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The United States State Safety Programme

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The United States State Safety Programme

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    1. The United States State Safety Programme

    2. What was the largest flying boat ever to fly? During world War 2, a consortium was formed by Howard Hughes and Henry Kaiser to create a giant, wooden, flying boat transport. The airplane was designated HK-1 for the Hughes-Kaiser consortium. After Henry Kaiser left the project the designation of the wooden aircraft was changed to H-4.  Later, a contest held among Hughes Aircraft employees produced the name Hercules.  Hughes did not like the name Hercules, nor did he appreciate the phrase Spruce Goose. He always referred to the airplane as the Flying Boat. The wooden buildings in which its components were constructed were the largest in the world at the time. They still stand at the old Hughes Airport property. Most of the wood used in the construction of the Flying Boat was Birch. The nails used to hold its wooden components in place were removed once the glue set. Considerable controversy surrounded its funding. The government funded the original project, which called for one prototype Flying Boat and the production of two additional aircraft.  The original government contract budgeted $18 million for three aircraft; however Hughes infused $7 million of his own capital into the project. Only one flying boat was completed. It was flown once in 1947, then it was returned to its hangar, where it remained for thirty-three years. It was carefully stored, maintained almost as an active aircraft until 1980. Each month its engines were run up. An extensive air conditioning system maintained a carefully controlled environment for the wooden behemoth. The Flying Boat was removed from its hangar on October 29, 1980. For two days it floated in Los Angeles Harbor before it was lifted onto a temporary storage area on shore. On February 10, 1982 it was lifted from its storage location onto a barge. The next morning it was floated across the harbor to a giant geodesic dome to be displayed by the Wrather Corporation. Wingspan: 320 feet Length: 219 feet Wing Area: 11,430 square feet Maximum Take-off Weight: 400,000 pounds Maximum Cargo Payload: 130,000 pounds Powerplant: 8x 3,000 hp Pratt & Whitney R4360-4, 28 cylinder radials During world War 2, a consortium was formed by Howard Hughes and Henry Kaiser to create a giant, wooden, flying boat transport. The airplane was designated HK-1 for the Hughes-Kaiser consortium. After Henry Kaiser left the project the designation of the wooden aircraft was changed to H-4.  Later, a contest held among Hughes Aircraft employees produced the name Hercules.  Hughes did not like the name Hercules, nor did he appreciate the phrase Spruce Goose. He always referred to the airplane as the Flying Boat. The wooden buildings in which its components were constructed were the largest in the world at the time. They still stand at the old Hughes Airport property. Most of the wood used in the construction of the Flying Boat was Birch. The nails used to hold its wooden components in place were removed once the glue set. Considerable controversy surrounded its funding. The government funded the original project, which called for one prototype Flying Boat and the production of two additional aircraft.  The original government contract budgeted $18 million for three aircraft; however Hughes infused $7 million of his own capital into the project. Only one flying boat was completed. It was flown once in 1947, then it was returned to its hangar, where it remained for thirty-three years. It was carefully stored, maintained almost as an active aircraft until 1980. Each month its engines were run up. An extensive air conditioning system maintained a carefully controlled environment for the wooden behemoth. The Flying Boat was removed from its hangar on October 29, 1980. For two days it floated in Los Angeles Harbor before it was lifted onto a temporary storage area on shore. On February 10, 1982 it was lifted from its storage location onto a barge. The next morning it was floated across the harbor to a giant geodesic dome to be displayed by the Wrather Corporation. Wingspan: 320 feet Length: 219 feet Wing Area: 11,430 square feet Maximum Take-off Weight: 400,000 pounds Maximum Cargo Payload: 130,000 pounds Powerplant: 8x 3,000 hp Pratt & Whitney R4360-4, 28 cylinder radials

    3. ICAO: State’s “safety programme” An integrated set of regulations and activities aimed at improving safety. A management system for management of safety by the State Includes SMS requirements for aviation service providers ICAO has recently published objectives for a more comprehensive approach to safety – the “State Safety Programme,” that incorporates a comprehensive approach with defined roles, responsibilities, and relationships (the “three R’s”) for both government and industry. ICAO also stresses a “managerial approach” in which safety is to be managed in a manner similar to quality and financial management in aviation businesses. Each state (country) – CAA or, in our case, FAA – creates its own safety programmme – an integrated set of regulations and activities aimed at improving safety. The state safety programme is an integral part of an SMS. ICAO has recently published objectives for a more comprehensive approach to safety – the “State Safety Programme,” that incorporates a comprehensive approach with defined roles, responsibilities, and relationships (the “three R’s”) for both government and industry. ICAO also stresses a “managerial approach” in which safety is to be managed in a manner similar to quality and financial management in aviation businesses. Each state (country) – CAA or, in our case, FAA – creates its own safety programmme – an integrated set of regulations and activities aimed at improving safety. The state safety programme is an integral part of an SMS.

    4. Two audience groups States Service providers Three distinct requirements State safety programme (SSP) Acceptable level of safety (ALoS) Safety management System (SMS) Safety performance of the SMS Management accountability ICAO safety management requirements – The big picture I’m going to show the FAA’s understanding of ICAO SSP and SMS expectations, how we interpret them in the context of our system, and how we intend to meet them. I’m going to show the FAA’s understanding of ICAO SSP and SMS expectations, how we interpret them in the context of our system, and how we intend to meet them.

    5. A systematic approach to managing safety, including the necessary organizational structures, accountabilities, policies and procedures. Service providers are responsible for establishing an SMS. States are responsible, under the SSP, for the acceptance and oversight of service providers’ SMS. What is an SMS?

    6. ICAO Annex 6 “From 1 January, 2009, States shall require, as part of their safety programme, that an operator implement a safety management system acceptable to the State of the Operator…” The U.S. has filed a difference with ICAO Currently, there are no FAA authorized procedures to accept or approve Service Providers’ SMS’s

    7. The bridge Out of Chapter 11 of ICAO document that addresses the framework for development and implementation of a State Safety Programme. This bridge shows that the SMS requirements under the SSP to provide a structured framework allowing the State and service providers to interact more effectively in the resolution of safety concerns, showing the interactive nature of the SSP and the SMS and the interaction between the acceptable level of Safety (State) and the safety performance (service provider).Out of Chapter 11 of ICAO document that addresses the framework for development and implementation of a State Safety Programme. This bridge shows that the SMS requirements under the SSP to provide a structured framework allowing the State and service providers to interact more effectively in the resolution of safety concerns, showing the interactive nature of the SSP and the SMS and the interaction between the acceptable level of Safety (State) and the safety performance (service provider).

    8. SSP – SMS relationship Now that we have discussed SMS and you are familiar with the four components of SMS; policy, safety risk management, safety assurance, and safety promotion, lets go back to the safety assurance component and focus in on the AFS SAS. Let’s find out what the AFS SAS is, the role the AFS SAS will play in the AVSSMS, and its importance to you SAS will talk about laterNow that we have discussed SMS and you are familiar with the four components of SMS; policy, safety risk management, safety assurance, and safety promotion, lets go back to the safety assurance component and focus in on the AFS SAS. Let’s find out what the AFS SAS is, the role the AFS SAS will play in the AVSSMS, and its importance to you SAS will talk about later

    9. Design approval Production approval Continued operational safety Now that we have discussed SMS and you are familiar with the four components of SMS; policy, safety risk management, safety assurance, and safety promotion, lets go back to the safety assurance component and focus in on the AFS SAS. Let’s find out what the AFS SAS is, the role the AFS SAS will play in the AVSSMS, and its importance to youDesign approval Production approval Continued operational safety Now that we have discussed SMS and you are familiar with the four components of SMS; policy, safety risk management, safety assurance, and safety promotion, lets go back to the safety assurance component and focus in on the AFS SAS. Let’s find out what the AFS SAS is, the role the AFS SAS will play in the AVSSMS, and its importance to you

    10. ICAO and FAA SMS Framework The SMS Framework for service providers will be part of the ICAO requirements beginning on Nov. 18, 2010 for all Annexes except Annex 8. AVS has defined our own framework for our SSP, which is referred to as the AVSSMS. AVS is responsible for oversight (including regulation and certification) of aviation businesses and activities covered by ICAO Annexes 1, 6, 8, and 11. The SMS Framework for service providers will be part of the ICAO requirements beginning on Nov. 18, 2010 for all Annexes except Annex 8. AVS has defined our own framework for our SSP, which is referred to as the AVSSMS. AVS is responsible for oversight (including regulation and certification) of aviation businesses and activities covered by ICAO Annexes 1, 6, 8, and 11.

    11. The ultimate objective of the AVSSMS is to make sure that our risk controls are working across the industry and allow us to make integrated safety decisions One point of this slide is to briefly review how the four SMS components; policy, safety risk management, safety assurance, and safety promotion correlate to the AVS organization; in other words to give a top-level view of how AVS services / offices will function in the AVSSMS environment The AVS safety assurance function will aggregate safety assurance data from each of the services / offices (AFS, AIR, etc.) and share this data across AVS The ultimate objective of the AVSSMS is to make sure that our risk controls are working across the industry and allow us to make integrated safety decisions One point of this slide is to briefly review how the four SMS components; policy, safety risk management, safety assurance, and safety promotion correlate to the AVS organization; in other words to give a top-level view of how AVS services / offices will function in the AVSSMS environment The AVS safety assurance function will aggregate safety assurance data from each of the services / offices (AFS, AIR, etc.) and share this data across AVS

    12. SMS Framework for Aviation Service Providers; Framework Overview: A functional framework consisting of a set of requirements for SMS processes was originally developed and published as Appendix 1 to AC 120-92. The elements of that process were considered to be essential to development and implementation of an effective, comprehensive SMS for an aviation service provider’s organization. To provide clearer understanding, components, elements and processes are defined in terms of functional expectations, i.e., those characteristics that would be expected to be incorporated in a robust SMS. Functional expectations are further defined in terms of performance objectives and design expectations to better align with current system safety and ATOS models, as well as aligning with the ICAO numbering system and incorporating a few of the FAA Order VS8000.367 requirements, which were published after the SMS “Standard” in AC 120-92, Appendix 1. SMS Assurance Guide: Overview: The Safety Management System (SMS) Assurance Guide has been developed for assessment of the design and performance of aviation service providers’ SMS programs. The guide is intended to be used whether the assessments are being conducted by the service providers themselves, in internal audits and evaluations or by other third parties. The guide is organized in accordance with the Flight Standards SMS Framework, which shares structure and organization with the SMS Framework developed by the International Civil Aviation Organization (ICAO). The framework embodies the requirements expressed in FAA Order VS 8000.367, Safety Management System Requirements, Appendix B. The SMS Implementation Guide applies to both certificated and non-certificated air operators, aviation maintenance organizations, and flight training organizations that desire to develop and implement an SMS. It describes the phased implementation process, requirements to exit each level, roles of those involved in the Pilot Projects, and the SMS implementation strategy.SMS Framework for Aviation Service Providers; Framework Overview: A functional framework consisting of a set of requirements for SMS processes was originally developed and published as Appendix 1 to AC 120-92. The elements of that process were considered to be essential to development and implementation of an effective, comprehensive SMS for an aviation service provider’s organization. To provide clearer understanding, components, elements and processes are defined in terms of functional expectations, i.e., those characteristics that would be expected to be incorporated in a robust SMS. Functional expectations are further defined in terms of performance objectives and design expectations to better align with current system safety and ATOS models, as well as aligning with the ICAO numbering system and incorporating a few of the FAA Order VS8000.367 requirements, which were published after the SMS “Standard” in AC 120-92, Appendix 1. SMS Assurance Guide: Overview: The Safety Management System (SMS) Assurance Guide has been developed for assessment of the design and performance of aviation service providers’ SMS programs. The guide is intended to be used whether the assessments are being conducted by the service providers themselves, in internal audits and evaluations or by other third parties. The guide is organized in accordance with the Flight Standards SMS Framework, which shares structure and organization with the SMS Framework developed by the International Civil Aviation Organization (ICAO). The framework embodies the requirements expressed in FAA Order VS 8000.367, Safety Management System Requirements, Appendix B. The SMS Implementation Guide applies to both certificated and non-certificated air operators, aviation maintenance organizations, and flight training organizations that desire to develop and implement an SMS. It describes the phased implementation process, requirements to exit each level, roles of those involved in the Pilot Projects, and the SMS implementation strategy.

    13. SMS Voluntary Implementation: Pilot Projects Trial Project activities commenced in 2007 Voluntary SMS development AFS combined effort Objectives are to Develop: Implementation strategies, Oversight interfaces, and Gain experience for FAA and Service Providers See VIPP list Flight Standards is conducting a set of SMS Trial Projects that include small and large air operators and aviation maintenance organizations. Presently, almost 70 service provider organizations are developing SMS voluntarily under this program. The purpose of these projects is to learn and gain experience in actual practice of SMS development, implementation, and oversight. Service provider SMSs are currently voluntary for all service providers except the FAA’s ATO. The FAA is currently conducting rulemaking for service providers under Annexes 1, 6, and 8, under the direction of AVS.See VIPP list Flight Standards is conducting a set of SMS Trial Projects that include small and large air operators and aviation maintenance organizations. Presently, almost 70 service provider organizations are developing SMS voluntarily under this program. The purpose of these projects is to learn and gain experience in actual practice of SMS development, implementation, and oversight. Service provider SMSs are currently voluntary for all service providers except the FAA’s ATO. The FAA is currently conducting rulemaking for service providers under Annexes 1, 6, and 8, under the direction of AVS.

    14. Note; speaker can talk through the builds & use content of the following hidden slides (57-62) & leave those hidden for general audiences. For more technical, or in-depth applicability, unhide & use slides (57-62). Here is a notional view of an SMS maturity model. On the upper side, the attributes related to the technical processes of the operator (e.g. processes for flight ops, maintenance, training, etc) are shown. On the lower side of the diagram, the SMS capabilities are developed. The maturity of the SMS and, therefore, the dependence on it for safety management grows in each step. For example, at step two, the carrier has the capability to react in a positive manner to problems discovered in their operations but may not be fully able to take a proactive stance. To do this, they must have fully developed procedures and controls for AS activities. They must also have data repositories and processes developed to collect and process incident data and to document corrective actions. As the mature, these data systems will be used in increasingly proactive roles. It will be necessary to design specific criteria to validate attainment of these criteria for advancement out of each step and into the next. These criteria will then be continuously monitored by the FAA as part of the oversight process.Note; speaker can talk through the builds & use content of the following hidden slides (57-62) & leave those hidden for general audiences. For more technical, or in-depth applicability, unhide & use slides (57-62). Here is a notional view of an SMS maturity model. On the upper side, the attributes related to the technical processes of the operator (e.g. processes for flight ops, maintenance, training, etc) are shown. On the lower side of the diagram, the SMS capabilities are developed. The maturity of the SMS and, therefore, the dependence on it for safety management grows in each step. For example, at step two, the carrier has the capability to react in a positive manner to problems discovered in their operations but may not be fully able to take a proactive stance. To do this, they must have fully developed procedures and controls for AS activities. They must also have data repositories and processes developed to collect and process incident data and to document corrective actions. As the mature, these data systems will be used in increasingly proactive roles. It will be necessary to design specific criteria to validate attainment of these criteria for advancement out of each step and into the next. These criteria will then be continuously monitored by the FAA as part of the oversight process.

    15. AVSSMS Implementation Approach VS 8000.367 supplies a process for safety risk management (SRM) in the development of regulations, standards, and policies for implementation that apply system safety methods to development of these instruments. This is consistent with the ICAO vision of future rulemaking using the SRM process defined in ICAO doc 9859. For example, a State’s safety oversight function presently verifies that a State has a system of regulations, but neither requires a safety risk analysis to produce such regulations, nor monitors the effectiveness of regulations as safety risk controls. The SSP, on the other hand, considers regulations as safety risk controls and requires, through its safety risk management component, that the process of rulemaking be done using principles of safety risk management (identify hazards, assess the safety risks of the consequences of the hazards, and develop regulations that provide acceptable mitigation/control of the consequences of the hazards).VS 8000.367 supplies a process for safety risk management (SRM) in the development of regulations, standards, and policies for implementation that apply system safety methods to development of these instruments. This is consistent with the ICAO vision of future rulemaking using the SRM process defined in ICAO doc 9859. For example, a State’s safety oversight function presently verifies that a State has a system of regulations, but neither requires a safety risk analysis to produce such regulations, nor monitors the effectiveness of regulations as safety risk controls. The SSP, on the other hand, considers regulations as safety risk controls and requires, through its safety risk management component, that the process of rulemaking be done using principles of safety risk management (identify hazards, assess the safety risks of the consequences of the hazards, and develop regulations that provide acceptable mitigation/control of the consequences of the hazards).

    16. SMS Rulemaking One rule for all types of service providers Aviation Rulemaking Committee (ARC) Associations representing industry Working groups from service providers Advance Notice of Proposed Rulemaking (ANPRM) Initial solicitation for information comment from public No proposed rulemaking language To be issued later this year An Aviation Rulemaking Committee (ARC) has been established to obtain information and analysis from industry constituents regarding potential requirements for SMS. The ARC is divided into several working groups with approximately 100 total members. AVS-1 has selected three industry chairs for the committee. These tri-chairs will provide the leadership for the ARC. American Airlines United/ALPA (Airline Pilots Association) Boeing FAA published an Advance Notice of Proposed Rulemaking (ANPRM) to solicit additional information regarding SMS requirements, implementation, and oversight. The ARC will analyze comments coming from this ANPRM and prepare a summary of recommendations to the FAA. An Aviation Rulemaking Committee (ARC) has been established to obtain information and analysis from industry constituents regarding potential requirements for SMS. The ARC is divided into several working groups with approximately 100 total members. AVS-1 has selected three industry chairs for the committee. These tri-chairs will provide the leadership for the ARC. American Airlines United/ALPA (Airline Pilots Association) Boeing FAA published an Advance Notice of Proposed Rulemaking (ANPRM) to solicit additional information regarding SMS requirements, implementation, and oversight. The ARC will analyze comments coming from this ANPRM and prepare a summary of recommendations to the FAA.

    17. AFS SMS Program Office (PO) Authorized by Order FS1100.1A: AFS SMS Policy Focal point for SMS rulemaking Oversight and coordination of voluntary SMS implementation and testing Integration with oversight systems Policy, guidance, and tool development Training and outreach development and coordination FAA Order FS 1100.1A (rev dtd 9/28/08) Flight Standards Service Organizational Handbook identifies the responsibilities of the SMS Program Office. Chapter 11, Section 5 addresses the SMS PO: 5.      Flight Standards SMS Program Office. The FS SMS Program Office (PO) provides policy and guidance on AFS internal and external SMS requirements and interfaces. The SMS Program Office provides support to the AFS Director, Deputy Director, and Executive Steering Committee in execution of the AFS SMS doctrine. The SMS Program Office interfaces with the AVS SMS Working Group and is responsible for SMS concept development in accordance with AVS SMS doctrine and standards. The office provides direction, guidance, and coordination with points of contact in headquarters and field divisions in development of SMS policies, procedures, and work instructions, in accordance with the AVS Quality Management System (QMS). The office is responsible for SMS standardization and development of training requirements. Specific functions and responsibilities of the office include: a.      Focal point for AFS in future SMS-related rulemaking and policy development efforts. b.      Oversight and evaluation of SMS collaborative testing projects. c.       Standardization of concepts, functional requirements, and terminology across AFS managed and sponsored SMS programs, initiatives, and contracted activities. d.      Alignment of internal and external SMS development activities with AVS SMS standards and AVS Management Team and AFS Executive Steering Committee guidance. e.      Planning and coordination of SMS activities in AVS and AFS Business Plans. f.        Representation of AFS in the AVS SMS Working Group. g.      Ensure integration capability of oversight systems, both within AFS and also between AFS and other AVS lines of business. h.      Coordination with the ATOS Continual Improvement Section and headquarters policy divisions on SMS-oversight system relationships. i.        Development and maintenance of SMS policy and guidance documentation. j.        Development of AFS SMS training requirements and mentorship of SMS related FAA Academy training. k.      Development of measures of safety performance and effectiveness for both internal and external SMS. l.        Development and maintenance of SMS data collection and auditing tools. m.    Development and use of standardized outreach, familiarization, and orientation materials for SMS. n.      Coordination and management of an AFS SMS Standardization and Assistance Team to assist field organizations and service providers in development and implementation of voluntary and mandatory external SMSs. FAA Order FS 1100.1A (rev dtd 9/28/08) Flight Standards Service Organizational Handbook identifies the responsibilities of the SMS Program Office. Chapter 11, Section 5 addresses the SMS PO: 5.      Flight Standards SMS Program Office. The FS SMS Program Office (PO) provides policy and guidance on AFS internal and external SMS requirements and interfaces. The SMS Program Office provides support to the AFS Director, Deputy Director, and Executive Steering Committee in execution of the AFS SMS doctrine. The SMS Program Office interfaces with the AVS SMS Working Group and is responsible for SMS concept development in accordance with AVS SMS doctrine and standards. The office provides direction, guidance, and coordination with points of contact in headquarters and field divisions in development of SMS policies, procedures, and work instructions, in accordance with the AVS Quality Management System (QMS). The office is responsible for SMS standardization and development of training requirements. Specific functions and responsibilities of the office include: a.      Focal point for AFS in future SMS-related rulemaking and policy development efforts. b.      Oversight and evaluation of SMS collaborative testing projects. c.       Standardization of concepts, functional requirements, and terminology across AFS managed and sponsored SMS programs, initiatives, and contracted activities. d.      Alignment of internal and external SMS development activities with AVS SMS standards and AVS Management Team and AFS Executive Steering Committee guidance. e.      Planning and coordination of SMS activities in AVS and AFS Business Plans. f.        Representation of AFS in the AVS SMS Working Group. g.      Ensure integration capability of oversight systems, both within AFS and also between AFS and other AVS lines of business. h.      Coordination with the ATOS Continual Improvement Section and headquarters policy divisions on SMS-oversight system relationships. i.        Development and maintenance of SMS policy and guidance documentation. j.        Development of AFS SMS training requirements and mentorship of SMS related FAA Academy training. k.      Development of measures of safety performance and effectiveness for both internal and external SMS. l.        Development and maintenance of SMS data collection and auditing tools. m.    Development and use of standardized outreach, familiarization, and orientation materials for SMS. n.      Coordination and management of an AFS SMS Standardization and Assistance Team to assist field organizations and service providers in development and implementation of voluntary and mandatory external SMSs.

    18. Safety Management System Focus Group (SMSFG) Voluntary implementation user’s group Provides a two-way communications mechanism between SMS PO and participants in voluntary implementation Provides a forum for knowledge sharing among participants A set of working groups has been set up in AVS to develop action plans to transform oversight practices into the vision of the SSP, using the requirements of Order VS 8000.367 as a guide. The FAA has also set up and chairs an International Collaboration Group (ICG) to discuss alignment and harmonization of both internal (SSP, oversight) and external (service provider SMS) safety management tools, guidance material, measurements, and requirements. Currently, the U.S., Canada, Brazil, Australia, Switzerland, and EASA are participating. The ICG has commissioned several focus groups to work on hazard taxonomies, safety performance measurement, guidance and outreach materials, and; manufacturer SMS requirements. A set of working groups has been set up in AVS to develop action plans to transform oversight practices into the vision of the SSP, using the requirements of Order VS 8000.367 as a guide. The FAA has also set up and chairs an International Collaboration Group (ICG) to discuss alignment and harmonization of both internal (SSP, oversight) and external (service provider SMS) safety management tools, guidance material, measurements, and requirements. Currently, the U.S., Canada, Brazil, Australia, Switzerland, and EASA are participating. The ICG has commissioned several focus groups to work on hazard taxonomies, safety performance measurement, guidance and outreach materials, and; manufacturer SMS requirements.

    19. System safety isn’t a new concept 2001: System Safety Course offered at Academy 2002: SASO established 2006: ICAO Annex 6 2007: SMS Pilot Projects started 2008: ATOS 1.2 – based on 8900.1 – employed for oversight of all 14 CFR Part 121 operators 2009: Design of SAS begins (October 2008 - FY09) 2013: Target date for AFS SAS implementation in 14 CFR Parts 121, 135, 145 1970: Accident Prevention Program and Accident Prevention Specialist position created (evolved to Safety Program Manager) 1980’s: NPG / PTRS – standardizing the inspection process 1995: SPAS – providing data and analysis for management of oversight 1996: System Safety initiatives begun due to ValuJet accident 1998: ATOS – applying system safety to aviation oversight of select 14 CFR Part 121 operators Investigators have concluded the cargo bay fire that caused the deadly crash of ValuJet Flight 592 originated in volatile oxygen canisters mistakenly labeled and improperly packed, according to a highly placed source. The oxygen canisters were stored in the cargo bay. Federal investigators said many of the canisters were missing safety caps, and a cargo manifest listed them as being empty when they were not. "It was definitely not an electrical spark that ignited the fire," the source told CNN. "The canisters started the fire. There was nothing in the cargo bay that could have ignited the canisters." The National Transportation Safety Board begins a week of hearings Monday on the May 11 disaster that killed all 110 people aboard the Miami-to-Atlanta flight. The hearings will be used as a forum to pin blame to the canisters. The canisters have been considered a prime culprit since shortly after the plane plunged into the Everglades, a disaster that led to the carrier's grounding for 3 1/2 months and a sharp curtailment of its operations after it resumed service this fall. The Department of Transportation imposed an emergency ban on the shipment of oxygen canisters after the crash. During tests this month at a Federal Aviation Administration facility in New Jersey, oxygen canisters similar to those packed on Flight 592 were ignited and quickly reached temperatures of well over 1,000 degrees Fahrenheit. It remains unclear whether the fire ignited before or after takeoff. As previously revealed from the cockpit voice recorder, smoke and fire in the passenger cabin were reported about six minutes after the DC-9 left Miami International Airport. About three minutes after fire was discovered, the plane nose-dived into the Everglades. Sources say the blaze burned through the jet's flight control cables that help steer the aircraft. The cables run the length of the aircraft above the front cargo bay where the fire erupted. The ValuJet DC-9 that crashed had no smoke detectors or fire- suppression system in the cargo hold. Investigators have concluded the cargo bay fire that caused the deadly crash of ValuJet Flight 592 originated in volatile oxygen canisters mistakenly labeled and improperly packed, according to a highly placed source. The oxygen canisters were stored in the cargo bay. Federal investigators said many of the canisters were missing safety caps, and a cargo manifest listed them as being empty when they were not. "It was definitely not an electrical spark that ignited the fire," the source told CNN. "The canisters started the fire. There was nothing in the cargo bay that could have ignited the canisters." The National Transportation Safety Board begins a week of hearings Monday on the May 11 disaster that killed all 110 people aboard the Miami-to-Atlanta flight. The hearings will be used as a forum to pin blame to the canisters. The canisters have been considered a prime culprit since shortly after the plane plunged into the Everglades, a disaster that led to the carrier's grounding for 3 1/2 months and a sharp curtailment of its operations after it resumed service this fall. The Department of Transportation imposed an emergency ban on the shipment of oxygen canisters after the crash. During tests this month at a Federal Aviation Administration facility in New Jersey, oxygen canisters similar to those packed on Flight 592 were ignited and quickly reached temperatures of well over 1,000 degrees Fahrenheit. It remains unclear whether the fire ignited before or after takeoff. As previously revealed from the cockpit voice recorder, smoke and fire in the passenger cabin were reported about six minutes after the DC-9 left Miami International Airport. About three minutes after fire was discovered, the plane nose-dived into the Everglades. Sources say the blaze burned through the jet's flight control cables that help steer the aircraft. The cables run the length of the aircraft above the front cargo bay where the fire erupted. The ValuJet DC-9 that crashed had no smoke detectors or fire- suppression system in the cargo hold.

    20. SMS Guidance and Tools ICAO Doc 9859: Safety Management Manual (SMM) FAA Order 8000.369: FAA SMS Guidance Order VS 8000.367: AVS Requirements Document SMS Standard: AC 120-92 Appendix 1 Voluntary Implementation Guidance (Multiple Docs) Advisory Guidance has been published for voluntary implementation of SMS by air operators, aviation maintenance organizations, aviation training organizations, and airports: Operators, maintenance organizations, and trainers: AC 120-92 Airports: AC 150-200-37 Advisory Guidance has been published for voluntary implementation of SMS by air operators, aviation maintenance organizations, aviation training organizations, and airports: Operators, maintenance organizations, and trainers: AC 120-92 Airports: AC 150-200-37

    21. AFS SPOT Briefing Recipients In-Person Reached 142 offices with 126 briefings Reached 3300+ employees 2800+ field employees 500+ HQ employees WBT Reached almost 700 employees Talk about calendarsTalk about calendars

    22. What is the AFS SAS? The Safety Assurance System is the people, processes, and technology that provide confidence that air carriers and air agencies operate safely and manage safety to the highest degree possible in the public interest - System Approach for Safety Oversight (SASO) Requirements Document SAS will be the oversight system for 14 CFR Parts 121, 135, and 145

    23. What is the purpose of the SAS? Help fulfill the AFS vision / mission elements To be recognized and respected as the world leader on system safety through regulation and certification To promote safety through certification, surveillance, and the resolution of safety concerns Implement AFS’s safety assurance function of the AVSSMS Adapt oversight and target resources to areas of highest risk (i.e., scalability) Provide system safety-based oversight to 14 CFR Parts 121, 135, and 145

    24. SAS timeline

    25. AVSSMS Website http://www.faa.gov/about/initiatives/sms Supports safety promotion activities FAA Order VS 8000.370 and 2010 Flight Plan Target Development – Content determined by S/O reps Umbrella information on AVS SMS Repository for guidance material and experience

    26. Website Content

    27. FAA Website Home Page

    28. FAA Website Reference Library

    29. FAA Website Educational Page

    30. In closing, can you tell me where this is? Photos of planes landing at the old Kai Tak airport in Hong Kong.In closing, can you tell me where this is? Photos of planes landing at the old Kai Tak airport in Hong Kong.

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