1

History of Flight Safety

From reactive to predictive

Cpt. Morten YdalusHead of Safety Office

2

1908 Wright Flyer 2 Virginia

3

1937 Zeppelin LZ-129 New Jersey

4

1977 2 B-747 Tenerife

5

1979 DC-10 Chicago

6

2000 Concorde Paris

7

Concept of safety• Consider

– The elimination of accidents (and serious incidents) is unachievable.

– Failures will occur, in spite of the most accomplished prevention efforts.

– No human endeavour or human-made system can be free from risk and error.

– Controlled risk and controlled error is acceptable in an inherently safe system.

8

Concept of Safety (ICAO Doc 9859)

• Safety is the state in which the risk of

harm to persons or property damage is

reduced to, and maintained at or below,

an acceptable level through a

continuing process of hazard

identification and risk management.

9

80

70

60

50

40

30

20

10

0Today

TIME

Accident Statistics

Annual hull losses per million departuresWorldwide Commercial Jet FleetSources: IATA, NTSB and Boeing

10

Technical causes most common in the past

Ifsd-cfm56-0.003 -333.000-900-185

11

Today: 60-80 % Human Error

60-80 % Human Error Today

12

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%Today

TIME

Human Causes

Machine Causes

ACCIDENTS

13

14

The evolution of safety thinking

TECHNICAL FACTORS

HUMAN FACTORS

ORGANIZATIONAL FACTORS

TOD

AY

1950s 1970s 1990s 2010s

15

Safety Orientation 1.

Reactive Past oriented

Proactive Present oriented

Predictive Future oriented

16

Safety Orientation 2.

Reactive method

The reactive method responds to the

events that already happened, such as

incidents and accidents

Proactive method

The proactive method looks actively for the

identification ofsafety risks

through the analysis of the organization’s

activities.

Predictive method

The predictivemethod captures

systemperformance as

it happens in real-time

normal operations

17

Safety Orientation 3.

• Proactive safety is seeing and preventing an event before it happens.

• Reactive management is waiting for the accident to happen, then make corrections

18

Safety Management – Levels of intervention

Predictive Proactive Reactive

Highly efficient Very efficient Efficient

Safety management levels

Reactive

Desirable managementlevel

Inefficient

SafetySurveysAudits

FDM

MOR Accidentand occurrence

reports

HighMiddle

Low

Threats

Hazard IDSPI’s real time

18

Past and current safety culture

20

Can’t drive by just looking at the rear view mirror……

We need to develop a new safety culture

21

The safety culture ladder

PROACTIVESafety leadership and values

drive continuous improvement

Incr

easi

ngly

Info

rmed

Incr

easi

ng Tru

st a

nd A

ccou

ntab

ility

PREDICTIVE SMS is how we do business

round here

PATHOLOGICALWho cares as long as

we're not caught

REACTIVESafety is important, we do a lotevery time we have an accident

CALCULATIVEWe have systems in place to

manage all hazards

22

How to do it ?

• Start with collecting data• Design SPI’s• Identify hazards

23

DATA

• Obtaining a global picture of your organization’s data is a necessity

• Understanding data correlations• Know what you know (or don’t know)• Balance cost vs. possible system

output

24

Sources of data

Reports FDM Line checks

Aircraft technical

data

Training/checking

Surveys Audits Inspections

SPI’s

25

Purpose of SPI’s

• Primarily:“Support of and control in the risk management process.”

• But also:“Support the relation with over-sight authorities.”

26

The SPI’s

• The SPI will tell you where action is needed, however not what action.

• The SPI is not a measure of a safety level as such. Sometimes the SPI will be used as early possible warnings and will require an investigation to analyze the relevance of the warning.

• “SPI’s indicate how the management approach safety.”

27

A spectrum of SPI’s

• A spectrum of reactive, proactive and predictive indicators should be used.

• A useful SPI should be:- Valid; measure what we want to measure- Reliable; not dependent on individuals- Sensitive; respond on changes- Representative; cover all aspects- Resistant to bias; not be possible to manipulate- Cost-effective; not cost more than it gives

28

Real time safety performance• The Vision Monitor Tool:

29

30

31

32

33

34

35

36

37

A challenge to be faced by all airlines:• What is the future role of a SMS in an

industry that continues to evolve? – It needs to be a shift from reactive to

proactive orientation – A change from top down to bottom up

participation, with the emphasis on sharing knowledge within a learning organization/culture.

38

Questions ?