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Transcript of Module 4A: Hazard Identification & Risk Mitigation Worksheet · 2017-03-15 · Risk Mitigation >...
10/01/2017
1
Copyright © 2015 CAAS. No part of it may be used, circulated, quoted, or reproduced for distribution outside CAAS without prior written permission. Every care has been taken to ensure that the
information contained here is accurate. Nonetheless, CAAS does not warrant the currency, accuracy or completeness of the information contained in this document, nor does CAAS accept liability
for loss or damage including without limitation, indirect or consequential loss or damage, or any loss or damage whatsoever arising from reliance on the information contained in this presentation.
Module 4A:
Hazard Identification & Risk Mitigation
Worksheet
Copyright © 2015 Civil Aviation Authority of Singapore. All rights reserved.
Intermediate Objectives
2
2.1 SRM Strategy
2.2 Purpose of HIRM Worksheet
2.3 HIRM Terminology & Definitions
2.4 Customize HIRM Tool & SOP
2.5 Create Master Hazards Register
2.6 Prioritize Hazards for risk mitigation
2.7 Activate risk mitigation for selected Hazards
2.8 Project Unsafe Event/ Ultimate Consequence
2.9 Evaluate Defenses & Risk Index
2.10 Check Defenses to Risk Index Correlation
2.11 SRM Report
10/01/2017
2
Copyright © 2015 Civil Aviation Authority of Singapore. All rights reserved.
2.1 Safety Risk Mitigation - Strategy
�Know your operational SRM context within the aviation system -
3
Component MRO
Engine
MRO
Hangar
MRO
Airline
OPS
AIS
AMO
ATO
ANSPDMO
ATM
Engine
Aircraft
C UE H
C UE H
SAR-FF
AGA
CNS
Ground Control
Ground services
C UE H Comp
UE
C UE H
H
C UE HLine
Maint
H
UE
H
C UE HHangar
MaintC UE H
HC
Cargo /
DG handling
C UE HC UE HEngine
Maint
C
Fuel Suppliers
UE HCUE HComp
Maint
H UE
C UE
C UE
UE
C
C
H UC UEC HH UE C
H UE H
C UE
Define H>US>C in
your own
operational
context - within
the aviation
system
C
Copyright © 2015 Civil Aviation Authority of Singapore. All rights reserved. 4
OPS
AIS
AM O
ATO
ANSPDM O
ATM
Engine
Aircraft
C UE H
C UE H
SAR-FF
AGA
CNS
Ground Control
Ground services
C UE H Comp
UE
C UE H
H
C UE HLine
Maint
H
UE
H
C UE HHangar
MaintC UE H
HC
Cargo /
DG handling
C UE HC UE HEngine
Maint
C
Fuel Suppliers
UE HCUE HComp
Maint
H UE
C UE
C UE
UE
C
C
H UC UEC HH UE C
H UE H
C UE
Define H>US>C in
your own
operational
context - within
the aviation
system
C
>>> Define H>TE>C (sht 11A)
10/01/2017
3
Copyright © 2015 Civil Aviation Authority of Singapore. All rights reserved.
Component MRO
Engine MRO
Hangar MRO
Airline
5
>>> Define H>TE>C (sht 11A)
Copyright © 2015 Civil Aviation Authority of Singapore. All rights reserved.
� Three approaches to define your specific H>TE>UC threads
1. Hazard Approach -
6
SRA Table - Hazard Approach Individual SRM Tasks
H TE UC Task #
UC-1 1
UC-2 2
Nil UC-3 3
UC-4 4
UC-5 5
1. HAZARD (H) Approach
Thread
H-1
TE-1
TE-2
UC-5
H-1
TE-2
TE-1
UC-1
UC-2
UC-3
UC-4
H-1 > TE-1 > UC-1
H-1 > TE-1 > UC-2
H-1 > UC-3
H-1 > TE-2 > UC-4
H-1 > TE-2 > UC-5
10/01/2017
4
Copyright © 2015 Civil Aviation Authority of Singapore. All rights reserved. 7
2. Top Event (UE) Approach -
2. TOP EVENT (TE) Approach
SRA Table - TE Approach Individual SRM Tasks
H TE UC Task #
UC-3 3
H-1 UC-1Thread
H-2 TE-1 UC-2
H-3 > TE-1 > UC-3H-3 UC-3
H-1 > TE-1 > UC-1
2 H-2 > TE-1 > UC-2H-2 UC-2
H-1
TE-1
UC-1 1
H-3
Copyright © 2015 Civil Aviation Authority of Singapore. All rights reserved.
3. Consequence (Accident) Approach -
8
SRA Table - UC Approach Individual SRM Tasks
UC TE H Task #
H-1 1
H-2 2
H-3 3
H-4 4
3. ACCIDENT (Ultimate Consequence) Approach
TE-1
TE-2
H-1
H-4
H-2Thread
UC-1
TE-1H-1 > TE-1 > UC-1
UC-1H-2 > TE-1 > UC-1
TE-2H-3 > TE-2 > UC-1
H-3H-4 > TE-2 > UC-1
10/01/2017
5
Copyright © 2015 Civil Aviation Authority of Singapore. All rights reserved.
Risk Mitigation > ALARP
• Overall intent of a SRM exercise is to drive the risk index
(severity x likelihood) of a Hazard’s projected Consequence
to an acceptable or tolerable level (ALARP).
� A risk mitigation process is essentially achieved through the
modification or enhancement of existing defenses, or
incorporation of additional defenses.
9
Copyright © 2015 Civil Aviation Authority of Singapore. All rights reserved.
Three outcomes from a SRM exercise:
1. Hazard Elimination –
• Eliminate or remove the hazard altogether (and hence its potential
consequences).
• Possible only if the hazard can indeed be totally eliminated or
removed by conventional corrective actions such as repair,
replacement, rectification or disposal.
• Such hazards are usually temporary, transient or isolated in nature
and which do not necessitate resolution through a systematic SRM
protocol.
Example – Unclear/ damaged taxiway sign board. Replace/ repair sign
board (No SRM action required).
10
10/01/2017
6
Copyright © 2015 Civil Aviation Authority of Singapore. All rights reserved.
2. Risk Mitigation –
Mitigate against the Hazard’s Consequence by reducing its risk index (likelihood/ severity) to an acceptable or tolerable level. This is achieved through incorporation of new defenses or enhancement of existing defenses. Applicable for hazards which are of a permanent or recurring nature, and which cannot be eliminated through conventional corrective actions alone.
Example - Regular bird migration across an aerodrome. Hazard cannot be eliminated (require systematic SRM action).
11
Copyright © 2015 Civil Aviation Authority of Singapore. All rights reserved.
3. Avoidance – Avoid the Hazard (hence its Consequence) altogether by suspending or cancelling the operational activity or relevant portion of it. This is probably the result of a safety risk index level which remains highly intolerable/ unacceptable in spite of all possible (or economically viable) defenses being considered.
Example – Cancel volcanic airspace operations when volcanic activity is reported, because there are no viable alternate routes.
12
Risk Mitigation Strategies
10/01/2017
7
Copyright © 2015 Civil Aviation Authority of Singapore. All rights reserved.
Risk Mitigation Actions - Effectiveness
Each proposed defense or mitigation action should be examined from following perspectives:
• Effectiveness - mitigating action can reduce the risk severity/ likelihood.
• Cost/benefit - perceived benefits of the mitigation outweigh the costs.
• Practicality - mitigation can be implemented and how viable it will be.
• Acceptability - mitigation is congruent with stakeholder expectations.
• Enforceability - compliance with new rules, regulations or operating procedures can be monitored.
• Durability - mitigation will be sustainable and effective.
• Residual safety risks - Level of the resultant safety risk after mitigation and which may necessitate further risk control measures subsequently.
� Unintended consequences - Probability of introducing unintended hazards as a result of the new mitigating actions being put in place.
13
Copyright © 2015 Civil Aviation Authority of Singapore. All rights reserved.
2.2 Purpose of HIRM Worksheet
Hazard Identification & Risk Mitigation (HIRM) Worksheet [Risk mitigation illustration] Oct 14
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59
1. E
merg
enc
y
Pro
ce
du
re
2. B
ac
ku
p
Sy
ste
m
3.
Ab
no
rmal
Pro
ced
ure
4.
SO
P
5. S
pe
cia
l
Insp
n
6. G
M
7.
Org
an
iza
tion
Ap
pro
va
l
8.
Pe
rsonn
el
Ap
pro
va
l
9. T
RN
G
10.
Oth
ers
Esc
ala
tion
Facto
r [E
F]
Esc
ala
tion
Co
ntr
ol [E
C]
Sev
eri
ty x
Lik
elih
oo
d
Ris
k L
ev
el
1. E
merg
enc
y
Pro
ce
du
re
2. B
ac
ku
p
Sy
ste
m
3.
Ab
no
rmal
Pro
ced
ure
4.
SO
P
5. S
pe
cia
l
Insp
n
6. G
M
7.
Org
an
iza
tion
Ap
pro
va
l
8.
Pe
rsonn
el
Ap
pro
va
l
9. T
RN
G
10.
Oth
ers
Esc
ala
tion
Facto
r [E
F]
Esc
ala
tion
Co
ntr
ol [E
C]
Sev
eri
ty x
Lik
elih
oo
d
Ris
k L
ev
el
1. E
merg
enc
y
Pro
ce
du
re
2. B
ac
ku
p
Sy
ste
m
3.
Ab
no
rmal
Pro
ced
ure
4.
SO
P
5. S
pe
cia
l
Insp
n
6. G
M
7.
Org
an
iza
tion
Ap
pro
va
l
8.
Pe
rsonn
el
Ap
pro
va
l
9. T
RN
G
10.
Oth
ers
Esc
ala
tion
Facto
r [E
F]
Esc
ala
tion
Co
ntr
ol [E
C]
Sev
eri
ty x
Lik
elih
oo
d
Ris
k L
ev
el
1. E
merg
enc
y
Pro
ce
du
re
2. B
ac
ku
p
Sy
ste
m
3.
Ab
no
rmal
Pro
ced
ure
4.
SO
P
5. S
pe
cia
l
Insp
n
6. G
M
7.
Org
an
iza
tion
Ap
pro
va
l
8.
Pe
rsonn
el
Ap
pro
va
l
9. T
RN
G
10.
Oth
ers
Esc
ala
tion
Facto
r [E
F]
Esc
ala
tion
Co
ntr
ol [E
C]
Sev
eri
ty x
Lik
elih
oo
d
Ris
k L
ev
el
E-
PC
1
EF>E-
PC1
EC1>EF
>E-PC1
N-
PC1
EF>N-
PC1
EC>EF>
N-PC1
E-
RM1
EF>E-
RM1
EC>EF>
E-RM1
N-
RM1
EF>N-
RM1
EC>EF>
N-RM1
EF>E-
PC2
EC>EF-
F-PC2
N-
PC2
EF>N-
PC2
EC>EF>
N-PC2
EF>E-
RM2
EC>EF>
E-RM2
N-
RM2
EF>N-
RM2
EC>EF>
N-RM2
EF>E-
PC3
EC>EF>
E-PC3
EF>N-
PC3
EC>EF>
N-PC3
EF>E-
RM3
EC>EF>
E-RM3
EF>N-
RM3
EC>EF>
N-RM3
EF>E-
PC4
EC>EF>
E-PC4
EF>N-
PC4
EC>EF>
N-PC4
EF>E-
RM4
EC>EF>
E-RM4
EF>N-
RM4
EC>EF>
N-RM4
Description of New Preventive Controls [N-PC] Description of Existing Recovery Measures [E-RM] Description of New Recovery Measures [N-RM]
EF>E-PC1: No documented procedure/ instruction for such
reporting expectation.
N-PC2: SOP to be put in place to require that all aircraft
fuselage doors to be closed or sealed during silent hours,
especially when undergoing hangar maintenance checks.
EF>N-PC2: There may be occasions where fuselage doors
cannot be closed due to their being removed or dismantled
for maintenance.
EC>EF>N-PC2: For such cases, aircraft maintenance steps
leading to such doors shall be removed or backed-off from
the door by at least 3 feet, during silent hours.
Description of Existing Preventive Controls [E-PC]
E-PC1: Flight, cabin and maintenance personnel are normally
expected to report any rat sightings within an aircraft.
N-PC1: SOP to be put in place to require flight crew and
maintenance personnel to report rats sighting within aircraft
cabin.
E-RM1: Any operational aircraft reported with rat sighting is
normally subjected to a cabin inspection by maintenance
personnel during stayover check.
N-RM1: Special Inspection sheet (Ref SI/ A320/ 25/ 112) has been
raised to require any operational aircraft with reported sighting or
evidence of rats infestation to be scheduled for de-infestation
action by approved Pest Controller upon aircraft return to main
base.
4C
L3 -
Mo
de
rate
Ris
k
3B
R4
- L
ow
Ris
k
N-RM2: A routine "C" Check Maintenance Job Card has been raised
to call for inspection of all opened aircraft internal fuselage
compartments for evidence of rat droppings and necessary follow
up action. Ref: MJC-1C-53-45; SI/ A320/ 25/ 112.
Mu
ltip
le a
ircr
aft
sy
ste
m(s
) fa
ilure
or
mal
fun
ctio
n (
du
e t
o e
lect
rica
l wir
ing
da
mag
e b
y ra
ts).
Act
ua
l ra
t si
gh
tin
gs
or
evid
en
ce o
f
rat
dro
pp
ings
wit
hin
air
craf
t ca
bin
.
Ra
t (s
) in
fest
atio
n w
ith
in a
n
op
erat
ion
al A
32
0 a
ircr
aft
fu
sela
ge/
cab
in
3D
R3
- M
od
era
te R
isk
3B
R4
- L
ow
Ris
k
Ult
ima
te
Co
nse
qu
en
ce
Existing Preventive Controls [E-PC] Existing
RI & TNew Preventive Controls [N-PC]
Resultant
RI & TExisting Recovery Measures [E-RM]
Existing
RI & TNew Recovery Measures [N-RM]
Resultant
RI & T
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Ultimate Consequence Mitigation (as applicable) >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
Table B
1
Ha
zard
/ T
hre
at >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Unsafe Event Mitigation (as applicable) >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
Un
safe
Ev
en
t
4. ULTIMATE CONSEQUENCE [UC]: Multiple aircraft system(s) failure or malfunction (due to electrical wiring damage by rats).
Table A
1. OPERATION/ PROCESS: Pest control within A320 aircraft fuselage/ cabin.
2. HAZARD / THREAT [H/T]: Rat (s) infestation within an operational A320 aircraft fuselage/ cabin Hazard Code: OPS-ALPHA-TECH-H1-L2-13
3. UNSAFE EVENT [UE]: Rat (s) infestation confirmed through rat sightings or evidence of aircraft wiring damage by roden activities.
14
� Facilitate the performance and documentation of a safety risk mitigation
project for a specific hazard
10/01/2017
8
Copyright © 2015 Civil Aviation Authority of Singapore. All rights reserved.
2.3 HIRM Terminologies & Definitions >>> (HIRM sht 2)
Sheet 2: Definitions 06 Feb15
1 Hazard Identification & Risk
Mitigation (HIRM)
A structured procedure to identifiy hazards/ threats within a given operation, process or equipment and the evaluation of preventive
controls (defences, barriers) to mitigate against the projected consequence (s) . This HIRM procedure/ process is also commonly known
as Safety Assessment.
2 Operation/ Process Description of Organization/ Operation/ Process/ Equipment wherein the Hazard is identified/ reported/ originated from.
3 Hazard (H) Undesirable condition or object which may cause or contribute to an Unsafe Event or Ultimate Consequence. A hazard must be
specifically described and validated before commencing SRM process. Only permanent or recurring hazards may warrant SRM process.
4 Threat (T) Threats are essentially hazards which are more imminent/ immediate/ visible (hence more threatening) to an operation; in comparison
to more latent or less apparent (generic) hazards. Known or anticipated Threats should be proactively mitigated for, possibly with higher
priority over more latent hazards.
5 Unsafe Event (UE) Most credible unsafe situation, not yet amounting to an Ultimate Consequence or Accident. Usually an intermediate event/ situation
before an Ultimate Consequence/ Accident. Identification of an Unsafe Event is applicable only where there is a need to distinguish and
establish mitigating actions upstream and downstream of such an intermediate event (before the Ultimate Consequence/ Accident). If
this intermediate UE state is not applicable for a particular operation, then it may be bypassed as appropriate.
6 Ultimate Consequence Ultimate event or accident; most credible ultimate outcome.
7 Preventive Control (PC) A mitigating action or defence to block or prevent a Hazard/ Threat from escalating into an Unsafe Event or Ultimate Consequence.
Exisitng PCs refer to current/ known/ established PCs which have been in place before the current HIRM exercise. New PCs refer to new/
additional/ modified PCs being recommended, proposed or which have been put in place as a result of the current HIRM exercise.
8 Recovery Measure (RM) A mitigating action, barrier or defence to block or prevent an Unsafe Event from escalating into an Ultimate Consequence or Accident.
Existing RMs refer to current/ known/ established RMs which have been in place before the current HIRM exercise. New RMs refer to
new/ additional/ modified RMs being recommended, proposed or which have been put in place as a result of the current HIRM exercise.
9 Barrier A generic term, referring to a PC or RM, or a set thereof.
10 Barrier Strength Value (BSV) The Value of a specific Barrier's (PC/ RM) quality or strength.
Consolidated Barrier
Strength Value (CBSV)
The Consolidated (SUM) Value of a set (line) of Barrier's (PCs/ RMs) pertaining to a given UE/ UC.
11 Escalation Factor (EF) Possible latent or organizational condition/ factor which may weaken the effectiveness of a Preventive Control (or Recovery measure) .
Use where applicable only.
12 Escalation Control (EC) A mitigating action or defence to block or prevent an Escalation Factor from compromising or weakening a Preventive Control (or
Recovery Measure) . Use where applicable only.
13 Risk Index (RI) Risk Index refers to the combined Likelihood & Severity of an Unsafe Event or Ultimate Consequence, as projected (anticipated) from an
identified Hazard .
14 Existing Risk Index &
Tolerability
Determination of Existing Risk Index and Tolerability shall take into consideration Existing PCs/ RMs only. If the Existing Risk Index's
Tolerability is unacceptable, it is then apparent that evaluation of New (additional) PCs/ RMs would be necessary to reduce the Risk Index
to a new acceptable level. This may include modification or enhancement of existing PCs/ RMs.
15 Resultant Risk Index &
Tolerability
Resultant Risk Index and Tolerability is based on the combined Existing PCs/ RMs together with the New PCs/ RMs put in place as a
result of the completed risk management exercise.
15
Copyright © 2015 Civil Aviation Authority of Singapore. All rights reserved. 16
2.4 (a) Customize HIRM Worksheet (sht 4)
Hazard Identification & Risk Mitigation (HIRM) Worksheet [Risk mitigation illustration] Oct 14
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59
1.
Em
erg
en
cy
Pro
ced
ure
2. B
ac
kup
Syste
m
3. A
bno
rma
l
Pro
ced
ure
4.
SO
P
5. S
pe
cia
l
Insp
n
6. G
M
7.
Org
aniz
ati
on
Appro
val
8. P
ers
onn
el
Ap
pro
val
9.
TR
NG
10.
Oth
ers
Esc
ala
tion
Fac
tor
[EF
]
Esc
ala
tion
Con
trol [E
C]
Se
veri
ty x
Lik
elih
ood
Ris
k L
eve
l
1.
Em
erg
en
cy
Pro
ced
ure
2. B
ac
kup
Syste
m
3. A
bno
rma
l
Pro
ced
ure
4.
SO
P
5. S
pe
cia
l
Insp
n
6. G
M
7.
Org
aniz
ati
on
Appro
val
8. P
ers
onn
el
Ap
pro
val
9.
TR
NG
10.
Oth
ers
Esc
ala
tion
Fac
tor
[EF
]
Esc
ala
tion
Con
trol [E
C]
Se
veri
ty x
Lik
elih
ood
Ris
k L
eve
l
1.
Em
erg
en
cy
Pro
ced
ure
2. B
ac
kup
Syste
m
3. A
bno
rma
l
Pro
ced
ure
4.
SO
P
5. S
pe
cia
l
Insp
n
6. G
M
7.
Org
aniz
ati
on
Appro
val
8. P
ers
onn
el
Ap
pro
val
9.
TR
NG
10.
Oth
ers
Esc
ala
tion
Fac
tor
[EF
]
Esc
ala
tion
Con
trol [E
C]
Se
veri
ty x
Lik
elih
ood
Ris
k L
eve
l
1.
Em
erg
en
cy
Pro
ced
ure
2. B
ac
kup
Syste
m
3. A
bno
rma
l
Pro
ced
ure
4.
SO
P
5. S
pe
cia
l
Insp
n
6. G
M
7.
Org
aniz
ati
on
Appro
val
8. P
ers
onn
el
Ap
pro
val
9.
TR
NG
10.
Oth
ers
Esc
ala
tion
Fac
tor
[EF
]
Esc
ala
tion
Con
trol [E
C]
Se
veri
ty x
Lik
elih
ood
Ris
k L
eve
l
E-
PC
1
EF>E-
PC1
EC1>EF
>E-PC1
N-
PC1
EF>N-
PC1
EC>EF>
N-PC1
E-
RM1
EF>E-
RM1
EC>EF>
E-RM1
N-
RM1
EF>N-
RM1
EC>EF>
N-RM1
EF>E-
PC2
EC>EF-
F-PC2
N-
PC2
EF>N-
PC2
EC>EF>
N-PC2
EF>E-
RM2
EC>EF>
E-RM2
N-
RM2
EF>N-
RM2
EC>EF>
N-RM2
EF>E-
PC3
EC>EF>
E-PC3
EF>N-
PC3
EC>EF>
N-PC3
EF>E-
RM3
EC>EF>
E-RM3
EF>N-
RM3
EC>EF>
N-RM3
EF>E-
PC4
EC>EF>
E-PC4
EF>N-
PC4
EC>EF>
N-PC4
EF>E-
RM4
EC>EF>
E-RM4
EF>N-
RM4
EC>EF>
N-RM4
Description of New Preventive Controls [N-PC] Description of Existing Recovery Measures [E-RM] Description of New Recovery Measures [N-RM]
EF>E-PC1: No documented procedure/ instruction for such
reporting expectation.
N-PC2: SOP to be put in place to require that all aircraft
fuselage doors to be closed or sealed during silent hours,
especially when undergoing hangar maintenance checks.
EF>N-PC1: There may be occasions where fuselage doors
cannot be closed due to their being removed or dismantled
for maintenance.
EC>EF>N-PC1: For such cases, aircraft maintenance steps
leading to such doors shall be removed or backed-off from
the door by at least 3 feet, during silent hours.
Description of Existing Preventive Controls [E-PC]
E-PC1: Flight, cabin and maintenance personnel are normally
expected to report any rat sightings within an aircraft.
N-PC1: SOP to be put in place to require flight crew and
maintenance personnel to report rats sighting within aircraft
cabin.
E-RM1: Any operational aircraft reported with rat sighting is
normally subjected to a cabin inspection by maintenance
personnel during stayover check.
N-RM1: Special Inspection sheet (Ref SI/ A320/ 25/ 112) has been
raised to require any operational aircraft with reported sighting or
evidence of rats infestation to be scheduled for de-infestation
action by approved Pest Controller upon aircraft return to main
base.
4C
L3 -
Mo
de
rate
Ris
k
3B
R4
- L
ow
Ris
k
N-RM2: A routine "C" Check Maintenance Job Card has been raised
to call for inspection of all opened aircraft internal fuselage
compartments for evidence of rat droppings and necessary follow
up action. Ref: MJC-1C-53-45; SI/ A320/ 25/ 112.
Mu
ltip
le a
ircr
aft
syste
m(s
) fa
ilu
re o
r
malf
un
cti
on
(d
ue
to
ele
ctri
cal
wir
ing
dam
age
by
ra
ts).
Act
ual
rat
sig
hti
ngs o
r ev
iden
ce o
f
rat
dro
pp
ings w
ith
in a
ircr
aft
cab
in.
Rat
(s)
infe
stati
on
wit
hin
an
op
era
tio
na
l A
32
0 a
ircr
aft
fu
sela
ge/
cab
in
3D
R3
- M
od
era
te R
isk
3B
R4
- L
ow
Ris
k
Ult
ima
te
Co
nse
qu
en
ce
Existing Preventive Controls [E-PC] Existing
RI & TNew Preventive Controls [N-PC]
Resultant
RI & TExisting Recovery Measures [E-RM]
Existing
RI & TNew Recovery Measures [N-RM]
Resultant
RI & T
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Ultimate Consequence Mitigation (as applicable) >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
Table B
1
Ha
zard
/ T
hre
at >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Unsafe Event Mitigation (as applicable) >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
Un
safe
Ev
en
t
4. ULTIMATE CONSEQUENCE [UC]: Multiple aircraft system(s) failure or malfunction (due to electrical wiring damage by rats).
Table A
1. OPERATION/ PROCESS: Pest control within A320 aircraft fuselage/ cabin.
2. HAZARD / THREAT [H/T]: Rat (s) infestation within an operational A320 aircraft fuselage/ cabin Hazard Code: OPS-ALPHA-TECH-H1-L2-13
3. UNSAFE EVENT [UE]: Rat (s) infestation confirmed through rat sightings or evidence of aircraft wiring damage by roden activities.
10/01/2017
9
Copyright © 2015 Civil Aviation Authority of Singapore. All rights reserved. 17
2.4 (b) Customize SRM Procedure (sht 3)Safety Risk Mitigation (SRM) Process - Schematic
Where there is an Ultimate
Consequence (UC) in addition to an
Unsafe Event (UE), then the same
process as described for Preventive
Controls (PC) is to be applied for
Recovery Measures (RM) in columns
31 to 59.
Recovery Measures will address
defenses between the Unsafe Event
and its Ultimate Consequence.
10-11. Upon final completion of SRM
Worksheet, proceed to fill out the
SRM Report form and process the
completed SRM report (with the
completed SRM Worksheet) for
management approval.
4. If there are any known Escalation Factors (EF), then an associated Escalation Control (EC) will be
required. If a EC is not already existing, then it should be addressed under New-Preventive Control,
later.
5-6. Based on the annotated Existing Preventive Controls (E-PCs), assess and annotate the Existing
Risk Index (Severity & Likelihood) & its Tolerability in columns 14-15.
7. If the Existing Risk Index & Tolerability is deemed unacceptable, then proceed to identify or
recommend New Preventive Controls (N-PC)or Escalation Factors (EF) in applicable columns
provided (16-25).
8-9. Assess the Resultant Risk Index & Tolerability (columns 28-29) based on the annotated
Existing Preventive Controls plus the annotated New Preventive Controls, and associated ECs if any.
If the Resultant Risk Index is still deemed unacceptable, then you may need to review and enhance
the Existing as well as New Preventive Controls in order to obtain a more tolerable Risk Index.
1. Annotate required H, UE & UC information in Table A.
2. Repeat H, UE & UC information in Table B, columns 1, 30, 59 accordingly.
3. Identify and annotate Existing Preventive Controls (E-PC) in applicable columns provided (2 to
13).
Copyright © 2015 Civil Aviation Authority of Singapore. All rights reserved.
2.5 Create Master Hazards Register (sht 11>>>)
18
Sheet 11 Hazard & Risk Management Database (Register) 22Sep16 <<<
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Generic Hazard/
Threat
(Original Report)
Source of
Information*
Specific Hazard/
Threat*
Hazard
ID Code
Corrective
Action*
[Yes/ No]
SRM
Action*
[Yes / No]
SRM Priority
Level*
(H, M, L)
Dept / SectProject
I/C
Date
Activated
Date
Completed
/ Rpt Ref
Existing RI &
Tolerability
(UE/UC)
Resultant RI &
Tolerability
(UE/UC)
Next
Review
Date
Ex
am
ple
A320 aircraft
operation.
Cabin crew reported one
large rat sighted in
aircraft rear galley area
during cruise.
Inflight
incident
notification
report ref:
A320/ OPS/
012/ 2005.
[H] - Rats
infestation of
A320 aircraft
OPS-
ALPHA-
H1-M-
013
Nil Projected - Aircraft
wiring/ equipment
damage by rats.
No Yes Medium A320
Operations
ABC
1
2
3
Hazard ID Code:
Sector (1) - Organization (2) - Hazard No (3) - Priority Level (4) - Year (5)
1
2 Organization: Five letters code (eg ALPHA - Alpha Airline)
3
4
5
Hazard ID Code Illustration:a) OPS-ALPHA-H001-M-013 [Air Operations - Alpha Airline - Hazard #1 - Moderate Priority - Year 2013]
b) AGA-GATB-H005-L-012 [Aerodrome - Timbaktu Airport - Hazard #5 - Low Priority - Year 2012]
1
2
3
4
5
6
7
Sector: AGA / ANS / OPS / DMO / AMO / MDO* (*MDO - Materials Distribution Organizations, including fuel distribution)
*Explanatory Notes:
Reported/ Projected (UE/ C): Annotate UE/ C description as a "Reported" occurrence or a "Projected" occurrence. If multiple H>UE>C combinations involved, register each combination under a new Row (Each single H>UE>C
combination will constitute one potential SRM Task)
Priority Level: Hazard prioritization Level [High (Accident), Medium (Serious Incident), Low (Incident)].
Hazard No: Hazard number (eg H001) as assigned by the organization concerned within a given Year.
Year: Year when the Hazard was registered in the organization's Hazard Register.
Source of Information: Hazard information as may be extracted from - Voluntary Hazard Rpt, Occurrence Notification/ Investigation Rpt, Internal Audit Rpt, External Audit Rpt, Hazard Survey Rpt, Operational Data Review Rpt
Corrective Action: If the Hazard can be effectively eliminated through conventional corrective action (eg disposal, repair, replacement, modification), annotate YES with the action taken/ recommended. Otherwise annotate NO.
SRM Action: Annotate YES to indicate systematic SRM action is recommended (or has been taken already). Annotate NO if systematic SRM action is not recommended (or not necessary).
SRM Project Registration: This column for registration of assigned (new) SRM project, or a previously completed SRM project (with respect to the specific H>UE>C thread).
Specific Hazard/ Threat: If more than one Hazard/ Threat identified, register such additional Hazard/ Threat under new row/ item
Priority Level: SRM or Corrective Action Priority Level based on (Annex 13) occurrence category of the projected (or reported) Unsafe Event or Consequence. Accident - High; Serious Incident - Medium; Incident - Low.
Hazard Registration
Recommended ActionArea/
Operation/
Equipment
Ite
m
Hazard [H] / Threat [T]
SRM Project Registration*
SRM Project Assignment SRM Project CompletionUnsafe-Event [UE]
(Reported /
Projected)*
Consequence [C]
(Reported /
Projected)*
10/01/2017
10
Copyright © 2015 Civil Aviation Authority of Singapore. All rights reserved.
Register & Validate the Hazard
19
Generic Hazard/
Threat
(Original Report)
Source of
Information*
Specific Hazard/
Threat*
Hazard
ID Code
Corrective
Action*
[Yes/ No]
SRM
Action*
[Yes / No]
SRM Priority
Level*
(H, M, L)
Dept / SectProject
I/C
Date
Activated
Date
Completed
/ Rpt Ref
Existing RI &
Tolerabil ity
(UE/UC)
Resultant RI &
Tolerabil ity
(UE/UC)
Next
Review
Date
Exa
mp
le
A320 aircraft
operation.
Cabin crew reported one
large rat sighted in
aircraft rear galley area
during cruise.
Inflight
incident
notification
report ref:
A320/ OPS/
012/ 2005.
[H] - Rats
infestation of
A320 aircraft
OPS-
ALPHA-
H1-M-
013
Nil Projected - Aircraft
wiring/ equipment
damage by rats.
No Yes Medium A320
Operations
ABC
1
2
3
Hazard Registration
Recommended ActionArea/
Operation/
Equipment
Item
Hazard [H] / Threat [T]
SRM Project Registration*
SRM Project Assignment SRM Project CompletionUnsafe-Event [UE]
(Reported /
Projected)*
Consequence [C]
(Reported /
Projected)*
Generic Hazard/
Threat
(Original Report)
Source of
Information*
Specific Hazard/
Threat*
Hazard
ID Code
Corrective
Action*
[Yes/ No]
SRM
Action*
[Yes / No]
SRM Priority
Level*
(H, M, L)
Ex
am
ple
A320 aircraft
operation.
Cabin crew reported one
large rat sighted in
aircraft rear galley area
during cruise.
Inflight
incident
notification
report ref:
A320/ OPS/
012/ 2005.
[H] - Rats
infestation of
A320 aircraft
OPS-
ALPHA-
H1-M-
013
Nil Projected - Aircraft
wiring/ equipment
damage by rats.
No Yes Medium
1
2
3
Hazard Registration
Recommended ActionArea/
Operation/
Equipment
Ite
m
Hazard [H] / Threat [T]Unsafe-Event [UE]
(Reported /
Projected)*
Consequence [C]
(Reported /
Projected)*
Copyright © 2015 Civil Aviation Authority of Singapore. All rights reserved. 20
2.6 Prioritize Hazard for Risk Mitigation (sht 12)
Generic Hazard/
Threat
(Original Report)
Source of
Information*
Specific Hazard/
Threat*
Hazard
ID Code
Corrective
Action*
[Yes/ No]
SRM
Action*
[Yes / No]
SRM Priority
Level*
(H, M, L)
Ex
amp
le
A320 aircraft
operation.
Cabin crew reported one
large rat sighted in
aircraft rear galley area
during cruise.
Inflight
incident
notification
report ref:
A320/ OPS/
012/ 2005.
[H] - Rats
infestation of
A320 aircraft
OPS-
ALPHA-
H1-M-
013
Nil Projected - Aircraft
wiring/ equipment
damage by rats.
No Yes Medium
1
2
3
Hazard Registration
Recommended ActionArea/
Operation/
Equipment
Ite
m
Hazard [H] / Threat [T]Unsafe-Event [UE]
(Reported /
Projected)*
Consequence [C]
(Reported /
Projected)*
10/01/2017
11
Copyright © 2015 Civil Aviation Authority of Singapore. All rights reserved. 21
Hazard Prioritization Procedure (Illustration) Criteria Prioritization in relation to the occurrence category (severity) of the
Hazard’s credible Consequence.
Methodology a) Project the Hazard’s worst credible Consequence
b) Project this Consequence’s likely occurrence classification ie it will be
deemed to be an accident, serious incident or incident (per Annex 13
definition)
c) The Hazard’s prioritization is thus: Occurrence category of credible Consequence Hazard Priority
Accident High
Serious Incident Medium
Incident Low
Remarks This Option takes into consideration the severity of the Hazard’s projected
Consequence only.
Copyright © 2015 Civil Aviation Authority of Singapore. All rights reserved. 22
2.7 Activate Risk Mitigation Process (sht 12)Sheet 11 Hazard Identification & Risk Management Register (Database) 14/7/2016 <<<
Generic Hazard
Description
(Original Report)
Source of
Information*
Specific Hazard
Decription
Hazard
ID Code
Corrective
Action*
[Yes/ No]
SRM Action*
[Yes / No]
Priority
Level
(H, M, L)
Dept NameDate
Activated
Date
Completed
/ Rpt Ref
Existing Risk
Index &
Level
Resultant
Risk Index &
Level
Next
Review
Date
a) Aircraft wiring/
equipment damage by rat
(s)
No Yes Medium A320
Operations
ABC
b) Aircraft cabin / galley/
food contamination by
rat droppings/ urine
No Yes Low Cabin Crew /
Inflight
Catering
XYZ
1
2
3
Hazard ID Code:
Sector (1) - Organization (2) - Hazard No (3) - Priority Level (4) - Year (5)
1)
2) Organization: Five letters code (eg ALPHA - Alpha Airline)
3)
4)
5)
Example of Hazard ID Code:i) OPS-ALPHA-H001-M-013 [Air Operations - Alpha Airline - Hazard #1 - Moderate Priority - Year 2013]
ii) AGA-GATB-H005-L3-012 [Aerodrome - Timbaktu Airport - Hazard #5 - Low Priority - Year 2012]
a)
b)
c)
d)
e)
Ex
am
ple
On
ly
A320 aircraft
operation.
Cabin crew reported one
large rat sighted in aircraft
rear galley area during
cruise.
Sector: AGA / ANS / OPS / DMO / AMO / MDO* (*MDO - Materials Distribution Organizations, including fuel distribution)
*Explanatory Notes:
OPS-
ALPHA-
H1-L2-
013
Inflight incident
notification
report ref:
A320/ OPS/
012/ 2005.
Rat (s) infestation of
A320 aircraft
Safety Risk Mitigation Action
SRM Project Team/ SAG Risk Mitigation Project Completion
Hazard Registration
Hazard Validation & Recommended
ActionArea/
Operation/
Equipment
Credible Unsafe-Event/
Consequence*
[tentative]
Ite
m
Hazard (Threat/ Deficiency/ Unsafe-condition/ Object)
Priority Level: Hazard prioritization Level [High (Accident), Medium (Serious Incident), Low (Incident)] based on occurrence category (A13) of the hazard's projected Unsafe Event/ Consequence.
Hazard No: Hazard number (eg H001) as assigned by the organization concerned within a given Year.
Year: Year when the Hazard was registered in the organization's Hazard Register.
Source of Information: Hazard information as may be extracted from - Voluntary Hazard Rpt, Occurrence Notification/ Investigation Rpt, Internal Audit Rpt, External Audit Rpt, Hazard Survey Rpt, Operational Data Review Rpt
Credible Unsafe Event / Consequence: Tentative projection to facilitate hazard prioritization when assigning for SRM action only (refer Priority Level column)
Corrective Action: If the Hazard can be effectively eliminated through conventional corrective action (eg disposal, repair, replacement, modification), annotate YES with the recommended corrective action. Otherwise annotate NO.
SRM Action: Annotate YES to indicate systematic SRM action is recommended (essentially permanent/ recurring hazards). Annotate NO if systematic SRM action is not recommended (essentially temporary/ transient hazards).
Priority Level: SRM action Priority Level based on (Annex 13) occurrence category of the projected Unsafe Event or Consequence > Accident - High; Serious Incident - Moderate; Incident - LowDept NameDate
Activated
Date
Completed
/ Rpt Ref
Existing Risk
Index & Level
Resultant Risk
Index & Level
Next
Review
Date
A320
Operations
ABC
Cabin Crew /
Inflight
Catering
XYZ
Safety Risk Mitigation Action
SRM Project Team/ SAG Risk Mitigation Project Completion
10/01/2017
12
Copyright © 2015 Civil Aviation Authority of Singapore. All rights reserved. 23
2.8 Project Unsafe Event/ Ultimate Consequence (sht 13)
Table
A Hazard Identification & Risk Mitigation (HIRM) Worksheet [Risk mitigation illustration] 27 Mar 14
1. OPERATION/ PROCESS: Pest control within A320 aircraft fuselage/ cabin.
2. HAZARD / THREAT [H/T]: Rat (s) infestation within an operational A320
aircraft fuselage/ cabin Hazard Code: OPS-ALPHA-TECH-H1-L2-13
3. UNSAFE EVENT [UE]: Rat (s) infestation confirmed through rat sightings or evidence of aircraft wiring damage by
roden activities. 4. ULTIMATE CONSEQUENCE
[UC]: Multiple aircraft system(s) failure or malfunction (due to electrical wiring damage by rats).
Hazard Identification & Risk Mitigation (HIRM) Worksheet [Risk mitigation illustration] 27 Mar 14
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 591
. E
me
rge
nc
y
2.
Ba
cku
p
Sys
tem
3.
Ab
no
rma
l P
roc
ed
ure
4.
SO
P
5.
Sp
ec
ial
Ins
pn
6.
GM
7.
Org
an
iza
tio
n
Ap
pro
va
l
8.
Pe
rso
nn
el
Ap
pro
va
l
9.
TR
NG
10
. O
the
rs
Es
ca
lati
on
F
act
or
[EF
]
Es
ca
lati
on
C
on
tro
l [E
C]
Se
ve
rity
x
Lik
elih
oo
d
Ris
k L
ev
el
1.
Em
erg
en
cy
2.
Ba
cku
p
Sys
tem
3.
Ab
no
rma
l P
roc
ed
ure
4.
SO
P
5.
Sp
ec
ial
Ins
pn
6.
GM
7.
Org
an
iza
tio
n
Ap
pro
va
l
8.
Pe
rso
nn
el
Ap
pro
va
l
9.
TR
NG
10
. O
the
rs
Es
ca
lati
on
F
act
or
[EF
]
Es
ca
lati
on
C
on
tro
l [E
C]
Se
ve
rity
x
Lik
elih
oo
d
Ris
k L
ev
el
1.
Em
erg
en
cy
P
roc
ed
ure
2.
Ba
cku
p
Sys
tem
3.
Ab
no
rma
l P
roc
ed
ure
4.
SO
P
5.
Sp
ec
ial
Ins
pn
6.
GM
7.
Org
an
iza
tio
n
Ap
pro
va
l
8.
Pe
rso
nn
el
Ap
pro
va
l
9.
TR
NG
10
. O
the
rs
Es
ca
lati
on
F
act
or
[EF
]
Es
ca
lati
on
C
on
tro
l [E
C]
Se
ve
rity
x
Lik
elih
oo
d
Ris
k L
ev
el
1.
Em
erg
en
cy
2.
Ba
cku
p
Sys
tem
3.
Ab
no
rma
l P
roc
ed
ure
4.
SO
P
5.
Sp
ec
ial
Ins
pn
6.
GM
7.
Org
an
iza
tio
n
Ap
pro
va
l
8.
Pe
rso
nn
el
Ap
pro
va
l
9.
TR
NG
10
. O
the
rs
Es
ca
lati
on
F
act
or
[EF
]
Es
ca
lati
on
C
on
tro
l [E
C]
Se
ve
rity
x
Lik
elih
oo
d
Ris
k L
ev
el
E-
PC1
EF>E-
PC1
EC1>EF
>E-PC1
N-
PC1
EF>N-
PC1
EC>EF>
N-PC1
E-
RM1
EF (to
E-
RM1)
EC1 (to
EF)
N-
RM1
EF (to
N-
RM5)
EC1 (to
EF)
EF>E-
PC2
EC>EF-F-
PC2
N-
PC2
EF>N-
PC6
EC>EF>
N-PC6
EF1
(to E-
RM2)
EC (to
EF1)
N-
RM2
EF1 (to
N-
RM6)
EC (to
EF1)
EF>E-
PC3
EC>EF>
E-PC3
EF>N-
PC7
EC>EF>
N-PC7
EF2
(to E-
RM3)
EC (to
EF2)
EF>E-
PC4
EC>EF>
E-PC4
EF (to
E-
RM4)
EC (to
EF)
2. HAZARD / THREAT [H/T]:
3. UNSAFE EVENT [UE]: Rat (s) infestation confirmed through rat sightings or evidence of aircraft wiring damage by roden activities.
4. ULTIMATE CONSEQUENCE [UC]: Multiple aircraft system(s) failure or malfunction (due to electrical wiring damage by rats).
Table B
1
Ha
za
rd /
Th
rea
t >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Unsafe Event Mitigation (as applicable) >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
Un
safe
Ev
en
t
Existing Preventive Controls [E-PC]
Table A
1. OPERATION/ PROCESS: Pest control within A320 aircraft fuselage/ cabin.
Existing
RI & TNew Preventive Controls [N-PC]
Resultant
RI & T
Existing
RI & TNew Recovery Measures [N-RM]
Hazard Code: OPS-ALPHA-TECH-H1-L2-13Rat (s) infestation within an operational A320 aircraft fuselage/ cabin
Mu
ltip
le a
ircr
aft
sy
ste
m(s
) fa
ilu
re o
r
ma
lfu
nct
ion
(d
ue
to
ele
ctri
cal
wir
ing
d
am
ag
e b
y r
ats
).
3B
R4
- L
ow
Ris
k
Ult
ima
te
Co
nse
qu
en
ceResultant
RI & T
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Ultimate Consequence Mitigation (as applicable) >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
Ra
t (s
) in
fest
ati
on
co
nfi
rme
d t
hro
ug
h r
at
sig
hti
ng
s o
r e
vid
en
ce o
f ra
t d
rop
pin
gs.
4C
L3
- M
od
era
te R
isk
Existing Recovery Measures [E-RM]
Ra
t (s
) in
fest
ati
on
wit
hin
an
op
era
tio
na
l
A3
20
air
cra
ft f
use
lag
e/
cab
in
3D
R3
- M
od
era
te R
isk
3B
R4
- L
ow
Ris
k
Copyright © 2015 Civil Aviation Authority of Singapore. All rights reserved. 24
2.9 Evaluate Preventive Controls & Risk Index [H>UE]
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
1.
Em
erg
ency
2. Backu
p
Syst
em
3. Abnorm
al
Pro
cedure
4. SO
P
5. Special
Insp
n
6. G
M
7. O
rganiz
ation
Appro
val
8. Pers
onnel
Appro
val
9. TR
NG
10. O
thers
Esc
ala
tion
Fact
or [E
F]
Esc
ala
tion
Control [E
C]
Severity
x
Likelih
ood
Risk L
evel
1.
Em
erg
ency
2. Backu
p
Syst
em
3. Abnorm
al
Pro
cedure
4. SO
P
5. Special
Insp
n
6. G
M
7. O
rganiz
ation
Appro
val
8. Pers
onnel
Appro
val
9. TR
NG
10. O
thers
Esc
ala
tion
Fact
or [E
F]
Esc
ala
tion
Control [E
C]
Severity
x
Likelih
ood
Risk L
evel
E-
PC1
EF>E-
PC1
EC1>EF
>E-PC1
N-
PC1
EF>N-
PC1
EC>EF>
N-PC1
EF>E-
PC2
EC>EF-F-
PC2
N-
PC2
EF>N-
PC6
EC>EF>
N-PC6
EF>E-
PC3
EC>EF>
E-PC3
EF>N-
PC7
EC>EF>
N-PC7
EF>E-
PC4
EC>EF>
E-PC4
Description of New Preventive Controls [N-PC]
EF>N-PC1: There may be occasions where fuselage doors
cannot be closed due to their being removed or dismantled for
maintenance.
EC>EF>N-PC1: For such cases, aircraft maintenance steps
leading to such doors shall be removed or backed-off from the
door by at least 3 feet, during silent hours.
N-PC2: SOP to be put in place to require that cabin crew
stationed at galley door during catering truck food delivery
service, do keep a lookout to prevent any rat migration from
catering truck into aircraft cabin.
Description of Existing Preventive Controls [E-PC]
E-PC1: Flight, cabin and maintenance personnel are expected to
report any rat sightings within an aircraft.
N-PC1: SOP to be put in place to require that all aircraft
fuselage doors to be closed or sealed during silent hours,
especially when undergoing hangar maintenance checks.
Table B
1
Hazard
/ T
hre
at >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Unsafe Event Mitigation (as applicable) >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
Unsa
fe E
vent
Existing Preventive Controls [E-PC] Existing
RI & TNew Preventive Controls [N-PC]
Resultant
RI & T
Rat (s
) in
fest
ation c
onfirm
ed thro
ugh rat
sightings
or evid
ence
of ra
t dro
ppin
gs.
Rat (s
) in
fest
ation w
ithin
an o
pera
tional
A320 a
ircr
aft
fuse
lage/ ca
bin
3D
R3 - M
odera
te R
isk
3B
R4 - L
ow
Ris
k
10/01/2017
13
Copyright © 2015 Civil Aviation Authority of Singapore. All rights reserved.
Assess Severity Value of Risk Index
� Assess severity value of an Unsafe Event (or Consequence)
in relation to the Severity Descriptions within the Severity
Table (Sht 5)
25
Sheet 5: Severity Table (Basic) <<< 11-Nov-13
Level Descriptor
1 Insignificant
2 Minor
3 Moderate
4 Major
5 Catastrophic Loss of aircraft or multiple lives.
Severity Description (customise according to nature of
organization’s operations)
No significance to aircraft related operational safety.
Degrade or affect normal aircraft operational procedures or
performance.
Partial loss of significant/ major aircraft systems or result in
abnormal F/Ops procedure application.
Complete failure of significant/ major aircraft systems or result in
emergency F/Ops procedure application.
Copyright © 2015 Civil Aviation Authority of Singapore. All rights reserved.
Assess Likelihood Value of Risk Index
26
Sheet 6: Likelihood Table 07-Jan-14
Level Descriptor Likelihood Description
E Certain/ frequent Is expected to occur in most circumstances.
D Likely/ occasional Will probably occur at some time.
C Possible/ remote Might occur at some time.
B Unlikely/ improbable Could occur at some time.
A Exceptional/ impossible May occur only in exceptional circumstances.
Note: The Likelihood (Level) of a given UE/ UC is to be derived from the "Consolidated
Barrier Strength Value (CBSV)" of its line of PCs/ RMs. Refer to Sheet 6A of the Excel
HIRM Worksheet.
10/01/2017
14
Copyright © 2015 Civil Aviation Authority of Singapore. All rights reserved.
Assess Likelihood Value of Risk Index
27
Step 1 - Assess Consolidated Barrier Strength Value (CBSV) of Unsafe Event (or Consequence) - Sht 6A
Step 2 - Derive Likelihood value of Unsafe Event (or Consequence) based on the CBSV obtained – Sht 6A
Table 1 - Barrier Strength Value (BSV)
Weak, superficial or insignificant Barrier
Barrier Strength Description Barrier Strength
1
2
3
4
5
Barrier Strength
Poor
Fair
Satisfactory
Good
Excellent Best or most robust Standard/ Regulation/ Practice
Effective, recognised and established Barrier
Reasonable or acceptable Barrier
Barely viable or adequate Barrier
Table 2 - Consolidated Barrier Strength Value Assessment
<<< Consolidated BSV*
Barrier Sequence
1
Assessed BSV
2
4
3
3
2
4
5
2
3
1
15
6
7
8
*Note to Consolidated BSV:
1. BSV summation of the actual number of barriers OR
optimum number of barriers, whichever is the lesser.
2. Where actual number of barriers exceed the optimum
number of barriers, select the barriers with the highest
BSVs.
Table 3 - Optimum Number of Barriers
Severity Value of
UE/ C Severity Descriptor
4 Major
5 Catastrophic
2 Minor
3 Moderate 4 20 Table 4C
Optimum Number of
Barriers Optimum CBSV*
Applicable CBSV-
Likelihood Table
1 Insignificant 2 10 Table 4A
6 30 Table 4D
8 40 Table 4D
3 15 Table 4B
Details in HIRM Wsht Sht 6A >>>
Copyright © 2015 Civil Aviation Authority of Singapore. All rights reserved.
Evaluate Recovery Measures & Risk Index [UE>UC]
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59
1. E
merg
ency
Pro
cedure
2. B
ackup
Syste
m
3. A
bnorm
al
Pro
cedure
4. S
OP
5. S
pecia
l
Inspn
6. G
M
7.
Org
aniz
ation
Appro
val
8. P
ers
onnel
Appro
val
9. T
RN
G
10. O
thers
Escala
tion
Facto
r [E
F]
Escala
tion
Contr
ol [
EC
]
Severity
x
Lik
elih
ood
Ris
k L
evel
1. E
merg
ency
Pro
cedure
2. B
ackup
Syste
m
3. A
bnorm
al
Pro
cedure
4. S
OP
5. S
pecia
l
Inspn
6. G
M
7.
Org
aniz
ation
Appro
val
8. P
ers
onnel
Appro
val
9. T
RN
G
10. O
thers
Escala
tion
Facto
r [E
F]
Escala
tion
Contr
ol [
EC
]
Severity
x
Lik
elih
ood
Ris
k L
evel
E-
RM1
EF (to
E-
RM1)
EC1
(to EF)
N-
RM1
EF (to
N-
RM5)
EC1 (to
EF)
EF1
(to E-
RM2)
EC (to
EF1)
N-
RM2
EF1
(to N-
RM6)
EC (to
EF1)
EF2
(to E-
RM3)
EC (to
EF2)
EF (to
E-
RM4)
EC (to
EF)
Description of Existing Recovery Measures [E-RM] Description of New Recovery Measures [N-RM]
Mu
ltip
le a
ircr
aft
syst
em
(s)
failu
re o
r
malf
un
ctio
n (
du
e t
o e
lect
rica
l w
irin
g
dam
age b
y r
ats
).
3B
R4 -
Lo
w R
isk
Ult
imate
Co
nse
qu
en
ceResultant
RI & T
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Ultimate Consequence Mitigation (as applicable) >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
Rat
(s)
infe
stati
on
co
nfi
rmed
th
rou
gh
rat
sigh
tin
gs
or
evid
en
ce o
f ra
t
4C
L3 -
Mo
dera
te R
isk
Existing Recovery Measures [E-RM] Existing
RI & TNew Recovery Measures [N-RM]
Un
safe
Ev
en
t
E-RM1: Any operational aircraft reported with rat sighting
is subject to a cabin inspection by maintenance personnel
during stayover check.
N-RM1: Special Inspection sheet (Ref SI/ A320/ 25/ 112) has
been raised to require any operational aircraft with reported
sighting or evidence of rats infestation to be scheduled for de-
infestation action by approved Pest Controller upon aircraft
return to main base.
N-RM2: A routine "C" Check Maintenance Job Card has been
raised to call for inspection of all exposed aircraft internal
fuselage compartments for evidence of rat droppings and
necessary follow up action.
28
Same process to evaluate
Recovery Measures & Risk
Index as H>UE
10/01/2017
15
Copyright © 2015 Civil Aviation Authority of Singapore. All rights reserved. 29
2.10 Check Scope of Defenses to RI Correlation (sht 9)Sheet 9: Defences (PC/ RM) to Risk Index Correlation Guide ######
Severity LikelihoodRisk
Index #Risk Level 1. ERP
2. Backup
System
3.
Abnormal
Procedure
4. SOP
5. Special/
Duplicate
Inspn
6.
Guidance
Material
7.
Organizati
on
Approval
8.
Personnel
Approval
9. TRNG10. Others
(specify)
Global (industry
organization)
NAAService
Provider
Catastrophic (5) Certain / Frequent (E) 5E
Catastrophic (5) Likely / Occasional (D) 5D
Major (4) Certain/ Frequent (E) 4E
Catastrophic (5) Possible / Remote (C) 5C
Major (4) Likely / Occasional (D) 4D
Moderate (3) Certain / Frequent (E) 3E
Catastrophic (5) Unlikely / Improbable (B) 5B
Catastrophic (5) Exceptional / Impossible (A) 5A
Major (4) Possible/ Remote (C) 4C
Major (4) Unlikely / Improbable (B) 4B
Moderate (3) Likely / Occasional (D) 3D
Moderate (3) Possible/ Remote (C) 3C
Minor (2) Certain / Frequent (E) 2E
Minor (2) Likely / Occasional (D) 2D
Insignificant (1) Certain / Frequent (E) 1E
Major (4) Exceptional / Impossible (A) 4A
Moderate (3) Unlikely / Improbable (B) 3B
Moderate (3) Exceptional / Impossible (A) 3A
Minor (2) Possible/ Remote (C) 2C
Minor (2) Unlikely / Improbable (B) 2B
Insignificant (1) Likely / Occasional (D) 1D
Insignificant (1) Possible/ Remote (C) 1C
Minor (2) Exceptional / Impossible (A) 2A
Insignificant (1) Unlikely / Improbable (B) 1B
Insignificant (1) Exceptional / Impossible (A) 1A
Note: This Table is an illustration/ guide to the likely scope of PC/ RM categories which might be expected to be considered (where applicable) in relation to
the indicated Risk Index and levels. In principle, a wider scope of defenses can be expected for higher risk levels.
_ _
Op
tio
na
l
_ _
Op
tio
na
l
_
Op
tio
na
l
Op
tio
na
l
Yes
_
Op
tio
na
l
_
Op
tio
na
l
_
Op
tio
na
l
_
Op
tio
na
l
Op
tio
na
l
_ Yes Yes
Op
tio
na
l
Op
tio
na
l
Yes Yes Yes
Op
tio
na
l
Op
tio
na
l
Yes Yes
Op
tio
na
l
Yes
Yes Yes Yes YesYes
Possible PC/ RM Control LevelConsideration of PC/ RM Categories to Risk Levels (where applicable)
Yes Yes Yes Yes YesYes YesYes YesYes Yes Yes
Yes
Op
tio
na
l
Risk Index Description
R5 -
Negligible
Risk
R2 -
High Risk
R3 -
Moderate
Risk
R4 -
Low Risk
R1 -
Extreme
Risk
_
Op
tio
na
l
__ _
Yes Yes Yes
Copyright © 2015 Civil Aviation Authority of Singapore. All rights reserved. 30
2.11 SRM Project Report (sht 10)
SAFETY RISK MITIGATION REPORT
Organization Name SRM Report No:
Operation / Process / Area
Date:
Specific Hazard Description
Department:
Section:
Hazard ID Code** Reserved
Project start date: Project completion date: Next Review date:
*Existing Risk Index & Level*: *Resultant Risk Index & Level:
Documents Attached (as indicated below):
Item Document Yes/ No
1 Schematic output of the completed SRM project (eg completed HIRM Wsht or BTXP Diagram)
2 Summary of modified/ new defenses and required actions.
3 Other attachments (documents, drawings, references, standards, exceptions, etc.), if any
SRM Project Team Leader:
Sign-Date Name Designation
SRM Project Team Members:
Reviewed by SMS/ Safety/ Quality Manager:
_________________ ________________________________ ____________________________
Sign-Date Name Designation
Approved by (Department Head, etc):
Date Name/ Designation Signature
Note: Upon approval, forward Copy to SMS Office for HRM Master Register update/ closure
**Refer HIRM Wsht, Tab #11 – Hazard & Risk Management Register. *Refer HIRM Wsht Tab #8 – Risk Levels
10/01/2017
16
Copyright © 2015 Civil Aviation Authority of Singapore. All rights reserved. 31
Excel HIRM Worksheet
This is the Excel HIRM Worksheet >>>
Copyright © 2015 Civil Aviation Authority of Singapore. All rights reserved.
HIRM Worksheet – Quiz 1
Purpose of the HIRM Worksheet illustrated in this Section is:
a) to facilitate the performance and documentation of a safety risk
mitigation process for specific individual hazards
b) to facilitate the performance and documentation of a safety risk
mitigation process involving multiple hazards and consequences
simultaneously
c) Assist organizations in the development of their SRM procedures and
documentation requirements
d) (a) and (c) are correct
32
10/01/2017
17
Copyright © 2015 Civil Aviation Authority of Singapore. All rights reserved.
HIRM Worksheet – Quiz 2
Based on the HIRM definitions addressed in this Section, the term
“Unsafe Event” can mean:
a) Most credible unsafe situation, as projected from a given Hazard
b) Most credible unsafe situation, not yet amounting to an Ultimate
Consequence
c) An intermediate Event/ Situation before an accident
d) All above are correct
33
Copyright © 2015 Civil Aviation Authority of Singapore. All rights reserved.
HIRM Worksheet – Quiz 3
Based on the HIRM definitions addressed in this Section, the term
“Escalation Control” would mean a mitigating action or defense to
block or prevent :
a) an Escalation Factor from compromising or weakening a Preventive
Control
b) a Preventive Control from compromising or weakening an Escalation
Factor
c) an Escalation Factor from compromising or weakening a Recovery
Measure
d) both (a) and (c) are correct
34
10/01/2017
18
Copyright © 2015 Civil Aviation Authority of Singapore. All rights reserved.
HIRM Worksheet – Quiz 4
Based on the HIRM Worksheet addressed in this Section, the 10
categories of defenses shown in the Worksheet are meant to be
absolutely comprehensive and applicable to all operational context
and organizations:
a) TRUE
b) FALSE
35
Copyright © 2015 Civil Aviation Authority of Singapore. All rights reserved.
HIRM Worksheet – Quiz 5
Based on the SRM Procedure addressed in this Section, the
“Resultant Risk Index” of an Ultimate Consequence should be
based on:
a) the combined Existing Preventive Controls plus New Preventive
Controls which have been put in place
b) the combined Existing Recovery Measures plus New Recovery
Measures which have been put in place
c) the combined Existing Escalation Factors which have been put in place
d) the combined New Escalation Factors which have been put in place
36
10/01/2017
19
Copyright © 2015 Civil Aviation Authority of Singapore. All rights reserved.
HIRM Worksheet – Quiz 5
Based on the SRM Procedure addressed in this Section, the
Likelihood value of an Unsafe Event/ Consequence may be more
objectively derived by correlating the consolidated barrier strength
value of the unsafe event/ consequence with the Likelihood table:
a) TRUE
b) FALSE
37
Copyright © 2015 Civil Aviation Authority of Singapore. All rights reserved.
HIRM Worksheet – Quiz 6
The purpose of a Master Hazards Register is:
a) to collate all valid hazards within an organization as well as to
account for their subsequent SRM actions
b) to serve as an accident and serious incident reports Register and to
account for their subsequent investigation actions
c) to serve as a voluntary Error and Violation reports Register and to
account for their subsequent enforcement/ disciplinary actions
d) All above are correct
38
10/01/2017
20
Copyright © 2015 Civil Aviation Authority of Singapore. All rights reserved.
HIRM Worksheet – Quiz 8
The “Defenses to Risk Index Correlation” matrix shown in this
Section is meant to illustrate the rationale that :
a) Unsafe Events or Ultimate Consequences with high risk index levels
should warrant a more comprehensive scope of defenses to be put in
place
b) Preventive Controls or Recovery Measures with high risk index levels
should warrant a more comprehensive scope of defenses to be put in
place
c) Escalation Factors or Escalation Controls with high risk index levels
should warrant a more comprehensive scope of defenses to be put in
place
d) All above are correct
39
Copyright © 2015 Civil Aviation Authority of Singapore. All rights reserved.
Based on the HIRM Worksheet illustrated in this section, the code
annotated as “EF>N-PC1” in a Preventive Control cell would have the
following meaning:
a) This is the Escalation Factor to the New-Preventive Control No 1
b) This is the Escalation Control to the New-Preventive Control No 1
c) This is the Escalation Factor to the New-Recovery Measure No 1
d) This is the Escalation Control to the New-Recovery Measure No 1
HIRM Worksheet – Quiz 9
40
10/01/2017
21
Copyright © 2015 Civil Aviation Authority of Singapore. All rights reserved.
Based on the HIRM Worksheet illustrated in this section, the code
annotated as “EC>EF1>E-RM2” in a Preventive Control cell would
have the following meaning:
a) This is the Escalation Factor to Escalation Control No 1 affecting
Recovery-Measure No 2
b) This is the Escalation Control to Escalation Factor No 1 affecting
Existing-Recovery Measure No 2
c) This is the Escalation Control to Existing-Recovery Measure No 2
affecting Escalation Factor No 1
d) This is the Escalation Control to Escalation Factor No 1 affecting New-
Recovery Measure No 2
HIRM Worksheet – Quiz 10
41
Copyright © 2015 Civil Aviation Authority of Singapore. All rights reserved.
Purpose of raising a Safety Risk Mitigation (SRM) Report upon
completion of a SRM project is:
a) To allow management approval of the completed SRM project to be
documented
b) To provide documentary proof that a systematic safety risk mitigation
process had been conducted with respect to the specified hazard
c) To serve as evidence of the organization’s on-going SRM activities
d) All above are correct
HIRM Worksheet – Quiz 11
42
10/01/2017
22
Copyright © 2015 Civil Aviation Authority of Singapore. All rights reserved.
Congratulations!
for completing this Section 2 on HIRM Worksheet.
You are now able to:
� Understand and apply HIRM Terminology & Definitions� Customize HIRM Tool & SOP� Create Master Hazards Register� Prioritize Hazards for risk mitigation� Activate risk mitigation for selected Hazards� Project Unsafe Event/ Ultimate Consequence� Evaluate Defenses, Risk Index & Tolerability� Check Defenses to Risk Index Correlation� Raise a SRM Project Report
43
Copyright © 2015 Civil Aviation Authority of Singapore. All rights reserved.
Other SRM Tools – eg BTXP
Further information on BTXP SRM software tool in HIRM sht 14.
>>> BTXP 5 mins >>> BTXP Master
44