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Navigating the edge of riskBob Dodd, The Aloft GroupDr. Linda Bellamy, White Queen
International Air Safety Seminar
Flight Safety Foundation
Miami November 2015
+Outline
The Edge
BowTie concepts
Pushing the safety boundary
The view from the edge
BowTie navigation
Resilient risk management
Summary and conclusions
The Edge
Resilient behaviour – Organisation and Individuals
Top Event of Bowtie defines the edge
Small number of high level BowTies cover the operational space
BowTie Concepts
Anything that has the potential to cause harm.
It’s part of NORMAL Business
Aircraft approach and landing
Loading of aircraft during turnaround
The point in time when control over the Hazard is lostA possible cause for the Top Event
Measures taken to prevent or mitigate events
Pushing the Safety Boundary
Rasmussen, J. 1997 Risk management in a dynamic society: a modelling problem
“Under the presence of strong gradients behaviour will very likely migrate toward the boundary of acceptable performance”
“Rather than striving to control behaviour by fighting deviations from a particular pre-planned path, the focus should be on the control of behaviour by making the boundaries explicit and known and by giving opportunities to develop coping skills at boundaries” (Emphasis added)
Rasmussen, J. 1997 Risk management in a dynamic society: a modelling problem
Threat Pressure
Safety Pressure(Barrier and Behaviour)
Making boundaries explicit
What happens in here?
The view from the edge
+Resilience Case Studies (European SAFERA Project)
Top professionals
Resilience questionnaire
14
4 3 11
www.resiliencesuccessconsortium.com/resources
+ANTICIPATING
Scenario-thinking
Getting little things right
Switched on/vigilant to what can go wrong (risk aware)
Cognitive bias mitigation (e.g. countering routine, familiarity, what is easily remembered)
15
MONITORING
Switched on/Vigilant/Alert (for signal detection/change)
Stop and think - hold points/cross check/pause at critical steps
Multiple perspectives, cold eyes review
Cognitive bias mitigation
16
+RESPONDING
Experienced people
Know the safety margins, one’s own limitations
Open up communications.
Bring together people who can help to reduce the uncertainty.
Use of golden rules/principles (“lines in the sand”)
Time and (multiple) options available (redundancy/flexibility)
Cognitive bias mitigation (e.g. summit fever, aura of the expert, knee jerk reactions)
17
+LEARNING
Self-reflection, willing to learn
Communication/feedback/trust
Support decisions under high time pressure and uncertainty
Analyse, discuss & expand events
Simulation training
Capture & record
Cognitive bias mitigation (learning)
18
“Standard work methods are important for standard work, but when things are happening that are not standard and the organisation is only built around these standard procedures, you will lack people that have the possibility to think thoroughly. “
+Intervention Quadrant
19
Foreseen
risks
Unforeseen
risks
STANDARDRESILIENT
Standard Risk Management Interventions
Constraint, control
Coping with foreseen risks and avoiding things going wrong (failures)
Standards, rules and procedures
Designed-in risk control measures
Resilience Interventions (close to edge)
Adaptive & involved
Coping with unforeseen risks and recovering from deviations
Uncertainty reducing
Multiple options – redundancy, diversity
Questioning, second options
What kind of interventions?
Bowtie navigation
+ Leveraging Existing Data
Threats Safety Reports Observations
Barrier Failures Safety Reports ObservationsInvestigation FindingsAudit FindingsTechnical Data
Top Event Safety Reports ObservationsInvestigation FindingsTechnical Data
Recovery Failures Safety Reports ObservationsInvestigation FindingsTechnical Data
Consequences Industry Data
Threat
Risk C
ontro
l
Und
esire
d
Opera
tiona
l
Sta
te
Reco
very
Contro
lC
onse
que
nce
Threat
Threat
Risk C
ontro
lRisk C
ontro
l
Risk C
ontro
lRisk C
ontro
lRisk C
ontro
l
Risk C
ontro
lRisk C
ontro
lRisk C
ontro
l
Reco
very
Contro
l
Reco
very
Contro
lReco
very
Contro
l
Reco
very
Contro
l
Reco
very
Contro
l
Reco
very
Contro
lReco
very
Contro
l
Conse
que
nce
Conse
que
nce
Conse
que
nce
+ 23
Accid
ents
Seriou
s In
ciden
ts
Safety Events and ObservationsNormal
Operations
Reports:- Safety- Quality- Observations- Audits
Most accidents outside
organisation
Resilient Risk Management
+Changing the focus
Standard Risk Management
Before the fact
Known risks
Normative structured procedural
Organisational
Resilient Risk Management
Live – as it happens
Unknown or unexpected risks
Adaptive and flexible
Individual
Uncertainty
Time
Organisation
IndividualShifting roles in managing risk approaching and crossing the edge.
+Risk Management – Up to the edge and beyond
27
Strategic•High Level Risk Analysis (Annual)•BowTie Models covering operational phases•Based on global and local experience•Build on shared models (eg CARM)
Tactical•Monthly Analysis•Tracking trends in BowTie Data•Barrier Management•BT based investigation and audit
Operational•Live process•Shared role of organisation and individual•Train and support individuals for resilient behaviour in high uncertainty/time compressed situations
+Summary
Operating pressures can push organisational and individual behaviour towards the safety boundary.
Resilient organisations must:
Understand and make explicit the boundaries
Learn to operate at the edge
Recognise the limitations of standard risk management closer to the edge
Support, select and train individuals for resilient behaviours at the edge under conditions of uncertainty and time pressures
BowTie risk models can
Map the risk landscape around the edge
Measure performance dynamically using existing data sources