Hazard Identification Session 4

Hazard Identification Hazard Identification starts from two basic fundamental ideas: Something causes accidents Identify the hazard, latent or otherwise, and you go a long way in preventing the accident from occurring Accidents are organizational in nature It is the complexity of many organizational systems which give rise to failure. Usually it is difficult to pinpoint just one internal system and just one failure Here is what it looks like graphically IATA Training & Development Institute

Here is how it all fits together SAFETY BY DEFINITION A Continual Process of Hazard Identification & Risk Management (As Core Competencies) Let us look at this more closely IATA Training & Development Institute

Here is how it all fits together SAFETY BY DEFINITION A Continual Process of Hazard Identification & Risk Management (As Core Competencies) These are the two core competencies that each organization must master IATA Training & Development Institute

+ + REASON’S MODEL OF AN ACCIDENT 3-Window of Opportunity Anatomy of An Accident – What Causes Accidents? Any Accident has all three REASON’S MODEL OF AN ACCIDENT Defenses Unsafe Acts Preconditions Line Management Decision Makers Accident 3-Window of Opportunity Favorable conditions or sequence of events compounded by 1. and 2. 2-Unsafe Acts Active failures (errors or violations by the system’s operator) 1-Latent Unsafe Condition(s) i.e Gaps in supervision, undetected defects, failures of maintenance + + IATA Training & Development Institute

+ + REASON’S MODEL OF AN ACCIDENT 3-Window of Opportunity The Anatomy gives rise to the Prevention Prevention = Interrupt the cycle at any point REASON’S MODEL OF AN ACCIDENT Defenses Unsafe Acts Preconditions Line Management Decision Makers Accident 3-Window of Opportunity Identify and Avoid 2-Unsafe Acts Train & Prevent 1-Latent Unsafe Condition(s) Detect and Correct + + Take away any one of the three and the probability of accidents goes away IATA Training & Development Institute

Why are these core competencies important? HAZARD IDENTIFICATION + RISK MANAGEMENT These two core competencies are the very heart of any organizations SMS Everything else flows from this IATA Training & Development Institute

Hazard Identification What is a Hazard? The condition or circumstance that can lead to a loss of life or an aircraft First core competency IATA Training & Development Institute

Hazard Definition ICAO Definition states that Hazard is a condition, object or activity with the potential of causing injuries to personnel, damage to equipment or structures, loss of or reduction of, ability to perform a prescribed function Source ICAO IATA Training & Development Institute

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Understanding Hazards Hazards are easy to define Hard to identify Harder to understand Natural tendency is to describe a hazard as an outcome Describing a hazard by its outcome disguises its true nature A “runway incursion” or “unclear airport signage” IATA Training & Development Institute

Anatomy of an Accident Three necessary components to any accident REASON’S MODEL OF AN ACCIDENT Defenses Unsafe Acts Preconditions Line Management Decision Makers Accident 3-Window of Opportunity 2-Unsafe Acts 1-Latent Unsafe Condition(s) + + This is what most accidents are IATA Training & Development Institute

Here is how it all fits together SAFETY BY DEFINITION A Continual Process of Hazard Identification & Risk Management (Our Two Core Competencies) Latent Unsafe Conditions (as one of the three elements of an accident) IATA Training & Development Institute

“Latent” Unsafe Conditions Definition of Latent “Latent” means Resting into the background Not visible or apparent Accessible but undetected Now apply all these meanings to “Latent” Unsafe Conditions IATA Training & Development Institute

Safety Management System People Materials Procedures Tools Equipment Software Facilities There may be “latent” unsafe conditions in all of these components IATA Training & Development Institute

Detection of Latent Unsafe Conditions THERE ARE MANY SYSTEMS (none of which are unsafe when isolated) IATA Training & Development Institute

Accident Accident Causes are Non-Linear (so are the latent unsafe conditions) IATA Training & Development Institute

Latent Unsafe Conditions How do we identify them? We start with the paradigm shift in Safety Management IATA Training & Development Institute

Paradigm Shift in Safety Management Reactive method (Historical Analysis) Proactive method (Current Analysis) Predictive method (Real Time Analysis) The reactive method responds to the events that have already happened, such as incidents and accidents Look for trends & repetitive events The proactive method looks actively for the identification of safety risks through the analysis of current activities Look for repetitive events & non-linear associations The predictive method captures system performance as it happens in real-time & normal operations Look for deviations from system boundaries Clear shift towards the Predictive Method – this is the key IATA Training & Development Institute

Latent Unsafe Conditions Have a degree of predictabililty Predictive (Real time analysis) depends on (i) technology and (ii) a responsive feedback system Predictive method (Real Time Analysis) Predictive Analysis Captures system performance in real-time as it happens ANY DEVIATION FROM THE SYSTEM BOUNDARY IS A LATENT UNSAFE CONDITION Look for deviations from system boundaries IATA Training & Development Institute

Detecting “Latent” Unsafe Conditions using known concepts Use the same Three Concepts (Tools) previously used to determine an “acceptable level of safety” 80-20 Rule Power Curves Double Feedback Loops All these are good indicators of “Latent” Unsafe Conditions IATA Training & Development Institute

Let us be clear on what we are trying to do: We are attacking the first link in the causal chain of an accident REASON’S MODEL OF AN ACCIDENT Defenses Unsafe Acts Preconditions Line Management Decision Makers Accident 3-Window of Opportunity 2-Unsafe Acts 1-Latent Unsafe Condition(s) Detect and Correct + + We are here PREVENTION = INTERRUPT THE CYCLE AT THE FIRST LINK IN THE CAUSAL CHAIN OF EVENTS IATA Training & Development Institute

Elimination of Unsafe Acts: We are attacking the second link in the causal chain of an accident REASON’S MODEL OF AN ACCIDENT Defenses Unsafe Acts Preconditions Line Management Decision Makers Accident 3-Window of Opportunity 2-Unsafe Acts Train & Prevent 1-Latent Unsafe Condition(s) + + We are here PREVENTION = INTERRUPT THE CYCLE AT THE SECOND LINK IN THE CAUSAL CHAIN OF EVENTS IATA Training & Development Institute

Big difference between first and second REASON’S MODEL OF AN ACCIDENT Defenses Unsafe Acts Preconditions Line Management Decision Makers Accident 3-Window of Opportunity 2-Unsafe Acts 1-Latent Unsafe Condition(s) + + 1 = Latent, passive, not easily observed vs 2 = Active (it must happen) and is easily observable IATA Training & Development Institute

Eliminating Unsafe Acts Corrective action and elimination is always post occurrence (after the act) This means the unsafe act must: Occur Be recognized and noted as unsafe Be recorded and described Be subject to analysis Be subject to enhanced oversight IATA Training & Development Institute

Enhanced Oversight Identify further unsafe acts of a similar kind Enhanced Oversight is a condition of focused and directed attention and observation Identify further unsafe acts of a similar kind Identify system weakness which permitted the unsafe act to occur Shape or negotiate a “beta” fix for the weakness Observe and document the effectiveness of the “fix” Analyze and oversight to see if the fix is effective Fully document actions taken & exact nature of the fix INTEGRATE FIX INTO SMS ©Aurion®2008 No copy permitted IATA Training & Development Institute

Predictive method Unsafe acts can be easily observed in some instances Predictive (Real time analysis) depends on (i) technology and (ii) a responsive feedback system Predictive method (Real Time Analysis) Predictive Analysis Captures system performance in real-time as it happens ANY ACT WHICH IS A DEVIATION FROM THE SYSTEM BOUNDARY IS AN UNSAFE ACT Look for deviations from system boundaries IATA Training & Development Institute

Unsafe Act Reporting The majority of unsafe acts are reported The key element in the SMS Voluntary incentives to report unsafe acts Immunity from consequences if reported and detailed as to unsafe acts or possible unsafe acts IATA Training & Development Institute

Elimination of Unsafe Acts: We are attacking the second link in the causal chain of an accident REASON’S MODEL OF AN ACCIDENT Defenses Unsafe Acts Preconditions Line Management Decision Makers Accident 3-Window of Opportunity 2-Unsafe Acts Train & Prevent 1-Latent Unsafe Condition(s) + + We are here PREVENTION = INTERRUPT THE CYCLE AT THE SECOND LINK IN THE CAUSAL CHAIN OF EVENTS IATA Training & Development Institute

Safety from a New Perspective THE ELEMENTS CHAIN – Here are the essentials LATENT UNSAFE CONDITIONS UNSAFE ACTION WINDOW Of OPPORTUNITY Disrupt the Element Chain – take away any single element Remove latent unsafe conditions – examine all possibilities Avoid unsafe actions – examine all procedures Window of Opportunity – identify potential scenarios Safety = Disrupt Causal Chain IATA Training & Development Institute

NAPO

Any questions? IATA Training & Development Institute

Workshop – 2 Identify and List All Hazards Related to being in the Class Room