SMS Sans Frontières – presentation to AsBAA Shanghai and FSF BASS San Diego

Ir. Roger LeeDirector People, Safety and Quality

Metrojet April 2014

INTRODUCTION

Quick introduction of Metrojet’s CSQ TeamAsia’s Economic Development and Business Aviation growthImplementation of SMS – Metrojet’s experience in walking on the SMS frontièresOur commonality in safetyDelivering Safety san Frontiers as industry partners

2

GREETINGS FROM METROJET’S CSQ TEAM

3

THE CORPORATE SAFETY & QUALITY TEAM

Roger LeeDirector People, Safety

and Quality

TrainingCrisis Management

ERPEngineering

Cecilia LeeSenior Corporate Safety

& Quality Analyst

SecurityManagement Reporting

Ground Operational SafetyConfidential Reporting

System

Sue Ann LawCorporate Safety &

Quality Analyst

Occupational Safety and HealthEU-ETS

Safety PromotionsSafety and Quality Support

Operational World + Safety Officers

Hans von BlucherManager, Air Safety

Air SafetyFlight Data Monitoring

ONE AIRCRAFT DELIVERY TO ASIA PACIFIC EVERY THREE DAYS FOR THE NEXT 10 YEARS

5

870 aircraft currently , 2,845 expected by 2019

High growth rate of 16% per annum in China

Home to 6% of the worldwide business jet fleet

China - around 360 jets registered , 1000 business jets anticipated to arrive in the next 10 years

Fewer than 200 civil airports in China and many of them are not available to private aircrafts.

Business jets in Asia are more for personal use rather than corporate (9:1)

South Asia485 Business Jets

US$12.0bn

Oceania263 Business Jets

US$6.0bn

China635 Business Jets

US$21.0bn

Northeast Asia90 Business Jets

US$2.9bn

Southeast Asia

217 Business JetsUS$6.1bn

Source: Embraer Analysis – totals may differ due to rounding – sustained growth scenario

INFRASTRUCTURE TO SUPPORT BUSINESS AVIATION?

6

Circle Size indicates the number of aircrafts based at a location

• 360 Business Jets (Greater China)

• 190 public use airports

• Over 110 military only airports

• 1.6 airports per 100,000 km2 land

• Only 6 business jet MROs

China• 14’000 Business Jets• >5’000 public use

airports• >51 airports per

100,000 km2 land• 1.2 million jobs• 150 USD billion

economic output

USA

Sources: - US Figures: NBAA- China Figures: Asian Sky Group, Metrojet Research

METROJET 2013/14 FAST FACTS

7

34Aircraft in Fleet

2500Flight Legs

100,000Engineering Hours

7600Total Flight Hours

300Staff

22Nationalities

>100Pilots & FA

HK Home Carrier

17 yearsheritage in Hong Kong

>100Staff in Engineering

30%Market Share

650Charter Passengers

THE FLEET GROWS STEADILY

8

2010/11 2011/12 2012/13 2013/14

24 25 2734

42%fleet

increase since 2010

METROJET’S AIRCRAFT MAINTENANCE FACILITIES IN ASIA

9

China – Hong Kong, SAR- Metrojet’s Headquarters - 300 staff with over 70 pilots and 110 maintenance professionals - Offer a complete range of aircraft management, aircraft charter, and aircraft maintenance service- Open since 1997

China – Zhuhai- Joint Venture with Hanxing Zhuhai General Aviation to form Metrojet Hanxing, located at Zhuhai airport- Over 15,000 ft2 of hangar space- Enhance the overall aircraft maintenance capability in China Philippines – Clark - Metrojet Engineering Clark (MEC) was established in 2012- Located at Diosdado Macapagal International Airport (DMIA) in the Clark Freeport Zone- A Maintenance, Repair and Overhaul facility catering to increasing demands in the SE Asia region- Over 13,000 ft2 of hangar space

India – Mumbai- Joint venture with Taj Air to form TajAir Metrojet Aviation- Aircraft maintenance capabilities

COMMON PERCEPTION IN BUSINESS AVIATION

10

CROSSING THE FRONTIÈRES THROUGH 4 PILLARS OF SAFETY MANAGEMENT

11

LEADING BUSINESS AVIATION COMPANY IN ASIA

Safety Policy and Objectives

Safety Assurance

Safety promotion Safety Risk

Management

Best People ◦ Highest Standards ◦ Operational & Service Excellence

1 Customer

2 Product

3 People

4 Operations

5 Finance

CHALLENGES – SMS PILLAR ONE

12

Policies

“Plug and Play” policies, procedure and personnel?Complex regulatory environment evolved from commercial aviationSafety standard can potentially be used as commercial bargaining chip by clients

CHALLENGES – SMS PILLAR TWO

13

Risk Management

“Why do we need to risk assess? We have been flying this same route for so long?”“what is its value”“Secondary Duties” mentalityLack of skilled risk assessor – SME involvement crucialRetention of knowledge through a dynamic labour marketTime consuming

Tactical RA

Landscape RA

PDCA cycle

METROJET’S OPERATIONAL RISK PICTURE USING BOW TIE ANALYSIS

14

A

Root Cause, Precursor, or Triggering Event

B

Existing Controls or Avoidance Barriers

C

Undesirable Operational State (UOS)

D

Existing Controls or Recovery Barriers

E

Outcome

Risk

Lev

el

ALAR

P?

F

Additional Controls or Mitigation Required (feeds back into Column B)

Fina

l Ris

k

1. Circling approach

TAWS / EGPWS; Note to MLW: check MEL implications if EGPWS or any associated system is U/S.

Use of Global Navigation Satellite System (GNSS) based position feed to TAWS;

EGPWS database update protocols; Cockpit technology to assist situational

awareness (e.g. terrain overlay with certain aircraft);

Shared mental model and enhanced awareness through effective briefings;

Pilot awareness / training; Manual flying skills; Situational Awareness in relation to

proximity of terrain; Adherence to SOPs (task sharing, briefings,

use of checklists, standard calls and excessive-deviation callouts, mutual crosscheck and backup);

Cross-check of takeoff data: mass and balance, fuel distribution, wind component, runway conditions, flaps setting, V1/Vr speeds, and so on;

Adherence to sterile-cockpit rule; Compliance with the constant-angle non-

precision approach (CANPA) / constant descent final-approach (CDFA) concept;

Adequate use and supervision of automation;

Vertical and horizontal flight paths monitoring (situational and energy awareness);

Altimeter setting cross-check; Cross-checking cleared altitude versus

minimum safe altitude; Timely and adequate response to windshear

alert or warning; Timely go-around; Adherence to published missed-approach

procedure; Use of available aircraft technologies for

enhanced situation awareness (vertical situation display, head-up display, enhanced-vision, and so on);

Use of radio altimeter to improve situational awareness, provided that the flight crew are generally familiar with the terrain over which they are flying;

Awareness of: Minimum vectoring altitudes; Approach design criteria (PANS-OPS

versus TERPS); Relationship between track distance to

runway threshold and height (300 ft/nm rule-of-thumb);

Low-OAT correction to be added to minimum approach altitudes/heights;

Minimum safe radio-altimeter readings for each approach segment (IAF-IF, IF-FAF);

“Black-hole" or other visual illusions for prevailing approach / departure (e.g. Okinawa).

For Fatigue, see separate ‘Fatigue’ template.

Pre-CFIT condition: Loss of situational

(positional) awareness in relation to the proximity of terrain / surface;

Aircraft closing with terrain / surface – erosion of adequate safety margins.

Terrain Awareness Warning System TAWS (EGPWS) alert or warning;

Minimum Safe Altitude Warning (MSAW) warning – subsequent ATC intervention.

Timely and adequate flight crew response to EGPWS alert or warning - recovery of aircraft to a desirable operational state;

Land short (runway undershoot) event;

CFIT resulting in hull loss and fatalities.

2A* 1A*#

NO

Review and introduce to Company SOPs industry prevention strategies and best practices such as those produced by the FSF and Airbus (e.g. Flight Operations Briefing Notes – Operating Environment section: Enhancing Terrain Awareness);

Review SOPs and flight crew training to ensure compliance with the FSF ALAR Toolkit, the ALAR Risk Awareness Tool (RAT), the ALAR Risk Reduction Guide (RRG) and ALAR Briefing Notes;

Introduce aircraft / airport-specific Engine Out Standard Instrument Departure (EOSID) in case of engine failure after take-off at terrain limiting airports, using modern technology such as the subscription services of Guru or APG;

Provide additional flight crew training concerning the recognition of the precursors of CFIT, e.g. through awareness campaigns and through line training and testing – train the trainers accordingly;

CFIT awareness training (e.g. via simulator LOFT, using two Metrojet flight crew); Ensure that flight crew are properly training to carry out RNAV (GNSS)

approaches; Confirm the use the latest standard of EGPWS, fed with GPS-derived position

data; Ensure that adequate emergency escape routes exist in event of depressurisation

(e.g. over Iran); Ensure that QFE procedures are properly addressed in training; Develop and monitor Company SPIs to monitor significant events associated with

CFIT risk, e.g. from Safety Feedback Reports and through FDM: EGPWS warnings and alerts other than “pull up”; False / nuisance EGPWS warnings due to navigation or terrain database

errors; Incorrect flight crew response to EGPWS warnings; Unstable approaches continued to a landing (also as a proportion of all

unstable approaches); Significant deviations below glideslope (greater than x dots below yyy ft

AGL); Significant deviations about the localiser (greater than x dots below yyy ft

AGL); Altimeter setting errors.

Identify and analyse precursors through the examination of safety data from multiple reporting schemes, such as: Feedback from training (especially simulator) sessions; Pilots’ reports; FDM; Line observations; Survey and audit reports; Accident and incident investigations.

For Fatigue, see separate ‘Fatigue’ template.

2. Non-precision approach (especially premature descent to the next step-down altitude during a multiple-steps-down non-precision approach)

3. Unstable Approach, especially if slow and/or low (i.e. low energy state on approach) - flight below desired flight path during initial and/or final approach

4. Unclear / poor approach design and documentation / lack of familiarity with the approach or misreading of the approach plate, particularly where the approach features steps down from the IAF to the FAF

5. Failure to check navigation accuracy before approach

6. Lateral deviation during approach (STAR) 7. Incorrect or inappropriate radar vectoring by

ATC (i.e. below minimum vectoring altitude (MVA) and/or toward high terrain)

8. DME confusion (non-collocated DME versus ILS-DME), in identifying the final descent point

9. Premature descent to DA(H) before G/S intercept or premature descent to MDA(H) before final descent-point/FAF

10. Continued approach, when below DA(H) or MDA(H), after loss of visual references

11. QFE operations, especially if the EGPWS has to be turned off (e.g. Ordos in Inner Mongolia and Dalian)

12. Low altitude pattern following a go-around 13. Lack of effective flight path control during go-

around (e.g. go around in landing configuration with aircraft speed below VAPP resulting in significant loss of altitude)

14. Transition back to instrument flying during a go around

15. Failure to follow published missed-approach procedure

16. Failure to go-around 17. Descent / flight below segment or sector safe

altitude 18. Poor CRM (failure in cross checking /

coordination / monitoring) 19. Non-adherence to SOPs 20. ‘Press-on-itis’ 21. Fatigue 22. Inappropriate low altitude manoeuvring 23. Weather: rain, turbulence, and icing, may

increase flight crew workload and cause interference reducing the accuracy of radio navigation beacons / poor visibility and/or at night may lead to loss of situational awareness

24. Non- standard phraseology, leading to confusion and misunderstanding

25. Prolonged Loss of Communication (PLOC) 26. Low-on-fuel condition / fuel starvation 27. Low pitch attitude / shallow flight path /

altitude loss after lift-off 28. Flight below desired profile path during climb 29. Inability to make the prescribed minimum

climb gradient in event of engine failure after take-off at terrain limiting airports

30. Lateral deviation during climb (SID) 31. Altimeter setting error 32. Failure to revert to navaids raw data in case of

doubts about automation 33. Level Bust 34. “Black-hole" or other visual illusions 35. Late or inadequate response to windshear

warning

Root Cause, Contributing factors and initiating event

Existing defences

Undesirable state

Existing recovery barriers

Outcome

ALARP

METROJET’S RISK ASSESSMENT CRITERIA

15

Meaning in relation to People/life costs

Meaning in relation to financial/Property costs

Meaning in relation to reputational costs

Meaning in relation to Liability Cost

Meaning in relation to Environmental Cost

CHALLENGES – SMS PILLAR THREE

16

Safety Assurance

E-Audit and physical operational audit programme“What is business aviation?”Lack of designated FBOs and support facilities Lack of understanding in standardsHave to establish the level of compliance between our manuals and the “real world” – implementation of fleetwide Flight Data Analysis Programme – our biggest project so farInvestigation – 5’Ms, MEDA important

17

Incidents and Occurrences

a) Class A and B events in last reporting period b) Outstanding Insurance claims accumulated values

Headline Message: Sample: This reporting period, there have been 5 cases of

risk bearing events triggering the RED status

Trends

a) Reporting rate proportionality with ground

movement and flight ops exposure b) Rolling 3 months average of Class A and B

compared with last reporting period c) Class A and B personal injury events per 1000 staff

Headline Message: ……

Assurance

a) Level 1 and 2 regulatory audit findings b) Level 1 and 2 internal and external audit findings c) Outstanding actions and recommendations from

audits and investigation follow up d) Investigation recommendations follow up and

closure e) OHSE audit findings

Headline Message:

……

Safety Culture

a) SRB, SAG committee meetings held - schedule b) SRB, SAG committee meetings held - attendance c) SRB, SAG actions followed up and closed d) Regular review of the Safety and Quality Risk

Picture e) Corporate QMS and audits completed within

prescribed timescale f) Engineering internal audits completed within

prescribed timescale g) Number of anonymous safety reports h) Number of new reports from first time submitters

Headline Message:

……

METROJET’S SAFETY BALANCED SCORECARD

CHALLENGES – SMS PILLAR FOUR

18

Safety Promotion

Apprehensive - “trust” of the safety systemInfluence by “macro environment”International workforceTargeted communication with consideration of cultural and professional groups differencesApply to a mobile workforce who needs to access the information anytime, anywhereMultilingual Resource hungry if done properly!

PROMOTING SAFETY THROUGH GROWTH

19

• Theme of the 2-months• Safety Digest• Making use of IT Platform• Safety Mascot Competition

2013-2014 SAFETY MASCOT COMPETITION

20

THE CULTURAL CHALLENGES

21

TRAIN, TRAIN, TRAIN

22

SHARE SAFETY

Safety – we need to shareWithout information sharing, safety is dead

AS AN INDUSTRY, WHAT CAN WE DO?

24

Training– Clients– Staff– Regulators– Perspective staff

Sharing– Regional specific hazards and trends– Risk bearing occurrences– Global trends– Lessons learnt– Proactive data

Alignment– Alignment of safety standards and the “safety norm”

Understanding and declaring what the minimum standard is for Asia Business Aviation industryShare – lessons learnt, deidentified safety dataRisk based approachSafety Promotion ResourcesAsia Business Aviation safety forumSafety and ERP Industry Go team

CONCLUSION

With growth comes risks – which must be managed in a systematic and structured manner

Unfortunately, nothing called “plug and play” in aviation – having the policy, procedure or the hardware does not mean one is safe. These need to be continuously internalized.

Safety is one of the core functions of any aviation business, just like finance, marketing, engineering and flight operations which contribute towards the ROI, NPV and EBIT of an operator

Lets address safety as an industry team

25

FINALLY

26

BUSINESS AV SAFETY

27