UNITED NATIONS MISSION FOR THE REFERENDUM IN WESTERN

UNITED NATIONS MISSION FOR THE REFERENDUM IN WESTERN SAHARA AVIATION ORM IN MINURSO BRINDISI APRIL 2009

AREAS OF OPERATION

Bonifacio “BONI” Bonavente Philippines MINURSO Avn Safety Unit (a. k. a. Ramesh’ sidekick) ex-Philippine Air Force Attack Heli Pilot 4 yrs MONUC Air Operations

HOW WE WENT ABOUT IT ANY RISK IS MANAGEABLE

PRELIMINARIES Safety Management System Module 0 1 Phased approach to SMS implementation Module 8 SMS planning Module 5 5 Module Risks Module 9 SMS operation Module 6 SMS regulation Module 7 Introduction to SMS Module 3 3 Module 1 1 Module 2 2 Module Introduction to safety SMS course introduction. Basic safety concepts management Module 4 4 Module Hazards

A CONCEPT OF ACCIDENT CAUSATION Organization Workplace Managemen t decisions and organizatio nal processes Working conditions Source: James Reason Latent conditions trajectory People Errors and violations Defenses A c c i d e n t

THE ORGANIZATIONAL ACCIDENT Organizational processes Improve Monitor Latent conditions Reinforce Contain Workplace conditions Active failures Identify Defences

ORM TERMS Ø Hazard - A condition with the potential to cause personal injury or death, property damage, or mission degradation. Ø Risk - An expression of possible loss in terms of severity and probability. Ø Risk Assessment - The process of detecting hazards and assessing associated risks. Ø Operational Risk Management (ORM) - The process of dealing with risk associated with operations or activities, which includes risk assessment, risk decision making, and implementation of effective risk controls.

ORM PROCESS ØIdentify Hazards ØAssess Hazards ØMake Risk Decisions ØImplement Controls ØSupervise

ORM PRINCIPLES Ø Accept risk when benefits outweigh the cost. Ø Ø Ø Accept no unnecessary risk. Anticipate and manage risk by planning. Make risk decisions at the right level.

Ask yourself three crucial questions: Ø What can go wrong? Ø What am I going to do about it? Ø If I can’t do anything, who do I tell?

Core Values and ORM Principles 1. Accept risk when benefits outweigh the cost. Values Accountable for our actions. . . 2. Accept no unnecessary risk. ‘Work smart’ avoid shortcuts/steps that may cause injury or damage… Minimize risk taking … 3. Anticipate and manage risk by planning. Plan ahead. . . Take time to plan… Ask yourself the right questions. 4. Make risk decisions at the right level. Support the chain of command. . Know that you have choices… Do the right thing. . . right… 5.

Process of Aviation hazard Identification • Policy directive Aviation Operational Risk Management (ORM) • Through a brainstorming session with CAVO, Air Ops Officer, Tech Compliance Officer and MASO • List of Aviation Hazards applicable at MINURSO • Subjected to Matrix of Severity, Probability & Exposure Time • Refined and a Risk Level for each Hazard was derived • Each hazard at the risk level was subjected to mitigating factors • A fresh risk level was derived by matrix application & a state of applicable hazards are as projected • The recommendations could be ambitious but possible and achievable

ORM MATRIX PROBABILITY Frequent Occasional Remote Improbable Extremely improbable 5 S E V E R I T Y Catastrophic 5 4 3 2 1 25 20 15 10 5 Hazardous 4 2 16 12 8 4 Major 3 15 12 9 6 3 Minor 2 10 8 6 4 2 Negligible 1 5 4 3 2 1 RISK LEVELS

WEATHER RELATED HAZARDS

SAND STORMS Low Visibility 3 x 3= 9 Avoid flying during the Acceptable Undesirable occurrence, timely weather reports from Team Sites. Sand 2 x 2=4 accumulation Acceptable and undulation of landing strips Stop flying for the Acceptable duration of the occurrence, early airstrip clearance Engine 2 x 1=2 Avoid flying during Acceptable De-gradation Acceptable sandstorm, Precautionary measures of covering and blanketing vital parts of engine and airframe.

TORRENTIAL RAINS Low Visibility. 1 x 1 =1 Acceptable Avoid flying, flying only Acceptable as per pilot rating, if encountered not committed to landing. Use of helicopters. Landing Strip 2 x 4 = 8 Flooding, Damage to Undesirable landing strip. Stop flying, early repairs, Acceptable improvised surfacing of airstrips to allow rain water drainage. Use of helicopters Uneven wet patches 2 x 4 = 8 on landing strip Undesirable Stop flying, early repairs. Acceptable Use of helicopters. ADVECTION FOG Frequent Advection Fog Conditions. 2 x 4 =8 Undesirable Avoid flying during the Acceptable occurrence, timely weather reports from Team Sites. flying only as per pilot rating

HIGH TEMPERATURES Engine Limitations 4 x 3=12 Unacceptable Close monitoring of temperature Acceptable variance and adjusting operations schedule (summer schedule) Crew Fatigue 3 x 3 = 9 Undesirable Facilitation of accommodation, adjustments etc. Aircraft 3 x 3 = 9 Performance Undesirable Payload restrictions operations manual, schedule In-flight Turbulence Precautionary briefing to crew Acceptable and passengers, Aviation Safety Awareness briefing, strict adherence to cargo lashing. 2 x 2 = 4 Acceptable Landing & 3 x 4=12 Take-off Unacceptable conditions. comfortable Acceptable schedule as per Acceptable summer Avoid operations during out of Acceptable limit temperatures, payload restricted operations, longer landing strips. Use of Helicopters.

INFRASTRUCTURE RELATED HAZARDS

UNMANNED AIR STRIPS/ HELI LANDING SITES No two way 5 x 3 = 15 communications. Unacceptable Equip ATOs with hand held air band radios for landing clearance, ATO training, proposal for recruitment of airfield manager local staff at all unmanned air strips. Undesirable (recruitment of airfield manager) No ground 5 x 2 = 10 clearance for Unacceptable landing or takeoff. Equip ATOs with hand held air band radios for landing clearance, ATO training, proposal for recruitment of airfield manager local staff at all unmanned air strips. Undesirable (recruitment of airfield manager)

FIRE FIGHTING AND SAFETY EQUIPMENTS AT TS Inadequate 5 x 4 = 20 equipment and Unacceptable trained personnel Deployment of Unacceptable serviceable existing fire fighting equipment, ATO training on fire fighting, recruitment of qualified fire safety officer, proposal for procurement of medium duty fire/crash tenders for unmanned airstrips. , No crash, fire & 5 x 4 = 20 rescue facility Unacceptable ATO training on crash Unacceptable drills, proposal for positioning of crash emergency kits, proposal for procurement of medium duty fire/crash tenders for unmanned airstrips, ERP exercises. Liason with local authorities.

LANDING STRIP CONDITIONS Compact Soil 4 x 3 = 12 airstrip with Unacceptable frequent degradation. Regular resurfacing, Undesirable compacting, proposal for use of Marston Matting. Additional budget allocation. Additional take off 2 x 2 = 4 and landing roll Acceptable due lose surface. Additional available length Acceptable of landing strips Susceptible to tire 2 x 4 = 8 bursts. Undesirable Controlled long float touch Undesirable down landing technique. Foreign Damage ATO training, inspection Undesirable of landing strip before landing and take off. Object 3 x 4 = 12 Unacceptable

REFUELING FACILITIES FOR HELICOPTERS Fuel Contamination 2 x 5 = 10 Unacceptable Fuel pilferage 2 x 4= 8 Un desirable Fuel Coagulation 2 x 5 = 10 Unacceptable Early degradation of 4 x 3 = 12 equipment due Unacceptable inclement weather No effective fire 5 x 5 = 25 fighting capabilities Unacceptable No fuel station security 5 x 3 = 15 Unacceptable Unmanned fuel station. 5 x 2 = 10 Unacceptable Undergoing up. Acceptable gradation of fuel On completion facilities at team of the proposed sites to international up-gradation standards. Proposal for procurement of medium duty crash/fire tenders. Proposal for fencing, CCTV, security lighting etc. Periodic servicing of equipment, ATO training, refueling by trained aircrew only, crew training for refueling.

SEARCH AND RESCUE FACILITIES No dedicated 3 x 4 = 12 search and Unacceptable rescue in the eastern side of Berm No infrastructure 3 x 4 = 12 for effective Unacceptable response to accidents. No immediate 3 x 4 = 12 medical facilities Unacceptable at Team Sites. Effective ERP, regular Undesirable updating of ERP, Up gradation of infrastructure for crash emergency relief, Training of UNMOs for first aid, crash drills. Proposal for positioning of emergency crash kits at unmanned air strips.

AGEING FLEET Degradation in 2 x 2 = 4 aircraft and Acceptable equipment performance Regular monitoring of aircraft Acceptable performance for ageing factors, regular aircraft inspections. METEOROLOGICAL SERVICES No qualified 2 x 3 = 6 meteorological Undesirable services available at Team Sites. Employment of automated Acceptable weather monitoring devices. Positioning of adequate wind socks, ATO training for weather monitoring.

AIR TRAFFIC SERVICES 1. Uncontrolled 2 x 2 = 4 airspace with Acceptable only information services Effective flight following by Acceptable aviation section, strict adherence to aircraft reporting procedure, best use of area control available, 1. Insufficient Navigational aids Proposal for installation of low range portable NDB, Delineating airstrip markings and painting of threshold after laying of Marston Matting. Regular updating of Jeppesen for currently used on board GPS equipment. 3 x 3 = 9 Undesirable 1. Restricted 4 x 4 = 16 night flying Unacceptable capability and infrastructure Acceptable Only with installation of short range NDBs ATO training, crew training, Undesirable up gradation of night flying infrastructure, employment of night sun on helicopters.

MINES & UXOS Contaminated area of mines causing concern for emergency landings and reconnaissance for new landing sites. 4 x 5 = 20 Un acceptable Establishment of GIS section in mission for mapping and plotting and in coordination with Mine Action Cell mark areas of suspected mine activity, regular liaison with Moroccan Army on updating of mine activity, making these maps available to the crew for regular flying. Acceptable AVIATION SECURITY No existing infrastructure and manning to cater for aviation security at un manned airstrips and Heli- landing sites. 2 x 4 = 8 Undesirable Airstrip inspection by ATOs before and after operations, regular inspection by Technical Compliance and Aviation Safety. Undesirable (recruitment of airfield manager)

HUMAN RELATED HAZARDS

CREW FATIGUE Crew Fatigue due surroundings and high temperature 2 x 2 = 4 Acceptable Long intervals between crew rotations (Air Urga) 2 x 2 = 4 Acceptable Lack of recreation facilities. 2 x 2 = 4 Acceptable Additional Responsibility of ground clearance and assessment of meteorological conditions 2 x 3 = 6 Undesirable Preventive scheduling of flights, up gradation of recreational facilities, proposal for reduction in crew rotation period, training, motivation exercises, equipping and training ATOs for ground clearance and weather watch Acceptable MANNING Non availability of trained manpower at team sites for air operations and aviation requirement 4 x 4 = 16 Unacceptable Continuous and repetitive training for ATOs, proposal for recruitment of local Moroccan aviation qualified staff as Air Field Manager at Mahbas, Oum Drega and Asward airstrips Unacceptable

Mission Approach AVIATION ORM Implementation Task Group (ITG) formed in MINURSO on 05 Jun 08 and is headed by Chief Technical Services (CTS). Other members are: • CAVO, • MASO, • Air Operations Officer, • Technical Compliance Assistant and • ALO from Military component.

Cont…Mission Approach The ITG will carry out: • Determination of risk level for all aviation activities and all types of flights on a Risk Matrix; • Review of these risk levels at prescribed regular basis or when changes occur in mission mandate, objectives, and type of operations or assets • Update on the effects of the measures adopted in mitigation and review of the conditions for ORM

Implementation Process and Control by Air Operations • AOO to brief aircrew members of any risks inherent in the operation or mission; • AOO will follow up conditions during the mission and conduct an after mission action review to ensure that all went according to plan; • AOO will re-evaluate the plan or make adjustments as required to accommodate unforeseen issues and incorporating lessons learned for future use.

Implementation Process and Control by Contractor PIC • The Pilot-in-Command (PIC) of each aircraft shall sign the Aviation Risk Management Check List acknowledging that he was briefed, is fully prepared and capable of performing the mission. • To identify, control and reduce hazards to flight, a risk assessment must be performed before each flight by the aircrew during mission preparation. The CAVO will be directly involved and should there be undue pressure for a mission with an unacceptable risk, the CMS will be notified.

Risk Management Authority and Leadership • Aviation risk management is already a part of DPKO/ DFS standard operating procedures and defined in Chapter 3, Annex F of the DPKO/ DFS Aviation Manual published in May 2005. • The standard for risk management is leadership at the appropriate level of authority SRSG, CMS, CTS and CAVO making informed decisions to control hazards or accept risks. • The degree of risk determines the level of acceptance by the decision authority (SRSG, CMS, CTS and CAVO).

Feedback • • Aviation Risk Management Checklist Aircraft Technical Report After Mission Report Periodic Inspection Report produced by Aviation and Aviation Safety personnel • Aviation Observed Hazard Report

Application of Risk Management • CAVO will ensure that the Risk Management process is integrated into all planning phases of operations. • No unnecessary risk will be accepted • SRSG, CMS, CTS and CAVO have the authority to accept risks but also have the responsibility to protect personnel from unnecessary risk. • SRSG, CMS, CTS and CAVO must understand risks and be prepared to take risks to accomplish their mission.

Aviation ORM has been integrated into the MINURSO Aviation SOP….

Problems Encountered • Initial Apprehension – ORM already in AV Manual – What is new? – Reluctance to change • Compilation of SOP – Who to compile? – What format? – How to make it effective?

Lessons Learned • The policy directive issuance • Familiarization on SMS to Senior Management • ORM as a budget justification tool • Regular proactive measures in pursuing ORM • Adapted by other sections • Acceptance by the Mission Management

Achievements by ORM Policy • • • Refueling Infrastructure Fighting Capability at Airstrips Repair of HLS Identification Emergency Landing Sites Night Flying to Team Sites 100% Aviation Safety Awareness Well prepared ERP Adaptation of ORM process by other Sections

TS Mahbas Desert Runway Nearing Completion

ERODED FIRE EXTINGUISHER HOSES TS MAHBAS

FIRE FIGHTING CAPABILITY UPGRADE FOR THE TS

EQUIPMENT & FUEL SUSCEPTIBLE TO CONTAMINATION & DAMAGE

FUEL HOSES EMBEDDED IN HOT & COLD DESERT SAND

TS AVN FUEL EQUIPMENT BEFORE MODIFICATION

Modified Protection of Refueling Equipment in TS Awsard

ERP Stores Preparation/Inspection

“Complacency or a false sense of security should not be allowed to develop as a result of long periods without an accident or serious incident. An organization with a good safety record is not necessarily a safe organization. ” -International Civil Aviation Organization (ICAO) Accident Prevention Manual, 1984

ORM is a proven successful tool for operational use, but it has equal application to many types of activities where there is risk associated.

ORM Alternate Definition DON’T FALL PREY TO…… Occasional Risk Mismanagement

ORM in Real Life: Why They Have Safety Observers Should the nose be that close to the ground?

Yes, if someone forgot to install the gear pins. . . and someone else raised the gear handle. The air bags are going to raise the airplane.

It looks like those air bags work real good!

Hmm… maybe they work too good.

Uh oh. . . somebody forgot to use those air bags in the back. Hey! Who left that tail stand under the right elevator?

Ouch!

ORM is a process… not a program! It must become an inherent way of doing business