Patrick Murray

The “Safety Journey”

an air industry perspective

Patrick MurrayDirector

Griffith University Aerospace Strategic Study Centre

Aerospace Strategic Study Centre“Safety Through Education and Research”

Thank You

[email protected]

Thanks and acknowledgement

to:

•CASA

•Flight Global ACAS

•IATA

•ICAO

•University of Texas (HFRP)

•The LOSA Collaborative


[email protected] www.griffith.edu.au/aviation

Air Transport / Rail

Complex socio – technical systems

Passenger & freight transport

Vital part of national infrastructure

Transition from Government – private ownership

High reliability systems

Large investments in Safety

Inherently dynamic (unstable) system


Human Beings are involved

at all levels of the system

Scope

Safety in high reliability systems

Risk in airline operations

Airline safety trends

The “safety journey”

New paradigms (or old wine in new bottles)?


How do we measure Safety?

The absence of accidents ?

The presence of a Safety Management System ?

Does an increase in reported incidents show:

• A decrease in safety?

• An improvement in safety (better reporting culture)?

Regulatory compliance = safety?

Can organisations be compared?


The Issue

• Accident risk :

» Extremely high consequence

» Extremely low frequency

= Extreme Risk(but very difficult to measure and manage)


No system

beyond this

point

10-2

10-3

10-4

10-5

10-6

Civil Airlines

Nuclear Industry

Railways (First World)

Charter

FlightsHymalaya

mountaineering

Road Safety

Anesthesiology

Blood transfusion

Professional Fishing

Crop spraying

Very unsafe Ultra safe

Medical risk

average

Chemical Industry (total)

Helicopters

10-1

Tubes/metros

Relative system safety


Risk of Fatality

Surgery

Adapted from

Rene Almaberti 2006

10-2 10-3 10-4 10-5 10-6

The story of the

next accident will

be a repeat of

previous accidents

The story of the next

accident is a

combination of parts of

previous accidents or

incidents, in particular

using the same

precursors

The next accident is

an original story and

context never seen

before together.

Decomposition of

the story may reveal

a series of already

seen micro incidents,

but for the most

part, not previously

considered as

consequential


40’s-70’s Reducing pilot workload

70’s-90’s Improving situational awareness / CRM

90’s- Promoting organisational safety / QA

Mid 90’s- understanding human error / culture

Next challenge : Improving resilience ??

The Long and Winding Road


Griffith Aerospace Safety Centre


Everyone makes errors

The ubiquity of human error...



If we really accept that errors will always be a

part of the human condition - perhaps even a by

- product of that ingenuity and resilience that

only human beings exhibit....

...then it is only by analysis of these errors

(ingenuity?) and the surrounding context can we

move to the next frontier in safety....

Safety Management

System Data Sources

Normal Operations

Monitoring

Flight Data

Analysis

Voluntary

Reporting

Predictive Proactive Reactive

Highly efficient More efficient Efficient

Safety management potential

Reactive

Inefficient

Surveys

Audits Incident

Reports

Accidentreports

Normal Operations

Normal Operations Monitoring

Safety management instruments


ACCIDENTS &

INCIDENTS

UNREPORTED

OCCURRENCES

•Loukopoulos/Dismukes, 2002, NASA


• LOSA formally endorsed by ICAO as an industry best practice for monitoring normal operations

• ICAO Doc 9803 (LOSA) published in 2002


Flight deck observations by trained and

calibrated observers

• No jeopardy to crew

• All data de-identified & confidential

• Significant data cleaning to remove “noise”

• Report on:

Specific threat environment

Nature and prevalence of errors

Threat and error management by crews

Methodology


Intentional non – compliance

40+ Airlines / 9,000+ flights

Approx 28% of all errors were

associated with

Intentional non - compliance


Why do violations occur?

A culture where getting the job done is more

important than safety?

Unworkable rules and procedures?

Personnel using „short-cuts‟ and „work-arounds‟ to

achieve organisational goals

Are we suppressing human ingenuity?


VIOLATION or “Getting the job done” ?

What is Culture?

“Values and practices that we share with others that help define us

as a group” .......“Who we think we are, what we believe in and

what is important to us”

(Prof Ashleigh Merritt - 1997)

“The way we do things around here”

(Anon)

“When I hear the word “culture”, I want to reach for my Luger”

(Reich Marshal Herman Goering 1936)


“The way we do things around here -

when no-one is watching”!

My suggestions about safety would be acted

upon if I expressed them to management.

Safety

Culture

The managers in Flight Operations listen to us

and care about our concerns.

Management will never compromise

safety concerns for profitability•.

I am encouraged by to report any unsafe

conditions I observe.

I know the proper channels

to report my safety concerns.

I am satisfied with Chief Pilot and

Assistant Chief Pilot availability.

Safety Culture Survey Questions


% Crews with an Undesired State

14%

54%67%

01020304050

60708090

100

Low Safety Culture

Crews

Avg Safety Culture

Crews

High Safety Culture

Crews

Sc

ale

0-1

00

Base

Rate


Safety culture and crew performance

PATHOLOGICAL

Who cares as long as

we’re not caught

Organisational and

Individual Trust

Organisational

Openness and

Communication

-REACTIVE

Safety is important when

we have an accident

PROACTIVE

We fix problems that we

find

CALCULATIVE

We have systems in place

to manage hazards

GENERATIVE

Safety is fully integrated

into all operations

+

-

+

Adapted from

Prof Patrick Hudson

Where is your

organisation ?

Safety Culture

• The Columbia Space Shuttle

Accident Investigation Board found

that… NASA’s organisational

culture had as much to do with the

accident as the foam did…

Columbia Accident

Investigation Board

Report August

2003

Have you ever wondered why you pay extra for

Business Class?

Example of reactive safety management


Aircraft are certified (windshield, engines etc), to continue flying after an impact of any bird below4 lbs and multiple impacts of smaller birds

Resistance assessed by “chicken-guns”

But….Speed at impact too small in certification test36 species of bird weigh over 4 lbs in North America30% ingestion of birds weighing over 4 lbs (USA)

New regulation coming: >> 8 lbs

But geese may weigh over 15 lbs and fly in “squadrons” !!


Proactive Safety – the next generation?


If we only look at the future in the light of the past……

….our understanding of what has happened inevitably

colours our anticipation and preparation for what

could go wrong and thereby holds back the requisite

imagination that is essential for safety

The next generation of safety will be organisations,

groups and individuals who are resilient ….

…..recognise, adapt to and absorb variations, changes,

disturbances, disruptions, and surprises – especially

disruptions that fall outside of the set of disturbances

the system is designed to handle


Improving Safety

• Management and union leadership demonstrate

commitment to safety

• Understanding and applying the „safety balance‟ of

production versus safety

• Integrated application of risk management principles

– By operators

– By regulators

• Risk (not compliance) based investigations

• Fair and accountable safety processes

“A Just Culture” ?

Thank You

[email protected]

Thanks and acknowledgement

to:

•CASA

•Flight Global ACAS

•IATA

•ICAO

•University of Texas (HFRP)

•The LOSA Collaborative


[email protected] www.griffith.edu.au/aviation

Technology

Patrick Murray