“Safety, Risk Management, Governance and Accountability”

1. “Safety, Risk Management, Governance and Accountability” Kathy Fox, Transportation Safety Board April 11, 2013 Business Aviation Safety Seminar Montreal, QC

2. Outline • Evolution of accident investigation • Organizational Drift into failure • Evolution of Safety Management Systems (SMS) • Investigating for organizational factors • Goal conflicts • Inadequate risk analysis • Employee adaptations • Weak signals • The role of governance / regulatory oversight

3. Background • “What” happened vs. “why” it happened • Evolution of accident investigation: • aircraft design • cockpit design • physiological factors • psychological influences on decision-makingand risk-taking • performance of the flight crew, not just the pilot (CRM, TEM) • organizational factors

4. Balancing Competing Priorities Service Safety

5. Limits of Acceptable Performance Rasmussen, J. (1997). Risk management in a dynamic society: a modelling problem. Safety Science, 27, 183-213

6. Organizational Drift “Drift is generated by normal processes of reconciling differential pressures on an organization (efficiency, capacity utilization, safety) against a background of uncertain technology and imperfect knowledge.” Dekker, S. (2005). Ten Questions About Human Error: A New View of Human Factors and System Safety. Lawrence Erlbaum Associates, Inc.

7. Impact of Management By their nature, management decisions tend to have a wider sphere of influence on how the organization operates, and a longer-term effect, than the individual actions of operators. Decision-makers need to develop “mindfulness” to avoid “blind spots.” Weick, K. E. & Sutcliffe, K. M. (2007). Managing the Unexpected: Resilient Performance in an Age of Uncertainty. (2nd ed.) John Wiley & Sons Inc.

8. A “Mindful Infrastructure” Would … • Track small failures • Resist oversimplification • Remain sensitive to operations • Maintain capabilities for resilience • Take advantage of shifting locations of expertise • Listen for, and heed, weak signals * Weick, Karl E.; Kathleen M. Sutcliffe (2001). Managing the Unexpected - Assuring High Performance in an Age of Complexity. San Francisco, CA, USA: Jossey-Bass. pp. 10–17. ISBN 0-7879-5627-9.

9. Characteristics* of Effective Safety Management • a strong organizational emphasis on safety; • high collective efficacy (i.e., a high degree of cooperation and cohesiveness); • congruence between tasks and resources; • a culture encouraging effective and free-flowing communications; • clear mapping of its safety state; • a learning orientation; • clear lines of authority and accountability. *Westrum, R. (1999). Organizational Factors in Air Navigation Systems Performance (Review Paper for NAV CANADA.)

10. Safety Management Systems (SMS) SMS integrates safety into all daily activities. “It is a systematic, explicit, and comprehensive process for managing safety risks … it becomes part of that organization’s culture, and [part] of the way people go about their work.” Reason, J. (2001). In search of resilience. Flight Safety Australia September-October, 25-28.

11. SMS Requires the Following:

12. Investigating for Organizational Factors Goal conflicts Inadequate risk analysis Employee adaptations Missed “weak signals” COMPLEX INTERACTION = NO SINGLE FACTOR AS SOLE CAUSE

13. Goal Conflicts TSB Investigation Report A04H0004

14. Inadequate Risk Analysis TSB Investigation Report A07A0134

15. Aircraft Attitude at Threshold

16. Employee Adaptations Faced with time pressures or multiple goals, workers and management may be tempted to create “locally efficient practices.” Why? To get the job done! Past successes are taken as a guarantee of future safety.

17. Employee Adaptations (cont’d) Kelowna Flightcraft Boeing 727 at St. John’s International Airport. TSB Investigation Report A11A0035

18. Weak Signals YVR seaplane dock, 16 November 2008 (A08P0353)

19. Weak Signals (cont’d) Collision with terrain: Sandy Bay, SK (A07C0001)

20. Weak Signals (cont’d) “We didn’t see [these recent accidents] coming, and we should have … the data were trying to tell us something.” -William Voss, President and CEO of Flight Safety Foundation

21. SMS in Air Carrier Operations Findings as to Risk (SunwingA11O0031) When an operator’s proactive and reactive SMS processes do not trigger a risk assessment, there is an increased risk that hazards will not be mitigated. Operators that do not recognize a reportable occurrence may not conduct an investigation or preserve data from the digital flight data recorder. If operators do not thoroughly document aircraft malfunctions, there is an increased risk that deficiencies will not be corrected. The acceptance by flight crews and companies of known equipment problems could put safety at risk.

22. Pilot Error or Management Error? Drift, goal conflicts and adaptations are natural No one sets out to have an accident; they just want to get the work done The decision to value production over safety is implicit

23. Pilot Error or Management Error? (cont’d) With each success, people underestimate the amount of risk involved If investing in safety improved quarterly returns, the company would do it There is a complex relationship between culture and process

24. The Role of Governance / Oversight Q) Who holds decision-makers to account? A) Board of Directors / owner Shareholders / financial backers Customers Insurance companies Regulators All of the above

25. Governance / Oversight (cont’d) TSB Investigation Report A10Q0098

26. Governance / Oversight (cont’d) “The gap between what is legal and what is safe already is large, and it will get bigger. … Is this regulatory approach sustainable? Is it fair to airlines that do everything right? Is it fair to an unknowing public?” -William Voss, Flight Safety Foundation

27. TSB Watchlist • Marine • Safety management systems • Loss of life on fishing vessels • Air • Collisions with land and water • Landing accidents and runwayoverruns • Risk of collisions on runways • Safety management systems • Rail • On-board video and voice recorders • Following signal indications • Passenger trains colliding with vehicles

28. Conclusions • “Mindful infrastructure” • Effective Safety Management depends on “culture” and “process” • Organizational accountability is key • Effective regulatory oversight is essential • Success takes commitment, perseverance, and time

29. QUESTIONS?