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SMS, Governance and Accountability

Kathy Fox, Board MemberTransportation Safety Board of Canada

Signal Charlie Human Factors SeminarPensacola, Florida

13-14 September 2012

Outline

• Evolution of accident investigation• Drift into failure• Safety Management Systems (SMS)• Investigating for organizational factors

o Inadequate risk analysiso Employee adaptationso Goal conflictso Weak signals

• The role of governance / regulatory oversight

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Background

• “What” happened vs. “why” it happened• Evolution of accident investigation:

– aircraft design– cockpit design– physiological factors– psychological influences on decision-making

and risk-taking– performance of the flight crew, not just the pilot (CRM,

TEM)

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Reason’s Model (“Swiss cheese”)

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D e f en c e s

A c tiv it ie sP r o du c t iv e

U n s a fe A c t s

O c c u rr e n c e

O c c ur re n c e O p po r tu n it y

L ine M a na g e m e ntD e fi c ie n c i e s

L a te n t U ns a fe C o n d it io n s

P r e co n d it io n s

A c tiv e F ai lu r e s &

A c tiv e F ai lu r e s

L im it ed W in d o w o f

P r e c u r s o r s o f U n s a feA c t s

P s y c h o l o g ic a l

In ad eq u ate

L a te n t U ns a fe C o n d it io n s

L a te n t U ns a fe C o n d it io n s

L a te n t U ns a fe C o n d it io n s

M ak e rsD e c is io n -

F a l l ib l e D e c is i o n s

Balancing Competing Priorities

Service Safety

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Limits of Acceptable Performance

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Organizational Drift

“Drift is generated by normal processes of reconciling differential pressures on an

organization (efficiency, capacity utilization, safety) against a background of uncertain

technology and imperfect knowledge.”-Dekker (2005)

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MK Airlines (October 2004)

Impact of Management

By their nature, management decisions tend to have a wider sphere of influence on how the organization operates, and a longer-term effect, than the individual actions of operators.

Decision-makers need to develop “mindfulness” to avoid “blind spots.”

-Weick & Sutcliffe (2007)

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A “Mindful Infrastructure” Would …

• Track small failures• Resist oversimplification• Remain sensitive to operations• Maintain capabilities for resilience• Take advantage of shifting locations of expertise• Listen for, and heed, weak signals

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Safety Management Systems (SMS)

SMS integrates safety into all daily activities.

“It is a systematic, explicit, and comprehensive process for managing safety risks … it becomes part of that organization’s culture, and [part] of the way people go about their work.”

-Reason (2001)

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SMS Requires the Following:

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SMS Requirements in Canada

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• Airline operators

• Maintenance organizations

• Certified airport authorities

• Privatized providers of air navigation services

• Coming soon: commuter airlines, air taxis, flight-training units

Investigating for Organizational Factors

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• Inadequate risk analysis

• Employee adaptations

• Goal conflicts

• Missed “weak signals”

COMPLEX INTERACTION = NO SINGLE FACTOR AS SOLE CAUSE

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Inadequate Risk Analysis

TSB Investigation Report A07A0134

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Aircraft Attitude at Threshold

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TSB Investigation Report A07Q0213

Inadequate Risk Analysis (cont’d)

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Employee Adaptations

• Faced with time pressures or multiple goals, workers and management may be tempted to create “locally efficient practices.”

• Why? To get the job done!

• Past successes are taken as a guarantee of future safety.

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Employee Adaptations (cont’d)

TSB Investigation Report A09W0037

Goal Conflicts

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YVR seaplane dock, 16 November 2008 (A08P0353).

Weak Signals

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Collision with terrain: Sandy Bay, SK(A07C0001)

Weak Signals (cont’d)

“We didn’t see [these recent accidents] coming, and we should have … the

data were trying to tell us something.”

-William Voss, President and

CEO of Flight Safety Foundation

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Pilot Error or Management Error?

• Drift, goal conflicts and adaptations are natural• No one sets out to have an accident; they just

want to get the work done• The decision to value production over safety is

implicit

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Pilot or Management Error? (cont’d)

• With each success, people underestimate the amount of risk involved

• If investing in safety improved quarterly returns, the company would do it

• There is a complex relationship between culture and process

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The Role of Governance / Oversight

Q.) Who holds decision-makers to account?

A.) Board of Directors / owner

Shareholders / financial backers

Customers

Insurance companies

Regulators

All of the above

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Governance / Oversight (cont’d)

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TSB Investigation Report A10Q0098

Governance / Oversight (cont’d)

“The gap between what is legal and whatis safe already is large, and it will getbigger. … Is this regulatory approach

sustainable? Is it fair to airlines that do everything right? Is it fair to an

unknowing public?”

-William Voss, Flight Safety Foundation

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Conclusions

• Old views of safety are changing

• No one can predict the future perfectly

• “Mindful infrastructure”Effective SMS depends on “culture” and “process”

• Accountability is key

• Regulatory oversight

• Success takes time

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Questions?

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