[Peetwo]

WTD? - Su_Spence lets loose Dr A (LSD) in the risk analysis and SSRP broom cupboard!!

Have some suspicions about what may have kicked this off? However bizarrely last Friday, without any media lead up or fanfare, the following was posted on the CASA LinkedIn page:

Civil Aviation Safety Authority
47,355 followers
3d •

If you’re a small aviation operator, developing a scalable safety management system can be daunting task.

To assist, we’ve published a range of risk analysis bowties for small and large aeroplane and rotorcraft operators. Bowties are useful for understanding the link between threats and hazards, how they produce consequences, and the controls or barriers used to mitigate risk. 

Check them out today:                 
https://lnkd.in/gBeqcS9z

https://media.licdn.com/dms/image/D5622A...E3kxRaHdvU

  Hmm...passing strange but up until this morning LinkedIn remained the only form of social and mainstream media that CASA utilised to announce these apparently useful aids for helping identify and analyse safety risk in individual aviation industry sectors??

If they were hoping for some professional positive appraisal, then unfortunately the comments run at about 50:50 (positive/negative) and most of the more insightful SME comments are very much in the negative:

Mike Allocco, Emeritus Fellow ISSS
• 2nd
System Safety Engineering and Management of Complex Systems; Risk Management Advisor...Complex System Risks
2d
It is so sad that safety people don't recognize rebranding of safety terms... As if the new buzzwords create some magical thoughts... There is nothing new or magical with Safety I, II, III, Hoping, Agile, Lean, Differently, Zero, Black Swans, Gray Rhino’s, Quantum Risk, Design Confusion… Just read any book on safety from the 1960's on out...

What is going on these days with safety sound bites? Nothing is a substitution for research skills... Don't be distracted from doing the work of the identification, elimination, or the control of risks to acceptable levels…

---

Matthew Wuillemin
• 2nd
Training Captain - Bonza Airlines 737MAX
2d

All good stuff , but it’s usually the unforeseen hazard / risk that pops up ( Black Swan ) .. assessing all of these realistically is at the core , and often humans are poor at credible risk evaluation. Until there’s a high level event then 20/20 hindsight kicks in and the phrase ‘ we will change things so this never happens again “ .. till it does.

Which brings me to the link itself:

Using our bowtie risk analysis

Bowtie analysis is a risk analysis methodology allowing stakeholders and risk owners to better understand:

• risks
  
• associated threats (causal factors)
  
• consequences (outcomes)
  
• preventative and recovery controls (barriers).
  

A key benefit of the bowtie methodology is it creates a visual representation between threats and hazards. It also shows how threats and hazards interact to produce consequences and the barriers or controls that could prevent an event or reduce its impact.

This is a valuable tool to help you better understand how effective your current controls are and identify new or enhanced controls.

We have developed a series of bowties across various sectors for the following risk categories, including:

• loss of control inflight
  
• controlled flight into terrain
  
• mid-air collision
  
• runway incursion
  
• runway excursion
  
• human performance
  
• technical
  
• organisational.
  

The human performance, technical and organisational bowties complement the operational bowties where human performance, technical or organisational issues may be a factor for a control not being effective.

These are often identified as escalating factors. We have developed separate bowties for these to address the relevant threats these could introduce.

Reading a bowtie analysis

The following bowties identify the relevant regulatory controls (preventative and recovery) for the specific threat and consequence for each of the risks. These include:

• the hazard: something with the potential to cause risk
  
• the top event: in the middle of the diagram is the moment control is lost over the hazard
  
• the threats: are what could cause the top event on the left-hand side of the diagram
  
• the preventative controls: these are the barriers that sit between the threats and the top event to prevent the event from happening
  
• the consequences: are the possible outcomes resulting from the top event being realised. You can find these on the right-hand side of the diagram
  
• the recovery controls: are the barriers on the right side of the top event that prevent the top event resulting in unwanted consequences
  
• escalating factors: a condition that leads to increased risk by defeating or reducing the effectiveness of a control. Escalating factors can also have controls assigned to reduce the likelihood of that factor happening...
  

     
Hmm...so the bowties that CASA have produced, as an aid to industry, singularly focusses on regulatory controls? I've got a feeling I know where this is heading but to be sure let's pick an example - how about: ATO-SA Controlled Flight into Terrain

Here is the PDF link: https://www.casa.gov.au/sites/default/fi...errain.pdf

 
Hmm...clear as mud?? - 

While on the 'Using our bowtie risk analysis' webpage you'll notice this link: Please use our SSRP contact form for any of the following requests:

The SSRP reference piqued my interest because of the history of Sector Risk Profiles that were being proactively developed and promoted by former CEO of the 4As Phil Hurst, during the tail end of the McCormick regime and into the short-lived Skidmore era:



Page 4 AAAA response to ASRR report: https://www.infrastructure.gov.au/sites/...ia_Ltd.pdf

&.. (from 05:58)

Senator Fawcett, David asked:

Senator FAWCETT: I am happy to put my questions on notice, given the time constraints. Mr Skidmore, the
industry has been very positive about sector risk profiles. I would like an update on where CASA's view is with
that process, who you have got working on it and what resources you are investing in it. It appears to be a good
way of collaborating with industry.

Mr Skidmore: I will take that on notice, and thank you very much for those comments.

Answer:

CASA considers that Sector Risk Profiling (SRP) is an effective risk management tool to assist the aviation
industry in developing an understanding of the effects of risks in order to maximise their aviation safety
performance. SRPs that have already been developed are in the areas of aerial application and aerial mustering.
In 2016 CASA expects to publish SRPs in aerodromes, small aeroplanes, large aeroplanes and offshore
helicopter transport. The SRPs in helicopter emergency medical services and aerial ambulance sectors are
expected to be published in 2016-17.

The profiles are developed by a team of subject matter experts drawn from CASA’s operational areas that
collect and analyse relevant data. The data and other additional information are reviewed collectively by CASA
and representatives from the relevant sector prior to finalising the SRP.

History will show that only about 4 of the proposed dozen SRPs were completed before being kyboshed by the St Commode. It would now appear that even those 4 published SRPs are no longer easily accessible off the Fort Fumble website. However I was able to track down one of the 4 SRPs: https://www.casa.gov.au/sites/default/fi...sector.pdf

Using the sector risk profile

The purpose of the aerial mustering sector risk profile is
to present a picture of the key risks and effects arising from
the operations of the sector’s fleet of aircraft at a given point
in time.

CASA and selected industry sector participants developed
the sector risk profile through a process in which risks were
jointly identified, assessed and evaluated for treatment. When
fully implemented these risk treatments should reduce the risk
profile of the sector. The responsibility for implementation of
the treatment measures for which industry has accountability
rests with authorisation holders, operators and pilots.

The sector risk profile is dynamic and will change over time
to reflect changes in the sector and the environment. The risk
treatments are subject to a monitoring plan that measures
change in safety performance following implementation of
the risk reduction measures. An evaluation plan evaluates the
effectiveness of the risk reduction measures.

Hmm...like Chalk & Cheese, you know where Dr A can stick his regulatory mumbo, jumbo BOWTIEs?? -

MTF...P2