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AVIATION HAZARD MANAGEMENT

Risk Assessment &


Hazard Management
Cliff Edwards
Aviation Safety Consultant
Aviation Hazard Management Ltd

Sponsored by Shell Malaysia Exploration & Production

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AVIATION HAZARD MANAGEMENT

Risks and Hazards


These are not new concepts to aviation, but
have been dealt with covertly.
The most significant change that SMS brings
is that now the accountable manager must
accept the risks of the organisation and
demonstrably manage these to acceptable
levels, or personally hold the liability for
those risk.
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AVIATION HAZARD MANAGEMENT

Hazards & Risks what are they?


A hazard is something with the potential to
cause harm, therefore, it must have energy in
its own right.
Risk in its simplest term is a calculation, it is
the measure of how often something might
happen and how bad it might be.
(Frequency x Consequence).
A third key term used in this process, is threat.
Threats cause the release of hazards.
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AVIATION HAZARD MANAGEMENT

Risk Assessment

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AVIATION HAZARD MANAGEMENT

Risk Management
It is not possible to be free of risk, nor is it desirable.
However, the risks should be understood and manageable.
Assessment of risks requires a process that is measurable and
can be reliably used repeatedly.
In operation hazard do get released and a hazardous event
occurs, you need to know what are the potential events and
how they might effect your operations.
It is essential for a company to be prepared to deal with the
hazardous event and their potential consequences.
In reality it is the hazardous events that are normally risk
assessed, not the hazard itself.
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AVIATION HAZARD MANAGEMENT

Risk Assessment
The purpose of risk assessment is to clearly establish the
dimensions of the risks faced, both :
To rank them in order of importance and.
To bring them to senior managements attention.

Senior management are accountable for the risks and the


provision of risk reducing measure to bring these to
acceptable levels.
Therefore, it is important that a reliable, repeatable
process backed up with the best available data is used to
do the risk assessment.
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AVIATION HAZARD MANAGEMENT

Risk Assessment
Two basic approaches to risk assessment:
Quantitative
Systematic assessment using facts to accurately calculate
the frequency of each potential outcome in terms of
severity.
Typically this is done during aircraft design and build to
assess the potential failure rate of all critical parts.
Qualitative
Assessment through expert opinion, informed by evidence
of past incidents/accidents and failure rates.
This is the preferred method for Risk Assessment in SMS
systems.
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AVIATION HAZARD MANAGEMENT

Risk Assessment Matrix


Increasing Probability

Potential Consequence of the Incident


A
Rating

People

Environ-

Assets

Reputation

the aviation

ment

Industry

No
injury

Zero
Effect

Zero
damage

Slight
injury

Slight
Effect

Slight
damage <
US$ 10K

Minor
injury

Minor
Effect

Minor
damage <
US$ 50K

Limit ed
Impact

Serious
injury

Localised
Effect

Local
damage <
US$ 250K

Considerable
Impact

Single
fatality

Major
damage <
US$ 1M

National
Impact

Multiple
fatality

Extensive
damage >
US$ 1M

International
Impact

Major
Effect
Massive
Effect

Not Known in

B
Known to
have
occurred in
aviation

C
Occurred in
your
company

Occurred
more than 3
times in
company

E
Occurred
more than 3
times in 1
location

No Impact
Slight
Impact

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ro -MS
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a
an al ures
M rm d
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e
o
N roc
ate
r
p
po n
r
co io
in uct re
d
re easu
m
le
b
a
er
l
to
n
I
Assessment

C5

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Hazard Management

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Hazard Management
The concept of Risk or Hazard management is based on the
following steps.
Identify potential sources of harm (Hazards).
Evaluate the worst case potentially of each hazard (Risk
Assessment).
Identify all undesirable events or circumstances associated
with each hazard which could result in harm being caused
(Threats).
Develop or improve appropriate measures to prevent
occurrence (Controls).
If possible return the situation to ops normal or reduce the
impact incurred (Mitigation Measures).
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AVIATION HAZARD MANAGEMENT

How to Identify Hazards


Learning from Incidents: Learning from incidents is helpful
but is not systematic and expensive, but when they occur you
do need to learn.
Hazid: A Hazid (Hazard identification) is a facilitated
brainstorming session with a team of subject matter experts
(pilots or engineers).
Hazop: A Hazop (Hazard Operability) is a systematic review
of all business processes (time consuming, but very
systematic).
Generic Hazard Models: There are a small number of generic
hazard models available and these can significantly reduce the
manpower hours needed to do this work.
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AVIATION HAZARD MANAGEMENT

HAZID Process
Scope
Scope the change define what the
objective is intended to achieve
when the change is implemented.
Action and Review

Appoint

Allocated Action Parties act and report


the achievement of the plan and measure
if the expected benefits are delivered.
Document

Appoint a team of subject matter


experts, a trained facilitator and a
recorder for the brainstorming
session.

A Plan for the achievement of the


actions identified in the brainstorming,
especially the critical paths.

Brainstorm
What could go wrong with the
planned changes.

Summarise
The brainstorming session and where possible
what controls are needed to manage the perceived
problem areas. Identify the critical paths,
milestones and targets.
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AVIATION HAZARD MANAGEMENT

Hazard Management Methodology


Hazard and Effects Management Process (HEMP)
Are people,
environment
or assets exposed
HEMP
processes
were
developed
by the
Identify
to potential harm?
Nuclear Industry,
this is a four part process:

Assess

What are the causes and consequences?


How likely is loss of control?
What is the risk and is it ALARP?
Can the causes be eliminated?

Control

What controls are needed?


How effective are the controls?

Recover

What recovery measures are needed?


Are recovery capabilities suitable and sufficient?
Can the potential consequences be mitigated?

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AVIATION HAZARD MANAGEMENT

HAZARDS
HAZARDS

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HAZARDS
CFIT, Fuel
Human Error
Unairworthy
Aircraft

Redundant
Systems

Threat

Physical
Barriers

Threat

Classic
Hazard Accountability
Training
Model
Competencies
Threat

Procedures
Threat

Awareness

Assurance

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Hazard Controls
Controls are typically those already used in aviation such as:
Procedures
Regulations
Checklists
Briefings
Challenge and Response
Competency
System Redundancy
Physical Barriers
Supervision
Two crew operations
Training
Maintenance
Standards
Effective planning
Audits
Housekeeping
Awareness
Security
Management & leadership
Team working
Personal Protective Equipment
Medicals
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Bow Tie Analysis Tool


e
v
i
t
c
a
e
R

tive
Control

Escalation
Factor

Threat control

Threat

Hazard

Hazardous
Event

Recovery

Pro
ac

HEMP Process Tool


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AVIATION HAZARD MANAGEMENT

TIGER
Cage Door Locking
System
Twin Locks & Warning
Lights
Unserviceable System
Records & Maintenance

Simple
Example of
the Bow-Tie

Hazard
Threat
Control
Escalat
ion
Control

Tiger out of
the Cage

Shoot Tiger, or drive back in


cage
Miss Tiger, or Tiger Evades
Keeper
Competent Keepers

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Recovery
Escalation
Control
Consequence
Mitigation

Tiger Bites Keeper


Effective
Emergency
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Response Plan

AVIATION HAZARD MANAGEMENT

Life Cycle Locations of an Aircraft Operation in


Hazard Management Terms
All phases of flight

Taxiing
Preparation for flight

Maintenance

Taxiing

Head Office
Using the Bowtie approach it is the recovery measures that determine the
need for a separate hazardous event analysis, and these are dependant on
the location.
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AVIATION HAZARD MANAGEMENT

Deviation from

Aircraft

Deviation from

Intended Aircrew

Systems Failures

Intended

Flight Training

Inc. Dynamic

Aircraft Air-test

Failures

Missions

Missions

Loss of

Proximity

containment

to a Third

of Dangerous

Party or

Goods

Obstacle
Flammable
Materials

in proximity to a

Hazardous Event Map

Aircraft Deviates

Loss of

Exceedance of

from Intended

Separation with

Aircraft

Flight Path

other Aircraft

Limitations

Unairworthy

Aircraft Deviates

Static Out of

Aircraft Released

from Intended

Balance

to Service

Ground Track

situations

source of ignition

Encountering

Uncontrolled

Encountering

Loss of

proximity of

Adverse Weather

containment

GSE to Aircraft

Conditions

of fuel or oil

Loss of

Interface with

containment

Suppliers

of fluid and gas


under pressure

Unexpected
External
Conditions

Uncontrolled
people in close
proximity to an
Running engine

Use of unsafe
lifting
equipment

Interface with

Encounter

Interface with

Maintenance

with a potential

Air Charter

Contractors

HSE occurrence

Carriers

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AVIATION HAZARD MANAGEMENT

Engineer to carry out


night maintenance EXAMPLE
task

SMS MANAGEMENT

Resource planning
Working time
Staff competencies
allocates enough time limitations regulated checked against profi
QA department does
random night audits

Effective task cards


available
Worksheet completion
informative & correct
Handover of work is
Tell me Show me
Post maintenance
checks always done

Night Shift Supervisor


To monitor task progress

Compliant practices Workplace culture


always used
supportive

Management accountabilities clearly und


Hazardous events identified
Risk assessments carried out and report
Controls identified, tested and monitored
Systematic audit programme in place
Management reviews carried out routine

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AVIATION HAZARD MANAGEMENT

Using Bowtie Software


BowTieXP
www.bowtiexp.com

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AVIATION HAZARD MANAGEMENT

What are my
hazards?
What happens when the hazard
is released?
What happens when control is
lost?
Hazardous or
Top Event

What causes the hazard


to be released?
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How can the event


develop?
What are the potential
outcomes?

How can control


be
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lost?

AVIATION HAZARD MANAGEMENT

How do we prevent the hazard


from being released?

How do we limit the severity


of the event?

How do we keep control?

How do we minimise the


effects?

Hazard

Hazardous
or Top
Event

How might controls fail?


How could their effectiveness
be undermined?

How do we make
sure controls do not
fail?

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AVIATION HAZARD MANAGEMENT

Hazard

Hazardous
or Top
Event

What tasks do we do to make sure


the control continues to work?
Include design, operations,
maintenance, management.
Tasks

Management System

Audit

How do we verify that the


tasks have been done?

Compliance
Monitoring

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AVIATION HAZARD MANAGEMENT

Aircraft
deviates from
intended safe
flight path

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AVIATION HAZARD MANAGEMENT

Aircraft
deviates from
intended safe
flight path

Air Safety, Safety Management Systems, Human Factors in Aviation Management, Continuing Airworthiness
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AVIATION HAZARD MANAGEMENT

Aircraft
deviates from
intended safe
flight path

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AVIATION HAZARD MANAGEMENT

Aircraft
deviates from
intended safe
flight path

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Active Safety
Management

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Page 29

AVIATION HAZARD MANAGEMENT

Aircraft
deviates from
intended safe
flight path

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AVIATION HAZARD MANAGEMENT

Aircraft
deviates from
intended safe
flight path

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