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Safety Information: The Cooperation between
Aviation and Judicial Authorities
Madrid, 24 – 25 March 2011Madrid, 24 – 25 March 2011
The Evolution from Just to Accountability Culture
Safety expectations at the turn of the XXI Century
Captain Gustavo J. Barba RománCOPAC deputy president
ICAO SMS/SSP instructor
Safety Information: The Cooperation between
Aviation and Judicial Authorities
Madrid, 24 – 25 March 2011Madrid, 24 – 25 March 2011
Setting the scene“The increased competition has resulted in continuing downward pressure on revenue yields and consequent business re-organisation”. IATA–Icon , August 2001
As forecasted,The world must be alert to the threats posed by change, citing the rise of powerful, fast-growing new economies and the fact that many of the former major economies with a long aviation tradition are "struggling".
FSF chairman Lynn Brubaker says, March 2011 [EASS Istanbul]
Safety Information: The Cooperation between
Aviation and Judicial Authorities
Madrid, 24 – 25 March 2011Madrid, 24 – 25 March 2011
Safety implicationsIndustry Over emphasis on commercial objectives
Unbalance allocation of resources between production and protection
Lack of safety performance regulations
ICAO request SSP for Member States from November 2006 & SMS for A/C operators and AMO from January 2009
Regulators dismantled
Growing and serious shortage of qualified safety oversight staff, liberalization
of airlines and competency markets demanded changes in the regulatory
schemes . Budget pressures are prompting European politicians to target aviation-safety groups:
"Understaffed regulators are probably going to be even more understaffed”. Bill Voss, FSF
CEO, March 2011
“There simply isn't the same depth of experience or consistent expertise there was years
ago”. Mike Ambrose, ERA president, March 2011
Safety Information: The Cooperation between
Aviation and Judicial Authorities
Madrid, 24 – 25 March 2011Madrid, 24 – 25 March 2011
Root cause was a Failure of
Management
Decisions made that increased the risk
of the blowout saved time and money
without being proved safe
Financial pressures systematically
biased decision making in favor of time-
and cost savings
This disaster likely would not have
happened if BP have had committed to
safety first
Reality check,
Safety Information: The Cooperation between
Aviation and Judicial Authorities
Madrid, 24 – 25 March 2011Madrid, 24 – 25 March 2011
A concept of accident causation
Activities over which any organization has a reasonable degree of direct control: budget and human resources, business
plan, etc.
Factors that directly influence the efficiency of people in aviation workplaces: fatigue, training, technical failures, aircraft
turnaround times, etc.
Actions or inactions by people (pilots, controllers, maintenance engineers, aerodrome staff, etc.) that have an immediate
adverse effect.
Resources to protect against the risks that organizations involved in production activities generate and must control.
Conditions present in the system before the accident, made evident by triggering factors
Latent conditions trajectory
There is a widespread belief in the aviation industry that the effects of commercial developments can cascade down through organization to affect flight deck operations. This threat is likely to increase as the pace of commercial developments increases. IATA–Icon , August 2001
Safety Information: The Cooperation between
Aviation and Judicial Authorities
Madrid, 24 – 25 March 2011Madrid, 24 – 25 March 2011
Evolving System Safety
Key PrinciplesShared responsibility for safety
Regulations do not ensure safety
Surveillance by the regulator will not identify all safety risks
Evolving methods for understanding and managing safety risks are necessary
Public demand for safety improvements
ICAO Safety Management SARPs
Three distinct Standards
State Safety Programme (SSP)
Acceptable Level of Safety (ALoS)
Safety Management Systems (SMS)
Safety performance of the SMS
Management accountability
Obligation or willingness to account for one’ s actions
Safety Information: The Cooperation between
Aviation and Judicial Authorities
Madrid, 24 – 25 March 2011Madrid, 24 – 25 March 2011
Safety data driven approachStates shall require, as part of their SSP, that a [service provider] implement an SMS acceptable to the State that, as minimum:
Focus on Hazard identification
a) Identifies safety hazardsb) Ensures the implementation of
remedial action necessary to maintain agreed safety performance
c) Provides for continuous monitoring and regular assessment of the safety performance
d) Aims at a continuous improvement of the overall performance of the safety management system
1 – 51 – 5
AccidentsAccidents
30 – 10030 – 100
Serious incidentsSerious incidents
100 – 1000100 – 1000
IncidentsIncidents
1000 – 40001000 – 4000
Latent conditionsLatent conditions
SMS
Hazard identification is a wasted effort if restricted to the aftermath of rare occurrences where there is serious injury, or significant damage
Safety Information: The Cooperation between
Aviation and Judicial Authorities
Madrid, 24 – 25 March 2011Madrid, 24 – 25 March 2011
Hazard Identification by reportingWhy people are
reluctant to report? Retaliation
Self-incrimination
Embarrassment
Liability
Just CultureIndividuals are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training but which result in a reportable event; but
Where gross negligence, willful violations and destructive acts are not tolerated
But, Just Culture is not enough:
Only good will understandingNo relationship with Judicial AuthoritiesNo commitment with safety concerns resolutionsFocus on protecting operational staff from active failuresNo managerial accountabilities by latent conditions
Safety Information: The Cooperation between
Aviation and Judicial Authorities
Madrid, 24 – 25 March 2011Madrid, 24 – 25 March 2011
Protection of sources of informationHazards to sourcesCivil Litigation
Regulatory sanctions
Criminal Proceedings
Company disciplinary actions
Public disclosure
Principles of protectionInformation from reporting and recording processes at SMS will not be used as evidence for enforcement action
Safety information must not be used for purposes other than the purposes for which it was collected (ICAO Assembly Resolution 35/17)
Legal guidance in ICAO Annex 13, Attachment E
Safety Information: The Cooperation between
Aviation and Judicial Authorities
Madrid, 24 – 25 March 2011Madrid, 24 – 25 March 2011
One step beyond by ICAO SARPs
Management commitment
and responsibility
Clear statement about
provision of the necessary
resources for the
implementation of the safety
policy and ensure the
implementation of remedial
action necessary to
maintain agreed safety
performance
Lines of accountability
A safety management
system shall clearly define lines
of safety accountability
throughout the operator’s
organization, accountability for
safety including a direct on
the part of senior
management.
Safety Information: The Cooperation between
Aviation and Judicial Authorities
Madrid, 24 – 25 March 2011Madrid, 24 – 25 March 2011
How to asses the safety accountability ? Duty of Care
Responsibility or the legal obligation of a person or organization to avoid acts or omissions (which can be reasonably foreseen) to be likely to cause harm to others
It is owned by every party of the other contracting parties
The first element to proceed with an action in negligence
Test for duty of careSome required concurrent conditions:
The foreseeable harm or injury; The possible magnitude of the
potential harm or injury; The usefulness of the conduct to the
defendant; The feasibility of alternative conduct; The costs and burdens associated
with the alternative conduct; The relative usefulness of the
alternative conduct; and, The relative safety of the alternative
conduct
Safety Information: The Cooperation between
Aviation and Judicial Authorities
Madrid, 24 – 25 March 2011Madrid, 24 – 25 March 2011
Disclosing accidents/incidents predictors: Not only to know: What-Who-When? Also is essential: Why & How?
Safety data is needed for that: No protection of sources of information
= No safety data available
Managing Accountabilities: Are essential to ensure SMS performance in a very complex and
competitive industry Regulatory accountability shall be addressed by a balanced and
sustainable enforcement policy Judicial accountability shall operate to encourage compliance with
the appropriate regulations and procedures Judicial Authorities shall protect operational staff ,that take
actions to comply safety regulations, against employer reprisals
Cooperation is needed between aviation and judicial authorities for:
Safety Information: The Cooperation between
Aviation and Judicial Authorities
Madrid, 24 – 25 March 2011Madrid, 24 – 25 March 2011
A balanced perspective
……The pilot-in-command must bear responsibility for The pilot-in-command must bear responsibility for
the decision to land and take-off in Dryden… However, the decision to land and take-off in Dryden… However,
it is equally clear that the it is equally clear that the air transportation system air transportation system
failed himfailed him by allowing him to be placed in a situation by allowing him to be placed in a situation
where he did not have all the necessary tools that where he did not have all the necessary tools that
should have supported him in making the proper should have supported him in making the proper
decision decision … … [Honourable Virgil P. Moshansky ]