Safety Management System A True Partnership. Michael R. DiLollo- Martin Gauthier

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2 Safety Management System A True Partnership Michael R. DiLollo- Martin Gauthier

3 Agenda Introduction Who is Air Transat? Transat s Financial Performance Why SMS? Overview of our Quality Safety Management System (QSMS) Lessons learned from our 2 years of experience Next steps

4 Introduction Air Transat is subsidiary of a vertically integrated organization, Transat AT the eight largest travel company in the world. Transat TRZ is traded on the Toronto Stock Exchange (TSE) 2003 revenue 2.1 Billion $CDN Fleet of 13 wide-body aircraft (Airbus 310, 330) 1800 Employees (250 Pilots) The implementation of SMS was fast-tracked by the events of August 2001 ** in CDN $

5 Overview of Our Quality Safety Management System (QSMS) Multi lateral initiative between management, unions, employees, and Transport Canada in February 2002 (Regulator) It is a component of a Management Control System that deals with Quality and Safety With the components of the QSMS, a just safety culture can be created and ultimately continuously improved upon but change is not so easy (Everyone s view)

6 The Components of QSMS Accountable Executive Safety Management Plan Safety Oversight reactive & Proactive Training Quality Assurance/SMS Evaluation Documentation Emergency Response Plan

7 Key Elements for successful implementation Commitment TRUST at all levels Good labour relations Common goals, objectives and vision Union, management, employees, regulator Focused Leadership Effective Communication Measurements

8 The ft view of Quality Safety Management System (QSMS) Related Programs What? & Why? Audits & LOSA QSMS FDM QSAP What? Why? Legend: QSAP- Quality Safety Action Report LOSA- Line Oriented Safety Audits

9 Change, how difficult can it be? Shallow Operational What we are doing is right - we just need to do it better - no change to mission, values, strategy Deep Strategic Cultural The fundamentals are right - but we need to refocus - change objectives, strategies, possibly mission We have to change the way that we think and act - change vision, values and leadership Deepest Paradigm We have to recreate the business - or disappear - change, redefine and recreate the total enterprise Degree of difficulty

10 Change Vehicles: Different Levels of Intervention Operational Restructure Reengineer Rightsize Focus on efficiency Strategic Improve business planning Restructure service portfolio Realign facilities/processes Focus on effectiveness Cultural Change leadership Change vision and values Change performance drivers Paradigm Redefine the business Change definition of success Focus on attitudes/beliefs Focus on survival

11 The Reality of Deep Change Change is toughest when... A long track record of success An entrenched culture No crisis! Therefore Either the leadership has to change, or the leadership has to change.

12 Acceptance or True Value Shift? Performance Level Focus, Focus, Focus. Value Shift Belief Creative Application Acceptance Understanding Rejection Awareness Time

13 Some of our results - The reporting culture is increasingly healthy Air Safety Reports 2002 vs 2003 (Fiscal) Report frequency / 100 Segments Target Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct

14 Risk aggregate - all functions Risk Distribution 2002 VS 2003 Per 100 Segments Severe High Med Low Min CUM Year Previous Year

15 Accidents - material damage Material Damage Per 100 Segments Accident reported Direct cost USD $10, $8, $6, $4, $2, $-

16 Lessons Learned Change before you must, act quickly and maintain momentum Focus Create a shared understanding, build trust, involve employees Communicate Realize that past successes can breed inflexibility and arrogance Cultural change is getting people s heart and mind moving in the same direction Emphasis on the «Why» and not on the «Who» The Regulator s role is paramount (breaking the blame storming and promoting the brain storming)

17 Lessons Learned (cont d) Regulators role in bridging the issues between H&S issues and Safety issues Chose your champions commensurate with their competencies Celebrate small successes Safety is good business

18 Next Steps Deployment of a phased, competency based training program integrating employees, mangers and executives in the effective application of the components and the elements of the QSMS Implementation of an integrated Quality Management System Update of our safety management system database Decentralization of the flight safety department Augmenting the effectiveness of programs Documentation updates CASS Apr2004_FDM.ppt

19 In closing. Like a fine wine which is nurtured in the correct environment, Safety will improve with age. THANK YOU, MERCI

20 Integrated Safety Oversight and Management Jim Ballough Director FAA Flight Standards Service

21 Topics Systems, Processes, & Management System Safety ATOS Safety management Systems Integrated Safety Management Systems 2

22 What s s a System? A system is a composite of people, tools, procedures, materials, equipment, facilities, and software operating in a specific environment to perform a specific task or achieve a specific purpose, support, or mission requirement. Systems People Tools Procedures - Roland and Moriarty, System Safety Engineering and Management Software Equipment Facilities Materials...a set of components that act together as a whole to achieve a common goal 3

23 Processes A set of interrelated activities that convert inputs into outputs (ISO ) If you can t describe what you re doing as a process you don t know what you re doing. -W. Edwards Deming 4

24 Organizational Systems Aviation Systems (AS) are Organizations Their primary components are People Their processes are the sets of Activities that the people perform to accomplish the organization s goals Their Structures are the manner in which their people interact and how they do their jobs This necessitates an Organizational Focus to analysis and management of the system 5

25 Aviation Systems - Production Aviation systems are the systems that convert inputs to outputs to provide goods and services to customers Productive systems also consume resources and work in defined, sometimes rapidly changing business and operational environments Modern aviation systems are often complex, frequently changing networks of suppliers and other service providers, e.g.: Contract maintenance and training Ramp services Engineering and technical services Code shares, wet leases and alliances Business support (e.g. IT, admin) 6

26 Oversight Systems - Protection Basic Compliance Quality Control (QC) System Safety Process/Quality Assurance (QA) Regulatory Components Voluntary Components Traditional oversight systems stressed external (FAA) oversight and a one size fits all compliance approach Future oversight must be collaborative and tailored to system needs 7

27 Operational Environments Each system operates in a specific environment Environments include: The physical environment The business and economic environment The national and cultural environment The resource environment The regulatory environment Systems must continually adapt to changes in their environment to operate efficiently, profitably, and safely 8

28 Open Systems The modern aviation system is characterized by: Environmental complexity Environmental turbulence Change is constant, frequent, and significant Adaptation of the productive system to the market environment is a recognized business reality Adaptation of the safety system to the current operational environment is also necessary 9

29 Safety and Quality Safety is an an outcome of an organization s processes Safety management is really the result of management of process quality Managing the fundamental properties of process quality is the key to safety Safety Management is based upon quality management principles 10

30 System Safety Process Risk Management Define Define Objectives Objectives Hazard Hazard Identification: Identification: Identify Identify Hazards & Hazards Consequences & Consequences System Descriptions System Descriptions Risk Analysis: Risk Analysis: Analyze Hazards Analyze & Hazards Identify & Risks Identify Risks Risk Risk Assessment: Assessment: Consolidate & Prioritize Risks Consolidate & Prioritize Risks System/Process Review System/Process Review Yes Documentation Decision Decision Making: Making: Develop an Develop Action an Plan Action Plan Validation of Validation Control: of Control: Results for Further Action Results for Further Action No Modify Modify System/Process System/Process 11

31 Air Transportation Oversight System (ATOS) System safety approach to regulatory compliance and enhanced safety management Organizes regulatory structure into 7 systems, 14 subsystems, and ~100 elements Each element evaluated for design of processes (systems), implementation of systems and system performance Structured instruments (Data Collection Tools) used Each element is evaluated in six areas (six system attributes) Risk targeting tools included based on SSPM 12

32 ATOS Systems & Sub-Systems Systems Aircraft Configuration Control Manuals Flight Operations Personnel Training & Qualifications Route Structure Flight, Rest, & Duty Time Technical Administration Aircraft Manual Requirements Programs & Procedures Maintenance Personnel Qualification Approved Routes & Areas Airman & Crew Limitations Key Personnel Records & Reports Dispatch & Release Training Programs Maintenance Personnel Other Programs Organization Crew & Dispatch Qualifications Mechanic & Repairman Certification 13

33 Air Carrier Operations System Model (ACOSM) Systems and Subsystems System Management Flight Operations Maintenance Inspection Engineering Training (Maintenance, Crew, Other) Resource Management Planning Passenger Services Maintenance Management & Control Training Requirements Management Resource Requirements Analysis Policy & Procedure Development Cargo Handling Maintenance Quality Assurance Training Design & Development Resource Control & Procurement Operational Control Ground Operations & Services Aircraft Maintenance Training Delivery Material Handling & Distribution Information Management Aircraft Operations Engineering Support Training Evaluation Human Resource Management 14

34 Processes Happen Responsibility/Authority (Management Responsibility) - Who will make it happen? Procedures How will we make it happen? Controls How will we make sure the right things happen and the wrong ones don t? Process Measures How will we tell what happened? Interfaces Making it all happen together. 15

35 Risk Management System Validation Risk Targeting Evaluate environment Evaluate system design Identify Hazards/system deficiencies Evaluate resources Analyze/Assess risk Evaluate Performance Take action to mitigate risk (defenses) Validate defenses Safety Management is not an add-on, but an essential part of the system s core business. - James Reason 16

36 ATOS Toolset System assessment tools (Safety Needs and Status) System Safety Assessment Tool (SSAT) Air Carrier Assessment Tool (ACAT) System evaluation tools (System Validation) Safety Attribute Inspection (SAI) Element Performance Inspection (EPI) Risk Management Tools (Risk Targeting) Risk analysis/assessment ( Mod 7 ) Action Planning ( Mod 8 ) 17

37 Good Safety is Good Business Safety and Quality Management Systems Integrated Quality Management System (QMS) and Safety Program A means for the organization to manage safety efforts Stresses a comprehensive approach that is a part of the organization s business plan Based on JAR-OPS and Quality System guidelines Several countries have developed regulations and/or advisory material including: Canada Australia United Kingdom New Zealand (Internal Quality Assurance) 18

38 Aviation Safety Oversight Processes System Configuration Control System Validation Risk Targeting Regulatory Surveillance Investigation Reports Voluntary Cert holder DB FOQA ASAP VDRP Information Influence Regulatory Certification Enforcement Presence Voluntary Education Diplomacy AS Environment Inputs AS Mgmt Core Fly Fix Train Risk Outputs Support Fix Train Supply Safety Management and Oversight System Processes (SMS/OS) Protection Relational Processes Aviation System Processes (AS) Production 19

39 ATOS or SMS? Answer: Yes! However, the title should be ATOS and SMS ATOS provides: Regulator s (FAA) system for safety oversight Technical content for evaluation of the AS via the SMS SMS provides: A management system for the certificate holder to oversee their own safety of operations A more proactive means of interacting with FAA 20

40 Information Influence OS (e.g. ATOS) Relational Processes System Configuration Control System Validation Risk Targeting AS Protection SMS Production Safety / Quality Management and Oversight 21

41 SMS Core Functions Safety Management Policy Measurable Objectives Management and Other Organizational Responsibilities Safety Risk Management Practices and Procedures Auditing, Assessment, and Evaluation, Information Management Data Analysis Safety Action (Corrective, Preventive, Emergency) Resource Management Training of Personnel 22

42 Voluntary Programs Collaborative programs for information and influence Established programs (AFS-230): Advanced Qualification Program (AQP) Flight Operational Quality Assurance (FOQA) Aviation Safety Action Program (ASAP) Voluntary Disclosure Reporting Program (VDRP) Internal Evaluation Programs (IEP, under consideration) Joint Quality Review Team (JQRT; UAL CMO-OPS) Joint accomplishment of ATOS SAI s Collaborative action plan FAA independent validation via EPI s 23

43 Program Integration Regulator OS (e.g. ATOS) ATOS Process Owner SMS JQRT VDRP Safety / Quality Management and Oversight IEP ASAP FOQA AS 24

44 System Maturity SMS development should follow a phased-in process As the SMS matures, the certificate holder assumes more responsibility for primary safety oversight The FAA must continue to validate both the AS and the SMS 25

45 Safety System Maturation AS Maturation AS Controls In place AS Process Measures Defined System Integration (Interfaces/Attribute validation) 3 4 JQRT SAI s Complete Demonstrated Mgmt System Capabilities IEP/Audit Program Developed PRDB & Tracking/Analysis procedures developed AS Procedures in place AS Controls Defined 2 IRDP Developed VDRB in place IT Resource Plan AS in Basic Compliance AS Resp/Auth & AS Process/ Procedures Defined 0 1 SMS Proposal SMS Procedures Draft SMS Organization Plan Resp/Auth for SMS SMS Structure SMS Maturation 26

46 Risk Management parting words Carelessness and overconfidence are more dangerous than deliberately accepted risk - Wilbur Wright, 1901 Wilbur Wright gliding, 1901 Photographs: Library of Congress 27