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29 April 2008 CASS 2008
Just a Piece in a Jigsaw Puzzle …
Systems Dynamics and Safety in Canadian Aviation
29 April 2008 CASS 2008
Overview
What is a system?How does it work?Why does it fail?
29 April 2008 CASS 2008
What is a System?
Nested decision-making
29 April 2008 CASS 2008
The WorkspaceThe Workspace
The CrewThe Crew
Constraining ActivityConstraining Activity
The Environment
Commercial ActivityCommercial Activity
What is a System?
29 April 2008 CASS 2008
Activity at the level of ‘Production’
PressureMax Temperature
Min
Conditional <79% N1
Continuous <94% N1
Continuous
29 April 2008 CASS 2008
PPPP
29 April 2008 CASS 2008
PPPPPrivate Processing + Public Performance
29 April 2008 CASS 2008
PPPPPrivate Processing + Public Performance
29 April 2008 CASS 2008
PPPPPrivate Processing + Public Performance
29 April 2008 CASS 2008
Task: Arrange 11 trees,To be planted in 6 rowsEach row to contain 4 trees
29 April 2008 CASS 2008
Task: Arrange 11 trees,To be planted in 6 rowsEach row to contain 4 trees
29 April 2008 CASS 2008
Activity at the level of ‘Organization’
Aircraft 1 Aircraft 2
29 April 2008 CASS 2008
GroundController
TowerController
BN2 DHC-8
29 April 2008 CASS 2008
29 April 2008 CASS 2008
29 April 2008 CASS 2008
OSTC
Operations
POI
CBAD
Certification
Province of Ontario
Operator
29 April 2008 CASS 2008
OSTC
Operations
POI
CBAD
Certification
Province of Ontario
Operator
29 April 2008 CASS 2008
OSTC
Operations
POI
CBAD
Certification
Province of Ontario
Operator
29 April 2008 CASS 2008
OSTC CBAD
Certification Operations
POI
Province of Ontario
Operator
29 April 2008 CASS 2008
OSTC CBAD
Certification Operations
POI
Operator
Province of Ontario
?
29 April 2008 CASS 2008
ExploitationPlanningDeicing
FacilitationCertification
Oversight
29 April 2008 CASS 2008
S
P
29 April 2008 CASS 2008
A
BP C
S
29 April 2008 CASS 2008
Production
• Technology• Procedures• Pilot ‘Knowing’
29 April 2008 CASS 2008
Representation of Information
Normal
(Green)
1173
1071
1020
660
RPM
Fuel Cut-off
Caution(Amber)
Max (Red)
Over-limit
1064 Overspeed Governor
Indication System
Condition Lever
PEC
29 April 2008 CASS 2008
29 April 2008 CASS 2008
Pilot’s Construction of Risk
• Feather Prop v Engine Shut down• No red lines• Situation stable• Viewed as technical problem, not an
operational problem
29 April 2008 CASS 2008
What the Safety Management System Said
Risk: If the event happens again the probability of a major accident is not increased or increased only under extreme circumstances
Seriousness: On this occasion the probability of a major accident was not increased but the event was indicative of a quality problem that could affect safety
29 April 2008 CASS 2008
System Dynamics
• Normalization of Deviance• Asynchronicity
29 April 2008 CASS 2008
System Dynamics
• Normalization of Deviance• Asynchronicity
29 April 2008 CASS 2008
Manufacturer
Operator
Authority
AOM
QRH
OM pt ‘B’
AFM
29 April 2008 CASS 2008
System Dynamics
• Normalization of Deviance• Asynchronicity
29 April 2008 CASS 2008
Conclusion
• Individuals act to create solutions to operational problems in real time
• Individuals act in a context driven by systems dynamics
• Safety is a product of people, not organizations
29 April 2008 CASS 2008
And finally …
Strategic decisions shape behaviour
29 April 2008 CASS 2008
And finally …
Strategic decisions shape behaviour
…but maybe not in the way you’d planned!
29 April 2008 CASS 2008
Thank you for your attention
Norman MacLeod
