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25/08/2010
AVIATION SAFETY COUNCIL MEETING OF
25 AUGUST 2010
OPERATIONAL RISK MANAGEMENT.
AN HELICOPTER ON DOMESTIC FLIGHT (SPA TO BARCLAYVILLE)
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BACKGROUND TO UN DFS / DPKO AVIATION
OPERATION RISK MANAGEMENT
In complying with the United Nations, DPKO and
DFS Policy Directive on Aviation Operational
Risk Management (ORM), dated 10 April 2008.
explains the procedures to be followed in
UNMIL everyday aviation activity before any
flight can be executed.
 DPKO and DFS Aviation Operational Risk
Management (Implementing Guidelines).
 DMS UNMIL ORM Implementing Road Map
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OPERATIONAL RISK MANAGEMENT: WHAT IS IT?
A systematic process of identifying
and assessing hazards in terms of
risk, then implementing actions to
control that risk to an acceptable
level and monitoring the controls for
effectiveness.
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ORM SIX STEPS
The six steps in implementing Operational Risk
Management (ORM), also known as Risk Management
Process is:
 Step 1: Hazard Identification.
 Step 2: Risk Assessment.
 Step 3: Analyse Risk Control Options.
 Step 4: Choose Risk Control Measures.
 Step 5: Implement Risk Control
 Step 6: Supervise and Review.
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OPERATIONAL RISK MANAGEMENT
PROCESS
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HARZARDS: WHAT ARE AVIATION HARZARDS?
Any real or potential conditions that can cause
injury, illness, or death to personnel, damage to
or loss of a system, equipment, or property, or
damage to the environment.
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RISKS: WHAT ARE AVIATION RISKS?
An expression of an impact and
possibility of an accident in terms of
potential mishaps severity and
probability of occurrence
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WHAT IS RISK SEVERITY?
We define risk severity in terms of effects for:







Property damage
Finance losses
Liability inflicted
People injured or killed
Environment damage or degradation
Image damage
Public confidence erroded
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WHERE DO AVIATION HAZARDS AND RISKS
COME FROM?
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MACHINE (AIRCRAFT)
When assessing your aircraft, determine:





its airworthiness
its weight and centre-of-gravity;
its performance under the anticipated conditions;
its fuel load and fuel requirements;
Maintenance : if it has adequate, functional equipment.
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MEDIA (ENVIRONMENT)

Meteorological Conditions: Local Weather patterns, Temperature, Humidity,
Ceiling, Wind, Precipitation, Thunderstorm, Rainstorm, Reduced visibility;
Determine how the weather affects your flight route & duration?
Take action to avoid poor weather conditions.

Operational : Maps and Charts, Terrain, Wildlife, Vegetation, Obstacles
and Natural Lighting conditions.

Hygiene: Aircraft Ventilation, Air quality, Noise, Dust, Other air
contaminants.

Destination airfield / helipad surface conditions : Paved surface, Gravel
surface, Mud, Dust, and hills.
Communication : Know the area radio frequencies and monitor other
aircraft communication in the area
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MAN
Selected Personnel : Right person, Trained
and Professional.
 Performance : Awareness, Perception,
Distractions, Stress, Peer pressure, Adaptive
skills pressure, workload, Fatigue.
 Personal Factors : Expectations, Job
satisfaction, Family pressure, and Personal
Discipline, and Organizational culture.

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MANAGEMENT
Policy and Objectives
 Standards : Doctrine statements, Criteria,
 Procedures : Regulations, SOPs, Checklists
 Controls : Operating limits, Rest, Restrictions,
Training, and Rules
 Decision Making : Who, What, When, Where,
What level, and Communication.

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MISSION
UNITED NATIONS SECURITY COUNCIL
RESOLUTION # 1509 OF 23/09/2003
 Policy : Clear and not ambiguous
 Objectives : Well understood, Complex, Well
defined, and easily obtainable
 How do Policy and Objective interact with the
other 4Ms (Machine, Man, Management, and
Media) ?
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ORM SIX STEPS
EXPLANATION TO
THE SIX STEPS
ORM PROCESS
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STEP 1
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STEP 2
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STEP 3
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STEP 4
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STEP 5
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STEP 6
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Item
Nr
1
Item / Phase
(Activity)
Day CASEVAC
(Hostile -UAU)
Day /Night CASEVAC
(Hostile -UTAIR)
Hazards
*Rebels/Insurgents
* Weather
* Area Security
* Aircraft Type and
equipment
* Human factors:
* Crew qualified,
* Crew fatigue
*Flow of Communication
* Media Coverage for
image protection
Risk
Control Measures
* Aircraft crash due to SAM
and or rebel fire
* A/C returning back to base
due to bad weather
* A/C & Crew hostages by
rebels upon landing
* Aircrew being hit by rebel fire
prior to landing/ take off
*Patient dies before aircraft
reach destination
* Send Gunship as cover
for MI8
* Ensure accurate weather
info
* Send ground troops
security prior to arrival of
MI8
* Provide security escorts
onboard MI8
* Ensure aircrew task is
qualified to fly the mission
Implementation
Plan
*Develop a coordinating
FRAGO /Impl plan
incorporating all tasking,
requirements of all
involved (Force Air Ops,
Aviation, Security,
JOC,MOVCON, JLOC etc)
& send to all concerned
for implementation
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Residual
Risk
Acceptabl
e
Decision
Responsibility
*DMS
*CAVO
*FC
*UNPOL Comm
*AOC
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Item
Nr
2
Item / Phase
(Activity)
Helipad Recce, Aerial
Reconnaissance, Air ,
Foot Patrols, Rapid
Response, Deployment ,
Reinforcements
Hazards
*Area Security
* Weather
* topography of the area
*Helipad condition
*Obstacles surrounding
helipad
*Flow of Communication
* Human factors
* Media coverage for
image protection
* Third party damage or
injuries
Risk
Control Measures
Implementation
Plan
* Aircraft can be fired at by
rebels
* Heli don’t reach destination
due to route weather
*Heli cannot land due to bad
helipad condition
* Heli crash due to technical
problem / unforeseen
obstacles
*Patrolling troops hostage ,
wounded or killed due to
encounter with
rebels/insurgents
* Persons on ground injured or
property destroyed
* Send Gunship as cover
for MI8
* Ensure accurate weather
info
* Send ground troops
security prior to arrival of
MI8
* Provide security escorts
on board MI8
* Ensure aircrew task is
qualified to fly the mission
*Aircraft to follow strict
maintenance procedures
*Develop a coordinating
FRAGO /Impl plan
incorporating all tasking,
requirements of all
involved (Force Air Ops,
Aviation, Security,
JOC,MOVCON, JLOC etc)
& send to all concerned
for implementation
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Residual
Risk
Acceptabl
e
Decision
Responsibility
*CAVO
*AOC
*FC
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Hazard
Assigned Task (Organizational and mission statement)
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Potential Causes
Potential Effects
Control Measures
Panic and erratic behavior among operational
personnel leading to incidents or accidents
Undesirable work habits and work behaviors and an
unacceptable culture and work practices.
Less effective team work, work performance, and lack
of dedication leading to cutting corners in following
regulations and SOPs
5C
Train & Educate, Motivate and Selection of
Personnel
5D
Improve Task Design, Limit exposure to
adverse conditions, Detailed briefings and
Motivate.
Management effectiveness in timely decision making, and
resources allocation.
3
Aircraft performances
and other operational challenges.
Unproductive competitions among operators of different
aircraft (flight crew and mechanics) leading to unsafe
practices
Less effective utilization of specific aircraft and over use
of others leading to fatigue and stress that affect
effective operations.
Adverse weather (heavy rains, thunderstorms , and restricted
visibility)
VMC operations always.
Panic among flight crew leading to confusion and loss of
reference in VMC , (Visual Flight Rules (VFR)
Less effective and timely decision making leading to
less effective execution of precautionary actions.
Inadequate aviation infrastructures, no basic navigational aids and
poorly maintained airfields and helipads.
Flying crew creating practices and procedures to
accomplish an aviation activity in contravention of SOPs,
rules and regulations in remote areas .
Development of unsafe cultures, practices and misuse
of air assets (aircraft) causing degradation of assets and
their components.
5
Risk Category
Fulfilling the mission statement creates confusion, anxiety
and fear among operating personnel
2
4.
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5B
4A
3C
Improve Task Design, Train & Educate,
Motivate
Briefings, Train & Educate, Demonstration of
effects and Limit exposures
Improve Task Design, Train & Educate, Warn,
Briefings, Motivate, Back-ups redundancy,
and Mission operational capabilities.
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UN 162 Tasked to Fly Passengers and Cargo from Spriggs Payne Airfield (SPA) to Barclaysville
ASCM by RASO - WA 25/08/2010
on 25/08/2010, departing SPA at 0945 Hrs
-File Flight Plan SPA
to Barclayville.
-Weather Briefing
-Pre-flight checks
-Loading (fuel, pox,
cargo)
-Departure briefing.
-Continue climb
and cruise.
-Change radio frequency to 118.5
Mhz
- UN 162 to divert to Zwedu due to
poor weather.
- VMC to IMC
-Obtain taxi clearance
-----
-Taxi to holding position
and request take-off
clearance
-Take-off and set course on
planned route
--
2
3
!
1
-UN 162 diverted to fly
-UN 162 has
diverted to
Zwedru
- Weather at
Zwedru i
6
to Zwedu
-Maintain listening
watch on 118.5 Mhz.
- Check fuel available
and found three hours
endurance.
-
-Weather en-route
detonating fast
- VM C weather to
IMC weather
------------
4
5
!
|
7
-UN 162 diverted to Zwedru
and tried contacting the
ALO on 118.5 Mhz.
- No response
-UN 162 contacted Air
Operations Centre on HT
frequency 8864 Khz
- Air Ops Centre grants
diversion to Zwedru.
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-UN 162, parks, shutdown, off-load
passengers as transit pox.
-Awaits for weather in
Barclayville to improve.
- UN 162 wait for Air Ops
Centre for weather update
for Barclayville
--------
8
-------
-UN 162
approaches
Zwedru.
- No radio
contact with
ALO on 118.5
Mhz
-UN 162 flies
overhead to observe
conditions on Zwedru
runway.
-UN 162 approaches,
and lands on the
helipad within the
apron area.
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-UN 162 approaches
but the weather is
deteorating again.
--------
|
9
!
|
--
UN 162 decides to
land at Zwedru
10
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Risk
Risk
Probability
Catastrophic
A
Frequent
5
Occasional
4
Remote
3
Severity
Hazardous
B
5 B
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Major
C
5 C
Minor
D
Negligible
E
5 D
4 A
3 C
Improbable 2
Extremely
Improbable 1
1 C
1 E
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ACTIVITY ACCEPTABLE OR REQUIRES RISK
CONTROL MEASURES ?
See below !!!
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CONCLUSION

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All human activities involving a technical device or processes entail
elements of risks.
Do not panic at hazards, there are ways of controlling them.
Weigh risks and hazards based on knowledge, experience, and mission
requirement.
Encourage others to follow similar risk/hazards management principles.
Hazard analysis and risk assessment do not free us from good judgment,
they improve it.
It is more important to set clear objectives and parameters for risk
assessment than to find a “cookbook” approach and procedures.
There are no “safety problems” in the planning and design. There are only
management problems that, if left unresolved, may cause mishaps or
accidents.
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QUESTIONS
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