Individual Assignment
AERO 2370 – Engineering Risk Management in Aviation
OVERVIEW:
1. Each student is required to research and submit a written assignment report via Turnitin in Canvas by the due date.
2. The Case Study is about the fatal accident involving aircraft VH-PFT and the circumstances associated with the collision with terrain accident reported by the Australian Transport Safety Bureau (ATSB) in its Aviation Occurrence Investigation, AO-2014-192 Final dated 21 July 2016.
ASSIGNMENT TASK:
3. Review critically and analyse the Australian Transport Safety Bureau (ATSB) Aviation Occurrence Investigation, AO-2014-192 Final dated 21 July 2016 as well as any other publicly available information.
4. You are to choose either Hypothesis 1 or Hypothesis 2 for your assignment report.
4a) HYPOTHESIS 1 –
“The operator’s safety risk management processes and practices were not sufficient to facilitate the identification of all key operational risks associated with low-level flying that was being conducted on Sydney Hobart race yachts.”
4b) HYPOTHESIS 2 –
“The operator’s safety risk management processes and practices were sufficient to facilitate the identification of all key operational risks associated with low-level flying that was being conducted on Sydney Hobart race yachts.”
5. You are to use the information in Appendix 1 as the REFERENCE TEMPLATE FOR HAZARD AND RISK MANAGEMENT PROCEDURE FOR THE AIRLINE.
6. As a minimum, your report must contain all the “Sections” and “Contents” (highlighted in red) in Appendix 2.
7. The report must be at least 2800 to 3000 words (main body font size – 11pts, line spacing – single). See Appendix 2 for exact word count breakdown for each section. Failure to meet this requirement will incur a penalty.
8. Note also that each section must also not be less than 90% of the total word count allowed as a penalty will apply. See details in Appendix 2.
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9. The report must be submitted via “Turnitin” in Microsoft Word format only. For late assignments accepted, a penalty of 5% per day of the total marks obtained may be applied after the due date.
10. Referencing should conform to the Harvard Style (Refer to the blackboard or the RMIT website for information and guidance if needed).
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SOME RELATED DOCUMENTS FOR REFERENCE
(Downloadable from the Internet)
ATSB Report, AO 2014-192 – https://www.atsb.gov.au/media/5770792/ao-2014-192-final.pdf
SMS for RPT Operations – Civil Aviation Advisory Publication (CAAP) SMS -1(0) – https://www.casa.gov.au/files/sms-1pdf
Integration of Human Factors into SMS – Civil Aviation Advisory Publication (CAAP) SMS -2(0) – https://www.casa.gov.au/files/sms-2pdf
NTS & Assessment for RPT Operations – Civil Aviation Advisory Publication (CAAP) SMS -3(1)- https://www.casa.gov.au/files/sms-3-1pdf
Civil Aviation Order 82.1 – https://www.legislation.gov.au/Details/F2014C00742
Civil Aviation Order 82.3 – https://www.legislation.gov.au/Details/F2015C00117
CASA Fatigue Risk Management Handbook – https://www.casa.gov.au/files/frmspdf
International Civil Aviation Organisation (ICAO) Safety Management Manual Document 9859 3rd Edition
Airlines of Tasmania website: http://airtasmania.com.au/
Airlines of Tasmania Safety Policy: http://airtasmania.com.au/about-us/safety/
CIVIL AVIATION REGULATIONS 1988 – REG 157 – http://www.austlii.edu.au/au/legis/cth/consol_reg/car1988263/s157.html
Avoidable Accidents No. 1 – Low-level flying – http://www.atsb.gov.au/publications/2010/avoidable-1-low-level-flying.aspx
ABC News article – http://www.abc.net.au/news/2016-07-21/pilots-manoeuvre-outside-training-in-fatal-yacht-race-crash/7648460
ABC News article – http://www.abc.net.au/news/2014-12-30/debris-found-after-light-plane-crashes-during-sydney-to-hobart/5992298
SBS News Article – http://www.sbs.com.au/news/article/2014/12/30/sydney-hobart-yacht-raised-alarm-about-tasmania-plane-crash
RA-Aus Accident Investigations – http://www.recreationalflying.com/tutorials/accidentreports/index.html
Recent RA-Aus fatal accident history – http://www.recreationalflying.com/tutorials/safety/intro2.html
CASA “Our regulatory philosophy” – https://www.casa.gov.au/about-us/standard-page/our-regulatory-philosophy
Small aeroplane sector takes part in risk workshop – https://www.casa.gov.au/book-page/small-aeroplane-sector-takes-part-risk-workshop
INVESTIGATING LINKAGES BETWEEN AN OCCURRENCE AND AN
ORGANISATION’S SAFETY SYSTEM PERFORMANCE. http://www.isasi.org/Documents/library/technical-papers/2016/Thurs/Fitzpatrick%20-%20SMS%20and%20fatigue.pdf
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APPENDIX 1 – REFERENCE TEMPLATE FOR HAZARD AND RISK MANAGEMENT PROCEDURE FOR THE AIRLINE.
1.1 HAZARD IDENTIFICATION PROCESS
Hazards can only be controlled if their existence is known. They will be identified from a range of sources including, but not limited to:
brain-storming using experienced personnel;
development of risk scenarios;
trend analysis;
feedback from training;
safety surveys and operational oversight safety audits;
monitoring of normal operations;
state investigations of accidents and serious incidents; and
information exchange systems (similar operators, regulators, etc)
internal safety reports
The Safety Manager will record identified hazards in the Hazard Register located on the Safety System drive. The register records generic hazards related to company operations. The Safety Manager will assign any reported hazards to one of the generic hazards as part of the resolution of Safety Reports.
1.2 REPORTING SYSTEMS
We understand that through the safety reporting system, underlying situations or conditions that have the potential to endanger the safety of aircraft operations can be identified. Greater levels of reporting, even what may be classified as minor issues, will allow us to monitor the safety performance of our organisation and to identify developing safety trends.
1.2.1 Internal Reporting System
All members of staff of the airline and organisations that interface with us are encouraged to participate in the safety reporting system. Safety reports will be submitted by staff and organisations that interface with us using the Safety Report. Copies of the form are available at Section X of this Manual and the controlled documents drive on the company storage device.
Once completed the form should be sent to the Safety Manager.
Upon receipt of a report, the Safety Manager will evaluate and prioritise the report using the procedures laid out in this manual and complete the relevant sections of the Safety Report and Hazard Register.
Due to the nature of the work carried out by the airline and the services that it provides to the aviation industry, it may at times be required to submit safety reports to other organisations. This task will be carried out in consultation with the Safety Manager.
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1.2.2 Statutory Reporting Requirements
Accidents and Incidents (Reportable Matter) Reporting
All of the airline staff or contractors (Responsible Persons) shall report “Reportable Matters”, as detailed in Regulation(s) 2.3 and 2.4 of the Transport Safety Investigation Act 2003, and in accordance with the procedures in this Manual.
The fundamental objective of air safety investigations is the prevention of accidents and incidents and AIP ENR 1.14 details reporting requirements for all Air Traffic accidents and incidents.
Immediately Reportable Matters (IRM)
These matters are defined in regulation 2.3 of the Transport Safety Investigation Act 2003. The airline require all (Responsible Persons) to report these matters, in accordance with the procedures in this Manual, to the organisation and required regulatory authority.
Routine Reportable Matters (RRM)
These matters are defined in Regulation 2.4 of the Transport Safety Investigation Act 2003. The airline require all (Responsible Persons) to report these matters, in accordance with the procedures in this Manual, to the organisation and required regulatory authority.
1.3 SAFETY SURVEYS
Safety surveys provide a forum for staff to express their knowledge and opinions on all aspects of the Safety Management System as well as providing valuable feedback to Management about the health of the Company safety culture.
Safety surveys are conducted on an annual basis as either a questionnaire or confidential interview.
The Safety Manager will conduct all surveys. Key findings and observations of the interview and questionnaire will be recorded using the Safety Survey and Safety Questionnaire forms. Paper, and/or electronic copies of the Safety Survey shall be kept by the Safety Manager.
Findings and observations will be reviewed and, when required, acted upon by the Safety Manager and the Safety Committee. Staff will be advised of survey findings via newsletters.
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1.4 RISK MANAGEMENT AND MITIGATION
1.4.1 Risk Assessment Process
The safety manager will carry out any risk assessment activities. Other staff
members with the relevant expertise may be called from time to time by the
safety manager to assist, but the overall responsibility still rests with the safety
manager. The process includes an evaluation of the information contained
within the Safety Report/s as well as commissioning further collection of
additional data if required before performing the formal risk assessment.
Form XX and the following likelihood and consequence tables will be used for
risk assessment of Safety Reports and Change Management processes as
required.
Identification of the severity / consequence of the event (Table 1)
Take into account any current mitigation measures and assess the severity in
terms of the worst possible realistic scenario.
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The Safety Manager will enter the results into the Safety Report and Hazard Register.
Risk Tolerability Matrix (Table 3)
The Risk Tolerability Matrix will be used to assess how tolerable the risk, and the priority of response required, using the results obtained from the assessment of the consequences and likelihood.
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1.4.2 Risk Mitigation
This stage will be carried out by the Safety Manager with, when required, assistance from subject matter experts.
Mitigation measures are actions or changes, such as changes to operating procedures, equipment or infrastructure, to reduce either/both the consequences and/or likelihood. Risk mitigation strategies at the airlines will generally fall into three categories:
Avoidance: The operation or activity is cancelled or avoided because the safety risk exceeds the benefits of continuing the activity, thereby eliminating the risk.
Reduction: The frequency of the operation or activity is reduced or action is taken to reduce the magnitude of the consequences of the risk.
Segregation: Action is taken to isolate the effects of the consequences of the risk or build in redundancy to protect against them.
Prior to introducing measures to reduce or eliminate the risk, the Safety Manager will review the risk assessment to ensure that any measures that are introduced do not lead to other hazards being introduced into the system.
The Safety Manager will then prepare and implement a treatment plan which shall be kept with the relevant Safety Report. The Safety Manager will also record this stage in the Safety Report and Hazard Register and prepare a quarterly report for the Safety Committee.
1.4.3 Monitor and Review
We understand that there is a need to monitor and review the effectiveness of all stages of the risk management process. To meet this requirement the Safety Manager will record each stage of the risk management process. This will include assumptions, methods, data sources, analyses, results and reasons for decisions. This data will then be used to support the procedures and processes outlined in Safety Assurance.
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Appendix 2
TABLE OF CONTENTS
Section
Contents
Note
1
RMIT Cover Sheet For submission of Work for assessment – http://mams.rmit.edu.au/s1llva641yxuz.pdf
(Not included in total word count)
2
Table of Contents
(Not included in total word count)
3
Introduction (Not more than 280 words)
10% of Total Word Count
3.1
Background, context or a general orientation to the topic so that the reader has a general understanding of the area you are discussing.
3.2
An outline of issues that will and will not be discussed in the essay (this does not have to be a detailed list of the ideas that you will discuss). An outline should be a general overview of the areas that you will explore
3.3
A thesis or main idea which is your response to the question (Hypothesis 1 or 2).
4
Literature Review (Not more than 560 words)
20% of Total Word Count
4.1
Australian Transport Safety Bureau (ATSB) Aviation Occurrence Investigation, AO-2014-192 Final dated 21 July 2016
4.2
ICAO Document 9859 3rd Edition
4.3
CASA CAAP SMS-1(0)
4.4
CASA CAAP SMS-2(0)
4.5
CASA CAAP SMS-3(1)
4.6
CASA’s Low Level Flying Regulations
4.7
Airline’s Hazard and Risk Management Procedure Template
5
Key operational risks associated with low-level flying that was being conducted by the airline on the Sydney – Hobart race yachts using CASA’s Risk Management Framework Model for the airline (Not more than 1120 words)
40% of Total Word Count
5.1
ESTABLISH THE CONTEXT
5.2
IDENTIFY THE RISKS
5.3
ANALYSE RISKS
5.4
EVALUATE RISKS
5.5
RISK TREATMENT
5,6
MONITOR AND REVIEW
5.7
COMMUNICATE AND CONSULT
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Section
Contents
Note
6
Factors which contributed to the accident
(Not included in total word count)
7
Hazard and Risk Register
(Not included in total word count)
8
Findings (Not more than 560 words)
20% of Total Word Count
9
Recommendations (Not more than 140 words)
5% of Total Word Count
10
Conclusion (Not more than 140 words)
5% of Total Word Count
11
References
(Not included in total word count)
12
List of Figures Used
(Not included in total word count)
13
List of Tables Used
(Not included in total word count)
14
Acronyms Used
(Not included in total word count)
15
Appendices
(Not included in total word count)
