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SMS in Practice- Information Gathering and RiskManagementSMS Seminar & WorkshopOctober 25/26 2007Tokyo, Japan
Michael Mugridge, BCommManager, Quality ServicesAir [email protected]
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Background: Air Canada Legacy Systems
British Airways Safety Information System(BASIS): only used by Flight Operations, Flight
Safety SurPass Audit Software:
only used by Maintenance
Parklane Injury system only used for reporting of personal injuries
for claims purposes
Discrete systems which did not communicate
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Decision made by the Executive toconsolidate:
Document Control; Audits; Safety Reporting; and
into a single Information Managementtool
Background: Air Canada Legacy Systems
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Benefits of Integration
help meet Transport Canada SMS andIOSA requirements
one taxonomy model
one risk model
efficiencies with respect to operations andmaintenance of a single it system
standardization of functionality across the
business units easier Corporate reporting
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The Software Solution:
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EtQ Reliance Web-based, enterprise system for Quality
Management.
Flexible Workflow Engine, it allows: workflows
forms fields,
reports
to be configured without programming. In other words build your system
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Reliance Notifications E-mail notifications can be used to:
Notify users that they have a task to perform e.g.
> Approve a document> Complete an audit checklist> Do a risk assessment
Notify users when they are late
Provides hyperlink directly to document.
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Three Principle Modules Implementation
at Air Canada
small grouptrials
Safety Reporting
ImplementedAudit and
Corrective/Preventive Action
ImplementedDocument Management
and Control
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Document Control
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Document Management and Control For company policy and procedure documents
Provides control over source documents (e.g.Microsoft Word)
Automates: creation of draft copy;
review and comment; approval (includes Transport Canada approval);
etc.
Provides a central repository for current; and archived documents
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Document Control FeaturesApproved documents areseparated from Drafts
(Pending)
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Document Control Features (contd)
Draft (Pending) documents travel through a
workflow for all value-added work: review and comment, approvals; translation;
printing, distribution, uploading; etc
Draft
Review &
Comment
Internal
Approval Approved
Regulatory
Approval
PENDING
APPROVED
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Document Control Features (contd)
Approved
ARCHIVED OBSOLETE
[automatic]
Manual Archive
Superseded documents are automaticallyarchived
Obsolete documents may be manually archived
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Document Control Features (contd)Reliance can monitor a documents date and
warn (via e-mail) of potentially outdated
content
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Reliance screen
E-mail
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Audit and Corrective & Preventive Action
(CAPA)
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Question Bank (question profiles) Each audit question only exists once.
If question is revised, all checklists using that
question are updated. Questions are revision controlled
Old versions are archived.
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Audit Templates Checklist templates points to questions in
question bank
Audit template point to checklists
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Question Bank
Audit Templates
Audit type 1
Audit type 2 QuestionQuestionQuestion
Checklist 3
Question
QuestionQuestionChecklist 2
QuestionQuestionQuestion
Checklist 1
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Audit Records Creating an audit of a certain type
copies the template contents intorecords.
Templates remain untouched.
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Audit Document (Record)
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Checklist Document (Record)
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Question Document (Record)
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Audit Record Workflows
Lead auditor can manage the audit record and assignchecklists to individual auditors for completion
Draft Scheduled In Progress Accomplished Closed
Audit Record
Draft Assigned Completed
Checklist Document
Draft Completed
Question Document
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Audit Corrective Action
LinksCAPA are automatically linked to the Audit Report
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Audit Corrective Action
Links Audit question contains link to CAPA
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CAPA Document Workflow
DraftCorrective
Action Plan
CAP
Approval
ImplementationVerification &
Effectiveness *Completed
Auditor
Auditee
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Fields - Draft
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Fields Draft (contd)
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Root Cause Analysis
Uses HFACS model which will be covered inthe Safety Module
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Fields - Corrective Action Plan
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Fields - Implementation
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Fields Verification and Validation
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Output Reports Audit
WebFocus: Web-based reporting tool
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Sample Report
Pdf but can be other format
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Safety Reporting
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Safety Reporting
Provides a single, platform for reporting safetyevents and hazards / concerns
Used by several different Branches andBusiness Units
Uses intuitive Risk Assessment Model (IRAM)
and root cause analysis/causal factors model(HFACS)
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Occurrence Form
Contains approximately 200 fields
Shows / hides sections/fields depending on
user entries e.g. Disruptive passenger
Environment
Injury Turbulence
Equipment damage
Fuel dump
O W kfl
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Occurrence Workflow
Draft Investigate
Review
WithManagement
Finalize
Report Finished
Risk
Assessment
Low risk
High risk
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Phase - Draft
Employee checks box to determine type of report
Ph D ft G l S ti
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Phase Draft: General Sections
Ph D ft G l S ti
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Phase - Draft: General Sections
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Phase - Draft: Context Specific Sections
plus context specific sections
Occurrence Workflow
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Occurrence Workflow
Draft Investigate
Review
WithManagement
Finalize
Report Finished
Risk
Assessment
Low risk
High risk
Risk
Assessment
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Risk Assessment
Air Canada has developed an intuitive RiskAssessment Matrix
Provides guidance words to front-line staff tomake quick assessments without statistics
User chooses:
Probability of occurrence Severity of outcome
The matrix provides a direction letter AD
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Guidance Words
Exist for the following possible incidentoutcomes:
Injury Illness
Aircraft damage
Equipment / facility damage
Safety of flight
Environmental
Regulatory
Security
Sample Guidance Words for Severity for
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Sample Guidance Words for Severity forSafety of Flight
Low; activation of a safety system or safety procedure with correct crew response an avoidance maneuver that is deemed not to have been required loss of single primary system with redundant system available. smoke, smell, or fire/spark that was brief, identifiable, and extinguished
Medium; activation of a safety system or safety procedure followed by an incorrect crew
response, which however did not result in an increased safety threat an avoidance maneuver that is deemed to have been required loss of multiple primary systems with redundant systems available an un-commanded flight control input that is easily counter controlled.
smoke, smell, or fire that was prolonged and identifiable, but contained orextinguished. High;
activation of a safety system or safety procedure with incorrect response whichdid result in an increased safety threat
an avoidance maneuver that is deemed to have been aggressive or prolonged loss of a primary system with no redundant system available
an un-commanded flight control input that is difficult to counter control smoke, smell, or fire that was prolonged and not identifiable, or not contained,
or not extinguishable. Critical;
hull loss
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Risk Assessment The Challenge
How to make all the guidance wordsavailable via the software?
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Phases Risk Assessment
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Selecting the Appropriate Severity
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Phases Risk Assessment
The overall risk for an incident is the highestrisk for any one outcome
The employee is also provided with direction
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Risk Assessment - Example
Occurrence Workflow
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Draft Investigate
Review
WithManagement
Finalize
Report Finished
Risk
Assessment
Low risk
High risk
Investigate
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Phases Investigation and Recommendation
Investigate: Supervisor or trained investigatorperforms investigation: Executive Summary of Occurrence Factual Information of Occurrence Analysis of Occurrence Findings
Recommendations (Corrective and PreventativeActions)
Categorizes the incident various ways HFACS
Immediate Effect Incident Category
I id t R t
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Incident Report
I ti ti D t il
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Investigation Details
Occurrence Causal Factors is the HFACS field
Human Factors Accident ClassificationS t (HFACS) I l t ti
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System (HFACS) Implementation
User can choose asmany as needed
Human Factors Accident ClassificationSystem (HFACS) Implementation
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System (HFACS) Implementation
Entire tree structure is captured to facilitate roll-up analysis
Occurrence Workflow
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Draft Investigate
Review
WithManagement
Finalize
Report Finished
Risk
Assessment
Low risk
High risk
Review
WithManagement
Finalize
Report
Review and Finalize Phases
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Review and Finalize Phases
Review Review with responsible management to agree with
Corrective Actions Finalize Report
Investigator:
> creates Corrective Action documents (same as
Audit module)> Finishes report.
Output Reports WebFocus
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Output Reports - WebFocus
Reports for Safety (accident, incident, concern)are being developed.
Questions?
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Questions?