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

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Presentation on theme: "Session No. 1 Basic Contemporary Safety Concepts SMS Senior Management Workshop SMS Senior Management Workshop Rome, 21 May 2007."— Presentation transcript:

1 Session No. 1 Basic Contemporary Safety Concepts SMS Senior Management Workshop 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 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 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  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 Forensic Safety Management

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 Accident investigation

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

7 Operational performance Operationaldeployment Systemdesign Baseline performance Operational drift System Performance “In the Wild”

8 Managing Safety–Navigating the Drift Baseline performance “Practical drift” Operational performance Organization Navigational aids ReactiveProactivePredictive

9 The Navigational Aids  Reactive systems Accident investigation Accident investigation Incident investigation Incident investigation  Predictive systems Electronic safety data acquisition systems Electronic safety data acquisition systems Direct observation safety data acquisition systems Direct observation safety data acquisition systems  Proactive systems Mandatory reporting systems Mandatory reporting systems Confidential reporting systems Confidential reporting systems Voluntary self-reporting systems Voluntary self-reporting systems

10 Safety Data Systems and Levels of Intervention Baseline performance “Practical drift” Operational performance organization Predictive ProactiveReactiveHighly efficientVery efficient Efficient Safety management levels Reactive Desirable management level Inefficient ASR Surveys Audits ASRMOR Accident and incident reports H i g h M i d d l e L o w Hazards FDA Directobservationsystems

11 Operational performance Operationaldeployment Systemdesign Baseline performance Operational drift Managing Safety: Collapsing the Drift Operationaldeployment Systemdesign Operational drift Operational performance Baseline performance

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

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

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

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

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

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

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

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

20 …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 … A balanced perspective


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