The Bow Tie methodology as Safety Assurance Audit
“The Bow Tie methodology as Safety Assurance Audit tool in checking Recovery Mode & Escalation Control Factors appropriateness” 2 nd Business Aviation Safety Conference, 6 -7 Feb. 2012, Munich, Germany Capt. Claudio D. Caceres, MSc, SMS Lecturer & Auditor Picture: Claudio D. Caceres©
Agenda • Have failure recovery measures been implemented? • Have failure escalation control measures been implemented? • Are they consistence with the type of operation? Munich, Germany 6 th -7 th Feb. 2012
Things happen to operations (analytical) • Munich, Germany 6 th -7 th Feb. 2012
Things happen to operations (visually) Munich, Germany 6 th -7 th Feb. 2012
The Bow. Tie - essential elements Proactive Controls Reactive Controls NORMAL MODE RECOVERY MODE Munich, Germany 6 th -7 th Feb. 2012
Bow Tie: an Elegant visualization INDUCTION TRAINING Munich, Germany 6 th -7 th Feb. 2012
Hazard: Aircraft in Motion Elimination Munich, Germany 6 th -7 th Feb. 2012 Prevention Reduction Mitigation
When water temp. & sea are a factor… Elimination Munich, Germany 6 th -7 th Feb. 2012 Prevention Reduction Mitigation
Safety Office: it will look like this… Munich, Germany 6 th -7 th Feb. 2012
Adding an Escalation factor Munich, Germany 6 th -7 th Feb. 2012
Prescription Munich, Germany 6 th -7 th Feb. 2012 Safety audit shall Verify & Validate BOTH O. M FAA . A. D Ann . EAS AA Novembre 2009 11 Performance ⎋-‰ DOC OSA 3 -L 980 Ann esso 1– Lice esso nse 6 -A CFT OPS Ann esso Fa 9 Ann cilitatio esso n 1 Inve 3 – Acc. s t. Ann ess Airp o 14 – Ann orts ess Secu o 17 – rity Ann esso 18 – D. G DOC. . 96 Trai 83 – HF DOC ning 895 9 Man – SMS ual DOC 937 6 P DOC Man rep OP S 9 ua Aud 806 Sla fe it M. anu ty al . D. Documentation, Activity or Hardware. pe re lated. Pa rt C Man – Rou te ual O. M. –T rain Man ing ual Gro und OPS Man SAF ual ETY Man FRM ual e S SEC URI TY Man ual E. R. P. Ma MA nua NTE l NIM M. E IENTO. L Y. LIST MA A PRO UADLE EN CAV E D LI O E S. AUD DAD R ITO RIA LIST A FO RM ULA RIO CER S TIFI CAD PLA OS NIF ICA 201 CION 1 PRO TOC OLO RIES PELIGR GOS OS Y O. M. – Ty nual S Ma O. M – OP C . ENA CIRC . BRAS AL IL A. D OTRO S A. D The glue is an open positive Safety Culture V . NA . PEN COD SA: Control effectiveness Required control 1 1
Control effectiveness Munich, Germany 6 th -7 th Feb. 2012
Summarizing • The $$$ or ROI benefits of Risk assessment • Bow. Tie as an effective communication & a lo$$ control tool • Bow. Tie as an effective auditing tool • Continuous improvement 6. Review & Update 5. Record your findings 2. Hazard Identif. 4. Decide Precaut. STANDARD IZATION Munich, Germany 6 th -7 th Feb. 2012 1. Safety policy 3. Risk Assess. - $$$=IMPROVEMENT
Further reading • • • Bow. Tie XP: www. governors. nl Dekker Sidney (2011), Drift into Failure, Ashgate. ICAO Doc. 8958 – Safety Management System Manual, 2 nd. Ed. Center for Chemical Process Safety of the American Inst. Of Chemical Engineers (1993). Guidelines for Auditing Process Safety Management System, www. gfs. gov. hk/eng/link. htm (Operator of B-HRN) (B-HRN) Preliminary Incident Report: http: //www. cad. gov. hk/reports/B-HRN%20 Preliminary%20 Report%202 -2011_eng. pdf B-HRN media report: www. youtube. com/watch? v=m. Dt. Twl. Ik 8 y. I S-93 Cougar Accident: www. tsb. gc. ca/eng/rapports-reports/aviation/2009/A 09 A 0016. pdf UK CAA, CAP 641, Report of the Review of Helicopter Offshore Safety and Survival. • The Abysmal Performance of the Inflatable Liferaft in Helicopter Ditchings By Capt(N) C. J. Brooks and P. L. Potter* • • ftp: //ftp. rta. nato. int/Pub. Full. Text/RTO/MP/RTO-MP-019/$MP-019 -23. PDF Helicopter Safety (2007), Petroleum Extension Service, Texas University at Austin, USA. Negative outcome from training: www. tsb. gc. ca/eng/rapports-reports/aviation/2008/a 08 a 0007. pdf ISO 31000/2009 Risk Management – Principles and Guidelines Contacts: Capt. Claudio Daniel Caceres +41 (0)79 287 80 99 - sms@mycs. it Continuous Safety – www. mycs. it - via Muttals, 2 -7515 Sils Baselgia, Switzerland- Munich, Germany 6 th -7 th Feb. 2012
- Slides: 14