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Session No. 1 Basic Contemporary Safety Concepts
SMS Senior Management Workshop Rome, 21 May 2007 1 1 1
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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
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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
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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
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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
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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
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System Performance “In the Wild”
design Baseline performance Operational deployment Operational performance Operational drift
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Managing Safety–Navigating the Drift
Baseline performance “Practical drift” Operational performance Organization Navigational aids Reactive Proactive Predictive
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The Navigational Aids Reactive systems Accident investigation
Incident investigation Predictive systems Electronic safety data acquisition systems Direct observation safety data acquisition systems Proactive systems Mandatory reporting systems Confidential reporting systems Voluntary self-reporting systems
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Safety Data Systems and Levels of Intervention
Safety management levels H i g h M d l e L o w Baseline performance “Practical drift” Operational performance organization Hazards Reactive Predictive Proactive Reactive FDA Direct observation systems ASR Surveys Audits ASR MOR Accident and incident reports Highly efficient Very efficient Efficient Inefficient Desirable management level
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Managing Safety: Collapsing the Drift
Operational deployment System design Operational drift Operational performance Baseline performance Operational performance Operational deployment System design Baseline performance drift
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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
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Organizational processes
Performance-based Safety Organizational processes Latent conditions Workplace 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
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Performance-based Safety
Organizational processes Latent conditions Workplace Defences Active failures 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
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Performance-based Safety
Organizational processes Latent conditions Workplace Defences Active failures Organizational processes Latent conditions Defences Technology Training Regulations Resources to protect against the risks that organizations involved in production activities must confront
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Performance-based Safety
Organizational processes Latent conditions Workplace Defences Active failures Organizational processes Workplace conditions Workforce stability Qualifications and experience Morale Credibility Ergonomics … Factors that directly influence the efficiency of people in aviation workplaces
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Performance-based Safety
Organizational processes Latent conditions Workplace Defences Active failures Organizational processes Workplace conditions Active failures Errors Violations Actions or inactions by people (pilots, controllers, maintenance engineers, aerodrome staff, etc.) that have an immediate adverse effect
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Performance-based Safety
Organizational processes Latent conditions Workplace Defences Active failures Organizational processes Latent conditions Workplace Defences Active failures Improve Identify Monitor Contain Reinforce
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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)
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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 …
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