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NTSB Recommends SMS for HEMS Operators
The National Transportation Safety Board (NTSB) will propose 19 new safety recommendations aimed at minimizing the risks of Helicopter Emergency Medical Services (HEMS) operations.
The recommendations will address a wide range of safety improvements including the development of a low-altitude airspace infrastructure, adoption of safety management systems (SMS) and data monitoring programs, and pilot use of new technologies such as night vision goggles.
The new recommendations were developed following the February 3-6 NTSB hearing that evaluated factors that led to an increasing number of HEMS accidents. From 2003 through 2008, 77 people died in 85 HEMS accidents with 2008 being the worst for HEMS operations. In 2008 there were 29 fatalities in eight accidents.
Improving safety of Emergency Medical Service (EMS) flights is on the NTSB's "Most Wanted List" of aviation safety improvements. On February 7, 2006, the NTSB issued four recommendations in conjunction with its January 25, 2006 special investigative report on EMS safety.
The following recommendations have been categorized as "open," with the FAA's response considered "unacceptable:"
- Require that all flights with medical personnel on board be conducted in accordance with FAR Part 135 regulations. (Currently, flights with medical personnel on board, but no passengers onboard, may operate under the less stringent provisions of Part 91.)
- Develop and implement flight risk evaluation programs.
- Require the installation of TAWS on aircraft.
Once the final 19 safety recommendations are published, operators will no doubt implement them as needed. In the mean time, these discussions and recommendations continue to remind us that the implementation of an SMS now will save time and money in the long term.
Public Issue Reporting Module Available with SMS ProTM
Public users can now submit aviation safety, quality, security & compliance issues in SMS Pro, the most complete and affordable SMS application on the market. We believe that everyone should have the opportunity to report issues that may help aviation service providers enhance safety and improve quality.
In the past, only employees and authorized contractors were able to report issues to SMS Pro's Web-based aviation safety management system. This rule was enforced to facilitate the feedback loop; i.e., users reporting issues would receive email confirmations and be able to see the status of their issue at any time.
A limitation of the new public issue reporting module is that Safety Managers must communicate to the individual that submitted the safety issue via contact information supplied by the user. Remaining functionality basically remains the same.
The business process for the public issue reporting is as follows:
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Public user submits issue;
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Safety manager receives email notification with link to reported issue;
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If reporter supplied an email, the reporter will also receive an email thanking the person for submitting the report;
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Safety manager manages the issue similar to any other issue and may communicate to the reporter when the issue is resolved or more information is required;
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Safety manager may classify the issue differently, based on the source (SMS Pro allows complete customization of issue classification).
Not all aviation service providers will want to allow all Web users to report issues to their aviation SMS. If they feel that employees or others are abusing the system, alternatives can be arranged, such as changing the URL used to access the public issue reporting page.
Direct employees should continue to use the reporting features in SMS Pro set up by their company rather than use the pubic SMS issue reporting module in SMS Pro.
The public issue reporting module does not come packaged with any version of SMS Pro (SMS Pro Enterprise, SMS Pro Lite and Free versions). The reason it does not come packaged with a version is that the module and URL remains unique to each organization based on their base URL and their customized menu structure.
To implement the public issue reporter, NWDS installs the module onto the client's SMS Pro application. Then NWDS provides the URL to the operator to place on their public Web site. This link will take users to the SMS Pro application where they can report issues.
To see how public users can submit aviation SMS issues, click here.
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Risk Management
A key operator responsibility is to determine all possible hazards, evaluate their effects to the organization and the environment, take and prove that all measures necessary have been taken to prevent an event/accident and to limit the consequences.
The adoption of a safety management system (SMS) is the best approach to safety and loss prevention. SMS evolves from the principle of approaching safety on a proactive rather than a reactive basis and to make it an integral part of the way the organization conducts business.
Despite improvement in programs and systems, accidents continue to occur, primarily due to human failures and poor safety management practices. An SMS helps ensure that suitable measures are in place to control hazards and that they are properly managed and continuously upgraded at all times. Risk management plays a central role in the SMS, since it demonstrates that the SMS functions through the methods by which hazards are identified and controlled.
Principles of Risk Management
The fundamental principles of risk management are:
Identify: Are people, environment or company assets exposed to harm? What are the hazards?
Assess: What are the causes and consequences? How likely is loss of control? What is the severity of consequences? What is the risk and can it be reduced?
Prevent: Can the causes be eliminated? What preventive measures are needed? How effective are the controls?
Recover: Can the potential consequences be mitigated? What recovery measures are needed? Are recovery capabilities suitable and sufficient?
Basic risk management components can be visualized in a "bow-tie diagram", as shown in Figure A below. A hazard, defined as the potential to cause harm, is released in the form of an initiating event. The bow-tie approach assumes that a hazard is represented by one or several threats, which have the potential to lead to the event. Consequences are the potential outcomes of an event. Preventive measures are technical or procedural measures that act as 'barriers' to prevent or minimize the likelihood of a hazard. Recovery or mitigation measures are actions specified to stop propagation of the events and/or to limit the severity of the consequences. Also, there could be secondary controls designed to avoid escalation factors; that is, situations where defeat or impairment of the primary preventive or recovery measures can occur.
The top event is presented in the center of the bow-tie diagram. The left-hand side of the figure is the causal path showing threats and the corresponding preventive measures. The right-hand side of the figure shows a potential sequence of events following the hazard and the corresponding recovery measures. The figure also shows a link of controls with the corresponding safety critical activities; that is, actions taken to ensure that the controls are effective at all times.
Applying the Bow-Tie Analysis
Figure A shows an example of a bow-tie analysis for fuel loading operations at a fuel storage site. Fuel from storage tanks is pumped to a loading station where it is transferred to fuel trucks using flexible hoses. The hazard of particular concern is a potential rupture of a hose during loading operations.
The top event is linked to the threats. The selected top event is 'Loading hose rupture,' which can be initiated by the driver leaving without being disconnected and the hose bursting during operations.
The potential consequences can be sustained release of fuel from loading station pipeline, release of fuel from the fuel truck and fire or explosion.
For each threat, the preventative measures are identified as shown on the left-hand side of the figure.
The same is done for the recovery measures as shown on the right-hand side of the figure where a 'hose rupture' has occurred and the recovery mode is triggered to avoid consequences.
For each preventive and recovery measure, the link to the party responsible for the execution of the corresponding safety critical task, required to support the control measure, is identified. The escalation factors are also considered along with the corresponding secondary controls.
An assessment of the control being in place is then made by considering the number, nature and quality of the individual measures against the risk encountered.
For the implementation of the bow-tie methodology described above, there is a specifically designed software tool, called SMS Pro™. The package provides suitable platforms for demonstrating the analysis of hazards and their controls and the linkage to a company's processes and to an individual's responsibilities.
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