Safety Risk Management Training 2010-11-18 Dong Xiaoguang Quality Boeing Shanghai Proprietary
SAG 培训安排 SAG Training Agenda Safety Action Group Training and Kick off Workshop Agenda Item
Time
Objective
Materials
Why you are here
1 hour
Provide understanding of SAG purpose and mission
Draft Team Charter document
Overview of SMS and Key Elements
1 hour
Identify where SAG fits in the overall SMS structure
SMM
Overview of Risk Management
2 hours
Learn risk management theory
Aaron's PPT
Safety Risk Management Process Doc
1 hour
Understand company policy
SRM
Review Hazard List
1 hour
Familiarity with data sources
Hazard List Excel file
HIDRA
2 hours
Use of tools
HIDRA software
MET
1 hour
Key Data source
MET system
Table top Risk Analyis
1 hour
Classroom practice
MET Detail reports and data collection sheet
Field Surveys
2 hours
Practical experience
MET Detail reports and data collection sheet
RCCA Overview
2 hours
Assuring effectiveness
RCCA PPT
Boeing Shanghai Proprietary
SAG 特许执照 Safety Action Group Charter Team Name Safety Action Group
Program Name Safety Management System
Safety Leader Sun Xianghua
Sponsor Bernard Hensey
Facilitators Chen Sheng, Dong Xiaoguang
Leader Stephen Yan
Mission Statement: Identify hazards through the review of historical data and task analysis. Determine levels of risks and prioritize tasks that are above the permissible risk thresholds for root cause identification and corrective action planning. Develop effective metrics to measure improvement. Report to the BSH Quality and Safety Committee on progress and key issues. Deliverables Hazard List Risk Analyses Corrective Action Plans Metrics Scope & Boundaries Initially, focus efforts on airplane maintenance activities; identify risks associated with safety of people, property and airplanes. After process has matured and initial maintenance issues have been addressed, determine risks with other aspects of the business including Facilities, Supply Chain and other non airplane maintenance activities. Duration / Commitment 1.Initially team training and team formation – 16 hours 2.Weekly meetings – 1 to 2 hours/week 3.Task analyses, hazard identification, risk assessment, risk management.- 4 hours/week 4.One year assignment Boeing Shanghai Proprietary
Tier 1 SMS Deployment Project Plate Project:
Sponsors: Bernard Hensey Xianghua Sun
Deploy Boeing Shanghai Aviation Services’ Safety Management System (SMS) Objective:
•Establish Safety Management System that satisfies CAAC, FAA and EU requirements •Be an industry leader in SMS •Exceed CAAC expectations •Harmonize BSH SMS with Boeing Fleet Services
9.1
9.30
SMM drafted
SMM internal approval
10.15 1、HIDRA development finished 2、Process Doc. Developed
Major Deliverables: • SMS Documentation set up • Safety Action Group Established • Risk Management Tools Established • Training and Promotion Program Created • Risk Analyses completed and actions initiated • SMS Program Audit • CAAC MOC Renewed
10.30
11.30
1、Establish SAG Team 2、Start Hazard ID
Overall Status / Accomplishments: SMM in process of integration with MMM. Project plates created for Tier 2 items Hazard ID and Risk Analysis process has been internally reviewed and undergoing comment disposition HIDRA customized SAG set up SMM Integration into MMM
Updated: 11/05/10 Project Status: G
Y
Responsible: Lead: Stephen Yan SME: Randy Bentley Support Members: Dong Xiaoguang (QA) Zhu Jie (HM) Chen Sheng (QA) Li Zhaoben (EHS)
12.31
Develop Training Plan
2011
Integrate Safety Audits with Quality Audit Process
Percent Complete: 40% Project ECD Q1-2011
1.21 SMS Application to CAAC
3.21 CAAC MOC Renew
Next Steps: • • • • •
Identify SAG members and charter the team Identify procedural gaps and update as necessary Develop detailed training and promotion plan HiDRA Customization Risk Analysis and Evaluation
Risks: Conflict with the production
Help Needed:
1 Boeing Shanghai Proprietary
Tier 2 SMS Deployment Project Plate
Safety Management Manual Project Deliverable: A Safety Management Manual that is integrated into the Maintenance Management Manual that fully addresses the requirements of CAAC, FAA and EASA Scope: Gap Analysis, Requirements of AC-145-15, FAA & EASA, SMM Bilingual Draft, Integration of draft into MMM, Internal Coordination, Informal Discussions with CAAC on contents and format, Final Approval
09.15
09.30
10.10
GAP Analysis
SMM drafted
Discuss with CAAC
Status: • • • •
Safety management manual has been drafted SMM internal review was conducted SMM has been combined with MMM. Draft is in informal CAAC review.
Major Tasks: • Gap analysis (Requirements of AC-14515, FAA&EASA) • SMM draft • Discuss with CAAC • Integrate into MMM • Internal coordination, review and approval • Submit to CAAC for approval
10.19
11.15
11.30
SMM initial internal review
Integrate into MMM
SMM internal approval
Updated: 11/4/2010
Responsible Person: Lead: Stephen Yan
Project Status:
Support Dong Xiaoguang Chen Sheng Liu Xudong
G
Y
Percent Complete: 70%
SMS Elements:
Project ECD 1/15/2011
12.15 Informal CAAC Review
2011
1.15
Submit to CAAC for approval
Next Steps: • Collect any CAAC suggestions • Complete the integration of SMM into MMM • Final Internal Review and Approval •
Risks/Concerns: • Challenges of being the pilot company for implementation • Efficient integration of SMM into MMM
Help Needed: None Boeing Shanghai Proprietary
1
Tier 2 SMS Deployment Project Plate
Safety/Quality Audit Integration Project Deliverable: Integrate Safety Audit Process into the Quality Audit Process
Scope: Procedures, checklists, protocols, corrective action tracking, classification, staffing, scheduling, effectiveness reviews, closure, visibility, trend analysis
11.8 Kick off integration project
Status: • Project not yet started
11.30 Draft combined procedure
Responsible Person: Lead – Randy Bentley Support -
Major Tasks:
Updated: 11/4/10 Project Status: W
12.15
12.31
Audit forms and report format
Audit Schedule
W
SMS Elements:
• Integrate Safety Audit requirements into Quality audit procedure • Combine Safety and Quality audit protocols • Combine safety audit resources (auditors) from Quality, Aviation Safety and EHS • Establish audit forms and reports that work for both Safety and Quality • Create Training Plan and Materials • Establish Combined Quality and Safety annual audit schedules
• 3.1.2 Internal Audits by Operational Departments
Percent Complete: 2% Project ECD 02/01/2011
2011
1.05 Audit Protocols
1.15 Implement Training
Next Steps: • Draft combined safety and quality audit procedure
Risks/Concerns: • Competing resources Help Needed:
1 Boeing Shanghai Proprietary
Tier 2 SMS Deployment Project Plate
Safety Risk Management Process Responsible Person:
Safety Risk Management (SRM) including Hazard Identification and Risk Assessment (HIDRA). SRM(HIDRA) Process procedure will describe how to conduct risk analyses, evaluations and controls.
Lead – Dong Xiaoguang Support – Randall Bentley – Huang Yufang – Stephen Yan
Scope: • Documents – SRM Process procedure • Software – HIDRA Tool • Coordination with SAG (Safety Action Group) and STP (Safety Training Program)
SRM Process flow chart
10.1
SRM Process procedure draft
10.20 HIDRA Tool purchase approval
10.31 HIDRA Tool customization
Major Tasks: • SRM Process flow • SRM Process procedure draft • Support SRM Process for SAG Training • HIDRA Tool purchase • HIDRA Tool customization • HIDRA Tool user guide • Support HIDRA Tool training
SRM Process procedure review
SRM Process procedure and flow chart verification
11.15 HIDRA Tool HIDRA Tool purchase verification
SRM Process flow chart – Completed SRM Process procedure outline – Completed SRM Process procedure draft – 100% SRM Process procedure review – 70% complete HIDRA Tool purchase – PO is in process HIDRA Tool customization – 70% HIDRA Tool verification – To be completed by Nov 15th HIDRA Tool user guide – TBD Coordination of HIDRA Tool training – In process, with Chen Sheng
SRM Process procedure approval
11.30
Project Status: G
Y
SMS Elements: Component 2.0 Safety Risk Management (SRM) •2.1 Hazard Identification and Analysis Process
Percent Complete: 50% Project ECD 12/31/2010
•2.2 Risk Assessment and Control Process
Coordinate SRM Process for SAG Training
12.22
HIDRA Tool user guide
Status: • • • • • • • • •
Updated: Nov. 4th
Project Deliverable:
12.31
2011
1.15
Coordinate HIDRA Tool training
Next Steps: • • • •
SRM Process procedure review SRM Process procedure and flow chart verification HIDRA Tool Customization HIDRA Tool user guide development
Risks/Concerns: • Hazard List prepared before the SRM Process verification • HIDRA Tool customization finished before Randy’s departure
Help Needed: • Huang Yufang’s continuous help for translation and review of documents
1 Boeing Shanghai Proprietary
Tier 2 SMS Deployment Project Plate
Safety Action Group Project:
Deploy the SAG/Analysis part of Boeing Shanghai Aviation Services’ Safety Management System (SMS) Scope: Member criteria, team member selection, team charter, team training, operating rhythm, forms, documentation, risk metrics, LT visibility
Major task : • SAG Launch • All SAG members Training • The Hazard analysis measures develop to a satisfactory level.
Responsibility: Lead – Chen Sheng SME – Aaron Dong
Updated: 11/04/10 Project Status: G
Y
SMS Element: 1.3 Key Safety Personnel 2.1 Hazard ID & Analysis 2.2 Risk Assess & Control 3.1.7 Analysis of Data
Percent Complete: 30% Project ECD Nov.-2011
11.8
11.12
SAG member Criteria & Selection
SAG Kickoff
Create Hazard analysis forms
11.15
11.19 SAG member training
11.30
12.10
SAG member Start HIDRA Activity RCCA training
Create Safety audit checklist
Status :
Next Steps:
• • • • •
• • • •
SMS SAG select criteria be in draft Hazard analysis form and register list be in draft(80%) Training material of SAG be in prepared (50%) Individual Safety Audit procedure(80%) Safety Audit checklist(90%)
12.17
The SAG process Running smoothly and wait for internal audit
12.26
12.31 All the base requirement available and effective including Website, Tool, Skill
Create Training courseware Establish MET/HIDRA access Delivery the Safety Audit checklist as require. Establish WEB page.
Risk/Concerns: • Selection of the right people for SAG membership
Help Needed: • MS Office support for creation of hazard identification data collection 1 form Boeing Shanghai Proprietary
Tier 2 SMS Deployment Project Plate
Safety Training Program Project Deliverable: Safety Training Program is the core of the SMS, and it contains all the training refer to the safety in company. It is the basis of company safety training. Scope: • Safety Training program • Safety Training Curriculum • Safety Training Courseware development • PTP (Post Training Program) • Enterprise Training Management System • Instructors
9.20 Begin Safety Training Program
10.20 Safety Training program draft
Randall Bentley Xin Youqing (YC)
Major Tasks: • Safety Training program • Safety Training Curriculum • Safety Training Courseware • Safety Training • Integrate the Safety Training in to PTP (Post Training Program)
11.01
11.09
Safety Training program draft translated into English
Safety Training program review in the SMS Team
11.30
Updated: 11/04/10 Project Status: G
Y
SMS Elements: •Component 4.0 Safety Promotion •Element 4.1 Competencies and Training •Process 4.1.2 Training
Percent Complete: 40% Project ECD 11/01/2010
12.02
1.Safety Training program internal approved 2. Safety Training Courseware completed
Status: • • • • • • • •
Responsible Person: Lead –Liu Xudong Support –Stephen Yan
Safety Training
12.20
2011
Safety Training Curriculum completed
01.10 Safety Training Program Integrate with PTP
Next Steps:
Safety Training program draft --- 100% Safety Training program draft translated into English --- 100% Safety Training program review in the SMS Team --- 100% Safety Training program internal approved --- 0% Safety Training Courseware develop --- 0% Safety Training Curriculum develop --- 20% Safety Training --- 0% Integrate Safety Training Program into PTP (Post Training Program) --- 0%
• • • • •
Safety Training program internal approved Safety Training Courseware develop Safety Training Safety Training Curriculum develop Integrate Safety Training Program into PTP
Risks/Concerns: • Safety Training Program Integrate with PTP should be coordinated with the PTP. • Safety Training Courseware Development resources. • Safety Training will take with the Orientation training.
Help Needed: YC’s continuous help for integrating Safety Training with PTP. Boeing Shanghai Proprietary
Tier 2 SMS Deployment Project Plate
Safety Communication Project Deliverable: Safety Promotion makes Safety Management System better implemented and communicated.
Scope:
Updated: Nov. 5th
Responsible Person: Lead – TBD Support – TBD
Project Status:
Major Tasks:
W
Y
SMS Elements: • Safety Culture • Safety Publicity • Safety Communication • Improvement of existing systems – e.g. Discipline • Safety Committee Meeting Improvement – Agenda and Matrix
10.1
10.30 Safety Culture – Description in SMM/MMM
11.15 Safety Publicity
• • • • • •
11.30 Safety Communication
• Element 4.1 Competencies and Training Process 4.1.1 Personal Expectations (Competence) • Element 4.2 Communication and Awareness
2011
12.15 System Meeting Improvement
Status: • • • • • •
Component 4.0 Safety Promotion
Safety Culture Safety Publicity Safety Communication Safety Process Improvement Disciplinary Safety Promotion Review
Safety Focal System
Disciplinary System Reviewing
Percent Complete: UNK
1.15 Safety Promotion Review
Project ECD 1/30/2011
1.30 Communication with employees
Next Steps:
Safety Culture – Description in SMM/MMM – 100% completed Safety Publicity – Initial work started Safety Communication – Initial work started Safety Meeting Process Improvement - Not yet started Safety Focal System – Not yet started Disciplinary System Reviewing – Not yet started
• •
Safety Publicity – Work site Safety Communication – Intranet
Risks/Concerns: • Enough Time
Help Needed: • Identification of the Responsible person and budget Boeing Shanghai Proprietary
1
为什么要进行安全管理？ Why Safety Management? 事件数量
1
灾难事故 Catastrophe
29
事故征候 Major Accident 事件 Minor Incident
300
差错 Errors
10,000
Boeing Shanghai Proprietary
为什么要建立安全管理体系 ？ Why SMS?
为什么要建立安全管理体系 Why SMS?
维修单位建立安全管理体系是局方要求 SMS is regulatory requirement
建立安全管理体系也是上海波音自身的需要 SMS is also a Boeing Shanghai need
Boeing Shanghai Proprietary
为什么要建立安全管理体系 ？ Why SMS? SMS 系统的审定是对现有 CAAC 维修许可证的补充合格 审定，关系到维修许可证的有效性。也是批准新维修能 力的前提条件。 The acceptance of SMS by CAAC impacts the validity of our Maintenance Organization Certificate and the approval of new capabilities.
安全事件、维修事故、维修事故征候可能导致严重的后果 Safety events, incidents and accidents can be costly. Injury to people; damage to equipment; insurance; Reputation, lose of potential customer; Safety record
Boeing Shanghai Proprietary
为什么要建立安全管理体系 ？ Why SMS? 2009 年 10 月 12 日，民航总局飞标司下发了局发 明电（ 2009 ） 3353 号文，《关于下发〈维修单位的安 全管理体系〉咨询通告以及有关要求的通知》。 On Oct 12th, 2009, the Flight Standard Division of CAAC sent telecom document (2009)3353: Notification about Releasing the AC of “Safety Management System in Maintenance Corporations” and related requirements.
通知要求：各维修单位需在三年的时间内建立 SMS 系统，局方将于 2012 年 7 月开始实施 CCAR145 维修许可补充审定。 It is required that maintenance corporations must establish SMS within future 3 years and the bureau will conduct the supplement examination and approval for CCAR 145 from July, 2012. Boeing Shanghai Proprietary
什么是安全管理体系？ What is SMS? 安全管理体系 – 正式的、自上而下的、有条理的管理安全 风险的做法。其包括安全管理的系统的程序、措施和 政策 。 SMS – The formal, top-down business-like approach to managing safety risks. It includes systematic processes, practices, and policies for the management of safety. 安全管理体系 提供了一种系统的方法管理安全，变被动反 应为主动管理，最终实现预防性管理。 SMS provides a systematic approach to actively manage safety and ultimately achieve preventive management. Boeing Shanghai Proprietary
什么是安全管理体系？ What is SMS?
安全管理体系组成部分 Components of SMS:
安全政策与目标 Safety Policies and Objectives 安全风险管理 Safety Risk Management 安全保证 Safety Assurance 安全促进 Safety Promotion
Boeing Shanghai Proprietary
什么是安全风险管理？ What is SMS? 安全风险管理 Safety Risk Management
安全管理体系的核心部分 Core of the SMS
系统与工作分析 System and Task Analysis
危险源识别 Hazard Identification
风险分析 Risk Analysis
风险评价 Risk Assessment
风险控制 Risk Control
Boeing Shanghai Proprietary
什么是安全风险管理？ What is SMS?
使公司的危险源能得到全面、充分的识别并对风险进 行科学的合理的分析和评价，进而确定风险的可接受 度，制定风险控制措施，从而将风险降至并保持在公 司可接受的水平或其以下。
Make hazards can be identified fully and adequately with risk scientifically and reasonably analyzed and assessed by to determine the risk acceptability, develop risk controls and keep the risk to the assure that risks to the company are properly managed acceptable level in the company.
Boeing Shanghai Proprietary
什么是危险源？ What is HAZARD?
危险源： 有可能导致人员受到伤害、疾病或死亡，或 者系统、设备或财产遭破坏或受损，或者环境受到破坏 的任何现有的或潜在的状况。
结果 ： 导致人员伤害和财产损失的状况。
在推工作梯的过程中，工作梯是危险源之一
工作梯与飞机发生碰撞是结果
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什么是危险源？ What is HAZARD? 实例 Example: 器材运输过程中没有妥善保护
维修人员超出其授权范围工作 缺乏沟通
照明问题 照明
计量工具的精度不够
未有效控 制适航性 资料 通风不好
器材没有标识 未进行工时偏差分析
未做工作就签署工作单和放行
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器材没有 妥善保护
什么是风险？ What is RISK? 风险 – 综合考虑严重性和可能性，而对某一 危险源可能导致危险或严重后果的一种衡量 。 Risk – The composite of predicted severity (how bad) and likelihood of the potential effect of a hazard in its worst credible system state. 风险的可能性 Probability 风险的严重性 Severity
Boeing Shanghai Proprietary
评价标准 – 可能性 Assessment Criteria - Probability 可能性 定性描述
内容
等级 / 分值
频繁的
可能发生很多次 ( 已经频繁地出现过 )
5
经常的
可能不断发生 ( 经常发生过 )
4
偶尔的
不太可能的，但有可能发生 ( 很少发生过 )
3
极少的
几乎不可能发生 ( 未听说发生过 )
2
难以想像该事件会发生
1
不太可能的
Probability of occurrence Qualitative Description Frequent Occasional
Content and Meaning Likely to occur many times (has occurred frequently) Likely to occur some times (has occurred infrequently)
Level /Value 5 4
Remote
Unlikely, but possible to occur (has occurred rarely)
3
Improbable
Very unlikely to occur (not known to have occurred)
2
Extremely Improbable
Almost inconceivable that the event will occur
1
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评价标准 – 可能性 Assessment Criteria - Probability
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评价标准 – 严重性 Assessment Criteria - Severity 严重度 定性描述 灾难性的
内容 •设备不可修复地损坏； •致人员死亡或终身残疾。
等级 5
•安全裕度大大降低，身体上的压力或工作负荷使操作人员不能依靠自身的能力
重大的
准确或完全执行其任务； •致多个人员受到严重伤害或局部残疾； •主要设备严重损坏。
4
•安全裕度显著下降，由于工作负荷增加或工作条件影响，工作人员效率下降，
严重的
且应对不利工作条件的能力下降； •严重维修差错，严重不安全事件； •操作 / 运行受到影响或生产率降低，致人员受伤，需损失工时； •对客户、合同商影响较大，公司形象受损。 •启动应急程序 / 预案。
3
轻微的
•运行限制 •一般维修差错，一般不安全事件。 •对外界（社会 / 公众）有较小影响，公司形象受到关注； •致人员受伤，需进行医学治疗。
2
•安全信息，几乎没有影响； •致人员轻微受伤，需急救处理。
1
可忽略的
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评价标准 – 严重性 Assessment Criteria - Severity Severity Qualitative Description Catastrophic
Level /Value
Contents/Meaning •Irreparable and irreversible damage to equipments; •Death or permanent disability to person. •A
Hazardous
large reduction in safety margin, physical distress and workload such that the operator cannot be relied upon to perform their task accurately or completely; •Major injury or partly disability to several persons ; •Serious damages to major equipments.
5
•A
Major
Minor
Negligible
significant reduction in safety margin ,a reduction in the ability of the operators to cope with adverse operating conditions as a result of increase in workload, or as a result of conditions impairing their efficiency; •Serious maintenance errors and unsafe events; •Operating limited and impact on operation or production efficiency reduce, Man-hour loss caused by injury ; •Big impact to customers, contractors and damage of company’s imagine; •Use of emergency response procedure/plan
4
•Operating limitations; •General Maintenance Errors and unsafe events; •Less influence to external environment( including
imagine concern; •Injury to persons required medical treatment. •Safety information, little •Slight wound to person,
; which need first aid.
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society/the public), company
3
2
1
评价标准 – 严重性 Assessment Criteria - Severity
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风险等级 Risk Level 严重 性 可能性
1
2
3
4
5
5
5
10
15
20
25
4
4
8
12
16
20
3
3
6
9
12
15
2
2
4
6
8
10
1
1
2
3
4
5
Boeing Shanghai Proprietary
风险等级 Risk Level 风险等 级 一级
等级 描述 低风险 中等风险
二级
风险区域 （风险值）
评估标准 描述
绿色区域 （1～3）
可接受
黄色区域 （ 4 ～ 12 ）
三级
预警
相关部门不需采取进一步行动。
绿色
缓解后可 接受
1. 在部门经理组织采取控制措施进行全 面管理后运行。 2. 相关部门对控制措施的执行情况进行 持续监控。
黄色 预警
不可接受
1. 停止运行，包括停止新的系统设计和现 有系统的更改；停止新的和更改后 的作业或程序。 2. 重新评估，安全经理 / 责任经理必须采 取进一步控制措施来消除相关危险 源或控制可能导致更大风险的因素 。
高风险 橙色区域 （ 15 ～ 25 ）
后续行动
Boeing Shanghai Proprietary
红色 / 橙 色预 警
风险等级 Risk Level Risk Lev el
Description
Level 1
Low Risk
Level 2
Level 3
Moderate Risk
High Risk
Risk Area (Score)
Criteria Description
Green area （ 1～ 3）
Acceptable
Yellow area （ 4 ～ 12 ）
Orange area （ 15 ～ 25 ）
Follow-up
Warning
No further action required to be taken by related department
Green
Acceptable with mitigation
1. Operation should be ongoing after department manager lead and take the controls; 2. Related department shall continuously monitor the implementation of the controls measure.
Yellow Alert
Unacceptable
1. Suspend the process including design of new system or procedure and change to current system or procedure; 2. Re-assessment and further control shall be taken to mitigate hazards or control factors potentially causing higher risk by Safety Manager or Accountable Manager.
Red /Yellow Alert
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安全风险管理流程 What Is SRMP?
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系统与工作分析 System and Task Analysis a
人员（资格、监督管理、人为因素、个人防护等） Staff (such as qualifications, supervision and management, human factors, personal protection, etc.)
b
技术文件（如各种手册、操作程序、技术标准的签署、执行等） Technical Documents (such as sign and implementation of manuals, procedures, technical standards)
c
信息传递 Communication
d
工具设备（管理、使用、计量、校验、安全防护等） Tools and Equipments (such as management, usage, measuring, calibration, safety guarding, etc.)
e
航材等器材（验收、订货、运输、存储等） Aviation Materials (such as check and acceptance, ordering, transportation, storage, etc.)
f
系统硬件（如飞机、发动机、特种车辆等） System Hardware (such as aircraft, engine, special vehicle, etc.)
g
系统软件（如航材管理系统、计划流程等） System Software (such as Aviation Management System, Planning process, etc.)
h
授权管理 Authorization Management
i
适航管理 Airworthiness Management
j
质量 / 安全审核 Quality/Safety Audit
k
客户管理 Customer Management
l
供应商管理 Supplier Management
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系统与工作分析 System and Task Analysis m
承包商管理 Contractor Management
n
档案管理 Documentation Management
o
技术资料管理 Technical Data Management
p
质量检查 Quality Inspection
q
与管理机构沟通 Communication with Authority
r
外界环境（社会、公众） External Environment (such as Politics, Public Opinion, etc.) 运行环境（各系统的系统功能或各系统中各岗位的活动及为系统运行和使用提供指南的有关程序 等） Operation Environment (such as system functions and activities, operation procedures etc.)
s
t
维修环境 Maintenance Environment
u
外委和购买的产品和服务 Product and Service purchased or outsourced
v
公司与航空维修系统中的其他组织（如机场、相邻单位等）间的相互作用及系统间的相互影响 Interaction between Boeing Shanghai and other organizations in aviation maintenance system
w
现有的控制措施 Current Controls
x
以上各项的相互影响
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系统与工作分析 System and Task Analysis 步骤 Steps
收集信息（包括能够说明系统的各种手册、程序及不安全事件等信息。 ） Information Collection
记录管理（例如，在 MET 系统内创建新项目进行跟踪管理。） Records Management
形成清单（例如，由 MET 数据库导出清单或人工统计危险源识别清单） Forming Inventory
判别分类（如果没有同类安全信息，则对其进行分类并录入 HIDRA 。） Category of Information
工作分析 Task Analysis;
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系统与工作分析 System and Task Analysis
工作分析 Task Analysis –
分解子过程（将生产 / 管理过程 / 活动分解为二级或更细子过程 ，直至可以清晰地将每个单元独立出来。）； Breakdown of sub-processes
–
找出子过程的单元工作 / 活动； Sub-process unit of tasks/activities;
–
找出该工作 / 活动的工作场所条件； Environment conditions of each unit ;
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找出影响该工作 / 活动的其他因素； Other factors affecting the task/activities;
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得出系统流程（包括子系统的流程）； Draw system process & sub-process flow chart
–
分析易错环节（包括各工作流程中的关键环境、困难环节）。 Boeing Shanghai Proprietary
危险源识别 Hazard Identification 步骤 Steps
危险源识别：从工作 / 活动及其环境 / 条件中识别危险源； Hazard identification;
危险源分析： Hazard Analysis;
描述危险源； Describe the hazard;
识别构成要素； Identify key elements;
分析可能后果。 Analyze the possible consequences.
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危险源识别 Hazard Identification
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危险源识别 Hazard Identification 方法 Methods
“5 Whys” 法、“鱼骨图”法 ;
对工卡进行梳理、逐步分析；
以对象（流程、部门、岗位、工作场所等）为主线进行梳理； 层次分析法对子因素和根原因进行识别；
公司作业安全分析（ JSA ）、各类检查单和审核单、 MEDA 调 查表进行分析识别。
“5 Whys” Analysis, Fishbone Analysis, Fault Tree Analysis
Analyzing A/C Task Cards
Take processes, departments, posts, work sites for Analytic Hierarchy Process (APH) Analysis.
Job Safety Analysis (JSA), checklists and protocols, MEDA
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危险源识别 Hazard Identification
原则 Principle
尽量采用定量分析。 Do analysis as quantitatively as possible.
进行根原因分析。 Conduct Root Cause Analysis.
分析有害后果。 Analyze harmful consequences. Harmful consequences
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风险分析 Risk Analysis
可能性的确定 Determination of Probability
严重性的确定 Determination of Severity
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风险评估 Risk Evaluation
风险值的计算 R = P x S Risk score: R = P x S
现有控制措施的风险值是多少？ How much is the current?
根本原因分析。 Root Cause Analysis. – 问题描述 Problem Definition – 收集数据或证据 Gather Data/Evidence – 识别根原因 Identify the Root Cause associated with the defined problem 可能造成的有害后果分析。 Analysis of the potential adverse consequence
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风险评估 Risk Evaluation 步骤 Steps
采取现有控制措施后的风险是多少？ What’s the current risk level?
该风险是否可接受？ Is the risk acceptable?
该风险是否可消除？ Is the risk eliminable?
该风险是否可缓解？ Is the risk mitigable?
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风险控制 Risk Control 步骤 Steps
发出预警 Early Warning
风险控制措施的制定 Risk Control Development
风险控制措施的预评价 Pre-evaluation of Risk Controls
风险控制措施的实施 Implementation of Risk Controls
风险控制措施的再评价 Re-evaluation of Risk Controls Boeing Shanghai Proprietary
风险控制 Risk Control 原则 Principles - Hierarchy of Controls
根除原则 Elimination
替代原则 Substitution:
工程措施原则 Engineering Control
行政控制原则 Administration
人事措施原则 Personnel Measure
个人防护用品原则 Personal Protective Equipment (PPE)
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示例 Examples
风 险事 件 R isk
Slide during Engine Run Test
发 动 机 试 车 时 发 生 意 外 滑 动
严重度 Severity
因素 Factors
权重 Weight
可忽略的 Negligible
轻微的 Minor
严重的 Major
重大的 Hazardous
灾难性的 Catastrophic
可忽略的 Negligible
人员伤害 People Injury
0.35
0
0.125
0.125
0.125
0.625
0.35
设备损害 equipment Damage
0.30
0
0
0.125
0.625
0.25
0.30
社会影响 Society Influence
0.19
0
0.125
0.125
0.375
0.375
0.19
运营影响 Operation Impact
0.16
0
0.125
0.375
0.5
0
0.16
Boeing Shanghai Proprietary
发 动 机 试 车 时 发 生 意 外 滑 动
风 险 事 因素 件 Factor R s i s k
人 People
机 Machin e
管 Manag e m en t
环
示例 权重 Weight
子因素 Sub-factor
可能性 Probability 基本不可能 Extremely Improbabl e
Examples 权重
不太可能的 Improbable
极少 Remot e
偶尔 Occasio nal
频繁 Frequ e nt
Weight
0.3
违反标准操作程序 Violation of Working Procedure
0.4
0
0.125
0.375
0.5
0
人员技能不足 Lack of Skill
0.2
0.125
0.375
0.5
0
0
人员心理生理状况较差 Poor Mental or Physical Status
0.4
0
0.375
0.25
0.375
0
工具设备存在缺陷 Tool/Equipment Defect
0.6
0.125
0.125
0.25
0.5
0
飞机系统存在故障 Failure of System
0.4
0.375
0.375
0.25
0
0
手册、程序 Manual/Procedure
0.6
0
0.375
0.125
0.25
0.25
培训 Training
0.2
0
0.25
0.25
0.5
0
人员管理 Personnel Management
0.2
0.375
0.5
0.125
0
0
0.3
0.25
自然环境
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提问 Q&A
Questions??
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根原因纠正措施 Root Cause Corrective Action
Project Title Here Corrective Action Plan
Date Here
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Team Name
Organization
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Containment
xxx
xxx
xxx
xxx
xxx
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Problem Statement
ď Ž
xxx
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5-Why Analysis 1st Why xxx
2nd Why xxx
Problem Statement
3rd Why
4th Why
5th Why
xxx
xxx
xxx
xxx
xxx
xxx
xxx
xxx
xxx
xxx
xxx
xxx
xxx
xxx
xxx
Boeing Shanghai Proprietary
5-Why Analysis 1st Why xxx
2nd Why xxx
Problem Statement
3rd Why
4th Why
5th Why
xxx
xxx
xxx
xxx
xxx
xxx
xxx
xxx
xxx
xxx
xxx
xxx
xxx
x
xxx
xxx
Boeing Shanghai Proprietary
Corrective Action Plan ď Ž
Cause - I
Action
Responsible
Assign Dt.
Comp. Dt
Deliverable
xxx
xxx
xxx
xxx
xxx
Boeing Shanghai Proprietary
Comments
Corrective Action Plan ď Ž
Cause - II
Action
Responsible
Assign Dt.
Comp. Dt
Deliverable
xxx
xxx
xxx
xxx
xxx
Boeing Shanghai Proprietary
Comments
CA Effectiveness ď Ž
Implement CAP (CAP Milestone)
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Any Questions?
Any Questions?
Boeing Shanghai Proprietary