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17-MAR-2010 Meeting SMS Goals Through AQP and Risk Management John Ross CEO OK3 Grou p Inc. The Spectrum Group Civil Aviation Team Associate

17-MAR-2010 Meeting SMS Goals Through AQP and Risk Management John Ross CEO OK3 Group Inc. The Spectrum Group Civil Aviation Team Associate

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Page 1: 17-MAR-2010 Meeting SMS Goals Through AQP and Risk Management John Ross CEO OK3 Group Inc. The Spectrum Group Civil Aviation Team Associate

17-MAR-2010

Meeting SMS Goals Through AQP and Risk Management

John Ross

CEO OK3 Group Inc.

The Spectrum Group Civil Aviation Team Associate

Page 2: 17-MAR-2010 Meeting SMS Goals Through AQP and Risk Management John Ross CEO OK3 Group Inc. The Spectrum Group Civil Aviation Team Associate

The Story Behind the OK3 Group The “Perfect Approach” to Safety through

Risk Management and Integrated Processes

Page 3: 17-MAR-2010 Meeting SMS Goals Through AQP and Risk Management John Ross CEO OK3 Group Inc. The Spectrum Group Civil Aviation Team Associate

An increase in accidents caused by human factors Increased complexity of the operating environment Increased sophistication of the aircraft and automation Increased sophistication of training devices Need for curriculum development and modifications through

use of a systematic data collection process with validations Need to integrate training and safety into operations

throughout the Corporation

AQP and Risk Management Developed in the Airline Industry in Response to:

Page 4: 17-MAR-2010 Meeting SMS Goals Through AQP and Risk Management John Ross CEO OK3 Group Inc. The Spectrum Group Civil Aviation Team Associate

Regulatory Landscape

AC 120-92Introduction to Safety Management Systems

The FAA is transitioning the traditional oversight process from a quality control approach with principal emphasis on surveillance of compliance with technical standards to a systems approach that stresses the systemic nature of aviation businesses and the larger system as a whole

Page 5: 17-MAR-2010 Meeting SMS Goals Through AQP and Risk Management John Ross CEO OK3 Group Inc. The Spectrum Group Civil Aviation Team Associate

Regulatory Landscape

…from a quality control approach…

Page 6: 17-MAR-2010 Meeting SMS Goals Through AQP and Risk Management John Ross CEO OK3 Group Inc. The Spectrum Group Civil Aviation Team Associate

Regulatory Landscape

FAA Airline

Objective: Public Safety

Objective: Serve customer

Protection Production

Surveillance

AuditsApprovals

…from a quality control approach…

Page 7: 17-MAR-2010 Meeting SMS Goals Through AQP and Risk Management John Ross CEO OK3 Group Inc. The Spectrum Group Civil Aviation Team Associate

Regulatory Landscape

…to a systems approach…

Page 8: 17-MAR-2010 Meeting SMS Goals Through AQP and Risk Management John Ross CEO OK3 Group Inc. The Spectrum Group Civil Aviation Team Associate

Regulatory Landscape

FAA Airline

Objective: Public Safety

Objective: Serve customer

Protection

Surveillance

AuditsApprovals

Production

…to a systems approach…

Page 9: 17-MAR-2010 Meeting SMS Goals Through AQP and Risk Management John Ross CEO OK3 Group Inc. The Spectrum Group Civil Aviation Team Associate

Regulatory Landscape

FAA Safety Management

System Airline

Objective: Public Safety

Objective: Serve customer

Protection

Surveillance

AuditsApprovals

Production

…to a systems approach…

Page 10: 17-MAR-2010 Meeting SMS Goals Through AQP and Risk Management John Ross CEO OK3 Group Inc. The Spectrum Group Civil Aviation Team Associate

Regulatory Landscape

FAA Safety Management

System

Airline Operating System• Flight Ops• OCC / Dispatch• Maint & Insp• Cabin Safety• Gnd Handling• Cargo Handling• Training

Objective: Public Safety

Objective: Serve customer

Protection

Surveillance

AuditsApprovals

Production

…to a systems approach…

Page 11: 17-MAR-2010 Meeting SMS Goals Through AQP and Risk Management John Ross CEO OK3 Group Inc. The Spectrum Group Civil Aviation Team Associate

Regulatory Landscape

FAA Safety Management

System

Airline Operating System• Flight Ops• OCC / Dispatch• Maint & Insp• Cabin Safety• Gnd Handling• Cargo Handling• Training

Objective: Public Safety

Objective: Serve customer

Protection

Airline Safety Management

System

Surveillance

AuditsApprovals

Production

…to a systems approach…

Page 12: 17-MAR-2010 Meeting SMS Goals Through AQP and Risk Management John Ross CEO OK3 Group Inc. The Spectrum Group Civil Aviation Team Associate

Regulatory Landscape

FAA Safety Management

System

Airline Operating System• Flight Ops• OCC / Dispatch• Maint & Insp• Cabin Safety• Gnd Handling• Cargo Handling• Training

Objective: Public Safety

Objective: Serve customer

Protection

Airline Safety Management

System

Surveillance

AuditsApprovals

Safety AssuranceRisk ManagementSafety Promotion

Production

…to a systems approach…

Page 13: 17-MAR-2010 Meeting SMS Goals Through AQP and Risk Management John Ross CEO OK3 Group Inc. The Spectrum Group Civil Aviation Team Associate

Regulatory Landscape

FAA Safety Management

System

Airline Operating System• Flight Ops• OCC / Dispatch• Maint & Insp• Cabin Safety• Gnd Handling• Cargo Handling• Training

Objective: Public Safety

Objective: Serve customer

Protection

Airline Safety Management

System

Surveillance

AuditsApprovals

Safety AssuranceRisk ManagementSafety Promotion

AuditsApprovals

Production

…to a systems approach…

Page 14: 17-MAR-2010 Meeting SMS Goals Through AQP and Risk Management John Ross CEO OK3 Group Inc. The Spectrum Group Civil Aviation Team Associate

Regulatory Landscape(FAA SMS Model)

FAA Safety Management

System

Airline Operating System• Flight Ops• OCC / Dispatch• Maint & Insp• Cabin Safety• Gnd Handling• Cargo Handling• Training

Objective: Public Safety

Objective: Serve customer

Protection

Airline Safety Management

System

Surveillance (sampling)

AuditsApprovals

Safety AssuranceRisk ManagementSafety Promotion

Production

…to a systems approach…

Page 15: 17-MAR-2010 Meeting SMS Goals Through AQP and Risk Management John Ross CEO OK3 Group Inc. The Spectrum Group Civil Aviation Team Associate

SMS Mandate

Task analysis for operational personnel and training personnel is required

Training as a safety risk control will be documented, measured and continuously monitored

Training as a preventive or corrective action will be documented, measured and continuously monitored

Training processes will be audited internally Training processes will be audited externally

Source: AFS-230, WATS, 4-09

Page 16: 17-MAR-2010 Meeting SMS Goals Through AQP and Risk Management John Ross CEO OK3 Group Inc. The Spectrum Group Civil Aviation Team Associate

Now, How Does AQP Work? Employs a systems approach to training Builds Technical Skills

Trains maneuvers to required proficiency Builds Risk Management Skills

Crews train and check in realistic scenarios Collects and analyzes de-identified training data to monitor

and improve the AQP De-identified data monitors and improves the system Identified data monitors and improves the individual and the

instructors

Page 17: 17-MAR-2010 Meeting SMS Goals Through AQP and Risk Management John Ross CEO OK3 Group Inc. The Spectrum Group Civil Aviation Team Associate

Benefits of AQP

More Efficient Training content based upon actual needs identified by data

collection and analysis More Realistic and Responsive

Emphasizes risk management from a human factors perspective Scenario driven, flexible curriculum; uses airline’s SOP’s Facilitative briefing & debriefing

Enhanced Training Quality Standardized training, from bottom up—good procedures are easier

to standardize, I/E CQT and IRR lead to standardization, and standardization becomes the expectation on the line

Page 18: 17-MAR-2010 Meeting SMS Goals Through AQP and Risk Management John Ross CEO OK3 Group Inc. The Spectrum Group Civil Aviation Team Associate

AQP Data Analysis

Page 19: 17-MAR-2010 Meeting SMS Goals Through AQP and Risk Management John Ross CEO OK3 Group Inc. The Spectrum Group Civil Aviation Team Associate

AQP Data Analysis

Page 20: 17-MAR-2010 Meeting SMS Goals Through AQP and Risk Management John Ross CEO OK3 Group Inc. The Spectrum Group Civil Aviation Team Associate

AQP Data Analysis

Training Performance Data

InvestigateEvaluate

MonitorAudit

Page 21: 17-MAR-2010 Meeting SMS Goals Through AQP and Risk Management John Ross CEO OK3 Group Inc. The Spectrum Group Civil Aviation Team Associate

AQP Data Analysis

FAA AFS-230

Training Performance Data

InvestigateEvaluate

MonitorAudit

Monthly Data Submissions

Page 22: 17-MAR-2010 Meeting SMS Goals Through AQP and Risk Management John Ross CEO OK3 Group Inc. The Spectrum Group Civil Aviation Team Associate

AQP Data Analysis

Training Performance Data

InvestigateEvaluate

MonitorAudit

Monthly Data Submissions

Annual Report and Review

FAA AFS-230

Page 23: 17-MAR-2010 Meeting SMS Goals Through AQP and Risk Management John Ross CEO OK3 Group Inc. The Spectrum Group Civil Aviation Team Associate

AQP Data AnalysisProtection Production

Training Performance Data

InvestigateEvaluate

MonitorAudit

Monthly Data Submissions

Annual Report and Review

…a systems approach…

FAA AFS-230

Page 24: 17-MAR-2010 Meeting SMS Goals Through AQP and Risk Management John Ross CEO OK3 Group Inc. The Spectrum Group Civil Aviation Team Associate

Comparison - SMS and AQPSMS Model AQP Model

Page 25: 17-MAR-2010 Meeting SMS Goals Through AQP and Risk Management John Ross CEO OK3 Group Inc. The Spectrum Group Civil Aviation Team Associate

Introduce AQP and gain buy-in and acceptance from… Line Pilots and Line Flight Attendants

Begin with straight forward training and evaluation Instructors/ Check Airmen

Begin with basic data collection processes FAA

Make optimum use of existing industry precedents Keep data submissions, updates, reports, etc. “clean” and on time

Leadership Develop a cost-effective program Get it right the first time Continual PROMOTION from executive leadership

Secrets to AQP Success

Page 26: 17-MAR-2010 Meeting SMS Goals Through AQP and Risk Management John Ross CEO OK3 Group Inc. The Spectrum Group Civil Aviation Team Associate

Risk Management Is Integral to the AQP philosophy An outgrowth of AQP’s success resulted in the FAA’s Safety

Management System (SMS) Like AQP, SMS uses data collection, analysis and feedback for

corrections (risk management) to the system Tears down departmental silos creating “One Process, One

Language”! Is the vehicle to be used in creating and maintaining a

Corporation’s Safety Culture Just as it becomes ingrained into corporate culture, it can

actually be carried over into one’s personal life

Page 27: 17-MAR-2010 Meeting SMS Goals Through AQP and Risk Management John Ross CEO OK3 Group Inc. The Spectrum Group Civil Aviation Team Associate

ABC’S for Decision Making

• Analyze the task/situation• Build Barriers to minimize risk In Risk Management, Barriers are GOOD! They PREVENT, TRAP and MITIGATE errors!• Communicate Risks and Intentions• Sense - Does this decision really make sense!

With the ABC’S, you have an easy to remember, simple to use model to aid in the decision making process,

especially during TIME CRITICAL situations

ABC’S

Page 28: 17-MAR-2010 Meeting SMS Goals Through AQP and Risk Management John Ross CEO OK3 Group Inc. The Spectrum Group Civil Aviation Team Associate

A Analyze the Situation

How is my Situational Awareness? Am I in the Green, Yellow, or Red?

What “Barriers” can I build that can keep me or get me back “In The Green”

Page 29: 17-MAR-2010 Meeting SMS Goals Through AQP and Risk Management John Ross CEO OK3 Group Inc. The Spectrum Group Civil Aviation Team Associate

B Build Barriers

Policies and Procedures

Flows and Checklists

Briefings and External Resources

Automation

Flying Skills , Knowledge, Techniques, and Experience

Barriers provide DEFENSES against ERRORS, and most importantly, CONSEQUENTIAL ERRORS! For Pilots, 5 Main Areas

Page 30: 17-MAR-2010 Meeting SMS Goals Through AQP and Risk Management John Ross CEO OK3 Group Inc. The Spectrum Group Civil Aviation Team Associate

C Communicate

Communicate RISKS and INTENTIONS

Remember……Aviate, Navigate, then Communicate

Communicate CLEARLY, realizing that in stressful situations, hearing patterns change and communication patterns MUST change

Page 31: 17-MAR-2010 Meeting SMS Goals Through AQP and Risk Management John Ross CEO OK3 Group Inc. The Spectrum Group Civil Aviation Team Associate

S Does this Decision Make Sense?

If it does, then:

Do It

Continue to analyze the results of the decision, and do ABC again, if necessary

Debrief the results 90% of all learning occurs when events are de-briefed properly!

Page 32: 17-MAR-2010 Meeting SMS Goals Through AQP and Risk Management John Ross CEO OK3 Group Inc. The Spectrum Group Civil Aviation Team Associate

How About “LUCK”?

AccidentIncidentViolation

Error

LUCK!

LUCK!LUCK!

Without a Risk Management Process….. your luck will eventually run out!!

Page 33: 17-MAR-2010 Meeting SMS Goals Through AQP and Risk Management John Ross CEO OK3 Group Inc. The Spectrum Group Civil Aviation Team Associate

Analyzing the Colgan Accident

Sterile cockpit, crew rest, fatigue, training issues

Checklist deficiencies or untimely use

Non existent monitoring of automation, stick pusher recognition, stall horn

Insufficient or poorly timed briefings. Poor monitoring skills

Uncommanded flap retraction, poor stall recognition and recovery

Policies, andProcedures,

Flows and Checklists

Briefings and Ext Resources

Automation

Knowledge, Skills, Techniques, and Experience

Flows and Checklists

Page 34: 17-MAR-2010 Meeting SMS Goals Through AQP and Risk Management John Ross CEO OK3 Group Inc. The Spectrum Group Civil Aviation Team Associate

No Processes, No Luck!

Hazards

Threats

MAJOR ACCIDENT! MAJOR FATALITIES!

ErrorsErrors

ErrorsErrors

Page 35: 17-MAR-2010 Meeting SMS Goals Through AQP and Risk Management John Ross CEO OK3 Group Inc. The Spectrum Group Civil Aviation Team Associate

Building a Corporate Safety Culture Using the OK3 Group Model

• Adapt the model’s barriers SPECIFIC to each department

Page 36: 17-MAR-2010 Meeting SMS Goals Through AQP and Risk Management John Ross CEO OK3 Group Inc. The Spectrum Group Civil Aviation Team Associate

Build Barriers for Inflight

Policies and Procedures (FAM)

Flows/Checklists (Quick Reference Handbook ?)

Briefings and Teamwork

Preflight Equipment Checks

Skills , Knowledge, and Experience

Barriers provide DEFENSES against ERRORS, and most importantly, CONSEQUENTIAL ERRORS! For Flight Attendants, 5 Possible Categories

Page 37: 17-MAR-2010 Meeting SMS Goals Through AQP and Risk Management John Ross CEO OK3 Group Inc. The Spectrum Group Civil Aviation Team Associate

• Adapt the model’s barriers

• Risk Management Training

• AQP Model Training System

Building a Corporate Safety Culture Using the OK3 Group Model

Page 38: 17-MAR-2010 Meeting SMS Goals Through AQP and Risk Management John Ross CEO OK3 Group Inc. The Spectrum Group Civil Aviation Team Associate

• Adapt the model’s barriers

• Risk Management Training

• AQP Model Training System

• Training and Operations SMS

Building a Corporate Safety Culture Using the OK3 Group Model

Page 39: 17-MAR-2010 Meeting SMS Goals Through AQP and Risk Management John Ross CEO OK3 Group Inc. The Spectrum Group Civil Aviation Team Associate

End result?

• Adapt the model’s barriers

• Risk Management Training

• AQP Model Training System

• Training and Operations SMS

Building a Corporate Safety Culture Using the OK3 Group Model

Page 40: 17-MAR-2010 Meeting SMS Goals Through AQP and Risk Management John Ross CEO OK3 Group Inc. The Spectrum Group Civil Aviation Team Associate

End result?

“One Process, One Language”

• Adapt the model’s barriers

• Risk Management Training

• AQP Model Training System

• Training and Operations SMS

Building a Corporate Safety Culture Using the OK3 Group Model

Page 41: 17-MAR-2010 Meeting SMS Goals Through AQP and Risk Management John Ross CEO OK3 Group Inc. The Spectrum Group Civil Aviation Team Associate

The OK3 Group Risk Management Model:The Foundation for “One Process, One Language”

Page 42: 17-MAR-2010 Meeting SMS Goals Through AQP and Risk Management John Ross CEO OK3 Group Inc. The Spectrum Group Civil Aviation Team Associate

Thank you for your attention!

[email protected]

Questions?