SAFETY

MANAGEMENT SYSTEM
IMPLEMENTOINTI ATO-
ORGANISAATIOSSA

CASE COPTERSAFETY






SMS Foorumi 17.11.2015
Tampere
AGENDA

Coptersafety Oy
Coptersafety SMS concept
ConFnuous improvement
Safety culture
Professionalism

INTRODUCTION

COMPANY

›  The foundaFon for the Coptersafety business idea was the strong market posiFon of the
AgustaWestland AW139 and the change that is occurring in the simulaFon based
training.
›  Coptersafety Ltd is a privately owned Finnish company established iniFally by a team of
Nordic rotary wing professionals to provide
–  highest quality helicopter training services for industry-wide safety and excellence;
–  an independent, neutral and geographically well-positioned training service platform for various helicopter
manufactures

›  ATO and first Full Flight Simulator (AW139, Level D) operaFve as of Autumn 2014
›  Training provided by instructors with extensive experience in aircraY(s) concerned
›  Simulators, Training Center services and training programs can be tailored to meet the
specific needs
›  Nordic locaFon with a 365/24/7 Training Center in the Helsinki Airport, Finland
INTRODUCTION

FINNAIR FLIGHT ACADEMY

›  Close co-operaFon with Finnair Flight Academy in terms of faciliFes, Training Center
services and simulator maintenance provides highest simulator reliability and a solid
foundaFon for the best possible training experience and outcome
›  Finnair Flight Academy has over 50 years of training experience.
›  One of the world’s oldest operaFng airlines, was established on 1923.
›  Its operaFons focus on transporFng passengers between Europe and Asia via Helsinki
›  24.000 simulator hours annually
›  Around 15.000 customer visits per annum

4
INTRODUCTION

TRAINING OVERVIEW

›  Coptersafety is offer a full range of flight and mission training to the operators of the
AW139 helicopter involved in Search and Rescue, EMS, offshore and law enforcement.
›  Standard Flight Training
–  The standard training courses are designed to maintain and enhance the aircrew’s proficiency in accordance with civil
aviation authority and corporate standards. Coptersafety will offer type rating qualification and conversion training for pilots
requiring a type rating on the AW139 helicopter. Once a pilot has transitioned to the AW139, Coptersafety will offer all the
required recurrent training necessary to meet certification standards.
›  Mission Training
–  Mission-specific training courses for night vision goggles (NVG), search and rescue (SAR), offshore operations, emergency
medical services (EMS) and under-slung loads.

›  AW139 service offering

–  Type RaFng Courses SP/MP (ATR&ITR), Recurrent Training, TRI Courses, Special OperaFons (NVG, SAR, ARA and HoisFng)

›  Other courses
–  MCC, CRM, NVG, HUET
 SAFETY MANAGEMENT SYSTEM

SMS COMPONENTS

1.  Safety Policy and ObjecFves 1.  Responsibility and accountability

2.  Safety Risk Management 2.  Safety Policy
•  Hazard idenFficaFon
•  Safety risk assessment 3.  IdenFficaFon of Safety Hazards
•  Risk control
4.  EvaluaFon and management of
3.  Safety Assurance associated risks
•  ValidaFng the effecFveness of
safety risk controls 5.  EffecFve acFons for miFgaFon
•  Management of change
(baselines) 6.  Compliance monitoring provides
•  ConFnuous improvement of SMS feedback to the organizaFon
management
4.  Safety PromoFon
•  CommunicaFon
•  OrganisaFonal learning
Adapted ICAO Doc 9859. 2009 Adapted EASA-OPS. EU N:o 965/2012
SAFETY RESPONSIBILITIES

ATO ORGANISATION

BOARD

ACCOUNTABLE MANAGER TRAINING OFFICE

QUALITY MANAGER
SAFETY MANAGER

AUDITORS HEAD OF TRAINING MANAGER FLIGHT

SIMULATORS

OUTSOURCED FSTD
CHIEF THEORETICAL
CHIEF FLIGHT INSTRUCTOR MAINTENANCE AND
KNOWLEDGE INSTRUCTOR
SUPPORT

THEORETICAL KNOWLEDGE
INSTRUCTORS FLIGHT INSTRUCTORS

STUDENTS
SAFETY RESPONSIBILITIES


SAFETY RESPONSIBILITIES

Safety is everyone’s responsibility and all staff shall be aware of their safety roles
and responsibiliFes.
All personnel are responsible for working safely and maintaining a safe work
environment.
Personnel are required to conduct themselves in a manner that is consistent with
the Company safety rules and policies.
All employees and students are responsible for reporFng to the Safety Manager
about safety related occurrences and observaFons, that they discover.
The more informaFon the company gets from actual operaFons, more accurate are
the risk assessments and more effecFve are the related risk miFgaFons.


 SAFETY RESPONSIBILITIES

SAFETY RESPONSIBILITIES OF SENIOR MANAGEMENT

Establishing levels of acceptable risk

Establishing safety policy
Establishing safety performance goals
AllocaFng sufficient resources
Overseeing system performance
Modifying policies and goals, as necessary

Accountable Manager has the final authority and responsibility for;
•  the allocaFon of resources;
•  the acceptance of risks;
•  supporFng the SMS

 SAFETY RESPONSIBILITIES

SAFETY MANAGER FUNCTIONS

Manages SMS implementaFon plan on behalf of the accountable manager
Facilitates hazard idenFficaFon and risk analysis and management
Monitors correcFve and prevenFve acFons to ensure their accomplishment
Provides periodic reports on safety performance
Maintains safety documentaFon
Plans and organizes staff safety training
Provides independent advice on safety maiers


 SAFETY POLICY AND OBJECTIVES

SAFETY POLICY

Procedural frameworks
•  Strategic statement
•  Should be pracFcal

Roles, responsibiliFes and relaFonships

ExecuFve management
•  High level top-down guidelines

 SAFETY POLICY AND OBJECTIVES

SAFETY POLICY
Safety is one of our core business func0ons and we are commi4ed to developing, implemen0ng and constantly improving
strategies and processes to ensure that all our ac0vi0es take place under a balanced alloca0on of organiza0onal resources,
aimed at maintaining the highest levels of safety performance and mee0ng all applicable standards while delivering our
service.

Coptersafety Oy Safety Policy is based on our safety culture commitment. It is defined below and signed by the Accountable Manager.

Our commitment is to:

•  Develop and embed a safety culture in all our acFviFes that recognizes the importance and value of effecFve safety management and
acknowledges at all Fmes that safety is paramount;
•  AcFvely develop and improve our safety processes to conform with world-class standards and acceptable level of safety;
•  Establish and measure our safety performance against realisFc safety performance indicators and targets;
•  Comply with and, whenever possible, exceed legislaFve and regulatory requirements and standards;
•  Control the risks associated with all acFviFes to a level as low as reasonably pracFcable;
•  ConFnually improve our safety performance through management processes that ensure that relevant safety acFon is taken and is effecFve;
•  Ensure that sufficient skilled and trained human resources are available to implement safety strategies and processes;
•  Ensure that all staff are provided with adequate and appropriate safety informaFon and training, are competent in safety maiers, and are
allocated only tasks commensurate with their skills;
•  Clearly define for all staff their accountabiliFes and responsibiliFes for the development and delivery of our safety strategy and performance;
•  Ensure externally supplied systems and services to support our operaFons are delivered meeFng our safety performance standards; and
•  Ensure that no acFon will be taken against any employee who discloses a safety concern, unless such disclosure indicates, beyond any
reasonable doubt, an illegal act, gross negligence, or a deliberate or willful disregard of regulaFons or procedures.

 SAFETY RISK MANAGEMENT

HAZARD IDENTIFICATION - SAFETY REPORTING

ReporFng culture
•  Transparency of operaFons


Feedback to the management
•  System design


Hazard register update
•  ClassificaFon
•  Risk assessment
•  Trend monitoring


Nature of Just Culture
 SAFETY RISK MANAGEMENT

HAZARD IDENTIFICATION – SAFETY REPORTING

Hazards can only be controlled if their existence

is known.
Through the safety reporFng system,
underlying situaFons or condiFons that have
the potenFal to endanger the safety of
operaFons can be idenFfied.
Safety reporFng can be reacFve (from an event
that has happened) or proacFve (from a
potenFally unsafe situaFon being idenFfied) or
predicFve (trying to predict what might happen
in the future).
Coptersafety’s hazard idenFficaFon process
may include any items from anything around
the FSTD related operaFons and business.

 SAFETY RISK MANAGEMENT

HAZARD IDENTIFICATION - SAFETY REPORTING

The overall purpose of the safety reporFng system is to
use reported informaFon to improve the level of safety
performance of the organisaFon and not to airibute
blame.

Coptersafety Oy has a culture of open reporFng of all

occurrences in which management will not iniFate
disciplinary acFon against any personnel who, in good
faith, discloses a hazard or safety occurrence due to
unintenFonal conduct.

Every employee at Coptersafety Oy is obliged to report

any deviaFon or problem found in the Company
operaFons.

Safety reports shall be filed with IQSMS reporFng

module, which also includes possibility of the
ConfidenFal report. Anonymous report can be made
only with paper format report. Paper format reports are
available in the office faciliFes and briefing rooms.

 SAFETY RISK MANAGEMENT

SAFETY REPORTING – JUST CULTURE

An effecFve Safety Management System requires a ‘Just Culture’ to be in place. A
just culture encourages and supports people to provide essenFal safety related
informaFon in a non-threatening environment, but is clear about where the line is
drawn between acceptable and unacceptable behaviour.
Just Culture is a culture in which individuals are not punished for acFons, omissions
or decisions taken by them that are commensurate with their experience and
training, but where gross negligence, willful violaFons and destrucFve acts are not
tolerated.
IntenFonal willful violaFon and gross negligence are considered as unacceptable
behavior of a Company employee. Such behavior is considered as serious threat for
the Company’s future and future of all personnel in the Company. Omission, slips,
lapses, mistakes and un-intenFonal violaFons are considered as human errors and
will not start the Just Culture disciplinary acFons.

 SAFETY RISK MANAGEMENT

SAFETY REPORTING – HAZARD IDENTIFICATION

The hazard idenFficaFon process includes following steps:
•  ReporFng of hazards, events or safety concerns;
•  CollecFon and storage of safety data;
•  Analysis of the safety data; and
•  Feedback and distribuFon of the safety informaFon disFlled from the safety data.
The reacFve method responds to the events that already happened, such as
incident and accident reports.
The proacFve method looks acFvely for the idenFficaFon of safety risks through the
analysis of organizaFon’s acFviFes (for example from FSTD Reliability Data).
The predicFve method captures system performance as it happens in real-Fme
normal operaFons to idenFfy potenFal future problems.
Coptersafety keeps Hazard Register in IQSMS database to track all hazard analysis,
risk assessment and risk reducFon acFviFes.

 SAFETY RISK MANAGEMENT

SAFETY REPORTING – HAZARD IDENTIFICATION

Extended Event Risk ClassificaDon (EERC)
•  Extended Event Risk ClassificaFon is a rouFne risk assessment tool used by Safety
Manager for assessing risk of hazards revealed by safety reporFng from personnel
or students. Extended Event Risk ClassificaFon will be documented in IQSMS
database for each safety related Incident.
Safety Risk EvaluaDon (SRE)
•  Safety Risk EvaluaFon is a risk assessment tool used by the Safety Manager for risk
assessment in depth. SAG may perform Safety Risk EvaluaFon for rouFne risk
assessments.
Safety Review (SR)
•  Safety Review is a risk assessment tool used by SAG for in-depth assessment for
unknown or un-acceptable risks. SAG may perform Safety Reviews on request of
Safety Review Board.

SAFETY RISK MANAGEMENT

SAFETY INVESTIGATION

InvesFgaFon is a process conducted for the

purpose of accident prevenFon which
includes the gathering and analysis of
informaFon, the drawing of conclusions,
including the determinaFon of causes and,
when appropriate, the making of safety
recommendaFons.

The invesFgaFon process is triggered by a
noFficaFon (safety report) submiied in
accordance with the established safety
reporFng scheme.
SAFETY RISK MANAGEMENT

SAFETY RISK MANAGEMENT - NEGATIVE TRAINING

If any of customers or students receives

negaFve training, their flight safety in real
aircraY may be endangered aYer the training
session.

NegaFve training means that if the flight
crews learn wrong skills, techniques or
procedures, they will apparently use those
skills in real aircraY, which again might
endanger flight safety.

 SAFETY ASSURANCE

SAFETY ASSURANCE

Monitoring and measurement

•  Key Performance Indicators - KPI
•  Safety Performance Indicators – SPI
•  ValidaFon of control effecFveness
•  Regular follow-up
•  ReporFng
•  Safety studies
•  Safety reviews
•  Audits
•  Safety surveys
•  Safety invesFgaFons
•  DocumentaFon
 SAFETY ASSURANCE

SAFETY ASSURANCE

Change management
•  CriFcality of systems and acFviFes
•  i.e. SOP updates
•  Stability of systems and operaFonal environment
•  i.e. growth of operaFons, outsourcing of funcFons, changes in fleet, new
desFnaFon, economical and financial status, poliFcal or regulatory
environment
ConFnuous improvement of the SMS
•  Internal evaluaFons
•  Internal / external audits

 SAFETY ASSURANCE

SAFETY PERFORMANCE MONITORING

Safety performance monitoring and measurement is the process by which the safety
performance of the organisaFon is verified in comparison to its safety policies and objecFves.

Safety Performance is expressed by Safety Performance Indicator (SPI) values and Safety
Performance target values, which will be defined by Safety Review Board. Targets and Indicators
are not fixed, they should be modified or changed as the Company Safety Performance will
change or because there might be internal or external changes that have adverse effect on
safety.

Safety Performance Indicators shall be short-term, measurable objecFves reflecFng the safety
performance of Safety Management System. Safety Performance Indicators and Targets are
evaluated annually.
 SAFETY ASSURANCE

MANAGEMENT OF CHANGE PROCESS

The Management of Change is a formal process
that idenFfies external and internal change that
may affect established cultures, processes and
services.

It uFlises the organisaFon’s exisFng risk
management process to idenFfy potenFal hazards
that will ensure that there is no adverse effect on
safety.

Change can introduce new hazards that could
impact the appropriateness and effecFveness of
any exisFng risk miFgaFon.

 SAFETY ASSURANCE

MANAGEMENT OF CHANGE – SAFETY ACTION GROUP

Permanent Safety AcFon Group meeFng will The Safety AcFon Groups oversees and
gather minimum four Fmes a year. reviews:
Temporary Safety AcFon Groups will gather when •  OperaFonal safety of the safety risk
requested by Accountable Manager or Safety management processes;
Manager. The Safety Manager may also
parFcipate in the Safety AcFon Groups. •  Appropriate resoluFon and miFgaFon of
idenFfied risks;
•  Assessment of the impact on safety of
Risk Analysis operaFonal changes;
- Safety and change inputs •  ImplementaFon of correcFve acFon
plans;
SAG
-  Define miFgaFon acFons
•  CorrecFve acFon is achieved within
agreed Fmescales;
-  Follow-up
-  Risk level up-date •  The effecFveness of previous safety
recommendaFons, safety promoFon and
Line OperaDons safety training.
- ImplementaFon of acFons
 SAFETY ASSURANCE

CONTINUOUS IMPROVEMENT
Coptersafety conFnually seeks to improve its Quality and Safety performance.

ConFnuous improvement is achieved through:

•  ProacFve evaluaFon of day to day operaFons, faciliFes,
equipment, documentaFon and procedures through
safety audits and surveys;
•  EvaluaFon of an individual’s performance to verify the
fulfilment of their safety responsibiliFes;
•  ReacFve evaluaFons in order to verify the effecFveness
of the system for control and miFgaFon of risk e.g.
incidents, accidents and invesFgaFons;
•  Tracking organisaFonal changes to ensure that they are
effecFve;
•  IdenFfying the lessons to be learned from external and
internal occurrences.

 EMERGENCY RESPONSE

EMERGENCY RESPONSE PLAN

The Emergency Response Plan of Coptersafety

sets out the responsibiliFes, roles and acFons for
the various agencies and personnel involved in
dealing with emergencies.
The Emergency Response Plan (ERP) is intended
to provide guidance to responsible managers
responding to emergency events.

All managers must be trained in the use of ERP.
Safety Manager shall arrange the required iniFal
training, which must include the theory and
pracFce of the use of this plan.

 EMERGENCY RESPONSE

EMERGENCY RESPONSE PLAN

TransiFon from normal to emergency operaFons

and designaFon of emergency authority

Assignment of emergency responsibiliFes,
authorisaFon by key personnel for acFons and
coordinaFon of efforts to resolve the emergency

Safe conFnuaFon of operaFons or return to normal
operaFons as soon as PracFcable



SAFETY PROMOTION

SAFETY PROMOTION

Context for safe operaFons – safety culture

Internal and external communicaFon

OrganisaFonal learning – uFlizaFon of free
lessons
SAFETY PROMOTION

SAFETY PROMOTION

The Safety Manager will, as part of its safety

promoFon acFviFes, develop and maintain a
safety training program that ensures that
personnel are trained and competent to
perform their SMS duFes.
All company staff shall receive safety awareness
training upon employment regarding:
•  Safety Policy and objecFves;
•  SMS roles and responsibiliFes;
•  SMS standards;
•  Safety Culture and ReporFng;

•  Human and organizaFonal factors.

SAFETY MANAGEMENT SYSTEM

SAFETY
POLICY

OPERATIONS DATA COLLECTION (FSTD Operations, Training, FSTD maintenance etc.)

External
Conditions

REPORTING SAFETY QTG

SYSTEM AUDITS SYSTEM

AUDIT REPORTS, QTG FINDINGS,

IMPLEMENTATION REPORTS NCRs SNAGS

SAFETY DATABASE

RISK MITIGATING
ACTIONS MANAGEMENT OF HAZARD
(line organisation) CHANGE IDENTIFICATION
SAFETY
PROMOTION &
TRAINING
NO#
SAFETY Acceptable RISK
TREND ANALYSIS
RECOMMENDATIONS risk? ASSESSMENT
SAFETY
YES# ASSURANCE &
SPIs
CONTINUE
OPERATIONS
 SAFETY CULTURE

SAFETY CULTURE

Safety Culture is the set of enduring values

and aqtudes regarding safety, shared by
every member of every level of an
organisaFon.
The Coptersafety Culture is the way we do
things here.

How we behave when no

one is watching!

Adapted Matti Sorsa.

 SAFETY CULTURE

”CULTURE EATS STRATEGY FOR LUNCH”

If culture is not fully aligned with risk strategy, culture wins.

Adapted Dawson McDonald Consulting. 2014

SAFETY CULTURE

PROFESSIONALISM IN THE COCKPIT

Though Europe’s safety record is quite good, the staFsFcs are sFll staggering. Eight
out of ten accidents are caused by human failure.
In an ongoing effort to develop a strong safety culture in aviaFon, we endeavour
to probe deeper and deeper into the subject of Human Factors in the hope of
beier understanding who we are.
Professionalism is one such Human Factors topic that has received much aienFon
in recent years.
Yet there is a general – but false – assumpFon that professionalism is a commonly
understood virtue. Experts opinions vary widely on what this virtue is and how
best assess it.
When asked to describe what professionalism in the cockpit looks like, a typical
response is; “I know it when I see it.”

Adapted Yann Lemasson. Bombardier. 2013

Tony Cern. Going Pro. 2011
SAFETY CULTURE

PROFESSIONALISM IN THE COCKPIT

The following probable causes and findings are from actual accident and
incident reports;
›  “...the pilots’ unprofessional behaviour, deviaFon from standard operaFng
procedures, and poor airmanship, which resulted in an in-flight emergency
from which they were unable to recover...”
›  “The pilots’ nonessenFal conversaFon below 10,000 feet MSL was contrary to
established sterile cockpit regulaFons and reflected a demeanor and cockpit
environment that fostered deviaFon from established standard procedures,
crew resource management disciplines, division of duFes, and
professionalism, reducing the margin of safety well below acceptable limits ...”
›  “The flight crew’s noncompliance with standard operaFng procedures,
including the captain’s abbreviated taxi briefing and both pilots’ non perFnent
conversaFon, most likely created an atmosphere in the cockpit that enabled
the crew’s errors.”

Adapted Yann Lemasson. Bombardier. 2013.

Source NTSB.
SAFETY CULTURE

PROFESSIONALISM IN THE COCKPIT

Sadly, professionalism is too oYen something best recognized by its

absence.

The cost of the professional gap in the cockpit results in
a serious erosion of the safety net.

Adapted Yann Lemasson. Bombardier. 2013

SAFETY CULTURE

PROFESSIONALISM IN THE COCKPIT

”Am I behaving professionally within my

organization?”
“I’m a pro because I am doing all I can to
III – Professionalist
be the best I can and further the
objectives of my peers, my organizations,
and the industry as a whole”

”Am I abiding by the rules of my
II – Complier professional organization?”
“I’m a pro because I meet and maintain
certain standards.”

”Am I part of a professional organization?”
“I’m a pro because I earn a paycheck in
I - Member this industry”

Adapted Tony Cern. Going Pro. 2011

SAFETY CULTURE

PROFESSIONALISM IN THE COCKPIT

What does Being a Professional Mean Today?

Perfection
Normalized Excellence
Precision

Efficiency

Effectiveness

Safety
Hazard

Survival
Violation “Good Enough”
Crushing Grip of Mediocrity
Incident

Accident

Fatality Personal and Organizational Failure Zone

Adapted Tony Cern. Going Pro. 2011

24 Tony Kern, Going Pro, Pygmy Books, 2011, p. 156
COPTERSAFETY ATO

THANK YOU!