1 Evolving Approaches to Managing Safety and Investigating Accidents Kathy Fox, Member...
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- Slide 1
- 1 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
- Slide 2
- 2 Presentation Outline Practicing Safety Accident causation and
prevention Safety Management Systems (SMS) Role of the
Transportation Safety Board (TSB) Conclusion
- Slide 3
- 3 Early Thoughts on Safety Follow standard operating procedures
+ Pay attention to what youre doing + Dont make mistakes or break
rules + No equipment failure = Things are safe
- Slide 4
- Safety Zero Risk But why not? 4
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- 5 Balancing Competing Priorities Service Safety
- Slide 6
- 6 Reasons Model
- Slide 7
- 7 Sidney Dekker Understanding Human Error People do their best
to reconcile different goals simultaneously. A system isnt
automatically safe. Production pressures influence trade-offs.
______ Dekker, S. (2006) The Field Guide to Understanding Human
Error, Ashgate Publishing Ltd.
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- 8 Sidney Dekker Understanding Human Error (cont.) ______
Dekker, S. (2006) The Field Guide to Understanding Human Error,
Ashgate Publishing Ltd. Human Error ToolsTasks Operating
Environment
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- Why Focus on Management? Management decisions have a wider
sphere of influence on operations have a longer term effect create
the operating environment 9
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- 10 Safety Management Systems (SMS) Integrating safety into an
organizations daily operations. A systematic, explicit and
comprehensive process for managing safety risks it becomes part of
that organizations culture, and the way people go about their work.
- James Reason, 2001
- Slide 11
- 11 Safety Management Systems (SMS) (contd) 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
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- 12 Key Elements of SMS Hazard Identification Incident Reporting
and Analysis Strong Safety Culture
- Slide 13
- 13 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
- Slide 14
- 14 SMS: Hazard identification (contd) Challenges (contd):
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
- Slide 15
- Alaska Airlines Flight 261 Loss of Control and Impact with
Pacific Ocean (January 2000) 15 From NTSB report AAR0201
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- 16 MK Airlines Reduced Power on Takeoff and Collision With
Terrain Halifax, NS (October 2004)
- Slide 17
- 17 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?
- Slide 18
- 18 Touchdown Short of Runway Fox Harbour, NS (November
2007)
- Slide 19
- 19 Aircraft Attitude at Threshold
- Slide 20
- 20 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.
- Slide 21
- Weak Signals 21 Transwest Air, Collision with Terrain Sandy
Bay, SK (January 2007)
- Slide 22
- 22 SMS: Incident Reporting (contd) Challenges (contd):
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
- Slide 23
- 23 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
- Slide 24
- 24 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.
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- 25 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 peoples 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.
- Slide 26
- SMS: Benefits and pitfalls Nothing will always guarantee that
all hazards will be found, analyzed and eliminated. However, SMS is
a benefit where its implemented. 26
- Slide 27
- 27 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.
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- 28 About the TSB (contd) Reasons 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)
- Slide 29
- 29 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
- Slide 30
- 30 Summary (contd) Accident investigators must focus on what
made sense at the time, not be judgmental, avoid hindsight bias 2
Accountability requires organizations and professionals to take
full responsibility to fix problems 3, 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.
- Slide 31
- 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. 31
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