2014-05-16

Pegasus Airlines – Risk Based Approach to Management SystemCapt. Kemal HELVACIOĞLU – Vice President of Safety, Quality & Compliance

Risk Management System

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Safety Management System actually uses the elements of ISO 31000 Risk Management. Ourphilosophy is to coordinate all risks of the company via an internationally recognized standard.

Risk Management Process According to ISO 31000

Establishing the Context

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To achieve an integrated risk management system, first we had to establish context. We have built adepartment that monitors all operational areas to see if risks are managed properly.

Integrated Airline Management System

Some items to consider:

Risk Management itself should be done bydepartments themselves; the role of thecentralized risk management functionshould only be overseeing the process.

Definition of risk criteria and riskassessment methodologies are key tosystematic risk management.Departments should be trained accordingto these decisions and everyone shouldspeak the same language.

Establishing the context is a continuous,evolving process.

Integration of Management SystemsAs stated in ICAO Doc 9859 Safety Management Manual Section 2.9, the organization should integrateorganizational management systems designed to achieve specific organizational goals.

Benefits

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reduction of duplication and therefore of costs;

reduction of overall organizational risks and an increase in profitability;

balance of potentially conflicting objectives; and

elimination of potentially conflicting responsibilities and relationships.

QMS SMS

Quality Safety

Quality assurance Safety assurance

Quality control Hazard identification and risk control

Quality culture Safety culture

Compliance with requirements Acceptable level of safety performance

Prescriptive Performance‐based

Standards and specifications Organizational and human factors

Reactive > Proactive Proactive > Predictive

ICAO Doc 9859 Table 5-1. Summary comparison of QMS and SMS

Hazard Identification

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Hazard Identification

Reporting (AQD: Aviation Quality Database)1

Audits and LOSA2

Teledyne End to End Solutions and Flight Data Monitoring System3

Trend Analysis5

Safety Surveys4

New Destination Risk Assessment Studies7

Management of Change Studies6

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We always try to have technological hazard identification methods:

External Events and Studies8

Reporting and AQD1

Safety Audits Risk Assessments

OperationsEnvironmental Health and Safety

Human Factors

Security

A single view of your data7

Audits2

Safety and Quality Audits

DGCA Audits

IOSA

Integrated Management System Audits

Audits from the Ministry of Labour regarding Occupational Health and Safety Risks

SAFA/SANA Audits

Various audits are being coordinated through AQD Audit Module.

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LOSA (Line Operations Safety Audits)2

Via LOSA we are trying to identify inured errors in the operation. We try to conductLOSA at least once in two years.

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Accidents

Incidents

Normal Operations

QAR

Voluntary Incident Reports

LOSA

Accident InvestigationMandatory Incident Reports

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3Teledyne End to End Solutions and Flight Data Monitoring System

3Teledyne End to End Solutions and Flight Data Monitoring System

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Teledyne End to End Solutions and Flight Data Monitoring System3

We use AirFASE and Vision software to monitor flight safety trend of the airline.

Vision Event InvestigationsAirFASE Event Investigations

Engineering AirFASE

Engineering AirFASE for predictive trend monitoring of technical performance.

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Safety Surveys4

Through our intranet system, we conduct online safety surveys every year and comparethe results with the previous year.

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3,2

3,4

3,6

3,8

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4,2

4,4

4,6

EğitimDepartmanı

Uçuş İşletmeDepartmanı

KabinHizmetleriDepartmanı

Mali İşler veIK

Departmanı

TeknikDepartman

DestekHizmetlerDepartmanı

Yer İşletmeDepartmanı

BilgiTeknolojileriDepartmanı

KaliteDepartmanı

TicaretDepartmanı

Department Averages

2012

2013

Trend Monitoring5

To monitor company safety trend, we are preparing graphics of occurrence numbers usingmoving average method. We always try to compare ourselves with global statistics.

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0,000,501,001,502,002,503,003,504,00

01.10 04.10 07.10 09.10 12.10 03.11 06.11 09.11 12.11 03.12 06.12 09.12 12.12 03.13 06.13 09.13 12.13 03.14

per 1

0.000 Flights

Month.Year

TCAS Reports per 10.000 FligthsEurocontrol Data IATA Summer Data Pegasus 12 Month Moving Average Pegasus 3 Month Moving Average

We join various reporting initiatives to be aware of global trends.

IATA FDX (Flight Data eXchange)

IATA Steades

Eurocontrol EVAIR

Management of Change Studies6

We are conducting detailed management of change studies before serious changes affecting thecompany. IATA corporate risk methodology is used here in conjunction with bowtie methodology.

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New Destination Risk Assessment Studies7

Before new destinations, a group of specialists from various departments visit theairport for hazard identification and risk analysis.

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External Events and Studies8

We also use external events, studies and emerging issues for hazard identification.

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Risk Analysis

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Risk Analysis - BowTie MethodologyRisk analysis is done using bowtie methodology.

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We always try to put at least one technological barrier to minimise the effects of human factors.

Bowtie graphs are being built using BowTieXP software which makes it very easy tocommunicate risks to the various levels of the company.

Risk Evaluation

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Risk EvaluationAfter risks are analysed, we evaluate them using the risk matrix.

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Likely to occur many 

times

Likely to occur 

sometimes

Unlikely but possible, may occur once in a few years

Extremely unlikely but may happen in aviation

Nearly impossible

1 to 10‐3 10‐3 to 10‐5 10‐5 to 10‐7 10‐7 to 10‐9 < 10‐9

RiskProbability

Frequent Probable RareExtremely 

RareExtremely Improbable

RiskSeverity

5 4 3 2 1

Multiple fatality

> 10.000.000 Euro

International exposure

Irreversible damage to 

environment Catastrophic A

Single fatality200.000 ‐ 10.000.000 

Euro

National exposure

High but reversible damage

Major B

Serious injuries requiring 

hospitalization

20.000 ‐ 200.000 Euro

Industry or regulator exposure 

only

Significant but 

reversible damage

Moderate C

Minor injuries  requiring  medical attention

100 ‐ 20.000 Euro

Minor exposure, can be forgotten 

quickly

Minor and reversable damage

Minor D

No InjuryNo damage,   < 1000 Euro

No exposureNo damage 

to environment

Negligible E

Basic probability assessment

Environm

ent

Repu

tatio

n

Fina

ncial

Peop

leObjective probability 

assessment    (per flight cycles)

Pegasus Airlines Risk Matrix

Risk Treatment

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Risk TreatmentIf a risk is in an unacceptable area, we minimise it by strengthening a barrier or adding anew one.

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Honeywell Launch CustomerRDR-4000 Weather Radar Software Upgrade on

B737NG Aircraft

TCAS ATC PANEL

Risk TreatmentPriority is always technological improvements that can minimise human errors.

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Risk Treatment

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A good emergency response system is also a necessary barrier. Apart fromdocumentation, trainings and exercises we enhance it with technological improvements.

Communication and Consultation

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Communication and ConsultationWe facilitate or take part in various meetings for the purposes of risk communication andconsultation.

Safety Meetings

Quarterly Board Meetings

Semi-annual Safety Committee Meetings

Monthly Safety Review Board Meetings

Monthly Safety Action Group Meetings

Weekly Operational Meetings of Departments

Monthly FDM Meetings

Fatigue SAG Meetings

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SAFETY COMMITTEE

BOARD

SAFETY REVIEW BOARD

FLIGHT OPERATION MEETINGS

FATIGUE SAFETY ACTION GROUP

FLIGHT DATA MONITORING

WORKING GROUP

SAFETY ACTION GROUP

TECHNICALMEETINGS

GROUND OPERATIONMEETINGS

CABIN SERVICESMEETINGS

Safety Performance IndicatorsSafety performance indicators are defined in the start of every year and safetyobjectives of departments are chosen accordingly.

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SPIs are monitored after every quarterfirst by Safety Action Group and thenby Safety Review Board.

We try to choose same SPIs everyyear to monitor our trend.

Safety PromotionWe communicate risks to people via various technological means, using magazines,bulletins, read and signs and EFB.

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SPECIAL AIRPORTSSummary of Occurrences

Magazines

Bulletins

Read and Signs

Special Airports section in EFB

Monitoring and Review

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Monitoring and ReviewRisk management is a continuous process. We always monitor and review our existing barriers to seeif they are still efficient and effective.

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IncidentXP

Enterprise Risk ManagementNow, our aim is to continue standardizing and improving the risk culture of other departments in thecompany by establishing Enterprise Risk Management.

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CreditRisks

MarketRisks

LiquidityRisks

TechnicRisks

FlightRisks

CabinRisks

GroundRisks

CargoRisks

StrategicRisks

ENTERPRISE RISK MANAGEMENT

PoliticalRisks