Risk-based Oversight

Risk-based Oversight

Definitions

Risk-based Oversight (RBO): A way of performing oversight, where:

  • planning is driven by the combination of risk profile and safety performance; and
  • execution focuses on the management of risk, in addition to ensuring compliance.

Risk Profile: The elements of risk that are inherent to the nature and the operations of the regulated entity, this includes:

  • the specific nature of the organization/operator;
  • the complexity of its activities;

the risks stemming from the activities carried out.

Safety Performance: The demonstration of how effectively can a regulated entity (e.g. operator) mitigate its risks, substantiated through the proven ability to:

  • comply with the applicable requirements;
  • implement and maintain effective safety management;
  • identify and manage safety risks;
  • achieve and maintain safe operations;

the results of past certification and/or oversight also need to be taken into account.

Performance-based Oversight

EASA explains the relationship between Performance-based Oversight (PBO) and Risk-based Oversight (RBO) as:

The concept of "performance" conveys the idea of tangibly measuring the health of the system under scrutiny and ultimately assessing its overall performance. Performance indicators, as a means to measure, may specifically help to either identify risks within that system or measure safety risks or monitoring actions mitigating these risks. This means that a PBO can also support the identification of areas of greater risk and serve the risk assessment and mitigation exercise. This is where PBO meets RBO. [1]

Discussion

The implementation of Safety Management Systems signals a shift from reactive and compliance based oversight to a new model that includes proactive and performance-based tools and methods.

Recognising that compliance alone cannot assure safe operations, and that effective and affordable regulatory oversight needs to be targeted, most regulators have altered the relationship between the operators and the Competent Authorities to ensure that greater oversight is applied to those that need it. To achieve this, Inspectors need to be able to assess safety performance and the key factors that influence it. If an Operator's Compliance Monitoring Function demonstrates that regulatory and procedural compliance is being monitored effectively internally then it will attract less external oversight.

A risk-based approach to oversight entails the assessment of the performance influencing factors, organisational changes and other safety performance indicators that make up an operator's risk profile. An operator's risk profile will inevitably be dynamic. The regulator must have a process that acquires and analyses different sources of intelligence that provide insight into the changing risks in an operation such as:

  • reported occurrences;
  • reorganisation and restructuring (e.g new management and reporting structures, new operating bases, new aircraft types, changing working practices);
  • retirement/departure of a key employee (e.g new accountable managersafety manager, or operations director);
  • financial health of the organisation;

Those operators with a high-performing SMS and clear safety leadership will attract less oversight.

Accidents and Incidents

The following events in the SKYbrary database of Accident and Incident reports feature Ineffective Regulatory Oversight as a contributory factor:

On 18 November 2022, the crew of an Airbus A320neo about to become airborne as it departed Lima were unable to avoid a high speed collision with an airport fire appliance which unexpectedly entered the runway. The impact wrecked the vehicle killing two of its three occupants and a resultant fuel-fed fire severely damaged the aircraft although with no fatalities amongst its 107 occupants. The vehicle was found to have entered the runway without clearance primarily as a consequence of inadequate briefing for an exercise to validate emergency access times from a newly re-located airport fire station.

On 10 August 2019, the left Rolls Royce Trent 1000 engine of a Boeing 787-8 just airborne from Rome Fiumicino suddenly malfunctioned and was shut down. A MAYDAY was declared and the flight returned for an overweight landing during which both left main gear tyres deflated. The underlying cause of the engine failure was found to have been intermediate pressure turbine blade detachment attributable to previously-identified serviceability issues. Wider concerns were identified in relation to the key underlying engine certification standards and to the hazard created by the ejection of large quantities of engine debris into a densely populated area.

On 28 March 2018, a Boeing 767-300 and a Boeing 737-700 were being simultaneously pushed back in darkness from adjacent parking positions as cleared when their respective tailplanes collided causing substantial damage. The comprehensive Investigation found that the 737 clearance conflicted with both a previously-issued clearance to the 767 aircraft and with the actual location of the 737. It also found that the controller’s error had been compounded by the wing walkers tasked with external monitoring of both pushbacks being in the drivers’ cabs because it was raining and a context of systemic ramp operations inadequacy was identified as contributory.

On 3 August 2009, control of a rotary UAV being operated by an agricultural cooperative for routine crop spraying in the south western part of South Korea was lost and the remote pilot was fatally injured when it then collided with him. The Investigation found that an inappropriately set pitch trim switch went unnoticed and the consequentially unexpected trajectory was not recognised and corrected. The context was assessed as inadequacies in the operator’s safety management arrangements and the content of the applicable UAV Operations Manual as well as lack of recurrent training for the operators’ qualified UAV remote pilots.

On 22 April 2019, a Eurocopter-Kawasaki BK-117C-1 helicopter was being positioned for an aeromedical evacuation the following day when it was unintentionally flown into the sea at night. The three crew members were able to evacuate from the partially submerged aircraft before it sank. The accident was attributed to the single pilot’s loss of situational awareness due to loss of visual depth perception when using night vision goggles. The relevant aircraft operator procedures and the applicable regulatory requirements were both found be inadequate relative to the operational risk which the flight involved.

Related Articles

Further Reading

References

  1. ^ "Practices for risk-based oversight"; Edition 1, published by EASA 22 November 2016
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