Multi-Crew Cooperation: For Helicopter Pilots

Risk Management

Risk management has long been the backbone of aviation operations and, particularly, Safety Management Systems to identify hazards and mitigate (reduce or eliminate) the risk of that hazard occurring.  It is one of the first steps by an operator to identify and develop strategies to manage the aviation hazards associated with its operation.

What is Risk?

Risk is defined as "the chance or possibility of something happening that could have an impact on the desired outcome."

Risk Management

Risk Management is the sum of the coordinated activities an organisation does to direct and control risk (AS/NZS ISO 31000:2009). Risk management aims to make sure risks are identified and managed to an acceptable level.

Why pilots?

As a pilot, it is essential to have an understanding of the principles of risk management, both in terms of understanding an operator’s risk management systems and risk mitigators (this includes the policies, processes and actions put into place to minimise a particular risk), as well as to be able to apply the principles of risk management to flight operations.

An understanding of the principles of risk management leads to effective:

Threat Error Management

Crew Resource Management, and

Multi-Crew Co-operation practices.

Key Components

A Risk Management System involves two (2) fundamental activities:

Identifying hazards: 

Situations or conditions that may lead to incidents and accidents.

Assessing (analysing) and mitigating the risks:

Methods or practices to reduce or eliminate the hazard to prevent incidents and accidents.

The Process

Key Definitions

To understand risk management, we need to understand what a hazard is and then relate this to the risk and then to the management of the risk.

Hazard

A hazard is an event or a situation that could result in damage, injury or a dangerous outcome.

Risk

A risk is the chance of something happening that could impact a desired outcome.  It could be either a positive or negative risk.

Risk is measured in terms of the consequence versus the likelihood of the event.

Risk = Likelihood x Consequence

In aviation, we tend only to consider the negative aspects of risk related to the safety of the flight.

Mitigation

Mitigation is the measures taken to eliminate a hazard or reduce the likelihood or severity of a risk.

Management

Management is the act of collating all the relevant information and resources (including people) and then putting this together to accomplish a desired goal or objective.

Management encompasses planning, organising, resourcing, staffing, leading, directing and controlling an organisation or group or effort to accomplish a goal.

Identifying Hazards

The first part of any risk management process is to identify the hazards. Only when a hazard has been identified can you determine the best way to eliminate or reduce the risk. Different types of hazards need to be considered.

Visible hazards

Visible hazards are usually obvious; they can be easily seen, smelt, heard, tasted, or felt.  Examples in aviation may include a faulty light or a rough-running engine.

Hidden hazards

Hidden hazards can include physical hazards such as electricity and radiation and hazards such as inadequate training, stress, system failure, and the effects of altitude.

Emerging hazards

Emerging hazards are hazards that initially seem minor and do not receive attention but soon become worse and could cause significant damage, such as a tiny oil leak or an issue with teamwork amongst crew members.

Methods to identify

There are many ways to identify hazards; some include:

Task Analysis

Brainstorming

SWOT analysis

Risk Dimension Analysis

Workplace inspections

Interviews with staff

Surveys

Safety meetings

Checklists

Audits

Safety investigations

Hazard reports

Audit reports

Review and analysis of incident and other safety reports

Injury and illness history

Industry data and experience

Information from similar organisations.

Structured approach

It is important to take a structured approach to identify hazards to reduce the chance of missing something. More than one method of identifying hazards may be used.  Past hazard and incident reports is one of the most important sources of hazard information. Brainstorming may also highlight new emerging hazards.

What to consider

When identifying hazards, you would consider:

Who (stakeholders) needs to be involved.

For example, include ground staff, senior staff and less experienced staff to give a broader perspective.

Consider all aspects.

For example, aircraft, equipment, human factors, environmental factors, organisational, how busy we are, and even what changes are taking place.

Key questions

When identifying hazards, keep asking yourself:

What can happen?

How can it happen?

Why could it happen?

When could it happen?

Where could it happen?

Document the hazards

Record each of the hazards identified into a register, and identify:

the hazard

what current controls there are to reduce the risk of this hazard occurring.

Risk Assessment (Analysis)

What next

Once hazards are identified, they need to be assessed.  To analyse the risk, determine:

What is the consequence of this risk?

What is the likelihood of this risk occurring?

Consequence

Each organisation may define its own way of determining the consequence level.

The consequence level may consider:

Injury to staff or the public

Loss of aircraft/equipment

Publicity and the impact on reputation and client confidence

Financial risk, etc.

Each hazard is then rated based on its level of consequence as follows:

Likelihood

Each hazard is then rated on the likelihood of it occurring as follows:

Risk matrix

By combining the Consequence with the Likelihood, a Risk Matrix can be created.

Risk level

For each hazard, based on the consequence and likelihood rating, you can determine the risk level for each hazard as follows:

HIGH

Considerable potential for fatalities or serious injuries or the loss of an aircraft or equipment.

MEDIUM

Moderate potential for injuries requiring hospitalisation or the damage of an aircraft or equipment.

LOW

Minimal potential for injuries (above those requiring First Aid) or for any consequential damage to aircraft or equipment.

What next

Once assessing each hazard, prioritise the risks from highest to lowest, and then consider how to treat each risk.

Controlling the Risk:  Risk Mitigation

Once you have identified the hazards and assessed the risk in terms of consequence and likelihood, it is time to consider ways to mitigate (reduce or eliminate) the risk.

Risk treatment

You can consider different actions or design resources that will reduce the consequence of a risk, the likelihood of a risk, or both.

Strategy

When considering methods to control the risk, you may consider methods to:

Avoid the risk by adopting a different way of doing something or choosing to no longer conduct an activity because it is deemed too high a risk.

Reduce the risk – identify ways to reduce the risk through controls, etc.

Share the risk – get someone to share the responsibility for the risk.

Refer the risk – get someone else to treat the risk, for example, asking a supplier to reduce the risk of a hazard associated with a piece of equipment, or

Retain the risk – decide to carry the risk that remains.

What to consider

When considering ways to mitigate the risk, consider:

Human Factors: health, stress management, fatigue, experience levels, workload.

Aircraft and equipment: lighting, labels, instrumentation, automation, etc.

Environment: weather, terrain, airport, airspace, night-time, visual illusions.

External pressures.

Methods to mitigate

When considering methods to mitigate the risk, you may consider:

Limitations or restrictions: Limiting a task to only multi-crew operations

Procedures:  Use of checklists (create or modify checklists)

Equipment: Modify equipment/aircraft to reduce the risk; for example, put a protective shield over a dangerous item, colour code items, add new lighting or change labels to give clearer meaning.

Training: Modify or add training to provide greater awareness and training in a procedure.

One or more methods may be combined to reduce the risk.

Be aware

Beware that mitigation may introduce new hazards or risks to the operation.  For example, new lighting may prove distracting or confusing and not achieve the original aim.

Be realistic

Not all mitigation is appropriate. For instance, it is not wise to expect consistent, error-free human performance as the only way to prevent an accident.

Challenge the team to determine whether the mitigation they propose is realistic given what they know about people, equipment and operations. If there is doubt, have them consider what else can be done.

Consistent results

A mitigation method may not be effective all the time and, therefore, may require more than one mitigation treatment.

Challenge and test

The team should challenge and test whether the mitigation proposed will be effective.  This may involve brainstorming scenarios in which these mitigation approaches are implemented.

Be practical

It may not be practical to expect that a high amount of resources (in terms of people or expenditure) be applied to mitigate a risk.  Sometimes a simple checklist can be as effective as sophisticated automation at a fraction of the cost.

Case Study: Risk Assessment Checklist

Becker Helicopters uses a S.T.A.R. checklist to assess the risks for a particular task. STAR stands for:

STOP, THINK, ASSESS and RATE.

An example of a STAR checklist is provided in Appendix 1: Example STAR Checklist.

Threat Error Management

Threat Error Management (TEM) is a relatively new title for something aviators have been doing for a long time but have not formally articulated or discussed as a crew.  TEM involves:

identifying any threats both external to the aircraft and internal to the aircraft

identifying any possible areas for the crew and others to make errors

putting a strategy in place to manage these threats and errors.

Preparation and mentoring

Having the crew identify and verbalise threats and errors allows the instructor to mentor and the trainee to learn what to look for regarding threats and errors.

Before take-off, it brings to the front of the crew’s mind those areas that could pose a problem and allows solutions to be thought of before the event.

TEM Principles and Model

CASA definition

Threat and Error Management (TEM): The process of detecting and responding to threats and errors to ensure that the ensuing outcome is inconsequential.

That is, the outcome is not an error, further error or undesired state.

ICAO definition

The Threat and Error Management (TEM) framework is a conceptual model that assists in understanding, from an operational perspective, the inter-relationship between safety and human performance in dynamic and challenging operational