Implementing an Integrated SMS

“Development, Implementation, Output and Return”

Greg Wyght
VP Safety & Quality
CHC Helicopter Corporation
“CHC Integrated SMS - an Internal Review”

1. Challenge to Aviation, 4 Main Threats

2. The Design of an Integrated SMS
3. Start at the Top - Philosophical Approach
4. Structured Process & Basic Processes
5. Sub-Systems within the “Integrated System”
6. A Simple Four Step Approach to Initiatives
7. 11 Attributes of the IHST SMS Model
8. SQID Overview with SMS Trend Analysis
9. Return on Investment (ROI)
 Most Common Casual Factors
(The Top 4 are Human Error Related)

Top Causal Factors account for 80+% of Accidents:

#1 - Controlled Flight Into Terrain (CFIT)

(#1 for the past 7 years!!)

#2 - Pilot Procedural Error

(Human Error in the cockpit)

#3 - Release of an Un-airworthy Aircraft

into Service
(Human Error in Maintenance)

#4 - Mid Air Collision

(accounts for 2% of accidents)
 SMS Balances your Business Drivers
(Helps Executives set Healthy, Informed Business Goals)

“…an SMS can not be complicated…method of dealing with conflicting values...”

Kieron McFadyen

Business Management vs. Safety Management

Business Model SMS Model

Mission Goal
Vision Leadership Targets
Strategy Strategy

Implement Implement
Observe Observe
Functional
Analyze Analyze
Improve Improve
Purpose (Goal) of the SMS

Goal: To create and maintain a safe healthy working

environment for all CHC colleagues, passengers, and
visitors.

To achieve this goal, the Integrated SMS has three (3)

main disciplines:
1 To produce fully airworthy aircraft in a safe working
environment (Quality Assurance/Airworthiness);

2 To then operate those airworthy aircraft safely

(Flight Safety);

3 To ensure that all work activities undertaken are

progressed in a safe and environmentally responsible
manner (Occupational Health, Safety, Security & EMS)
 Mission, Vision and Strategy
Purpose of the Safety & Quality Department

Mission:
To provide Compliance Monitoring for all Safety & Quality related issues.

Vision:
To be unequaled as an advisory service ensuring all hazards are identified, assessed
and controlled to as low as reasonably practicable.

Strategy:
Our Mission shall be achieved through a corporate wide system which includes:

a) “closed loop” occurrence reporting,

b) standardized auditing,

c) corrective and preventative action tracking,

d) performance measurement.
 Integrated SMS

Designing the
Integrated Safety Management System (SMS)
 Three Prerequisites for an SMS

1. Corporate
Approach
to Safety

2. Effective 3. Systems to
Organization Achieve Safety
for Safety Oversight
1) Comprehensive Corporate Approach
A Commitment from the Top!
“An organization can’t help but take on the
character of it’s leader!”

“My Safety Philosophy” (Sylvain Allard):

1) All accidents are preventable

2) Management is “the art of control”

3) Accidents are examples of a loss of

control,
Therefore
4) Accidents are a “failure of management!”
5) Management must do what is reasonably
practicable to prevent accidents.
2) An Effective Organization for Safety
Corporate S&Q Organisation
CEO

VP Safety & Quality * VP & CFO Finance

VP GSS VP Human Resources

VP Legal Services VP Corp. Development - M&A

President President Managing Director

3 Main Disciplines
Heli One in Safety & Quality in CHC Operations:
Global Operations European Operations

1) Flight
Head of
Safety (TRI & TRE,HeadBase
of
Manager and FSO regionally).
Head of
Safety & Quality Safety & Quality Safety & Quality
2) Aviation Quality Assurance (Supervisory Engineers - Airworthiness).
Safety & Quality Mngr
Safety & Quality Mngr Safety & Quality Mngr
3) Occupational
America’s Health and Safety (HESS Manager or AME’s).
America’s UK

Safety & Quality Mngr Safety & Quality Mngr Safety & Quality Mngr
Europe SE Asia Ireland

HESS Manager Safety & Quality Mngr Safety & Quality Mngr
Europe Australia Denmark

Safety & Quality Mngr Safety & Quality Mngr

Africa Holland

Safety & Quality Mngr Safety & Quality Mngr

Mid East / FSU / India Norway

Safety & Quality Mngr Safety & Quality Mngr

Nigeria Survival Equipment

Safety & Quality Mngr Safety & Quality Mngr

Brazil Other
 2) An Effective Organization
Documenting the Integrated SMS
Integrated
Safety
Management
System New for CHC
Exposition
TC Did Not Complies with;
Like this Model 1) CAP 712, and
Integrated 2) ISO 9001, and
SMS Generic
SMS 3) ISO 14001, and
Compliance Safety
Compliance 4) Risk Mgnt Stds.
Procedures Case
Procedures
5) Customer Standards, &
6) TC Flight 2005

Emergency
JAR OPS 1 JAR OPS 3 Part 145 JAR FCL 2 HESS
Response
OPS OPS OMME JAR 147 Manual
Manual

Standard
Maintenance Standard Training Financial HESS Support
Maintenance Operating Training Financial HESS & ERP Support
Procedures Standard
Operating Procedures Procedures Procedures Procedures
Procedures Procedures
Maintenance Training Procedures
Procedures Financial Procedures
HESS & ERPProcedures
Support
Operating
Procedures Procedures Procedures Procedures Procedures Procedures
Procedures
 2) An Effective Organization
Communication Flow

Corp. Board
Level Review
Div.
Exec. S&Q Meeting
Level

BU Safety Steering Committee

Level Base Start-up Meetings
AOC Occurrence Review Board (ORB)
Level Fleet Review Meeting
Base Monthly HESS Meetings Tool Box Meetings
Level Passenger Safety Briefings Preflight Flight Planning Meetings
Surveys - Feedback from the Bases
3) Systems to Achieve Safety Oversight

• Occurrence & Hazard Reporting

• Non-Conformance Reporting

• Corrective & Preventative Action Tracking

• Event Investigation & Analysis

(OPEMS/MEMS)

• Safety, Quality & Environmental Auditing

• Flight Data Monitoring (FDM/FOQA/HOMP)

• HUMS (Health & Vibration Monitoring)

3) Systems to Achieve Safety Oversight
“Non-Punitive Reporting System”
 3) Systems to Achieve Safety Oversight
“Non-Punitive Reporting System”

Wind Direction

12
X
3) Systems to Achieve Safety Oversight
“Non-Punitive Reporting System”
3) Systems to Achieve Safety Oversight
“Selling an Initiative to Management”

CHC’ Risk Management Strategy is

built on a simple 4 step process;

1) Identify the Hazard - Audit, Occurrence Review or HAZID

2) Assess the Impact the Hazard may have on Operation

(quantify the impact in a language managers understand.)

3) Brain Storm Possible Controls – Staff Participation!!

4) Develop a “Business Case” for Implementation!

(What’s the cost of implementing vs. not implementing?)

E.g. #1 – S76 Blade Tip: Loss of Revenue (no penalty) $ 0

Cost of Parts (2 per year) $20,000
Annual Cost, nothing changed $20,000+
Cost of the “Intervention” $-10,000
Total savings in the first year $10,000
3) Systems to Achieve Safety Oversight
“Selling an Initiative to Management”

CHC’ Risk Management Strategy is

built on a simple 4 step process;

1) Identify the Hazard - Audit, Occurrence Review or HAZID

2) Assess the Impact the Hazard may have on Operation

(quantify the impact in a language managers understand.)

3) Brain Storm Possible Controls – Staff Participation!!

4) Develop a “Business Case” for Implementation!

(What’s the cost of implementing vs. not implementing?)

E.g. #2 – Malaria: Loss of Productivity $ 5,000

Airfare – Repatriation $28,000
Total Cost of Malaria $33,000
Cost of “Mosquito Trap” $ -8,000
Total savings if prevented $25,000
3) Systems to Achieve Safety Oversight
“Selling an Initiative to Management”
CHC’ Risk Management Strategy is
built on a simple 4 step process;
1) Identify the Hazard - Audit, Occurrence Review or HAZID

2) Assess the Impact the Hazard may have on Operation

(quantify the impact in a language managers understand.)

3) Brain Storm Possible Controls – Staff Participation!!

4) Develop a “Business Case” for Implementation!

(What’s the cost of implementing vs. not implementing?)

E.g. 3 – Mid-Air Collision: Loss of Revenue $ 2.4 Mil.

Potential Litigation Losses $140.0 Mil.
Airframe – Replacement $ 7.6 Mil.
Total Cost of an Accident $150.0 Mil.
Cost of TCAS in all Aircraft $ 1.8 Mil.
Likelihood of Realizing Loss 1 in 15 years
Annual Cost of not installing $ 10.0 Mil.
Total Savings(1st year) if prevented $8.2 Mil.
3) Systems to Achieve Safety Oversight
“Selling an Initiative to Management”
CHC’ Risk Management Strategy is
built on a simple 4 step process;
1) Identify the Hazard - Audit, Occurrence Review or HAZID

2) Assess the Impact the Hazard may have on Operation

(quantify the impact in a language managers understand.)

3) Brain Storm Possible Controls – Staff Participation!!

4) Develop a “Business Case” for Implementation!

(What’s the cost of implementing vs. not implementing?)

Other Examples: -Flu Shots for Family Members of Staff

-Simulators Dry Leased to allow for LOFT
-FDM installed in A/C in Nigeria, Brazil, etc.
-Garmin 530 (Moving Map) with TAWS
-Externally Mounted Life Rafts in the S76
-406/GPS Capable PLB’s, Strobes, Sea Markers
 What is the End Result of the System?
“We can determine we have reached ‘ALARP’”?
(ALARP - As Low As Reasonably Practicable”)

Catastroph Bankrupt
e cy
High
HighRISK
RISK High COST

Zero
ZeroCOST
COST Zero
RISK

Point of Diminishing Returns

(Greatest Reduction in Risk vs. Cost)
 What is the End Result of the System?
“We can determine we have reached ‘ALARP’”?

Managers use the Risk Assessment to build a business case – investing to reach ALARP
 What is the End Result of the System?
“We can determine we have reached ‘ALARP’”?

Business Management vs. Safety Management

Catastrophe Bankruptcy

RISK
RISK HIGH

COST
COST LOW

Point of Diminishing Returns

(Greatest Reduction in Risk vs. Cost)
 International Helicopter Safety Team (IHST)
(Go to “www.ihst.org/sms” for more detail)
“SMS Tool Kit” - the IHST’s 11 Attributes of an SMS

1) SMS Management Plan

2) Safety Promotion
3) Document and Data Information Management
4) Hazard Identification and Risk Management
5) Occurrence and Hazard Reporting
6) Occurrence Investigation and Analysis
7) Safety Assurance Oversight Programs
8) Safety Management Training Requirements
9) Management of Changes
10) Emergency Preparedness and Response
11) Performance Measurement and Continuous Improvement
Safety & Quality Integrated Database (SQID)
Consider the Landing Gear Event
Last Quarter SMS Performance
Reporting by Type of Report

Note all Report Types

are increasing month
on month.

- Aug 07 - Sept 07 - Oct 07

Last Quarter SMS Performance
Proactive & Reactive

Note the Proactive Reporting

is increasing as quickly as
Reactive Reporting.

This is a positive indication

that staff have a level of trust
that the “system” is working.
 Reporting Culture Index
Measures Number of Reports per 1000 Hours

We average between 10 and 20 reports

per 1000 hours.
Trend Analysis Function in SQID
Making Sense of SMS Data

The Flight Safety Report is another of

several reporting options built into SQID
to assist the user in the analysis of
Trends within the Integrated SMS.
Trend Analysis Function in SQID
Making Sense of SMS Data
Trend Analysis Function in SQID
Making Sense of SMS Data
Trend Analysis Function in SQID
Making Sense of SMS Data
 Trend Analysis Function in SQID
Second Scenario – What is the SMS Data telling us about Human Factors?

Organizational Supervision
Influences Problems Preconditions Errors and Violations

Note the three areas of

concern.

Does there seem to be

a logical connection?
 Trend Analysis Function in SQID
Second Scenario – What is the SMS Data telling us about Human Factors?

Note the three areas of

Concern circled in Black.

Does there seem to be

a logical connection?

CHC would also note the

areas circled in Red as the
weakness in Organization
Processes, and errors in
Personnel Training may
be related

For the purpose of this

exercise, lets drill down one
more layer to the Base level
in South East Asia.
 Trend Analysis Function in SQID
Second Scenario – What is the SMS Data telling us about Human Factors?

Note the concentration

of contributing Human Factors,
Covering each of the four levels
of HFACS.

Could poor “Organizational

Process”, and “Poor Supervision”
Set up “Poor working Conditions”
That are causing the errors
Seen in Songkhla?

Lets search the SQID database?

 Trend Analysis Function in SQID
Second Scenario – What is the SMS Data telling us about Human Factors?

CHC S&Q department assigned an investigator

to conduct a Tripod root cause analysis.

VP of Operations & Resources and VP of S&Q

Traveled to the base to conduct a review to
identify the underlying issues causing the
repeat occurrences.

The review identified the operation is:

a) straining to meet customer flight demand
b) not adequately supervised / managed
c) suffering lack of customer attention on
the facilities

CHC reviewing a change in the management

structure

The customer committed to reducing pressure

on crews, and to making appropriate changes
to their facilities.
Trend Analysis Function in SQID
Third Scenario – Comparing Aircraft Types of Variants.
Best Practice Function in SQID
Yesterday Scenario – EC155 suffers a structural failure.

22 Reports since
I left Vancouver.

Note 07-04666
 Best Practice Function in SQID
Yesterday Scenario – EC155 suffers a structural failure.

1) One of our post-holders informed by contact in industry, 2) Report uploaded to SQID

3) Alert sent from SQID to relevant managers 4) Post Holders around the world advised
5) Photos available to all when arriving at work. 6) Post Holders around the world advise crews
 Best Practice Function in SQID
Yesterday Scenario – EC155 suffers a structural failure.

1) One of our post-holders informed by contact in industry, 2) Report uploaded to SQID

3) Alert sent from SQID to relevant managers 4) Post Holders around the world advised
5) Photos available to all when arriving at work. 6) Post Holders around the world advise crews
 Best Practice Function in SQID
Yesterday Scenario – EC155 suffers a structural failure.

1) One of our post-holders informed by contact in industry, 2) Report uploaded to SQID

3) Alert sent from SQID to relevant managers 4) Post Holders around the world advised
5) Photos available to all when arriving at work. 6) Post Holders around the world advise crews
 All Accidents
All Types of Operations – Including Training Accidents

•2002 – S76 Training Accident

-AS332 Roll-over on Deck

•2003 – Pilot Disorientation (Single Pilot SAR)

•2004 – Landed Short due Torque Limiter (UN)

•2005 – Descended below the Glide Slope on ILS

•2006 – AS365 Impacted the sea during missed approach

(7 Fatalities)
Accidents each Year per 100,000 Hrs Flown
Yellow Bars shows the decreasing 5 year Rolling Average

2.00

1.80

1.60

1.40

1.20

1.00

0.80 R

0.60

0.40

0.20

0.00
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Series2 Series3
Accidents each Year per 100,000 Hrs Flown
With Trend Line Shown

Chart Title

2.50

2.00

1.50
Accident Rate
Log. (Accident Rate)

1.00

0.50

0.00
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
 Accident Rate Comparison

10 Accident Rate Benchmarking

2006 Data taken from IHST, and OGP “Air Safety Online” and “1998-2003 OGP”

8 6.80
Acc. Per 100,000

6
hours flown

4
2.60 5 Year Rolling
2 1.86 Average Ending May
2007

0.27 0.42
All Twin Off-shore Average
Helicopters Helicopters Operation CHC Major
Airline
 Air Safety Performance in Offshore Oil & Gas
Fixed Wing & Helicopter
(Over 1500 Aircraft Operators with well Over 1,000,000 flown per year)

Fatal Accidents/million hrs

Commercial airline 0.6

Commuter airline 2.0

Offshore helicopter transportation 6.4

General Helicopter Operations 23.0

 Accident Rate Comparison
per 100,000 Hrs Flown

25
Accident Rate Benchmarking
23.0 2007 Data taken from OGP Presentation
Provided by the OGP Aviation Subcommittee

20
Acc. Per 100,000
hours flown

15 10 Year Rolling Average

Fatal Accident Rate
Ending May 2007
10
6.4
5
0.20 0.17 0.06
All Off-shore Average Average
Helicopters Operation Commuter CHC Major
Airline Carrier
 Equipment Installed based on Lessons from the SMS
(CHC’s Trending looks at both internal and external SMS data and trends)

Accident Prevention Systems:

• EGPWS – the best system available to prevent CFIT
• TCAS/TCAD Traffic Collision Avoidance
• FDM - Flight Data Monitoring to enhance training and procedures
• HUMS/VXP – to monitor vibrations and health of the airframe
• Moving Map GPS with TAWS to enhance spatial orientation
• Enhanced Vision System – improve sight picture on approach as in corporate jets
• Electronic Flight Bags – to reduce cockpit distractions (administrative paperwork)
• Self contained FDM unit for older analog aircraft – to enhance training

Loss Mitigation Systems:

• ISAT – automatic satellite tracking and communication system
• Externally Mounted Life Rafts to ensure rafts are deployed during a ditching
• Automatically Deploying Floats – to reduce the risk of them not inflating
• Crash Position Indicators (CPI’s) – using satellites to locate aircraft faster
• Four way advanced Personal Locator Beacons in Crew Life Vest
• High back seats with four point harness
 CHC Safety & Quality Summit 2007
Managing Human Factors in an Integrated SMS Framework

•312 delegates from 140+ organizations and 27

countries

•18 instructors, 48 safety related courses in 3 days

•Consistent with CAST and the IHST’s goal of an 80%

reduction in accidents by 2016.

•Over half of the attendees indicated on their Summit

feed-back forms that the Summit was “the best
(aviation) safety training conference we’ve ever
attended”.
 Countries Represented at
CHC Summit 2007

- 27 Countries Represented at the Summit

 CHC Safety & Quality Summit 2008

“Practical Tools to Build your Safety Culture”

Leveraging your SMS to Reduce Human Error

March 31st to April 2nd 2008 in Vancouver

Key Note Speakers: Dr. Scott Shappell & Dr. Doug Weigman
Dr. Patrick Hudson, Dr. Bill Rankin, Dr. Peter Gardner
FSF, Boeing, Sikorsky, Eurocopter, ICAO, IATA, Bains & Simmons,
HAC, HAI, PHI’s Chief Pilot, Bristow/Airlog FDM, & more

Everyone is invited!
www.chcsafetyqualitysummit.com
 Safety & Quality Summit 2008
“www.chcsafetyqualitysummit.com”

Thank You