Manual of Air Safety - Spanglefishs3.spanglefish.com/s/22631/documents/safety-specifications/maa-mas...Manual of Air Safety ... ASMS that form part of the DAEMS Project are: ... Adjust

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Manual of Air Safety

MAS Issue 3 - Aug 13 Page 1 of 42

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►REFERENCE◄

►All users of this document are recommended to refer to the Foreword within MAA01-MAA Regulatory Policy◄

Table of Contents

Table of Figures ....................................................................................................................... 4 Chapter 1: INTRODUCTION................................................................................................ 5 REGULATORY CROSS-REFERENCE ................................................................................... 5

Purpose................................................................................................................................. 5 Authority ................................................................................................................................ 5 MAA Policy............................................................................................................................ 5

BACKGROUND ....................................................................................................................... 5 ASMS IMPLEMENTATION...................................................................................................... 6 STRUCTURE OF ASMS.......................................................................................................... 6 Chapter 2: ASMS REQUIREMENTS ................................................................................... 7 REGULATORY CROSS-REFERENCES................................................................................. 7 SECTION 1 - POLICY.............................................................................................................. 7

Introduction ........................................................................................................................... 7 POLICY REQUIREMENTS...................................................................................................... 9 POLICY - CONTEXT ............................................................................................................. 10

Safety Priority and Objective............................................................................................... 10 Scope .................................................................................................................................. 10 ASMS Documentation......................................................................................................... 10 Aviation Documentation ...................................................................................................... 11

SECTION 2 - ORGANIZATION ............................................................................................. 12 Introduction ......................................................................................................................... 12

ORGANIZATION REQUIREMENTS...................................................................................... 12 ORGANIZATION - CONTEXT ............................................................................................... 13

Responsibilities and Organization....................................................................................... 13 Separation and Independence ............................................................................................ 13 Competencies ..................................................................................................................... 14 Training and Education ....................................................................................................... 14 Defined Interfaces with Adjacent ASMS – Including Suppliers and Contracted Services... 14

SECTION 3 – SAFETY MANAGEMENT ACTIVITIES........................................................... 15 Introduction ......................................................................................................................... 15

SAFETY MANAGEMENT ACTIVITIES REQUIRMENTS ...................................................... 16 SAFETY MANAGEMENT ACTIVITIES - CONTEXT ............................................................. 17

Assurance Programmes...................................................................................................... 17 Risk Management Programme ........................................................................................... 17

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Management of Change ......................................................................................................18 Reporting and Investigation of Occurrences........................................................................18 Communication ....................................................................................................................19 Emergency Arrangements ...................................................................................................19

SECTION 4- SAFETY PERFORMANCE................................................................................20 Introduction ..........................................................................................................................20

SAFETY PERFORMANCE REQUIREMENTS.......................................................................20 SAFETY PERFORMANCE - CONTEXT ................................................................................20

Safety Targets......................................................................................................................20 Retention of Data .................................................................................................................20 Evaluation and Feedback of Data........................................................................................21 System Review ....................................................................................................................22

CHAPTER 2 - ANNEX A: SAFETY TARGETS - GUIDANCE ................................................23 SMART Targets ...................................................................................................................23 Performance Targets ...........................................................................................................23 Risk Based Targets..............................................................................................................24

Chapter 3: AIR SAFETY CULTURE ...................................................................................25 AIR SAFETY CULTURE – BACKGROUND ...........................................................................25

What Is Culture? ..................................................................................................................25 What Is Air Safety Culture?..................................................................................................25

MANAGING A JUST CULTURE.............................................................................................27 Safety Culture and Error Management ................................................................................28 Determining Culpability ........................................................................................................28 Just Culture Policies, Processes and Models ......................................................................28

CHAPTER 3 - ANNEX A: AIR SAFETY CULTURE FRAMEWORK......................................30 CHAPTER 3 - ANNEX B: DEFENCE AVIATION JUST CULTURE AND ERROR MANAGEMENT POLICY STATEMENT.................................................................................33 CHAPTER 3 - APPENDIX1 TO ANNEX B: DEFENCE AVIATION JUST CULTURE – BELIEFS AND DUTIES ..........................................................................................................34

Beliefs ..................................................................................................................................34 Duties...................................................................................................................................34

CHAPTER 3 - ANNEX C: ERROR INVESTIGATION PROCESS AND USE OF DA FAiR ....35 CHAPTER 3 - APPENDIX 1 TO ANNEX C: DAEMS ERROR INVESTIGATION MANAGEMENT PROCESS ...................................................................................................39 CHAPTER 3 – APPENDIX 2 TO ANNEX C: JUST CULTURE CULPABILITY MODEL – DEFENCE AVIATION FLOWCHART ANALYSIS OF INVESTIGATION RESULTS (DA FAiR)40



TABLE OF FIGURES

Figure 1 ASMS Key Elements ................................................................................................. 6 Figure 2 Examples of types of performance targets .............................................................. 24 Figure 3 Components of an Engaged Air Safety Culture....................................................... 26 Figure 4 Behaviours and Interventions .................................................................................. 38 Figure 5 DAEMS Error Investigation Management Process.................................................. 39 Figure 6 Just Culture Culpability Model – Defence Aviation Flowchart Analysis of Investigation Results (DA FAiR) (Part 1) ............................................................................... 40 Figure 7 Just Culture Culpability Model – Defence Aviation Flowchart Analysis of Investigation Results (DA FAiR) (Part 2) ............................................................................... 41




Chapter 1: INTRODUCTION

REGULATORY CROSS-REFERENCE

1. This chapter supports and must be read in conjunction with the following:

RA1200 – Defence Air Safety Management.

Purpose

2. To detail the Military Aviation Authority (MAA) Air Safety Management System (ASMS) requirements, against which the MAA will seek assurance. Requirements are based upon the top-level ASMS requirements, but encompass the totality of the MRP.

3. RA1200 covers:

a. Policy.

b. Organization.

c. Safety Management Activities.

d. Safety Performance.

4. These elements are described, as an expansion of the AMC, in Chapter 2.

Authority

5. The Secretary of State (SofS) for Defence requires the MAA to assure appropriate standards are met in the delivery of military Air Safety through independent end-to-end assurance process. Full detail of the MAA authority is contained in the MAA01.

MAA Policy

6. The MAA requires Aviation Duty Holders to establish, maintain and assure an effective, auditable ASMS that is consistent with the requirements in RA1200, (Air Safety Management). The Aviation Duty Holder (DH) construct is the vehicle to draw together the totality of Air Safety. Organizations providing support to Aviation DHs will be DH ‘facing’ ie they provide the required Air Safety input to the Duty Holder. Aviation DH facing organizations will, therefore, require Air Safety management arrangements to interface with their respective DHs and be part of the MAA’s DH assurance process.

BACKGROUND

7. Safety management ensures a systematic, explicit, pro-active and auditable approach to the management of Air Safety risks to achieve a level of safety where such risks are reduced at least tolerable and As Low As Reasonably Practicable (ALARP). An effective ASMS provides a means of achieving enhanced safety performance that meets or exceeds the basic requirements associated with safety and quality. The Defence Aviation Error Management System (DAEMS) Project aims to improve elements of safety management across Defence aviation, with the aim of exploiting near-miss events1. Elements within the ASMS that form part of the DAEMS Project are: an understanding of human factors; a standardized and embedded just culture; occurrence reporting of near-miss events;

1 Events that did not cause an incident or accident at the time, but might do if repeated in the future.


MAS UNCONTROLLED COPY WHEN PRINTED investigation of near-miss events; and learning lessons from near-miss events. Requirements for these elements are stated in Chapter 2 with guidance in Chapter 3 (►Air Safety◄ Culture), RA1440 (Human Factors), RA1410 (Occurrence Reporting) and RA1420 (Investigation).

ASMS IMPLEMENTATION

8. RA1200 identifies the minimum key requirements2 to be met within an ASMS, however, in common with all other SMS regulation, these are not prescriptive. This provides flexibility in how the principles can be delivered across the complexity and diversity of Defence Aviation organizations, enabling existing processes and practice to be exploited. By mapping and reviewing current safety management arrangements, including regulation, addressing gaps and aligning effort, efficiencies may be made that compensate for any additional resource required to achieve an effective ASMS.

STRUCTURE OF ASMS

9. The fundamental elements and requirements of the management framework and associated activities of an SMS are consistent regardless of which industry they are applied to; any apparent differences are simply due to different approaches in packaging. The MAA ASMS requirements are divided across the 4 key elements of the model of continuous improvement3 (Fig1) and expanded on in Chapter 2, where each element and associated requirements are grouped and contextual guidance given. Where an ASMS requirement is met and specified pan-defence through the MRP (eg Occurrence Reporting), this is referenced.

Policy

Organization

Safety Management Activities

Safety Performance

Continuous

Improvement Loop

PlanAdjust

Review Act

Figure 1 ASMS Key Elements

2 Derived from analysis of emerging requirements (ICAO, EASA and Eurocontrol) and good practice; reviewed regularly. 3 The ‘plan, act, review and adjust’ model at fig 1 is synonymous with Deming’s ‘plan, do check, act’ model of continuous feedback.



Chapter 2: ASMS REQUIREMENTS

REGULATORY CROSS-REFERENCES

1. This chapter supports and must be read in conjunction with the following:

RA1020 - Roles and Responsibilities: Duty Holder.

RA1200 - Defence Air Safety Management.

►RA1205 - Air System Safety Case◄

RA1210 - Management of Operating Risk (Risk to Life).

RA1410 - Occurrence Reporting.

RA1420 - Service Inquiries (SI) – Convening Authority (CA).

RA1430 - Aircraft Accident Response & Post Crash Management.

RA2335 - Flying Displays and Special Events.

SECTION 1 - POLICY

Introduction

2. The Safety Management (SM) policy defines the fundamental approach that an organization will adopt for managing Air Safety4 and sets the tone of the safety culture of the organization from the top. It is essential that the safety policy has the full, active and sustained support at the highest level of an organization and clearly sets out its Air Safety aspirations and intentions.

3. Safety policy for Defence Aviation is set by the MAA, encompassing the SofS’s objectives of continuous improvement and recognizing the balance of safety against operational capability by reducing risks to life (RtL) to at least tolerable and ALARP. This policy is promulgated in RA1200 and must be reflected in subordinate ASMS.

4. The Aviation DH is legally accountable for the safe operation of systems in their area of responsibility (AoR) and for ensuring that RtL are reduced to at least tolerable and ALARP. Aviation DH must establish and maintain an effective ASMS that will, wherever possible, exploit the MOD’s existing aviation regulatory structures, publications, and management practices whilst satisfying RA1200. Responsibility for developing the ASMS policy, providing Air Safety assurance5 to the DH and managing the ASMS framework will be delegated to an individual within the organization who has a degree of separation from the delivery6 of operational capability such that their advice and guidance is not unduly influenced by operational pressures. This individual is termed the ‘safety manager’ for the purpose of this manual. Personnel assigned to this role, are expected to sit at a senior management level commensurate with the size and complexity of the organization. Responsibility for meeting the safety objectives is clearly a command chain function.


4 Note that a holistic SMS policy may have been adopted by some organizations, encompassing all H&S and functional safety areas, of which Aviation is a sub-set. In this case, the ASMS would ‘plug into’ the overarching SMS. 5 ‘Adequate confidence and evidence, through due process, that safety (and environment [where applicable]) requirements have been met.’ - JSP 815 Annex B Glossary; MAA 02 –MAA Master Glossary. The ASMS needs to provide assurance internally to the Duty Holder and externally to MAA. 6 Often termed ‘ensurance’ in the wider MOD SMS.



5. The following table sets out the ASMS policy requirements:



POLICY REQUIREMENTS

Ref ASMS Policy Requirements Note: Where and RA prescribes elements of the ASMS the RA contains the definitive requirement and should be read in conjunction with this Manual

P1a a. Safety Priority. The priority afforded to safety must be clear and take into account the balance to be struck with respect to delivery of operational capability through the ALARP principle.

(1) Aviation DHs are personally accountable for their responsibilities and must, therefore, ultimately determine for themselves the level of AS risk they are willing to accept.

(2) Aviation DHs are bound to reduce the risk to life (RtL) within their Area of Responsibility (AoR) to both Tolerable and ALARP.

P1b

Safety Objective

b. Safety Objectives. The safety objective must be clear and consistent with both the MAA and DESB policy of continuous improvement.

P2 Scope The scope of the ASMS must be defined.

P3a a. General. Aviation DHs should establish and maintain an effective, documented ASMS that will, wherever possible, exploit the MOD’s existing aviation regulatory structures, publications, and management practices in order to demonstrate an acceptable means of compliance with RA1200 and this publication, and has review and amendment procedures. An ASMS description, processes and procedures must be documented and recorded in a Safety Management Plan (SMP).

Within this system the following criteria must be met:

P3b b. Duty Holders, Commanders and Accountable Managers Commitment. The commitment of the command chain to the ASMS must be clearly articulated.

P3c c. Positive ►Air◄ Safety Culture. The policy must foster and support a positive safety culture. ►◄(see Chapter 3).

P3d

ASMS Documentation

d. Risk Management. Formal Air Safety Risk Management must form an integral component of an Aviation DH’s documented ASMS.

P4 Aviation Documentation

Defence Aviation organizations must have documented policy and procedures for the safe control of aviation activities (as are contained within the MRP, Aviation Duty Holder’s and Commanders Order’s, AESIs, AESOs and Aircraft Document Set (ADS)). These will include formal acceptance, handover/takeover and management of an air system’s safety case, hazard log and risk register.

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POLICY - CONTEXT

Safety Priority and Objective

6. The priority that the Aviation DH assigns to safety and the safety objectives of the organization must be explicit and as a minimum include:

a. Safety Priority. Due to the unique operating capability requirements of Defence Aviation, safety cannot always be the “highest” priority. Defence Aviation organizations must be prepared to justify the balance attained under the ALARP principle on demand. Guidance on risk management and the ALARP principle is in RA1210.

b. Objective(s). The organization must state what the ASMS is trying to achieve and must be cognisant of all constraints. The ASMS construct will deliver this aim. Ultimately, safety performance must be measured against safety targets that have been derived from the safety objective(s). Safety Performance guidance at Section 4 to this chapter provides more detail.

Scope

7. The ASMS scope must be clearly identified. Those working within the ASMS and those outside it and/or interfacing with it need to know how the ASMS affects them. Guidance on boundaries and interface management with other ASMS is at Section 2 to this chapter, Organization. The scope may be best presented in diagrammatic form and must identify all boundary ASMS and the interfaces between them. It is important that the authority of the ASMS for those within scope is made clear; this may be captured in the ‘Command Commitment’ safety statement, which provides a vehicle to cover the scope and/or reinforce the authority of the ASMS.

ASMS Documentation

8. A documented, auditable system that describes how an organization meets the ASMS requirements is essential if all personnel and external agencies must understand the ASMS and their role within it. An ASMS description, processes and procedures must be documented and recorded in a safety management publication, often termed the Air Safety Management Plan (ASMP). The key is to include information common to the whole organization; detailed local procedures in other documents will be cross-referenced from this central ASMS document, not included verbatim. Subordinate local ASMPs may be appropriate for larger, more complex organizations. Whilst the ASMP will reference the totality of this Chapter, within the documentation, the following underpinning criteria must be addressed:

a. Duty Holders, Commanders and Accountable Managers Commitment. The policy documentation needs to make clear the command intent and the importance of the ASMS to the achievement and maintenance of operational capability. The Duty Holders, Commanders and Accountable Managers will demonstrate endorsement of the policy by means of a prominent signed safety statement that is reviewed frequently, as part of the policy documentation, highlighting the importance of Air Safety and its priority; this is crucial to promote and sustain the desired safety culture. Adequate resourcing and appropriate empowerment of the Safety Manager and all associated support are essential as physical and visible manifestations of the highest level of command/management commitment to Air Safety.

b. Positive ►Air◄Safety Culture. ►Material relating to Air Safety Culture can be found within Chapter 3◄



Aviation Documentation

9. Documentation forms a vital part of an ASMS, in order to ensure the safe control of aviation activities. Aside from the specific ASMS Documentation required at para 4 above, Aviation Duty Holders, Commanders and Accountable Managers must ensure the creation and control of documents to detail policy and procedures for the safe control of aviation activities. Such documents include: Aviation Duty Holders, Commanders Orders, Accountable Managers AESIs and AESOs, platform specific safety cases, hazard logs and the Aircraft Document Set (ADS); all must be managed to ensure that they appropriately detail standards and practices to be followed. Documents must be maintained and held for periods laid down within appropriate orders and company polices. Document interfaces must be identified, documented and managed. A clear and concise auditable document trail is a key piece of safety evidence underpinning and supporting a robust safety case.



SECTION 2 - ORGANIZATION

Introduction

1. Policy within the ASMS details the safety performance required and sets conditions for the safety culture. In order to achieve these aims, organizational arrangements must be defined to meet these requirements, setting the management process and the roles and responsibilities of staff working within the ASMS. It is important to note that whilst ASMS implementation undoubtedly requires careful resourcing, a gap analysis approach to set-up will quickly identify that many existing management practices can be aligned to deliver within the ASMS.

2. In line with JSP 815 and the wider MOD SMS, the organization of an ASMS may be considered as 2 parts: those responsible for assurance7 regarding implementation, maintenance and oversight of the ASMS framework and output; and, those responsible for the delivery8 of acceptably safe aviation activity, who will be staff at all levels involved in aviation related activities and applying the ASMS processes (operators, producers, supervisors, commanders, senior management etc). Separation9 of these 2 safety strands provides a visible ‘self-policing’ mechanism to enable balancing of the operational imperative and funding priorities against the organization’s safety risk appetite.

3. The following table describes the ASMS Organizational Requirements:

ORGANIZATION REQUIREMENTS

Ref ASMS Organization Requirements Note: Where and RA prescribes elements of the ASMS the RA contains the definitive requirement and should be read in conjunction with this Manual

O1

Responsibilities and Organization

General. The ASMS documentation must detail a defined safety organizational structure that covers the authorities, responsibilities and accountabilities for safety at appropriate levels within the organization in order to deliver appropriate governance arrangements and an appropriate level of strategic Air Safety oversight and assurance to the Aviation DH. This must include the identification of the SDH, ODH and DDHs along with their respective senior operators (SO) and chief air engineers (CAE), including their specific responsibilities and authorities.

Within the ASMS, the responsibilities detailed within MAA 01 and RA 1020, must be imparted to the SDH, ODH, DDH, SO and CAE roles.

O2 Separation and Independence

The safety management organization must demonstrate a level of separation such that its activities are not unreasonably constrained by operational or commercial pressures.

7 ‘Adequate confidence and evidence, through due process, that safety (and environment [where applicable]) requirements have been met.’ – JPS 815 Annex B Glossary. 8 Across the wider MOD SMS, other terms used may include ‘Ensurance’ and ‘Implementation’; all denote the same meaning.


9 Within industry, the term ‘independence’ is used; within the MoD true independence cannot be achieved so the term separation is used.

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Ref ASMS Organization Requirements Note: Where and RA prescribes elements of the ASMS the RA contains the definitive requirement and should be read in conjunction with this Manual

O3 Competencies Personnel engaged in aviation activities must be suitably qualified, trained and experienced. Appropriate competencies must be set for safety related jobs.

DH competencies are set out in RA1020.

O4a a. Appropriate safety awareness training and education must be in place for Management and Staff.

O4b

Training and Education

b. Completion of the biannual DH Air Safety Course (DHASC) is be mandatory for ODHs and DDHs, and it is desirable for them to have undertaken Regulator Accredited Trg in Aircraft Operations & Airspace Rules and Procedures.

O5 Defined Interfaces with adjacent ASMS

Boundaries. Arrangements for all boundaries/interfaces with higher, same-level and lower-level SMSs must be detailed.

O6 Suppliers and Contracted Services

The ASMS arrangements must ensure adequate and satisfactory arrangements for the safety of contracted services.

ORGANIZATION - CONTEXT Responsibilities and Organization 4. Defence Aviation requires specific roles to have defined Air Safety responsibilities. Key amongst these are Aviation DHs and their named senior operators and chief engineers; these roles are regulated in RA 1020. Other specific roles include station/unit level roles such as Flight Safety and Foreign Object Debris (FOD) Prevention Officers. However, more general roles such as commanding officers, authorizing officers, engineering officers, air traffic controllers and aircraft captains also have Air Safety responsibilities set out in the MRP. Local arrangements that provide the framework of individual ASMS will vary according to the role of the organization and/or its size. Where a larger organization sets up an overarching ASMS, top-level documentation will detail roles and responsibilities down to an appropriate level and subordinate Systems or Plans will document lower levels as required.

5. The ASMS adds value to existing aviation supervision both by and within levels of command, across Defence Aviation through establishing appropriate means to ensure that senior leadership has appropriate strategic oversight of the system to meet their personal, legal responsibilities. RA1020 mandates governance arrangements within the Aviation DH ASMS, reinforces the command commitment and facilitates: risk escalation, trend spotting, assurance and transparency. RA1400 gives further guidance on Air Safety roles such as Aviation Duty Holders and FOD Prevention Officers.

Separation and Independence 6. This principle is about seeking to provide clear water between those responsible for the assurance of Air Safety and those charged with delivering both operational and Air Safety performance. Separation (MoD term) and independence (industry term) reduces the possibility that operational or resource pressure could inappropriately influence Air Safety performance.



Competencies 7. Personnel engaged in aviation activities must be suitably qualified, trained and experienced ie SQEP. Personnel empowered with safety manager, implementation or assurance duties/responsibilities must be suitably trained and/or have appropriate experience. The issue of competencies may be considered in 2 parts.

a. Assurance. Other than for Aviation DHs (see RA1020) general competencies for safety managers have yet to be developed at MOD level.

b. Delivery. Competencies for those engaged in aviation activities are well established already across Defence Aviation and are detailed in the MRP and/or Aviation Duty Holders and Commanders Orders.

Training and Education 8. Personnel must be aware of their Air Safety role as part of an engaged safety culture. Formal safety management and Air Safety related training will be annotated to roles with Air Safety responsibilities to deliver required competencies. 9. All personnel must have appropriate training and experience to be able to undertake their tasks safely. Personnel are also required to understand their duty of care to those that may be affected by their acts or omissions. An essential tool in reducing occurrences and incidents is effective publicity, education and training that generates increased safety awareness and engenders a safety culture. Further detail is in RA1440.

Defined Interfaces with Adjacent ASMS – Including Suppliers and Contracted Services 10. The relevant relationships and links with all other higher, peer and lower level ASMSs, including Aviation DH facing support organizations, will be captured. Internally, the ASMS will consider not only its own safety activities but also those of any Aviation DH facing organizations (for example ATM), supporting suppliers and contractors, some of which may sit out with the Aviation DH direct command chain. The ASMS will detail what requirements, constraints, information and action must be passed between them and how this may be done. It may be useful to represent these relationships diagrammatically. Examples of boundary areas may include, but not limited to, interaction with:

a. The MAA.

b. The organization’s Health and Safety SMS. The Command Environment and Safety Officer (CESO) will advise.

c. Other Aviation DHs (as appropriate).

d. TLB/TFA areas. For example the Front-Line Commands (FLC), and DE&S.

e. Joint Organizations. For example how the ASMS reaches into it, or, does the Joint organization have its own ASMS and how are those boundaries managed?

f. Operations under CDS Directive. The links to PJHQ to meet the Aviation DH’s responsibilities within the nominated operational command chain.

g. Subordinate SMSs (where applicable).

h. Other military and/or civilian suppliers and contracted organizations. This may involve the supplier/contractor being required to adopt, or be consistent with, the organization’s ASMS, or could be as simple as providing required information in a specific format.

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SECTION 3 – SAFETY MANAGEMENT ACTIVITIES

Introduction

1. Safety management activities shape, control and assure more general aviation management activities (such as personnel selection, training, supervision, equipment design and maintenance, the creation and use of procedures), that directly control Air Safety risk. All safety management activities may be considered as one of the following activity types:

a. Monitoring. Monitoring provides the means to maintain regular surveillance of Air Safety and the activities within it. It is achieved through a variety of pro-active means, such as audit, formal risk management and supervision.

b. Review. Historically, these have been retrospective, reactive activities; arrangements made to report, investigate and attempt to learn lessons from past, reportable, safety accidents/incidents/occurrences (see RA1410) coupled with communication mechanisms to disseminate the findings. However, by improving reporting systems, particularly for capturing what may be termed ‘near miss events10’ emerging trends may be targeted through pro-active measures to prevent a more serious event occurring.

c. Change management. All change must be assessed and managed in a proactive and proportionate manner so as to consider the Air Safety risks of a change before change commences. All activities must be documented and recorded in line with ASMS policy.

d. Emergency Arrangements. Emergency arrangements must be put in place to respond to aviation incidents and accidents so that the impact is limited and contained in accordance with RA1410, RA1420 and RA1430. Emergency planning processes and procedures must be scaled accordingly and recorded and documented within the appropriate ASMS Safety Management Plan (SMP).

2. Where extant activities and practices associated with the above areas are deemed appropriate to the ASMS these will be exploited. The ASMS creates one coherent framework enabling the activities to be coordinated efficiently. The way in which all of these activities are carried out can help to promote a positive safety culture; conversely the wrong approach may destroy it. For instance, the implications of inappropriate or excessive punitive action11 on the just culture ethos must be considered; but does not preclude punitive action ever being taken. Clearly there are occasions where such action is appropriate and individuals recognize this. However, punishing ‘honest mistakes’ may prove detrimental to voluntary reporting and prevent trends being identified, stifling an important, pro-active element of SM. Likewise, audits and inspections must be done in a way that encourages reporting of bad practices so that they may be corrected and not hidden.


10 The ASMS will seek to pro-actively capture empirical evidence of those occurrences that could have hazarded aircraft operations or personnel. This approach will be used in the DAEMS Project, (coordinated by MAA). 11 DAEMS will provide a pan-MOD model for the assessment of culpability.



SAFETY MANAGEMENT ACTIVITIES REQUIRMENTS

Ref ASMS Safety Management Activities Requirements Note: Where and RA prescribes elements of the ASMS the RA contains the definitive requirement and should be read in conjunction with this Manual

SMA1 Assurance Programmes

Assurance programmes must be constructed to check that AS related regulations, procedures, standards or principles are being complied with. Audits that are not specifically AS related will be assessed for their relevance in identifying and mitigating AS risks.

SMA2

Risk Management and Risk Registers

All UK military flying operations and support activities must be subject to a DH or DH facing RM programme that must comply with RA 1210 and be approved by the appropriate authority under their ASMS.

SMA3

SMA3a a. Tasking and Personnel Changes. Changes to aviation related tasking, competency requirements, training and organization will be assessed with respect to safety significance prior to their implementation. Organizational change management will be conducted in accordance with JSP 375 Vol 2 Lft 58.

SMA3b b. Regulatory Changes. Changes to aviation related regulation (orders, instructions, procedures, standards etc) will be assessed with respect to safety significance prior to their implementation.

SMA3c c. Equipment Changes. Changes to aviation related equipment must be assessed with respect to safety significance prior to their implementation in accordance with the appropriate document: DME 5000 series (and single service RTSA manuals), JSP 454, JSP 430 and POSMS.

SMA3d

Management of Change

d. Impact on Safety Policy. All relevant changes must be reflected in safety policy.

SMA4 This requirement is broken out into the following 2 criteria:

SMA4a a. Accident/Incident Reporting. Organizations must comply with RA1410, RA1420.

SMA4b b. Reporting. Arrangements will be in place to enable all staff to communicate significant safety concerns to an appropriate level of management for resolution.

SMA4c

Reporting and Investigation of Occurrences

c. Data Analysis and Exploitation. Organizations may have in place appropriate AS data (ASIMS reports and other data) analysis and exploitation to enable AS trends to be spotted and pre-emptive action to be taken as organizations

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Ref ASMS Safety Management Activities Requirements Note: Where and RA prescribes elements of the ASMS the RA contains the definitive requirement and should be read in conjunction with this Manual

seek to identify emerging hazards iaw RA1400.

SMA5 This requirement is broken out into the following 2 criteria (RA 1400):

SMA5a a. Safety Promotion. Arrangements must be in place for the ongoing promotion of Air Safety across the whole organization at all levels.

SMA5b

Communication

b. Lesson Dissemination. Arrangements will be in place to disseminate lessons identified widely within the organization at all levels.

SMA6 Emergency Arrangements

RA1410, RA1420 and RA1430 must be followed.

SAFETY MANAGEMENT ACTIVITIES - CONTEXT

Assurance Programmes

3. Assurance12 activities are targeted at specific areas and many levels, both vertically and horizontally, across Defence Aviation. Activities that are not specifically for the purposes of Air Safety (eg standardization units, QA) can provide assurance that Air Safety related directives, procedures, standards or principles are being complied with and contribute to maintaining controls on Air Safety risks.

4. In addition to the above, specific ASMS assurance activity will be programmed to ensure appropriate application of the requirements of the ASMS and assure its ongoing effectiveness. An example is the FODEval (see RA1400). ASMS audits enable strategic oversight and facilitate the maintenance of risks at an acceptable level. However, there is potential for overlapping activity with non-ASMS specific assurance, which may cause wasted resources for the auditing organization and that being audited. Mapping out all assurance activity in the ASMS documentation is a way to avoid this. The MAA will undertake periodic assurance audits of DH ASMS, and other DH facing organizations as appropriate, as required under RA1200 and monitor selected flying displays as required under RA2335.

Risk Management Programme

5. A formal Risk Management (RM) programme gives the command chain visibility of the risks they are carrying and improves and adds coherence to safety activities so that an organization may be assured that Defence Aviation activities are carried out at an appropriate level of risk.

6. RM. RA1210 provides specific detail on pan-Defence Air Safety risk management.


12 Note that for the purposes of this Manual ‘assurance’ can be gained from any formal assessment of compliance, including activities titled: audits, inspections, evaluations and surveys.



Management of Change

7. The Haddon-Cave Nimrod Review sought better change management across Defence Aviation. Managing change is the process of thinking through the potential unwanted consequences of changes to organization, training, equipment, rules and so on. Change occurs very often and it can be difficult to assess changes in the time allowed. This is another area in which a formal risk management approach may help in practical change assessment.

8. Changes are made to make improvements, reduce costs or meet constraints or objectives. However, changes may introduce new hazards or increase the risk of existing hazards. It is essential that changes scrutinised before implementation to ensure that any safety risks associated with the change meet policy. For change management of equipment and organization, MOD wide policy is contained within DME 5000 series (and JSPs 430 and 454 for maritime and land based equipment) and JSP 375 Vol 2 Lft 58 respectively. Other forms of change are may require review of policy owned by each organization.

9. Formal risk assessment may be used to assess more objectively the risks arising from a change, particularly complex or large changes. Pan-defence policy on Air Safety risk assessment is contained in RA1210.

Reporting and Investigation of Occurrences

10. Most safety programmes will have arrangements for the reporting, investigation and recording of occurrences; Defence Aviation is no exception, particularly with respect to the most severe occurrences, ie. Accidents and serious incidents. Defence Aviation occurrence reporting is mandated across all aviation disciplines (aviation, ATM and engineering), by RA1410.13

11. The SMS seeks to pro-actively capture empirical evidence of those occurrences that could have hazarded aircraft operations or personnel. If accidents represent the tip of an iceberg, it is the ‘could have been’ data that represents the mass below the waterline. Capturing these lower level events will provide data that can be analysed and exploited to enable trends to be spotted and pre-emptive action to be taken as organizations seek to identify emerging hazards and appropriately reduce risks in a cost effective manner. Within Defence Aviation electronic occurrence reporting and open reporting schemes are hosted on the pan–Defence ASIMS as detailed in the RA1410 Aviation Duty Holders and Commanders must promote and encourage reporting to maximise the potential for preventing occurrences through pro-active data analysis and exploitation. The MOD wide introduction of ASIMS has enabled “Hazard Observations” to be reported, which encourages reporting of events that could have caused an occurrence. The next step to enhance reporting and become more pro-active is through the DAEMS Project.

12. Mechanisms will be in place to enable staff to report significant safety concerns directly to senior commanders/managers within the organization. This provides a ‘safety valve’ that enables concerns to be escalated outside the command chain. While this would not be expected to be used routinely within a healthy ASMS, the presence of such mechanisms demonstrates the importance an organization places upon unfettered safety oversight and contributes to the overall tenor of the safety culture. The confidential reporting schemes detailed in RA1410 meet this requirement.

13 DAEMS will provide a pan-MOD Error Management System as it is rolled out.



13. Subject to classification, extant procedures and its particular terms of reference (TOR) the purpose of occurrence investigation is to establish the facts of a particular accident, incident, occurrence or event and make recommendations in order to prevent recurrence. Minor occurrences will generally be investigated locally and more serious occurrences and accidents will almost always be subject to a service inquiry (SI) under the Armed Forces Act 2006 (for guidance on the AFA 2006 and SI regulation 2008 see JSP 832). Comprehensive procedures for aviation occurrence investigation are contained in RA1420.

Communication

14. Safety Promotion and Lesson Dissemination. Many lessons may be identified through the ASMS, however learning the lesson is much harder to achieve. Aviation safety staffs must also ensure there is adequate self-publicity of their own responsibilities and activities. Safety staffs must endeavour to publicise the ASMS, convey safety-critical information, and explain why particular safety actions are taken and why safety procedures are introduced or changed. It is essential that mechanisms are in place within the ASMS for the promotion of safety and the wide dissemination of lessons identified. Information will be gleaned from various sources; the outcome of safety occurrences and human factors open reporting are obvious ones for lessons identified. There may also be scope for initiatives, such as local trend monitoring which may pick up weaknesses that have not yet caused an occurrence. Improvement of this function will be an integral part of the DAEMS Project. This, or indeed any of the monitoring or Review activities, may prompt safety reviews/surveys to target emerging areas of concern. Further guidance is contained in RA1440.

Emergency Arrangements

15. Emergency arrangements have to be put in place to respond to accidents so that the impact is limited and contained. Accident, incident, disaster and post crash management (PCM) plans must be established at all sites where aircraft operations take place on a regular basis. In addition, provision for off base incidents must be made and amplified in specific instructions, such as detachment orders. RA1420 and RA1430 provide for SI CA and PCM respectively.

16. Foreign Object Debris (FOD) Prevention. FOD is defined as any material (including loose articles) that originates from any source, either external to or part of an aircraft, which can cause damage to that aircraft or its equipment. It excludes any damage resulting from bird-strikes, which are the subject of separate and specific formal reporting procedures. FOD presents a significant risk to Air Safety since latent damage caused by foreign objects could cause catastrophic failure at any time. Personal injury, loss of life, damage to or loss of an aircraft through avoidable FOD risk undermines MOD safety principles. Effective precautions and systems must be implemented to prevent and minimise FOD occurrences. Whilst FOD is an inevitable part of aircraft operations, every effort must be made to ensure that all avoidable FOD incidents are prevented. All personnel in the Defence aviation community must proactively take a personal interest in and responsibility for FOD prevention in their areas of responsibility. FOD prevention is an essential element of Flight Safety and must be managed, and given appropriate priority, by Command, Group, Unit and Contractors’ Flight Safety Organizations as described in RA1400.



SECTION 4- SAFETY PERFORMANCE

Introduction

1. This section provides the ‘proof’ that will show that the organizational arrangements and associated activities meet the objectives of the Air Safety policy, allowing the effectiveness of the ASMS to be judged. The documentation required by a formal ASMS will ensure that corporate knowledge is routinely captured.

SAFETY PERFORMANCE REQUIREMENTS

Ref ASMS Safety Performance Requirements Note: Where and RA prescribes elements of the ASMS the RA contains the definitive requirement and should be read in conjunction with this Manual

SP1 Safety Targets Suitable targets will be set that can be linked to the ASMS Policy objectives to show they are being met.

SP2 Retention of Data Record Keeping. Appropriate safety records will be kept to enable safety performance to be analysed, maintain an audit trail and provide appropriate safety assurance to all associated with, and dependent upon, the ASMS and to external authorities for audit purposes.

SP3 This requirement is broken out into the following 2 criteria.

SP3a a. Analysing Safety Performance. Safety performance will be measured regularly against targets and analysed.

SP3b

Evaluation and Feedback of Data

b. Reporting Safety Performance. Safety performance will be reported in a timely manner.

DHs will report performance against Risk Boundaries on a rolling annual basis for all aircraft types in their AoR.

SP4 System (ASMS) Review

Suitable arrangements will be in place to enable review of performance and the system and facilitate improvements.

SAFETY PERFORMANCE - CONTEXT

Safety Targets

2. Safety performance is measured against targets derived from the objective(s) expressed within the ASMS Policy. Depending on the safety policy, safety targets may be expressed in many ways; whichever is used will reflect the legal and societal constraints that the ASMS works within. The notes at Annex A provide some guidance and cover: SMART targets, performance targets and risk based targets.

Retention of Data

3. Record Keeping. Records provide empirical data and traceability that may be used to identify and solve safety problems. There is also significant benefit associated with capturing corporate knowledge, which is of particular value in the Defence environment where personnel move positions on a regular basis. A risk register may be particularly useful for



bringing together key elements and references of the audit trail. Safety records are produced throughout the ASMS; appropriate procedures and formats (eg risk register) will be established at a high enough level to ensure common processes/formats are used to reap the obvious benefits. When creating a policy on record keeping it is essential to understand the constraints from a broad spread of sources:

a. Legal Requirements. The CAA regulates civil aviation through the Air Navigation Order, the requirements of which are amplified by CAA publications. These regulations are not mandatory for Defence Aviation, yet some occurrence reports are used by both military and civil aviation, such as the AIRPROX report. The CAA sets the regulations on the retention of these records.

b. MOD and Government Policy. The retention of records is constrained by departmental and wider Government policy, such as the Freedom of Information Act.

c. Defence Aviation Policy. The occurrence reporting system for Defence Aviation, including the policy for record retention is defined in RA1410.

d. The Usefulness of Records for Trend Analysis. How trend analysis is conducted, and on what occurrences, will dictate how long the records will be kept. This is particularly important for the analysis of safety significant events, which provides a crucial, pro-active means to spot trends at a benign stage, which may indicate an increasing likelihood of an accident in the future.

e. Data Storage. Growing use of electronic data capture and storage, such as Flight Data Monitoring, may be beneficial as it allows greater data storage. However, care must be taken to ensure that the data can be interrogated despite the media readers of that data format becoming obsolete.

Evaluation and Feedback of Data

4. Analysing Safety Performance. The operating context is an important factor in assessing safety performance. A straight comparison between the accident or incident rates of 2 separate years will not enable a proper judgement to be made on safety performance. Considerations include the following:

a. Amount of Activity (eg Flying). Year on year flying rates will be different. Targets set against a representative unit of time, such as flying hours, allow better like for like comparison. In order to provide comparable occurrence information, a rate may be calculated for specific occurrences. A rate may be defined as the number of events divided by the exposure to those events. The most common method is to relate occurrences to flying hours and, since the resultant figure would be very little, the result must be multiplied by 10,000:

Rate = (number of occurrences/flying hours) x 10,000

b. Alternatively, where the occurrence relates to a phase of flight or maintenance, some other measure may be more appropriate. If, for example, landing accidents are being analysed, the number of occurrences per 10,000 landings (and/or rollers) could be calculated. For maintenance occurrences, a useful gauge might be per 10,000 maintenance hours.

c. Type of Activity (eg Flying). Different types of flying bring different levels of risk and how much risk is deemed acceptable will vary according to the need to complete the task (risk appetite). For example, it is reasonable to expect that operational flying



will incur more risk than flying for the purposes of training, with the natural corollary of a higher accident and incident rate over a period of time. Records must distinguish between activities considered higher risk and those of lower risk so that reasonable comparisons can be made.

d. Environment. Notwithstanding the type of flying, risk levels also differ with respect to where aviation is taking place. For example, toleration of risk will be different between the same aircraft flying in Mountainous Terrain verses Open countryside.

e. Timing. Formal analysis will take place at a time relevant to the area of safety performance under consideration and the need to report performance. If analysis takes place randomly, an imprecise picture of performance may result; similarly if analysis takes place too seldom, opportunities may be lost to improve performance.

f. Information sharing. Where appropriate, such information will be shared with other aviation authorities, directly or on request, to assist them in designing occurrence prevention measures of their own.

Note: Clearly the above considerations are biased towards the activity of flying, there is read across to any aviation related activity. ASIMS is available through the MOD Intranet therefore registered users of the System are able to perform their own data analysis. In the first instance advice and/or guidance will be sought from Unit FS Officers, but the MAA Occurrences Branch is also available for assistance if required.

5. Reporting Safety Performance. Safety reports will be produced from the analysis to assure the Aviation DH14 that targets, and therefore policy, are being met. Consequently, what to report, and to whom, will be derived from the policy requirement and relevant targets. As a minimum, the Aviation DH needs assurance that his Policy is effective and being followed; these activities will be captured under Air Safety Management Activities.

System Review

6. It is important to obtain feedback on the system itself so that failings can be identified and/or improvements may be made. Once a system is documented it must be subject to regular review.

Annex A. Safety Targets Guidance.

14 At the highest level of the ASMS there is also a requirement to provide evidence of assurance to the MAA.




CHAPTER 2 - ANNEX A: SAFETY TARGETS - GUIDANCE

SMART Targets

1. Targets will be Specific, Measurable, Achievable, Realistic and Time related (SMART).

a. Specific. Targets will be specific in order to pinpoint what is required. In particular, the targets will enable performance of specific interest to be measured, eg. The safety performance in the UK or safety performance during training etc. See also guidance on operating context for analysing safety performance.

b. Measurable. Targets will be measurable or reporting performance against them may not be representative or objective.

c. Achievable. Attempting to achieve a target that is not achievable will lead to a sense of failure and a possible waste of resources.

d. Realistic. Realistic targets will ensure that only those activities of interest are covered.

e. Time-related. Targets could be restricted within a period of time to enable meaningful data collection and comparison on a like-for-like basis.

Performance Targets

2. Measurement of performance requires targets that adequately define the required level of performance. Performance may be measured relatively or absolutely in conjunction with what is being measured, the output or the processes that produce the output. Combinations of these are illustrated in Figure 2.

a. Absolute and Relative Targets. Absolute targets set a level of performance that is not necessarily related to previous performance; often they are set by a regulator based on a legal requirement, societal concerns or norms, a limitation of resources or as a result of analytical study. Relative targets compare performance against previous performance or the performance of a similar organization. The DESB policy for continuous improvement can be readily built into relative performance targets.

b. Output and Process Targets. The output of an SMS is the rate of accidents or incidents in a period of time – ie. What has happened. Setting targets against the rate of accidents and incidents only, although obvious, has limitations:

(1) Incidents are often under reported and may be a poor indicator of safety performance.

(2) Making improvements to the SMS based on output performance only is reactive.

Process targets attempt to ensure that the conduct of processes known to improve safety performance, such as standardization checks and audits, is satisfactory. The greatest drawback with process targets is that the effect on safety performance in terms of reduced accidents and incidents is neither guaranteed nor predictable.



Figure 2 Examples of types of performance targets

Output Process

Absolute Below 0.2 accidents per 10,000 fg-hrs.

Below 5 Cat A or B attributable airprox/year.

100% of all units audited in 1-year period.

90% of Sqn aircrew combat ready at any time.

All risks identified and reduced ALARP.

Relative Year-on-year reduction in accidents. 10% reduction in airprox in 5 years.

Not normally used, but could include indicators such as the increased uptake of ISO 9000 within contractors.

Risk Based Targets

3. Risk based policy is often expressed with reference to the ALARP principle, such as ‘all risks must be reduced ALARP’. Although not properly targets, use of the ALARP principle allows organizations to make risk based strategic and tactical decisions. Policy guides these decisions by defining a risk appetite through risk levels against which appropriate risk control measures can be applied. Further guidance for this and for all risk management considerations is contained in RA1210.




Chapter 3: AIR SAFETY CULTURE

►Chapter 3 has been subjected to extensive re-write for this issue of the MAS. Individual change marks are therefore not presented◄

AIR SAFETY CULTURE – BACKGROUND

What Is Culture?

1. Haddon-Cave cites the Columbia Accident Investigation Board (CAIB)15 definition of Organisational Culture16:

“Organisational Culture refers to the basic values, norms, beliefs and practices that characterise the functioning of a particular institution. At the most basic level, organisational culture defines the assumptions that employees make as they carry out their work; it defines “the way we do things here”. An organisation’s culture is a powerful force that persists through reorganisations and the departure of key personnel.”

From this, a simple, useful, working definition of culture can be derived as:

“The way we do things around here”.

In terms of forming and shaping culture, it is useful to consider the following 3-level hierarchy :

Thinking – the process through which values and/or beliefs are considered and debated and through which understanding is formatted and set. This is the activity through which a Mindset is achieved. Attitude – understood as values, beliefs, and/or understanding held. This is the formula through which a Mindset is maintained. Behaviour – understood as values, beliefs, and/or understanding expressed. This is the form through which a Mindset is evidenced.

What Is Air Safety Culture?

2. The use of the term Safety Culture originates from the investigation into the Chernobyl disaster in 198617. There are many different definitions available, utilised throughout a wide range of safety critical industries, but there is no single internationally recognised definition. The term ‘Engaged Culture’ is one used by NASA to stress the active and inclusive nature of the desired culture and one subsequently adopted by Haddon-Cave18. The MAA have adopted the ‘Engaged Culture’ term and, tailoring it for the Defence Air Environment, have adopted the following definition of Engaged Air Safety Culture:

An Engaged Air Safety Culture is that set of enduring values and attitudes, regarding Air Safety issues, shared by every member, at every level, of an organisation. It refers to the extent to which each individual and each group of the organisation: seeks to be aware of the risks induced by its activities; is continually behaving so as to preserve and enhance safety; is willing and able to adapt when facing safety issues; is willing to communicate safety issues; and continually evaluates safety related behaviour.

15 CAIB was set up in 2003 following the loss of NASA Space Shuttle “Columbia”. 16 Nimrod Review Chapter 17, Page 449, Para 17.5 17 International Nuclear Safety Group (INSAG) – “Summary Report on the Post-Accident Review Meeting on the Chernobyl Accident”, 1988. 18 Nimrod Review Chapter 27, Page 572, Para 27.11



3. A positive, pro-active and engaged safety culture is crucial to reap the maximum benefit from the ASMS. Military aviation is a highly sophisticated and complex system of people, equipment and processes. It is therefore important to understand and manage the fundamental characteristics and limitations of human performance in such complex systems – human factors (HF). HF aims to increase awareness and improve management of the human element and provides the necessary tools to improve safety and efficiency. HF policy, training requirements and guidance are contained in RA1440.

4. Building on the work of Professor James Reason19, and developing the list of Safety Culture characteristics detailed in the Nimrod Review20, the MAA have developed a model of Engaged Air Safety Culture shown in Fig 3.

Figure 3 Components of an Engaged Air Safety Culture

19 Managing the Risks of Organizational Accidents, Reason J, Aldershot, 1997, page 195. 20 Nimrod Review Chapter 27, Page 575, Para 27.33




The components of this model are discussed further below:

a. ‘Values and Behaviours’ Components:

(1) Just Culture. All personnel must understand that honest errors can be made a Just Culture is the cornerstone in ensuring that such errors are dealt with fairly and appropriately. However, it needs to be understood that this is not a blameless culture and deliberate violations of rules and regulations could result in disciplinary action.

(2) Reporting Culture. Open and honest reporting of safety concerns by all stakeholders is essential, to understand and manage the potential causes of future accidents. The exploitation of a Just Culture and ASIMS are vital for a healthy reporting culture.

(3) Learning Culture. Learning followed by communication is a central part of a safety culture. If lessons identified within one sphere are not effectively communicated across all areas, there is potential for undesired outcomes to be repeated. Proper investigation of occurrences and management of resultant recommendations is key to an effective learning culture, facilitated by ASIMS.

(4) Questioning Culture. Haddon Cave cites Questioning Culture as being the keystone of a Safety Culture. People and organizations need to be encouraged to ask questions such as “Why?”, “What if?” and “Can you show me?” as opposed to making and accepting assumptions.

(5) Flexible Culture. The complex and diverse nature of Defence Aviation dictates that the response to safety concerns be flexible. Rigid adherence to inadequate policies will not enable satisfactory resolutions to problems. Policy will evolve to meet challenges presented by the complexities of the Defence Aviation Environment.

b. Underpinning Components:

(1) Leadership Commitment. It is widely accepted that leadership commitment is vital if a successful Safety Culture is to develop within an organization; it is unrealistic to expect the desired culture to flourish if the leadership are not committed to it.

(2) Open Communication. Clear and unguarded communication of safety related information, throughout all levels of the organization, is required if the intelligence contained within such information is going to be exploited to the full.

(3) Effective Decision Making. Air Safety needs to be fully embedded within all aspects of an organizations decision making processes to ensure that the safety impact of any decisions is considered and understood.

5. For each of the above components, it is useful to define what good may ‘look like’ which, in turn, may aid the assessment of Safety Culture in an organization. A framework is provided at Annex A to this chapter providing goals (ie what good might ‘looks like’) for each of the components which, if achieved, might indicate an Engaged Air Safety Culture. Within this framework, a breakdown of the type of themes/indicators, which may be worthy of consideration within each of the components, is also included in order to help improve granularity and to aid understanding.

MANAGING A JUST CULTURE

6. In the aftermath of any kind of unwanted safety-related event, in any organization, a tension may be created between the requirements of safety and discipline, and a tendency for the



organization to protect itself by placing responsibility on individuals. Effective safety requires finding out what happened to prevent recurrence, while the disciplinary requirement must ensure that, where rules have been broken without cause or need, appropriate sanctions are brought to bear. A carefully defined and widely understood Just Culture will provide a standardised environment within which the requirements of honesty, professional behaviour and the desire for mission success can be incorporated with the application of appropriate discipline and accountability. This will also enable the desire for learning and improvement to be realised. However, this is much more than just a standardised environment and reporting mechanism. A Just Culture comprises both a set of beliefs and a set of duties that are expected from the individuals as well as from the organization as a whole. The beliefs and duties that underpin healthy occurrence reporting and fair and effective investigation are listed in the commander’s policy statement template at Annex B to this Chapter, and are based on the following principles:

a. Individuals are encouraged to contribute actively to improving safety and will be commended for owning up to mistakes that occur in an honest endeavour to do their best.

b. Defence Aviation, and all involved in it, acknowledges that it is the human condition to make errors and understand the role that HF play in both aviation and safety.

c. Personnel, regardless of status, experience or employer must know they will be treated in a fair, consistent, objective and swift manner.

d. Personnel, whatever their role, have a responsibility to actively participate in the reporting system (see RA1410 for the reporting format to be used) and to support learning and improvement in safety. Failing to report occurrences and hazards will no longer be acceptable and may, in itself, incur sanction.

7. Establishing and maintaining an open and fair reporting atmosphere can be difficult. Aviation Duty Holders, Accountable Managers and Commanders at all levels, must ensure that:

a. They act reasonably where any occurrence indicates that an inadvertent, and not premeditated, error by an individual has happened, agreeing that free and full reporting is the primary aim; in order to establish why an event happened. Every effort will be made to avoid action that may inhibit future reporting.

b. In the context of error management, unpremeditated or inadvertent error will not lead to disciplinary action, but a breach of professional standards and behaviour may.

Safety Culture and Error Management

8. Regulation covering Occurrence Investigation can be found at RA1410. The fragility of an Engaged Safety Culture, especially a Just Culture within a military hierarchy, means that consistency of approach is vital. As investigations progress, there must be clear lines between the non-judgemental investigation, the Review Group or meeting, and any judgemental or disciplinary action. However, if the investigation highlights any potential criminal or disciplinary actions, then this must be brought to the attention of the chain of command at the earliest opportunity.

Determining Culpability

9. When an event, or number of different events, lead to an occurrence then culpability for each separate event needs to be determined. Determination of culpability is underpinned by a number of established tests which are described in Annex C to this Chapter.

Just Culture Policies, Processes and Models

10. Organizations must incorporate a Just Culture into their implementation of the DAEMS Project using the 3 key components shown below. The templates given here may be adapted as




necessary for local and environmental use, at command, group and unit level. However, in order to preserve consistency of approach and culture across Defence Aviation, variations will be limited to those needed to link the Defence Aviation Just Culture with unit missions, and to align terminology with local usage.

a. Just Culture and Error Management Policy. The Defence Aviation Just Culture and Error Management Policy statement, which can be used as a template for a local Just Culture and Error Management Policy statement, is at Annex B.

b. Error Investigation Process. A template for the process to be followed for Error Investigation, to be used in conjunction with the occurrence reporting and investigation processes is at Appendix 1 to Annex C. A description of how the Defence Aviation Flowchart Analysis of Investigation Results (DA FAiR) Culpability Model must be used within this process is contained within the body of Annex C.

c. Culpability Model. The DA FAiR Culpability Model itself is at Appendix 2 to Annex C. Once an investigation is complete, this model must be used to review the results and establish culpability. It is not to be used to make any judgement on culpability without a proper investigation taking place. However, the model can be used to support the Just Culture policy by demonstrating how fair treatment will be ensured, and illustrating where the ‘red line’ for culpable actions falls.

Annexes:

Annex A. Air Safety Culture Framework

Annex B. Defence Aviation Just Culture and Error Management Policy Statement

Annex C. Error Investigation Process and Use of DA FAiR



CHAPTER 3 - ANNEX A: AIR SAFETY CULTURE FRAMEWORK

Component Themes/Indicators

Values and Behaviours

Just Culture

The distinction between acceptable/unacceptable behaviour (The ‘line in the sand’) is appropriately defined and communicated.

Unsafe behaviour is dealt with appropriately.

Safe behaviour is rewarded appropriately.

Human error is treated consistently and in line with policy.

The perception throughout the organisation is that human errors and unsafe acts are dealt with fairly and consistently.

Investigations are carried out iaw a formal process and by trained investigators.

There are sufficient numbers of trained (and current) investigators.

There is a willingness to admit that people make errors.

Goal: An atmosphere of trust where people are encouraged, and even rewarded, for providing safety related information and where it is clear to everyone what is acceptable and unacceptable behaviour.

Investigations cut across all levels of the organization.

Reporting Culture

There is a functioning and effective Air Safety Reporting System

There is a functioning and effective ‘4-worlds’ Error Management System

There is appropriate awareness of the Air Safety reporting and Error Management systems at all levels.

There is effective management of Air Safety related reports.

The number of reports is commensurate with the size/type of the organisation.

The ‘age’ of reports is appropriate for the organisation.

The Air Safety/Error Management reporting system is fully inclusive and available to everyone who needs access. (access to contractors etc)

Sufficient people are trained on the Air Safety/Error Management reporting system and new arrivals are trained/briefed in an appropriate timeframe

There is a willingness to report Air Safety occurrences/near misses/errors.

There is a positive attitude within the organization, at all levels, towards Air Safety/Error Management reporting.

There is confidence, at all levels, in the Air Safety/Error Management reporting system?

The value of reporting is understood

There are no unjust negative consequences towards those who have submitted reports.

There is no perception that there will be unjust negative consequences for those who have submitted reports.

Goal: An organisational climate where people readily report problems, errors and near misses.

Those submitting reports are given appropriate and timely feedback.




Learning Culture

Reported occurrences are dealt with appropriately.

Follow up actions are monitored at an appropriate level.

Follow up actions are timely/robust/effective.

Follow up actions are tracked through to completion.

Lessons Identified are appropriately disseminated.

There is evidence of trend analysis (undertaken and effective?)

There is an appetite within the organisation for learning from experience (from both good and bad experiences)

Goal: Organisational willingness and competence to draw the right conclusions from its safety information and to take appropriate actions based upon those conclusions.

Questioning Culture

The organisation works proactively to attempt to prevent occurrences before they happen.

There is a positive attitude towards the identification of new risks.

Challenging of processes and assumptions is encouraged.

The danger of ‘organisational norms’ is understood and managed.

Goal: A culture where people are engaged and ready to ask “what if?” and “why?” questions that provide the antidote to assumptions and reduce the possibility of incubated mistakes.

Flexible Culture

There is a clear appetite for and evidence of Continual Improvement within Air Safety

Organisation change programmes are appropriately scrutinised for Air Safety implications

Goal: An organisation that can adapt to changing circumstances and demands while maintaining its focus on safety.



Component Themes/Indicators

Underpinning Elements

Leadership Commitment

There are clearly defined leadership/management responsibilities for Air Safety.

There is clearly demonstrable leadership/management commitment towards Air Safety.

There is an appropriate understanding of Air Safety risks within levels of management.

Air Safety is sufficiently resourced (Established, manned, trained).

Goal: An organisation where leadership commitment to Air Safety exists without question.

Open Communication

Management are ‘connected’ to workforce on Air Safety related issues.

Management understand the workforce’s view of Air Safety.

Individuals understand their particular role in Air Safety.

Workforce feel that Air Safety concerns are taken seriously by management.

Workforce have inclusive and appropriate involvement in Air Safety related meetings?

Goal: An environment where Air Safety issues are openly and effectively communicated throughout the organisation.

Air Safety related communication is effective throughout all levels of the organisation

Effective Decision Making

Air Safety plays a fundamental role in day to day decision making.

Air Safety has an appropriate priority against output.

Any evidence of a ‘can do’ attitude is appropriate and risk based.

Goal: An environment where the consideration of any impact on Air Safety is clearly embedded within any decision making process.




CHAPTER 3 - ANNEX B: DEFENCE AVIATION JUST CULTURE AND ERROR MANAGEMENT

POLICY STATEMENT 1. This policy establishes an open and honest reporting culture within (insert Organization/ Ship/Unit/Stn) in which all personnel, regardless of status; experience or employer can expect to be treated in a fair, consistent, objective and timely manner.

2. The mission of (insert Organization/ Ship/Unit/Stn) is to (insert mission). 3. To achieve this objective it is essential to attain the highest possible flight safety standards in all aspects of the output of (insert Organization/ Ship/Unit/Stn). To ensure this, we must systematically and actively manage events and balance the potentially conflicting requirements of safety and standards with operational necessity. I intend to do this within a Just Culture that encourages open and honest reporting of such events.

4. I recognise that it is the human condition to make errors, and that human factors play an important role in aviation and safety. It is my intent to implement an exemplary Error Management System (EMS) that recognises best practice and meets the highest regulatory standards. I encourage everyone to contribute actively to improving safety and assure you that you will be commended for owning up to mistakes made in an honest endeavour to do your best.

5. All personnel involved in aviation activity at (insert Organization/Ship/Unit/Stn), regardless of status, experience or employer, will be treated in a fair, consistent, objective and timely manner. However, all personnel involved in aviation activity at this unit also have a responsibility to actively participate in the EMS by reporting occurrences and hazards so that learning and improvement can happen. At the heart of this Just Culture are some core beliefs and duties that we must all share – these are summarised below and listed in bullet form at Appendix 1 to this Annex.

6. Under this Just Culture (insert Organization/ Ship/Unit/Stn) will follow a defined, consistent system for the management of errors. The deciding part of this system will be independent of the employer or chain of command. This is neither a “blame” nor “no-blame” culture. All incidents will be investigated by trained personnel approved by me and, where incidents are reported in a timely and open manner, the presumption of blamelessness will be the norm and the expectation is that disciplinary action will be the exception. If any disciplinary or administrative action is needed, this will not be done without a proper investigation and a full review of the findings of that investigation. Nevertheless, the following serious failures of personnel to act responsibly will still attract sanction under this policy:

a. Premeditated or intentional acts of damage to equipment or property.

b. Actions or decisions involving recklessness which no reasonably prudent person, with relevant training and experience, would take.

c. Failure to report incidents as required by this policy.

7. All personnel, wherever they work in (insert Organization/ Ship/Unit/Stn) and whatever their role, must recognise that they have a part to play and a responsibility to participate actively in the process of attaining the highest flight safety standards.

8. This Just Culture, and the associated reporting system, will enable (insert Organization/ Ship/Unit/Stn) to meet the operational requirements efficiently while ensuring the highest possible flight safety standards. The system will drive errors to a low level whilst recognising that people will make errors and the Just Culture will provide every possible support to personnel to meet this goal.

Appendix:

1. Defence Aviation Just Culture – Beliefs and Duties



CHAPTER 3 - APPENDIX1 TO ANNEX B: DEFENCE AVIATION JUST CULTURE – BELIEFS AND DUTIES

Beliefs

All those involved in aviation activities at (insert Organization/ Ship/Unit/Stn):

• Recognise that professionals will occasionally make mistakes.

• Recognise that even professionals will develop unhealthy routines of behaviour.

• Are intolerant of reckless conduct.

• Recognise that inappropriate blame gets in the way of error management.

• Expect that errors will be reported.

• Accept that we are all accountable if we choose to take risk.

• Expect that safety standards will improve if we manage errors effectively.

• Believe that when something goes wrong all will be treated fairly and with complete integrity while we investigate whether mistakes have been made, and why, in our collective efforts to get things right for the next time.

Duties

All those involved in aviation activities at (insert Organization/ Ship/Unit/Stn) have a duty to:

• Raise your hand and admit ‘I have made a mistake’.

• Raise your hand when you see risk.

• Manage risk at the appropriate level.

• Avoid and be intolerant of reckless behaviour.

• Encourage uninhibited reporting without fear or embarrassment.

• Actively participate in the Defence Aviation Error Management System (DAEMS) Project in order to help create a learning culture.

• Understand clearly that the Just Culture provides a qualified immunity from sanctions while investigations take place and any culpability is established.

• Understand clearly the ‘red line’ between acceptable and unacceptable behaviour.

• Provide active leadership, appropriate to your position in the organization, to the Just Culture at (insert Organization/ Ship/Unit/Stn), its beliefs and duties.



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CHAPTER 3 - ANNEX C: ERROR INVESTIGATION PROCESS AND USE OF DA FAIR

1. The process diagram at Appendix 1 to this Annex illustrates how error investigation processes, and the DA FAiR culpability model, will be used to consider occurrences, incidents, errors or near misses. The DA FAiR model is intended for use by a suitable Occurrence Review Group (ORG) that relies on the results of a non-judgemental investigation to resolve any question of culpability, arising due to the actions of an individual or group of individuals. The determining factor that will enable the ORG to establish if there is any culpability will be the question of intention: whether the actions and ensuing consequences were intended by the individual. Where appropriate, the ORG will make recommendations regarding appropriate disciplinary or administrative action; however, it will remain the responsibility of the command chain (with appropriate legal advice if necessary) to determine and enact any action in accordance with Service procedures. The only exception to this is if it appears that a potential offence under Schedule 2 of the Armed Forces Act 2006 has been committed, or if the incident falls under the proscribed circumstances described in that Act, in which case Service Police must be involved from the outset of the investigation.

2. The DA FAiR Culpability Model at Appendix 2 to this Annex comprises a flowchart to determine behavioural classifications based upon information gathered during a non-judgemental investigation, and a framework for assessing the relative levels of culpability or accountability ascribed to those behavioural classifications. Application of the model requires a degree of sensitivity and discretion but will ensure an impartial and consistent judgement as to what are deemed acceptable and unacceptable actions. It relies upon a complete and comprehensive investigation having been conducted by trained personnel and will not be used in isolation or without the support of such an investigation. Application of DA FAiR will lead to one of 8 behavioural classifications which can be considered in 3 categories:

a. Unintended Action, Unintended Consequence. Where neither actions nor consequences were as intended by those involved, the actions would be considered as errors.

b. Intended Action, Unintended Consequence. Where the actions were planned but the consequences were not. This category contains the majority of the behavioural classifications including mistake, situation rule-breaking, unusual situation rule-breaking, rule-breaking to benefit the organization, selfish rule-breaking and recklessness.

c. Intended Action, Intended Consequence. Where both actions and consequences were as planned, the actions would be considered as sabotage.

3. Procedure for Using the DA FAiR Model. Using the DA FAiR flowchart, the ORG will answer the questions posed based on the information gathered during the investigation. If clarification or further information is necessary to answer the questions, the ORG must verify any issues with the error investigation team before continuing with the analysis. The Just Culture policy requires the ORG to assess whether actions were reasonable, given the conditions at the time of the occurrence, by applying the Substitution and Routine Tests when answering each question throughout the flowchart.

a. The Substitution Test. This considers whether another ordinary person with the same competence would behave in the same way in similar circumstances. This test is used to assess whether another individual sharing similar knowledge, experience and perceptions, special skills, education and training, physical characteristics and mental capacity might have reasonably followed the same course of action. If the answer is yes, then it is inappropriate for the individual to be deemed culpable. This will be an evaluation by the ORG based on advice from representatives of the individual’s peer group who have the

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same rank and certification capability as well as similar levels of experience. The individual circumstances of an event will dictate how the response to each question is determined. However, the following is a guide to issues that will be considered when answering the specific questions in the DA FAiR model:

(1) Was there a conscious, substantial and unjustifiable disregard for risk? Did the individual knowingly take a significant risk whilst ignoring the potential for harm that could be caused to others?

(2) Was there malicious intent for the consequence? Did the individual maliciously set out to cause the event?

(3) Were rules intentionally broken? Did the individual knowingly contravene rules or not follow procedures in order to undertake the task?

(4) Was a correct plan of action selected? Would the plan of action selected by the individual have ever achieved its goal?

(5) Given the conditions at the time, could the task have been done in accordance with the rules? Given the circumstances the individual found themselves in, was it possible to complete the task in line with rules or procedures?

(6) Were the conditions outside normal experience and practice? Did the individual find themselves in a situation which differed considerably from the usual operating environment?

(7) Was the action of benefit to the individual? Did the individual consider that their actions were for the good of the organization or business, or were they based upon blatant self-interest?

b. The Routine Test. This considers whether the event in question has happened before to either the individual or the organization. Establishing whether the behaviours are routine or whether the event has happened previously will have a direct influence upon determining the most appropriate intervention. This test seeks to ascertain whether:

(1) The actions of the individual were normative, in that they were a reflection of the normal way of working. This would also align with the findings of the substitution test above.

(2) The individual had been involved with similar occurrences before.

(3) The organization had experienced similar occurrences before; but that remedial actions had failed to prevent recurrence (examples might include replenishing a propulsion system engine oil tank with an incorrect fluid, or selecting an incorrect but nearby and similar cockpit switch).

4. Outcomes – Behavioural Classifications. Applying the Substitution and Routine Tests, and responding to the questions in the DA FAiR model, will lead the ORG to one of a number of behavioural classifications. These are summarized below:

a. Error. An error is an action that does not go according to plan. Errors can either be due to an individual doing something other than what they intended to do (error of commission) or failing to do something because of an issue with concentration or memory (error of omission). For example, misinterpreting information on a gauge, pulling an incorrect circuit breaker, or forgetting to complete the last step of a task because of an interruption.

b. Mistake. A mistake is an action that goes according to plan but where the plan is inadequate to achieve the desired outcome. Known as a ‘cognitive error’, a mistake occurs


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when an individual does what they planned to do, but where they ought to really have done something else if they wanted to achieve their goal. For example, using out of date information to perform a task.

c. Situational Rule-Breaking/Violation. In some situations, given the conditions at the time, deliberately not following, or actively violating, the rules may have been the only way to complete a task. Individuals may assert that, given the circumstances in which they found themselves, that was the only way to get the task done. For example, not using the correct equipment to do a task as the equipment was unserviceable at the time.

d. Unusual Situation Rule-Breaking / Violation. This classification takes account of those unusual occurrences where rules are deliberately not followed, or violated, in unforeseen or undefined situations. Not every situation can be anticipated when individuals find themselves in extraordinary circumstances.

e. Rule-Breaking/Violation for Organizational Gain. This classification covers situations in which an individual deliberately fails to follow rules with the aim of benefiting the organization. An individual may believe that their actions were for the good of the organization in terms of a reduction of time, cost or resource, or in the avoidance of potential losses, or in achieving organizational goals such as meeting schedules or targets. For example, missing out steps in a task that are judged to be superfluous in order to meet a deadline set by management.

f. Selfish Rule-Breaking/Violation. This classification caters for deliberately not following rules with the aim of benefiting the individual. Actions can be ‘corner-cutting’ to complete a task more quickly or to circumvent seemingly laborious procedures. They can also be ‘thrill-seeking’ as a means of alleviating boredom or as a demonstration of ability or skill. Motivational in cause, such rule-breaking can be encouraged or condoned in the drive to meet targets. For example, not completing a task to get away from work on time; not using the correct equipment because it requires effort to obtain.

g. Recklessness. Recklessness is conscious, substantial and unjustifiable disregard of visible and significant risk. While there is no intent to do harm to others, recklessness implies that an individual knowingly ignored the potential consequences of their actions. For example, coming into work under the influence of alcohol.

h. Sabotage. Sabotage is malicious or wanton damage or destruction. To determine whether an individual’s actions constitute sabotage there needs to be intent for both the actions and the consequence to cause damage, disrupt operations or incite fear.

5. Determining Levels of Culpability and Appropriate Interventions. The resulting behavioural classification aligns with a relative level of culpability within the model, which is determined largely by the intention of both actions and consequences. Dependent upon ascribed culpability, changes may be made at the individual, task, situation or environment level and may require appropriate administrative or disciplinary action. A Just Culture requires a notional ‘red line’ to be drawn, which distinguishes what behaviour is broadly acceptable to the organization and what is not. The DA FAiR helps the ORG, and thus the command chain, to determine which behaviours will be managed through disciplinary action; these are optimizing rule-breaking for personal gain, recklessness and sabotage. The vast majority of other behaviours will be managed through improving performance-influencing factors, although the reality of legal due process means that in a small number of cases the outcome (eg death, very serious injury or level of ‘write-off’ cost) or intent might result in separate proceedings, leading to administrative or disciplinary action. In making its recommendation to the command chain regarding appropriate action to take, the ORG will consider the Proportionality Test and determine an intervention suited to the attributed behaviour classification using the following guidance:

a. The Proportionality Test. This considers the safety value that any punishment would have. This test will be used to determine the appropriate extent of any administrative or disciplinary action in terms of its contribution to safety, learning and improvement.

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b. Determining the Intervention. In order to determine intervention(s) the ORG will consider what needs to happen to reduce the likelihood of recurrence at both the individual level and the organizational level. For an intervention to be successful in its aim to reduce the likelihood of recurrence, it needs to be appropriate to the type of behavioural classification determined using the DA FAiR model. Errors, mistakes and rule-breaking all have differing psychological and motivational precursors and it is essential therefore that consideration is given to this when developing an intervention. These are outlined in Figure 4 below.

Behaviour Intervention

Error Review task for human performance issues, particularly if errors occur regularly. Encourage reporting from staff to uncover other potential error provocative tasks and near misses.

Mistake Address cognitive errors through performance management and training. Encourage reporting from staff to uncover other error provocative tasks and near misses.

Situation Rule-Breaking Address any systemic problems. Encourage reporting from staff to uncover other potential sub-optimal situations. Reinforce acceptable / unacceptable behaviour with staff and management. Apply appropriate counselling or minor administrative action (MAA) where necessary.

Unusual Situation Rule-Breaking

Review how staffs are trained to react in emergency situations. Apply appropriate counselling or MAA where necessary.

Rule-Breaking to Benefit the Organization

Address any systemic problems. Reinforce acceptable/unacceptable behaviour, ‘norms’ or expectations with staff and management through coaching or mentoring. Apply appropriate counselling or MAA where necessary.

Selfish Rule-Breaking Manage through disciplinary or administrative action and/or counselling. Action to address any systemic problems may also be necessary.

Recklessness Manage through administrative or disciplinary action. Action to address any systemic problems may also be necessary.

Sabotage Manage through administrative or disciplinary action. Civil and/or criminal prosecution may also occur. Action to address any systemic problems may also be necessary.

Figure 4 Behaviours and Interventions

Appendices:

1. DAEMS Error Investigation Management Process

2. Just Culture Culpability Model – Defence Aviation Flowchart Analysis of Investigation Results (DA FAiR)


CHAPTER 3 - APPENDIX 1 TO ANNEX C: DAEMS ERROR INVESTIGATION MANAGEMENT PROCESS

Figure 5 DAEMS Error Investigation Management Process

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CHAPTER 3 – APPENDIX 2 TO ANNEX C: JUST CULTURE CULPABILITY MODEL – DEFENCE AVIATION FLOWCHART ANALYSIS OF INVESTIGATION RESULTS (DA FAIR)

Figure 6 Just Culture Culpability Model – Defence Aviation Flowchart Analysis of Investigation Results (DA FAiR) (Part 1)



No

YesNoNoYes

No

No

No Yes

YesYes Yes

YesYes

Investigation Complete

ErrorRule-breaking /

Violation for Organisational

Gain

Unusual Situation Rule-breaking /

Violation

Was a correct plan of action selected?

Mistake

No

No

Given the condition at the time, could the task have been done in accordance

with the rules?

Recklessness

Sabotage

SituationalRule-breaking /

Violation

SelfishRule-breaking /

Violation

Was there maliciousintent for the consequence?

Were the rules intentionally broken?

Was there a conscious, substantial

and unjustifiable disregard for risk?

Were the conditions outside normal experience and

practice?

Was the action of benefit to the individual?

DA FAiR v9 – May 10

No

YesNoNoYes

No

No

No Yes

YesYes Yes

YesYes

Investigation Complete

ErrorRule-breaking /

Violation for Organisational

Gain

Unusual Situation Rule-breaking /

Violation

Was a correct plan of action selected?

Mistake

No

No

Given the condition at the time, could the task have been done in accordance

with the rules?

Recklessness

Sabotage

SituationalRule-breaking /

Violation

SelfishRule-breaking /

Violation

Was there maliciousintent for the consequence?

Were the rules intentionally broken?

Was there a conscious, substantial

and unjustifiable disregard for risk?

Were the conditions outside normal experience and

practice?

Was the action of benefit to the individual?

DA FAiR v9 – May 10 Figure 7 Just Culture Culpability Model – Defence Aviation Flowchart Analysis of Investigation Results (DA FAiR) (Part 2)

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Intentionally Blank
