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

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

3. 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/serious incident investigation

4. 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

5. System Performance “In the Wild”
design
Baseline performance
Operational
deployment
Operational performance
Operational
drift

6. Managing Safety–Navigating the Drift
Baseline performance
“Practical
drift”
Operational performance
Organization
Navigational aids
Reactive
Proactive
Predictive

7. 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

8. 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

9. Managing Safety: Collapsing the Drift
Operational
deployment
System
design
Operational drift
Operational performance
Baseline performance
Operational performance
Operational
deployment
System
design
Baseline performance
drift

10. Emerging Paradigm–Performance-Based System
Deterministic – The world as it should be
Aviation system – as pre-specified – is perfect
Compliance based
Outcome oriented
Accident/serious incident 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

11. 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)