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Case Study: Implementing Safety Management System (SMS)
in Malaysia Airlines
Corporate Safety, Security,
Health & Environment
(CSSHE)
19th August, 2008
DCA-SMS 2
Presentation OutlinePresentation Outline
Overview Why are we doing it? How are we doing it? SMS Open Reporting Culture Safety Action Plan Safety Dashboard Safety Management Review
DCA-SMS 3
Overview SMS Life Cycle Model
Framework Content Action Plan
Policy Accountabilities Flight Safety
Programme Accident &
Incident Prevention Programme
Risk Management Programme
Emergency Response Programme
Audits and inspections
Safety goals
Manuals Structure Scheduled SMS
Training Program Flight Data
Analysis / IFDAT / Safety Forums
Risk Matrix / Risk Register
Emergency Response Plans/ Special Assistance Teams
Audits process / programs/ sharing
Safety dashboards
Safety Action Plans
Safety Dashboards
Safety Meetings Safety Reviews Safety Coms log Safety
Investigators Safety Auditors Safety drills Board Safety
Reports Management
Safety Reports Staff Safety
Reports Practice Drills
Started 2006, Relaunch in Feb 2007
DCA-SMS 4
Why are we doing it?
To build a sustainable safety culture in MAS
Develop predictive safety management capability• Visible Safety Values driven from top• Clear safety accountabilities in place• Effective safety oversight structure• Safety action plans corporate wide• Safety Dashboards in place• Open Reporting institutionalized• Systems supported safety trends monitoring• Safety reviews• Safety Reporting
DCA-SMS 5
Accountable ManagerIdris Jala
GM CSSHECapt. Dr. Ooi Teong Siew
BSSC
Oversight LinkagesLegend
CSI - Corporate Safety InvestigationCSQ - Corporate Safety QualityOSD - Occupational Safety DeptEMC - Emergency Management CentreOCC - Operations Control CentreEM - Engineering & Maintenance
Head of SecurityJeff Nor Jettey
AGM CSICapt Karim Mutalib
AGM CSQRasul Razak
Senior Mgr EMCMohd Fuad Sharuji
Mgr OSDAhmad Kamal
Mgr EnvironmentMustafa Ishak
Mgr Biz SupportZamani Harun
AGM OCCSyed Othman
S. Mgr Grp ITNazri
GM CommercialGermal Singh
AGM Flt Ops (FS)Capt. Missman
FireflyCapt Wong KY
SM Airport OpsZamri Muslimin
SM MASKargoIbrahim Salleh
SM Med CentreDr. Daljit Parmar
AGM E&MMohan S
Mgr IFSMdm Choong
MASWingsCapt Valentine
Corporate Safety Security Health Environment Corporate Safety Security Health Environment (CSSHE) Direct Reports and Oversight Linkages(CSSHE) Direct Reports and Oversight Linkages
DCA-SMS 6
Safety Reporting Framework
HighlightsHighlights
Safety DashboardsSafety Dashboards
Safety Action PlansSafety Action Plans• Strategies, actions, KPI’s, prioritiesStrategies, actions, KPI’s, priorities• Status reports & current measuresStatus reports & current measures
• Level 1, 2 & 3 dashboards Level 1, 2 & 3 dashboards • KPI’s versus current measuresKPI’s versus current measures
• Key dashboard improvementsKey dashboard improvementsand concerns. and concerns.
• Key project completion or delaysKey project completion or delays
DCA-SMS 7
Safety Dashboard Framework
Level 1Level 1Safety CriticalSafety Critical
Level 2Level 2Safety OversightSafety Oversight
Level 3Level 3Domains & SubsidiariesDomains & Subsidiaries
• 266 Domain & Subsidiary Measures 266 Domain & Subsidiary Measures that define line safety system that define line safety system effectivenesseffectiveness
• 79 Safety Oversight Measures that 79 Safety Oversight Measures that define the effectiveness of oversight define the effectiveness of oversight functionsfunctions
• 7 Safety Critical Measures that 7 Safety Critical Measures that define the health of the safety define the health of the safety system system
DCA-SMS 8
Tier 1 KPI (Safety Critical) / Tier 2 KPI (Safety Oversight)
These KPI have been identified as the high level key measures of SSHEperformance across the Company. It provides targets and currentmeasurements and the traffic lights are decided as follows:
On or better than Target
Deviate Target by up to 30%
Deviate Target by greater than 30%
DCA-SMS 9
19%13%45%23%
11%11%57%21%
30%10%40%20%
Tier I KPI Tier 2 KPI Tier 3 KPI
Accidents
Open Reports
Safety Occurrence
Lost Time Injury
Security Occurrence
Engineering
DCA Non Compliance
Total 7 KPI
Oversight
CSI (2)CSQ(4)CSIS(3)FOQA(2)OSD(4)SEC(2)
INFO SEC(4)ENV(4)EMC(6)
Domains
FO / IFO (13)E&M(9)AO(6)
Subsidiaries
FY(8)MW(6)
MKargo(6)
Total 79 KPI Total 266 KPI
Oversight
CSI (12)CSQ(12)CSIS(12)FOQA(7)OSD(12)SEC(9)
INFO SEC(16)ENV(11)EMC(15)
Domains
FO / IFO (43)E&M(39)AO(17)
Subsidiaries
FY(29)MW(15)
MKargo(17)
• Tier 1 Insights
Serious incidents contributed to up tick in safety occurrence
• Tier 2 Insights
Training issues eg availability of training program, lack of qualified safety auditors / investigations, use of systems (CSIS) contributed to the high % of “reds”
Investigation /audit close outs is the next highest cause for the high “reds”
• Tier 3 Insights
Needs prioritization of resources to close out open items
Discipline of action to deliver to the set targets will be required
Upskilling of team will be required
WORK IN PROGRESS
Proposed High Level Overview Report
DCA-SMS 10
SAP / Dashboards Targets/Lifecycle
Starting Up
October 08
December 08
January 09
Renewed 09Targets
Accident “Cliff”
yyy
aaa bbb
ccc
xxx
20
23
15
42July 08
DCA-SMS 11
Open ReportingOpen Reporting
Chairman issued Open Reporting Policy Company wide
Total Safety Reports Received (Rate/10,000)(2005 - 2008)
68
108
159
292
0
50
100
150
200
250
300
350
2005 2006 2007 Jan-Jun'08
rate
/ 10
,000
fli
gh
t cy
cle
Total Safety Reports Received (Actual No)(January - July 2008)
4
5
8
11
84
144
100
99
321
848
0 100 200 300 400 500 600 700 800 900
ME
CHIRPS
A/C GND
Industrial
FltInc
HZD
SEC
GND
ASR
CAB
# of Reports Received
Open Reporting has increased significantly every year
Reporting system is a key component for success
Data analysis a prerequisite for insights
Share, share, share….
DCA-SMS 12
No.
KPI Target Actual MeasurementStatus
Indicator
Remarks
1 Air Accidents 0 0 # of hull loss accident G NIL hull loss accident
2 # of Open Reports 2500 1624# of safety report received in MAS (YTD)
GApprox 12% more than target YTD
3 Safety Occurences
Air Occurrences
Air Safety Reports (ASR) > 59 55# of occurrence /10,000 flight cycle
A
Cummulative average ASR High Impact Occurrences < 6.12 10.9 R
Cabin Occurrences reports > 57 127.6 G
Ground Occurrences
Aircraft Ground Accidents (AGA) <2.5 1.68 # of occurrence /10,000 flight cycles
G Cummulative average
Apron Accident (AA) <1.9 3.37 R
Industrial Accident (IA) <0.2 1.11 /1,000 employees G
4 Lost Time Injury (LTI)
DOSH Reportable LTI (>=4 days) <63
# of cases (YTD) A
Tier One KPI
Example O
nly
DCA-SMS 13
FOQA Top events for Jan-June 2008
Although there is a decrease in the trend from April to Jun ’08 for fleet wide, the trend for B737 keeps increasing. The B737 fleet office has been tasked to conduct deeper analysis and come up with plans to mitigate this issue. Other fleets have been instructed to implement all recommendations formulated during FO Safety Boot Camps initiated by Flight Safety and Human Factors Department (FSHF).
162 246
658
92 419
4
1371
250
817
30 6
1309
557
1221
85
923
479
1509
158 174 54
1180
539
1143
174 135 18
877
485
1100
130 57 60
0
500
1000
1500
2000
2500
3000
3500
Rate per 10,000 Flights
Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08
Chart 1 All Fleet for Unstabilized Approach from Jan - Jun 2008
Analysis Based on Rate per 10,000 Flights
Deviation from glideslope Deviation from centreline Descent rate high below 400' Late Ldg Flap Late Ldg Gear Low on approach
FOQA Analysis is an Important Predictive Tool
DCA-SMS 14
Emergency Management Centre Status
• The target of 910 SAT volunteers is currently 50% short of the required numbers. In particular the trained TEC’s is only 10% of the required number. This is being addressed by a recruitment and training program that will be delivered over the coming 12 months.
• It was identified through the code share audit program (conducted by CSQ) that there are a number of inconsistencies with regard to the emergency response content in Code Share Partner Agreements. EMC will liaise with International Affairs to address these gaps
• 68 of the 74 MAS stations have received an ERP briefing. Only 68 stations have submitted their station ERP; which is below target.
• EMC is working with Aviem International to ensure actual capability of contracted services in event of accidents abroad.
• Presently only 2 mutual assistance agreements have been established with MAS code share partners. The target is to establish 7 of these agreements before December 2008
Example O
nly
DCA-SMS 15
SMS Workshop SMS Workshop
2007 SMS Workshop Participant by Department
32
88
79
72
234
11
17
19
19
0 50 100 150 200 250
CSSHE
MasKargo
Flight Operations
Airport Operation
Engineering
Infight Services
HR
Corporate Services
Others
# of participant
DCA-SMS 16
Safety Reporting To Management / Board
BoardBoard
Accountable Accountable Managers MeetingsManagers Meetings
Safety Council Safety Council MeetingsMeetings
• Chaired by NPH Chaired by NPH • Line Management issues and risksLine Management issues and risks• MonthlyMonthly
• Level 1, 2 & 3 dashboards Level 1, 2 & 3 dashboards • KPI’s versus current measuresKPI’s versus current measures• Chaired by MDChaired by MD• Quarterly Quarterly
• Key dashboards Key dashboards • Key project completion or delaysKey project completion or delays• Chaired by Board MemberChaired by Board Member• Monthly at BoDMonthly at BoD• Quarterly at BSSCQuarterly at BSSC
DCA-SMS 17
End of PresentationEnd of PresentationQ&AQ&A