in greater risk for the operation!

51. 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

52. 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

53. Are We Rewarding the Right People?  Supervisors know who will & won’t 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

54. 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?

55. How the Processes Gives Insight Risk Management ( e.g.: hazard identification, risk assessment Foresight Monitoring (e.g.: supervision, Inspections, audits, HUMS Oversight Safety Reporting & Investigation Hindsight Insight

56. How the Processes Interact Risk Management Proactive Planning Monitoring Proactive Checking Safety Reporting & Investigation Reactive Checking Feedback / Feed-forward But all three processes are also there to Act to introduce improvements… Continuous Improvement These improvements are vital if you are going to achieve & sustain a zero rate

57. 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? Risk Management MonitoringSafety Reporting & Investigation All 3 can result in Action

58. ATTITUDE “What lies behind us and what lies before us are tiny matters compared to what lies within us.” Ralph Waldo Emerson

59. “ The hardest thing to do, and the right thing to do are usually the same thing.”

60. COMMUNICATION BARRIERS  Position/Rank  Age  Gender  Organization culture  Predispositions (attitude)  Assumptions

61. Summary  The guiding principle of risk management is elimination of accidents  “Safety’s” role is the maximization of effectiveness and efficiency  A Safety Management System aims to establish and maintain this control 1. Reduce loss (people, production, assets, environment) 2. Strengthen Management performance and organizational culture 3. Advance the Technology and knowledge base 4. Demonstrate Compliance 5. Provide a performance advantage