PDF: Safety Management in Your Organisation - CASA Part 66

Safety Management in Your Organisation (9.9.3) Learning Objectives 9.9.3.1 Describe aspects of a safety management system, risk management and just culture (S). 9.9.3.2 Explain how error investigation occurs in a typical organisation and the need for a human factors training progra...

Safety Management in Your Organisation (9.9.3) Learning Objectives 9.9.3.1 Describe aspects of a safety management system, risk management and just culture (S). 9.9.3.2 Explain how error investigation occurs in a typical organisation and the need for a human factors training program (S). 2023-01-12 B-09 Human Factors Page 329 of 340 CASA Part 66 - Training Materials Only  Safety Management in Your Organisation Safety Management System (SMS) As you are working in a Part 145 organisation, your company will have a Safety Management System (SMS) in place. The CASA website has information about SMS at https://www.casa.gov.au/safety- management/landing-page/safety-management-systems CASA CASA SMS The universally accepted framework for SMS includes four main components and twelve elements, representing the minimum requirements for an SMS: Safety policy and objectives Management commitment and responsibility Safety accountabilities Appointment of key safety personnel SMS implementation Contractors/third party interfaces Coordination of emergency response planning SMS documentation. Safety risk management Hazard identi cation Risk assessment and mitigation. 2023-01-12 B-09 Human Factors Page 330 of 340 CASA Part 66 - Training Materials Only  Safety assurance Safety performance monitoring and measurement Internal safety investigation The management of change Continuous improvement of the SMS. Safety promotion Training and education Safety communication. More information on about each element can be found in Chapter 5 of the ICAO Safety Management Manual - https://www.casa.gov.au/ les/icao-safety-management-manual-3rd-editionpdf 2023-01-12 B-09 Human Factors Page 331 of 340 CASA Part 66 - Training Materials Only  Risk Assessment and Management Risk assessment is an important step in protecting aircraft maintenance staff, as well as complying with the law. It helps put the focus on the risks that really matter in the workplace, the ones with the potential to cause real harm. In many instances, straightforward measures can readily control risks, for example ensuring spillages are cleaned up promptly so people do not slip, or cupboard drawers are kept closed to ensure people do not trip. The law does not expect workplaces to eliminate all risk, but people must be protected ‘as far as reasonably practicable’. A risk assessment is simply a careful examination of what, could cause harm to people in the workplace, to ensure that enough precautions are implemented. People have a right to be protected from harm caused by a failure to take reasonable control measures. Accidents can ruin lives and affect business pro tability if productivity is lost, machinery is damaged, insurance costs increase, or people have to go to court. Accountable managers are legally required to assess the risks in a workplace so that a plan to control them may be implemented. Image by Jason Goh from Pixabay The law does not expect workplaces to eliminate all risk 2023-01-12 B-09 Human Factors Page 332 of 340 CASA Part 66 - Training Materials Only  Steps for Conducting Risk Assessment There are ve steps for conducting risk assessment: Identify the hazards Decide who might be harmed and how Evaluate the risks and decide on precautions Record your ndings and implement them Review your assessment and update if necessary. It is important to avoid overcomplicating the risk assessment process. In many organisations, the risks are well known, and necessary control measures are relatively easy to apply. For example, employees who move heavy loads could injure their backs and people are most likely to slip or trip at certain places. Organisations must use this knowledge to take reasonable precautions that avoid injury to their employees. Risk assessments can be done by a single person who doesn’t have to be a health and safety expert. In larger organisations, health and safety advisers can help conduct risk assessments. Staff or their representatives should be involved in the process. They will have useful information about how the work is done that will make your assessment of the risk more thorough and effective. When thinking about risk assessment, remember: A hazard is anything that may cause harm, such as chemicals, electricity, working from ladders, an open drawer etc. The risk is the chance, high or low, that somebody could be harmed by these and other hazards, together with an indication of how serious the harm could be. 2023-01-12 B-09 Human Factors Page 333 of 340 CASA Part 66 - Training Materials Only  Image by Reid Middleton Hazard versus risk 2023-01-12 B-09 Human Factors Page 334 of 340 CASA Part 66 - Training Materials Only  'Just' Culture The principle of a just culture is necessary for the free ow of information within an organisation. A just culture ensures that people are not reluctant to report errors or hazards and have no fear of retribution or punishment if they highlight mistakes that they or other people have made. A just culture does not mean a 'no-blame' culture. It all depends on your employers’ expectations. If you are working to your employer's expectations, then the principles of liability mean that your employer will accept blame if you make an honest mistake. Therefore, in a just culture, your employer cannot ask you to accept blame for honest mistakes, even if there is damage, injury or death. If you are working outside your employer's expectations however, the situation is different. Mistakes made when acting outside your employer's expectations are better known as violations. Employees become liable for their own actions when acting outside their employer's expectations. Damage, injury and death become the responsibility of the individual rather than the organisation. © Aviation Australia Safety culture scale Disciplinary Policy Discipline within a just culture needs to follow similar principles, whereby honest mistakes and errors made when working in accordance with your employer's expectations are not punished. However, violations and other blatant disregard for safety, rules and guidelines must incur a suitable discipline. 2023-01-12 B-09 Human Factors Page 335 of 340 CASA Part 66 - Training Materials Only  Reporting Errors In a just culture, and in Safety Management Systems in general, reporting is encouraged. Free reporting is one of the markers of a healthy organisation, as it indicates that employees are motivated to report hazards, near-misses, errors and potential problems, without fear of retribution. This not only corrects existing problems, but also works to proactively improve the workplace, and informs all staff of the improving conditions, what went wrong, why and how it was xed. ICAO, 2013 Effective safety reporting – Five Basic Characteristics 2023-01-12 B-09 Human Factors Page 336 of 340 CASA Part 66 - Training Materials Only  Error Investigation When errors occur in an organisation with a poor culture, they are often glossed over, blamed on a single cause, or ignored. In a healthy organisation, an error reported is a chance to make the organisation better. Even incidents and accidents that cause damage or injury are treated as a chance to correct issues within the workplace that could occur again. That is why the reporting of near-misses is so important. A near-miss is an incident that, given slightly different circumstances, would cause damage or injury. Therefore, reporting and investigating a near miss is capturing all the underlying causes of the incident, without the trauma of damage or injury, and helping to ensure those circumstances never happen again. When an error, near-miss, accident, or serious incident occurs, an investigation process is set in motion to uncover any possible failure within the system, determine the reasons for the failure and ensure that it doesn't happen again. Thus, in a safety management environment, the investigation process has a distinct role, as process that is initiated when safety defences and other barriers in the system have failed. Image by ODSC Error investigations 2023-01-12 B-09 Human Factors Page 337 of 340 CASA Part 66 - Training Materials Only  Action to Address Problems Investigations contribute to the continuous improvement of the system by revealing the root causes of accidents/incidents and the lessons to be learned from the events. When the root cause is known, then decisions about corrective actions can be better informed. Most investigation exercises uncover a variety of hazards and threats. These may include not only obvious physical threats but also any latent or organisational factors within the overall system. Addressing and rectifying the issues becomes the responsibility of managers nominated in the SMS as being accountable. Image by Arena Solutions Corrective action is the responsibility of managers nominated in the SMS Feedback to Employees An important element of the SMS, including error investigation is to keep employees informed about what has happened, why it happened and what will be done to rectify the situation. The progress of investigations is vital information to convey to employees, especially if the error or incident directly affects their work and if they have had input into the investigation process. Human Factors Training Program This Human Factors (HF) training program forms part of the SMS 'Training and Education' element. Human factors awareness is identi ed as an integral part of safety management and continuous improvement within an organisation. CASA specify that employees in a Part 145 Approved Maintenance Organisation study human factors principles every two years after their 'initial' introduction to HF. 2023-01-12 B-09 Human Factors Page 338 of 340 CASA Part 66 - Training Materials Only  HF Continuation Training CASA specify in AMC/GM for Part 145 that: ‘… all employees involved in any maintenance, management, quality and safety audit functions should receive human factors continuation training (of an appropriate duration in each two-year period).’ This may include: Post-holders, managers, and supervisors; Certifying employees, AMEs, aeronautical product workshop maintenance employees, and specialist maintenance technicians; Technical support personnel such as planners, engineers, and technical records staff; Quality control/assurance and SMS employees; Human factors staff/human factors trainers; Supply department staff, and purchasing department staff; Ground equipment operators; and Contract staff in the above categories. Image by National Business Aviation Association HF Continuation training should be completed every two years According to CASA 2023-01-12 B-09 Human Factors Page 339 of 340 CASA Part 66 - Training Materials Only  ‘Continuation training should concentrate upon those areas in the company where problems and errors are occurring; where hazards stemming from HF in uences have been identi ed and where human factors guidance material details training is most necessary. These may be identi ed from the quality system, occurrence reporting/Maintenance Error management system, or other mechanisms.’ 2023-01-12 B-09 Human Factors Page 340 of 340 CASA Part 66 - Training Materials Only