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Safety is a good business practice

Safety is a good business practice. Corporate Aviation Safety Record per 100,000 departures. Business Aviation Summary Accident rate has flattened over last 5 years 53% of accidents are in the landing 18% of accidents occur on takeoff 10% of accidents on approach

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Safety is a good business practice

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  1. Safety is a good business practice

  2. Corporate Aviation Safety Recordper 100,000 departures

  3. Business Aviation Summary Accident rate has flattened over last 5 years 53% of accidents are in the landing 18% of accidents occur on takeoff 10% of accidents on approach 17% of fatal accidents occurred during training flight 36% of accidents occurred during ferry flights

  4. Normal Accidents… (system) • Occur because of the complexity of the systems • Design • Equipment • Procedures • Operators-(60-80%) • Supply/materials • Environmental • Each failure alone is trivial by itself, and expected to occur because nothing is perfect.

  5. Organizational Accidents… • Warnings are ignored • Unnecessary risk are taken • Normalization of Deviance * • Sloppy work is performed • Deception/downright lying practiced • Production pressures • Occurs in ALL organizations

  6. Operator accidents… • Workload is more bunched • Long periods of inactivity • Short burst of intense activity • Each are error inducing modes • Long periods of passive monitoring make one unprepared to act in emergencies Study found pilots make one error every 4 minutes which were caught quickly or are insignificant

  7. What are the main causes of accidents? (The Dirty Dozen) Lack of Communication Complacency Lack of Knowledge Distractions Lack of Team Work Fatigue Lack of Resources Pressure Lack of Assertiveness Stress Lack of Awareness Norms SMS

  8. Paine Stewart crash

  9. Investigations of other accidents in which flight crews attempted to diagnose a pressurization problem or initiate emergency pressurization instead of immediately donning oxygen masks following a cabin altitude alert have revealed that, even with a relatively gradual rate of depressurization, pilots have rapidly lost cognitive or motor abilities to effectively troubleshoot the problem or don their masks shortly thereafter. In summary, the Safety Board was unable to determine why the flight crew could not, or did not, receive supplemental oxygen in sufficient time and/or adequate concentration to avoid hypoxia and incapacitation. PROBABLE CAUSE: The National Transportation Safety Board determines the probable cause of this accident was incapacitation of the flight crewmembers as a result of their failure to receive supplemental oxygen following a loss of cabin pressurization, for undetermined reasons.

  10. SMS ???

  11. SMS is a Tool • Not a fail-safe system • Can’t Eliminate stupid • Can’t Substitute for experience

  12. WHAT SMS CAN DO • Raise level of awareness of hazards • Documents policies, procedures, training • Identifies and analyzes hazards • Establishes mitigations that MIGHT work • Provides a means to improve • Establishes a means to build upon safety culture

  13. Can SMS prevent accidents??? • SMS is a Management Tool • Garbage in-Garbage out • Effective within an sound safety culture • Not a Fail-Safe Tool

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