Aviation Safety Management System

Dec. 16, 2008
The goal: An 80% reduction in accidents by 2016

The use of helicopters has grown tremendously in the past 20 years. In particular, there has been substantial growth in the law enforcement and helicopter emergency medical services (HEMS) sector of the industry. Unfortunately, there has also been an increase in accidents involving helicopters. In an effort to address this disturbing and deadly increase, the 2005 International Helicopter Safety Symposium marked the beginning of an industry wide goal to reduce helicopter accidents by 80% by the year 2016. The entire effort is broadly inclusive and allows all segments of the industry such as operators, manufacturers, vendors and other interested parties a chance to come together in this admirable goal.

One of the initiatives introduced in this initiative is the "Safety Management System". No longer is safety considered as a separate topic. More than just tips and suggestions, the Safety Management System is a coordinated, comprehensive set of processes designed to direct and control resources to optimally manage safety. Safety becomes part of the entire process and culture and seemingly unrelated circumstances are scrutinized and examined to make a safer operation.

Every time the National Transportation Safety Board investigates an accident and comes up with their probable cause statements, it is almost always a series of events, better known as the accident chain that occurred, ultimately resulting in an accident. For example, the crash of a charter aircraft was ultimately blamed on fuel exhaustion. The pilots simply ran out of gas. However, an examination of the accident chain revealed many reasons why this inexplicable reason became a reality. The flight crew arrived at their home base for a fairly easy day of work ahead of them. Just a couple of short flights and they would be home by dinnertime. The pilot-in-command, (Captain) ordered thirty gallons of fuel to be place in each fuel tank of the aircraft. (Many aircraft have two fuel systems/tanks). When the fuel truck arrived, the fueler confirming the fuel order pointed to the aircraft and said, "Thirty?" The First Officer, thinking the fueler meant thirty a side, replied, "Yes." (Error chain #1; failure to communicate). Company policy required one of the two pilots to remain with the aircraft during fueling.

In light of torrential rain, the pilots elected not to personally observe the fuel order, which was a departure from company procedure (error chain #2). After fueling, the pilots are normally handed the fuel receipt for a final check on how much fuel was obtained. Since the aircraft was at its home base, the fuel company simply directly billed the operator and no receipts changed hands. Although it was within police and procedure, it marked another error in the accident chain. (Error chain #3). Finally, if the pilots had observed a lower than expected reading on the fuel gauge, they might have attributed it to an inaccurate fuel gauge, a problem that had been noted by previous flight crews. This accident involved a series of events, both within and outside policy and procedure that all contributed to a deadly accident. The Safety Management System is designed to catch these errors before they become a problem.

A similar approach could be taken when examining police line-of-duty deaths. In the last 20 years, felonious deaths have been decreasing. This is attributed to better equipment, better officer awareness and better training. Unfortunately, accidental deaths in the line-of-duty, in particular, traffic accidents are climbing. Why is this happening? Could it be officer fatigue due to the introduction of 12 hour shifts? After all, 12 hour shifts were virtually unheard of 20 years ago. Are their more distractions in the patrol car itself including multiple computers and radios? Finally, do the officers themselves carry more distractions in the form of cellular phones, Blackberrys and PDAs? Perhaps a combination of all the above? The Safety Management System attempts to look at all aspects of the process.

The Safety Management System stresses empowerment and accountability at all levels. It also mandates all concerned parties to take an active role in making flying safer. It gives everyone involved a better way to recognize and manage risks. Let's face it, police work and flying will always have risks. It is our job to reduce and mitigate these risks as best we can.

Another refreshing aspect of the Safety Management System is that inadvertent, lapses in policy and procedural lapses are encouraged to be reported without penalty to the reporter. A helicopter crew self reported to their supervisors that they had inadvertently left off the transmission filler cap when conducting the preflight and had flown the aircraft potentially exposing the transmission fluid to contamination. A fairly expensive inspection was required and the brass ordered their transfers. When it was pointed out to the brass that the crew came forward, on their own, to report this lapse, and that it was highly unlikely that future crews would be so forthcoming, cooler heads prevailed and the transfers were rescinded.

Perhaps the application of these Safety Management System principles could help reduce police line-of-duty deaths as well?

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