Case Study: Implementing Safety Management System (SMS)

in Malaysia Airlines

Corporate Safety, Security,

Health & Environment

(CSSHE)

19th August, 2008

DCA-SMS 2

Presentation OutlinePresentation Outline

Overview Why are we doing it? How are we doing it? SMS Open Reporting Culture Safety Action Plan Safety Dashboard Safety Management Review

DCA-SMS 3

Overview SMS Life Cycle Model

Framework Content Action Plan

Policy Accountabilities Flight Safety

Programme Accident &

Incident Prevention Programme

Risk Management Programme

Emergency Response Programme

Audits and inspections

Safety goals

Manuals Structure Scheduled SMS

Training Program Flight Data

Analysis / IFDAT / Safety Forums

Risk Matrix / Risk Register

Emergency Response Plans/ Special Assistance Teams

Audits process / programs/ sharing

Safety dashboards

Safety Action Plans

Safety Dashboards

Safety Meetings Safety Reviews Safety Coms log Safety

Investigators Safety Auditors Safety drills Board Safety

Reports Management

Safety Reports Staff Safety

Reports Practice Drills

Started 2006, Relaunch in Feb 2007

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Why are we doing it?

To build a sustainable safety culture in MAS

Develop predictive safety management capability• Visible Safety Values driven from top• Clear safety accountabilities in place• Effective safety oversight structure• Safety action plans corporate wide• Safety Dashboards in place• Open Reporting institutionalized• Systems supported safety trends monitoring• Safety reviews• Safety Reporting

DCA-SMS 5

Accountable ManagerIdris Jala

GM CSSHECapt. Dr. Ooi Teong Siew

BSSC

Oversight LinkagesLegend

CSI - Corporate Safety InvestigationCSQ - Corporate Safety QualityOSD - Occupational Safety DeptEMC - Emergency Management CentreOCC - Operations Control CentreEM - Engineering & Maintenance

Head of SecurityJeff Nor Jettey

AGM CSICapt Karim Mutalib

AGM CSQRasul Razak

Senior Mgr EMCMohd Fuad Sharuji

Mgr OSDAhmad Kamal

Mgr EnvironmentMustafa Ishak

Mgr Biz SupportZamani Harun

AGM OCCSyed Othman

S. Mgr Grp ITNazri

GM CommercialGermal Singh

AGM Flt Ops (FS)Capt. Missman

FireflyCapt Wong KY

SM Airport OpsZamri Muslimin

SM MASKargoIbrahim Salleh

SM Med CentreDr. Daljit Parmar

AGM E&MMohan S

Mgr IFSMdm Choong

MASWingsCapt Valentine

Corporate Safety Security Health Environment Corporate Safety Security Health Environment (CSSHE) Direct Reports and Oversight Linkages(CSSHE) Direct Reports and Oversight Linkages

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Safety Reporting Framework

HighlightsHighlights

Safety DashboardsSafety Dashboards

Safety Action PlansSafety Action Plans• Strategies, actions, KPI’s, prioritiesStrategies, actions, KPI’s, priorities• Status reports & current measuresStatus reports & current measures

• Level 1, 2 & 3 dashboards Level 1, 2 & 3 dashboards • KPI’s versus current measuresKPI’s versus current measures

• Key dashboard improvementsKey dashboard improvementsand concerns. and concerns.

• Key project completion or delaysKey project completion or delays

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Safety Dashboard Framework

Level 1Level 1Safety CriticalSafety Critical

Level 2Level 2Safety OversightSafety Oversight

Level 3Level 3Domains & SubsidiariesDomains & Subsidiaries

• 266 Domain & Subsidiary Measures 266 Domain & Subsidiary Measures that define line safety system that define line safety system effectivenesseffectiveness

• 79 Safety Oversight Measures that 79 Safety Oversight Measures that define the effectiveness of oversight define the effectiveness of oversight functionsfunctions

• 7 Safety Critical Measures that 7 Safety Critical Measures that define the health of the safety define the health of the safety system system

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Tier 1 KPI (Safety Critical) / Tier 2 KPI (Safety Oversight)

These KPI have been identified as the high level key measures of SSHEperformance across the Company. It provides targets and currentmeasurements and the traffic lights are decided as follows:

On or better than Target

Deviate Target by up to 30%

Deviate Target by greater than 30%

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19%13%45%23%

11%11%57%21%

30%10%40%20%

Tier I KPI Tier 2 KPI Tier 3 KPI

Accidents

Open Reports

Safety Occurrence

Lost Time Injury

Security Occurrence

Engineering

DCA Non Compliance

Total 7 KPI

Oversight

CSI (2)CSQ(4)CSIS(3)FOQA(2)OSD(4)SEC(2)

INFO SEC(4)ENV(4)EMC(6)

Domains

FO / IFO (13)E&M(9)AO(6)

Subsidiaries

FY(8)MW(6)

MKargo(6)

Total 79 KPI Total 266 KPI

Oversight

CSI (12)CSQ(12)CSIS(12)FOQA(7)OSD(12)SEC(9)

INFO SEC(16)ENV(11)EMC(15)

Domains

FO / IFO (43)E&M(39)AO(17)

Subsidiaries

FY(29)MW(15)

MKargo(17)

• Tier 1 Insights

Serious incidents contributed to up tick in safety occurrence

• Tier 2 Insights

Training issues eg availability of training program, lack of qualified safety auditors / investigations, use of systems (CSIS) contributed to the high % of “reds”

Investigation /audit close outs is the next highest cause for the high “reds”

• Tier 3 Insights

Needs prioritization of resources to close out open items

Discipline of action to deliver to the set targets will be required

Upskilling of team will be required

WORK IN PROGRESS

Proposed High Level Overview Report

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SAP / Dashboards Targets/Lifecycle

Starting Up

October 08

December 08

January 09

Renewed 09Targets

Accident “Cliff”

yyy

aaa bbb

ccc

xxx

20

23

15

42July 08

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Open ReportingOpen Reporting

Chairman issued Open Reporting Policy Company wide

Total Safety Reports Received (Rate/10,000)(2005 - 2008)

68

108

159

292

0

50

100

150

200

250

300

350

2005 2006 2007 Jan-Jun'08

rate

/ 10

,000

fli

gh

t cy

cle

Total Safety Reports Received (Actual No)(January - July 2008)

4

5

8

11

84

144

100

99

321

848

0 100 200 300 400 500 600 700 800 900

ME

CHIRPS

A/C GND

Industrial

FltInc

HZD

SEC

GND

ASR

CAB

# of Reports Received

Open Reporting has increased significantly every year

Reporting system is a key component for success

Data analysis a prerequisite for insights

Share, share, share….

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No.

KPI Target Actual MeasurementStatus

Indicator

Remarks

1 Air Accidents 0 0 # of hull loss accident G NIL hull loss accident

2 # of Open Reports 2500 1624# of safety report received in MAS (YTD)

GApprox 12% more than target YTD

3 Safety Occurences

Air Occurrences

Air Safety Reports (ASR) > 59 55# of occurrence /10,000 flight cycle

A

Cummulative average ASR High Impact Occurrences < 6.12 10.9 R

Cabin Occurrences reports > 57 127.6 G

Ground Occurrences

Aircraft Ground Accidents (AGA) <2.5 1.68 # of occurrence /10,000 flight cycles

G Cummulative average

Apron Accident (AA) <1.9 3.37 R

Industrial Accident (IA) <0.2 1.11 /1,000 employees G

4 Lost Time Injury (LTI)

DOSH Reportable LTI (>=4 days) <63

# of cases (YTD) A

Tier One KPI

Example O

nly

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FOQA Top events for Jan-June 2008

Although there is a decrease in the trend from April to Jun ’08 for fleet wide, the trend for B737 keeps increasing. The B737 fleet office has been tasked to conduct deeper analysis and come up with plans to mitigate this issue. Other fleets have been instructed to implement all recommendations formulated during FO Safety Boot Camps initiated by Flight Safety and Human Factors Department (FSHF).

162 246

658

92 419

4

1371

250

817

30 6

1309

557

1221

85

923

479

1509

158 174 54

1180

539

1143

174 135 18

877

485

1100

130 57 60

0

500

1000

1500

2000

2500

3000

3500

Rate per 10,000 Flights

Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08

Chart 1 All Fleet for Unstabilized Approach from Jan - Jun 2008

Analysis Based on Rate per 10,000 Flights

Deviation from glideslope Deviation from centreline Descent rate high below 400' Late Ldg Flap Late Ldg Gear Low on approach

FOQA Analysis is an Important Predictive Tool

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Emergency Management Centre Status

• The target of 910 SAT volunteers is currently 50% short of the required numbers. In particular the trained TEC’s is only 10% of the required number. This is being addressed by a recruitment and training program that will be delivered over the coming 12 months.

• It was identified through the code share audit program (conducted by CSQ) that there are a number of inconsistencies with regard to the emergency response content in Code Share Partner Agreements. EMC will liaise with International Affairs to address these gaps

• 68 of the 74 MAS stations have received an ERP briefing. Only 68 stations have submitted their station ERP; which is below target.

• EMC is working with Aviem International to ensure actual capability of contracted services in event of accidents abroad.

• Presently only 2 mutual assistance agreements have been established with MAS code share partners. The target is to establish 7 of these agreements before December 2008

Example O

nly

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SMS Workshop SMS Workshop

2007 SMS Workshop Participant by Department

32

88

79

72

234

11

17

19

19

0 50 100 150 200 250

CSSHE

MasKargo

Flight Operations

Airport Operation

Engineering

Infight Services

HR

Corporate Services

Others

# of participant

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Safety Reporting To Management / Board

BoardBoard

Accountable Accountable Managers MeetingsManagers Meetings

Safety Council Safety Council MeetingsMeetings

• Chaired by NPH Chaired by NPH • Line Management issues and risksLine Management issues and risks• MonthlyMonthly

• Level 1, 2 & 3 dashboards Level 1, 2 & 3 dashboards • KPI’s versus current measuresKPI’s versus current measures• Chaired by MDChaired by MD• Quarterly Quarterly

• Key dashboards Key dashboards • Key project completion or delaysKey project completion or delays• Chaired by Board MemberChaired by Board Member• Monthly at BoDMonthly at BoD• Quarterly at BSSCQuarterly at BSSC

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End of PresentationEnd of PresentationQ&AQ&A