The Concept of Safety Zero accidents or serious incidents — a view widely held by the travelling public; Freedom from hazards, i.e. those factors which cause or are likely to cause harm; Attitudes of employees of aviation organizations towards unsafe acts and conditions; Error avoidance; and Regulatory compliance.
What is Safety? The state in which the possibility of harm to persons or of property damage is reduced to, and maintained at or below, an acceptable level through a continuing process of hazard identification and safety risk management.
Evolution of Safety Thinking Traditional Approach: Focus on outcomes (causes) Unsafe acts by operational personnel Assign blame/punish for failure to “perform safety” Address identified safety concern exclusively Identifies: WHAT? WHO? WHEN? But not always disclose: WHY? HOW?
Evolution of Safety Thinking TECHNICAL FACTORS HUMAN FACTORS ORGANIZATIONAL FACTORS 1950s1970s1990s2000 TODAY
Organizational Accident Organizational processes Identify Improve Work place conditions Defences Active failures Monitor Contain Reinforce Latent conditions
People, Context & Safety People & Safety
People, Context & Safety Understanding Human Performance
People, Context & Safety Understanding Human Performance
People, Context & Safety Processes & Outcomes
SHEL(L) Model S S L L E E H H L L S - Software H - Hardware E - Environment L - Livewire
SHEL(L) Model Important factors affecting human performance: a)Physical factors b)Physiological factors c)Psychological factors d)Psycho-social factors
SHEL(L) Model Interfaces between different components of the aviation system: a)Liveware-Hardware (L-H) b)Liveware-Software (L-S) c)Liveware-Liveware (L-L) d)Liveware-Environment (L-E)
Errors & Violations ErrorDeviationAmplification Degradation / Breakdown Incident / Accident Operational Errors – Investigation of major breakdowns
Errors & Violations ErrorDeviationAmplification Normal flight Safety Management – On almost every flight
3 Strategies to Control Operational Errors 1. Reduction strategies a)Human-centred design; b)Ergonomic factors; and c)Training. 2. Capturing strategies a)Checklists; b)Task cards; and c)Flight strips. 3. Tolerance strategies a)system redundancies; and b)structural inspections.
Errors vs. Violations General types of violations: 1.Situational violations occur due to the particular factors that exist at the time, such as time pressure or high workload. 2.Routine violations are violations which have become “the normal way of doing business” within a workgroup. 3.Organization-induced violations, which can be viewed as an extension of routine violations. The full potential of the safety message that violations can convey can be understood only when considered against the demands imposed by the organization regarding the delivery of the services for which the organization was created.
Errors vs. Violations Safety Space Violation Space Exceptional violation Space System’s production objectives Incident Accident Understanding Violations MinimumMaximum High Low RISK SYSTEM OUTPUT
Organizational Culture National Organizational Professiona Professional
Organizational Culture Organizational literature proposes three characterizations of organizations, depending on how they respond to information on hazards and safety information management: a) pathological — hide the information; b) bureaucratic — restrain the information; and c) generative — value the information.
Organizational Culture a)National culture differentiates the national characteristics and value systems of particular nations. b)Professional culture differentiates the characteristics and value systems of particular professional groups c)Organizational culture differentiates the characteristics and value systems of particular organizations
Effective Safety Reporting Effective safety reporting builds upon certain basic attributes, such as: a) Senior management places strong emphasis on hazard identification as part of the strategy for the management of safety; b) Senior management and operational personnel hold a realistic view of the hazards faced by the organization’s service delivery activities; c) Senior management defines the operational requirements needed to support active hazard reporting, ensures that key safety data are properly registered, demonstrates a receptive attitude to the reporting of hazards by operational personnel and implements measures to address the consequences of hazards;
Effective Safety Reporting d) Senior management ensures that key safety data are properly safeguarded and promotes a system of checks and); e) Personnel are formally trained to recognize and report hazards and understand the incidence and consequences of hazards in the activities supporting delivery of services; and f) There is a low incidence of hazardous behaviour, and a safety ethic which discourages such behaviour.
Effective Safety Reporting – 5 basic traits Information People are knowledgeable about the human, technical and organizational factors that determine the safety of the system as a whole Willingness People are willing to report their errors and experiences Accountability People are encouraged (and rewarded) for providing essential safety-related information. However, there is a clear line that differentiates between acceptable and unacceptable behaviour Flexibility People can adapt reporting when facing unusual circumstances, shifting from the established mode to a direct mode thus allowing information to quickly reach the appropriate decision- making level Learning People have the competence to draw conclusions from safety information systems and the will to implement major reforms Effective safety Reporting
Safety Investigation to put losses behind; to reassert trust and faith in the system; to resume normal activities; and to fulfil political purposes.
Safety Investigation Safety investigation for improved system reliability: a)to learn about system vulnerability; b)to develop strategies for change; and c)to prioritize investment of safety resources.
Outline Fundamentals of Safety Safety Management System Components of SMS Legislation Summary Safety Stereotype Management Dilemma Need for Safety Management Strategies for Safety Management Imperative of Change Building Blocks – SMS Responsibilities of Managing Safety Safety Stereotype Management Dilemma Need for Safety Management Strategies for Safety Management Imperative of Change Building Blocks – SMS Responsibilities of Managing Safety
Safety Stereotype The safety stereotype: safety first vs. safety is an organizational process Safety is not first priority in aviation safety is just organizational process.
Dilemma of 2 P’s: Production Protection Management Dilemma
Minor-major accident Need for Safety Management Major air disaster are rare Incidents occur more frequently Ignoring the major could lead to an increase number of more serious accidents Major air disaster are rare Incidents occur more frequently Ignoring the major could lead to an increase number of more serious accidents
Minor-major accident Economics of Safety Need for Safety Management Accidents cost money Insurance can help but not all There are many uninsured cost Lost of confidence of the travelling public Accidents cost money Insurance can help but not all There are many uninsured cost Lost of confidence of the travelling public
Minor-major accident Economics of Safety Publics perceived safety while traveling Need for Safety Management Prerequisite for a sustainable aviation business
Strategies for Safety Management System Design Operational deployment Operational performance Baseline performance The practical drift Source: Scott A. Snook
Reactive method The reactive method responds to events that have already happened, such as incidents and accidents Reactive method The reactive method responds to events that have already happened, such as incidents and accidents Proactive method The proactive method looks actively for the identification of safety risks through the analysis of the organization’s activities Proactive method The proactive method looks actively for the identification of safety risks through the analysis of the organization’s activities Predictive method The predictive method captures system performance as it happens in real-time normal operations to identify potential future problems Predictive method The predictive method captures system performance as it happens in real-time normal operations to identify potential future problems
Strategies for Safety Management Hazards PredictiveProactiveReactiveReactive Strategies – Levels of intervention and tools FDA Direct observation systems ASR Survey Audits ASRMOR Accident and incident reports Highly efficient Very efficient EfficientInsufficient Safety management levels Desirable management levels High HighMiddleLow
The management of change Aircraft and Equipment are changing overtime Hazards that are by product of change Change can introduce new hazard Formal Process for the Management of change Critically of system and activities Stability of systems and operational environment Past performance Imperative of Change
The traditional safety paradigm relied on the accident/serious incident investigation process as its main safety intervention and method, and it was built upon three basic assumptions: a) The aviation system performs most of the time as per design specifications (i.e. baseline performance); b) Regulatory compliance guarantees system baseline performance and therefore ensures safety (compliance-based); and c) Because regulatory compliance guarantees system baseline performance, minor, largely inconsequential deviations during routine operations (i.e. processes) do not matter, only major deviations leading to bad consequences (i.e. outcomes) matter (outcome oriented). Imperative of Change
It is based on the notion of managing safety through process control, beyond the investigation of occurrences, and it builds upon three basic assumptions also: a) The aviation system does not perform most of the time as per design specifications (i.e. operational performance leads to the practical drift); b) Rather than relying on regulatory compliance exclusively, real- time performance of the system is constantly monitored (performance-based); and c) Minor, inconsequential deviations during routine operations are constantly tracked and analysed (process oriented). Imperative of Change
1. Senior Management’s commitment to the management of safety 2. Effective safety reporting 3. Continuous monitoring 4. Investigation of safety occurrences 5. Sharing safety lessons learned and best practices 6. Integration of safety training for operational personnel 7. Effective implementation of standard operating procedures (SOP’s) 8. Continuous improvement of the overall level of safety 8 Building Blocks - SMS
The responsibilities for managing safety can be grouped into four generic and basic areas, as follows: a)Definition of policies and procedures regarding safety. Policies and procedures are organizational mandates reflecting how senior management wants operations to be conducted. b)Allocation of resources for safety management activities. Managing safety requires resources. The allocation of resources is a managerial function. c)Adoption of best industry practices. The tradition of aviation regarding safety excellence has led to the continuous development of robust safety practices. Aviation has, in addition, a tradition regarding exchange of safety information through both institutional and informal channels. 4 Responsibilities of Managing Safety
d) Incorporation of regulations governing civil aviation safety. There will always be a need for a regulatory framework as the bedrock for safety management endeavours. In fact, sensible safety management can develop only from sensible regulations. 4 Responsibilities of Managing Safety
In summary, safety management: a) includes the entire operation; b) focuses on processes, making a clear differentiation between processes and outcomes; c) is data-driven; d) involves constant monitoring; e) is strictly documented; f) aims at gradual improvement as opposed to dramatic change; and g) is based on strategic planning as opposed to piecemeal initiatives. Summary