1. 1 JOINT HELICOPTER SAFETY IMPLEMENTATION TEAM (JHSIT) SMS Presentation June 6, 2007 Sao Paulo, Brasil Greg Wyght Vice President Safety & Quality CHC Helicopter Corporation Co- Chair, JHSIT gwyght@chc.ca

2. 2 An effective Safety Management System is essential to achieving & sustaining a zero accident rate along with other quality programs The following briefing will discuss the key elements of the SMS Tool that the JHSIT is developing for delivery in the IHSS conference, September 2007 Montreal. Introduction

3. 3 Management is: the art of “controlling or directing resources to achieve objectives” A System is: “a coordinated & comprehensive set of processes” A Process is: “a systematic series of actions” An SMS is: a comprehensive set of processes designed to control and direct resources to achieve (safety) objectives. An SMS will need to consider: People Training Hardware & Software Policy & Procedures etc It is not some kind of giant IT ‘system’ you can buy off the shelf What is a Safety Management System (SMS)

4. 4 Safety Achievement Finance Plan Targets & Objectives Budget Accountabilities Levels of Authority Procedures Safety Plan Targets & Objectives Budget Line Management Authorities Accountabilities Procedures Financial Management SystemSafety Management System Accountants Audit Plan Checks and Balances Audits Balance Sheets Audits Monitoring/Line Checks Audit Plan Safety Committee Financial Management vs. Safety Management Comparing Two “Systems”

5. 5 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 A Framework for Safety Management

6. 6 Management Systems Technology and standards Improved culture Incident rate Time “A company’s culture is derived from the management’s actions, not its words and unfortunately is usually fear driven. The culture should be “Just” and “Learning” and actively lived by all the staff. Culture it is about Shared beliefs and perceptions of the Company.” Goal: The Reduction of Accidents

7. 7 Leadership and Accountability (including Top Level Policies) Risk Assessment and Hazard Management Standard Procedures (SOP’s) & Safe Work Practices Information and Document Control Training and Competency (Realistic, Comprehensive, but Simple) Systems for Reporting Hazards, Occurrences, Incidents & Accidents Systems for collecting, analyzing, and storing data (root cause, etc.) Corrective action strategies and procedures for tracking closeout. Auditing and ongoing Compliance Monitoring (QA of system) Crisis Management and Emergency Response An SMS must: a) address factors that contribute to an event, rather than just the event itself or the people involved. b) be Reactive & Proactive – Hazard/Deficiency Reports, Audits, Safety meetings, Aviation Safety Report reviews, Safety Cases, Suggestion box, Flight Data Monitoring (FDM) and Health Usage Monitoring (HUMS). c) consider Latent & Active failures - Are we training a way that leads to events on the flight line later? Is there a system defect? Some Elements of an SMS

8. 8 Proactive Risk Management

9. 9 “SMS Tools” that will be Available

10. 10 1.It makes good business sense for long term growth 2.Widely recognized as best practice 3.A contractual requirement for many of your customers 4.Increasingly becoming a regulatory requirement, for example: The International Civil Aviation Organisation made having requirements for an SMS a recommended practice last year It will become an ICAO standard in 2009 So our aviation regulators will need to implement SMS rules by 2009 Why is Having an SMS Important?

11. 11 Before we commence an activity where we are implementing a change we need to proactively: Understand the associated hazards Understand the risks they pose Cost Benefit Analysis Put controls in place to ensure the risk is acceptable These controls need to include controls for emergencies situations too The JHSIT plans to deliver risk management tools & techniques to make this process easier for small operators Simplified tools and techniques for conducting a Job Safety Analyses, Hazard Identification, Risk Assessments etc. Simple Cost Benefit model. 3 Main Processes: #1) Risk Management

12. 12 Identify the Hazard - Audit, Occurrence Review or HAZID Assess the Impact the Hazard may have on Operation - quantify the impact in a language managers understand. Brain Storm Possible Controls – Staff Participation!! Develop a “Business Case” for Implementation! (What’s the cost of implementing vs. not implementing?) E.g. #1 – S76 Blade Tip: Loss of Revenue (no penalty)$ 0 Cost of Parts (2 per year)$20,000 Annual Cost, if nothing changed$20,000+ Cost of the “Intervention”$-10,000 Total savings in the first year$10,000 Basic Cost Benefit Analysis Data-Driven Safety Initiatives 3 Main Processes: #1) Risk Management

13. 13 During an activity we need to proactively monitor that risk is being managed acceptably When they are not that’s when safety leaders intervene The JHSIT plans to demonstrate examples of monitoring tools & techniques to help simplify this process. Tools & techniques will include: Safety surveys Behavioural based safety observations Crew Resource Management Simple and inexpensive helicopter flight data monitoring program for light aircraft (known as HOMP, FOQA or FDM) Helicopter Health & Usage Monitoring Systems (HUMS) 3 Main Processes: #2) Monitoring

14. 14 3 Main Processes: #2) Monitoring

15. 15 When problems occur you need a means for safety concerns to be raised: Accidents, incidents, near misses, new hazards, errors, deficiencies etc You then need to investigate independently to a level appropriate to their significance The focus is on learning, improving & prevention The JHSIT plans to demonstrate some simple and inexpensive reporting tools and techniques. Tools such as HAI’s Occurrence and Defecting Reporting tools etc. 3 Main Processes: #3) Safety Reporting

16. 16 3 Main Processes: #3) Safety Reporting

17. 17 We must recognise that humans can and do make errors! We must recognise that errors & at-risk behaviour are often provoked by system problems i.e. flawed, missing or inconsistent controls Tackling these controls is a powerful means of improvement So we need to encourage safety reports in order to learn & improve A human error or at-risk behaviour is thus a starting point not a finishing point Managing Human Error must be part of an SMS

18. 18 “HFACS” Analysis Tool Human Factors Analysis and Classification System Organizational Influences Resource Management Organizational Climate Organizational Process Unsafe Supervision Level of Supervision Planned Activities Rules & Regulations Problem Correction Organizational Influences Unsafe Supervision Preconditions For Unsafe Acts Unsafe Acts Preconditions For Unsafe Acts Conditions of Personnel Working Conditions Practices of Personnel Unsafe Acts & Conditions ErrorsViolations Decision Based Technique Based Routine Violation Exceptional Violation Attention/ Memory Knowledge Based Perceptual Error

19. 19 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: Wilful recklessness or malicious intent Gross negligence Persistent sub-standard performance An SMS only works within a “Just Culture”

20. 20 Was the Job understood? Sabotage or Malevolent Act Were the results as intended? Were the actions as intended? Knowingly violating Procedures? Pass Substitution Test? Defective Training or Selection Experience? Negligent Error History of Violating Procedures? No Blame Error Yes No Yes Are Procedures Clear and Workable? Reckless Violation ** * No Yes * No ** Repeated Incidents with Similar Root Causes Increasing Individual Culpability / Diminishing Individual Culpability Severe Sanctions Final Warning and Negative Performance Appraisal First Written Warning Coaching / Greater Supervision Until Behavior is Corrected Documented for the Purpose of Prevention Awareness and Training will Suffice Start Here QA Check “Just Culture” Model Rules of Fair Play for Managers *Indicates a “System” induced error. Manager/Supervisor must evaluate what part of the system failed, and what Corrective and Preventative Action is required. Corrective and Preventative Action shall be recorded on the appropriate form for management review (either the NCR form or the Incident Report as applicable).

21. 21 Risk Management ( e.g.: hazard identification, risk assessment, JSA, safety cases etc) Foresight Monitoring (e.g.: supervision, CRM, Inspections, audits, HUMS, HOMP, Behavioural Based Program etc) Oversight Safety Reporting & Investigation Hindsight Insight 3 Process Lead to Insight

22. 22 JHSIT’s goal is to deliver simple tools for these three processes, allowing small operators to: understand the hazards & risks they face determine a cost effective way to control those risks know how effective these controls are in their operation be informed when controls fail drive continuous improvements to take us towards achieving & sustaining a zero accident rate Why is Insight Important to Leaders?

23. 23 Obrigado! SMS Team Lead Ray Wall Director Quality & Safety Bristow Group, Western Hemisphere 337-365-6771 ray.wall@bristowgroup.com Hooper Harris US DOT/FAA Commuter, On Demand, & Training Center Branch 202-267-3437 (USA) hooper.harris@faa.gov Gregory F. Wyght Vice President, Safety & Quality CHC Helicopter Corporation 604-232-7428 (Canada) gwyght@chc.ca International JHSIT Co-Chairs