1. La protección de las fuentes de información sobre la seguridad operacional – La perspectiva técnica La protección de las fuentes de información sobre la seguridad operacional – La perspectiva técnica Capt. Daniel Maurino Capt. Daniel Maurino Seguridad de Vuelo y Factores Humanos – OACI Seminario de Seguridad ASPA/OACI Cuidad de México, 10 – 11 Abril 2007 Cuidad de México, 10 – 11 Abril 2007

2. Focus on the outcome (s) Focus on the outcome (s) 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 investigation Accident 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 investigation Accident investigation

12. Protecting Safety Data – An Odyssey Clearly defined objective Clearly defined objective üProtect sources of safety information At the intersection of safety, law & politics At the intersection of safety, law & politics üThe solution – Safety and Law üThe Implementation – Political will An inescapable reality An inescapable reality No safety data protection = No SMS No safety data protection = No SMS

13. Denial: ritualistic blaming leading to self-delusion Denial: ritualistic blaming leading to self-delusion Repair: cover-up, cosmetic re-writing denying learning Repair: cover-up, cosmetic re-writing denying learning Reform: engaging the political will Reform: engaging the political will Protecting Safety Information – Excuses and Fear