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SMS, Governance and Accountability. Kathy Fox, Board Member Transportation Safety Board of Canada Signal Charlie Human Factors Seminar Pensacola, Florida 13-14 September 2012. Outline. Evolution of accident investigation Drift into failure Safety Management Systems (SMS) - PowerPoint PPT Presentation
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SMS, Governance and Accountability
Kathy Fox, Board MemberTransportation Safety Board of Canada
Signal Charlie Human Factors SeminarPensacola, Florida
13-14 September 2012
Outline
• Evolution of accident investigation• Drift into failure• Safety Management Systems (SMS)• Investigating for organizational factors
o Inadequate risk analysiso Employee adaptationso Goal conflictso Weak signals
• The role of governance / regulatory oversight
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Background
• “What” happened vs. “why” it happened• Evolution of accident investigation:
– aircraft design– cockpit design– physiological factors– psychological influences on decision-making
and risk-taking– performance of the flight crew, not just the pilot (CRM,
TEM)
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Reason’s Model (“Swiss cheese”)
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D e f en c e s
A c tiv it ie sP r o du c t iv e
U n s a fe A c t s
O c c u rr e n c e
O c c ur re n c e O p po r tu n it y
L ine M a na g e m e ntD e fi c ie n c i e s
L a te n t U ns a fe C o n d it io n s
P r e co n d it io n s
A c tiv e F ai lu r e s &
A c tiv e F ai lu r e s
L im it ed W in d o w o f
P r e c u r s o r s o f U n s a feA c t s
P s y c h o l o g ic a l
In ad eq u ate
L a te n t U ns a fe C o n d it io n s
L a te n t U ns a fe C o n d it io n s
L a te n t U ns a fe C o n d it io n s
M ak e rsD e c is io n -
F a l l ib l e D e c is i o n s
Balancing Competing Priorities
Service Safety
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Limits of Acceptable Performance
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Organizational Drift
“Drift is generated by normal processes of reconciling differential pressures on an
organization (efficiency, capacity utilization, safety) against a background of uncertain
technology and imperfect knowledge.”-Dekker (2005)
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MK Airlines (October 2004)
Impact of Management
By their nature, management decisions tend to have a wider sphere of influence on how the organization operates, and a longer-term effect, than the individual actions of operators.
Decision-makers need to develop “mindfulness” to avoid “blind spots.”
-Weick & Sutcliffe (2007)
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A “Mindful Infrastructure” Would …
• Track small failures• Resist oversimplification• Remain sensitive to operations• Maintain capabilities for resilience• Take advantage of shifting locations of expertise• Listen for, and heed, weak signals
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Safety Management Systems (SMS)
SMS integrates safety into all daily activities.
“It is a systematic, explicit, and comprehensive process for managing safety risks … it becomes part of that organization’s culture, and [part] of the way people go about their work.”
-Reason (2001)
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SMS Requires the Following:
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SMS Requirements in Canada
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• Airline operators
• Maintenance organizations
• Certified airport authorities
• Privatized providers of air navigation services
• Coming soon: commuter airlines, air taxis, flight-training units
Investigating for Organizational Factors
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• Inadequate risk analysis
• Employee adaptations
• Goal conflicts
• Missed “weak signals”
COMPLEX INTERACTION = NO SINGLE FACTOR AS SOLE CAUSE
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Inadequate Risk Analysis
TSB Investigation Report A07A0134
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Aircraft Attitude at Threshold
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TSB Investigation Report A07Q0213
Inadequate Risk Analysis (cont’d)
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Employee Adaptations
• Faced with time pressures or multiple goals, workers and management may be tempted to create “locally efficient practices.”
• Why? To get the job done!
• Past successes are taken as a guarantee of future safety.
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Employee Adaptations (cont’d)
TSB Investigation Report A09W0037
Goal Conflicts
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YVR seaplane dock, 16 November 2008 (A08P0353).
Weak Signals
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Collision with terrain: Sandy Bay, SK(A07C0001)
Weak Signals (cont’d)
“We didn’t see [these recent accidents] coming, and we should have … the
data were trying to tell us something.”
-William Voss, President and
CEO of Flight Safety Foundation
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Pilot Error or Management Error?
• Drift, goal conflicts and adaptations are natural• No one sets out to have an accident; they just
want to get the work done• The decision to value production over safety is
implicit
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Pilot or Management Error? (cont’d)
• With each success, people underestimate the amount of risk involved
• If investing in safety improved quarterly returns, the company would do it
• There is a complex relationship between culture and process
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The Role of Governance / Oversight
Q.) Who holds decision-makers to account?
A.) Board of Directors / owner
Shareholders / financial backers
Customers
Insurance companies
Regulators
All of the above
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Governance / Oversight (cont’d)
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TSB Investigation Report A10Q0098
Governance / Oversight (cont’d)
“The gap between what is legal and whatis safe already is large, and it will getbigger. … Is this regulatory approach
sustainable? Is it fair to airlines that do everything right? Is it fair to an
unknowing public?”
-William Voss, Flight Safety Foundation
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Conclusions
• Old views of safety are changing
• No one can predict the future perfectly
• “Mindful infrastructure”Effective SMS depends on “culture” and “process”
• Accountability is key
• Regulatory oversight
• Success takes time
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Questions?
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