Session No. 1 Basic Contemporary Safety Concepts

1. Session No. 1Basic ContemporarySafety Concepts SMS Senior Management Workshop Rome, 21 May 2007

2. For Starters • The total elimination of risk is unachievable • Errors will occur, in spite of the most accomplished prevention efforts • No human endeavour or human-made system can be free from risk and error • Controlled risk and error are acceptable in an inherently safe system

3. Concept of safety (Doc 9859) • Safety is the state in which the risk of harm to persons or property damage is reduced to, and maintained at or below, an acceptable level through a continuing process of hazard identification and risk management

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

5. 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 investigation

6. 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

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

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

9. 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

10. 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

11. 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

12. Emerging Paradigm–Performance-Based System Deterministic – The world as it should be • Aviation system – as pre-specified – is perfect • Compliance based • Outcome oriented • Accident 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

13. Performance-based Safety Organizational processes Workplace conditions Latent conditions Active failures Defences Organizational processes • Policy-making • Planning • Communication • Allocation of resources • Supervision • … Activities over which any organization has a reasonable degree of direct control

14. Organizational processes Workplace conditions Latent conditions Active failures Defences Performance-based Safety Organizational processes • Inadequate hazard identification and risk management • Normalization of deviance Latent conditions Conditions present in the system before the accident, made evident by triggering factors

15. Organizational processes Organizational processes Workplace conditions Latent conditions Latent conditions Active failures Defences Defences Performance-based Safety • Technology • Training • Regulations Resources to protect against the risks that organizations involved in production activities must confront

16. Organizational processes Organizational processes Workplace conditions Workplace conditions Latent conditions Active failures Defences Performance-based Safety • Workforce stability • Qualifications and experience • Morale • Credibility • Ergonomics • … Factors that directly influence the efficiency of people in aviation workplaces

17. Organizational processes Organizational processes Workplace conditions Workplace conditions Latent conditions Active failures Active failures Defences Performance-based Safety • Errors • Violations Actions or inactions by people (pilots, controllers, maintenance engineers, aerodrome staff, etc.) that have an immediate adverse effect

18. Organizational processes Organizational processes Workplace conditions Workplace conditions Latent conditions Latent conditions Active failures Active failures Defences Defences Performance-based Safety Improve Identify Monitor Contain Reinforce

19. 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)

20. A balanced perspective …The pilot-in-command must bear responsibility for the decision to land and take-off in Dryden… However, it is equally clear that the air transportation system failed him by allowing him to be placed in a situation where he did not have all the necessary tools that should have supported him in making the proper decision …