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Uncovering human factors risks Gaining  visibility  of  opera2onal  human  factors  issues  through  the  Safety  Management  System    

Overview of the presentation

Presentation topics

•  Gaining visibility of Human Factors risks –  Safety reporting systems, investigations –  Safety audits –  Risk Management Systems –  Fatigue Risk Management Systems –  Flight Data Monitoring –  Safety Climate Survey

•  Managing human factors risks –  Non-Technical Skills (NTS) training –  Safety promotion activities –  Changing policies, processes and systems

•  Future directions

Virgin Australia’s Safety Management System model

Gaining visibility of human factors risks

Ways of gaining visibility and managing human factors risks

Sources of data to gain visibility of HF risks

Ways to manage HF risks

Safety reporting and investigations

Our goal: to ascertain the error-producing conditions in our daily operations, by encouraging reporting of

the following;

Flight OperationsNumber of Operational Safety Occurrences by Risk

0

30

60

90

120

150

180

Very

Low

Low

Mod

erat

e

Hig

h

Extr

eme

Very

Low

Low

Mod

erat

e

Hig

h

Extr

eme

Very

Low

Low

Mod

erat

e

Hig

h

Extr

eme

Aug-11 Sep-11 Oct-11

Num

ber o

f Occ

urre

nces Accountable Indirect

Safety reporting and investigations

Safety reporting and investigations

Safety audits

•  More proactive way to reveal day-to-day issues (particularly undetected errors and conditions)

Some examples – Flight safety: data entry errors due to task

saturation – Cabin safety: fatigue-related errors in door

procedures – Ground safety: slight deviations from SOPs

due to low familiarity with the operation

Risk Management Systems

•  Identifying HF-related risks associated with operational changes

•  Distribution and escalation of risk management tools (i.e. risk registers)

Example: SOP change during the takeoff phase

–  Risk of behavioural reversion –  Risk of miscommunication between

Captain and First Officer –  Risk of reducing reaction times, etc.

Fatigue Risk Management Systems (FRMS)

•  The FRMS reporting processes & communications systems are a significant part of data collection on crew wellbeing.

•  Example: alteration of the Australia-LAX pairings for a longer layover.

Flight Data Monitoring

•  Provides objective, detailed technical data

•  Allows for verification of crew’s recollections

•  Examples: – Rejected takeoff actions – Rates of descent on

approach – Breaches that are unknown

to the crew

Safety Climate Survey

•  Allows for a collation of feedback from crew

•  Will be conducted

organisation-wide in 2012.

Gaining visibility: Bringing together all information sources  

‘Gaining visibility’

The key is having all levels of management having an appropriate level of knowledge

about the human factors-related risks

Managing human factors risks

Sources of data to gain visibility of HF risks

Ways to manage HF risks

NTS courses and other safety training

•  Providing skills and knowledge to crew and other ‘safety critical’ staff

•  Can incorporate ‘lessons learned’ from investigations, audits, reports

•  Allows for a consistency in approaching human factors issues

Technical training enhancements

Safety promotion activities

•  Promoting greater safety awareness and knowledge through targeted messaging.

•  Examples –

– Management ‘road shows’ – Monthly publications – Safety campaigns

Changes to policies, process and procedures

•  Making organisation-wide changes should be the goal, in addition to training.

•  Examples: – Flight: Pre-descent briefing checklist

improvements – Cabin: changing crew rest policies to allow for

more effective in-flight sleep. – Ground: developing Local Operating

Procedures to accommodate unique port procedures

Where to from here?

•  Further improving visibility of human factors risks by; –  Improving investigators’ analytical skills – Moving towards performance-based auditing – Flight Data Monitoring trend data

effectiveness •  Further improving the management of human

factors risks by; – Expanding human factors education and

‘skilling’

Any questions?

Thank you!

Heather Fitzpatrick Safety and Quality Advisor

Virgin Australia Phone: +61 434 602 983

Email: heather.fitzpatrick@virginaustralia.com.au