Safety Management – Safety Management – A Compromise Between A Compromise Between

Production and ProtectionProduction and Protection

Captain Dan MaurinoCaptain Dan MaurinoFlight Safety and Human Factors – ICAOFlight Safety and Human Factors – ICAO

Worldwide Symposium on Performance of the Air Navigation SystemWorldwide Symposium on Performance of the Air Navigation SystemMontrealMontreal

26 – 30 March 200726 – 30 March 2007

The First Ultra-Safe Industrial SystemThe First Ultra-Safe Industrial System

Ultra-safe system (mid 1990’s onwards)Ultra-safe system (mid 1990’s onwards)Business management approach to Business management approach to

safety (SMS)safety (SMS)Routine collection and analysis of Routine collection and analysis of

operational data operational data

1010-3-3

1010-5-5

1010-7-7

Fragile system (1920’s -1970’s)Fragile system (1920’s -1970’s)Individual risk management & intensive trainingIndividual risk management & intensive trainingAccident investigationAccident investigation

Safe system (1970’s – mid 1990’s)Safe system (1970’s – mid 1990’s)Technology & regulationsTechnology & regulationsIncident investigationIncident investigation

Less than one Less than one catastrophic breakdown catastrophic breakdown per million production cyclesper million production cycles

Truth or Falsehood?

TruthTruth

What is the fundamental purposeWhat is the fundamental purposeof a business organization?of a business organization?

The Business Management PerspectiveThe Business Management Perspective

To achieve specific production goals, service To achieve specific production goals, service providers must manage providers must manage corecore business processesbusiness processes

Managing safety is one such business processManaging safety is one such business processSafety Safety management is a management is a core business functioncore business function just just as financial management, HR management, as financial management, HR management, etcetc..

To achieve specific production goals, service To achieve specific production goals, service providers must manage providers must manage corecore business processesbusiness processes

Managing safety is one such business processManaging safety is one such business processSafety Safety management is a management is a core business functioncore business function just just as financial management, HR management, as financial management, HR management, etcetc..

A Balanced CompromiseA Balanced Compromise

ProductionProductionProtectionProtection

ResourcesResources

The DilemmaThe Dilemma

Production

ProtectionProtection

Bankruptcy

Resources

Resources

The DilemmaThe Dilemma

Production

ProtectionProtection

Resources

Resources

Catastrophe

Building Safety Resilience…Building Safety Resilience…

RiskRisk

HighHigh

LowLow

System outputSystem outputMaximumMaximum MinimumMinimum

SafetySafetySpaceSpace

TrainingTraining

System’s System’s Production Production Objective(s)Objective(s)

RegulationsRegulationsTechnologyTechnology

……Upon Business Management PracticesUpon Business Management Practices

Safety issues are a Safety issues are a byproductbyproduct of activities of activities related to production/services delivery. related to production/services delivery.

Managing safety – An analysis of an Managing safety – An analysis of an organization's resources and goals leading to organization's resources and goals leading to

Balanced and realistic Balanced and realistic allocation of resourcesallocation of resources between protection and production goalsbetween protection and production goals

Support of the Support of the needsneeds of the organization of the organization

Safety issues are a Safety issues are a byproductbyproduct of activities of activities related to production/services delivery. related to production/services delivery.

Managing safety – An analysis of an Managing safety – An analysis of an organization's resources and goals leading to organization's resources and goals leading to

Balanced and realistic Balanced and realistic allocation of resourcesallocation of resources between protection and production goalsbetween protection and production goals

Support of the Support of the needsneeds of the organization of the organization

Production, Protection & ICAO SARPsProduction, Protection & ICAO SARPsStates shall establish a States shall establish a safety programmesafety programme, in , in

order to achieve an order to achieve an acceptable level of safetyacceptable level of safety in: in:The operation of aircraft The operation of aircraft The maintenance of aircraft The maintenance of aircraft The provision of air traffic services The provision of air traffic services Aerodrome operationsAerodrome operations

States shall establish a States shall establish a safety programmesafety programme, in , in order to achieve an order to achieve an acceptable level of safetyacceptable level of safety in: in:The operation of aircraft The operation of aircraft The maintenance of aircraft The maintenance of aircraft The provision of air traffic services The provision of air traffic services Aerodrome operationsAerodrome operations

Production, ProtectionProduction, Protection & ICAO SARPs & ICAO SARPsStates shall require, as part of their safety programme,

that a [service provider] implements a safety management system accepted by the State that, as a minimum: Identifies safety hazards Ensures that remedial action necessary to maintain

an acceptable level of safety is implemented Provides for continuous monitoring and regular

assessment of the safety level achieved Aims to make continuous improvement to the

overall level of safety

States shall require, as part of their safety programme, that a [service provider] implements a safety management system accepted by the State that, as a minimum: Identifies safety hazards Ensures that remedial action necessary to maintain

an acceptable level of safety is implemented Provides for continuous monitoring and regular

assessment of the safety level achieved Aims to make continuous improvement to the

overall level of safety

Enter Acceptable Level of SafetyEnter Acceptable Level of Safety

The acceptable level of safety to be achieved shall be The acceptable level of safety to be achieved shall be established by the State(s) concernedestablished by the State(s) concerned

Minimum safety performance that service providers should achieve while conducting their core business functions

Each agreed acceptable level of safety should be commensurate to

Complexity of individual service provider specific operational contexts

Availability of service provider resources to address safety concerns

The acceptable level of safety to be achieved shall be The acceptable level of safety to be achieved shall be established by the State(s) concernedestablished by the State(s) concerned

Minimum safety performance that service providers should achieve while conducting their core business functions

Each agreed acceptable level of safety should be commensurate to

Complexity of individual service provider specific operational contexts

Availability of service provider resources to address safety concerns

In Search of the Balanced CompromiseIn Search of the Balanced Compromise

Statesafety

programme

Organization’ssafety

management system (SMS)

Organization’sproductionprocesses

Objective:Publicsafety

Objective:Controlsafety risk

AcceptanceOversight

Objective:Achieve commercialgoals andcustomer satisfaction

Safety assurance

Oversight

ProductionProductionProtectionProtection

ResourcesResourcesProtection

ProductionProduction

Denial: ritualistic rejection of Denial: ritualistic rejection of changechange

Repair: cover-up, cosmetic Repair: cover-up, cosmetic adaptation denying progress adaptation denying progress

Reform: engaging the will to Reform: engaging the will to changechange

Safety Management – Excuses and FearSafety Management – Excuses and Fear