ATO afety isk anagement - CRESP

1 ATOS afetySafetyRiskManagementPresented By: Mi hl F lt ikMichael FalteisekFederal Aviation AdministrationAir Traffic Organization-Office of SafetyManager, Safety Risk ManagementFederal AviationAdministration1 What Is the FAA s Safety Management System?SMS Definition* An integrated collection of processes, procedures, policies, and programs that are used to assess define and manage the safetyused to assess, define, and manage the safety risk in the provision of ATC and navigational servicesservices* AOV Safety Oversight Circular 08-06, ATO Safety Management System (SMS) Definitions ygyg y()Federal AviationAdministration2 SMS ComponentsULTUREORGANS afety PolicySafety PromotionIdentified New HazardsFETY CUNIZATIONSRMS afety AssuranceIdentified New HazardsNAS Changes NeededONAL SANAL SAF Identify hazards Analyze, assess, knowingly accept, and mitigate risk Monitoring plansAssurance Monitor NAS & mitigations through.

2 Audits & Evals Investigations Data AnalysesANIZATIOETY CULgp Data AnalysesMonitoringSafety Risk MitigationsORGALTURES afety CommunicationsSMS Implementation PlanFederal AviationAdministration3 SMS in the FAA ATO Formal system approach to managing the safety risk of Air Traffic Control (ATC) and navigation services Provides consistent processes and documentation in managing safety risk Provides a standardized methodology to identify and address safety hazards that occur within the National Airspace System (NAS) or in which some element ofAirspace System (NAS) or in which some element of the NAS is a contributing factorFAA Fli ht PlG l FAA Flight Plan GoalFederal AviationAdministration4 SMS Historical HighlightsFederal AviationAdministration5 Safety RiskSafety Risk ManagementFederal AviationAdministration6 Risk Assessment of ALLC hangesASSESS THE RISKB aseline as of March 14, 2005 SAFE?

3 NASCHANGEC ontinuous MonitoringMaintain and Improve the Safety of the NASM aintain and Improve the Safety of the NASI mpact to Safety?National Airspace System:Is comprised of airspace; airports; aircrafts; pilots; air navigation facilities; air traffic control (ATC) facilities; communication, surveillance, navigation, and supporting technologies and systems; operating rules, regulations, policies, and procedures; and the people who implement, sustain, or operate the system componentsFederal AviationAdministration7ppp,, pypSafety Risk Management and the ATOS afety Risk ManagementDescribe SystemDescribe SystemIdentify HazardsIdentify HazardsAnalyze RiskAnalyze RiskAssess RiskAssess RiskTreat RiskTreat RiskAirspace ChangeNew ProcedureNew SystemTECH OPS ChangeFederal AviationAdministration8 SRM Decision ProcessPreliminarySafety AnalysisChFurther SftYesYesYesRisk Level Could Thi I t dDoes ItIs RiskYesChange ProposedSafety Analysis ConductedYesYesNoNoYesNoAcceptable Documented in SRMDThis Introduce Safety Risk Into theNAS?

4 Does It Affect the NAS?LevelAcceptable?Risk Level Unacceptable No FurtherSafetyAliNoNoNoNo FurtherAnalysisDocumented in SRMDA nalysisNecessaryDecisionAnalysisNecessar yDecision Documented in SRMDMF ederal AviationAdministration9 SRM Process Define scope and objectives Define stakeholders Identify criteria and plan for risk m anagem ent effort (including any m odeling/ sim ulation potentially required) Describe system/change (use, environm ent, and intended function,including planned future configuration)Describe SystemDescribe SystemIdentify hazards (what can go wrong?) that exist in the context of the NAS change Use structured approach Be com prehensive (and do not dism iss hazards prem aturely) Em ploy lessons learned and experience supplem ented by checklistsincluding planned fu tu re configuration)Id e n tify HazardsId e n tify HazardsFor each hazard.

5 Identify existing mitigations/controls Determ ine risk (severity and likelihood) of outcom e Q u a lita tive o r q u a n tita tive (p re fe rre d )Analyze RiskAnalyze RiskAssess RiskAssess Risk Rank hazards according to the severity and likelihood of their risk Select hazards for detailed risk treatm ent (based on risk)Treat RiskTreat Risk Identify feasible mitigation options Develop risk treatm ent plans Im plem ent and verify M onitorFederal AviationAdministration10 Severity DefinitionsEffectHazard Severity ClassificationOn: Minimal 5 Minor4 Major3 Hazardous2 Catastrophic1 Conditions resulting in a minimal reduction in ATC services, or aConditions resulting in a slight reduction in ATC services, or a loss ofConditions resulting in a partial loss of ATC services, or a loss ofConditions resulting in a total loss of ATC services, (ATC Zero) or a loss ofConditions resulting in a collision between aircraft,ATC Servicesin ATC services, or a loss of separation resulting in a Category D Runway Incursion (RI)1, or proximity eventservices, or a loss of separation resulting in a Category C RI1, or Operational Error (OE)

6 2services, or a loss of separation resulting in a Category B RI1, or OE2(ATC Zero) or a loss of separation resulting in a Category A RI1 or OE2between aircraft, obstacles or terrain Flightcrew receives Potential for Pilot PD due to response to Near mid-air collision ConditionsFlightcrew receives TCAS Traffic Advisory (TA) informing of nearby traffic, or, Pilot Deviation (PD) where loss of Potential for Pilot Deviation (PD) due to TCAS Preventive Resolution Advisory (PRA) advising crew not to deviate from present vertical profile, PD due to response to TCAS Corrective Resolution Advisory (CRA) issued advising crew to take vertical action to avoid developing conflict with Near mid-air collision (NMAC) results due to proximity of less than 500 feet from another aircraft or a report is filed by pilot or flight crew member that a collision Conditions resulting in a mid-air collision (MAC) or impact with obstacle or terrain resulting in hull loss, multiple Flight Crewairborne separation falls within the same parameters of a Category D OE 2or proximity Event Minimal effect on operation ofor, PD where loss of airborne separation falls within the same parameters of Category C (OE)

7 2, orReduction of functionaltraffic, or, PD where loss of airborne separation falls within the same parameters of a Category B OE 2, or, Reduction in safetyhazard existed between two or more aircraft Reduction in safety margin and functional capability of the aircraft requiring crew to follow emergency proceduresfatalities, or fatal injuryoperation of aircraft Reduction of functional capability of aircraft but does not impact overall safety normal procedures as per AFM Reduction in safety margin or functional capability of the aircraft, requiring crew to follow abnormal procedures as per AFMemergency procedures as per AFMF ederal AviationAdministration11 Severity Definitions (cont d)EffectOn: Hazard Severity ClassificationMinimal 5 Minor4 Major3 Hazardous2 Catastrophic1 Flying Minimal injury or discomfort to passenger(s) Physical discomfort to passenger(s) ( extreme braking action; clear air turbulence causing unexpected movement of aircraft causing injuries to one Physical distress on passengers ( abrupt evasive action.))

8 Severe turbulence causing unexpected aircraft movements)Minor3injury to greater Serious4injury to passenger(s) Fatalities, or fatal5injury to passenger(s)Flying Publiccausing injuries to one or two passengers out of their seats) Minor3injury to greater than zero to less or equal to 10% of passengers Minor3injury to greater than 10% of passengerspg1 As defined in 2005 Runway Safety Report2 As defined in FAA Order Air Traffic Quality Assurance and N JO Error Reporting, Investigation, and Severity PoliciesSeverity Policies3 Minor Injury - Any injury that is neither fatal nor Serious Injury - Any injury which: (1) requires hospitalization for more than 48 hours, commencing within 7 days from the date the injury was received; (2) results in a fracture of any bone (except simple fractures of fingers, toes, or nose); (3) causes severe hemorrhages, nerve, muscle, or tendon damage; (4) involves any internal organ.

9 Or (5) involves second- or third-degree burns, or any burns affecting more than 5 percent of the body InjuryAny injury that results in death within 30 days of the accidentFederal AviationAdministration125 Fatal Injury -Any injury that results in death within 30 days of the Definitions NAS Systems & ATC Operational NAS Systems ATC Oper ati onal Flight Procedures Quantitative Qualitative Individual Item/SystemATC Service/ NAS Level SystemPer Facil ity NAS-wide ySystemFrequent Probability of occurrence per operation/ operational hour isequal to or greater than 1x10-3 Expected to occur about once every 3 months for an item Continuously experienced in the systemExpected to occur more than once

10 Per week Expect ed to occur more than every 1-2 days Probability of occurrence perExpected toExpected toExpected toExpect ed toProbability of occurrence per operation/ operational hour is equal to or greater AProbable Probability of occurrence per operation/ operational hour is less than 1x10-3, but equal to or greater than 1x10-5 Expected to occur about once per year for an item Expected to occur frequently in the system Expected to occur about once every month Expect ed to occur about several times per month qgthan 1x10-5 Probability of occurrence per operation/ operational hour isExpected t o Expected to occur Expected to Expected to Probability of occurrence per operation/ operationalBRemote operation/ operational hour is less than or equal to 1x10-5 but equal to or greater than 1x10-7 poccur several times in life cycle of an item numerous times in system life cycle poccur about once every year poccur about once every few months per operation/