La protección de las fuentes de información sobre la seguridad operacional – La perspectiva técnica

1. La protección de las fuentes de información sobre la seguridad operacional –La perspectiva técnica Capt. Daniel Maurino Seguridad de Vuelo y Factores Humanos – OACI Seminario de Seguridad ASPA/OACI Cuidad de México, 10 – 11 Abril 2007

2. 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

3. 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

4. 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

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

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

7. 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

8. 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

9. 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

10. 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

12. Protecting Safety Data – An Odyssey • Clearly defined objective • Protect sources of safety information • At the intersection of safety, law & politics • The solution – Safety and Law • The Implementation –Political will • An inescapable reality • No safety data protection = No SMS

13. Protecting Safety Information – Excuses and Fear • Denial: ritualistic blaming leading to self-delusion • Repair: cover-up, cosmetic re-writing denying learning • Reform: engaging the political will