SWISS OPERATIONS SAFETY ASSURANCE

Transcription

1 SWISS OPERATIONS SAFETY ASSURANCE Netzwerk Risikomanagement, Schwerpunkt «Gelebte Risikokultur» Marco Müller, Head of Operations Safety Assurance Pete Steinmann, Head of Quality and Risk Management 1 OPERATIONS SAFETY ASSURANCE / OS

2 SAFETY MANAGEMENT AN ONGOING CHALLENGE 2 OPERATIONS SAFETY ASSURANCE / OS

3 SAFETY MANAGEMENT SYSTEM REACTIVE / PROACTIVE SAFETY MANAGEMENT Accidents Reactive Focus Incidents Proactive Focus Exceedances Normal Operations Accident Precursors Incident Precursors 3 OPERATIONS SAFETY ASSURANCE / OS

4 SWISS SAFETY MANAGEMENT DEPENDANT ON CULTURE STRATEGY CULTURE STRUCTURE SYSTEMS 4 OPERATIONS SAFETY ASSURANCE / OS

5 SWISS SAFETY MANAGEMENT SWISS SAFETY CULTURE An informed culture A just culture A reporting culture A learning culture 5 OPERATIONS SAFETY ASSURANCE / OS

6 SAFETY MANAGEMENT THE BALANCING ACT PRODUCTION PROTECTION MANAGEMENT CULTURE Earn money, but in a safe way! 6 OPERATIONS SAFETY ASSURANCE / OS

7 Risk Management in an Airline As an Airline we face two distinct Focal Points of Threats: From the Inside (System and/or Human Errors) > Safety From the Outside (Acts of Violence, Sabotage, ) > Security Providing Safety and Security means managing these Threats by Virtue of Risk Management. Reducing Risks versus Total Safety / Security 7 OPERATIONS SAFETY ASSURANCE / OS

8 SAFETY SYSTEMS SWISS SAFETY CULTURE ORM (Operational Risk Management) Aircraft Data Acquisition System (ADAS) Event Measurement System (EMS) Project Management PragmaPlus SMS (Safety Management System) Operations Report (OR) / Air Safety Report (ASR) Cabin Report Ground Report Technical Report Confidential Safety and Security Report, Anonymous Report Feedbacks, Direct Communication, Discussions 8 OPERATIONS SAFETY ASSURANCE / OS

9 Overview of Operational Risk Management Framework ORM Operational Risk Management ORE Operational Risk Evaluation ORA Operational Risk Assessment Simple Risks: Individuals Very small groups (2-3) 30 Min - 1Hr SWISS Quality Manual Process O Produces Risk Evaluation Document Can lead to ORA Complex Risks: Workshop Expert groups (7-12) 4 Hrs + SWISS Quality Manual Process O Produces a Risk Assessment Report Optional Presentation 9 OPERATIONS SAFETY ASSURANCE / OS

10 ORA Example: Mixed Fleet Flying (MFF) 14 OPERATIONS SAFETY ASSURANCE / OS

11 IMPORTANT ATTRIBUTES OF ORA (and ORE as well) Diversität in der Gruppenzusammensetzung: Diversität stellt sicher, dass die Abweichungen der einzelnen Schätzungen sich gegenseitig ausgleichen und verschiedene Meinungen über die Thematik kombiniert werden. Resultate werden verständlicher. Unabhängigkeit der Gruppenmitglieder: Unabhängige Gruppenmitglieder garantieren, die Gruppenmeinung nicht durch Diskussionen in eine bestimmte Richtung beeinflusst oder verschoben wird. Mitarbeiter der selben Hierarchiestufe sind untereinander unabhängiger als von Vorgesetzten. Unbeeinflusste Aggregation der Meinungen: Das arithmetische Mittel aller Einzelschätzungen wird errechnet. Es stellt das Ergebnis des Gruppenentscheidungsfindungsprozesses dar. Allen Meinungen wird das selbe Gewicht beigemessen. Sie werden weder gewertet noch diskutiert, ausser zum Verständnis. Übereinkommen und Kompromisse behindern die Unabhängigkeit und verursachen oft Beeinflussungen. 15 OPERATIONS SAFETY ASSURANCE / OS

12 Method: Calibration and Consensus 16 OPERATIONS SAFETY ASSURANCE / OS

13 We, as Humans, will always have the last Word 17 OPERATIONS SAFETY ASSURANCE / OS

14 Flight Data Monitoring Example of Event Trigger OPERATIONS SAFETY ASSURANCE / OS

15 Flight Data Monitoring Example of Event Trigger 15 OPERATIONS SAFETY ASSURANCE / OS

16 Human Factors Die zentrale Herausforderung für die Sicherheitskultur Human Factor Risiko (Active Failure) IATA ACCIDENT CLASSIFICATION SYSTEM (HUM): H1 Intentional noncompliance Deliberate and intended deviation from operator procedures H2 Proficiency Flight crew performance failures due to deficient experience, knowledge or skills H3 Communication Miscommunication, misinterpretation or failure to communicate pertinent information; CRM H4 Procedural Unintentional deviation in the execution of operator procedures and/or regulations H5 Incapacitation Fatigue Flight crewmember unable to perform duties due to physical or psychological impairment 16 OPERATIONS SAFETY ASSURANCE / OS

17 Human Factors Die zentrale Herausforderung für die Sicherheitskultur - Organisations Risiko (Latent Conditions) - Safety Management - Training - Standards, Checking and Auditing - Communications - Technology and Equipment - Operational planning and scheduling - Change Management - Selection Systems - Managerial Environment 17 OPERATIONS SAFETY ASSURANCE / OS

18 Human Factors Die zentrale Herausforderung für die Sicherheitskultur Lösungsansätze Rekrutierung und Selektion Grundausbildung (Sicherheitskultur) Weiterbildung und Check HAD / CRM Selektion Ausbildung Weiterbildung Checksystem Crew Resource Management Flugdatenauswertung 18 OPERATIONS SAFETY ASSURANCE / OS

19 Safety Management KPIs SPIs PRODUCTION PROTECTION MANAGEMENT CULTURE 26 OPERATIONS SAFETY ASSURANCE / OS

20 Safety Performance Indicators / SPIs According to the Safety Management Manual (ICAO SMM) the level of safety is expressed through: Safety indicators Safety targets Acceptable level of safety 27 OPERATIONS SAFETY ASSURANCE / OS

21 Safety Performance Indicators / SPIs THE VISION: All SPIs shall represent the same percentage towards a target level of 100%: (Measured Value Acceptable Level) / (Target Level Acceptable Level) * 100 Target level Measured Value Acceptable level 28 OPERATIONS SAFETY ASSURANCE / OS

22 Safety Performance Indicators / SPIs An animation of possible states The SPI is on the 12 o clock position. Its value is zero. 29 OPERATIONS SAFETY ASSURANCE / OS

23 Safety Performance Indicators / SPIs An animation of possible states If the SPI performance drops below zero, then the acceptable level of safety is not met. 30 OPERATIONS SAFETY ASSURANCE / OS

24 Safety Performance Indicators / SPIs An animation of possible states As soon as the SPI performance becomes positive it is moving clockwise towards green, but remains critical in the first 15% of performance. 31 OPERATIONS SAFETY ASSURANCE / OS

25 Safety Performance Indicators / SPIs An animation of possible states This is the normal range of an SPI. In the green arc, with a trend to move towards the target level of safety. 32 OPERATIONS SAFETY ASSURANCE / OS

26 Safety Performance Indicators / SPIs An animation of possible states Finally, a full circle means the target of 100% has been reached. 33 OPERATIONS SAFETY ASSURANCE / OS

27 Safety Performance Indicators / SPIs SPI REPRESENTATION Not acceptable Caution Acceptable level Target-> Yearly evolution of one SPI for trend analysis. 34 OPERATIONS SAFETY ASSURANCE / OS

28 NORMALIZATION OF DEVIATION A SUBTLE MOVEMENT TOWARDS THE SAFETY MARGINS Warning flags: - Balance between production and protection favors production - Standards are defined that are virtually impossible to meet - Only performance KPIs, no widely disseminated safety targets (SPIs) - General acceptance of operational pressure as normal, justifying deviations from SOP - Stoppuhrmentalität - Each isolated element can be explained, justified - The overall big picture is often missed - MINDSET! 35 OPERATIONS SAFETY ASSURANCE / OS

29 NORMALIZATION OF DEVIATION A SUBTLE MOVEMENT TOWARDS THE SAFETY MARGINS 36 OPERATIONS SAFETY ASSURANCE / OS

30 THANK YOU FOR YOUR ATTENTION! Marco Müller, Head of Operations Safety Assurance Pete Steinmann, Head of Quality and Risk Management 30 OPERATIONS SAFETY ASSURANCE / OS