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Transcript of Patrick Murray
The “Safety Journey”
an air industry perspective
Patrick MurrayDirector
Griffith University Aerospace Strategic Study Centre
Aerospace Strategic Study Centre“Safety Through Education and Research”
Thank You
Thanks and acknowledgement
to:
•CASA
•Flight Global ACAS
•IATA
•ICAO
•University of Texas (HFRP)
•The LOSA Collaborative
Aerospace Strategic Study Centre“Safety Through Education and Research”
[email protected] www.griffith.edu.au/aviation
Air Transport / Rail
Complex socio – technical systems
Passenger & freight transport
Vital part of national infrastructure
Transition from Government – private ownership
High reliability systems
Large investments in Safety
Inherently dynamic (unstable) system
Aerospace Strategic Study Centre“Safety Through Education and Research”
Human Beings are involved
at all levels of the system
Scope
Safety in high reliability systems
Risk in airline operations
Airline safety trends
The “safety journey”
New paradigms (or old wine in new bottles)?
Aerospace Strategic Study Centre“Safety Through Education and Research”
How do we measure Safety?
The absence of accidents ?
The presence of a Safety Management System ?
Does an increase in reported incidents show:
• A decrease in safety?
• An improvement in safety (better reporting culture)?
Regulatory compliance = safety?
Can organisations be compared?
Aerospace Strategic Study Centre“Safety Through Education and Research”
The Issue
• Accident risk :
» Extremely high consequence
» Extremely low frequency
= Extreme Risk(but very difficult to measure and manage)
Aerospace Strategic Study Centre“Safety Through Education and Research”
No system
beyond this
point
10-2
10-3
10-4
10-5
10-6
Civil Airlines
Nuclear Industry
Railways (First World)
Charter
FlightsHymalaya
mountaineering
Road Safety
Anesthesiology
Blood transfusion
Professional Fishing
Crop spraying
Very unsafe Ultra safe
Medical risk
average
Chemical Industry (total)
Helicopters
10-1
Tubes/metros
Relative system safety
Aerospace Strategic Study Centre“Safety Through Education and Research”
Risk of Fatality
Surgery
Adapted from
Rene Almaberti 2006
10-2 10-3 10-4 10-5 10-6
The story of the
next accident will
be a repeat of
previous accidents
The story of the next
accident is a
combination of parts of
previous accidents or
incidents, in particular
using the same
precursors
The next accident is
an original story and
context never seen
before together.
Decomposition of
the story may reveal
a series of already
seen micro incidents,
but for the most
part, not previously
considered as
consequential
Aerospace Strategic Study Centre“Safety Through Education and Research”
40’s-70’s Reducing pilot workload
70’s-90’s Improving situational awareness / CRM
90’s- Promoting organisational safety / QA
Mid 90’s- understanding human error / culture
Next challenge : Improving resilience ??
The Long and Winding Road
Aerospace Strategic Study Centre“Safety Through Education and Research”
Griffith Aerospace Safety Centre
Aerospace Strategic Study Centre“Safety Through Education and Research”
Everyone makes errors
The ubiquity of human error...
Griffith Aerospace Safety Centre
Aerospace Strategic Study Centre“Safety Through Education and Research”
If we really accept that errors will always be a
part of the human condition - perhaps even a by
- product of that ingenuity and resilience that
only human beings exhibit....
...then it is only by analysis of these errors
(ingenuity?) and the surrounding context can we
move to the next frontier in safety....
Safety Management
System Data Sources
Normal Operations
Monitoring
Flight Data
Analysis
Voluntary
Reporting
Predictive Proactive Reactive
Highly efficient More efficient Efficient
Safety management potential
Reactive
Inefficient
Surveys
Audits Incident
Reports
Accidentreports
Normal Operations
Normal Operations Monitoring
Safety management instruments
Aerospace Strategic Study Centre“Safety Through Education and Research”
ACCIDENTS &
INCIDENTS
UNREPORTED
OCCURRENCES
•Loukopoulos/Dismukes, 2002, NASA
Aerospace Strategic Study Centre“Safety Through Education and Research”
• LOSA formally endorsed by ICAO as an industry best practice for monitoring normal operations
• ICAO Doc 9803 (LOSA) published in 2002
Aerospace Strategic Study Centre“Safety Through Education and Research”
Flight deck observations by trained and
calibrated observers
• No jeopardy to crew
• All data de-identified & confidential
• Significant data cleaning to remove “noise”
• Report on:
Specific threat environment
Nature and prevalence of errors
Threat and error management by crews
Methodology
Aerospace Strategic Study Centre“Safety Through Education and Research”
Intentional non – compliance
40+ Airlines / 9,000+ flights
Approx 28% of all errors were
associated with
Intentional non - compliance
Aerospace Strategic Study Centre“Safety Through Education and Research”
Why do violations occur?
A culture where getting the job done is more
important than safety?
Unworkable rules and procedures?
Personnel using „short-cuts‟ and „work-arounds‟ to
achieve organisational goals
Are we suppressing human ingenuity?
Aerospace Strategic Study Centre“Safety Through Education and Research”
VIOLATION or “Getting the job done” ?
What is Culture?
“Values and practices that we share with others that help define us
as a group” .......“Who we think we are, what we believe in and
what is important to us”
(Prof Ashleigh Merritt - 1997)
“The way we do things around here”
(Anon)
“When I hear the word “culture”, I want to reach for my Luger”
(Reich Marshal Herman Goering 1936)
Aerospace Strategic Study Centre“Safety Through Education and Research”
“The way we do things around here -
when no-one is watching”!
My suggestions about safety would be acted
upon if I expressed them to management.
Safety
Culture
The managers in Flight Operations listen to us
and care about our concerns.
Management will never compromise
safety concerns for profitability•.
I am encouraged by to report any unsafe
conditions I observe.
I know the proper channels
to report my safety concerns.
I am satisfied with Chief Pilot and
Assistant Chief Pilot availability.
Safety Culture Survey Questions
Aerospace Strategic Study Centre“Safety Through Education and Research”
% Crews with an Undesired State
14%
54%67%
01020304050
60708090
100
Low Safety Culture
Crews
Avg Safety Culture
Crews
High Safety Culture
Crews
Sc
ale
0-1
00
Base
Rate
Aerospace Strategic Study Centre“Safety Through Education and Research”
Safety culture and crew performance
PATHOLOGICAL
Who cares as long as
we’re not caught
Organisational and
Individual Trust
Organisational
Openness and
Communication
-REACTIVE
Safety is important when
we have an accident
PROACTIVE
We fix problems that we
find
CALCULATIVE
We have systems in place
to manage hazards
GENERATIVE
Safety is fully integrated
into all operations
+
-
+
Adapted from
Prof Patrick Hudson
Where is your
organisation ?
Safety Culture
• The Columbia Space Shuttle
Accident Investigation Board found
that… NASA’s organisational
culture had as much to do with the
accident as the foam did…
Columbia Accident
Investigation Board
Report August
2003
Have you ever wondered why you pay extra for
Business Class?
Example of reactive safety management
Griffith Aerospace Safety Centre
Aircraft are certified (windshield, engines etc), to continue flying after an impact of any bird below4 lbs and multiple impacts of smaller birds
Resistance assessed by “chicken-guns”
But….Speed at impact too small in certification test36 species of bird weigh over 4 lbs in North America30% ingestion of birds weighing over 4 lbs (USA)
New regulation coming: >> 8 lbs
But geese may weigh over 15 lbs and fly in “squadrons” !!
Aerospace Strategic Study Centre“Safety Through Education and Research”
Proactive Safety – the next generation?
Griffith Aerospace Safety Centre
If we only look at the future in the light of the past……
….our understanding of what has happened inevitably
colours our anticipation and preparation for what
could go wrong and thereby holds back the requisite
imagination that is essential for safety
The next generation of safety will be organisations,
groups and individuals who are resilient ….
…..recognise, adapt to and absorb variations, changes,
disturbances, disruptions, and surprises – especially
disruptions that fall outside of the set of disturbances
the system is designed to handle
Aerospace Strategic Study Centre“Safety Through Education and Research”
Improving Safety
• Management and union leadership demonstrate
commitment to safety
• Understanding and applying the „safety balance‟ of
production versus safety
• Integrated application of risk management principles
– By operators
– By regulators
• Risk (not compliance) based investigations
• Fair and accountable safety processes
“A Just Culture” ?
Thank You
Thanks and acknowledgement
to:
•CASA
•Flight Global ACAS
•IATA
•ICAO
•University of Texas (HFRP)
•The LOSA Collaborative
Aerospace Strategic Study Centre“Safety Through Education and Research”
[email protected] www.griffith.edu.au/aviation