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Managing Safety in Performance-Based Systems Captain Dan Maurino Captain Dan Maurino Flight Safety and Human Factors – ICAO Worldwide Symposium on Performance.

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Presentation on theme: "Managing Safety in Performance-Based Systems Captain Dan Maurino Captain Dan Maurino Flight Safety and Human Factors – ICAO Worldwide Symposium on Performance."— Presentation transcript:

1 Managing Safety in Performance-Based Systems Captain Dan Maurino Captain Dan Maurino Flight Safety and Human Factors – ICAO Worldwide Symposium on Performance of the Air Navigation System Montreal 26 – 30 March 2007

2 Focus on outcomes Focus on outcomes Unsafe acts at the tip of the arrow Unsafe acts at the tip of the arrow Blame & punishment for failure to perform safely Blame & punishment for failure to perform safely Address specific safety concern exclusively Address specific safety concern exclusively Forensic Safety Management

3 The Underlying Paradigm–Rule-based System Deterministic – The world as it should be Aviation system – as pre-specified – is perfect Aviation system – as pre-specified – is perfect Compliance based Compliance based Outcome oriented Outcome oriented Accident/serious incident investigation Accident/serious incident investigation

4 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

5 Operational performance Operationaldeployment Systemdesign Baseline performance Operational drift System Performance In the Wild

6 Managing Safety–Navigating the Drift Baseline performance Practical drift Operational performance Organization Navigational aids ReactiveProactivePredictive

7 The Navigational Aids Reactive systems Reactive systems Accident investigation Accident investigation Incident investigation Incident investigation Predictive systems 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 Proactive systems Mandatory reporting systems Mandatory reporting systems Confidential reporting systems Confidential reporting systems Voluntary self-reporting systems Voluntary self-reporting systems

8 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

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

10 Emerging Paradigm–Performance-Based System Ecological – The world as it is Aviation system – as pre-specified – is imperfect Aviation system – as pre-specified – is imperfect Performance based Performance based Process oriented 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 Aviation system – as pre-specified – is perfect Compliance based Compliance based Outcome oriented Outcome oriented Accident/serious incident investigation Accident/serious incident investigation

11 Performance-Based Safety: The ABC A. Senior managements 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)


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