Organizational Culture of Taxi Company by emi90305

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									SMS
Implications for
Education


                                                          Jim Dow
                            Chief, Flight Training & Examinations
                                                 Transport Canada

                                                 Presentation to
                   National Training Aircraft Symposium
                                                          4674888

                                                      March 2009
   I hear and I forget.
I see and I remember.
I do and I understand.
       -Confucius
 System means a group of interdependent
 processes and people working together to
achieve a defined result. A system comprises
     policies, processes and procedures.
Informed Culture                              Learning Culture
People understand the                         People are encouraged to
hazards and risks involved                    develop and apply their
in their own operation.                       own skills and knowledge to
Staff work continuously                       enhance organizational
to identify and overcome                      safety.
threats to safety.                            Staff are updated on safety
                                              issues by management.
                             Safety Culture   Safety reports are fed back
                                              to staff so that everyone
                                              learns the lessons.
Reporting Culture
People are encouraged to
voice safety concerns.                        Just Culture
When safety concerns are
                                              Atmosphere of trust where
reported they are analyzed
                                              reporting is encouraged and
and appropriate action is
                                              where a line is drawn
taken
                                              between acceptable and
                                              unacceptable behaviours.
              A System Change
   Role     Traditional Approach           SMS Approach
Inspector   Inspectors are regulatory   Inspectors are system
            compliance auditors.        evaluators.
Company     The company responds to     The company proactively
            regulatory requirements.    manages risks.
Transport   TC inspects aircraft,       TC assesses whether
Canada      records, and personnel      companies have effective
            directly.                   processes to ensure
                                        safety.
                 Implementation
                     Operator                        In Force
Airlines/AMO                                           2005

ATS Operations                                         2008
Airports (Group 1)                                     2008
Airports (Group 2)                                     2009
Aerial Work, Air Taxi, Commuter, Flight Training,      2009
AMO
Heliports, Water Airports, Approved Manufacturers,     2010
Aircraft Certification
          Implementation Phases
   Initial         1 Year         2 Year           3 Year
   Review        Follow-up      Follow-up        Follow-up
Accountable    SMS Plan,       Proactive hazard Training
Executive      Policies, and   identification
               Procedures
Gap Analysis                                   Quality
               Reactive                        Assurance
Implementation Reporting
               System
plan and                                       Emergency
responsible
person                                         Preparedness
            SMS Components
    Component                            Element
                         Safety Policy

                         Non-Punitive Safety Reporting Policy

                         Roles, Responsibilities & Employee
Safety Management Plan   Involvement
                         Communication

                         Safety Planning, Objectives and Goals

                         Performance Measurement

                         Management Review
         SMS Components
Component                          Element
                   Identification and Maintenance of Applicable
                   Regulations
Documentation
                   SMS Documentation
 Management
                   Records Management

                   Reactive Processes

                   Proactive Processes
Safety Oversight   Investigation and Analysis

                   Risk Management
            SMS Components
    Component                            Element
       Training          Training, Awareness and Competence

   Quality Assurance     Operational Quality Assurance

Emergency Preparedness   Emergency Preparedness and Response
                   SMS - ICAO
Component                             Knowledge
                     Principles of safety management

                     Corporate safety philosophy, safety policies, safety
                     standards, etc.
Initial Training     Importance of complying with safety
                     policy/procedures
    All Staff
                     Corporate safety record

                     Corporate safety goals/objectives

                     Corporate safety management programs –
                     reporting systems, LOSA, etc.
                     Ongoing internal assessment of safety
                     performance
                   SMS - ICAO
Component                            Knowledge
                     Reporting accidents, incidents, perceived hazards

                     Lines of communication for safety matters
Initial Training
                     Dissemination of safety information
    All Staff
                     Safety awards

                     Safety audits

                     Safety promotion
                     SMS - ICAO
     Component                               Knowledge
                            Procedures for reporting accidents/incidents

                            Unique hazards facing operational personnel

                            Procedures for hazard reporting
All Operational Personnel
                            Specific safety initiatives (e.g. FOQA)

                            Safety committee

                            Seasonal safety hazards/procedures

                            Emergency procedures
              SMS Knowledge
 Component                              Knowledge
                      Aviation accident history

                      Quality control

                      Quality assurance
Evolution of safety
  management          Quality system

                      Safety management system

                      Operational vs system quality assurance

                      Safety and security

                      System complexity
                 SMS Knowledge
     Component                              Knowledge
                           Reason’s Model

                           SHEL Model
Organizational Culture and
Human Factors in Aviation Rasmussen’s Ladder
                           Cause and effect

                           Bias
             SMS Knowledge
 Component                           Knowledge
                    Hazard definition and identification

                    Risk assessment process
Risk Management
                    Proactive vs reactive processes
                    Threat and error management

Incident/Accident   Techniques
  Investigation     Process
                SMS Knowledge
    Component                             Knowledge
                          Safety reporting systems
 Data Collection and
                          Design and categorization
     Processing
                          Manual vs electronic databases

                          Root cause

                          Trend
Evaluation and Analysis   Fault tree

                          Maintenance Error Decision Aid (MEDA)

                          Procedural Event Analysis Tool (PEAT)
                  SMS Knowledge
      Component                             Knowledge
                            Management involvement

                            Employee involvement

     Safety Program
                          Process vs procedure
Development and Operation
                            Safety performance measurement

                            Documentation

                            Regulatory requirements

                            System evaluation
               SMS Knowledge
    Component                            Knowledge
                         Theory – containment and mitigation
Emergency Planning and
                         Planning
      Response
                         Procedures
        SMS Information

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