from basi-indicate to safety systems to aviation … of sa...• basi – air safety investigator,...
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From BASI-Indicate to Safety Systems to Aviation Safety Regulation in 2010
Dr Graham EdkinsGroup General Manager, Personnel Licensing, Education and Training
April 2006
April 2006
Where I am coming from…?Variety of professional safety roles in Rail and Aviation as regulator, investigator and safety manager
Rail• Rail investigator – Westrail & Victorian Rail Safety Regulator
• Chair, National Rail Safety Regulators Panel (RSRP)
• Chair, Safety Management Systems Expert Panel (SMSEP), Special Commission of Inquiry into the Waterfall rail accident
• Member, SCOT Rail Group Steering Committee on Co-regulation
Aviation• BASI – Air Safety Investigator, CASA – GGM PLET
• Qantas – Chief Psychologist, Head Human Factors, GM Safety Systems & Education
• Previous President, Australian Aviation Psychology Association (AAvPA)
• Vice Chair, IATA Human Factors Working Group
April 2006
Co-author: CASA (1998) Aviation Safety Management: An operators guide.
Keynote Speaker CASA (2000) Safety Management Systems National Roadshow
Chair: Standards Australia: AS5022 Rail Safety Investigations
Member: Standards Australia: AS4292 Rail Safety Management
Member: Industry Development Group CASR 119: Safety Management Systems
ICAM (Incident Causa Analysis Method) Trainer – BHP Billiton
Master of Psychology (Organisational) – rail human factors
PhD applied in safety management systems (aviation)
Where I am coming from…?
Westrail – circa 92-94
April 2006
Antecedents
Signals Passed at Danger (SPAD)
The Reason Model ~ circa 1990• Developed from Professor James Reason’s work on human
error and “organisational accidents”
Proactive safety indicators ~ circa 1992• Tripod Delta for Shell Petroleum• MESH for British Airways• PRISM / REVIEW for British Rail
Focus on proactive identification of General Failure Types (GFTs)
April 2006
The Reason Model
Organisational and System Factors
“Unsafe
Acts”
Latent Conditions (adapted from Reason, 1990)
ActiveFailures
Contextual Conditions Human
Involvement
Limited window/sof opportunity
Absent or Failed Barriers
ACCIDENT
People, Task, Environment
April 2006
General Failure TypesHardwareDesignMaintenance ManagementProceduresError-enforcing ConditionsHousekeepingIncompatible GoalsCommunicationOrganisationTrainingDefences
April 2006
Railway Problem Factors (RPF’s)
1738
9291
12643
5528
5350
342141
0 20 40 60 80 100 120 140 160 180
Organisational PoliciesEquipment Design
HousekeepingManagementStaffing
Rules/ProceduresWorking ConditionsSupervisionStaff Attitude
MaintenanceOperating EnvCommunication
Training
April 2006
ImplicationsPeople are very adept at making global estimates of hazards/riskOwnership and participation in safety management drives commitmentFocus on GFT’s avoids focus on individual error and potential “blaming process”Complement to “systems” approach to accident investigationManagement tool - Sets priorities with finite resourcesAssumes safety is a management problem
Bureau of Air Safety Investigation (94-97)
April 2006
Context
11 June 1993, VH-NDU Monarch Airlines accident, Young NSW – 7 fatalities2 October 1994 VH-SVQ – Seaview Air Crash, en-route Lord Howe Island – 9 fatalities1995, Staunton Commission Inquiry into Seaview Air and CAA1995, Inquiry into safety of General Aviation sector – Plane Safe
April 2006
Myths
Safety programs only applicable to high capacity operatorsCostly to implementRequire system safety expertise
Indicate program developed in 1995-1997 and trialled within Kendell airlines
April 2006
INDICATE assumptions
People know what the safety hazards are within their work area – but need to be given opportunity to reportFear of blame contributes to reporting reluctanceFeedback consistency affects reporting cultureDefence failures are often revealed too late!
April 2006
Proactive defence evaluation model*
* Edkins, G.D. (1998). The INDICATE safety program; evaluation of a method to proactively improve airline safety performance. Safety Science, 30: 275-295
April 2006
Six core safety activities
1. Appointing an operational safety manager who is available to staff as a confidant for safety-related issue
2. Conducting a series of staff focus groups to proactively identify company safety hazards
3. Establishing a confidential safety reporting system for staff to report safety hazards
4. Conducting monthly safety meetings with management
5. Maintaining a safety information database to record, manage and evaluate safety recommendations
6. Ensuring that safety information is regularly distributed to all staff.
Intervention group Control Group
Yes No
Yes No
Yes Yes
Yes No
Yes No
Yes No
April 2006
Proactive identification of safety hazards 5 simple steps:
i. Identify potential airline safety hazards that may threaten the safety of passengers
ii. Rank the severity of hazardsiii. Identify current defencesiv. Evaluate the effectiveness of each defencev. Identify additional defences
April 2006
Methodology
April 2006
Airline Safety Culture Index
4144
59 50
70 74
25
45
65
85
105
125
T1 T2 T3
InterventionControl
NOTE: Score between 25-125, the LOWER the score the BETTER the result
April 2006
Risk Perception - Severity
140
90 85
139
93
116
020406080
100120140160180
T1 T2 T3
InterventionControl
April 2006
Risk Perception - Likelihood
76
39 35
76
5066
020406080
100120140160180
T1 T2 T3
InterventionControl
April 2006
Reporting culture – volume of safety reports submitted
60
4549
90
102030405060708090
100
T1 T2
InterventionControl
April 2006
Qualitative analysis
INTERVENTION• “ I think the INDICATE program is a great idea and with its persistence will force management into improving areas and procedures that are unsafe. ”
• “ There are countless things that can trip up an airline in regard to safety. It’s a fine balance between safety and economics. Vigilance is the best safety net, therefore programs like this make me feel that this is a safe airline. ”
CONTROL• “ People are reticent to share experiences and discuss safety incidents they may have had, as they feel their positions will be under threat. ”
• “ There is a general feeling that management practices are reactive and not proactive…..”
April 2006
INDICATE - LessonsSimple ideas are often effectiveStructured framework for communicating safety messages is crucialSafety culture has an influence on attitude and behaviourContinual evaluation of a SMS is crucial – complacency is easySafety systems need to continually evolve – 12 months later, INDICATE became outdated for Kendell!
Qantas – 1997-2003
April 2006
Case Study
Runway Overrun, BangkokSeptember 1999
Executive Director, Public Transport Safety Victoria
(PTSV) 2003-2005
1 2 3
April 2006
A Case Study of Systematic Failure in Rail Safety: The Waterfall Accident
April 2006
Human Compensatory Ability: A case study of a Runaway Train!
April 2006
Implications for Organisations and Regulators
April 2006
Implications for Organisations (1)
Do you have Integrated Safety Management Systems –not stand alone?Are Risk Management activities system wide and proactive?Do you have formal document control processes, particularly for change management activities?Does your organisation have expertise and a requisite understanding of human and organisational factors?Does your organisation have a program for continued professional development in safety science?
April 2006
Implications for Organisations (2)
Is safety culture measured on a periodic basis?Do your employees really believe that there is a justapproach to incident/accident investigation?What evidence could you present that indicates your organisation has a learning culture?Do you have an integrated safety information management system that drives strategy?Do you have a human systems integration program that incorporates principles of error tolerance?
April 2006
Implications for Regulators (1)
Is the regulator sufficiently independent and autonomous from government?Is there a function for the independent (from regulator) conduct of safety investigations?Does the regulator have expertise and an ongoing professional development program in human and organisational factors and safety science?How does the regulator ensure that they don’t lose touch with current industry practices?
April 2006
Implications for Regulators (2)
Does the regulator comprehensively assess the adequacy of safety accreditation/AOC and change management applications to ensure that they are rigorous?Does the regulator require industry operators to collect causal factors data to an agreed standard so that emerging safety deficiencies can be identified across various sectors? Does the regulator have sufficient resources to enable compliance and accreditation activities to be effectively achieved?
CASA 2005-
April 2006
AIRSERVICES AUSTRALIAAir Traffic Control
Airspace Management
Aeronautical Information
Airport rescue & fire fighting services
Radio navigation aids
DEPARTMENT OF TRANSPORT & REGIONAL SERVICESInternational and domestic aviation policy advice
International airline operations regulation
Management of participation in ICAO
Administration of aviation security standards
Publication of air service statistics
AUSTRALIAN TRANSPORT SAFETY BUREAUIndependent investigation of aircraft accidents/incidents
Analysis of safety data
CIVIL AVIATION SAFETY AUTHORITY (CASA)
Standards
Regulatory Services
Compliance
Safety Promotion
Aviation Safety Responsibilities
April 2006
April 2006
SurveillanceOld Approach
Task-focussedTended to focus on end-product of the systemsIdentified problems tended to be fixed by “patches”Inflexible planning processMuch repetition of tasksChecklist based
New Approach
Focuses on • Organisation’s systems• Systems used to produce safe
outcomesRequired fixes based on the systems needed to produce consistent resultsSurveillance planning is organisation-basedPlanning based on sector and individual organisation riskUses team-based audit techniques where practicalRecording systems are guideline-based.
April 2006
1995 – Introduction of SMS – Dick Wood1996 – SAPCOM – industry advisory group1998 – First Guidance booklet (Aviation Safety Management: An operator’s guide)1998 – National launch SMS concepts (Reason/Hudson)2000 – Release of discussion paper on SMS2001 – National education roadshow “System of safety” – Rob Lee/Graham Edkins2002 – NPRM CASR 119, multimedia guidance material2003-2005 – focus on small to medium size operators
2006 – safety case (exposition) and integrated SMS
History of CASA SMS
April 2006
NotificationRegistration
Development
Safety Case (Exposition) Outline
Consulting & informing
Safety Duties•HAZID & safety assessment
•Design SMS•Outline control measures•Demonstrate adequacy
Safety Case Preparation
Submission
Maintenance
Appeals/Reviews
Amendment/Revision
Co-ordination
Modification
Issuing AOC or Cof A
Safety Oversight
Education
Liaison
Periodic Review
Review after Accidents / Incidents
Review
Consultation Review
Prepare Conclusion
Communicate Conclusion
Adequacy Tests
CASA Actions
Industry Actions
Both
New AOC/CofA Existing AOC/CofA
April 2006
What might be CASAs focus in 2010?One third - Safety Research and Analysis.Development of Safety regulations which target known safety risks and supported by credible and appropriate safety analysis. Safety Modelling. A greater emphasis in providing Industry with the Management and Safety Systems models which they can criteria reference there own safety performance against.
One third - Education and Training.Supporting CASA Oversight and Compliance staff (and Industry), with the skills and competencies to build and evaluate SMS’s.
One Third - Compliance and safety oversight.Risk Based Audits. Referencing/Measuring Operators safety profile against particular models of safety efficiency and effectiveness. Working with Operators and Case managing continuous improvements.
April 2006
What CASA might look like?
400-500 staff rather than 700CASA dominant workforce profile - 30 something, male or female, systems backgroundFocus on particular pax carrying operators based on identified riskGeneral aviation, sports aviation, aerial work –more self regulatingMain activity – safety education
April 2006
The future of SMS
SMS will be integrated into all management systems. It will not be an appendage - it will be an integral part of normal day to day operations.
CASA’S focus will be on how well these systems are designed and how well they are functioning.
Operators will need to demonstrate continuous improvement and reapply for AOC/CofA every 3-5 years (exposition/safety case)
April 2006
April 2006
In case you forgot what I said !
Regulatory safety requirements are increasing– Safety case and risk management
– Integrated Safety Management Systems
– Demonstrate continuous improvement
Unplanned change is your biggest risk
Taking your people with you, “hearts and minds” , in that
change process is vital (the regulator will look for
assurance this has been done!)
April 2006
Final words
“Safety is a little like boarding an aircraft with no destination; the journey never ends”
Don’t stick your head in the sand !
April 2006
Questions?