.riprendiamo il filo

1. 04/03/2012 Ingegneria Aerospaziale Manutenzione degli Aeromobili gabriele renzulli 1 ….riprendiamo il filo…

2. 04/03/2012 Ingegneria Aerospaziale Manutenzione degli Aeromobili gabriele renzulli 2 IL FILO CONDUTTORE Fattori di successo della sfida: La motivazione nell’ intraprendere e condurre la sfida La comprensione, l’adozione e la condivisione dei valori alla base della missione Il soddisfacimento dei fabbisogni organizzativi

3. 04/03/2012 Ingegneria Aerospaziale Manutenzione degli Aeromobili gabriele renzulli 3 LA SICUREZZA è VALORE FONDANTE

4. un evento infausto sarebbe FATALE per l’ Impresa

5. 04/03/2012 Ingegneria Aerospaziale Manutenzione degli Aeromobili gabriele renzulli 5 La SICUREZZA è VALORE FONDANTE del Trasporto Aereo E’ interesse dell’ Imprenditore che la cultura positiva della SICUREZZA si radichi a tutti il livelli organizzativi La SICUREZZA è un “BENE FINANZIARIO” dell’ Imprenditore

6. 04/03/2012 Ingegneria Aerospaziale Manutenzione degli Aeromobili gabriele renzulli 6 L’ Operatore necessita della gestione sistematica e proattiva dei rischi associati alle: Operazioni Volo Operazioni a Terra Attività di Engineering & Maintenance ovvero nacessita di un Safety Management System da estendere anche alle attività in outsourcing (manutenzione, handling, aeroporti……)

7. 04/03/2012 Ingegneria Aerospaziale Manutenzione degli Aeromobili gabriele renzulli 7 SAFETY MANAGEMENT SYSTEM Attingiamo dalle norme: JAR-OPS 1.037 <<an operator shall establish an accident prevention and flight safety programme, which may be integrated with the Quality System: including programmes to achieve and maintain risk awareness by all persons involved in operations>> basato su ICAO Recommended Practice (Annex 6 Pt1)

8. 04/03/2012 Ingegneria Aerospaziale Manutenzione degli Aeromobili gabriele renzulli 8 SAFETY MANAGEMENT SYSTEM normativa Comunitaria e Nazionale recepimento della Direttiva Comunitaria 2003/42 EC Occurrence Reporting in Civil Aviation tramite Decreto Legislativo n° 213/06

9. 04/03/2012 Ingegneria Aerospaziale Manutenzione degli Aeromobili gabriele renzulli 9 SAFETY MANAGEMENT SYSTEM …riferiamoci ad una presentazione didattica ICAO della tematica SMS

10. Two basic concepts Safety programme – An overarching and integrated set of provisions Safety management system – A means for the implementation of a safety programme Two levels of responsibility for implementation State Operator (Airline, ATS provider, aerodrome operator)

11. Worldwide Hull Loss Projection Based on Expected Fleet Growth

12. Concept of safety (Doc 9859) Safety is the state in which the risk of harm to persons or property damage is reduced to, and maintained at or below, an acceptable level through a continuing process of hazard identification and risk management.

13. The evolution of safety thinking

14. Concept of safety Consider The elimination of accidents (and serious incidents) is unachievable. Failures will occur, in spite of the most accomplished prevention efforts. No human endeavour or human-made system can be free from risk and error. Controlled risk and error is acceptable in an inherently safe system.

15. A concept of accident causation

16. A concept of accident causation

17. Policy-making Planning Communication Allocation of resources Supervision …

18. The organizational accident

19. The organizational accident

20. The organizational accident

21. The organizational accident

22. The organizational accident

23. People and safety Aviation workplaces involve complex interrelationships among its many components. To understand operational performance, we must understand how it may be affected by the interrelationships among the various components of the aviation work places.

24. Processes and outcomes

25. People and safety – SHEL model

26. People and safety – SHEL model

27. Operational performance and technology In production-intensive industries like aviation, technology is essential. The operational consequences of the interactions between people and technology are often overlooked, leading to human error.

28. Understanding operational errors Human error is considered contributing factor in most aviation occurrences. Even competent personnel commit errors. Errors must be accepted as a normal component of any system where humans and technology interact.

29. Errors and safety – A non linear relationship Statistically, millions of operational errors are made before a major safety breakdown occurs What about errors? We tend to think that error cause accidents because most of the time we can trace accidents scenarios back to some human error. But there are (only) about 2 accidents per million flight hours (worldwide) and several errors are committed during each flight. This gives millions of errors without an accident. So can we get rid of these million of errors to prevent accidents ? Is it the right strategy? Of course, the answer is no. The findings of a series of experiments show that errors are largely under the control of cognition and are somewhere needed to that control. 70 to 80% of errors are recovered quite soon after production. Expert operators are also controlling the effects of most of the errors that they do not recover. Findings show that these un-recovered errors have far less safety consequences with experts than with novice operators. What about errors? We tend to think that error cause accidents because most of the time we can trace accidents scenarios back to some human error. But there are (only) about 2 accidents per million flight hours (worldwide) and several errors are committed during each flight. This gives millions of errors without an accident. So can we get rid of these million of errors to prevent accidents ? Is it the right strategy? Of course, the answer is no. The findings of a series of experiments show that errors are largely under the control of cognition and are somewhere needed to that control. 70 to 80% of errors are recovered quite soon after production. Expert operators are also controlling the effects of most of the errors that they do not recover. Findings show that these un-recovered errors have far less safety consequences with experts than with novice operators.

30. Accident investigation – Once in a million flights

31. Safety management – On almost every flight Flaps omitted

32. Errors and consequences Three strategies for the control of human error Error reduction strategies intervene at the source of the error by reducing or eliminating the contributing factors. Human-centred design Ergonomic factors Training …

33. Errors and consequences Three strategies for the control of human error Error capturing strategies intervene once the error has already been made, capturing the error before it generates adverse consequences. Checklists Task cards Flight strips …

34. Errors and consequences Three strategies for the control of human error Error tolerance strategies intervene to increase the ability of a system to accept errors without serious consequence. System redundancies Structural inspections …

36. Culture Culture binds people together as members of groups and provides clues as to how to behave in both normal and unusual situations. Culture influences the values, beliefs and behaviours that people share with other members of various social groups.

37. Three cultures

38. Three distinct cultures National culture encompasses the value system of particular nations. Organizational/corporate culture differentiates the values and behaviours of particular organizations (e.g. government vs. private organizations). Professional culture differentiates the values and behaviours of particular professional groups (e.g. pilots, air traffic controllers, maintenance engineers, aerodrome staff, etc.). No human endeavour is culture-free

39. Safety culture A construct An outcome, not a process The introduction of safety management concepts lays the foundation upon which to build a safety culture Safety culture cannot be “mandated” or “designed”, it evolves. It is generated “top-down”

40. Three options Organizations and the management of information Pathological – Hide the information Bureaucratic – Restraint the information Generative – Value the information

41. Three possible organizational cultures

42. Why SM ? – The first ultra-safe industrial system

43. The essential is invisible to the eyes

44. Navigating the drift

45. Strategies – Summary

47. The imperative of change As global aviation activity and complexity continues to grow, traditional methods for managing safety risks to an acceptable level become less effective and efficient. Evolving methods for understanding and managing safety risks are necessary.

48. Safety management – Nine building blocks Senior management’s commitment to the management of safety. Effective safety reporting. Continuous monitoring through systems to collect, analyse, and share safety-related data arising from normal operations.

49. Safety management – Nine building blocks Investigation of safety occurrences with the objective of identifying systemic safety deficiencies rather than assigning blame. Sharing safety lessons learned and best practices through the active exchange of safety information. Integration of safety training (including Human Factors) for operational personnel.

50. Safety management – Nine building blocks Effective implementation of Standard Operating Procedures (SOPs), including the use of checklists and briefings. Continuous improvement of the overall level of safety. An organizational culture that fosters safe practices, encourages safety communications and actively manages safety with the same attention to results as financial management.

51. Responsibilities for managing safety These responsibilities fall into four basic areas: Definition of policies and procedures regarding safety. Allocation of resources for safety management activities. Adoption of best industry practices. Incorporating regulations governing civil aviation safety.

52. Two definitions Hazard – Condition, object or activity with the potential of causing injuries to personnel, damage to equipment or structures, loss of material, or reduction of ability to perform a prescribed function. Risk – The chance of a loss or injury, measured in terms of severity and probability. The chance that something is going to happen, and the consequences if it does. A wind of 15 knots blowing directly across the runway is a hazard. The possibility that a pilot may not be able to control the aircraft during take off or landing, resulting in an accident, is one risk .

53. Examples of hazards

54. Examples of hazards

55. The focus of hazard identification Hazard identification is a wasted effort if restricted to the aftermath of rare occurrences where there is serious injury, or significant damage.

56. In summary Hazard: an existing condition Risk: the chance that an event can happen

58. Risk probability Definition(s) Probability – The chance that a situation of danger might occur.

59. Second fundamental – Risk probability

60. Risk severity Definition(s) Severity – The possible consequences of a situation of danger, taking as reference the worst foreseeable situation.

61. Risk severity Define the severity in terms of: Property Health Finance Liability People Environment Image Public confidence

62. Third fundamental – Risk severity

63. Fourth fundamental – Risk assessment

64. Fourth fundamental – Risk tolerability

65. Risk management

66. Fifth fundamental – Risk control/mitigation Definition(s) Mitigation – Measures to eliminate the potential hazard or to reduce the risk probability or severity. Risk mitigation = Risk control (Mitigate – To make milder, less severe or less harsh)

67. Risk mitigation – Defences Recalling the three basic defences in aviation: Technology Training Regulations

68. Risk mitigation at a glance

70. As of 23 November 2006 States shall establish a Safety Programme, in order to achieve an acceptable level of safety in: The operation of aircraft The maintenance of aircraft The provision of air traffic services Aerodrome operations The acceptable level of safety to be achieved shall be established by the State(s) concerned

71. As of 23 November 2006 States shall require, as part of their safety programme, that an [operator, maintenance organization, ATS provider, certified aerodrome operator] implements a Safety Management System accepted by the State that, as a minimum: Identifies safety hazards Ensures that remedial action necessary to maintain an acceptable level of safety is implemented Provides for continuous monitoring and regular assessment of the safety level achieved Aims to make continuous improvement to the overall level of safety

72. What is the fundamental objective of a business organization?

74. Safety programme – SMS relationships

75. Clarifying the use of terms Safety oversight – Is what the CAA performs with regard to the operators/service providers SMS. Safety assurance – Is what the operators/service providers do with regard to safety performance monitoring and measurement Safety audit – Is what the CAA performs with regard to its safety programme and the operators/service providers perform with regard to the SMS.

76. In summary Safety – The state in which the risk of harm to persons or property damage is reduced to, and maintained at or below, an acceptable level through a continuing process of hazard identification and risk management. Management – Allocation of resources. System – Organized set of processes and procedures.

77. The components of SMS Safety policy and objectives Safety risk management Safety assurance Safety promotion

78. The elements of SMS Safety policy and objectives 1.1 – Management commitment and responsibility 1.2 – Safety accountabilities of managers 1.3 – Appointment of key safety personnel 1.4 – SMS implementation plan 1.5 – Coordination of the emergency response plan 1.6 – Documentation Safety risk management 2.1 – Hazard identification processes 2.2 – Risk assessment and mitigation processes 2.3 – Internal safety investigations

79. The elements of SMS Safety assurance 3.1 – Safety performance monitoring and measurement 3.2 – The management of change 3.3 – Continuous improvement of the safety system Safety promotion 4.1 – Training and education 4.2 – Safety communication

80. Safety responsibilities – An example

81. 04/03/2012 Ingegneria Aerospaziale Manutenzione degli Aeromobili gabriele renzulli 81 SAFETY REVIEW BOARD

82. 04/03/2012 Ingegneria Aerospaziale Manutenzione degli Aeromobili gabriele renzulli 82 CAMO è di QUALITA’ ed è SICURA

83. The final objective – Integration

86. 04/03/2012 Ingegneria Aerospaziale Manutenzione degli Aeromobili gabriele renzulli 86 grazie della vostra attenzione