Modelled Risk Scenarios for an Aviation SMS Shell Aircraft International Aviation Hazard Management...

Shell Aircraft international

Modelled Risk Scenarios for an Aviation SMS

Shell Aircraft International

Aviation Hazard Management Ltd

International Federation of Airworthiness


ICAO - SMS mandatory from 2009

UK Oil Industry - SMS mandated since 1992

Piper Alpha Disaster - Cullen Report

‘it was irresponsible to operate a business without understanding the risks and managing the hazards that

existed within that business’


Aim: to produce a Transportable Hazard Analysis

SAI - Facilities, tools & models

UKFSC - expertise (pilots

& engineers)

Hazard Analysis Team


HEMPHazard and Effects Management Programme

- Identify (the hazard, and hazardous events)

- Assess (the Risks)


HEMPHazard and Effects Management Programme

- Identify (the hazard, and hazardous events)

- Assess (the Risks)

- Control (the threats that might release the hazard that leads to the hazardous event)- Recover (from the hazardous event, if possible before incurring an unwanted consequence)


HazardousEvent

HAZARDS

MITIGATION

THREAT

CONSEQUENCES

CONTROL

CONTROL

ESCALATION

ESCALATION

CONTROL

RECOVER

Manage / ControlThe causes

MinimizeThe results

The Bow-Tie Analysis Tool

www.bowtie.com

http://www.bowtie.com/


Bow-Tie Shape


Risk Scenarios

Team identified 450 potential eventsunmanagable number for detailed analysis

by generic grouping, combining threats & threat controls

reduced list of 35 separate Risk Scenarios


Example of Bow-TieXP as an analysis tool

Aircraft in motion

Aircraft deviates from intended safe flight path


Who does What, Why and How?


Human Error

Release of an Unairworthy Aircraft to Service


Hazard Modelling

Using HEMP the team focused on Hazardous Events

HazardousEvent

‘Potential hazardous events are what need to be risk assessed, rather than the hazard itself’

Test needed to check for gaps


LocationsLocation A - Aircraft on the ground in preparation for or recovery from service

Location B - Aircraft in motion - on the ground

Location C - Aircraft in Motion - Airborne

Location D - Aircraft Undergoing Maintenance

Location E - Offices and Facilities


Hazardous Events - Example of coding

HE 18ACD - Loss of Containment - Dangerous Goods

HE = Hazardous Event

18 = sequential by discipline (except 1 & 2)

ACD = Locations

Disciplines - Operational, Maintenance, HSE related, Organisational & Management


HE 1CDeviation from intended safe flight path‘Situations causing a signicant departure from a safe, intended heading, altitude, speed, flight level and or track’.

GENERIC PRIMARY OPERATIONAL HAZARDOUS EVENTS

HE 2ADRelease of an unairworthy aircraft to service‘Situations resulting in the inadvertent release of an aircraft following maintenance, or servicing actions, which is not fully airworthy’.


Operational HE 4BC - Aircraft major system failures including dynamic failure of components

Maintenance HE 19D - Lost of containment fluid or gas under pressure

HSE Related HE 22 AD - Encountering adverse weather conditions

Organisation &Management

HE 30E - Contracted corporate commitments at variance to company resources


These generic analyses can be customised for use by any

aircraft operator

Modelled Risk Scenarios for an Aviation SMS Shell Aircraft International Aviation Hazard Management...

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