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

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

Risk Management and Integrated Processes

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:

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


…from a quality control approach…


FAA Airline

Objective: Public Safety

Objective: Serve customer

Protection Production

Surveillance

AuditsApprovals

…from a quality control approach…


…to a systems approach…


FAA Airline



Protection

Surveillance

AuditsApprovals

Production



FAA Safety Management

System Airline



Protection

Surveillance

AuditsApprovals

Production




System

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



Protection

Surveillance

AuditsApprovals

Production




System




Protection

Airline Safety Management

System

Surveillance

AuditsApprovals

Production




System




Protection


System

Surveillance

AuditsApprovals

Safety AssuranceRisk ManagementSafety Promotion

Production




System




Protection


System

Surveillance

AuditsApprovals


AuditsApprovals

Production


Regulatory Landscape(FAA SMS Model)


System




Protection


System

Surveillance (sampling)

AuditsApprovals


Production


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

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

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

AQP Data Analysis

AQP Data Analysis

AQP Data Analysis

Training Performance Data

InvestigateEvaluate

MonitorAudit

AQP Data Analysis

FAA AFS-230


InvestigateEvaluate

MonitorAudit

Monthly Data Submissions

AQP Data Analysis


InvestigateEvaluate

MonitorAudit


Annual Report and Review

FAA AFS-230

AQP Data AnalysisProtection Production


InvestigateEvaluate

MonitorAudit


Annual Report and Review

…a systems approach…

FAA AFS-230

Comparison - SMS and AQPSMS Model AQP Model

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

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

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

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”

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

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

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!

How About “LUCK”?

AccidentIncidentViolation

Error

LUCK!

LUCK!LUCK!

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

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,


Briefings and Ext Resources

Automation

Knowledge, Skills, Techniques, and Experience


No Processes, No Luck!

Hazards

Threats

MAJOR ACCIDENT! MAJOR FATALITIES!

ErrorsErrors

ErrorsErrors

Building a Corporate Safety Culture Using the OK3 Group Model

• Adapt the model’s barriers SPECIFIC to each department

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

• Adapt the model’s barriers

• Risk Management Training

• AQP Model Training System





• Training and Operations SMS


End result?






End result?

“One Process, One Language”






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

Thank you for your attention!

[email protected]

Questions?

Documents

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