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Shell Aircraft international
Modelled Risk Scenarios for an Aviation SMS
Shell Aircraft International
Aviation Hazard Management Ltd
International Federation of Airworthiness
Shell Aircraft international
ICAO - SMS mandatory from 2009
UK Oil Industry - SMS mandated since 1992
Piper Alpha Disaster - Cullen Report
‘it was irresponsible to operate a business without understanding the risks and managing the hazards that
existed within that business’
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Aim: to produce a Transportable Hazard Analysis
SAI - Facilities, tools & models
UKFSC - expertise (pilots
& engineers)
Hazard Analysis Team
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HEMPHazard and Effects Management Programme
- Identify (the hazard, and hazardous events)
- Assess (the Risks)
Shell Aircraft international
Shell Aircraft international
HEMPHazard and Effects Management Programme
- Identify (the hazard, and hazardous events)
- Assess (the Risks)
- Control (the threats that might release the hazard that leads to the hazardous event)- Recover (from the hazardous event, if possible before incurring an unwanted consequence)
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HazardousEvent
HAZARDS
MITIGATION
THREAT
CONSEQUENCES
CONTROL
CONTROL
ESCALATION
ESCALATION
CONTROL
RECOVER
Manage / ControlThe causes
MinimizeThe results
The Bow-Tie Analysis Tool
www.bowtie.com
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Bow-Tie Shape
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Risk Scenarios
Team identified 450 potential eventsunmanagable number for detailed analysis
by generic grouping, combining threats & threat controls
reduced list of 35 separate Risk Scenarios
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Example of Bow-TieXP as an analysis tool
Aircraft in motion
Aircraft deviates from intended safe flight path
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Who does What, Why and How?
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Shell Aircraft international
Shell Aircraft international
Shell Aircraft international
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Shell Aircraft international
Human Error
Release of an Unairworthy Aircraft to Service
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Shell Aircraft international
Hazard Modelling
Using HEMP the team focused on Hazardous Events
HazardousEvent
‘Potential hazardous events are what need to be risk assessed, rather than the hazard itself’
Test needed to check for gaps
Shell Aircraft international
Shell Aircraft international
LocationsLocation A - Aircraft on the ground in preparation for or recovery from service
Location B - Aircraft in motion - on the ground
Location C - Aircraft in Motion - Airborne
Location D - Aircraft Undergoing Maintenance
Location E - Offices and Facilities
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Hazardous Events - Example of coding
HE 18ACD - Loss of Containment - Dangerous Goods
HE = Hazardous Event
18 = sequential by discipline (except 1 & 2)
ACD = Locations
Disciplines - Operational, Maintenance, HSE related, Organisational & Management
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HE 1CDeviation from intended safe flight path‘Situations causing a signicant departure from a safe, intended heading, altitude, speed, flight level and or track’.
GENERIC PRIMARY OPERATIONAL HAZARDOUS EVENTS
HE 2ADRelease of an unairworthy aircraft to service‘Situations resulting in the inadvertent release of an aircraft following maintenance, or servicing actions, which is not fully airworthy’.
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Operational HE 4BC - Aircraft major system failures including dynamic failure of components
Maintenance HE 19D - Lost of containment fluid or gas under pressure
HSE Related HE 22 AD - Encountering adverse weather conditions
Organisation &Management
HE 30E - Contracted corporate commitments at variance to company resources
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These generic analyses can be customised for use by any
aircraft operator