BUREAU OF AIR SAFETY INVESTIGATION
The BASI-INDICATE Safety
Program
Implementation Guide
The BASI-INDICATE Safety Program: Implementation Guide
Version 1.0
Date of issue:
January 1998
Copyright
© 1998 Bureau of Air Safety Investigation
Caveat:
BASI believes that safety information is of great value. If the safety information in this manual is passed
to others for use, the copyright restrictions do not apply to material printed in The BASI-INDICATE
Safety Program: Implementation Guide. Readers are encouraged to copy or reprint the information
contained in this manual for further distribution, but should acknowledge BASI as the source.
This manual was designed and prepared for the Bureau of Air Safety Investigation by:
Wordware Pty Ltd
192 Burwood Road
Hawthorn Vic 3122
Table of Contents
The BASI-INDICATE Safety Program
Implementation Guide
Table of Contents
Preface.......................................................................................................................Preface-1
1. Why the BASI-INDICATE Safety Program Was Developed....................................... 1-1
1.1 Background to the Development of the BASI-INDICATE Safety Program........... 1-2
1.2 How to Obtain the BASI-INDICATE Software Program...................................... 1-3
2. Basic Principles of the BASI-INDICATE Safety Program .......................................... 2-1
2.1 The Premise Underlying the BASI-Indicate Safety Program................................. 2-2
3. Introduction to the BASI-INDICATE Safety Program................................................ 3-1
3.1 Program Overview ............................................................................................... 3-2
3.2 Program Detail..................................................................................................... 3-4
Annex 3A. Checklist for Implementing the BASI-INDICATE Safety Program .......... 3A-1
4. Tailoring the BASI-INDICATE Safety Program ......................................................... 4-1
4.1 Tailoring the BASI-INDICATE Safety Program to the Company......................... 4-2
4.2 Suggested levels of Application of the BASI-INDICATE Safety Program............ 4-3
5. The Strengths of the BASI-INDICATE Safety Program ............................................. 5-1
5.1 Strengths.............................................................................................................. 5-2
5.2 Ownership of the Program.................................................................................... 5-3
5.3 Minimising the Costs of Aviation Accidents and Incidents................................... 5-4
6. Further Information ...................................................................................................... 6-1
6.1 Further Information about the BASI-INDICATE Safety Program......................... 6-2
6.2 Further Reading ................................................................................................... 6-3
6.3 References ........................................................................................................... 6-4
Approved by Director of Bureau of Air Safety Investigation
ig211000tp.doc Version 1.0: January 1998
Cover and TOC: 4 pages
Page i
The BASI-INDICATE Safety Program
Implementation Guide
Table of Contents
Appendix A. Sample of Potential Aviation Safety Hazards ............................................ A-1
Appendix B. Sample Confidential Safety Report Form .................................................. B-1
Appendix C. Sample Output of a Focus Group .............................................................. C-1
Appendix D. Summary of the BASI-INDICATE Safety Program.................................. D-1
D.1 Identifying Needed Defences in the Civil Aviation Transport Environment ........ D-2
D.2 How Does the BASI-INDICATE Safety Program Work? ................................... D-3
D.3 How Do Staff Use the BASI-INDICATE Safety Program to Report a Safety
Hazard?...................................................................................................................... D-4
D.4 Strengths of the BASI-INDICATE Safety Program ............................................ D-4
Cover and TOC: 4 pages
Page ii
Approved by Director of Bureau of Air Safety Investigation
Version 1.0: January 1998 ig211000tp.doc
Preface
This BASI-INDICATE Safety Program: Implementation Guide describes the
requirements for the formal and proactive management of safety within an
aviation company. The program was developed to provide simple, cost
effective and reliable means of capturing, maintaining, monitoring and
reporting information about safety hazards.
The BASI-INDICATE Safety Program is owned and managed by an aviation
company. It provides the company with a:
l
structured framework for critically evaluating and continually improving
the integrity of aviation safety measures
l
formal communication channel to regularly identify and report
weaknesses in aviation regulations, policies and standards to BASI. Any
safety issues that are reported to the Bureau are at the discretion of the
company and the failure or success of the program is determined by the
company.
This manual provides implementation guidelines to companies and personnel
in the aviation industry on how to implement a proactive safety management
program. Although the program is directed at the aviation industry, the
principles set out for safety management also apply other industries.
The BASI-INDICATE Safety Program was trialed by a major Australian
regional airline to evaluate whether the program would have a positive
influence on safety performance. The successful results of the trial are
presented in the 1998 BASI report: An evaluation of the BASI-INDICATE
safety program.
Approved by Director of Bureau of Air Safety Investigation
ig211000pr.doc Version 1.0: January 1998
Preface: 1 page
Page Preface-1
1
Why the BASIINDICATE Safety
Program Was
Developed
The BASI-INDICATE Safety Program
1. Why the BASI-INDICATE Safety Program Was Developed
Implementation Guide
1.1 Background to the Development of the BASI-INDICATE Safety Program
1.1 Background to the Development of the BASI-INDICATE
Safety Program
Chapter 1: 3 pages
Page 1-2
1.1.1
On October 2 1994, VH-SVQ, an Aero Commander 690B aircraft operated
by Seaview Air, crashed into the Pacific Ocean, fatally injuring the nine
persons on board. As a result of the accident, a public commission of inquiry
into the relationship between Seaview Air and the then Civil Aviation
Authority (CAA) was established. The inquiry became known as the
Staunton Commission.
1.1.2
The Staunton Commission was not the only inquiry into Australian aviation
safety at that time. In December 1995, a report of the inquiry into the safety
of the general aviation and regional airline sectors by the House of
Representatives Standing Committee on Transport, Communications and
Infrastructure was released. The report is titled Plane Safe, but is commonly
known as the Morris Report.
1.1.3
A common conclusion of these inquiries was that management must take
full responsibility for safety, and that both the aviation industry and
aviation safety authorities must be more proactive in identifying safety
deficiencies, so that the potential for accidents is reduced.
1.1.4
Despite the recommendations of reports of both inquiries, there are currently
few formal proactive safety management programs designed to prevent
accidents within the Australian aviation industry. In part, this is due to a
number of misconceptions that proactive Safety Programs are only applicable
to high-capacity operators, costly to implement and require system safety
expertise for effective management.
1.1.5
The Bureau of Air Safety Investigation (BASI) has developed a proactive
Safety Program to address these misconceptions and provide a safety tool
for aviation companies that is cost effective, simple and flexible, called the
BASI-INDICATE Safety Program. For further details on the background to
and theory behind the program, refer to the 1996 BASI report Proactively
monitoring airline safety performance: INDICATE (Identifying Needed
Defences in the Civil Aviation Transport Environment).
1.1.6
During the development of the BASI-INDICATE Safety Program,
discussions with low-capacity passenger-carrying operators revealed that
many companies perceive proactive safety management programs as useful,
but they lack the necessary knowledge, skills and resources to develop such
programs. Therefore, BASI has produced this practical implementation and
software guide to enable organisations to implement the BASI-INDICATE
Safety Program and tailor it to their operational needs.
Approved by Director of Bureau of Air Safety Investigation
Version 1.0: January 1998 ig21100001.doc
1. Why the BASI-INDICATE Safety Program Was Developed
1.2 How to Obtain the BASI-INDICATE Software Program
The BASI-INDICATE Safety Program
Implementation Guide
1.2 How to Obtain the BASI-INDICATE Software Program
1.2.1
The BASI-INDICATE Software Program was developed to complement the
BASI-INDICATE Safety Program. BASI makes the software program
available to all aviation companies free of charge. However, users must
agree to the terms and conditions governing operation of the program.
Details on how to obtain the BASI-INDICATE Software Program, the terms
and conditions governing its use, installation requirements and operating
instructions are outlined in The BASI-INDICATE Safety Program: Software
Guide.
Approved by Director of Bureau of Air Safety Investigation
ig21100001.doc Version 1.0: January 1998
Chapter 1: 3 pages
Page 1-3
2
Basic Principles of
the BASI-INDICATE
Safety Program
The BASI-INDICATE Safety Program
Implementation Guide
2. Basic Principles of the BASI-INDICATE Safety Program
2.1 The Premise Underlying the BASI-Indicate Safety Program
2.1 The Premise Underlying the BASI-Indicate Safety
Program
2.4.4
The basic premise underlying the BASI-INDICATE Safety Program is that
staff will generally report safety hazards within their work area if they are
given sufficient opportunity.
2.1.1
A hazard is any event or situation that has the potential to cause damage or
injury.
2.1.2
However, some staff are reluctant to report safety hazards for fear of blame
or retribution, particularly if the problem reflects negatively on management.
In addition, some smaller aviation companies do not have formal operational
safety officers that staff can access directly and/or confidentially report
safety hazards. In other cases, safety hazards may be reported but get lost in
company bureaucracy and little feedback is ever given to the originator. As a
result, potential safety problems remain unchecked.
2.1.3
The implementation of the BASI-INDICATE Safety Program will minimise
these types of communication problems by providing a simple, but
structured, process to ensure that consistent and high-quality safety
feedback is disseminated to all staff.
2.1.4
To achieve this, it is necessary to understand how accidents occur and the
crucial role that safety defences play in preventing accidents and incidents.
Safety Defence Failures
2.1.6
Chapter 2: 6 pages
Page 2-2
Safety defences are barriers or safeguards put in place to protect a system
from both human and technical failure. According to Maurino, Reason,
Johnson and Lee (see also Appendix D for details), defences serve a number
of essential functions, including:
Essential function
Example of defence
Awareness and understanding
Crew Resource Management is a defence that is
designed to highlight the value of crew
communication
Detection and warning
A Traffic Collision Avoidance System (TCAS)
provides flight crew with a timely warning
regarding an impending collision
Protection
Aircraft seats are designed to withstand g forces
Recovery and containment
Fire suppression systems are required for many
aircraft engines and cargo areas
Escape and rescue
In the event of an aircraft crash, an emergency
locater transmitter aids in the rescue of
survivors
Approved by Director of Bureau of Air Safety Investigation
Version 1.0: January 1998 ig21100002.doc
2. Basic Principles of the BASI-INDICATE Safety Program
2.1 The Premise Underlying the BASI-Indicate Safety Program
The BASI-INDICATE Safety Program
Implementation Guide
2.1.7
The breakdown of one or more defences can be determined in the aftermath
of an accident as shown in the following examples of incidents in Finland and
the United States of America.
2.1.8
The examples show how important it is for a company to regularly identify
what defences are currently in place to contain potential safety hazards.
However, rather than waiting for accidents to reveal defence failures, the
BASI-INDICATE program provides a method to proactively evaluate
potential defence failures on a regular basis.
Example 1
2.1.9
The incident:
l
At 0500 on the morning of 6 June 1995, a licensed aircraft maintenance
engineer (LAME) towed an ATR 72 aircraft from the hangar and
prepared it for engine runs. After discussion with the maintenance
supervisor, it was decided that the LAME would conduct the engine runs
on his own.
l
The LAME carried out the post-maintenance engine run and other
required tests. After having found the aircraft serviceable, he used the
radio to obtain a clearance to taxi to a position on the terminal apron.
Releasing the parking brake, he increased thrust to get the aircraft
moving, but quickly realised that the nosewheel steering was not
working. He tried to apply the normal brakes by depressing the brake
pedals but found that these did not work either. While the aircraft
continued moving towards the hangar, the LAME sat motionless in the
seat for about eight seconds. He then rapidly reduced power on both
engines and selected reverse thrust. These actions were undertaken too
late to stop the aircraft before the nose and right wingtip hit the hangar
door, causing considerable damage to the aircraft.
2.1.10 The investigation:
l
The investigation of the incident found that the aircraft was fully
serviceable before colliding with the hangar. The normal brakes and
nosewheel steering did not operate because the electric pumps supplying
hydraulic pressure to these systems had not been switched on. Despite
this, sufficient pressure was available in the parking brake accumulator
(and shown on the gauge on the cockpit hydraulic panel) to stop the
aircraft by use of the parking brake handle.
2.1.11 The following defence failures were evident in the report.
l
The LAME’s engine run training was inadequate. The training had been
conducted on an ad hoc basis by several instructors over nine months
without the guidance of a syllabus. Not enough training was allocated to
handling emergencies such as using the park brake to stop the aircraft in
the event of brake failure. Also, no refresher training of LAMEs in
engine runs and taxiing was conducted.
Approved by Director of Bureau of Air Safety Investigation
ig21100002.doc Version 1.0: January 1998
Chapter 2: 6 pages
Page 2-3
The BASI-INDICATE Safety Program
Implementation Guide
2. Basic Principles of the BASI-INDICATE Safety Program
2.1 The Premise Underlying the BASI-Indicate Safety Program
l
A checklist was not used during the engine start. This allowed the
LAME to start taxiing the aircraft with the hydraulic pumps switched
off. Despite a written company maintenance policy that required a
checklist to be used for all engine runs and taxiing, only some
maintenance personnel used the checklist for all engine runs, some used
it for extensive engine runs but not short duration runs, some only used
the pilot’s engine start checklist and others did not use a checklist at all.
l
The aircraft was taxied with only one person in the cockpit. This was
contrary to company policy. Had another person been in the cockpit, the
failure to switch on the hydraulic pumps may have been detected and the
accident avoided.
l
The company quality system failed to identify the poor state of the
instructions relating to engine run training and taxiing of ATR 72
aircraft. It also did not detect that maintenance personnel were
disregarding the instructions on use of checklists and ignoring the
practice of requiring more than one staff member for taxiing tasks.
l
The LAME was inexperienced in performing engine runs and taxiing,
possibly because of inadequate training or lack of recent engine run
practice. This may have affected his ability to solve the problem of lack
of brakes and nosewheel steering when taxiing. Despite his lack of
confidence, the LAME did not request assistance from his supervisor
with the engine run on the day of the accident.
Example 2
2.1.12 The accident:
Chapter 2: 6 pages
Page 2-4
l
Late at night on 7 January 1994, a Jetstream J 41 aircraft operated by a
United States commuter airline was flying a scheduled service from
Dulles International Airport, Washington D.C to Columbus, Ohio. It
crashed during the approach to Columbus, killing five of the eight crew
and passengers on board.
l
The crew commenced the Instrument Landing System (ILS) approach to
runway 28 Left in conditions of low visibility and icing. The pilot in
command elected to fly a high-speed approach with the autopilot keeping
the aircraft on the ILS glideslope and localiser. The Before Landing
checklist was not completed until late in the approach, distracting the
crew from their primary duties of monitoring the approach. The
aircraft's airspeed, which was never stabilised during the approach, was
not monitored by the crew and decreased until the stall warning system
sounded. The crew failed to react appropriately to the stall warning and
the aircraft crashed.
Approved by Director of Bureau of Air Safety Investigation
Version 1.0: January 1998 ig21100002.doc
2. Basic Principles of the BASI-INDICATE Safety Program
2.1 The Premise Underlying the BASI-Indicate Safety Program
The BASI-INDICATE Safety Program
Implementation Guide
2.1.13 The following defence failures were evident in the report.
l
The Federal Aviation Administration (FAA) had no adequate stabilised
approach criteria.
l
The airline and FAA had no adequate requirement for proper cockpit
crew coordination.
l
Pilot training simulators were not available within the airline.
l
A newly upgraded captain on a new aircraft was paired with a co-pilot
who had almost no experience in airline operations.
2.1.14 Applicability of this example to Australian operators:
Even though this accident occurred overseas, many of the lessons from it are
equally applicable in Australia. The combination of poor planning, a poorly
flown approach, inadequately trained pilots, the absence of effective crew
resource management and bad weather is just as deadly in Australia as in any
other country.
Identifying Inadequate Defences
2.1.15 Figure 2.1 presents a slightly modified version of Reason’s (1990) widely
cited model of accident causation. The model highlights the important role
that defences play in preventing accidents and acknowledges that the
individual components of Reason’s model—organisation, workplace and
person/team—are difficult to identify before an accident because latent
failures are usually unforeseeable, workplace factors are dynamic, and errors
or violations are unpredictable. The model implies that the integrity of safety
defences can be more accurately determined. This is because defences are
tangible, and thus measurable, components in a system. It is much easier to
evaluate the probable failure of a safety defence than to identify the potential
existence of a latent failure.
2.1.16 However, identifying inadequate defences does not mean that latent failures
or individual errors can be ignored. Focusing on inadequate defences simply
puts the responsibility of safety back on the structure of the organisation.
For example, if an inadequate defence is a lack of staff knowledge about the
use of fire extinguishers, this automatically highlights a need to evaluate the
company policy relating to ongoing emergency training. Regularly
evaluating defences provides a tangible means by which latent
organisational failures can be identified. The BASI-INDICATE Safety
Program has been designed to evaluate safety defences regularly so that
the risk of an accident is minimised.
Approved by Director of Bureau of Air Safety Investigation
ig21100002.doc Version 1.0: January 1998
Chapter 2: 6 pages
Page 2-5
The BASI-INDICATE Safety Program
Implementation Guide
2. Basic Principles of the BASI-INDICATE Safety Program
2.1 The Premise Underlying the BASI-Indicate Safety Program
Defences
Engineered safety devices
Policies, standards, controls
Organisation
Workplace
Person/Team
Management
decisions and
organisational
processes
Error and
violation
producing
conditions
Errors and
violations
Difficult to identify pre - accident
Procedures, instructions,
supervision
Training, briefing, drills
Personal protective
equipment
Proactively identifiable
Figure 2.1. Proactive defence evaluation model
Chapter 2: 6 pages
Page 2-6
Approved by Director of Bureau of Air Safety Investigation
Version 1.0: January 1998 ig21100002.doc
ACCIDENT
3
Introduction to the
BASI-INDICATE Safety
Program
The BASI-INDICATE Safety Program
Implementation Guide
3. Introduction to the BASI-INDICATE Safety Program
3.1 Program Overview
3.1 Program Overview
3.1.1
A great deal of material has been published about safety management. Some
of the more useful references are outlined in chapter 6 under Further
Reading. These books identify the essential elements that make up a safety
management program, but few provide a simple methodology to implement
these essential elements and evaluate whether they are working.
3.1.2
This chapter provides a structured process for establishing and maintaining
the BASI-INDICATE Safety Program, which contains all the recognised
essential elements of a typical safety program, but can be tailored to meet the
diverse operational needs of individual aviation companies. The principles
underlying the program apply to all companies, regardless of their size,
function or resources available within the company. Further details on how
the BASI-INDICATE Safety Program can be tailored to suit a company's
size is provided in chapter 4.
The Three Critical Elements
3.1.3
The BASI-INDICATE Safety Program is based on three elements which are
critical for the success of any safety program within an organisation:
1.
Safety must be recognised as a priority within the company.
2.
Senior management must be committed to improving safety standards.
3.
Appropriate resources must be allocated for safety management.
If any one of these elements is not present, a safety program is unlikely to be
successful. The authority to commit resources, spend money and bring about
safety change must be present.
The Six Core Safety Activities
3.1.4
3.1.5
Chapter 3: 15 pages
Page 3-2
Once the three critical elements are in place, the BASI-INDICATE Safety
Program involves implementing and maintaining six core safety activities:
1.
Appointing an Operational Safety Manager.
2.
Proactively identifying aviation safety hazards by conducting a series of
staff focus group discussions.
3.
Establishing a confidential safety reporting system.
4.
Establishing regular safety meetings with management.
5.
Maintaining a safety information database.
6.
Ensuring that vital safety information is regularly communicated to all
staff.
Using the checklist in Annex 3A will help you implement these core safety
activities in your organisation.
Approved by Director of Bureau of Air Safety Investigation
Version 1.0: January 1998 ig21100003.doc
3. Introduction to the BASI-INDICATE Safety Program
3.1 Program Overview
The BASI-INDICATE Safety Program
Implementation Guide
Desired Outcomes
3.1.6
These core safety activities are not new, but are common to most safety
programs. Essentially, they are structured processes designed to achieve the
following desirable outcomes:
l
the continual identification and correction of safety hazards within the
company
l
staff who are actively involved in company safety management
l
the provision of current information on the safety health of the
organisation
l
staff that are motivated to be more safety conscious
l
more open communication between different departments, and between
management and staff, with access provided to safety information for
those who need it.
Approved by Director of Bureau of Air Safety Investigation
ig21100003.doc Version 1.0: January 1998
Chapter 3: 15 pages
Page 3-3
The BASI-INDICATE Safety Program
Implementation Guide
3. Introduction to the BASI-INDICATE Safety Program
3.2 Program Detail
3.2 Program Detail
1. Appointing an Operational Safety Manager
3.2.1
The Operational Safety Manager in an aviation company plays a critical role
in safety management. Staff must regard him/her as being credible and
trustworthy, and he/she must have a good working relationship with
management.
3.2.2
Ideally the Operational Safety Manager position should be full time, to
ensure that sufficient attention is paid to safety. However, many smaller
companies do not have the resources to justify this. In such organisations, the
Operational Safety Manager’s role can be fulfilled on a part-time basis—for
example, by a current line pilot. Depending on the size of the company, the
Operational Safety Manager may require the assistance of several safety
officers.
3.2.3
The most important criterion in selecting the Operational Safety
Manager and safety officers is that they must be enthusiastic, keen to
improve safety and have sufficient experience and maturity to discuss
sensitive safety issues with senior management. Appointing someone who
wants the job for the right reasons will ensure the success of the program. All
incumbents should have a reputation for trust and professionalism in the
carrying out of their duties.
3.2.4
The Operational Safety Manager’s role is multi-faceted, and may involve the
following tasks:
l
coordinating regular safety meetings with management
l
ensuring staff that are new to the company are made aware of the BASIINDICATE Safety Program
l
coordinating safety training for new personnel and refresher training for
existing staff
l
encouraging staff to use the confidential safety reporting system
l
being available to all staff as a confidential contact for safety-related
issues
l
providing timely advice and assistance on safety matters to management
and staff at all levels
l
ensuring that vital safety information is communicated to all staff
l
participating in accident and incident investigations
l
regularly evaluating and improving the company’s safety program.
3.2.5
The Operational Safety Manager should be given the authority to report
directly to the chief executive officer of the company.
3.2.6
The Operational Safety Manager should not occupy any other management
role, and should be aware of the confidential nature of his/her position.
Chapter 3: 15 pages
Page 3-4
Approved by Director of Bureau of Air Safety Investigation
Version 1.0: January 1998 ig21100003.doc
3. Introduction to the BASI-INDICATE Safety Program
3.2 Program Detail
The BASI-INDICATE Safety Program
Implementation Guide
2. Proactively Identifying Aviation Safety Hazards
3.2.7
Aviation safety hazards can be proactively identified by conducting focus
group discussions with as many company staff and management as possible.
Focus Group Discussions
3.2.8
Focus group discussions enable staff to become more actively involved in
establishing and maintaining a safety management program within the
company.
3.2.9
The purpose of the group discussions is to provide participants with a
structured method to identify the company hazards that have the greatest
potential to compromise aviation safety.
3.2.10 This means that basic workplace occupational health and safety issues are
not normally covered in the group discussions, but need to be covered
elsewhere in accordance with normal legislative requirements.
Guidelines for Focus Groups
3.2.11 Each focus group discussion should generally take about two hours.
Although this is time-consuming and may be a possible drain on company
resources, there are overriding advantages in conducting these group
discussions. They:
l
provide the company with a current assessment of its safety performance
l
encourage staff to report safety problems
l
show that management is encouraging and valuing staff participation in
safety management
l
reaffirm that the company is committed to safety
l
make staff more aware of the safety implications of their job.
3.2.12 It is not necessary to conduct the focus group discussions on a regular basis.
However, it is recommended that the discussions occur at least annually
and/or when the organisation is undergoing a major change—for example,
when the company acquires a more complex aircraft or is expanding its
operations.
Approved by Director of Bureau of Air Safety Investigation
ig21100003.doc Version 1.0: January 1998
Chapter 3: 15 pages
Page 3-5
The BASI-INDICATE Safety Program
Implementation Guide
3. Introduction to the BASI-INDICATE Safety Program
3.2 Program Detail
Guidelines
3.2.13 There are no hard and fast rules for conducting effective focus groups, but
the general guidelines provided below apply.
Chapter 3: 15 pages
Page 3-6
l
The number and position of staff who should take part in focus group
discussions will depend on the size of the company, but generally the
focus groups should include captains, first officers, other technical flight
crew, flight attendants, licensed and unlicensed aircraft maintenance
engineers, ground crew, customer service personnel and flight operations
staff. In addition, attendance at these focus groups need not be limited
to full-time or part-time employees, but can include casual or contract
staff.
l
Ideally, each focus group should comprise participants who perform
similar functions—for example, participants who are all pilots or all
engineers. This avoids having to identify hazards associated with more
than one job. However, this may not be practical in smaller companies,
in which case a mixed group is appropriate.
l
Company management should be included in the group discussions
because they have a broader perspective on safety issues. Having
management participate also sends a message to staff that the company
is strongly committed to the safety management program.
l
Whether an organisation should conduct separate management focus
groups and staff focus groups depends on the current state of
management-staff relations—for example, some staff may feel inhibited
about identifying aviation hazards if management are present.
l
The focus groups should be facilitated by the Operational Safety
Manager with the assistance of a scribe.
l
The goal of focus group discussions is for management and staff to learn
something new from the participants. Therefore, it is best to let
participants speak for themselves, with limited involvement by the
facilitator.
l
The facilitator’s role is not to lead the participants in a particular
direction, but to let the group set the content of the discussions. All
participants should have equal opportunity to put their view forward.
However, the airing of personal grievances should be strongly
discouraged.
l
The optimal size of a focus group is generally six to eight people. More
than eight participants means a greater workload for the facilitator and
fewer than six may not be an optimal use of the Operational Safety
Managers’ time.
Approved by Director of Bureau of Air Safety Investigation
Version 1.0: January 1998 ig21100003.doc
3. Introduction to the BASI-INDICATE Safety Program
3.2 Program Detail
The BASI-INDICATE Safety Program
Implementation Guide
Five Steps to Identifying Aviation Safety Hazards
3.2.14 The basic process for identifying aviation safety hazards involves following
five simple steps.
1 Identifying potential safety hazards (particularly those that may
threaten the safety of fare-paying passengers)
ò
2 Ranking the severity of hazards
ò
3 Identifying current defences
ò
4 Evaluating the effectiveness of each defence
ò
5 Identifying additional defences
Figure 3.1. Proactive hazard identification process
Step 1
Identifying potential aviation safety hazards
3.2.15 Ask the question: What are the hazards within an operational area?
3.2.16 To answer this question:
l
The group should be given a few minutes during which each participant
lists any hazards in the company he/she can identify.
l
The facilitator then asks each participant to suggest a hazard until all
hazards identified by the individual participants have been listed.
3.2.17 At this early stage, the group should avoid discussing the hazards identified.
It is much better to brainstorm ideas rather than over-analysing items and
inhibiting the free flow of information.
3.2.18 The outcome of this step should be a list of hazards that reflect the group’s
perception of potential safety hazards within the company. It is expected that
some of the items on the list will be closely related. Therefore, before moving
to Step 2, these items should be collapsed into a smaller, more manageable
group list.
3.2.19 A sample list of potential safety hazards that reflects many of the safety
issues faced by aviation companies can be found in Appendix A.
Approved by Director of Bureau of Air Safety Investigation
ig21100003.doc Version 1.0: January 1998
Chapter 3: 15 pages
Page 3-7
The BASI-INDICATE Safety Program
Implementation Guide
Step 2
3. Introduction to the BASI-INDICATE Safety Program
3.2 Program Detail
Ranking the severity of hazards
3.2.20 Ask the question: How risky are these hazards?
3.2.21 To answer this question:
l
The facilitator should ask each participant to evaluate each hazard in
terms of whether he/she regards it to be severe, minor or negligible.
l
Each person should assign a number from 1 to 3 for each hazard to
indicate its severity, with 3 indicating the most severe.
To help participants rate a hazard, they should be asked to think about
the potential outcome of the hazard. If the outcome is the loss of an
aircraft and/or passenger fatalities, the hazard can be ranked as severe
and given a rating of 3. Minor and negligible hazards can be given a
rating of 2 and 1 respectively.
3.2.22 This provides a simple, but objective, method to achieve group consensus on
hazard severity and ensures validity across different groups.
Step 3
Identifying current defences
3.2.23 Ask the question: What defences are in place within the company to contain
these hazards?
3.2.24 To answer this question:
l
The participants are now required to identify current defences within the
company designed to minimise the potential of each hazard contributing
to an accident.
For example, if an engine failure during takeoff is a recognised hazard
for flight crew, possible defences may include regular aircraft
maintenance, good training and checking, pre-takeoff crew briefings and
a flight simulator to practise engine-failure scenarios.
Step 4
Evaluating the effectiveness of each defence
3.2.25 Ask the question: How effective are the defences?
3.2.26 To answer this question:
l
The group is now required to evaluate the effectiveness of each
identified defence.
For example, if a fire extinguisher has been identified as a defence
against an aircraft engine fire:
¡
are fire extinguishers easily accessible for staff?
¡
do staff know how to use them?
¡
are the fire extinguishers serviced on a regular basis?
If the answer to any one of these questions is no, then fire extinguishers
are not an effective defence against an aircraft engine fire.
Chapter 3: 15 pages
Page 3-8
Approved by Director of Bureau of Air Safety Investigation
Version 1.0: January 1998 ig21100003.doc
3. Introduction to the BASI-INDICATE Safety Program
3.2 Program Detail
Step 5
The BASI-INDICATE Safety Program
Implementation Guide
Identifying additional defences
3.2.27 Ask the question: What modifications are needed to existing defences or are
new ones required?
3.2.28 To answer this question:
l
Ask the participants to suggest whether additional controls or
procedures are needed, or if further modifications to current defences are
required.
For example, several aspects related to fire extinguishers may be
considered to be inadequate. Staff refresher training on the use of fire
extinguishers could be required or new equipment may need to be
purchased.
3.2.29 The outcome of this process is a list of inadequate defences that require
safety action.
3.2.30 A sample of the output of a focus group can be found in Appendix C.
The Types of Hazards Identified by this Process
3.2.30 Typically, two types of hazards are identified through this process:
l
Safety hazards that reflect deficiencies (real or potential) within various
operational areas of the company—for example, flight crew,
maintenance and ground crew. These hazards are the responsibility of
the company to address internally.
l
Systemic safety problems that may compromise the safety of the broader
aviation industry. These problems can be raised as safety deficiencies
for BASI (or the appropriate authority) to investigate.
3. Implementing a Confidential Safety Reporting System
3.2.31 The focus group process discussed in the previous section identifies hazards
that represent current aviation safety deficiencies. However, companies
operate within a dynamic environment, so safety hazards change over time.
Therefore, staff must be given the opportunity to identify additional hazards.
Approved by Director of Bureau of Air Safety Investigation
ig21100003.doc Version 1.0: January 1998
Chapter 3: 15 pages
Page 3-9
The BASI-INDICATE Safety Program
Implementation Guide
3. Introduction to the BASI-INDICATE Safety Program
3.2 Program Detail
3.2.32 The preferred method is for staff to consult their department manager or
supervisor. Minor problems can usually be resolved immediately. However,
a more serious problem may be better dealt with by raising the issue with a
nominated safety officer or the Operational Safety Manager, who then
includes the problem as a discussion item at the next safety meeting. The
Operational Safety Manager enters the item in the safety information
database.
3.2.33 Alternatively, a Confidential Safety Reporting System is an excellent means
of providing this opportunity to staff, particularly for reporters who prefer
that their identity not be disclosed and/or where the matter requires sensitive
handling.
l
Such a reporting system can be used by staff to report any concerns they
may have about safety within their work location, including witnessing
or experiencing unsafe work practices, or identifying deficient safety
equipment and/or facilities.
l
Hazard reporting systems are also integral to the process of preventing
serious occurrences. For example, a pilot or a LAME may sometimes
recognise a safety hazard that is known only to them. If these
experiences are never communicated, the opportunity to prevent an
incident or accident is lost.
3.2.34 A sample confidential safety report form is provided in Appendix B.
Guidelines
3.2.35 Some basic guidelines for establishing and maintaining a Confidential Safety
Reporting System are provided below.
Chapter 3: 15 pages
Page 3-10
l
For such a reporting system to work, it is important that management
create an atmosphere where staff feel comfortable about reporting safety
issues.
l
The reporting form should be sent to the Operational Safety Manager.
l
The reporting system should be confidential, but not anonymous. If it is
anonymous, the Operational Safety Manager cannot fully clarify the
nature of the problem and investigate the matter further. Anonymous
systems also tend to encourage the reporting of personal grievances by
staff, which are not necessarily relevant to improving company safety.
By being able to contact the originator of the report the Operational
Safety Manager is in a much better position to confirm that the problem
exists, evaluate how serious it is and determine what action is required.
l
The Operational Safety Manager must acknowledge the receipt of all
reports. One method of ensuring acknowledgment is to have a tear-off
strip at the bottom of the report form on which the reporter can record
his/her contact details.
Approved by Director of Bureau of Air Safety Investigation
Version 1.0: January 1998 ig21100003.doc
3. Introduction to the BASI-INDICATE Safety Program
3.2 Program Detail
The BASI-INDICATE Safety Program
Implementation Guide
Once the reported hazard has been investigated, the information can be
de-identified and entered on the safety information database of the
BASI-INDICATE Software Program (see also section 5. Maintaining a
Safety Information Database on page 3-13). The original form can then
be destroyed, but the tear-off strip can be sent back to the originator,
with any appropriate feedback.
Returning the tear-off strip also provides the author with confirmation
that his/her report is being addressed.
l
The reporting process should be promoted by advertising how to use it,
where forms are located and how confidentiality is guaranteed. The
results of the program should also feature regularly in newsletters or
company bulletins.
Reporting Hazards to BASI
&
AN Act 1920
Pt 2A
3.2.36 The hazard reporting system described above should not be used to report
safety incidents or accidents. Under the Air Navigation Act 1920, aviation
incidents or accidents must be reported to BASI using the Aviation Safety
Incident Reporting (ASIR) form or the Confidential Aviation Incident
Reporting (CAIR) System. Part 2A of the Act contains the detailed
legislative requirements for the reporting and investigation of accidents and
incidents.
3.2.37 In most cases, the BASI-INDICATE confidential reporting system will be
used by staff to report internal company safety hazards. However, in cases
where the reported hazard has potential safety implications for the broader
aviation industry, BASI should be informed. The report sent to BASI should
contain as much detailed information as possible, and include the contact
details for the company's Operational Safety Manager. To ensure
confidentiality, the reports should not identify any individual other than the
company’s Operational Safety Manager.
3.2.38 The BASI-INDICATE Safety Program provides a means for the company to
report industry hazards to BASI. (See also section 5. Maintaining a Safety
Information Database on page 3-13.) Once a hazard has been reported to
BASI, BASI creates a Safety Advisory Deficiency Notice (SADN) and
assigns a number and safety analyst to the reported hazard in order to
investigate the matter further and to issue safety recommendations, where
appropriate.
Approved by Director of Bureau of Air Safety Investigation
ig21100003.doc Version 1.0: January 1998
Chapter 3: 15 pages
Page 3-11
The BASI-INDICATE Safety Program
Implementation Guide
3. Introduction to the BASI-INDICATE Safety Program
3.2 Program Detail
4. Conducting Regular Safety Meetings
3.2.39 The purpose of the safety meetings is to manage, monitor and address the
hazards identified through the BASI-INDICATE Safety Program. All
managers of operational areas should attend so that communication about
important safety information is encouraged.
3.2.40 The outcome of the meetings is to achieve positive action on safety issues.
The resolution of safety issues usually requires the support and cooperation
of several line management areas.
Guidelines
3.2.41 Well-organised safety meetings can be an integral part of a safety program.
However, safety meetings have the potential to be unproductive.
3.2.42 Use the following guidelines to help ensure that the meeting is productive.
Chapter 3: 15 pages
Page 3-12
l
Because management are the decision-makers in an organisation, they
are in the best position to take action on safety issues. Therefore, it is
important that they attend the safety meetings. If they cannot attend, they
should send a representative.
l
If possible, the Operational Safety Manager should not chair these
meetings, but should act as a recorder. The chairperson should be
someone with sufficient authority and organisational skills to ensure that
positive safety benefits can be achieved—for example, the company’s
Chief Pilot.
l
A meeting should not involve more than six to eight people. Any more
than eight people means that the meeting can become difficult to
manage.
l
Attendance at the meeting does not need to be restricted solely to
management. It may be helpful to open the meeting up to any interested
staff who would like to attend, but restrict their involvement to one of
observation.
l
Ideally, schedule monthly meetings. However, do not meet for the sake
of it: cancel the next meeting if there is little to achieve. Do not cancel a
meeting because one manager cannot participate.
l
Schedule the meetings at a regular time—for example, the first Monday
of every month at 10 am.
l
Set a time limit for the meeting. This forces the group to keep on track,
allows managers to attend with minimal disruption to their schedule and
avoids the discussion of irrelevant issues. A meeting should not last any
more than 90 minutes. Longer meetings may affect the group’s ability to
concentrate.
l
If the agenda is not covered within that time frame, carry it forward to
the next meeting or re-evaluate how time-effective the group is.
Approved by Director of Bureau of Air Safety Investigation
Version 1.0: January 1998 ig21100003.doc
3. Introduction to the BASI-INDICATE Safety Program
3.2 Program Detail
l
The BASI-INDICATE Safety Program
Implementation Guide
Distribute minutes from the meeting to give to the attendees, and make
extra copies available on bulletin boards or in staff communal areas, to
keep everybody informed.
Agenda of Safety Meetings
3.2.43 A typical agenda for a meeting includes:
l
assessing the status of safety action items from the last meeting
l
reviewing and prioritising outstanding safety hazards within the system
l
reviewing all hazard reports and approving corrective actions
l
discussing the best strategy for feeding information back to staff on
action(s) already taken on previous safety issues
l
reviewing the effectiveness of the safety program and discussing
strategies for future improvements.
5. Maintaining a Safety Information Database
3.2.44 A safety program needs to collect a lot of information that must be recorded,
analysed and distributed to senior management and staff in different
departments within a company, and which may need to be disseminated to
other organisations and regulatory authorities.
3.2.45 If safety management information is not stored and managed within a
structured framework, valuable information can be lost. The safety
information database of the BASI-INDICATE Software Program has been
developed to provide a simple method of managing and communicating
important safety information, not only within a company, but also to the
appropriate aviation authorities/organisations.
Technical Specifications for the Safety Information Database
3.2.46 The safety information database of the BASI-INDICATE Software Program
has been created in Microsoft Access and is easily installed on any IBMcompatible personal computer. The only requirement for operating the safety
information database is Windows 3.1 or Windows 95. The program has been
designed as a stand alone, self-install package and Microsoft Access is not
needed to run the program. The program is installed via four 3.5-inch floppy
disks. Because it contains a mini-version of Access, the program uses
approximately 6 megabytes of memory.
Who in an Organisation Should Be Responsible for the Operation of
the Safety Information Database
3.2.47 It is recommended that the safety information database of the BASIINDICATE software program be operated by the company's Operational
Safety Manager and the format of the program mirrors the process that is
conducted in the focus group discussions.
Approved by Director of Bureau of Air Safety Investigation
ig21100003.doc Version 1.0: January 1998
Chapter 3: 15 pages
Page 3-13
The BASI-INDICATE Safety Program
Implementation Guide
3. Introduction to the BASI-INDICATE Safety Program
3.2 Program Detail
What the Safety Information Database Provides to an Organisation
3.2.48 The safety information database of the BASI-INDICATE Software Program
provides a structured framework for the Operational Safety Manager and
safety officers to:
l
monitor and amend a comprehensive list of hazards for each operational
area
l
issue recommendations that specify where further defences are required
l
print out and send recommendations to company senior management
and/or to BASI and other agencies
l
monitor any action being taken on current recommendations
l
print out any actions taken on safety issues, so that the information can
be sent to staff
l
present graphical representations of safety information.
6. Communicating Critical Safety Information to All Staff
3.2.49 The BASI-INDICATE Software Program provides a useful means of
distributing safety information to staff, management, other organisations and
regulatory authorities.
3.2.50 Within an organisation, dissemination of safety information can also be
improved by using the media listed below in Relevant Media for Distributing
Safety Information to distribute important information about hazards
identified by the BASI-INDICATE Safety Program.
3.2.51 Generally speaking, the more information that is communicated the better.
However, this does not mean that trivia should be distributed.
Relevant Media for Distributing Safety Information
3.2.52 Establishing a number of media that can communicate highly relevant safety
information within the company helps ensure that staff receive a clear
message that the company is serious about safety.
l
Company safety newsletters
Newletters can be very effective, but to ensure that people read them,
make sure the information is interesting and highly relevant. It may be
worth considering appointing an editor that has a flair for presentation
or desktop publishing.
l
Establishing a safety notice board
A good notice board only advertises critical information, otherwise staff
may ignore it. Only items that are related to safety should be posted.
Chapter 3: 15 pages
Page 3-14
Approved by Director of Bureau of Air Safety Investigation
Version 1.0: January 1998 ig21100003.doc
3. Introduction to the BASI-INDICATE Safety Program
3.2 Program Detail
l
The BASI-INDICATE Safety Program
Implementation Guide
Safety briefings
To ensure a good turnout, reserve these sessions for information that is
critical.
l
Distributing safety minutes to staff
Distributing minutes through the internal company mailing system is an
effective process of communicating safety information to all staff.
However, there is the risk of staff not reading them. This risk can be
reduced by having the minute signed by someone in a recognised
position of authority or addressing the recipient by name as a way of
personalising the information.
l
Safety reading files
Files are an effective means to communicate current action being taken
on safety issues. The file can be located in a staff communal area for
anyone to read in a quiet time.
Approved by Director of Bureau of Air Safety Investigation
ig21100003.doc Version 1.0: January 1998
Chapter 3: 15 pages
Page 3-15
Annex 3A. Checklist for
Implementing the BASI-INDICATE
Safety Program
Approved by Director of Bureau of Air Safety Investigation
ig21100003a.doc Version 1.0: January 1998
Annex 3A: 3 pages
Page 3A-1
Annex 3A. Checklist for Implementing the BASI-INDICATE
The BASI-INDICATE Software Program
Implementation Guide
3A.1 Checklist for Implementing the BASI-INDICATE
Safety Program
1.
Appointing an Operational Safety Manager
q
q
q
q
q
q
q
2.
Who will the Operational Safety Manager report to?
Will the Operational Safety Manager’s position be part-time or full-time?
Will extra remuneration be offered with the position?
Will the Operational Safety Manager require assistance?
In addition to the Operational Safety Manager, are safety officers required for
different departments or locations?
How many focus groups are needed?
When is the best time to run the groups?
Will management groups be run separately to staff groups?
Who will act as the scribe?
Who will facilitate the groups?
How will staff be encouraged to attend?
Establishing a Confidential Safety Reporting System
q
q
q
q
q
q
q
q
q
Annex 3A: 3 pages
Page 3A-2
How much authority will the Operational Safety Manager have?
Proactively identifying aviation safety hazards
q
q
q
q
q
q
3.
What criteria will be used to appoint the Operational Safety Manager?
How will the reporting system remain confidential?
How will staff find out about the reporting system?
Who will the reporting forms go to?
How will staff use the reporting forms?
What records will be kept?
Who will act on the reports?
How will feedback be given to the originator?
How will the results of the reporting system be publicised?
Will anonymous reports be accepted?
Approved by Director of Bureau of Air Safety Investigation
Version 1.0: January 1998 ig21100003a.doc
The BASI-INDICATE Software Program
Implementation Guide
q
4.
Who will chair the meetings?
Who will participate in the meetings?
Are the meetings freely open to staff to attend?
How often will meetings occur?
What records will be kept?
Where will the results of the meetings be sent?
What authority do the meetings have?
Maintaining a safety information database
q
q
q
q
q
6.
How will reports that are personal attacks or grievances be managed?
Establishing regular safety meetings with management
q
q
q
q
q
q
q
5.
Annex 3A. Checklist for Implementing the BASI-INDICATE
Is a computer or paper version required?
What access will the user have to the computer?
Is there a backup user trained in operating the software?
Will the information in the computer be secure?
If a computer system is used, is there a backup?
Ensuring that vital safety information is regularly communicated to all staff
q
q
q
q
What are the best media available within the company to distribute information?
How will critical safety information be distributed?
How will routine safety information be distributed?
How will you determine whether staff are reading the information?
Approved by Director of Bureau of Air Safety Investigation
ig21100003a.doc Version 1.0: January 1998
Annex 3A: 3 pages
Page 3A-3
4
Tailoring the BASIINDICATE Safety
Program
The BASI-INDICATE Safety Program
Implementation Guide
4. Tailoring the BASI-INDICATE Safety Program
4.1 Tailoring the BASI-INDICATE Safety Program to the Company
4.1 Tailoring the BASI-INDICATE Safety Program to the
Company
4.1.1
The BASI-INDICATE Safety Program is designed to be flexible and to be
tailored to the particular requirements of each aviation company.
4.1.2
Individual operators are responsible for determining how they are going to
implement the six core safety activities of the BASI-INDICATE Safety
Program, based on:
4.1.3
Chapter 4: 3 pages
Page 4-2
l
the size of the company—staff numbers and how many aircraft the
company operates
l
the location of the company—whether there is a central company
location or a number of geographically dispersed operational hubs
l
the safety resources available within the company.
Companies that want to go beyond the six core elements of BASIINDICATE to incorporate other complementary activities in their safety
management program should refer to Richard Wood, Aviation Safety
Programs: A management handbook. Refer to section 6.2 Further Reading.
Approved by Director of Bureau of Air Safety Investigation
Version 1.0: January 1998 ig21100004.doc
4. Tailoring the BASI-INDICATE Safety Program
The BASI-INDICATE Safety Program
4.2 Suggested LEVELS of Application of the BASI-INDICATE Safety Program
Implementation Guide
4.2 Suggested LEVELS of Application of the BASIINDICATE Safety Program
4.2.1
The suggested levels of application of the BASI-INDICATE Safety Program
are:
l
l
Level 1—fewer than 20 staff:
¡
focus groups
¡
safety recording system
¡
safety officer
¡
safety information distribution
Level 2—more than 20 staff:
¡
l
the six core activities (described in paragraph 3.1.4)
Level 3—large company:
¡
the BASI-INDICATE Safety Program can be used as a safety tool
within the overall safety management strategy.
Approved by Director of Bureau of Air Safety Investigation
ig21100004.doc Version 1.0: January 1998
Chapter 4: 3 pages
Page 4-3
5
The Strengths of the
BASI-INDICATE Safety
Program
The BASI-INDICATE Safety Program
Implementation Guide
5. The Strengths of the BASI-INDICATE Safety Program
5.1 Strengths
5.1 Strengths
5.1.1
Chapter 5: 4 pages
Page 5-2
The strengths of the BASI-INDICATE Safety Program are that:
l
It has been comprehensively evaluated and tested.
l
It has been developed in cooperation with the industry.
l
It is currently operational within a number of Australian aviation
companies.
l
It is simple and cost effective to implement and maintain.
l
It encourages staff to become more actively involved in safety.
Approved by Director of Bureau of Air Safety Investigation
Version 1.0: January 1998 ig21100005.doc
5. The Strengths of the BASI-INDICATE Safety Program
5.2 Ownership of the Program
The BASI-INDICATE Safety Program
Implementation Guide
5.2 Ownership of the Program
5.2.1
The BASI-INDICATE Safety Program is owned and managed by a
company. Safety hazards are reported to BASI at the discretion of the
company. The failure or success of the program in helping a company
identify, report, record, act and monitor safety hazards depends entirely on
the commitment of the company’s management and staff.
Approved by Director of Bureau of Air Safety Investigation
ig21100005.doc Version 1.0: January 1998
Chapter 5: 4 pages
Page 5-3
The BASI-INDICATE Safety Program
Implementation Guide
5. The Strengths of the BASI-INDICATE Safety Program
5.3 Minimising the Costs of Aviation Accidents and Incidents
5.3 Minimising the Costs of Aviation Accidents and
Incidents
Chapter 5: 4 pages
Page 5-4
5.3.1
The BASI-INDICATE Safety Program is designed to minimise the risk of
accidents occurring. Therefore, if a company does not have a safety
management program, it runs a higher risk of experiencing the costs
associated with an accident.
5.3.2
The direct costs of an accident relate to the physical damage and include:
l
death or injuries to persons involved
l
aircraft and equipment damage
l
property damage
l
replacement costs.
5.3.3
One study calculated that Australian aviation accidents generated losses to
society of approximately $45 million, or an average of $138,000 per accident
(Bureau of Transport and Communication Economics, 1988).
5.3.4
Studies by the Boeing Company estimated that the indirect costs of an
accident are at least four times as much as the direct costs. Indirect costs
include:
l
the loss of business and damage to reputation
l
costs associated with legal action and damages claims
l
increased insurance premiums
l
cost of aircraft recovery and clean-up
l
loss of productivity of personnel
l
loss of public confidence.
5.3.5
These costs suggest that maintaining a proactive and effective safety program
makes economic sense.
5.3.6
The BASI-INDICATE Safety Program provides aviation companies with a
relatively simple method of improving aviation safety at little cost. It also
enables them to bring safety issues to the attention of BASI, where
appropriate.
Approved by Director of Bureau of Air Safety Investigation
Version 1.0: January 1998 ig21100005.doc
6
Further Information
The BASI-INDICATE Safety Program
Implementation Guide
6. Further Information
6.1 Further Information about the BASI-INDICATE Safety Program
6.1 Further Information about the BASI-INDICATE Safety
Program
6.1.1
To find out more information about the development and theory underlying
the program and how the program works on a daily operational basis within
an aviation company, contact:
The BASI-INDICATE Project Manager
Bureau of Air Safety Investigation
GPO Box 967
Civic Square, ACT 2608
FREECALL: 1800 020 616
Fax: (02) 6247 1290
Chapter 6: 4 pages
Page 6-2
Approved by Director of Bureau of Air Safety Investigation
Version 1.0: January 1998 ig21100006.doc
6. Further Information
6.2 Further Reading
The BASI-INDICATE Safety Program
Implementation Guide
6.2 Further Reading
6.2.1
The BASI-INDICATE Safety Program is just the starting point for
improving the standard of safety management within a company. There are a
number of resources for those companies interested in finding out further
information. Some practical texts are provided below.
l
Boeing, Safety Program Model, Boeing Commercial Airplane Group:
Seattle (1996)
l
Ferry, T.S., Safety Management Planning Manual, The Merritt
Company Santa Monica, California (1989)
l
International Civil Aviation Organisation, Accident Prevention Manual
(Doc 9422-AN/923), Montreal, Canada (1984)
l
Peterson, D., Safety Management, Goshen, New York: Aloray Inc.
(1988)
l
Wood, R.H., Aviation Safety Programs: A Management Handbook,
Jeppeson Sanderson, Englewood, Colarado (1991)
Approved by Director of Bureau of Air Safety Investigation
ig21100006.doc Version 1.0: January 1998
Chapter 6: 4 pages
Page 6-3
The BASI-INDICATE Safety Program
Implementation Guide
6. Further Information
6.3 References
6.3 References
6.3.1
Chapter 6: 4 pages
Page 6-4
For more information about the BASI-INDICATE Safety Program, refer to:
l
Bureau of Air Safety Investigation Report, An Evaluation of the BASIINDICATE Safety Program, Canberra (1997)
l
Bureau of Air Safety Investigation Report, Proactively Monitoring
Airline Safety Performance: INDICATE (Identifying Needed Defences
In the Civil Aviation Transport Environment), Canberra (1996)
l
Bureau of Transport and Communication Economics, Cost of Aviation
Accidents in Australia 1988, Canberra (1988)
l
Maurino, D.E., Reason, J., Johnson, N. and Lee, R.B., Beyond Aviation
Human Factors, Hants, England, Avebury Aviation (1995)
l
Reason, J., Human Error, Cambridge University Press, New York
(1990)
Approved by Director of Bureau of Air Safety Investigation
Version 1.0: January 1998 ig21100006.doc
A
Appendix A. Sample
of Potential Aviation
Safety Hazards
The BASI-INDICATE Safety Program
Implementation Guide
Appendix A. Sample of Potential Aviation Safety Hazards
A.1 Sample Aviation Safety Hazards
A.1 Sample Aviation Safety Hazards
The following sample list of aviation safety hazards is not intended to be
comprehensive or to represent the set of hazards which are present within a
particular company. Company staff are invited to identify and provide
relevant examples of hazards that reflect the safety concerns within their
company, including those that are not included in this list.
Flight Crew
l
Instrument approaches
l
High workload during passenger boarding
l
Poor communication between operational areas
l
Flight crew rushing flight checklists/inadequate checklists
l
Mid-air collision
l
Poor communication from Air Traffic Services
l
Flight crew stress
l
Cargo fire
l
Poor airport ground lighting
l
Failure to follow company Standard Operational Procedures (SOPs)
l
Information overload from Notice to Airmen (NOTAMs)
l
In flight turbulence
l
Unsafe ground traffic movements
l
Failure of passengers to listen/follow instructions
l
Unaccompanied baggage
l
Carriage of dangerous goods
l
Poor communication between operational areas
l
Lack of recurrent LAME training
l
Poor communication within the maintenance department
l
Time pressure
l
Poor work continuity
l
Lack of up-to-date maintenance manuals
l
Poor cross-checking of maintenance procedures
l
Long working hours/demanding shift patterns
Maintenance
Appendix A: 3 pages
Page A-2
Approved by Director of Bureau of Air Safety Investigation
Version 1.0: January 1998 ig2110000A.doc
A. Appendix A. Sample of Potential Aviation Safety Hazards
A.1 Sample Aviation Safety Hazards
The BASI-INDICATE Safety Program
Implementation Guide
Ground Operations
l
Poor passenger control on tarmac
l
Lack of emergency equipment, procedures and training
l
Lack of sufficient airport tarmac lighting
l
Damage to aircraft during towing
l
Fuel spills/runway contamination
Approved by Director of Bureau of Air Safety Investigation
ig2110000A.doc Version 1.0: January 1998
Appendix A: 3 pages
Page A-3
B
Appendix B. Sample
Confidential Safety
Report Form
The BASI-INDICATE Safety Program
Implementation Guide
Appendix B. Sample Confidential Safety Report Form
{Name of Company}
Confidential Safety Report From
This form is a confidential means of reporting any concerns you have about safety within
{name of company}. If you feel that, during the performance of your duties, you
experienced or witnessed an event that was potentially unsafe, please complete the form
below and send it to the company Operational Safety Manager, using the envelope
provided. By submitting a report, you help identify unsound practices or facilities that
may compromise aviation safety. If you have any questions regarding this reporting
system, please contact {insert name}, the company Operational Safety Manager on Tel:
{insert telephone number}.
Brief description of the hazard
Recommendations for corrective action (if any)
Date:____________
Usual position (eg, FO, LAME):_________________________
$ -----------------------------------------------------------------------------------------------------------------
Name:_______________________________(your name will be kept strictly confidential)
Tel:_________________
Postal Address:______________________________________________________________
Please provide your contact details so we can clarify the information you have
submitted. Once the Operational Safety Manager has investigated the report, the tearoff strip will be returned to you and no record of your name will be kept.
Appendix B: 2 pages
Page B-2
Approved by Director of Bureau of Air Safety Investigation
Version 1.0: January 1998 ig2110000B.doc
C
Appendix C. Sample
Output of a Focus
Group
The BASI-INDICATE Safety Program
Implementation Guide
Appendix C. Sample Output of a Focus Group
C.1 Sample Output of a Focus Group
C.1 Sample Output of a Focus Group
The table on the following page provides an example of the evaluation of the
defences associated with the hazard “Lack of emergency equipment,
procedures and training”. It is not intended to be a comprehensive list of the
identified defences nor does it necessarily represent the list of defences, and
their effectiveness, which are present within a particular company. The table
simply provides a guideline for the structure of the process and will assist the
focus group facilitator to direct discussion appropriately. The same
guidelines may be applied to any other identified hazard. In addition, staff
should be encouraged to use the same thought process when reporting a
safety hazard or incident to the Operational Safety Manager, and when
submitting confidential reporting forms.
Appendix C: 3 pages
Page C-2
Approved by Director of Bureau of Air Safety Investigation
Version 1.0: January 1998 ig2110000C.doc
Appendix C. Sample Output of a Focus Group
C.1 Sample Output of a Focus Group
The BASI-INDICATE Safety Program
Implementation Guide
Operational Group: Company Ground Staff
Hazard: Lack of emergency equipment, procedures and training
Defence
Clear Standard
Operational
Procedures
(SOPs) for staff to
follow during
emergency situations.
Effective
Reason
No.
Current SOPs
are
non-standard,
not published
and not made
available to all
ground staff.
Regular staff-safety
meetings.
No.
Communication
aids.
No.
Emergency
response training.
No.
Emergency
response
equipment.
No.
Recommendations
Company
Recommend that the ground
staff manager ensure that
emergency SOPs and/or
emergency checklists / contact
numbers are accessible to all
ground staff.
Recommendations BASI
Recommend that the ground
staff manager conduct a general
review of training requirements
for ground staff in relation to
emergency procedures and the
conduct
of aircraft evacuation drills.
Not currently
Recommend that the ground
held in a
staff manager hold informal
consistent
fortnightly safety meetings
manner.
so that staff have the
opportunity to raise safety issues
of concern to them.
Headsets are Recommend that the ground
currently not staff manager and chief pilot
used during
request the standard use of
engine starts. headsets during the engine
start period, to establish
Hand signals
better flight and ground
used by
crew communication.
ground and
flight crew
Recommend that a review
are too
be conducted on the current
restrictive
use and adequacy of hand
and not
signals available for flight
universally
and ground crew
applied.
communication.
Ground staff Recommend that the ground
are unaware
staff manager liaise the
of the correct
airport firefighting service
application
and arrange a suitable
of fire
training course.
extinguishers.
Fire
Recommend that the ground
extinguishers staff manager ensure that all
are not easily ground vehicles are equipped
accessible
with current and serviceable
and are not
fire extinguishers.
fitted to all
ground
vehicles.
Approved by Director of Bureau of Air Safety Investigation
ig2110000C.doc Version 1.0: January 1998
Recommend that BASI
contact the Federal Airports
Corporation regarding the
optimal placement of fire
extinguishers, so that they
are closer to the aircraft
loading bays.
Appendix C: 3 pages
Page C-3
D
Appendix D.
Summary of the BASIINDICATE Safety
Program
The BASI-INDICATE Safety Program
Appendix D. Summary of the BASI-INDICATE Safety Program
Implementation Guide
D.1 Identifying Needed Defences in the Civil Aviation Transport Environment
D.1 Identifying Needed Defences in the Civil Aviation
Transport Environment
The BASI-INDICATE Safety Program is a new, proactive safety
management program for aviation companies, designed to improve the way
safety hazards are addressed within a company. In the past, safety hazards
reported by company staff risked getting lost in company bureaucracy,
especially in those organisations that provided little feedback to the reporter.
This could result in safety hazards remaining unchecked, which increases the
risk of accidents occurring.
Using the BASI-INDICATE Safety Program enables companies to not only
detect and rectify possible safety hazards within their own operation, but also
to bring safety deficiencies to the attention of BASI.
The BASI-INDICATE Safety Program provides a simple, but structured,
process to ensure consistent and high-quality safety feedback is regularly
distributed to all company staff. This is achieved via the following six core
safety activities.
1.
Electing an Operational Safety Manager or officer who is available to
staff as a confidante for safety-related issues.
2.
Conducting a series of staff focus groups to proactively identify safety
hazards within the company.
3.
Establishing a Confidential Safety Reporting System.
4.
Conducting regular safety meetings that include management.
5.
Maintaining a safety information database.
6.
Ensuring that safety information is regularly distributed to all staff.
The BASI-INDICATE Safety Program has been developed in consultation
with the aviation industry. It can be tailored to the requirements of different
operators.
An eight-month trial of the program within a major Australian regional
airline revealed that it can have a positive influence on safety performance,
specifically:
Appendix D: 4 pages
Page D-2
l
improving staff confidence in how safety is managed
l
increasing staff willingness to report safety hazards and incidents
l
improving safety communication between departments and between
management and staff.
Approved by Director of Bureau of Air Safety Investigation
Version 1.0: January 1998 ig2110000D.doc
Appendix D. Summary of the BASI-INDICATE Safety Program
D.2 How Does the BASI-INDICATE Safety Program Work?
The BASI-INDICATE Safety Program
Implementation Guide
D.2 How Does the BASI-INDICATE Safety Program Work?
Within the company, the Operational Safety Manager is responsible for
running the program. Depending on the size of the company, several safety
officers may be appointed for specific operational areas.
Safety meetings are conducted regularly with the Operational Safety
Manager and managers from each operational area (technical crew, cabin
crew, maintenance, ground crew, operations and union/association groups)
within the company. At these meetings safety issues raised by staff or
management at any level are discussed.
The company installs the BASI-INDICATE Software Program on the
company computer. The program:
l
records the nature of each safety hazard
l
records any action (or lack of) taken on each hazard
l
maintains the confidentiality of the submitter
l
generates a recommendation for either:
¡
a departmental manager
¡
senior management
¡
BASI or other aviation authorities such as CASA or the FAC.
The person/organisation to whom the notice of a hazard is sent depends on
the nature of the hazard and who is best equipped to assist in rectifying an
identified problem.
The success of the BASI-INDICATE Safety Program in improving safety
hazard management depends on:
l
senior management commitment to the program
l
staff willingness to report safety hazards.
Approved by Director of Bureau of Air Safety Investigation
ig2110000D.doc Version 1.0: January 1998
Appendix D: 4 pages
Page D-3
The BASI-INDICATE Safety Program
Appendix D. Summary of the BASI-INDICATE Safety Program
Implementation Guide D.3 How Do Staff Use the BASI-INDICATE Safety Program to Report a Safety Hazard?
D.3 How Do Staff Use the BASI-INDICATE Safety Program
to Report a Safety Hazard?
The preferred method is for staff to consult with their line manager or direct
supervisor. Minor problems can usually be resolved straight away. If it is a
bigger problem, it is then the responsibility of the line manager or supervisor
to raise the problem as a discussion item at the next safety meeting, as well as
forward the problem on to the Operational Safety Manager or relevant safety
officer. The Operational Safety Manager or the safety officer enters the
hazard on the BASI-INDICATE safety information database.
The alternative method is for the person identifying the hazard to fill in a
Confidential Safety Report Form and deliver it to the company Operational
Safety Manager, who enters the hazard on the BASI-INDICATE safety
information database and raises it at the next safety meeting.
The BASI-INDICATE safety information database ensures that management
addresses all safety-related concerns and provides a response so that the
hazard can be cleared from the agenda. However, the BASI-INDICATE
Safety Program cannot ensure that every hazard is rectified to the satisfaction
of all parties because monetary and practical issues also need to be taken into
account when dealing with potential hazards. A compromise position may
need to be reached.
D.4 Strengths of the BASI-INDICATE Safety Program
The BASI-INDICATE Safety Program provides a mechanism for staff to
become involved in safety issues, and at the same time provides a framework
in which company safety performance can be assessed in a rigorous and
scientific way.
Appendix D: 4 pages
Page D-4
l
It increases communication between the aviation industry and aviation
safety authorities.
l
It has been comprehensively evaluated and tested.
l
It has been developed in cooperation with the industry.
l
It is currently operational within a number of Australian aviation companies.
l
It is simple and cost effective to implement and maintain.
l
It actively involves staff in safety management.
l
It has the potential to standardise safety management practices across the
industry.
Approved by Director of Bureau of Air Safety Investigation
Version 1.0: January 1998 ig2110000D.doc