1. Hazard Identification
Session 4

2. 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
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3. 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
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4. 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
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5. + + 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 + +
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6. + + 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
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7. 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
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8. Hazard Identification
What is a Hazard?
The condition or circumstance that can lead to a loss of life or an aircraft
First core competency
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9. 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
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10. Lions in Africa

11. 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”
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12. 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
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13. 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)
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14. “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
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15. Safety Management System
People
Materials
Procedures
Tools
Equipment
Software
Facilities
There may be “latent” unsafe conditions in all of these components
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16. Detection of Latent Unsafe Conditions
THERE ARE MANY SYSTEMS
(none of which are unsafe when isolated)
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17. Accident
Accident Causes are Non-Linear (so are the latent unsafe conditions)
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18. Latent Unsafe Conditions
How do we identify them?
We start with the paradigm shift in Safety Management
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19. 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
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20. 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
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21. 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
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22. 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
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23. 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
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24. 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
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25. 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
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26. 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
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27. 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
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28. 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
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29. 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
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30. 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
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31. NAPO

32. Any questions?
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33. Workshop – 2 Identify and List All Hazards Related to being in the Class Room