Risk Management in Airline Industry .Ppt - PDF

					From BASI-Indicate to
Safety Systems to Aviation
Safety Regulation in 2010
Dr Graham Edkins
Group General Manager, Personnel
Licensing, Education and Training




                                    April 2006
       Where I am coming from…?
Variety of professional safety roles in Rail and Aviation as regulator,
investigator and safety manager
Rail
 •   Rail investigator – Westrail & Victorian Rail Safety Regulator
 •   Chair, National Rail Safety Regulators Panel (RSRP)
 •   Chair, Safety Management Systems Expert Panel (SMSEP), Special Commission of
     Inquiry into the Waterfall rail accident
 •   Member, SCOT Rail Group Steering Committee on Co-regulation

Aviation
 •   BASI – Air Safety Investigator, CASA – GGM PLET
 •   Qantas – Chief Psychologist, Head Human Factors, GM Safety Systems & Education
 •   Previous President, Australian Aviation Psychology Association (AAvPA)
 •   Vice Chair, IATA Human Factors Working Group
                                                                              April 2006
       Where I am coming from…?
Co-author: CASA (1998) Aviation Safety Management: An operators guide.
Keynote Speaker CASA (2000) Safety Management Systems National
Roadshow
Chair: Standards Australia: AS5022 Rail Safety Investigations
Member: Standards Australia: AS4292 Rail Safety Management
Member: Industry Development Group CASR 119: Safety Management Systems
ICAM (Incident Causa Analysis Method) Trainer – BHP Billiton
Master of Psychology (Organisational) – rail human factors
PhD applied in safety management systems (aviation)




                                                                April 2006
Westrail – circa 92-94
                    Antecedents
Signals Passed at Danger (SPAD)

The Reason Model ~ circa 1990
 • Developed from Professor James Reason’s work on human
   error and “organisational accidents”

Proactive safety indicators ~ circa 1992
 • Tripod Delta for Shell Petroleum
 • MESH for British Airways
 • PRISM / REVIEW for British Rail

Focus on proactive identification of General Failure Types (GFTs)

                                                          April 2006
                      Contextual
                                       The Reason Model
                      Conditions        Human
Organisational and System            Involvement
         Factors                                                Absent or Failed
                                                                   Barriers


                                            e
                                        sa f
                                     “Un ts”
                   People, Task,       Ac
                   Environment




                                                                 ACCIDENT

           Latent Conditions
                                    Active         Limited window/s (adapted from
                                   Failures        of opportunity   Reason, 1990)

                                                                   April 2006
       General Failure Types
Hardware
Design
Maintenance Management
Procedures
Error-enforcing Conditions
Housekeeping
Incompatible Goals
Communication
Organisation
Training
Defences
                               April 2006
    Railway Problem Factors (RPF’s)
                                                                             Organisational Policies
                     41                                                      Equipment Design
                    21                                                       Housekeeping
                    34
                                                                             Management
                              50
                                                                             Staffing
                              53
                                                                             Rules/Procedures
                     28
                              55                                             Working Conditions
                     43                                                      Supervision
                                                               126           Staff Attitude
                                              91                             Maintenance
                                              92                             Operating Env
                    38
                                                                             Communication
          17
                                                                             Training

0    20        40        60        80   100        120   140     160   180
                                                                                           April 2006
                 Implications
People are very adept at making global estimates of
hazards/risk
Ownership and participation in safety management
drives commitment
Focus on GFT’s avoids focus on individual error and
potential “blaming process”
Complement to “systems” approach to accident
investigation
Management tool - Sets priorities with finite resources
Assumes safety is a management problem
                                                  April 2006
 Bureau of Air Safety
Investigation (94-97)
                 Context
11 June 1993, VH-NDU Monarch Airlines
accident, Young NSW – 7 fatalities
2 October 1994 VH-SVQ – Seaview Air Crash,
en-route Lord Howe Island – 9 fatalities
1995, Staunton Commission Inquiry into
Seaview Air and CAA
1995, Inquiry into safety of General Aviation
sector – Plane Safe

                                         April 2006
                   Myths
Safety programs only applicable to high capacity
operators
Costly to implement
Require system safety expertise

Indicate program developed in 1995-1997 and
trialled within Kendell airlines


                                           April 2006
       INDICATE assumptions
People know what the safety hazards are within
their work area – but need to be given
opportunity to report
Fear of blame contributes to reporting reluctance
Feedback consistency affects reporting culture
Defence failures are often revealed too late!



                                           April 2006
Proactive defence evaluation model*




* Edkins, G.D. (1998). The INDICATE safety program; evaluation of a method to
proactively improve airline safety performance. Safety Science, 30: 275-295
                                                                                April 2006
              Six core safety activities
                                              Intervention group Control Group
1.   Appointing an operational safety
     manager who is available to staff as a          Yes            No
     confidant for safety-related issue
2.   Conducting a series of staff focus              Yes            No
     groups to proactively identify company
     safety hazards
3.   Establishing a confidential safety
     reporting system for staff to report            Yes            Yes
     safety hazards
4.   Conducting monthly safety meetings              Yes            No
     with management
5.   Maintaining a safety information                Yes            No
     database to record, manage and
     evaluate safety recommendations
6.   Ensuring that safety information is
     regularly distributed to all staff.             Yes            No
                                                                   April 2006
Proactive identification of safety hazards
             5 simple steps:

i. Identify potential airline safety hazards that
     may threaten the safety of passengers
ii. Rank the severity of hazards
iii. Identify current defences
iv. Evaluate the effectiveness of each defence
v. Identify additional defences

                                             April 2006
Methodology




              April 2006
      Airline Safety Culture Index
125

105

85
              74           Intervention
        70

65                         Control
                    50
         59              NOTE: Score between 25-125,
45                       the LOWER the score the
              44
                    41   BETTER the result
25
        T1    T2   T3
                                           April 2006
      Risk Perception - Severity
180
160
       140
140
       139   116
120
                   93
100                      Intervention
 80          90          Control
                   85
 60
 40
 20
  0
       T1    T2    T3

                                        April 2006
 Risk Perception - Likelihood
180
160
140
120
100                  Intervention
      76
 80        66        Control
 60   76        50

40
           39
20              35

 0
      T1   T2   T3

                                    April 2006
Reporting culture – volume of safety
         reports submitted
   100
    90
    80
    70
    60              60
                           Intervention
    50
                    45     Control
    40    49

    30
    20
    10         9
     0
          T1       T2
                                     April 2006
                   Qualitative analysis
INTERVENTION                                     CONTROL
• “ I think the INDICATE program is a            • “ People are reticent to share
great idea and with its persistence will         experiences and discuss safety
force management into improving areas            incidents they may have had, as they
and procedures that are unsafe. ”                feel their positions will be under
                                                 threat. ”
• “ There are countless things that can trip
up an airline in regard to safety. It’s a fine   • “ There is a general feeling that
balance between safety and economics.            management practices are reactive
Vigilance is the best safety net, therefore      and not proactive…..”
programs like this make me feel that this
is a safe airline. ”

                                                                            April 2006
          INDICATE - Lessons
Simple ideas are often effective
Structured framework for communicating safety messages
is crucial
Safety culture has an influence on attitude and behaviour
Continual evaluation of a SMS is crucial – complacency is
easy
Safety systems need to continually evolve – 12 months
later, INDICATE became outdated for Kendell!



                                                April 2006
Qantas – 1997-2003
    Case Study




Runway Overrun, Bangkok
    September 1999
                          April 2006
Executive Director, Public
Transport Safety Victoria
   (PTSV) 2003-2005




           1     2    3
A Case Study of
Systematic Failure
in Rail Safety:
The Waterfall
Accident




                     April 2006
Human Compensatory Ability: A
case study of a Runaway Train!




                            April 2006
Implications for Organisations and
           Regulators




                             April 2006
  Implications for Organisations (1)
Do you have Integrated Safety Management Systems –
not stand alone?
Are Risk Management activities system wide and
proactive?
Do you have formal document control processes,
particularly for change management activities?
Does your organisation have expertise and a requisite
understanding of human and organisational factors?
Does your organisation have a program for continued
professional development in safety science?
                                                April 2006
 Implications for Organisations (2)

Is safety culture measured on a periodic basis?
Do your employees really believe that there is a just
approach to incident/accident investigation?
What evidence could you present that indicates your
organisation has a learning culture?
Do you have an integrated safety information
management system that drives strategy?
Do you have a human systems integration program
that incorporates principles of error tolerance?
                                                 April 2006
  Implications for Regulators (1)
Is the regulator sufficiently independent and
autonomous from government?
Is there a function for the independent (from
regulator) conduct of safety investigations?
Does the regulator have expertise and an ongoing
professional development program in human and
organisational factors and safety science?
How does the regulator ensure that they don’t lose
touch with current industry practices?


                                               April 2006
    Implications for Regulators (2)

Does the regulator comprehensively assess the
adequacy of safety accreditation/AOC and change
management applications to ensure that they are
rigorous?
Does the regulator require industry operators to collect
causal factors data to an agreed standard so that
emerging safety deficiencies can be identified across
various sectors?
Does the regulator have sufficient resources to enable
compliance and accreditation activities to be effectively
achieved?
                                                 April 2006
CASA 2005-
   Aviation Safety Responsibilities
DEPARTMENT OF TRANSPORT & REGIONAL SERVICES
    International and domestic aviation policy advice
    International airline operations regulation
    Management of participation in ICAO
    Administration of aviation security standards
    Publication of air service statistics

AUSTRALIAN TRANSPORT SAFETY BUREAU
    Independent investigation of aircraft accidents/incidents
    Analysis of safety data


CIVIL AVIATION SAFETY                  AIRSERVICES AUSTRALIA
AUTHORITY (CASA)                            Air Traffic Control
   Standards                                Airspace Management
   Regulatory Services                      Aeronautical Information
   Compliance                               Airport rescue & fire fighting
                                            services
   Safety Promotion
                                            Radio navigation aids
                                                                             April 2006
April 2006
                    Surveillance
       Old Approach                       New Approach

Task-focussed                      Focuses on
Tended to focus on end-product      • Organisation’s systems
of the systems                      • Systems used to produce safe
Identified problems tended to be      outcomes
fixed by “patches”                 Required fixes based on the
Inflexible planning process        systems needed to produce
Much repetition of tasks           consistent results
Checklist based                    Surveillance planning is
                                   organisation-based
                                   Planning based on sector and
                                   individual organisation risk
                                   Uses team-based audit
                                   techniques where practical
                                   Recording systems are guideline-
                                   based.
                                                            April 2006
           History of CASA SMS
1995 – Introduction of SMS – Dick Wood
1996 – SAPCOM – industry advisory group
1998 – First Guidance booklet (Aviation Safety Management: An
operator’s guide)
1998 – National launch SMS concepts (Reason/Hudson)
2000 – Release of discussion paper on SMS
2001 – National education roadshow “System of safety” – Rob
Lee/Graham Edkins
2002 – NPRM CASR 119, multimedia guidance material
2003-2005 – focus on small to medium size operators

2006 – safety case (exposition) and integrated SMS

                                                       April 2006
New AOC/CofA               Existing AOC/CofA

                                                    CASA Actions

                                   Registration     Industry Actions
       Notification
                                                    Both


           Safety Case (Exposition)
           Outline
                                                        Appeals/Reviews

 Consulting &          Safety Duties
 informing                      •HAZID & safety         Amendment/Revision
                                assessment
                       •Design SMS
                       •Outline control measures        Co-ordination
                       •Demonstrate adequacy
                                                        Modification


           Safety Case Preparation                      Issuing AOC or Cof A


                                                        Safety Oversight
                      Submission
Development
                                                        Education

 Consultation                  Review
                                                        Liaison

 Adequacy Tests            Prepare Conclusion
                                                        Periodic Review

                      Communicate Conclusion
                                                        Review after
Review
                                                        Accidents / Incidents
                                                                                April 2006
                                                   Maintenance
What might be CASAs focus in 2010?
One third - Safety Research and Analysis.
Development of Safety regulations which target known safety risks and
supported by credible and appropriate safety analysis. Safety Modelling. A
greater emphasis in providing Industry with the Management and Safety
Systems models which they can criteria reference there own safety
performance against.

One third - Education and Training.
Supporting CASA Oversight and Compliance staff (and Industry),
with the skills and competencies to build and evaluate
SMS’s.

One Third - Compliance and safety oversight.
Risk Based Audits. Referencing/Measuring Operators safety profile against
particular models of safety efficiency and effectiveness.
Working with Operators and Case managing continuous improvements.
                                                                  April 2006
   What CASA might look like?
400-500 staff rather than 700
CASA dominant workforce profile - 30
something, male or female, systems background
Focus on particular pax carrying operators
based on identified risk
General aviation, sports aviation, aerial work –
more self regulating
Main activity – safety education

                                          April 2006
             The future of SMS

SMS will be integrated into all management systems. It
will not be an appendage - it will be an integral part of
normal day to day operations.

CASA’S focus will be on how well these systems are
designed and how well they are functioning.

Operators will need to demonstrate continuous
improvement and reapply for AOC/CofA every 3-5 years
(exposition/safety case)
                                                    April 2006
April 2006
In case you forgot what I said !

Regulatory safety requirements are increasing
    – Safety case and risk management
    – Integrated Safety Management Systems
    – Demonstrate continuous improvement

Unplanned change is your biggest risk
Taking your people with you, “hearts and minds” , in that
change process is vital (the regulator will look for
assurance this has been done!)
                                                       April 2006
                 Final words

“Safety is a little
like boarding an
aircraft with no
destination; the
journey never
ends”



                          Don’t stick your head in the
                                     sand !
                                             April 2006
Questions?




             April 2006

				
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