Transcript INVESTIGATION PROCESS - Flight Safety Foundation
“Safety, Risk Management, Governance and Accountability”
Kathy Fox, Transportation Safety Board April 11, 2013 Business Aviation Safety Seminar Montreal, QC
Outline
• • • • • Evolution of accident investigation Organizational Drift into failure Evolution of Safety Management Systems (SMS) Investigating for organizational factors o o o o Goal conflicts Inadequate risk analysis Employee adaptations Weak signals The role of governance / regulatory oversight 2
Background
• •
“What” happened vs. “why” it happened Evolution of accident investigation:
• • • • • • aircraft design cockpit design physiological factors psychological influences on decision-making and risk-taking performance of the flight crew, not just the pilot (CRM, TEM) organizational factors 3
Balancing Competing Priorities
Service Safety 4
Limits of Acceptable Performance
Rasmussen, J. (1997). Risk management in a dynamic society: a modelling problem. Safety Science, 27, 183-213 5
Organizational Drift
“Drift is generated by normal processes of reconciling differential pressures on an organization (efficiency, capacity utilization, safety) against a background of uncertain technology and imperfect knowledge.”
Dekker, S. (2005). Ten Questions About Human Error: A New View of Human Factors and System Safety. Lawrence Erlbaum Associates, Inc.
6
Impact of Management
By their nature, management decisions tend to have a wider sphere of influence on how the organization operates, and a longer-term effect, than the individual actions of operators.
Decision-makers need to develop “mindfulness” to avoid “blind spots.” Weick, K. E. & Sutcliffe, K. M. (2007). Managing the Unexpected: Resilient Performance in an Age of Uncertainty. (2nd ed.) John Wiley & Sons Inc.
7
A “Mindful Infrastructure” Would …
• • • • • • Track small failures Resist oversimplification Remain sensitive to operations Maintain capabilities for resilience Take advantage of shifting locations of expertise Listen for, and heed, weak signals * Weick, Karl E.; Kathleen M. Sutcliffe (2001). Managing the Unexpected - Assuring High Performance in an Age of Complexity. San Francisco, CA, USA: Jossey-Bass. pp. 10–17. ISBN 0-7879-5627-9.
8
• • • • • • •
Characteristics* of Effective Safety Management
a strong organizational emphasis on safety; high collective efficacy (i.e., a high degree of cooperation and cohesiveness); congruence between tasks and resources; a culture encouraging effective and free-flowing communications; clear mapping of its safety state; a learning orientation; clear lines of authority and accountability.
*Westrum, R. (1999). Organizational Factors in Air Navigation Systems Performance (Review Paper for NAV CANADA.) 9
Safety Management Systems (SMS)
SMS integrates safety into all daily activities.
“It is a systematic, explicit, and comprehensive process for managing safety risks … it becomes part of that organization’s culture, and [part] of the way people go about their work.” Reason, J. (2001). In search of resilience. Flight Safety Australia September-October, 25-28.
10
SMS Requires the Following:
Hazard Identification Incident Reporting and Analysis Strong Safety Culture
11
Investigating for Organizational Factors
• Goal conflicts • Inadequate risk analysis • Employee adaptations • Missed “weak signals”
COMPLEX INTERACTION = NO SINGLE FACTOR AS SOLE CAUSE
12
Goal Conflicts TSB Investigation Report A04H0004
13
Inadequate Risk Analysis TSB Investigation Report A07A0134
14
Aircraft Attitude at Threshold
15
Employee Adaptations
• Faced with time pressures or multiple goals, workers and management may be tempted to create “locally efficient practices.” • Why? To get the job done!
• Past successes are taken as a guarantee of future safety.
16
Employee Adaptations (cont’d) Kelowna Flightcraft Boeing 727 at St. John’s International Airport. TSB Investigation Report A11A0035
17
Weak Signals
YVR seaplane dock, 16 November 2008 (A08P0353) 18
Weak Signals (cont’d)
Collision with terrain: Sandy Bay, SK (A07C0001) 19
Weak Signals (cont’d)
“We didn’t see [these recent accidents] coming, and we should have … the data were trying to tell us something.”
-William Voss, President and CEO of Flight Safety Foundation
20
SMS in Air Carrier Operations
•
Findings as to Risk (Sunwing A11O0031)
When an operator’s proactive and reactive SMS processes do not trigger a risk assessment, there is an increased risk that hazards will not be mitigated.
• Operators that do not recognize a reportable occurrence may not conduct an investigation or preserve data from the digital flight data recorder.
• If operators do not thoroughly document aircraft malfunctions, there is an increased risk that deficiencies will not be corrected.
• The acceptance by flight crews and companies of known equipment problems could put safety at risk.
21
Pilot Error or Management Error?
• Drift, goal conflicts and adaptations are natural • No one sets out to have an accident; they just want to get the work done • The decision to value production over safety is implicit 22
Pilot Error or Management Error? (cont’d)
• With each success, people underestimate the amount of risk involved • If investing in safety improved quarterly returns, the company would do it • There is a complex relationship between culture and process 23
The Role of Governance / Oversight
Q) Who holds decision-makers to account?
A) Board of Directors / owner Shareholders / financial backers Customers Insurance companies Regulators
All of the above
24
Governance / Oversight (cont’d)
TSB Investigation Report A10Q0098 25
Governance / Oversight (cont’d)
“The gap between what is legal and what is safe already is large, and it will get bigger. … Is this regulatory approach sustainable? Is it fair to airlines that do everything right? Is it fair to an unknowing public?” -William Voss, Flight Safety Foundation
26
TSB Watchlist
Marine • Safety management systems • Loss of life on fishing vessels Air •
Collisions with land and water
•
Landing accidents and runway overruns
•
Risk of collisions on runways
•
Safety management systems
Rail • On-board video and voice recorders • Following signal indications • Passenger trains colliding with vehicles 27
Conclusions
• “Mindful infrastructure” • Effective Safety Management depends on “culture” and “process” • Organizational accountability is key • Effective regulatory oversight is essential • Success takes commitment, perseverance, and time 28
QUESTIONS?
29
30