20181001 right of way infringement - part 2€¦ · 20181001 right of way infringement - part 2...
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Learningfromincidentor,
…howanOccurrencecanfeedaRiskAssessment
RightofWayinfringementPartTwo
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PrefaceInPart1,webuiltacomprehensiveriskassessmenttohelpourairportmanagertocopewithoneofhismajorscenario,thatisthe“RightofWayinfringement”.RightofWayisageneraltermusedtodescribe"thelegalrightofapedestrian,vehicle,orshiptoproceedwithprecedenceoverothersinaparticularsituationorplace".Inanairportitappliestothepolicyinforceregulatingtrafficflow,amongstallpossiblemeansoftransport,inordertoensuresafeandexpeditiousoperations.Regulatingthissubjectisofaquitemajorconcernasaccident/incident,emergingfromcollisionamongsttwoormoremeansoftransport,notonlyhavegreatimpactonthesafetyofoperationsbut,moreover,onthedelayassociatedtosuchtheseandlast,butnotleast,onthecostsinvolvedindamages(SeeIATAGroundDamageDatabase).InthisPart2wewillshowhowonoccurrencecanactually,notonlyguaranteeausefulfollow-uptoreinforceandimprovetheriskassessmentitself,butalsoprovideinputtoquantifySPIs.WewillperformtheanalysisofanoccurrenceusingIncidentXPtoolbyCGERiskManagementSolutions.IncidentXPcombinesthemostinnovativeincidentanalysismethodsinonesafetytool,allowingyoutochoosewhichoneyouneed.Sixmethodstochoosefromaremostinnovativebarrierbasedincidentanalysismethods,selectedforIncidentXP.Theyare:Timeline,BSCAT™,TripodBeta(TB),BarrierFailureAnalysis(BFA),RootCauseAnalysis(RCA),TOP-SET®RCA.
IncidentXPcanbeusedeitherasastand-alonemoduleorinstrictrelationwithBowTieXPvisualriskassessment.Inthissecondcase,IncidentXPmakessurelessonslearntfromincidentsaremaximizedwhentransferredtotheglobalriskassessmentasafollow-upcontribution,enhancingsafetyassuranceprocess.
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GroundSafetyReportAGSRisreceived,elaboratedandimportedinIncidentXPasbelow(Figure1,2,3):
Figure1:GSRprocessedinIncidentXP
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Figure2:Placeofoccurrence
Figure3:Reportcontents
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Occurrenceanalysis,…orhowcanaRiskassessmentfeedstheanalysisTheanalysisoftheoccurrencestartswithaTimeLineDiagram(Figure4),wherealltheactorsandeventscanbeorganizedusingthetimereferenceline.Itisworthnotingthatthiswayofproceeding,appliesonlytooccurrencesinwhichitispossibletoidentifyastrictcause-effectrelationshipbetweenevents,thatistosaytheoccurrencecanberesolvedusing“sequential/epidemiological”modelsofaccidentanalysis.Caseswherethisisnotpossiblemustbemanagedwithotherapproaches,usually“systemic”ones,wheretheoccurrenceistreatedasan“emergent”phenomenonratherthana“resolved”one.
Figure4:TimeLineDiagram
NextstepistodrawaBFADiagramwithadeepanalysisofthebarriersinplace(Figure5).ThisisthepartwheretheRiskassessment,developedinPart1,feedstheoccurrencestudy,toanalysewhichbarriersareinplaceandeventuallywhichofthemhavefailed.
Figure5:BFAanalysisofoccurrence
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FromBFAanalysis,4recommendations(Figure6,7)areproducedwhichhavetwodifferentimpacts.ThisisthepartwheretheoccurrenceanalysisfeedstheRiskassessment.
Figure6:BFAstick-notesforactionsinplace
Figure7:Recommendationsafteranalysis
1. Strengtheningof3existingbarriers“HandlingCompanyOperationalManual”,“Airportmarkings”and“Airport
signs”withActions1to4;
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2. Introducinganewbarrier,“SafetyYellowCar”,inthenativeriskassessment,withAction4(Figure8);
Figure8:ModifiedRiskassessmentfollowingBFArecommendations
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Findingusefulnumbers,…orquantifyingSPIsandRiskAusefulfunctionalityofBowTieXPisreadingadevelopedriskanalysisthrough“IncidentXPeyes”.Ifalloccurrencesbelongingstothesamehazardsareexaminedinrelationstothesamenativeriskassessment(Figure11),countersforthreats/barriers/hazards/consequencesareautomaticallygeneratedanddisplayedwhenIncidentXPFilterisappliedON.ThisapproachisofanincrediblehelpwhentryingtoquantifyriskandSPIs(Figure9,10).ImagineyouhavecollectedalltheoccurrencesofonemonthbelongingstothecategoryofourTopevent“Closeproximitybetweenmean/objector2/moremeans”.Let’s concentrate only, for the sake of simplicity, to those occurrencesbelongings to the Threat “Improper moving Fuel Truck” (sameconsiderationscanbedoneforotherthreats).Applying IncidentXP Filter, we can count howmany times a Top event(numbers of Occurrences collected, T) and Consequence took place (CusuallylessthanT).Lookingatthebarrierswe’llhavedisplayedfailureinformation,includingtheir behaviour associated to the related threat line (B1, B2, B3, B4, B5):thesenumbersarestrictrelativestoSPIs.Ifwemanage,somehow,togetthetotalnumbersofmovementsofourfueltrucks(M),forinstancegettingthetotalnumbersofinvoicesproducedby all fuel providers inmymonthwindow (each invoice implies a truckmovement)wecanfinallygenerateBi/M(ifrom1to5),T/M,C/MratiosthatcanbeusedtogenerateSPIs/Topevent/Riskfrequency.Moreover,havingalwayscareoflinkingoccurrencestoriskanalysis,wherepossible,trendscanberefinedevenmore.Finally,thoseratiosarerealisticindicatorstobeusedwhenbarriersofsamekindareplacedinadifferentriskanalysiscontextduringaprospectiveapproach,whereusuallyprobabilitiesarenotsoclearapriori.
Figure10:BowTieXPriskanalysiswithIncidentFilterON
Figure9:BarriersCounters
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Figure11:NativeRiskassessmentwithBarrierGroupingON