Evolving Approaches to Managing
Safety and Investigating Accidents
Kathy Fox, Member
Transportation Safety Board of Canada
Canadian Women in Aviation Conference
Montreal, QC
June 17, 2011
1
Presentation Outline
• Practicing Safety
• Accident causation and prevention
• Safety Management Systems (SMS)
• Role of the Transportation Safety Board (TSB)
• Conclusion
2
Early Thoughts on Safety
Follow standard operating procedures +
Pay attention to what you’re doing +
Don’t make mistakes or break rules +
No equipment failure =
Things are safe
3
Safety ≠ Zero Risk
But why not?
4
Balancing Competing Priorities
Safety
Service
5
Reason’s Model
Defences
Occurrence
Inadequate
Productive
Activities
Limited Window of
Occurrence Opportunity
Un s afe Act s
Preconditions
P sych o lo g ic al
P recu rso rs o f U n safe
Act s
Line Management
De ficie n cies
Active Failures &
Latent Unsafe Conditions
DecisionMakers
F allib le Dec isio n s
Active Failures
Latent Unsafe Conditions
Latent Unsafe Conditions
Latent Unsafe Conditions
6
Sidney Dekker
Understanding Human Error
• People do their best to reconcile different
goals simultaneously.
• A system isn’t automatically safe.
• Production pressures influence trade-offs.
______
Dekker, S. (2006) The Field Guide to Understanding Human Error,
Ashgate Publishing Ltd.
7
Sidney Dekker
Understanding Human Error (cont.)
Tasks
Operating
Environment
Tools
Human
Error
______
Dekker, S. (2006) The Field Guide to Understanding Human Error,
Ashgate Publishing Ltd.
8
Why Focus on Management?
Management decisions
–
have a wider sphere of influence on operations
–
have a longer term effect
–
create the operating environment
9
Safety Management Systems (SMS)
Integrating safety into an organization’s daily operations.
“A systematic, explicit and comprehensive process for
managing safety risks … it becomes part of that
organization’s culture, and the way people go about their
work.”
- James Reason, 2001
10
Safety Management Systems (SMS)
(cont’d)
SMS requirements - Transport Canada
Accountable executive
Corporate safety policy and measurable safety goals
Identifying hazards and managing risks
Ensuring personnel are trained and competent
Internal hazard, incident and accident reporting and analysis
Documenting SMS
Periodic SMS audits
11
Key Elements of SMS
Hazard
Identification
Incident Reporting
and Analysis
Strong Safety
Culture
12
SMS: Hazard identification
Organizations must proactively identify hazards and
seek ways to reduce or eliminate risks.
Challenges:
• Very difficult to predict all possible interactions
between seemingly unrelated systems – complex
interactions. 1
_________
1
Perrow, C (1999) Normal Accidents, Princeton University Press
13
SMS: Hazard identification (cont’d)
Challenges (cont’d):
• Inadequate risk assessment of operational changes –
drift into failure, inability to think of ALL possibilities. 1,2
• Deviations from procedure become the norm. 3
_________
1
Dekker, S (2005) Ten Questions About Human Error, Lawrence Erlbaum Associates
2, 3
Vaughan, D. (1996) The Challenger Launch Decision, University of Chicago Press
14
Alaska Airlines Flight 261
Loss of Control and Impact with Pacific Ocean
(January 2000)
From NTSB report AAR0201
15
MK Airlines
Reduced Power on Takeoff and Collision With Terrain
Halifax, NS (October 2004)
16
Organizational Drift/
Employee Adaptations
• Difficult to detect from inside an organization.
• Front line workers create “locally efficient
practices” to get job done.
• Past successes taken as guarantee of future
safety.
• Were risks properly assessed?
17
Touchdown Short of Runway
Fox Harbour, NS (November 2007)
18
Aircraft Attitude at Threshold
19
SMS: Incident Reporting
Challenges:
• Determining which incidents are reportable.
• Analyzing ‘near miss’ incidents to seek opportunities to
make improvements to system.
• Shortcomings in companies’ analysis capabilities.
20
Weak Signals
Transwest Air, Collision with Terrain
Sandy Bay, SK (January 2007)
21
SMS: Incident Reporting (cont’d)
Challenges (cont’d):
• Performance based on error trends misleading: no
errors or incidents does not mean no risks.
• Voluntary vs. mandatory, confidential vs. anonymous.
• Punitive vs. non-punitive systems.1
• Who receives incident reports.
_________
1
Dekker, S. & Laursen, T. (2007) From Punitive Action to Confidential
Reporting Patient Safety and Quality Healthcare September/October
2007
22
SMS: Organizational Culture
• SMS is only as effective as the organizational culture
that enshrines it.
• Work groups create norms, beliefs and procedures
unique to their particular task, thus becoming the work
group culture. 1
• Undesirable characteristics may develop within
organization. 2
_________
1 Vaughan, D (1996), The Challenger Launch Decision, University of Chicago Press
2 Columbia Accident Investigation Report, Vol. 1, August 2003
23
SMS: Accountability
Recent trend: criminalizing human error
Consequences:
- Organizations become defensive.
- Safety-critical information not shared for fear of
reprisals.
As such, safety suffers.
________
Dekker, S (2007) Just Culture, Ashgate Publishing Ltd.
24
Elements of a “Just Culture”
(Dekker 2007)
• Encourages openness, compliance, fostering safer
practices, critical self-evaluation.
• Willingly shares information without fear of reprisal.
• Protects those who report their honest errors from blame.
• Avoids hindsight bias. Tries to see why people’s actions
made sense to them at the time.
• Recognizes there is no fixed line between culpable and
blameless error.
___________
Dekker, S (2007) Just Culture, Ashgate Publishing Ltd.
25
SMS: Benefits and pitfalls
• Nothing will always guarantee that all hazards will be
found, analyzed and eliminated.
• However, SMS is a benefit where it’s implemented.
26
About the TSB
• Independent organization investigating marine, pipeline,
rail and air occurrences.
• Finds out what happened and why.
• Makes recommendations to address safety
deficiencies.
• Does not assign fault or determine civil or criminal
liability.
27
About the TSB (cont’d)
• Reason’s Model adopted in early 90s.
– Multi-causality.
– Human error within broader organizational context.
• Integrated Safety Investigation Methodology (ISIM)
– Determining if full investigations are warranted
based on potential to advance safety.
– Use of various human and organizational factors
frameworks. (Westrum, Snook, Vaughan, Dekker)
28
Summary
• Adverse outcomes result from complex interactions of
factors difficult to predict.
• People at all levels in an organization create safety.
• ‘Near-misses’ must be viewed as “free opportunities”
for organizational learning.1
________
1 Dekker, S. & Laursen, T. (2007) From Punitive Action to
Confidential Reporting Patient Safety and Quality Healthcare
September/October 2007
29
Summary (cont’d)
• Accident investigators must focus on what made sense
at the time, not be judgmental, avoid hindsight bias2
• Accountability requires organizations and professionals
to take full responsibility to fix problems3, 4
________
2 Dekker, S. (2006) The Field Guide to Understanding Human
Error Ashgate Publishing Ltd.
3 Sharpe, V.A. (2004) Accountability Patient Safety and Policy
Reform Georgetown University Press
4 Dekker, S. (2007) Just Culture Ashgate Publishing Ltd.
30
References
•
Slide 7, 8, 30: Dekker, S. (2006) The Field Guide to Understanding Human
Error, Ashgate Publishing Ltd.
•
Slide 10: Reason, J. (2001) In Search of Resilience, Flight Safety Australia,
September-October, 25-28.
•
Slide 13: Perrow, C (1999) Normal Accidents, Princeton University Press.
•
Slide 14: Dekker, S (2005) Ten Questions About Human Error, Lawrence
Erlbaum Associates.
•
•
Slide 14, 23: Vaughan, D. (1996) The Challenger Launch Decision, University of
Chicago Press.
Slide 22, 29: Dekker, S. & Laursen, T. (2007) From Punitive Action to
Confidential Reporting Patient Safety and Quality Healthcare
September/October 2007.
Slide 23: Columbia Accident Investigation Report, Vol. 1, August 2003.
•
Slide 24, 25, 30: Dekker, S (2007) Just Culture, Ashgate Publishing Ltd.
•
Slide 30: 3 Sharpe, V.A. (2004) Accountability Patient Safety and Policy Reform
Georgetown University Press.
•
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