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SAFETY RISK ASSESSMENT REPORT

Date of Report: January 16, 2011 

Safety Risk Assessment (SRA) Topic: Major Events in the City of 

South Bend IN and their impact on the South Bend Regional Airport 

(SBN) 

Introduction

The St. Joseph County Airport Authority (SJCAA) chose for their first of three SRAs to 

analyze the impacts of major events in the City of South Bend IN on SBN operations. 

The SRA was conducted on December 16, 2010. This report and the attached 

documentation are intended to meet the requirements of the Safety Management 

System (SMS) Implementation Study (Study) for SRA reporting. 

SRA Process

The process used for this SRA closely followed the SBN SMS Program Manual Safety 

Risk Management (SRM) process. The detailed SRM process extracted from the SMS 

Program Manual is included in Appendix A of this report. This particular topic provided 

some challenges. Because the SJCAA staff and the airport’s tenants and airlines have 

been managing major events at SBN for many years; this SRA ultimately focused on 

existing practices and potential improvements. 

In order to focus the SRA and its analysis, a decision was made early in the SRA panel 

discussion to concentrate on Notre Dame Football games. Initially the panel considered 

including presidential arrivals in the scope of the SRA; but ultimately the panel 

determined that activities associated with the Notre Dame Football games have a much 

broader impact on airport operations. 

Findings

The SRA facilitation analyzed the risks as currently mitigated within the existing system. 

The SJCAA, tenants, and airlines have several mitigations currently in place that have 

been developed and improved upon over many years. The results from the SRA’s 

hazard identification and risk analysis demonstrated the effectiveness of the existing 

mitigations. The hazards that were analyzed produced one hazard that was determined 

to result in a medium level of risk and two others resulted in a low level of risk. 

Although the hazards were determined to be at acceptable levels as currently mitigated 

the panel identified several other possible mitigations that warranted investigation and 

possible implementation. See Appendix B for the SRA Documentation as approved 

and accepted by SJCAA staff following the completion of an SRA. 
 

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Summary 

As background, the SJCAA staff has conducted four SRAs over the past two years. 

The documentation has been modified to support improved processes and better staff 

participation. The SRA process however has not changed much. This SRA resulted in 

no residual risk assessment because current mitigations developed over the last few 

years result in an acceptable level of risk. 

One change is proposed to the SJCAA SMS Program Manual SRA process. When the 

SMS Program Manual was developed during the first Pilot Study, the term Safety Risk 

Management (SRM) was used to describe the SRA process. The documented product 

that would be developed was called the SRM Document (SRMD). This mirrored terms 

used by the FAA Air Traffic Organization (ATO). As a result of the SMS Implementation 

Study the term is consistently called SRA. Therefore; this change will be made to the 

SJCAA SMS Program Manual at the conclusion of the Study and as part of the final 

report. 

The SJCAA will be conducting two additional SRAs as part of the Study; a similar report 

will be developed that will describe the SRA topic, identified hazards, and outcomes. 

Please see the attached documentation for further details. 
 

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Appendix A 

Detailed SRM Process from SMS Program Manual 
 

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Safety Risk Management (SRM) Assessment Process

The following process assumes the project “owner” or “proponent” has already assembled the SRM 

panel. The panel includes Subject Matter Experts (SME) and stakeholders in the project or system. 

SRM is broken out into five (5) steps. They are: 

1. Describe the System 

2. Identify the Hazards 

3. Analyze the Risk(s) Associated with Each Hazard 

4. Assess Each Risk 

5. Treat/Mitigate Each Risk, Implement, Verify, and Monitor 

To conduct a successful SRM, there must be an understanding of the situation and system that is to be 

analyzed for hazards and risks. Each individual SRM may have different inputs and results. However, 

each SRM has basic fundamental parts that should be incorporated. Following is a brief outline of what 

each step of an SRM should include: 

Step 1: Describe the System uses the 5M Model: 

• Mission: What is the function of the system? 

• Media/Environment where does the system reside? (airport environment most 

likely) 

• “hu” Man/Person. 

o Operational Personnel 

o Maintenance Personnel 

o Engineering Personnel 

o Other (Airline, FAA, TSA) 

• Machine: Outline mechanical and human interface points. 

• Management: SOPs, checklists, rules, and regulations. 

• Bounded out: Determine what is NOT included in the system for review (OSHA 

regulations perhaps). 

Step 2: Identify the Hazards: FAA defines a hazard as: Conditions that exist in the system that 

can lead to injury, illness, or death to people; damage to or loss of a system, equipment, 

or property; or damage to the environment. 

Hazards can originate from multiple sources. They include: 

• Equipment 

• Operating Environment 

• Human Operator 

• Human-Machine Interface 

• Standard Operating Procedures (SOPs) 

• External Services 

Several tools may be used for Hazard identification; they include many of the business 

model tools used in other industries. Such as: 
 

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• Scenario Process Tool 

• Logic Diagram 

• Change Analysis 

• Cause and Effect Tool 

• Bow Tie Model 

However, the process of a “what-if” brainstorming session to create a Preliminary Hazard 

List (PHL) and then conducting a Preliminary Hazard Analysis to focus the remainder of 

the process is a preferred simple and direct method of approach. This process works 

well with a diverse SRM Panel that can represent different points of view in the system.

Step 3: Analyze the Risk(s) Associated with Each Hazard: 

• Identify the existing mitigations/controls in the system. (example: radio 

procedures for communication with ATC) 

• Determine the severity of risk for each hazard. What can happen that is 

reasonably anticipated? DO NOT factor in likelihood at this point. This is the 

severity. 

• Determine the likelihood of risk for each hazard. How often can it happen? Has it 

happened before (review previous incidents and accidents reports)? Use 

operational expertise and professional judgment if not enough information is 

available from previous data. Quantitative analysis is preferred over Qualitative. 

Step 4: Assess Each Risk(s) Associated with Each Hazard: Using the risk matrix, rank the 

hazards according to their severity and likelihood. 

• Hazards that are identified as a low risk do not need further mitigation or 

analysis. 

• Hazards that are identified as a medium risk do not require further mitigation; 

however, if mitigations can be implemented to reduce the risk, then the SRM 

Panel should consider deploying the mitigation. 

• Hazards that are identified as a high risk must be mitigated or avoided all 

together. A medium risk is the lowest level of acceptable risk. 

• Determine hazards for detailed risk mitigation (based on their risk level). 

Note: All high risks must be mitigated down to a medium risk or avoided 

altogether. All medium risks must be analyzed to determine if they can be lowered 

to a low level of risk. A medium level of risk is the minimal acceptable level of risk. 

All low levels of risk should be analyzed to determine if they can be eliminated 

altogether. 

Step 5: Treat/Mitigate Each Risk, Implement, Verify, and Monitor: Determine what 

treatment/mitigation measures may be implemented to reduce the risks as described 

above: 

a. Identify feasible mitigation options. 

• Mitigation options may include: 
 

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i. Training (example: additional radio operator training for ATCT 

communications). 

ii. Improved equipment (example: new table saw with updated safety 

devices). 

iii. Specific safety equipment (example: hard hats or reflective vests). 

iv. Reconfigure the system to improve a hazardous situation (example: 

realign aircraft parking positions to increase wingtip clearance between 

aircraft). 

b. Develop risk mitigation plans: 

• Determine what mitigation options are feasible (realistic). Review what mitigation 

options have been successful in the past. What new options are available now? 

• Determine if the mitigation that is put in place creates additional hazards. 

Example: A Passenger Boarding Bridges (PBB) used to board larger commercial 

aircraft eliminates the hazard of passengers walking on the aircraft ramp. 

However, by using a PBB you have introduced a new hazard into the system that 

is the act of pulling a large piece of equipment up to and coming in contact with a 

multimillion dollar aircraft. This new hazard and its associated risks must also be 

mitigated. 

• Determine the costs of mitigation. Each mitigation tool put in place has costs, in 

the form of time or money. Define this impact and document it. Costs should 

NOT be considered except when determining what mitigation options should be 

considered or used. It is important to know the costs so that the person accepting 

the risk and the mitigation has a complete picture of the impact. 

c. Document what will be completed for mitigation. 

d. Document what will be completed for monitoring the mitigation to ensure its 

effectiveness. 

• Monitoring should continue throughout the life cycle of the change. 

• Documentation of the monitoring should be reviewed periodically to ensure the 

mitigation is working. 
 

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Appendix B 

SRA Document 
SBN SMS 1 

SRA Document 

SBN SRA Documentation 

Major Events in South Bend IN. Impact to Airport Operations 

Safety Risk Assessment (SRA) Topic: 

The purpose of the SRA was to analyze the impacts on the airport of major events held in the city of South Bend. Specifically, 

events identified included Notre Dame Football games and presidential arrivals. Both types of events cause major disruption 

to the airport and require special operations and procedural changes to accommodate the event. The impacts and current 

procedures were analyzed to assess whether additional mitigations could improve the overall safety of handling these events 

at the airport. 

NOTE: The panel participants agreed to focus on Notre Dame football games to narrow the discussion. 

Existing System: 

The South Bend Regional Airport (SBN) is owned and operated by the St. Joseph County Airport Authority (SJCAA). SBN 

serves the City of South Bend IN, the northern region of the State of IN, and the southwest region of the State of Michigan. 

Runways: 

1. Runway 9R-27L, 8,412X 150 ft. (the primary) CAT I approaches to both ends 

2. Runway 9L-27R, 4,300 X 75 ft. [General Aviation Aircraft (GA) use only] no precision approaches, GPS and VOR 

approaches only 

3. Runway 18-36, 7,100 X 150 ft. no precision approaches, GPS and VOR approaches only 

Taxiways: 

Parallel taxiway system exists for all three runways. Runway 9R-27L has duel parallel taxiways, one on either side of the 

runway. 

Fixed Base Operator (FBO): 

SBN has one FBO, Atlantic Aviation. The FBO is located on the north side of Runway 9R-27L. The FBO provides ground 

handling services and refuels the majority of GA arriving and departing into SBN for major events. 

Aircraft parking ramps: 

Several aircraft parking ramps are used for GA parking; including the FBO ramp, UPS cargo ramp, Executive ramp, and the 

“Football” ramp which is only used for major events that require overflow parking. The Football ramp is located across A 

Taxiway from the FBO. Use of the Football ramp sometimes requires the use and closure of Taxiways A-3 and A-4. The type 

of event and the wind direction (runway use) will dictate whether A-3 and or A-4 are closed. On occasion, when the numbers 

of aircraft require more area for parking, Runway 18-36 is closed; and aircraft are parked between the parallel runways. 

However, Runway 18-36 has not been closed since the football ramp was opened. The Charter ramp, located on the south 

side of the airport, is used for the arriving football teams’ aircraft. (See attached airfield layout plan for the location of the 

identified ramps). 

Aircraft numbers and types: 

Based on SRA panel discussions, during the past three years the average number of aircraft on an event day is 

approximately 100. An event weekend duration is defined as noon on Friday until 1:00 PM on Sunday. The overall numbers 

for an event weekend are 1.5 times greater than a one-day event. Prior to the past three years, GA has numbered closer to 

300 for the event weekend. Total event related GA operations may number as high as 750 for the entire weekend. 

The types of GA very widely. However, GA most commonly includes small to medium size business aircraft, such as Citation 

Jets, Lears, and light twin engine. The arriving football teams typically use a Boeing 757. 

 
SBN SMS 2 

SRA Document 

Current procedures: 

FBO: Smaller GA are parked on the FBO ramp, the Football ramp, and the Executive ramp. Medium to larger sized GA are 

parked on the UPS ramp. All GA are parked so they can start engines and taxi out without requiring another aircraft to move. 

The FBO ensures that all GA are parked to accommodate this procedure. The FBO marshals all arriving GA to parking areas 

and transports flight crews and passengers via shuttle buses to the FBO building for ground transportation. The FBO offers a 

reservation system for incoming GA. Approximately 50% of the arriving GA take advantage of this system. The reservation 

system allows the FBO to be prepared to accommodate the aircraft type and the number of passengers on board, as well as 

any special needs. The FBO uses a dispatcher working on the Unicom frequency, to take information from in-bound GA and 

relay that information to the marshallers and shuttle bus drivers. Information is relayed using Nextel phones. “Follow Me” 

carts are used to lead GA to their parking positions. Designated walking and driving routes are used and marked with cones 

to assist with the transportation of crews and passengers. The FBO employs additional personnel to assist from other Atlantic 

Aviation locations (other airports). The process is reversed for departing GA. 

FAA Air Traffic Control Tower (ATC): During an event, the ATC closes A Taxiway between N Taxiway and A-2. This includes 

turnoffs A-3 and A-4 as previous mentioned. ATC directs landing GA to the FBO. ATC also uses a departure reservation 

system for the weekend events. This ensures individual GA has a specific departure time and therefore assists with 

dispersing and managing the volume of GA after the games. Additional staff is also deployed to provide additional oversight 

and staff rotations for controllers. 

SJCAA: Operations Team: files Notice to Airman (Notam(s)) to close Taxiway A as a movement area; it remains open as a 

non-movement area, so it is still available for aircraft movement. Physical barricades are sometimes used to help identify the 

transition between movement and non-movement areas. This facilitates the use of the Football ramp. Additional staff is 

assigned to the area to actively monitor and assist with GA parking, vehicle movements, and pedestrians. SJCAA operations 

team assists with the relocation of UPS aircraft from their cargo ramp to accommodate GA parking. SJCAA operations team 

gathers information from Atlantic Aviation concerning rental car reservations as well as other sources to facilitate discussion

between the FBO, ATC, and SJCAA regarding numbers of anticipated aircraft. SJCAA also holds an annual meeting to 

discuss changes and/or logistics associated with the upcoming football season. 

 

Exhibits: 

1. Airport Layout drawing 

2. Ramp designations 

3. SJCAA Risk Matrix and definitions 

Date: December 16, 2010 Facilitator: Dave Fleet (SMS Consultant) 

SRA Sponsor: Bruce MacLachlan, Manager for Operations and 

Maintenance SJCAA. 

Panel Participants 

Note: Sign in sheet is attached. 
SBN SMS 3 

SRA Document 

Hazard and Risk Assessment:

The panel identified the following list of potential hazards: 

1. Pedestrians on the airfield 

2. Jetblast 

3. Conflicting traffic on A taxiway (aircraft and vehicles) 

4. Inexperienced pilots 

5. Unfamiliar employees 

6. Weather 

7. Darkness 

8. Disgruntled and inebriated fans 

9. Noise 

10. Additional Foreign Object Debris (FOD) 

11. Human factors 

12. Fire/emergency response 

Table 1 identifies the potential hazards and the associated risk assessment. Note: the panel determined that after considering all 

the existing mitigations, not all hazards merited a full assessment of residual risk. Some hazards were combined to facilitate a 

concise risk assessment. 

Table 1 - Hazard and Risk Identification 

Hazard Risk Risk 

Assessment 

Mitigation Residual 

Risk 

1. Pedestrians on the airfield Impact to 

pedestrians 

Severity – Minor 

personal injury 

Likelihood – 

Probable 

Medium Risk 

1. The FBO provides designated walking 

paths. 

2. The FBO escorts all pedestrians to and 

from GA. 

3. The FBO and the SJCAA maintain visual 

contact with all pedestrians while they are 

on the airfield. 

4. The FBO trains all staff from other airports. 

5. The FBO maintains a list of between 5 and 

10 employees from other airports. Only 

those employees are allowed to work on 

major event days. 

MEDIUM 

2. Aircraft and vehicles using 

A Taxiway simultaneously 

Incident or 

accident 

between 

aircraft and or 

equipment 

Severity – Major 

Likelihood – 

Extremely Remote 

Low Risk 

1. All aircraft are marshaled to parking 

positions 

2. Wingtip clearances are maintained 

between aircraft to ensure adequate 

vehicle and aircraft movement around the 

aircraft 

3. Radio communications are established 

among the FBO, ATC, Pilots, and SJCAA 

4. Low speeds are maintained for both 

aircraft and vehicles 

LOW 

3. Aircraft and vehicles using 

A Taxiway 

Incursion of 

an adjacent 

movement 

area, 

especially 

Runway 9R27L 

Severity – Minor 

Likelihood – 

Extremely Remote 

Low Risk 

1. Physical barricades are in place 

2. Aircraft are parked to restrict exit from nonmovement areas 

3. FBO staff are trained in ramp area and 

airfield operations 

4. ATC maintains radio communication with 

SJCAA and the FBO 

5. SJCAA actively monitors the ramp areas 

LOW 
SBN SMS 4 

SRA Document 

Synopsis of Risk Assessment:

Hazard 1. The panel referred to limited records and their Subject Matter Experts (SMEs) to determine when the last time a 

pedestrian was injured on the airfield. There were no records of such an incident and the SME could not recall anyone becoming 

injured on the airfield. However, because the jetblast and propwash were so prevalent, the panel believed that potential damage

or irritation to eyes warranted a minor injury determination for Severity and a probable determination for Likelihood. The panel 

also noted that due to the low speed of vehicles and aircraft on the ramp area, this increased separation and therefore improved 

the margin of safety. 

Hazard 2. The panel referred to limited records and their SME to determine when the last time an aircraft or vehicle was 

damaged on the airfield. The only record noted was an accident that occurred approximately seven years ago when a limo driver 

left the proximity of his escort and backed into an aircraft causing minor damage to the aircraft. However, this incident was 

unrelated to a major event. The panel also agreed that the low speeds of aircraft and vehicles increased separation and 

therefore improved the margin of safety. 

Hazard 3. The last incursion at SBN occurred in 2007. Again, the incursion did not occur during a major event. The incursion 

occurred when an escorted vehicle took a turn too wide and incurred on A Taxiway. The last incursion that resulted in death and

or catastrophic damage to an aircraft or vehicle was believed to have occurred in 1994. Therefore, the panel agreed that 

although the incursion occurred during a major event day, the existing mitigations result in Minor and Extremely Remote. 

Note: most incursions at SBN have been associated with snow removal operations. Snow Removal might be a topic for a future 

SRA. 

Potential Additional Mitigations:

The panel discussed how to improve the current operations and procedures to increase safety and reduce the identified hazards 

and associated risks. A list of potential mitigations and actions items were developed. 

1. Hold separate coordination meetings specifically to address a potential scenario when the airport cannot 

accommodate additional aircraft. 

a. ACTION: The SJCAA will facilitate these meetings prior to 2011 football season. 

2. Commission a study of the ramps and runways used to park aircraft to determine the maximum number of 

aircraft that can be parked in each area. The study should include the types of aircraft, the clearances 

between aircraft, and clearances for vehicle movement such as emergency response. 

a. ACTION: The SJCAA will assess the ability to commission this study with the goal of completing the 

study prior to the 2011 football season. 

3. Develop a contingency plan for each aircraft parking area that will include findings from both Actions 1 and 2. 

The contingency plan is proposed to include an overall communication plan for internal and external 

communications within the airport community. 

a. ACTION: The SJCAA will coordinate this meeting and document the plan. 

4. Use barricades and or cones to mark pathways to the executive ramp and to demark routes to and from 

aircraft parking ramps and the FBO. 

a. ACTION: The SJCAA will coordinate this effort with the FBO and incorporate it in the 2011 plan. 

5. Use light stands to assist with nighttime operations. 

a. ACTION: The SJCAA will determine placement for lighting devices that will not interfere with pilot 

vision. 

The panel discussed that substantial progress had been made within the last few years regarding major events. Most of the 

mitigations listed above have been deployed within the past five years and each year improvements are made. The panel 

believes that these additional mitigations will provide a consistent approach year to year and will prepare the airport community 

for future events when 300 aircraft may be the average for Notre Dame Football games. 
SBN SMS 5 

SRA Document 

 Responsible Person Accepting 

 Residual Risk

SRA Document Preparer 

Signature: Signature: 

Title: Bruce MacLachlan, Manager of 

Operations and Maintenance 

Title: Dave Fleet, Principal, Dave Fleet 

 Consulting LLC 

Date: Date: January 16, 2010 

CAUTION: BE ALERT TO RUNWAY CROSSING CLEARANCES. READBACK OF ALL RUNWAY HOLDING INSTRUCTIONS IS REQUIRED.

AIRPORT DIAGRAM

AIRPORT DIAGRAM SOUTH BEND, INDIANA

(SBN)

10210

10210

SOUTH BEND, INDIANA

(SBN) AL-399 (FAA)

JANUARY 2010 ANNUAL RATE OF CHANGE

0.1^ W

1 8

3 6

N-1

27R

J-1

9 L

J-2

27L

9 R

FIELD

ELEV

799

4300 X 75 093.3^ 273.3^ NN NN A A A A B B B B B B B

B-6

A-6

B-5

A-5 A-4 A-3

B-4

B-3

A-2

B-2

A-1

B-1 J J J

N-2 T x x x

86^ 19.0’ W 86^ 18.0’ W

41^ 43.0’ N

41^ 42.0’ N

183.2^

7100 X 150 003.2^

FED-X RAMP

8414 X 150 093.3^

ELEV

788

ELEV

780

EXECUTIVE RAMP

NON- MOVE

AREA

ELEV

769

ELEV

790 273.3^

MAIN RAMP

SAFETY COMPLEX

ELEV

760

NON- MOVE

AREA

ILS HOLD

ILS HOLD

SOUTH BEND RGNL

SOUTH BEND RGNL

N-3 0.5% UP

0.5% DOWN N

TERMINAL

HANGARS

ATIS 118.15 SOUTH BEND TOWER

118.9 257.8 GND CON

121.7 CLNC DEL

121.9

960 D

FAA TECHNICAL OPERATIONS

TWR

884

FBO GENERAL

 AVIATION RAMP

VAR 4.5^ W

RWY 09L-27R

 S-45,D-60 RWY 09R-27L

 S-100, D-175, 2S-175, 2D-300 RWY 18-36

 S-100, D-175, 2S-175, 2D-300

EC-2

16 DEC 2010 to 13 JAN 2011

EC-2, 16 DEC 2010 to 13 JAN 2011

SJCAA SMS Risk Matrix 

Likelihood: 

Frequently Occurs once every week

Probable Occurs once every month

Remote Occurs once every 5 years

Extremely Remote Occurs once every 10 years

Extremely Improbable Occurs once every 20 years

Severity: 

Catastrophic Loss of aircraft, life and/or damage in excess of 

$1,000,000

Hazardous Severe injury or damage in excess of $100,000 and/or 

disruption of critical services (NAVAIDS, etc.) 

Major Significant (but repairable) damage to an aircraft, 

equipment or facility and/or minor injury 

Minor Minor damage to equipment or facilities 

No Safety Effect No injury, equipment or facility damage is possible