SMS Manual Part 4

TRANSMILE AIR SAFETY MANAGEMENT SYSTEM MANUAL

PROCESSES & PROCEDURES

TRANSMILE AIR SERVICES

TRANSMILE AIR

SAFETY MANAGEMENT SYSTEM MANUAL

Equate Business Performance to Safety Performance

SMM/TAS001/ISSUE 1 Rev. 1 Date 15/6/2009

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PART 4 SMS PROCESSES & PROCEDURES


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HAZARD IDENTIFICATION AND INCIDENT REPORTING (DCAM AN No. 101/AIC 06/2008) 1.

INTRODUCTION

1.1

One of the objectives of SMS is to reduce the number of maintenance errors and to mitigate the consequences of those which remain. TAS shall endeavour to provide an environment in which such errors may be openly discussed and investigated in order that the contributing factors and root causes of maintenance errors can be addressed.

1.2

This system would complement any present reporting system such as the Mandatory Occurrence Reporting (MOR), CMR process, Non-Compliance Reports, delay analysis etc. MERES/FERES would complement but NOT supplant any existing reporting scheme. Maintenance error shall be defined to have occurred when the maintenance system, including the human element, FAILS to perform in the manner expected in order to achieve its safety objectives.

1.3

The human element includes but is not limited to managers, engineers, technicians, maintenance planners, accountants, administrative staff - in fact this is applicable to any person contributing to the maintenance process.

2.

CORPORATE COMMITMENT

2.1

The TAS Safety Policy described in this SMM incorporates TAS corporate commitment to undertake the MERES/MOR/PIREPS/CHIRPS.

2.2

Managing errors shall be the responsibility of all personnel within TAS SMS group. The corporate commitment ensures that the company continues to provide an environment conducive for employees to report any errors that have been committed without the fear of any punitive action being taken.

2.3

The corporate commitment also ensures that the primary objective of the MERES/MOR is to examine not just what had happened but WHY it happened to determine the root cause and problems.

2.4

Further to this, the corporate commitment ensures that TAS workforce is informed of the investigation results through MERES MERES/MOR/PIREPS. This will ensure that the situational awareness of the work force is enhanced.

3.

MAINTENANCE/FLIGHT OPS ERROR REPORTING SCHEME (MERES/MOR)


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3.1

The aim of this scheme is to identify the factors contributing to the incidents and to make the system resistant to similar errors. It is important to examine not just what happened but WHY it happened in order to determine the root causes and problems.

3.2

TAS employees are required to use this reporting scheme to highlight any maintenance/flight ops error that they have committed or about to commit. This is a mandatory scheme made available to all TAS employees. 3.3 MERES Form - QA 1/014 and FERES Form – FO 1/04 shall be made available at all work locations. These forms shall be completed by any TAS personnel and deposited to the ‘MERES’/’FERES’ boxes placed at the work locations. Respective SMS department shall collect these reports for further analysis and appropriate actions.

3.4

All MERES/FERES/MOR/PIREPS submissions shall be investigated. The error investigation process shall be objective and have the primary intention to establish WHY the event/error happened. The contributory factors that led to the incident shall be studied and every effort shall be made to avoid any action that may inhibit further reporting.

3.5

As a result of the investigation analysis, TML shall implement appropriate measures to prevent the error from re-occurring or alternatively monitor future re-occurrences.

3.6

MOR reporting is applicable for Flight Ops.

4.

FEED BACK OF RESULT TO WORKFORCE

4.1

To ensure a closed loop system, the workforce shall be informed via the Safety Advisory Circulars (SACs), the result of the MEDA analysis.

4.2

The objective of the SAC is to share information with the workforce and create an increased situational awareness on their part. By sharing such information the entire TAS workforce can jointly develop a better understanding of contributory causes of maintenance error and develop a more focused human factors strategy.

5.

TRAINING ON PROCEDURES (Refer to Appendix 1)

5.1

To ensure the success of the reporting system, TAS Engineering shall conduct training to address the element of human factors and to create an awareness and understanding on the safety element whenever any maintenance task or maintenance related task is being performed.

5.2

TAS Engineering personnel shall undergo human factors (HF) training, in which the SMS training shall be embedded in. Part 3 Chapter 15 of the MOE provides further amplification of the HF training, its syllabus and TAS Engineering policy with regards to the HF training.

5.3

Safety reporting systems should not just be restricted to incidents but should include

provision for the reporting of hazards, i.e. unsafe conditions that have not yet caused an incident. Data from incident reporting systems can facilitate an understanding of the causes of hazards, help to define intervention strategies and help to verify the effectiveness of interventions. SMM/TAS001/ISSUE 1 Rev. 1 Date 15/6/2009

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5.4

6.


Flight Operations personnel shall undergo Crew Resource Management (CRM) training in which SMS training shall be embedded. Safety reporting system such as MOR, CHIRP and Pilot Route Report shall be emphasized throughout training of operational activities to ensure smooth process flow.

TRAINING IN

E-MOR REPORT

6.1

All pilots are trained to raise report (E-MOR).

6.2

Human factor training under CRM.

6.3

All flight crews are trained in Safety Emergency Procedures (SEP).


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SAFETY RISK MANAGEMENT (SRM) 1.

INTRODUCTION

1.1

Risk management shall serve to focus safety efforts on those hazards posing the greatest risks. It involves the identification, analysis and elimination (and/or mitigation to an acceptable or tolerable level) of those hazards, as well as the subsequent risks, that threaten the viability of the company.

1.2

Risk Management shall facilitates the balancing act between assessed risks and viable risk mitigation. It is an integral component of TAS safety management. It involves a logical process of objective analysis, particularly in the evaluation of the risks.

2.

RISK MANAGEMENT PROCESSES

2.1

Risk management shall comprise three essential elements:   

2.2

Hazard identification Risk assessment Risk mitigation

The SRM shall include the following processes:     

System and task analysis; Identify hazards; Analyse safety risk; Assess safety risk; and Control safety risk.

2.3

The SRM shall be applied to the following:  Initial designs of systems, organization and/or product  The development of operational procedures  Hazards that are identified in the safety assurance functions  Planned changes to the operational processes to identify hazards associated with those changes

2.4

Acceptable and unacceptable levels of safety risk shall be defined.


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RISK MANAGEMENT PROCESS FLOW CHART


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RISK ASSESSMENT 1.

GENERAL

1.1

Risk assessment, after having confirmed the presence of a safety hazard, is required to assess its potential for harm or damage. The assessment of the hazard involves three considerations: 1.

the probability of the hazard precipitating an unsafe event (i.e. the probability of adverse consequences should the underlying unsafe conditions be allowed to persist);

2.

the severity of the potential adverse consequences, or the outcome of an unsafe event; and

3.

the rate of exposure to the hazards. The probability of adverse consequences

becomes greater through increased exposure to the unsafe conditions. Thus, exposure may be viewed as another dimension of probability.

1.2

Risk assessment involves consideration of both the probability and the severity of any adverse consequences - the loss potential is determined. The hazards (the potential to cause harm) and the risk (the likelihood of that harm being realized within a specified period of time) shall be properly distinguished. A risk assessment matrix shall be used as a tool for prioritizing the hazards most warranting attention.

1.3

The hazard analyses shall be supplemented qualitatively through critical and logical analysis of the known facts and their relationships.

1.4

Risks shall be expressed in the terms as appropriate to the risk.

2.

ASSESMENT OF RISK

2.1

The problems shall first be defined which include defining the characteristics of the hazard, into a problem for resolution. Something that poses a significant risk will reflect these different backgrounds, exacerbated by normal human biases. How the safety issue is defined will affect the course of action taken to reduce or eliminate the hazards. In assessing the risks, all potentially valid perspectives must be evaluated and only the most suitable pursued.

2.2

The probability of causing harm or damage must be assessed and the likelihood of an event occurring can be assessed as:

2.2.1

Unlikely to occur


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Failures that are “unlikely to occur” shall include isolated occurrences, and risks where the exposure rate is very low or the sample size is small. The complexity of the circumstances necessary to create an accident situation may be such that it is unlikely the same chain of events will happen again. However, even if the possibility is only remote, the consequences of concurrent failures may warrant follow-up. Note - There is a natural tendency to attribute unlikely events to “coincidence”. Caution is advised. While coincidence may be statistically feasible, coincidence should not be used as an excuse for the absence of due analysis.

2.2.2

May occur Failures that “may occur” shall derive from hazards with a reasonable probability that similar patterns of human performance can be expected under similar working conditions, or that the same material effects exist elsewhere in the system.

2.2.3

Probably will occur Such occurrences reflect a pattern (or potential pattern) of material failures that have not yet been rectified. Given the design or maintenance of the equipment, its strength under known operating conditions, etc., continued operations will likely lead to failure. Similarly, given the empirical evidence on some aspects of human performance, it can be expected with some certainty that normal individuals operating under similar working conditions would likely commit the same errors or be subject to the same undesirable performance outcome.

2.3

Having determined the probability of occurrence, the nature of the adverse consequences if the event does occur must be assessed. The potential consequences govern the degree of urgency attached to the safety action required. If there is significant risk of catastrophic consequences, or if the risk of serious injury, property or environmental damage is high, urgent follow-up action shall be warranted.

3.

RISK ACCEPTABILITY

3.1

Based on the risk assessment, the risks shall be prioritized relative to other, unresolved safety hazards to ensure rational decisions can be made of allocating limited resources against those hazards posing the greatest risks to the organization.

3.2

Criteria/standards shall be defined within a risk assessment matrix, the values of which shall categorize the risk as acceptable or unacceptable.

3.2.1

Acceptable risk - No further action needs to be taken (unless the risk can be reduced further at little cost or effort).

3.2.2

Undesirable (or tolerable) – the organization/persons are prepared to live with the risk in order to have certain benefits, in the understanding that the risk is being mitigated as best as possible.

3.2.3

Unacceptable - Operations under current conditions must cease until risk is reduced to at least the Tolerable level.


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RISK TOLERABLE CHART


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RISK PROBABILITY


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RISK SEVERITY


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RISK INDEX


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RISK TOLERABILITY


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RISK MITIGATION 1.

GENERAL

1.1

Risks shall be managed to a level “as low as reasonably practicable” (ALARP), balanced against the time, cost and difficulty of taking measures to reduce or eliminate the risk.

1.2

When the acceptability of the risk has been found to be Undesirable or Unacceptable, control measures shall be introduced - the higher the risk, the greater the urgency. The level of risk can be lowered by reducing the severity of the potential consequences, by reducing the likelihood of occurrence or by reducing the exposure to that risk.

1.3

The optimum solution will vary depending on the existing circumstances and exigencies. In formulating meaningful safety action, an understanding of the adequacy of existing defences is required.

2.

DEFENCE ANALYSIS

2.1

The purpose of safety defences put in place is to protect people, property and the environment and used to reduce the probability of unwanted events occurring and to reduce the severity of the consequences associated with any unwanted events.

2.2

Defences shall be categorized as:

2.2.1

Physical defences These include objects that discourage or prevent inappropriate action, or that mitigate the consequences of events (for example, squat switches, switch covers, firewalls, survival equipment, warnings and alarms).

2.2.2

Administrative defences These include procedures and practices that mitigate the probability of an accident (for example, safety regulations, SOPs, supervision and inspection, and personal proficiency).

2.2.3

Before selecting appropriate risk mitigation strategies, why the existing system of defences was inadequate shall be first understood.

3.

RISK MITIGATION STRATEGIES

3.1

Risk mitigation can be of the following:

3.1.1

Exposure avoidance - The risky task, practice, operation or activity is avoided because the risk exceeds the benefits.

3.1.2

Loss reduction - Activities are taken to reduce the frequency of the unsafe events or the magnitude of the consequences.


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3.1.3

Segregation of exposure (separation or duplication) - Action taken is to isolate the effects of the risk or build in redundancy to protect against the risks, i.e. reduce the severity of the risk (for example, protecting against collateral damage in the event of a material failure, or providing back-up systems to reduce the likelihood of total system failure).

3.2

In evaluating risk mitigation, the effectiveness of each option shall to be evaluated before a decision is to be taken. Full range of possible control measures shall be considered and that trade-offs between measures be considered to find an optimal solution. Each proposed risk mitigation option shall be examined from following perspectives:

3.2.1

Effectiveness o

Level One) (Operations’ actions)

:

The safety action eliminates the risk, e.g. by providing interlocks to prevent thrust reverser activation in flight;

o

Level Two the (Control actions)

:

The safety action accepts the risk but adjusts

o

system to mitigate the risk by reducing it to a manageable level, e.g. by imposing more restrictive operating conditions; and

Level Three : The safety action taken accepts that the hazard can (Personnel actions) neither be eliminated (Level One) nor controlled (Level Two), so personnel must be taught how to cope with it, for example, by adding a warning, a revised checklist and extra training.

3.2.2

Cost/benefit, practicality, Challenge, Acceptability, Enforceability, Durability, Residual risks and new problems

3.3

When there is insufficient organizational will or resources, the problem shall be deferred to the training department to teach staff to cope with the risks.

3.4 Mitigation action which cannot be resolved at SAGs level will be referred to SRB,involving high cost mitigation action and further training.


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SAFETY INVESTIGATION INTRODUCTION Accidents result in damage and/or injury, and reactive investigations are rather inefficient from a safety perspective in that latent unsafe conditions posing significant safety risks may be overlooked. The focus of an accident investigation must be directed towards effective risk control. “Serious incident” are those incidents which good fortune prevented from becoming accidents. for example, a near collision with another aircraft or with the ground. Due to the seriousness of such incidents, they should be thoroughly investigated. Many incidences, although do not warrant investigations by either the regulatory authorities may be indicative of potentially serious hazards - perhaps systemic problems that will not be revealed unless the occurrence is properly investigated. For every accident or serious incident, there will likely be hundreds of minor occurrences, many of which have the potential to become an accident. It is important that all reported hazards and incidents be reviewed and a decision taken on which ones should be investigated and how thoroughly. For in-house investigations, the investigating team may require the assistance of specialists, depending on the nature of the occurrence being investigated, such as the pilots, maintenance engineers and safety specialists.

SCOPE OF SAFETY INVESTIGATIONS The extent of the investigation will depend on the actual or potential consequences of the occurrence or hazard. Hazard or incident reports that indicate high-risk potential should be investigated in greater depth than those with low risk potential. The depth of the investigation should be that which is required to clearly identify and validate the underlying hazards. Understanding why something happened requires a broad appreciation of the context for the occurrence. Although the investigation should focus on the factors that are most likely to have influenced actions, the dividing line between relevance and irrelevance is often blurred.

INFORMATION SOURCES Information relevant to a safety investigation can be acquired from a variety of sources, including: 

Physical examination of the equipment used during the safety event.



Documentation spanning a broad spectrum of the operation, for example: o o o

maintenance records and logs; certificates and licences; in-house personnel and training records and work schedules;


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o o o o o o


Standard Operating Procedures; training manuals and syllabi; manufacturers’ data and manuals; regulatory authority records; weather forecasts, records and briefing material; and flight planning documents.



Recordings (flight recorders and voice tapes).



Interviews conducted with individuals directly or indirectly involved in the safety event.



Direct observation of actions performed by operating personnel in their work environment. This can reveal information about potential unsafe conditions.



Simulations. Permit reconstruction of occurrence and facilitate a better understanding of the sequence of events that led up to the occurrence, and the manner in which personnel responded to the event.



Specialist advice. When necessary, consult with other professionals during an investigation.



Safety databases. Useful supporting information such as FDA, LOSA and NOSS programmes.

INTERVIEWS Information acquired through interviews clarifies the context for unsafe acts and conditions. It is used to confirm, clarify or supplement information learned from other sources. Interviews determine “what” happened. Interviews are often the only way to answer the important “why” questions which can facilitate appropriate and effective safety recommendations. The details of a system defect reported by operational personnel may differ from those observed by maintenance personnel during a service check. Supervisors and management may perceive issues differently than line personnel. All views must be accepted as worthy of further exploration. Conducting interviews To achieve the best results, employ following processes when interviewing:   

carefully preparing and planning for the interview; conducting the interview in accordance with a logical, well-planned structure; and assessing the information gathered in the context of all other known information.

INVESTIGATION METHODOLOGY The field phase of an investigation is used to identify and validate perceived safety hazards. Competent safety analysis is required to assess the risks, and effective communications are required to control the risks. When considering human error, an understanding of the conditions that may have affected human performance or decision-making is required. These unsafe conditions may be indicative of systemic hazards that put the entire aviation system at risk. Consistent with the SMM/TAS001/ISSUE 1 Rev. 1 Date 15/6/2009

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systems approach to safety, an integrated approach to safety investigations considers all aspects that may have contributed to unsafe behaviour or created unsafe conditions. Effective investigations follow an iterative process that may require going back and repeating steps as new data are acquired and/or as conclusions are reached.

SAFETY RECOMMENDATIONS When an investigation identifies hazards or unmitigated risks, safety action is required. The need for action must be communicated by means of safety recommendations to those with the authority to expend the necessary resources. The following considerations may apply: 

Action agency Ideally, problems should be addressed at the lowest possible level of authority, such as the departmental or sectional level.



What versus how Safety recommendations should clearly articulate what should be done, not how to do it. The focus is on communicating the nature of the risks requiring control measures. Avoid detailed safety recommendations which spell out exactly how the problem should be fixed. The responsible manager should judge the specifics of the most appropriate action for the current operating conditions. The effectiveness of any recommendation will be measured in terms of the extent to which the risks have been reduced, rather than strict adherence to the wording in the recommendation.



General versus specific wording Specific language should be used in summarizing the scope and consequences of the identified risks. On the other hand, since the recommendation should specify what is to be done (not how to do it), concise wording is preferable.

Formal safety recommendations warrant written communications. This ensures that the recommendations are not misunderstood and provides the necessary baseline for evaluating the effectiveness of implementation. However, it is important to remember that safety recommendations are only effective if they are implemented.


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CHART – INTEGRATED SAFETY INVESTIGATION METHODOLOGY


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SAFETY INVESTIGATION PROCESS FLOW

SRB REVIEW


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FLIGHT OPERATIONS


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SMS DATA AND RECORD MANAGEMENT

This section to be published.


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SMS Manual Part 4

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