Integrated Safety Managment System

Implementing an Integrated SMS“Development, Implementation, Output and Return”

Greg WyghtVP Safety & QualityCHC Helicopter Corporation

“CHC Integrated SMS - an Internal Review”

1. Challenge to Aviation, 4 Main Threats2. The Design of an Integrated SMS3. Start at the Top - Philosophical Approach4. Structured Process & Basic Processes5. Sub-Systems within the “Integrated System”6. A Simple Four Step Approach to Initiatives7. 11 Attributes of the IHST SMS Model8. SQID Overview with SMS Trend Analysis9. 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)

Business Management vs. Safety Management

Business Model SMS ModelMission GoalVision TargetsStrategy Strategy

Leadership

Implement Implement

Observe Observe

Analyze AnalyzeImprove Improve

Functional

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

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

2 To then operate those airworthy aircraft safely (Flight Safety);

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:

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.

Designing the Integrated Safety Management System (SMS)

Integrated SMS

Three Prerequisites for an SMS

3. Systems toAchieve Safety

Oversight

2. EffectiveOrganizationfor Safety

1. Corporate Approach to Safety

“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,

Therefore4) Accidents are a “failure of management!”

5) Management must do what is reasonably practicable to prevent accidents.

1) Comprehensive Corporate ApproachA Commitment from the Top!

PresidentGlobal Operations

CEO

Managing DirectorEuropean Operations

PresidentHeli One

VP Corp. Development - M&A

VP Safety & Quality * VP & CFO Finance

Head of Safety & Quality

VP Legal Services

Head of Safety & Quality

Head ofSafety & Quality

Safety & Quality MngrSE Asia

Safety & Quality MngrAustralia

Safety & Quality MngrAmerica’s

Safety & Quality MngrAfrica

Safety & Quality MngrMid East / FSU / India

Safety & Quality MngrNigeria

Safety & Quality MngrUK

Safety & Quality MngrIreland

Safety & Quality MngrDenmark

Safety & Quality MngrHolland

Safety & Quality MngrEurope

Safety & Quality MngrAmerica’s

VP Human Resources

Safety & Quality MngrNorway

VP GSS

2) An Effective Organization for SafetyCorporate S&Q Organisation

Safety & Quality MngrSurvival Equipment

Safety & Quality MngrBrazil

Safety & Quality MngrOther

HESS ManagerEurope

3 Main Disciplines in Safety & Quality in CHC Operations:1) Flight Safety (TRI & TRE, Base Manager and FSO regionally).2) Aviation Quality Assurance (Supervisory Engineers - Airworthiness).3) Occupational Health and Safety (HESS Manager or AME’s).

2) An Effective Organization Documenting the Integrated SMS

New for CHC

Complies with;1) CAP 712, and2) ISO 9001, and3) ISO 14001, and4) Risk Mgnt Stds.5) Customer Standards, &6) TC Flight 2005

JAR OPS 1OPS

JAR OPS 3OPS

Part 145OMME

JAR FCL 2JAR 147

HESSManual

EmergencyResponse

Manual

MaintenanceProcedures

StandardOperating

Procedures

TrainingProcedures

FinancialProcedures

HESSProcedures

SupportProceduresMaintenance

Procedures

StandardOperating

Procedures

TrainingProcedures

FinancialProcedures

HESS & ERPProcedures

SupportProceduresMaintenance

Procedures

StandardOperating

Procedures

TrainingProcedures

FinancialProcedures

HESS & ERPProcedures

SupportProcedures

HESS & ERPProcedures

HESSManual

GenericSafetyCase

IntegratedSafety

ManagementSystem

Exposition

SMSComplianceProcedures

GenericSafetyCase

IntegratedSafety

ManagementSystem

Exposition

Integrated SMS

ComplianceProcedures

EmergencyResponse

Manual

TC Did NotLike this Model

2) An Effective Organization Communication Flow

Monthly HESS Meetings Tool Box MeetingsPassenger Safety Briefings Preflight Flight Planning Meetings

Occurrence Review Board (ORB)Fleet Review Meeting

Safety Steering CommitteeBase Start-up Meetings

Exec. S&Q Meeting

BoardReview

Base Level

AOCLevel

BU Level

Div.Level

Corp. Level

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”

X

Wind Direction

12

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

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) $ 0Cost of Parts (2 per year) $20,000Annual Cost, nothing changed $20,000+Cost of the “Intervention” $-10,000Total 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 $ 5,000Airfare – Repatriation $28,000Total Cost of Malaria $33,000Cost of “Mosquito Trap” $ -8,000Total 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 yearsAnnual 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

3) Systems to Achieve Safety Oversight “Selling an Initiative to Management”

What is the End Result of the System?“We can determine we have reached ‘ALARP’”?

Bankruptcy

Catastrophe

High RISKHigh RISK

Zero RISK

High COST

Point of Diminishing Returns(Greatest Reduction in Risk vs. Cost)

(ALARP - As Low As Reasonably Practicable”)

Zero COSTZero 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’”?

BankruptcyCatastrophe

RISKRISK

LOW

HIGH

Point of Diminishing Returns(Greatest Reduction in Risk vs. Cost)

COSTCOST

Business Management vs. Safety Management

International Helicopter Safety Team (IHST) (Go to “www.ihst.org/sms” for more detail)

1) SMS Management Plan2) Safety Promotion3) Document and Data Information Management4) Hazard Identification and Risk Management5) Occurrence and Hazard Reporting6) Occurrence Investigation and Analysis7) Safety Assurance Oversight Programs8) Safety Management Training Requirements9) Management of Changes10) Emergency Preparedness and Response11) Performance Measurement and Continuous Improvement

“SMS Tool Kit” - the IHST’s 11 Attributes of an SMS

Safety & Quality Integrated Database (SQID)

Consider the Landing Gear Event

Last Quarter SMS PerformanceReporting by Type of Report

Note all Report Typesare increasing monthon month.

- Aug 07 - Oct 07- Sept 07

Last Quarter SMS PerformanceProactive & Reactive

Note the Proactive Reporting is increasing as quickly asReactive Reporting.

This is a positive indication that staff have a level of trust that the “system” is working.

Reporting Culture IndexMeasures Number of Reports per 1000 Hours

We average between 10 and 20 reports per 1000 hours.

Trend Analysis Function in SQIDMaking 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 SQIDMaking Sense of SMS Data

Trend Analysis Function in SQIDMaking Sense of SMS Data

Trend Analysis Function in SQIDMaking Sense of SMS Data

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

Note the three areas ofconcern.

Does there seem to be a logical connection?

Organizational Influences

SupervisionProblems Preconditions Errors and Violations

Note the three areas ofConcern circled in Black.

Does there seem to be a logical connection?

CHC would also note the areas circled in Red as the weakness in OrganizationProcesses, and errors inPersonnel Training may be related

For the purpose of this exercise, lets drill down onemore layer to the Base level in South East Asia.

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

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

Note the concentrationof 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 SQIDSecond 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&QTraveled to the base to conduct a review to identify the underlying issues causing therepeat occurrences.

The review identified the operation is:a) straining to meet customer flight demandb) not adequately supervised / managedc) suffering lack of customer attention on

the facilities

CHC reviewing a change in the management structure

The customer committed to reducing pressureon crews, and to making appropriate changesto their facilities.

Trend Analysis Function in SQIDThird Scenario – Comparing Aircraft Types of Variants.

Best Practice Function in SQIDYesterday Scenario – EC155 suffers a structural failure.

22 Reports since I left Vancouver.

Note 07-04666

Best Practice Function in SQIDYesterday 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 advised5) Photos available to all when arriving at work. 6) Post Holders around the world advise crews

Best Practice Function in SQIDYesterday 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 advised5) Photos available to all when arriving at work. 6) Post Holders around the world advise crews

Best Practice Function in SQIDYesterday 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 advised5) Photos available to all when arriving at work. 6) Post Holders around the world advise crews

All AccidentsAll 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 FlownYellow Bars shows the decreasing 5 year Rolling Average

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

1.60

1.80

2.00

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

Series2 Series3

R

Accidents each Year per 100,000 Hrs FlownWith Trend Line Shown

Chart Title

0.00

0.50

1.00

1.50

2.00

2.50

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

Accident RateLog. (Accident Rate)

Accident Rate Comparison

10

8

6

4

2

All Helicopters

Twin Helicopters

Off-shoreOperation

10

8

6

4

2

All Helicopters

Twin Helicopters

Off-shoreOperation

6.80

2.601.86

CHC

0.27

Accident Rate Benchmarking2006 Data taken from IHST, and OGP “Air Safety Online” and “1998-2003 OGP”

Acc.

Per

100

,000

hour

s flo

wn

5 Year Rolling Average Ending May 2007

AverageMajorAirline

0.42

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

All Helicopters

Off-shoreOperation

AverageCommuter Airline

25

20

15

10

5

All Helicopters

Off-shoreOperation

23.0

6.4

CHC

0.20 0.17

Accident Rate Benchmarking2007 Data taken from OGP Presentation

Provided by the OGP Aviation Subcommittee

Acc.

Per

100

,000

hour

s flo

wn 10 Year Rolling Average

Fatal Accident Rate Ending May 2007

AverageMajorCarrier

0.06

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 2007Managing 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 WeigmanDr. 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