Learning Points PDF

Preview

Summary

Learning Points for Safety Management - Good Luck!...

Description

3515NSC Safety Management 

The Titanic set sail on its maiden voyage on 14 April 1912. In the lecture, there were three human factors reasons given why the accident occurred. What were they? o The captain was under pressure from owners, media, passengers to set a new Trans-Atlantic record. o The decision was made to take shorter Great Circle route to the North knowing it greatly increased the chanced of colliding with an iceberg. o Overconfidence – “Titanic is unsinkable!”



Describe the traditional concept of aviation safety? o Tradition concept of safety sought answers from factors at the immediate scene of the event. Tech/human factors relating directly to specific event were examined. Broader reasons, eg, airline policies, were viewed as externalities. o The traditional approach focused on WHAT WHO WHEN (but not always Why/How)



By the mid-1990s the aviation industry had strategies to counter the technical and human factors influences on aviation accidents, but it realized that there was a need to address a third factor. What was it? o Organisational factors



The Piper Alpha Disaster highlighted that the causal factors for the accident were much broader than what occurred at the accident site. The report found that the regulator, the operator, the industry, and the stand-by ship owners all had a role in the disaster and the emergency response. What was the most significant recommendation in regard to the operator? o Operators were required to take responsibility for safety and present a safety case in regard to platform operations.



Patrick Hudson promoted the need to have the right organizational culture to improve safety performance. He outlined five safety culture indicators which led to his safety culture evolutionary ladder. Describe the five safety culture indicators? o Informed: Managers know what is really going on and workforce is willing to report their own errors and near misses. o Wary: Ready for the unexpected. o Just: A ‘no blame’ culture, with a clear line between the acceptable and unacceptable. o Flexible: Operates according to need. o Learning: Willing to adapt and implement necessary reforms.



Patrick Hudson promoted the need to have the right organizational culture to improve safety performance. He outlined five safety culture indicators which led to his safety culture evolutionary ladder. Describe the five elements of the safety culture evolutionary ladder ? Who cares as long as we are not caught. o Pathological: o Reactive: Safety is important, we do a lot every time we have an accident. o Calculative: There are systems in place to manage all hazards. o Proactive: Safety Leadership and values drive continuous improvement. o Generative: Safety is how we do business around here.



James Reason said that there are two types of accidents: those that happen to individuals and those that happen to organizations. He focused on the organizational accidents and said that these have multiple causes involving many people operating at different levels of their organization. What is the trend in regard to organization accidents and the changes in who they are affecting?

o The incidence of organizational accidents is increasing as the world is growing and using more complex higher technology solutions. o In a contemporary world, accidents have a devastating effect on uninvolved populations, assets and the environment. 

James Reason stated that organizational accidents are difficult events to understand and control. They occur very rarely (‘out of the blue’) and are hard to predict or foresee. The basic model used by Reason to explain whether organizational accidents occur uses the elements of hazards, defenses and losses. Define. o A hazard is something causing unavoidable danger, peril, risk or difficulty, possibly with the absence of predictability, chance or uncertainty. o Defenses are the barriers and safeguards that separate damaging and injurious hazards from losses, which are vulnerable people or assets. o Losses are vulnerable people or assets.



In James Reason’s basic model to explain organizational accidents, defenses are breached by ‘unsafe acts’ which are either ‘active failures’ or ’latent conditions’. Human decisions and actions are implicated in organisational accidents o Active Failures: where people make errors and commit violations that are a result of human psychology. These have a direct impact on the safety of the system and, because of the immediacy of their adverse effects, these acts are termed ‘active failures’. o Latent Conditions: Those where people working in complex systems make unintentional errors or violations as a result of the working environment (management policy, procedures, supervision, defects, failures, training, tools and equipment etc). They may be dormant factors for many years before they emerge as a result of the circumstances.



James Reason describes the tension between production and protection and states the case to have these two in the parity zone for high hazard ventures like aviation. What happens if you have too much production and too little protection? What happens if you have too much protection and too little production? o Too much production and too little protection in high hazard ventures leads to catastrophe. o Too much protection and too little production leads to bankruptcy.



Explain James Reason’s ‘Swiss Cheese’ Model and what it tells us? o Our ideal defense system has no holes. Reality looks more like Swiss Cheese with holes. Some holes are due to active failures and some due to latent conditions. If the holes all line up in successive layers of defense, then this leads to an accident. o Illustrates that accidents involve successive breaches of multiple layers of a system defense. o Contends that complex systems such as aviation are extremely well defended by payers of defenses, so that single point failures are rarely consequential in such systems.



James Reason adapted his Latent Conditions (unintentional errors or violations) Trajectory approach to be an analytical model to investigate aviation accident and incidents involving organisational causal factors. Describe this analytical model stressing the three defenses that addresses issues rising from the organisations, workplace and people? o Organisation: Management decisions and organizational processes. o Workplace: Working conditions o People: Errors and violations o Defenses: Training/Technology/Regulations.



Today, causal factor investigation of an accident can go much further than the cockpit. The organisation, the industry and who else are being challenged on their contribution to the accident?

o Regulatory authority and their decisions and actions. (CASA) 

Describe what is meant by the term ‘systems thinking’? o Systems thinking means understanding how individual elements within a system influence one another as a whole.



Root cause analysis is a systems approach to establishing the causes of problems, accidents and incidents. Describe what is mean by the terms ‘symptom of the problem’ and ‘underlying causes’. o Symptom of the problem is “the weed” above the surface, it’s obvious. o The underlying causes are “the root” below the surface that aren’t obvious.



In regard to root cause analysis, what is more effective: identifying the symptoms or establishing the root cause(s)? o Establishing the root cause is more effective for fixing a problem than just identifying the symptoms.



Describe the seven basic steps for root cause analysis? o Define the problem o Gather the data/evidence o Determine the causal relationships o Identify solutions without causing more problems o Identify the required changed o Implement the chosen solution o Monitor and review



The term ‘safety’ can have many meanings. What is the ‘Chicago’ Convention Annex 19 – Safety Management definition of ‘safety’ and what does it imply? o The state in which risks associated with aviation activities, related to, or in direct support of the operation of aircraft, are reduced and controlled to an acceptable level. o It implies that a ‘safe’ system is not a steady state but one which requires constant monitoring and appropriate risk mitigation measures to be taken.



Why is the ultimate goal of eliminating all aircraft accidents and/or serious incidents not achievable? o The aviation system cannot be completely free of hazards, threats and associated risks as human activities or human-built systems cannot be guaranteed to be absolutely free from operational errors and their consequences.



The Reason Model promotes the view that all accidents or serious incidents include ‘unsafe acts’ which are a combination of both active failures and latent conditions. When hazards occur, do they immediately breach the defenses for the occurrence to occur? o No, they can be a delayed consequence of decisions made at the highest levels of the system, which may remain dormant until their effects or damaging potential are activated by specific operational circumstances.



Frank Bird tells us that there is a relationship between the number of near accidents, property damage accidents, minor injuries, and serious or major injuries. What does this research tell us in regard to hazard elimination or reduction? o It means if we can identify and treat the hazards (eliminate or reduce) at lower levels then we reduce the chances of a serious or major injury occurring.



The Organizational Accident Model tells us what needs to be done for each of the elements in it being organizational processes, workplace conditions, active failures, latent conditions, and defenses. What is the action required for each of them? o Organisational Processes: Monitor o Workplace Conditions: Improve o Active Failures: Contain o Latent Conditions: Identify o Defences: Reinforce (Technology/Training/Regulations)



Scott A. Snook explains why organizations suffer a ‘practical drift’ away from their design baseline and why organizations have trouble maintaining their operational performance close to this line. Explain why ‘practical drift’ occurs? o The operational performance is different from baseline performance as a consequence of real life operations and changes in the operational and regulatory environment. o It’s a consequence of daily practice, a gradual departure from intended course of action due to external influences.



When it comes to Snook’s theory of practical drift state six reasons why it may occur? o Staff self optimise their interactions with technology o Technology that does not always operate as predicted o Procedures that can’t be executed as planned under certain operational conditions o Regulations that are not applicable with certain contextual limitations o Introduction of changes to the system, including the addition of new components o The interaction with other systems



The SHELL Model is a conceptual tool used to analyze the interaction of multiple system components as it provides a model of relationships between humans and other workplace components. What are the elements of the SHELL model and briefly explain their interaction? L-S relationship between human and supporting systems in workplace. (eg o Software: regulations, manuals, checklists, publications, SOPs) Includes recency of experience, accuracy, format, presentation, vocab, clarity and symbology. o Hardware: L-H relationship between human and physical attributes of equipment. Interface between human/technology and is handled by humans having to adapt to L-H mismatches. Has potential to mask deficiencies which may only become evident after occurrence. o Environment: L-E relationship between human and internal/external environment. Psychological, physiological, illness, fatigue, financial uncertainties, relationships, career concerns can be L-E or external sources. Aviation work environment includes disturbances to sleep and biological rhythms. o Liveware: L-L relationship among persons in work environment. Since crew etc function in groups it’s important to recognize communication and interpersonal skills as well as group dynamics play a role in determining human performance. Advent of CRM and ATS has created a focus on the management of operational errors across multiple aviation domains. Organisational culture also in this interface. o Liveware: Humans are the centre of the model in the workplace. Remarkably adaptable but subject to variations in performance. Not standardized to same degree as hardware.



When people commit ‘active failures’ what does this mean in regard to established procedures, protocols, norms or practices? o Done purposely o Willful intent to deviate from established procedures etc with consequences to cause harm or damage.



Active Failures o Human decisions and actions are implicated in organizational accidents where people make errors and commit violations that are a result of human psychology. These have a direct impact on the safety of the system and, because of the immediacy of their adverse effects.



Latent Conditions. o Where people working in complex systems make unintentional errors or violations as a result of the working environment (management policy, procedures, supervision, defects, failures, training, tools and equipment, etc). They may be dormant factors for many years before they emerge as a result of the circumstances.



Latent failures o Are unintentional and due to organizational factors.



Initially, safety management was introduced into specific operational areas of aviation by amending specific ‘Chicago’ Convention Annexes. It has now all been drawn into its own Annex. What is the Annex number and name? o Annex 19 – Safety Management



What is the ICAO manual name and number that describes the benefits and implementation of safety management? o Doc 9859 – Safety Management Manual



Moving towards safety management meant introducing Safety Management Systems and State Safety Programs. Define the term State Safety Programs? o A requirement placed on contracting states to have an integrated set of regulations and be conducting activities aimed at improving safety.



What is the general principle of a strong safety oversight regime? o Is to ensure that the national aviation industry provides a safety level equal to, or better than, that defined by the ICAO SARPs.



ICAO Doc 9734 Part A: Safety Oversight Manual describes how a State will establish and manage a safety oversight system. It provides for eight critical elements of safety oversight. List the eight critical elements and state whether they are about establishing or implementing a state safety oversight system? o Establishing: Primary Aviation Legislation Specific Operating Regulations State Civil Aviation System & Safety Oversight Functions Technical Personnel Qualifications & Training Technical Guidance, Tools & the Provision of Safety Critical Information o Implementing: Licensing, Certification, Authorisation &/or Approval Obligations Surveillance Obligations Resolution of Safety Concerns



A State Safety Program (SSP) consists of four components that form the fundamentals of a SSP. Name the four components? o State safety policy and objectives o State Safety risk management o State safety assurance o Safety Promotion



A State Safety Program (SSP) requires a State to set a national Acceptable Level of Safety Performance (ALoSP). Describe the term ALoSP? o The minimum level of safety performance of civil aviation in a state, as defined in its State Safety Program, expressed in terms of safety performance indicators compare with set safety performance targets.



What are the objectives of a State Safety Program? o The objective of the implementation process is to achieve progressive enhancement of a state’s existing safety management, administration and oversight processes.



How often does ICAO publish its Global Aviation Safety Plan (GASP) and what time period does it cover? Does ICAO have an expectation that every contracting State to the ‘Chicago’ Convention will have a mature State safety oversight system, including SSP and service providers having an SMS, by 2025? o Every year which lays down the safety program for the next 3 years. o By 2028



Australia has a State Safety Program which is first published in 2012. What major agencies have responsibility for aviation safety in Australia? o The Department of Infrastructure and Regional Development (DIRD/the Department) o Civil Aviation Safety Authority (CASA) o Australian Transport Safety Bureau (ATSB) o Airservices Australia (Airservices) o Australian Maritime Safety Authority (AMSA) o Bureau of Meteorology (BOM) o Department of Defence (Defence)



What civil aviation service providers are required to have a Safety Management System? o Air Operators o Air Traffic Service Providers o Aerodromes o Aerodrome Rescue and Fire Fighting Services (ARFFS) o Maintenance providers o Aeronautical telecommunication and radio navigation service providers o Flight training organisations o Integrated multi-crew pilot flight training, contracted recurrent training & contracted checking o Instrument flight procedure design



Describe the national Acceptable Level of Safety Performance (ALoSP) set by Australia? o Australia has not yet set it’s ALoSP



Define what is meant by the term ‘Safety Management System’ and what is its objective? o It is a systematic approach for service providers to manage safety, including the necessary organizational structures, accountabilities, policies and procedures. o Its objective is the safe operation of aircraft through the effective management of safety risk and is designed to continuously improve safety by identifying hazards, collecting and analyzing data and continuously assessing safety risks.



Describe how an SMS transfers responsibility for safety from regularity compliance towards a performance based system where the operator takes responsibility for the safety of their own aviation activities?

o It requires them to develop, implement and manage their own system for achieving safety performance outcomes. o Self Management = Enhanced safety performance o Regulatory Compliance= Baseline safety performance o Operators must develop their own management systems to reduce risk, which includes implementing systems for reporting and correcting shortcomings. 

Explain the purpose of the statement ’equal to or better than SARPs’ when it comes to safety maturity? o Marginal operator – equal to the SARPs – below > audit > compliant zone > complacency > audit o Established operator – better than – catalyst/practical drift > marginal > reaction > up o New operator – AOC issued > compliant zone



There are three approaches to improving an organization’s safety maturity being reactive, proactive and predictive. Describe all three approaches and what they achieve? Responding to things that have already happened. o Reactive: o Proactive: Where the likelihood and consequences of known potential hazards are identified before they occur. (active) o Predictive approach: Analysing data and environmental factors to predict future unforeseen events and to treat them before they occur.



The direct costs of an accident or major incident are easy to quantify and usually covered by an airline’s insurer. What a...