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Air Line Pilots Association, Int’l

Safety ManagementRisk Management Course

Module One: Tools for Decision Makers

July 13th, 2021

Captain Helena Cunningham

Delta Air Lines - Safety Committee Chairwoman


Day One of the Hostage Crisis

▪ Lavs

▪ Phasers – on STUN

▪ Breaks - every 45-60 minutes

▪ Emergency Exits

▪ Food plan – Hot Lunch

▪ RMC

– Day 1: Risk Management / SMS

– Day 2: ASAP

– Day 3: FOQA2 2021


▪ Safety is…

The Question…

3 2021


▪ Explore tools to evaluate

and participate in your

company’s safety

programs

▪ Basic SMS definitions and

concepts

▪ Introduce SRA/SRM

▪ SRA exercises

Today’s Goals

4 2021


…The CASC?

…Committee Member?

…MEC?

How Can This Help YOU…

FOCUS

5 2021


SMS & SRM Helps You…

▪ Assess and participate in

the safety performance of

your airline

▪ Make positive change in

addressing safety issues

▪ Improve company safety

management

▪ Take emotion / politics out

of decision making

At Your Airline…

6 2021


SMS & SRA helps you, a key stakeholder:

▪ Be more effective in risk assessment

decision-making

▪ Assess risk and help develop ALPA positions

Working with Government Agencies

and Industry Groups

7 2021


SMS and SRM will help you manage limited or

scarce resources.

▪ You can’t afford to fix everything

▪ Process is verifiable, consistent and

documented

▪ Everyone involved can (hopefully) agree on

where, and where not to, spend

In All Cases…

8 2021


▪ Safety…

▪ Management…

▪ Safety Management

System

– Safety Risk

Assessment

– Safety Risk

Management

Todays Agenda

9 2021


In this section we will discuss safety…

– Definitions

– Philosophies

– Concepts

SAFETY

10 2021


Understanding the

idea of…

SAFETY

First…

Or, at least, thinking about it!

11 2021


Is it just a marketing term?

12 2021


“… an inherent part of a well designed

system, a quality which produces known,

predictable, acceptable outcomes.”

Steve Smith, Office of System Safety

FAA

Safety is:

13 2021


“A thing is safe if its risks are judged to be

acceptable.- William W. Lowrance

“Of Acceptable Risk”

“Safety” is:

14 2021


“Safety in a system may be defined as a

quality of a system that allows the system to

function under predetermined conditions

with an acceptable minimum of accidental

loss.”

System Safety Engineering & Management,

2nd Edition, John Wiley & Sons 1990

ISBN 0471618160

Roland & Moriarty Say:

15 2021


Safety is: Let’s see…it’s a goal

… freedom from risk

… the absence of

accident precursors…

No, it’s controlled and

acceptable risk!

16 2021


Safety is …a continuous process of

identifying, eliminating, controlling, or

accepting, known hazards to achieve

acceptable levels of risk for any particular

process, activity or operation.

Steve Corrie, ALPA, FAA

How About….

17 2021


The reality is that not everyone will

agree with our definition of what is “unsafe”.

The challenge is to find out what level is

acceptable.

Our Challenge: to “sell,” or validate, our

perspective in a way that results in desired

change.

When you deal with “acceptable

level of risk…”

18 2021


“If we die, we want

people to accept it. We

are in a risky business,

and we hope that if

anything happens to us it

will not delay the

program. The conquest of

space is worth the risk of

life.”— Astronaut Virgil 'Gus' Grissom.

Context

19 2021


“Risk management is a more realistic term than

safety. It implies that hazards are ever-present,

that they must be identified, analyzed, evaluated

and controlled or rationally accepted.”

Jerome Lederer, director of the Flight Safety Foundation for 20 years

and NASA's first director of Manned Flight Safety.

Last Thought…

20 2021


▪ System

▪ Hazard

▪ Risk

▪ System Deficiency

▪ Mitigation (Controls/

System Defenses)

▪ Monitoring

More Safety Definitions…

21 2021


A group of

interacting,

interrelated, or

interdependent

elements

forming or

regarded as

forming a

collective unity

A “System”

22 2021

From “Managing Risk” by Dr. Vernon L.

Grose


Regulatory Safety System Safety

Two Ways

to Approach Safety

23 2021


A foundation of rules aimed to improve the

standards of safe products, services,

behavior, practice and of operating…the

level of which is governed by societal,

cultural, philosophical factors, legal systems,

technological progress and experience.

The Traditional Way –“Regulatory Safety”

24 2021


▪ You can’t write a regulation to address

every potential hazard…

▪ …but aircraft operators, designers, and

manufacturers must comply with

regulations…

– …so, the goal becomes compliance with

existing rules, possibly ignoring other hazards

Regulatory Safety Has Limits

25 2021


“Regulatory Safety” is

mostly:

REACTIVE

Inefficient - considering

what you often have to

do to change a rule!

Significant Limitation

26 2021


▪ Engineering beginnings

▪ US Mil Standard 882 – USAF contractors

were required to have a System Safety

Program

▪ Proven engineering risk based concept –

Some attempts to apply it to:

– Human performance

– Management and organizational issues

System Safety

27 2021


The application of special technical and managerial skills to

the systematic, forward-looking identification and control of

hazards throughout the life cycle of a project, program or

activity.

Calls for safety analyses and hazard control actions,

beginning with the conceptual phase of a system and

continuing through the design, production, testing, use and

disposal phases until the activity is retired.

System Safety Engineering & Management, 2nd Edition

John Wiley & Sons 1990 ISBN 0471618160

System Safety

28 2021


▪ A systematic and continuous life-cycle

process based on proactive identification of

Hazards, and analyses of their Risk.

▪ Not Reactive but…

▪ PROACTIVE

System Safety

29 2021


Active monitoring and …

Ongoing process

…a cycle

How does this compare to

Regulatory or Compliance

Safety?

System Safety requires…

IdentifyHazards

AnalyzeRisk

AssessRisk

ManageRisk

EvaluateHazardControls

ModifyProcess

IdentifyHazards

AnalyzeRisk

AssessRisk

ManageRisk

EvaluateHazardControls

ModifyProcess

30 2021


▪ Systematic, rigorous, forward-looking (proactive),

all encompassing

▪ Strict definitions (Sound Familiar?)

▪ The foundation is clear hazard identification

▪ Qualitative and quantitative risk analyses

▪ Adherence to the systematic process

▪ Performance measuring, evaluation & follow-up

System Safety Attributes

31 2021


Hazard Mitigation

before losses are sustained

PREDICTIVE

…based on “Acceptable

Levels of Risk”

System Safety applies…

32 2021


From Safety I to Safety II

Source: Eric Hollnagel, et al. (2013)33 2021


Take 10 minutes

Break time!

202134


Fundamentals

Welcome Back!

Management

35 2021


Organizations, Mishaps,

“Safety Culture”

Let’s look at…

37 2021


Organizations

38 2021


Organizational value systems include

prioritization or balancing policies covering

areas such as productivity versus quality,

safety versus efficiency, financial versus

technical, professional versus academic, and

enforcement versus corrective action.

ICAO

39 2021


…or With

Let’s look at the kinds of

organizations we work In…

G

Número Uno

BP

40 2021


▪ Blame the messenger

▪ Hide information

▪ Cover up failure

▪ Crush new ideas

▪ Shirk responsibility

▪ No employee/employer

bridging

Pathological Organization

Professor Ron Westrum-Eastern Michigan University

Ref: Complex Organizations: Growth, Struggle and Change

Prof. Ron Westrum - EMU

Out of Print

41 2021


▪ Very structured

process

▪ Lacks flexibility

▪ Paperwork &

meetings, meetings,

meetings

▪ Sometimes necessary

▪ Sometimes effective

Bureaucratic OrganizationProfessor Ron Westrum-Eastern Michigan University

42 2021


▪ Actively seek

information

▪ Shared responsibility

▪ Welcome new ideas

▪ Continuous evaluation

▪ Good internal

communication

▪ Employee/employer

bridging rewarded

Generative Organization

Professor Ron Westrum-Eastern Michigan University

43 2021

Air Line Pilots Association, Int’l44 2021


Why is this important?

45 2021


▪ Technical Era

– Fly/Crash/Fix/Fly – most accidents were mechanical

failure

▪ Human Factors

– Blame and Train - every accident “Pilot Error”

▪ Technology improvements and Human Factor

awareness = Low Accident Rate

▪ Organizational Era

– Safety Management?

– Most potential for further accident rate reduction

▪ 2020s – Resilience Engineering?

Safety Evolution

46 2021


Overlooking the Obvious

The Organizational Accident

Dr. James Reason, Manchester University

47 2021


…an accident that has, as its root causes:

▪Corporate culture, or

▪Corporate decision making

▪Or… Lack Thereof!

The Organizational Accident is..

48 2021


Organizational Failure ModelProfessor James Reason, University of Manchester

Active Failure

Decision-makers – Fallible decisions

Line Management - Deficiencies

Preconditions – Psychological precursors of

unsafe acts – Environment

49 2021


“Process”

instead of

“Events”

Organizational safety is all about…

50 2021


This is a “Process”

51 2021


….two components:

▪Latent Conditions

▪Active Failures

The Organizational Accident has…

52 2021


The errors and violations having an

immediate adverse effect are unsafe acts

Eliminating an Active Failure Event prevents

one accident from happening

Active FailuresProfessor James Reason, University of Manchester

53 2021


“Event Tree”

Root Causes

Active Failure

54 2021


Eliminating an Active Problem

Root Causes

X

55 2021


…situations placed in the system by decision

makers, or…

…conditions which are placed

in the system by decisions or

actions of those at some

distance from the immediate

operation

Latent Conditions

56 2021


Organizational Process

▪ Inadequate system

hazard identification

and risk management

▪ Cut-Backs in

Training

▪ Decreased

Surveillance

For Instance

Resource based safety decisions

Latent Conditions

57 2021


…may lie dormant

for a long time,

and only become

evident when they

combine with a

triggering

mechanism to

breach the

system’s defenses

Latent Conditions…

58 2021


…can trigger an Active Failure, or combine

with an active failure to result in a “loss.”

Eliminating a Latent

Condition may

eliminate many

incidents or

or accidents

Latent Conditions…

59 2021


▪ Avoid the temptation to focus on the smoking

hole – the Event

▪ Focusing on the Event or the Individual dooms us

to repetition

▪ Focus on the Process to get to the root cause

Where Should we Focus?

60 2021


Eliminating a Latent Problem

Investigation

XLatent

61 2021


We need to get to

“latent conditions”

as well as active

failures!

“Band Aid” solutions waste resources and deal with the Event (effect) - not the Process (cause.)

62 2021


Procedures, Regulations and Risk Controls

are established at a point in:

▪ Time

▪ Technology

▪ Culture

And What About Drift?

63 2021


▪ Pressures are always in flux:

– Time - OTP - Cost - Labor, Fuel, Supervision

etc.

▪ Things change but Procedures do not.

▪ Front Line employees and Supervisors meet

the challenge, adapt…

▪ Organizational Latent Condition:

– Stale procedures

– Now working past the safety barrier

Safety Drift…

64 2021


Operational/Safety Drift…

65 2021


Reason’s Organizational Accident is a

problem for any organization

“Every accident, no

matter how small,

is a failure of

organization.”K. R. Andrews, British jurist 1907

So What?

662021


They illustrate the failings of an

operating “culture” without safety

securely embedded

What do Organizational Accidents

Illustrate?

672021


Errors - Easy

▪ Slips and memory lapses

▪ Misunderstandings

▪ Mistakes

– Skill based

– Rule based

– Knowledge based

Violations – Complicated

▪ Deviation from standard procedures (SOP)

▪ Deviation FAR/Company Policy

Two Types of Unsafe Acts…

68 2021


Deliberate

▪ Intentional

▪ Disregard

▪ Willful

▪ Negligent

▪ Misconduct

Violations are complicated!

Not Deliberate

▪ Error

▪ Misunderstanding

▪ Knowledge

▪ Mistake

▪ Well-intentioned

It may be a violation of the rules

but …69 2021


The Compliance Philosophy represents a

focus on using—where appropriate—non-

enforcement methods, or “Compliance

Action.”

The New Improved FAA…

Compliance Philosophy

70 2021


Compliance Action is a new term to describe

the FAA’s non-enforcement methods for

correcting unintentional deviations or

noncompliance that arise from factors such

as flawed systems and procedures, simple

mistakes, lack of understanding, or

diminished skills. A Compliance Action is not

adjudication, nor does it constitute a finding

of violation.

Compliance Philosophy (2015)

71 2021


A Compliance Action is

intended as an open and

transparent safety

information exchange

between FAA personnel and

you. Its only purpose is to

restore compliance and to

identify and correct the

underlying causes that led to

the deviation.


72 2021


Examples of Compliance Actions include on-

the-spot corrections, counseling, and

additional training (including remedial

training).


73 2021

Air Line Pilots Association, Int’l74 2021


▪ What is Drift?

▪ What is a Latent Condition?

▪ Which end of the cheese is the source of

your most worrisome problems ?

Review

75 2021


…and What is It?

How Do We Depend on “Culture”…

76 2021


Corporate Culture

“The Way We Do Things Here”

77 2021


A Safety Culture

“Set of beliefs, norms, attitudes, roles and

social and technical practices concerned

with minimizing exposure of employees,

managers, customers and members of the

general public to conditions considered

dangerous or hazardous.”

Thesis

78 2021


Good Culture ▪ Policy is followed

through Practices

(Habits) - even when

no one is looking!

▪ Middle managements’

expectations are the

same as front-line

employee.

▪ Executive Management

is involved.

Culture Builds and Maintains Habits

Poor Culture ▪ Gap between Policy

and routine practices.

▪ Middle management is

squeezed and unable

to be balanced.

▪ Executive Management

is absent.

79 2021


A healthy safety

culture for both

the organization

and the individual

is the Goal.

Safety Culture

80 2021


▪ Probably know it when

you see it!

▪ Components:

– Informed

– “Just” or Professional

– Reporting

– Learning

What is a Safety Culture?

81 2021


It is…

▪ An informed culture

▪ People are trained for both their duties and

Safety Management.

▪ People understand hazards and risk and;

– work continuously to identify and overcome

threats.

What is a Safety Culture?

82 2021


A just or professional culture

▪ Errors are understood as unavoidable but

willful violations not tolerated.

– Clear “exclusion” process (ASAP Big 5).

▪ Workforce knows, and agrees, on what is

acceptable and unacceptable.

▪ Pilots and Company agree on, and follow,

data protection and reporting agreements.

A Safety Culture is

83 2021


A reporting culture

▪ People are encouraged to voice safety

concerns.

▪ People feel safe to self-report errors and

observations.

▪ When safety concerns are reported they are

analyzed and appropriate action is taken –

with feedback.

– No Black Hole

A Safety Culture is…

84 2021


Five Characteristics of Effective

Reporting

85 2021


A learning culture

▪ The organization investigates and

documents every report.

▪ Safety issues are brought formally to the

decision makes – continuous improvement.

▪ Staff are updated on safety issues by the

leadership.

▪ The organization is flexible and able to

change when warranted.

A Safety Culture is…

86 2021


Leadership at every

level forms a

“partnership” with

employees to develop

and maintain an

effective safety

program

In a “Safety Culture”

87 2021


▪ Sufficient resources are allocated to

maintain an efficient and safe operation –

flexible to change

▪ Safety concerns and suggestions are

acknowledged

▪ Feedback is provided on decisions

▪ Decisions for “no action” or “acceptable

risk” are explained

An “Aware” Management

Makes Certain that…

88 2021


A healthy safety culture relies on a high

degree of trust and respect between

personnel and management and must

therefore be created and supported at the

senior management level.

ICAO

89 2021


Safety Promotion — Includes training,

communication, and other actions to create

a positive safety culture within all levels of

the workforce…

FAA

90 2021


A “safety culture”

that got lost

Antithesis

91 2021


Seeing the same

operational

discrepancy so

many times and

with such regularity

that it becomes the

new system “norm”

Normalized Deviance

92 2021


Normalized Deviance vs. –

HF ViewWhy do people break

rules?

▪ Unnecessary

▪ Burdensome

▪ Just for the

inexperienced

▪ Just once

▪ They were just

guidelines

▪ Everybody does it

➢Humans work the

easiest, quickest, most

efficient way

intrinsically

➢Rule-breaking is part of

human nature

➢Deviation is normal!

93 2021


▪ Developed nuclear submarine technology

based on the Manhattan Project

▪ Over 60 years without a single process

safety accident

▪ Supporter of deviance;

Normalization of Excellence

▪ Outcast of naval leadership

Admiral Rickrover

94 2021


All done!

95 2021

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