Just a Piece in a Jigsaw Puzzle - Transport Canada fileJust a Piece in a Jigsaw Puzzle … Systems...

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

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The WorkspaceThe Workspace

The CrewThe Crew

Constraining ActivityConstraining Activity

The Environment

Commercial ActivityCommercial Activity

What is a System?

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Activity at the level of ‘Production’

PressureMax Temperature

Min

Conditional <79% N1

Continuous <94% N1

Continuous

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PPPP

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PPPPPrivate Processing + Public Performance

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PPPPPrivate Processing + Public Performance

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PPPPPrivate Processing + Public Performance

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Task: Arrange 11 trees,To be planted in 6 rowsEach row to contain 4 trees

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Task: Arrange 11 trees,To be planted in 6 rowsEach row to contain 4 trees

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Activity at the level of ‘Organization’

Aircraft 1 Aircraft 2

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GroundController

TowerController

BN2 DHC-8

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OSTC

Operations

POI

CBAD

Certification

Province of Ontario

Operator

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OSTC

Operations

POI

CBAD

Certification

Province of Ontario

Operator

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OSTC

Operations

POI

CBAD

Certification

Province of Ontario

Operator

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OSTC CBAD

Certification Operations

POI

Province of Ontario

Operator

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OSTC CBAD

Certification Operations

POI

Operator

Province of Ontario

?

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ExploitationPlanningDeicing

FacilitationCertification

Oversight

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S

P

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A

BP C

S

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Production

• Technology• Procedures• Pilot ‘Knowing’

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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

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Pilot’s Construction of Risk

• Feather Prop v Engine Shut down• No red lines• Situation stable• Viewed as technical problem, not an

operational problem

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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

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System Dynamics

• Normalization of Deviance• Asynchronicity

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System Dynamics

• Normalization of Deviance• Asynchronicity

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Manufacturer

Operator

Authority

AOM

QRH

OM pt ‘B’

AFM

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System Dynamics

• Normalization of Deviance• Asynchronicity

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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

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And finally …

Strategic decisions shape behaviour

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And finally …

Strategic decisions shape behaviour

…but maybe not in the way you’d planned!

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Thank you for your attention

Norman MacLeod