Managing Safety in Performance-Based Systems

Managing Safety in Performance-Based Systems Captain Dan Maurino Flight Safety and Human Factors – ICAO Worldwide Symposium on Performance of the Air Navigation System Montreal 26 – 30 March 2007

Forensic Safety Management • Focus on outcomes • Unsafe acts at the tip of the arrow • Blame & punishment for failure to “perform safely” • Address specific safety concern exclusively

The Underlying Paradigm–Rule-based System Deterministic – The world as it should be • Aviation system – as pre-specified – is perfect • Compliance based • Outcome oriented • Accident/serious incident investigation

Inefficiency and Perversity The beatings will continue until morale improves 2. Punishment 1. Exhortations to professionalism and discipline 3. Remedial Training 4. Add more procedures & regulations

Baseline performance System design Operational drift Operational performance Operational deployment System Performance “In the Wild”

Baseline performance Organization Operationalperformance “Practical drift” Navigational aids Reactive Proactive Predictive Managing Safety–Navigating the Drift

The Navigational Aids • Predictivesystems • Electronic safety data acquisition systems • Direct observation safety data acquisition systems • Reactive systems • Accident investigation • Incident investigation • Proactive systems • Mandatory reporting systems • Confidential reporting systems • Voluntaryself-reportingsystems

Baseline performance e l w organization d h o d g i L i M H Proactive Hazards Operational performance Predictive Reactive Reactive ASR FDA ASR MOR Accident and incident reports Surveys Direct observation systems Audits “Practical drift” Inefficient Highly efficient Very efficient Efficient Safety Data Systems and Levels of Intervention Safety management levels Desirable management level

Baseline performance Baseline performance System design System design Operational drift Operational drift Operational performance Operational performance Operational deployment Operational deployment Managing Safety: Collapsing the Drift

Emerging Paradigm–Performance-Based System Deterministic – The world as it should be • Aviation system – as pre-specified – is perfect • Compliance based • Outcome oriented • Accident/serious incident investigation Ecological – The world as it is • Aviation system – as pre-specified – is imperfect • Performance based • Process oriented • Safety data captured from daily, normal operations

Performance-Based Safety: The ABC • Senior management’s commitment to the management of safety • Initial analysis of system design and risk controls (safety risk management) • Continuous safety monitoring and analysis of safety data from normal operations (safety assurance)

Managing Safety in Performance-Based Systems

Managing Safety in Performance-Based Systems

Presentation Transcript

State-Based Patient Safety Reporting Systems

Managing Long-Lived COTS Based Systems

Managing Financial Performance

Managing Performance Priorities

Managing Health and Safety Performance

Managing poor performance

Intelligent Vehicle-Based Safety Systems IVBSS

Performance Assessment for Web-based Systems

Managing Performance

Performance Managing

Managing Contractor Performance

MANAGING FOR PERFORMANCE

Managing for performance

Managing Employee Performance

Managing PHP Performance

Managing safety in different cultures

Managing Fire Safety

Managing Employee Performance

Integrated Vehicle Based Safety Systems

Managing Safety Culture

Behavior Based Safety Training Improves on Company's Safety Performance

MANAGING STAFF PERFORMANCE