sms implementation in front-line department - … implementation in the... · sms implementation in...
TRANSCRIPT
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SMS Implementation in Front-line Department
CES Beijing Branch Flight Operation Department's experience
Captain Chen Bin16 June 2016
• Cooperation
• Introduction about China Eastern Airlines
• Safety Risk Management and Safety Assurance
• Challenge
• What we plan to do next...
Outline
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• A front line department - Flight Operation Department (FOD) in the Beijing Branch cooperated with COSCAP-NA to promote the implementation of SMS in the department since June, 2015.
• COSCAP-NA shared collective knowledge and experience.
Cooperation
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Introduction about CES
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Organization
Headquarters' Achievement
• CES updated their SMS in 2014 in accordance with the 3rd edition of the ICAO SMM.
• CES developed our SPI and TEM models during this time as well.
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Introduction about CES
Performanceindicators II
Performance indicators I
PerformanceObject
Performance monitoring
Process/RiskManagement
PerformanceObject
SPI
RM&SA
Safety Performance Objective
• Serious
Accident
• Accident
• Serious
Incidents
• Incidents
• ………
Air Collision
In flight damage
CFIT
Runway excursion
Runway Incursion
Heavy Landing
Landing on wrongRunway
Loss ofCommunication
Tailstrike
Ground damage
End States
Based on the past 4 years of safety information, we conclude the most possible accidents type
How to construct Safety Performance Indicators
Objectives Performance indicators I
Air Collision
U-001 Altitude deviationU-002 Enter into（NTZ）U-003 TCAS WarningU-004 Enter to Restriced, hazardous areaU-005 Separation deviationU-006 Wrong route/deviate from the routeU-007 Flight wrong procedure
In-flight damage
U-008 Engine failureU-009 ThunderstormsU-010 Speed exceedenceU-011 Bird strikeU-012 Speed high at gear downU-013 Fuel nonbalanceU-014 Stall/ Stick shakeU-015 Serious TurbulenceU-016 Exceedence of flps/slats limit speed in approachU-017 Acceleration high in flightU-018 Cabin Depressure
IATA Accident Category
Concequence
EGPWS Warning
…
Undesired State
Airport
ATC
Weather
…
Threat
1.Late configuration
2.pitch low at touchdown
3. …
Error
Analysis based on 10,000 safety reports
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Safety Management System
Status Monitoring
Threat and Error
• The CES Beijing Branch (hereinafter referred to as the
“Branch”) has been developing the SMS for six years,
during which an organizational structure in conformity
with the requirements of the Headquarter has been
established.
• The Branch has been able to perform the safety
management function in accordance with the SMS
manuals and procedures.
Introduction about CES
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About the frontline department
• The Flight Operation Department has two fleets (6
A321 and 7 A330).
• It operates domestic and international flights.
• Destination:
Shanghai, Guangzhou,Kunming, etc.
Sdyney, Saipan, Bangkok, Tokyo, Da Nang,
etc.
Introduction about CES
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• CES is still in the development stage in SMS
implementation
• The areas that have improved during SMS
implementation in the front line departments are in
safety risk management and safety assurance
throughout the organization.
Safety Risk Management
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Identified Opportunities for Improvement proposed by COSCAP-
NA
1. Some departments lack SMS personnel, especially part-time specialized staff in the operations departments thus reducing the efficiency of the SMS.
2. The network for safety information communication needs to be further developed. Unsafe event reporting and audit process works well. However other elements in the reporting system do not function efficiently including the employee’s voluntary safety reporting system.
Safety Risk Management
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Identified Opportunities for Improvement
3. Reactive identification of hazards during SMS implementation in
Beijing branch was efficient and rapid.
– However problems were created.
There are ten or more branches and 603 aircrafts in CES . Once an abnormal
incident or accident occurs in a branch even in another company, almost all of the
SMS personnel are tasked with preventing the same abnormal incident/ accident
from reoccurring in all parts of the company. This causes staff shortages in other
areas of the system which impacts other SMS components.
Safety Risk Management
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Safety Risk Management
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SRM workflow in the front-line department
Safety Risk Management
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Suggested Improvements proposed by COSCAP-NA
1. Improve the processing of hazard reports.
– Improve the reporting system by:
• Recruiting volunteers to work on SMS work.
• Providing adequate initial and recurrent training.
• Paying attention to and assigning importance to the work of
the personnel working within the reporting process.
Safety Risk Management
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Suggested Improvements
2. Improve the quality of the hazard reports so that the
workload of the analysts is reduced.
3. Develop clear and concise “job cards” for personnel
so that there is a clear understanding of tasks to be
performed when analyzing reports.
4. Ensure that staff understand that there is a certain
level of “pressure” in doing their jobs that is part of
the tasks to be performed.
Safety Risk Management
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Suggested Improvements
5. Encourage employees to work on voluntary hazard
reporting by highlighting/promoting the work of the
part-time staff.
6. There are several ways for employees to report hazards:
web page, phone App in developed by CES, telephone,
WeChat app and so on.
Safety Risk Management
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Suggested Improvements
7. Encourage the part-time staff to send the hazard reports by
WeChat. Everyone in the group on WeChat can see the
information sent by each other. After WeChat was implemented,
more employees followed the work of the part-time staff and
become more involved in the SMS.
8. Management further promote the policy to reward reporters.
This will improve the environment for voluntary hazard
reporting.
Safety Risk Management
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Suggested Improvements
9. Increase the efficiency of the reporting process especially the
investigation of the hazards.
– With the addition of the well-trained part-time collectors, the
efficiency of the analyst's work will increase.
– In order to provide the analyst with high quality hazard
reports, part-time collectors will conduct an initial
investigation on the hazard to confirm that a hazard does in
fact exist.
– The number of analysts needs to be increased.
Examples of process problems in the SRM procedure.
Example 1:
An operational hazard in Sapporo airspace reported by a CES employee.
Hazard:
The flight flew through Sapporo airspace enroute to Asahikawa from Beijing. The crew were confused by the operation in the Sapporo airspace. Generally when a flight makes an approach, it will be handed off app cpmtrolor tower of the destination airport, and use the QNH value provided by the destination airport. But according to the clearance provided by the Sapporo ACC, it seemed like the Sapporo ACC wanted to continue to control the flight, and asked the crew to use the Sapporo’s QNH value rather than the QNH provided by destination airport. Therefore the crew worried about the safety crossing altitude along the approach route and wanted an explanation from the Sapporo ACC.
Safety Risk Management
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The process:
1. The SMS office of the front line department received the hazard report
from the pilot.
2. By analysis, It was not acceptable that there existed several understanding
and measurement on this operation among the pilots in the Branch. The
office considered the hazard as being out of its area. Then the hazard report
was sent to the SMS office of the branch.
3. The branch asked for help from the CES agent in Sapporo.
4. The agent received a response from AKJ CAB of Japan after the discussion
between Sapporo CAB and AKJ CAB . Acronym: CAB – Civil Aviation Bureau.
Safety Risk Management
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Situation:
• AKJ CAB responded: “QNH 30.02 enroute given by Sapporo's ACC is the QNH data
for the Sapporo’s area. QNH 29.96 is the actual local setting for the AKJ area that
should be used during the instrument approach. Both the values of QRH are right .”
• CES did not get a direct answer. The question/hazard is still not addressed.
• In a response to AKJ CAB, CES expressed concern that the explanation offered was
confusing.
• So far CES has not received a further explanation from AKJ CAB.
Acronym: CAB – Civil Aviation Bureau. CES- China Eastern Airlines.
Safety Risk Management
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Problems Identified:
1. The investigation work is very difficult sometimes, especially when identified
hazards have to be coordinated with outside organizations or States.
2. There are some difficult question about skills and technique regarding flight
operation or missing history related to a hazard identified by pilots that can
not be resolved although the SMS office tried their best.
3. This leads to a late response or no response to the reporters which has a
negative affect on voluntary safety reporting.
4. The number of these kinds of issues is increasing as the company SMS
matures.
Safety Risk Management
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Example 2:
Non-standard phraseology used by ATC in Hong Kong.
Hazard:
• A pilot reported the non-standard communication terms -“ Line
up in turn”, used by ATC at the Hong Kong airport to express the
meaning “line up on the runway after the traffic has departed ”.
• The instruction confused the crew so that the crew almost made
an error and committed a runway incursion.
Safety Risk Management
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Process:
• The SMS office contacted the ATC of Hong Kong. According to ATC procedures,
they needed the detailed report including the flight information, the name of
the crew. The crew did not want to be involved in this investigation.
• Mitigation cannot be implemented except for release of a company warning
message by the SMS Office to the pilots.
The problem found from this kind of hazards:
These kinds of hazards have to be mitigated to a lower acceptance level
because of the lack of support and cooperation with outside agency or State.
Safety Risk Management
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1. The part-time personnel working on hazard collection/analysis are important to being able to process the number of the monthly hazard reports. They volunteer to do this kind of work. So far, the appropriate motivating mechanism has not been develped to encourage them to work for a longer period of time.
2. For various reasons, some hazards can not been mitigated to the lowest level possible. This kind of issue will increase as the procedure of SRM matures and becomes more efficient.
3. CES needs to develop SPIs in order to further promote the development of SMS. However the departments involved are struggling to develop such SPIs under significant workload.
Challenge
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1. Developing appropriate motivational mechanisms to keep SMS staff working efficiently.
2. Training of personnel – initial and recurrent.
3. Enhance communication with the Managing departments.
This improvement will enhance the work flows of the SMS. There is room for improvement in SMS in the front line departments. Improving the efficency of the SMS work is a matter of utmost urgency.
What we plan to do next...
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• There is an opportunity for improvement of the SMS in the front line department understanding that the current SMS environment is not yet mature.
• Improving the efficiency of the SMS workflow is a matter of utmost urgency.
Summary...
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