The management of risk is at the very heart of ICAO Annex 19 Safety Management: conducting this in a meaningful fashion should not only improve the safety of an operation with a better allocation of resources but satisfy a large portion of any SMS regulatory requirement.
During a Safety Promotion visit to a number of Service Providers earlier this year a risk assessment exercise was undertaken to review and discuss the process. Two pictures depicting non-aviation activities were shown, groups were asked to identify and define the risks, mitigate them and then explain how the mitigation would change the original risk assessment. This generated some interesting discussions on the process with a number of learning points and dare I say it, a bit of fun.
This visit coincided with the publication of the UK Air Accidents Investigation Branch report (1/2017) on the tragic Hawker Hunter accident at Shoreham air show in 2015. This report discusses in detail the risk assessments conducted for the air show, the UK CAA guidance on risk assessments and two reports by the UK Health and Safety Laboratory on these topics.
Reading the report whilst conducting the risk assessment exercises highlighted a number of important lessons some of which we were exploring within the exercises.
The mix of those participating in the discussions improved the risk assessment process.
- People with relevant technical experience to identify and adequately assess any risks
- People from a good range of technical backgrounds to identify as many risks as possible, and adequately assess any risks that span across disciplines
- Inexperienced people, or people from non-aviation areas of the business to challenge, to understand and to ensure clarity, sometimes point out the overlooked/obvious risks and widen the discussion in risk identification
The Shoreham report notes that not all relevant parties appear to have been consulted and a comprehensive list of foreseeable hazards were not identified. It is important that the people involved in aviation activities have a full understanding of the risks and that all plausible risks are identified.
When writing the risk it is important to write it in a way that clearly states what is being assessed, obvious isn’t it? However this is not that easy in all cases. A consequence of a risk written within the risk description may be expressed in a number of ways and these will affect the assessment of severity and likelihood. For example, if the risk consequence is written to involve damage to both an object and injury or fatal consequences to people, which of these is being assessed? Within the Shoreham report it notes that some risks were not clear, or well-defined. There was good practice contained in the UK CAA assessment guidance that recognised injury to people is the most important consequence to mitigate when conducting an assessment. Therefore, a risk may be written in the context of a consequence to people and another similar one to equipment. The equipment consequence may also then lead to another risk that has an impact on people depending on the function of that equipment, the loss of some critical aerodrome navigation equipment for example.
An incorrectly written risk can also lead to the incorrect identification of current mitigations and any additional mitigation. The Shoreham report notes that even if a risk is assessed as being ‘acceptable’ any potential mitigation should still be considered and implemented where practicable. Risks that are tolerable/tolerable if "as low as reasonably practicable" (ALARP) should have all achievable potential mitigations implemented to meet regulations and best/good practice even if they do not change the level of the risk within the assessment. The Shoreham report also notes that it was not clear how and why certain additional mitigations changed the likelihood and/or severity of the risk assessment. It is really important to consider that, if a particular mitigation was carried out, what exactly is the effect on the likelihood and/or severity, and noting this. Do your mitigations make sense in terms of their effect on the risk assessment? Do all staff understand the mitigations in place and the reason behind them?
When looking at mitigations, you should also ask if the mitigation itself introduces other risks. For example, the recent US ban on laptops in addressing one risk places lithium battery devices into the holds of aircraft where it affects another risk.
REVIEW/MANAGEMENT OF CHANGE
Once a risk assessment has been conducted there should be a process to review it with all the relevant people and a schedule for review. How do you manage a review when a person cannot attend? Reviews should look at any changes that may affect the risks and their mitigations, consider near misses and incidents with any lessons learnt that may identify new risks and/or may affect current risk assessments. A review should also look to see if the current mitigations are in place and are as robust as thought: is there any evidence or checking required? Notes of the review should be taken to record those taking part with their roles (qualifications) even if there are no changes made. The Shoreham report also questioned the version of the applicable risk assessment and how the assessments were signed off. Who in your organisation signs off the reviewed risk assessments? How is this done? How can you tell which is your latest version?
Changes to the size of an organisation, its systems, processes and changes to the operating environment must be risk assessed. This may, for example, be an introduction of an aircraft, aerodrome works, new equipment or change of ATC procedures. These changes should be reviewed against the current risk assessments; they may introduce new risks and they may have their own set of risk assessments. This process may also be conducted through the phases of a change, and once the change has been completed. For example in terms of aerodrome developments, the risks should be assessed through the phases of any works and once the works have been completed.
Good productive risk assessments do take time to create but they should lead to a clearer understanding, awareness and management of the risks in an organisation. With each review conducted the quality of the assessments should improve and the time taken to conduct these should shorten. Better risk assessments should also improve the allocation of resources to the greatest areas of risk, ensure all reasonable mitigations are in place and are actively working to prevent costly incidents.
If you would like to review the Shoreham report please visit: https://www.gov.uk/aaib-reports/aircraft-accident-report-aar-1-2017-g-bxfi-22-august-2015. (The Health and Safety Laboratory risk reports are appendices J and K.)
For incidents to review:
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