Safety Management Systems/ISBAO

Dan Brunskole, President

Jim Zawrotny, TBAG Consultant

The Brunskole Aviation Group, TBAG

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Who is IBAC? International Non-Government, Non-profit, Council

representing 14 member Associations (NBAA largest)

Conduct safety studies/provide statistics

Represent business aviation at ICAO

Manage the IS-BAO Program

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What is IS-BAO? Professional code of practice

World-wide industry standard

Developed by the industry for the industry

Based on ISO 9000 principles, tailored for aviation

Provides tools for risk analysis and self-directed risk management

Fits all sizes & missions, aircraft types

Foundation is a Safety Management System (SMS)

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What is a SMS? Proactive management of safety risks

Systematic process

Comprehensive process

Integrates operations, maintenance, finance and human resources

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SMS is Evolutionary Development of Safety 1950s-70s: High accident rate- Solution Technology

– Jet engines– Weather radar

70s-80’s: Declining accident rate- Quality Management and Human factors– Simulator training– CRM

Now—Flat accident rate - Recognition that accidents are organizational-– Safety Culture/ Safety Management Systems

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What Causes Accidents?

Most accidents are “organizational” in nature:

Latent conditions

Combine with or cause active failures– Errors or violations committed

by the system’s operators

And produce an accident

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Precursors to an Accident:

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Defenses against an Accident:AccidentDefences

Unsafe Acts

Preconditions

Line Management

Decision Makers

Windowof Opportunity

Unsafe Actsand LatentUnsafe Conditions

- James Reason’s MODEL

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Accident

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Terms: Hazard-The condition or circumstance that can lead to

physical injury or damage

Risk-The consequence of a hazard measured in terms of likelihood and severity

Mitigation-The measures taken to-– Eliminate a hazard– Reduce the likelihood– Reduce the severity of a risk

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Hazards, Risks, Mitigations

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Safety Management System

A process to manage the hazards and associated safety-risks inherent in an individual operation

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SMS Formula Identify hazards to YOUR operation

Assess and measure YOUR safety risks

Mitigate to eliminate hazards or reduce risks

Track mitigations to ensure they are APPROPRIATE AND EFFECTIVE

Modify mitigations as required

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IS-BAO/SMS provides a framework and structure

MRM

JAR

TrainingRan

Safety Drills

Checklist

MaintSchedule

Security PolicyWorksheets

Alcohol & Drugs Policy

HSE Policy

Ops Manual

ERPs

CAAReqs.

InsurancePolicy

No Structure

Policy

Process

Task

Structure

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Why do a SMS? Safety and Security

Teamwork

Loss Prevention/ Accident Prevention

Insurance and aircraft financing

Stakeholder and customer confidence

Due diligence

Regulator confidence and regulatory compliance

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Safety Analysis Studied 297 total and serious

business aircraft accidents

Conclusions: – IS-BAO could have certainly

or probably prevented 35 - 55%

ACCIDENT ANALYSIS, JET AND TURBOPROP BUSINESS AIRCRAFT 1998-2003, POTENTIAL IMPACT OF IS-BAO - Robert Woodhouse, MRAeS, May 2006

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Business Case: Cost of an AccidentDirect Losses Indirect Losses physical damage to the

aircraft

property damage

personal injury

loss of life

legal claims

loss of business

damage to reputation / good will

loss of key personnel / staff

increased insurance premiums / future insurability in question / loss exceeds insurance limits

loss of productivity (“actions” for defense)

environmental impact

loss of use of equipment (partially insured)

punitive damages / fines / regulatory action

costs of replacement equipment or supplemental lift

additional personnel costs, such as employee counselling recruitment and training

Goal: Loss prevention since an accident may incur significant losses!

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Business Case: “Cost” of Minor IncidentHangar rash on a Gulfstream IV… Direct (40 day repair period)

– Physical Damage: $313,800 Indirect

– Loss of Use: $635,595 charters– Lost Productivity: $17,300 for over 48

hours– Outside Advisors*: $13,000– Repair Oversight: $15,000 travel

expenses Total Cost: $994,695 Insurance Paid: $470,700 or 47%

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Business Case: “Cost” of Major Accident

HULL DAMAGECFR EXPENSE

PROPERTY DAMAGE(LIABILITY-3rd PARTY)

BODILY INJURY(LIABILITY-3rd PARTY)

PASSENGER BODILY INJURYCONSEQUENTIAL LOSSES

CREWINJURY

“Teterboro Challenger 600 Crash Spawns Claims” ~AINonline

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Business Case: “Cost” of Staff Injury Co-workers and supervisors lose time / productivity

tending to injured

Distracted staff discuss injury during “break” times

If serious, temporary staff needs training and / or overtime necessary

Lost time is not insured

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Regulatory Compliance– SMS PLUS COMPREHENSIVE STANDARDS: New

ICAO Annex 6 Part II requirements for non commercial operators of turbojet airplanes, large airplanes, and corporate operators (compliance date November 18, 2010) IS-BAO meets ICAO requirements

– SMS ONLY--ICAO requirement for SMS (Annex 6 Part 1) for commercial operators (January 1, 2009 deadline) Many States do not have rules in place Enforcement? FAA filed difference

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Why do a SMS? Some thoughts…. Risk ID through insurance

– Least effective as not all risks are insurable – Too narrow an approach– May not leverage firm’s culture, strengths

Waiting for hazards to be identified through accidents?– Do landings with no bent metal prove ops are safe?– “Tombstone” mentality– Accidents are few- lessons do not apply across the

board

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More thoughts… Is your operation as efficient and effective as it can be?

– Defining processes/ linking to risks makes operation more effective and efficient

Do you know you have…– Trust of your passengers? – What is “value” of CEO or key personnel?– Trust of regulators?

– Do you meet regulatory requirements?

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New ICAO SMS Elements: Safety Policy and Objectives

Safety Risk Management

Safety Assurance

Safety Promotion

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Safety Policy and Objectives Management commitment and responsibility

Safety accountabilities

Appointment of key safety personnel

Coordination of emergency response planning

SMS documentation

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Safety Risk Management Hazard identification

Safety risk assessment and mitigation

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Safety Assurance Safety performance monitoring and measurement

The management of change

Continuous improvement of the SMS

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Safety Promotion Training and education

Safety communication

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Getting Started: 12 Steps to a SMS

1. Study the SMS concept

2. Obtain senior management commitment

3. Establish SMS team

4. Determine what you have and what you need

5. Conduct initial hazard identification and risk assessment, and develop safety risk profile

6. Develop safety management strategy

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Implementation, cont.7. Identify safety accountabilities

8. Develop ongoing hazard identification and tracking system and risk assessment procedures

9. Develop emergency preparedness plan

10. Amend programs, procedures and documents as required

11. Conduct staff training and education

12. Track and evaluate safety management activities

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Summary SMS is “new” way of thinking about safety

– What is my risk?– Is it acceptable?– If not, how do I mitigate the risk?– How do I communicate/ implement these mitigations?

Goal- Reduce risks ALARP and build a Just Culture / Positive Safety Culture

It works!!

For more information:Jim Zawrotny, TBAG Consultant Jim.Zawrotny@ brunskoleaviationgroup.com

Dan Brunskole, President Dan.Brunskole@brunskoleaviationgroup.com

Member Associations see www.ibac.org or your Association website