implementing a safety management system at bell helicopter’s mirabel facility by michel roby
TRANSCRIPT
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Implementing a Safety Management System
at Bell Helicopter’sMirabel facility
ByMichel Roby
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Why did BHTCL choose to implement its SMS as of 2001?
• We have been crash-free since our operations started up in 1986 but…
• There have been a few near-misses• No system to document and investigate incidents• Assembly errors have been detected in Preflight• Our quality system should have detected and corrected
them during the manufacturing process• BHTCL wants to be a leader in Flight Safety
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BHTCL has two licenses
• Manufacturer and AMO
• A SMS is currently required by Transport Canada, but for AMO only
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• A question was raised: Should SMS be applied only to AMO or should it apply to the entire organization?
• BHTCL has chosen to apply its SMS to the entire organization because our AMO and Production activities share several common services, including manpower.
Applying the SMS
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These important steps were followed
• Policy signed by the President
• Definition of roles and responsibilities
• Programming of an online reporting system
• Training given to the Flight Safety Committee
• Communication to employees
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Roles and responsibilities
• Coordinator– Manages program on daily basis– Handles investigations further to observations– Sees to corrective action follow-up
• Flight Safety Committee– Makes sure the program runs smoothly– Provides monthly review of received observations– Takes part in some investigations– Makes recommendations to management
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Final report write-up and closure
Processing by coordinator
Lost objectTool found
FO
Corrective action followup and closure
Final reportValidation
Write-up and distribution
Processing by team
Flight mishapsIncident
Potential hazardFOD
How the processing is handled
Validation
Preliminary report
How an observation is processed
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Preliminary reportObserver creates report (preliminary)
Potential hazard, incident and FOD reports are automatically distributed to the coordinator, to his manager and to Flight Safety preliminary report readers
Preliminary report is automatically recorded as is (not modifiable)
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How an observation is processed
Final report write-up and closure
Processing by coordinator
Lost objectTool found
FO
Corrective action followup and closure
Final reportValidation
Write-up and distribution
Processing by team
Flight mishapsIncident
Potential hazardFOD
How the processing is handled
Validation
Preliminary report
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Validation
Coordinator validates the content of the preliminary report with the observer
Coordinator produces the official observation
report
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Choice of processing channel
Final report write-up and closure
Processing by coordinator
Lost objectTool found
FO
Corrective action followup and closure
Final reportValidation
Write-up and distribution
Processing by team
Flight mishapsIncident
Potential hazardFOD
How the processing is handled
Validation
Preliminary report
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Processed by the coordinator
Coordinator:
• Issues a search notice if object is suspected to be lost on aircraft. The search notice must be closed only by production and QC supervisors
• Investigates contributing factors
• Helps identifying root causes
• Ensures proper corrective actions are put in place and validates implementation.
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How an observation is processed
Final report write-up and closure
Processing by coordinator
Lost objectTool found
FO
Corrective action followup and closure
Final reportValidation
Write-up and distribution
Processing by team
Flight mishapsIncident
Potential hazardFOD
How the processing is handled
Validation
Preliminary report
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Final report
The Coordinator draws up the final report and sends it to the individual responsible of corrective actions.
Case closed
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Choice of processing channel
Final report write-up and closure
Processing by coordinator
Lost objectTool found
FO
Corrective action followup and closure
Final reportValidation
Write-up and distribution
Processing by team
Flight mishapsIncident
Potential hazardFOD
How the processing is handled
Validation
Preliminary report
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When processed by teamCoordinator distributes report to observer, to FSFRs (Flight Safety First Responders) , to Managers and Supervisors of departments involved (with voting button)
FSFRs and Managers / Supervisors show interest using voting button
Coordinator investigates contributingfactors
Task force establishes root causes and corrective actions
Coordinator proposes final report
Does task force validatefinal report ?
No
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How an observation is processed
Final report write-up and closure
Processing by coordinator
Lost objectTool found
FO
Corrective action followup and closure
Final reportValidation
Write-up and distribution
Processing by team
Flight mishapsIncident
Potential hazardFOD
How the processing is handled
Validation
Preliminary report
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The coordinator distributes the report to the observer, the Flight Safety First Responders, to task force, to Managers/Supervisors of the departments involved and to those in charge of implementing corrective action.
Final report validation, write-upand distribution
The Coordinator draws up final report
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How an observation is processed
Final report write-up and closure
Processing by coordinator
Lost objectTool found
FO
Corrective action followup and closure
Final reportValidation
Write-up and distribution
Processing by team
Flight mishapsIncident
Potential hazardFOD
How the processing is handled
Validation
Preliminary report
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Corrective action follow-up
The coordinator verifies whether corrective actions have been implemented.
Case closed
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Received observation reports
• Per 2000 work hours (2001 six months)
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Incidents history
• Per 2000 work hours (2001 six months)
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Major leaks during ground runs
• Per 2000 work hours 2001 six months
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Lessons learned
• Communication is a vital element for success
• Corrective action follow-up is a demanding but essential process if tangible results are to be obtained.
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Our SMS is a driver that helps…
• Reduce incident and accident risks• Stabilize and reinforce the manufacturing
processes• Lower non-quality related costs