International Helicopter Safety Team Safety Management System Toolkit

WHOSE JOB IS IT?
In 2007, the USJHSAT analyzed 197 reported
helicopter accidents for the year 2000 as recorded in
the NTSB’s U.S.A. database. The USJHSAT found that
a major contributing factor in many accidents was the
failure to adequately manage known risks. Due to the
lack of a systematic process, including leadership and
accountability, operators did not adequately prioritize
and address the risks that lead to most accidents.
The JHSAT studied 174 accidents for the year
2001. They found that in 146 of the 174 accidents,
“Pilot Judgment & Actions” was a factor. The Standard
Problem Statement (SPS), pilot judgment and actions,
dominated the problems, appearing in over 80
percent of the accidents analyzed.
The dominance of pilot judgment & actions factors
is similar to the conclusions of previous studies. The
pilot is the last link in the chain of events leading to
an accident – he or she is the only one who can
affect the outcome once the sequence of event problems
has started. If the pilot’s judgment and actions in
response to problems, whether pilot-initiated or not,
can be improved, there is the potential for more than
80 percent of the accidents to be mitigated, prevented
entirely or reduced from fatal to minor injury.
If the pilot had made a preflight risk assessment
and sounder decisions about helicopter position relative
to hazardous conditions, it is possible that the
precipitating event could have resulted in a nearly
uneventful precautionary or forced landing rather than
an accident.
Precipitating events may be beyond the pilot’s
control, such as system component failures, or they
may be pilot-induced, such as loss of engine power
due to lack of fuel. Other pilot-induced precipitating
events include the results of poor piloting skills and
poor decision-making. Piloting skills include physical
stick and rudder actions, visual scans, situational
awareness, recognition of environmental factors, and
the knowledge and proper control of aircraft performance.
Poor decision-making includes the pilot’s
making a conscious decision to put the aircraft in a
situation/environment that is outside his ability to
control, or outside the aircraft’s performance limits,
thereby eliminating recovery options. These situations
include improper airspeed, altitude, weather assessment,
aircraft loading and crew fatigue. The risk of a
pilot-caused accident is increased further when “pilot
situation awareness” and “ground duties” (37 percent
each) are combined with other problems including
safety management deficiencies.
The USJHSAT concluded that safety management is
not a separate independent concept in an organization.
Improved oversight of pilots and operations by
management is also highlighted by this analysis. This
oversight can be obtained by using some variation of
a formal integrated Safety Management System
(SMS). Among other things, the SMS requires training
for specific missions, the establishment and enforcement
of standard operating procedures, provision and
training of personnel to use risk assessment tools, and
most importantly, changing the safety culture to ensure
that all personnel put “safety” first. The cost benefit of
remaining “accident free” needs to be understood
and shared with the organization. Having an accident
is not only costly in the short term, but may have longterm
effects if that organization no longer uses an
operator’s helicopter services.
The SMS Toolkit will help develop a scalable safety
management system that will show both a return on
investment, and/or cost effectiveness from both financial
and safety perspectives. It will help organizations
develop an SMS designed to fit the size, nature and
complexity of their organization. This is a resource
document that provides comprehensive information on
each of the 12 SMS elements, including checklists for
each element that can assist an organization in developing
and implementing an SMS. It provides easy-touse
guidance and proven methods that will assist in
developing a systematic approach to managing
hazards or risks that cause accidents.
2 SMS Toolkit