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					System Safety and Risk Management




             Friday, July 22, 2011    Presented by AFS-900

                                     Amer M. Younossi
Module 1       Module 2     Module 3      Module 4        Module 5     Module 6

 Outline       How        Why      Objectives/Functions    Authority   Challenges   Summary




   Modules
           1 Why Flight Standards Is Implementing
               System Safety and Risk Management
           2   Risk Concepts
           3   System and Organizational Principles
           4   Human Factors
           5   Data and Analysis
           6   Risk Management


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                                                                       System Safety and Risk Management
Module 1       Module 2     Module 3      Module 4        Module 5     Module 6

 Outline       How        Why      Objectives/Functions    Authority   Challenges   Summary




   Module 1 Outline
              How did we get here?
              Why do system safety?
              AFS-900 objectives and functions
              Where is our authority?
              System safety challenges
              Summary
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                                                                       System Safety and Risk Management
         Module 1   Module 2     Module 3      Module 4        Module 5     Module 6

          Outline   How        Why      Objectives/Functions    Authority   Challenges   Summary




How Did The FAA Get Here?

   90-Day Safety Review
   White house and congressional
    mandates to reduce the
    accident rate by 80% in 10
    years




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                                                                            System Safety and Risk Management
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          Outline   How        Why      Objectives/Functions    Authority   Challenges   Summary




90-Day Safety Review
   The task force categorized issues into six general areas:
      certification policy and process

      resource targeting to address safety risks

      newly certificated air carrier operations and growth

      outsourcing and varied fleet mix

      inspector and air carrier guidance material

      inspector resources




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                                                                            System Safety and Risk Management
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           Outline   How        Why      Objectives/Functions    Authority     Challenges   Summary




Policy Statement of the FAA
   Aggressive attitude with respect to aviation safety
   Pro-active approach
   Air carrier to maintain the highest possible degree of
    safety
   Achieve this in the most economical and efficient
    manner to the government and the carrier
                                                                             Source: FAA Order 1000.1A




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                                                                              System Safety and Risk Management
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            Outline   How        Why      Objectives/Functions    Authority   Challenges   Summary




FAA Mission Statement
   Setting regulations and standards for:
      air carriers
                                            Flight Standards Vision
      air commerce                    To be recognized and respected world-
      air agencies                  wide as the foremost authority on system
                                        safety approaches for regulation and
      airmen, etc.                                 certification


   Accomplishing certification, surveillance, inspection,
    investigation and enforcement activities

   Managing the systems for registry of ...
     aircraft
                                                                                                           7
     airmen                                                                  System Safety and Risk Management
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          Outline   How        Why      Objectives/Functions    Authority   Challenges   Summary




Why Do System Safety
   Air traffic is increasing
   Aviation operations are becoming more complex
   FAA oversight staff and resources are constrained
      We can no longer afford to function as
        a direct source of QC
   Systems approach is proactive -
      Stresses process improvements

   System safety is good business


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                                                                            System Safety and Risk Management
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        Outline   How        Why      Objectives/Functions    Authority   Challenges   Summary




System Safety Defined


“The application of special technical and managerial skills
   in a systematic, forward-looking manner to identify and
     control hazards throughout the life cycle of a project,
                     program, or activity.”
                                                    Source: System Safety Course, FAA Academy




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                                                                          System Safety and Risk Management
         Module 1   Module 2     Module 3      Module 4        Module 5     Module 6

          Outline   How        Why      Objectives/Functions    Authority   Challenges   Summary




System Safety Philosophy
   System safety is:
      Validation of regulatory compliance

      Review and validation of systems and entire programs,
       not portions
      Application of safety attributes

      Application of risk management




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                                                                            System Safety and Risk Management
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          Outline   How        Why      Objectives/Functions    Authority     Challenges   Summary




AFS-900 Objectives
      “Air carrier certificates are our gold standard to
         measure how well we are accomplishing our
                       responsibilities.”
                                                                            Dave Gilliom ~ AFS-900


   Standardize air carrier certification
   Standardize systems and targeting risks
   Centralize information management functions
   Six Processes are ISO-9000 Certified

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                                                                             System Safety and Risk Management
           Module 1    Module 2     Module 3      Module 4         Module 5     Module 6

            Outline    How        Why      Objectives/Functions     Authority   Challenges   Summary




ATOS Model
                                     Module 2                      Module 3
Policy                               Certificate                   Surveillance
--------
--------                                                          Resource Mgmt
--------                            Management
--------
--------
--------         Module 1
--------          System                                                            Module 4
                Configuration                                                       Surveillance




                 Module 8                                                           Module 5
               Implementation                                                        Reporting


                                                             Module 6
                                  Module 7                    Evaluation
                                    Analysis

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                                                                                System Safety and Risk Management
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            Outline   How        Why      Objectives/Functions    Authority   Challenges   Summary




AFS-900 Functions
     Certification, Standardization, and Evaluation Team (CSET)
           Certification
           Surveillance/Evaluation Planning
           Aircraft conformity team
           Technical support program
     Air Transportation Oversight System (ATOS)
           Improve the certification and surveillance processes for air carriers
           Ensure regulatory compliance and incorporate a systems approach
           Enhance the surveillance process Standardize the surveillance processes
     Flight Standards Safety Analysis Information Center (FSAIC)
           Provide analytical support to Flight Standards
           Identify industry-wide risk areas
           Partnership with aviation safety research institutions
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                                                                              System Safety and Risk Management
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         Outline   How        Why      Objectives/Functions    Authority   Challenges   Summary




AFS-800 Function
System Safety Approach for General Aviation (SAGA)

     Improve the oversight process for general aviation

     Open communications with air operators.

     Identify focus areas to target, and provide feedback to
      operators.




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                                                                           System Safety and Risk Management
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         Outline   How        Why      Objectives/Functions    Authority   Challenges   Summary




Integrated System Safety Efforts
SASO ~ Systems Approach for Safety Oversight
     Business process procedures, guidelines, and
      automation tools

     Data quality enhancement and database
      standardization

     Risk management/analysis procedures and automation

     Interconnectivity of agency and industry databases

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                                                                           System Safety and Risk Management
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          Outline   How        Why      Objectives/Functions    Authority   Challenges   Summary




Where Is Our Authority?
   Title 49 44701, 44702
   Current 121 Rules




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                                                                            System Safety and Risk Management
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USC Title 49
  Sec. 44702. Issuance of certificates
  ...
  (B) considerations. - When issuing a certificate under this
      chapter, the administrator shall -
       (1) consider -
            (a) the duty of an air carrier to provide service with
              the highest possible degree of safety in the
              public interest.
       ...


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                                                                          System Safety and Risk Management
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         Outline   How        Why      Objectives/Functions    Authority   Challenges   Summary




USC Title 49
  Sec. 44701. General
   requirements
  (A) promoting safety. -
      The administrator of
      the FAA shall promote
      safe flight of civil aircraft
      in air commerce by
      prescribing -
  ...
      (2) regulations and
      minimum standards in
      the interest of safety                                                                           18
                                                                           System Safety and Risk Management
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         Outline   How        Why      Objectives/Functions    Authority   Challenges   Summary




14 CFR Part 121 Rules
14 CFR part 121.135 (a) (1)
  each manual required by
 §121.133 must -
   (1) include instructions and
  information necessary to
  allow the personnel
  concerned to perform their
  duties and responsibilities
  with a high degree of
  safety;
  ...
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                                                                           System Safety and Risk Management
         Module 1   Module 2     Module 3      Module 4        Module 5     Module 6

          Outline   How        Why      Objectives/Functions    Authority   Challenges   Summary




System Safety Challenges
   Operator’s organizational structures
      Systemic orientation and completeness of regulations

   Defining and measuring safety
   FAA and industry cultures
      Human factors

   Availability of valid, reliable data that are
    representative of the system
   Risk management application


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                                                                            System Safety and Risk Management
         Module 1   Module 2     Module 3      Module 4        Module 5     Module 6

          Outline   How        Why      Objectives/Functions    Authority   Challenges   Summary




Summary

   90 day safety review
   System Safety
   AFS-900




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                                                                            System Safety and Risk Management
   System Safety and Risk Management

Module 2
Risk Concepts




                Friday, July 22, 2011   Presented by AFS-900
Module 1       Module 2       Module 3         Module 4       Module 5      Module 6

 Outline       Fundamentals      Definitions       Concepts      Risk Factors   System Safety   Summary




   Module 2 Outline
              Fundamentals of Risk
              Definitions of Risk
              Common Concepts of Risks
              Risk Factors/Controls
              System Safety
              Summary
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                                                                           System Safety and Risk Management
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          Outline   Fundamentals      Definitions       Concepts      Risk Factors   System Safety   Summary




Risk Management
   Risk management is a core process to system safety.

   Risk management can be practiced at all levels and in all
    types of aviation.

    “Safety is not equivalent to risk free”
        – U.S. Supreme Court, 1972

    “Risk management is a more realistic term than safety…”
        – Jerome Lederer, 1928




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                                                                                System Safety and Risk Management
             Module 1   Module 2       Module 3         Module 4       Module 5      Module 6

              Outline   Fundamentals      Definitions       Concepts      Risk Factors   System Safety   Summary




Basic Risk Concepts
   Event
      Accident, Incident, Occurrence

      Undesired event resulting in loss


   Hazard
      Condition that can cause event


   Risk
      Likelihood / severity of event associated with the hazard
       Exposure to hazard...
             Likelihood of occurrence
             Severity of consequences
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                                                                                    System Safety and Risk Management
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          Outline   Fundamentals      Definitions       Concepts      Risk Factors   System Safety   Summary




Schools of Thought
   Product Development (“Traditional” SS)

   Organizational Psych (e.g. James Reason)

   Project Management (Risk Management – e.g. SEI)

   AFS’ approach is a blend




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                                                                                System Safety and Risk Management
         Module 1   Module 2       Module 3         Module 4       Module 5      Module 6

          Outline   Fundamentals      Definitions       Concepts      Risk Factors   System Safety   Summary




Definition(s) of Risk
   Several definitions exist, based upon the context for
    which they were developed

   More than one are used in AFS programs

   All have a common underlying set of concepts




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                                                                                System Safety and Risk Management
               Module 1    Module 2       Module 3         Module 4       Module 5      Module 6

                Outline    Fundamentals      Definitions       Concepts      Risk Factors   System Safety   Summary




Common Concepts
   What is it that I will run into, hit, trip on, etc.?
      Hazard, condition, failure, threat

   Something bad can happen to us
      Undesired event, mishap, consequence

   How likely is it to happen?
      Likelihood, probability (impact)1

   How bad will it hurt if it does?
      Severity, impact (impact)1



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     1   Source: Product school                                                        System Safety and Risk Management
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         Outline   Fundamentals      Definitions       Concepts      Risk Factors   System Safety   Summary




AFS Accepted Definition


 Safety risk is an expression of the impact of an undesired
   event in terms of event severity and event likelihood.
                              Source: FAA Order 8040.4, Safety Risk Management - Product School




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                                                                               System Safety and Risk Management
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           Outline   Fundamentals      Definitions       Concepts      Risk Factors   System Safety   Summary




Risk Factors and Control
   Most system risk is incurred through factors involving
    severity or likelihood

   Most deal with factors increasing likelihood of a
    hazardous condition

   Risk controls typically:
      Help detect likelihood-increasing factors

      Lower the likelihood

      Eliminate the hazard


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                                                                                 System Safety and Risk Management
        Module 1   Module 2       Module 3         Module 4       Module 5      Module 6

         Outline   Fundamentals      Definitions       Concepts      Risk Factors   System Safety   Summary




Risk Factors
  Things about the inherent hazard, system design, or
  organizational performance that affect risk likelihood or
  severity.
     Task complexity
     Environmental factors
     Difficult procedures
     Poor or missing supervisory controls
     Poor Communications


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                                                                               System Safety and Risk Management
          Module 1   Module 2       Module 3         Module 4       Module 5      Module 6

           Outline   Fundamentals      Definitions       Concepts      Risk Factors   System Safety   Summary




Risk Controls (Mitigation)
   Serve to reduce likelihood or severity

   Be wary of substitution risk

   Controls must recognize human factors and culture




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                                                                                 System Safety and Risk Management
          Module 1   Module 2       Module 3         Module 4       Module 5      Module 6

           Outline   Fundamentals      Definitions       Concepts      Risk Factors   System Safety   Summary




Risk Involving Organizations
   Inherent risk
      Cause of the problem


   Design deficiencies
      Failure provide controls on the problem


   Performance Deficiency
      Failure to comply with design

      failure to the design to control risk




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                                                                                 System Safety and Risk Management
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        Outline   Fundamentals      Definitions       Concepts      Risk Factors   System Safety   Summary




Inherent Hazards and Risk
                                                                                             ?
 Environment



                                                                                   Operation



        Hazard
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                                                                              System Safety and Risk Management
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      Outline   Fundamentals      Definitions       Concepts      Risk Factors   System Safety   Summary




System Design and Risk
                                   System
    Procedures
                                                           Process Controls
    Interfaces
                                                           Process Measures
    Resources



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                                                                            System Safety and Risk Management
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           Outline   Fundamentals      Definitions       Concepts      Risk Factors   System Safety   Summary




System Performance
   Conformance/compliance
       Are we complying with the design of the system?

   Effectiveness
       Does the system accomplish its intended function (control
        the risk factors)?




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                                                                                 System Safety and Risk Management
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           Outline   Fundamentals      Definitions       Concepts      Risk Factors   System Safety   Summary




Regulations as Risk Controls
   Based upon public law (49 USC 447)

   Regulations and approved programs may be risk
    controls.

   Effectiveness is bounded by specificity of regulations,
    programs, manuals, etc.

   Proper application is essential!



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                                                                                 System Safety and Risk Management
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          Outline   Fundamentals      Definitions       Concepts      Risk Factors   System Safety   Summary




System Safety Model
   The FAA will use the System Safety Process Model as a
    basis.

   Model was adapted from Nicholas J. Bahr by AFS-900
    and ASY-300 for use by Flight Standards




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                                                                                System Safety and Risk Management
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        Outline   Fundamentals      Definitions       Concepts      Risk Factors    System Safety      Summary




System Safety Process                                                                  Risk Management

                                                         Hazard Identification:
     Define Objectives                            Identify Hazards & Consequences



    System Descriptions                                     Risk Analysis:
                                                   Analyze Hazards & Identify Risks


                                                         Risk Assessment:
                                                     Consolidate & Prioritize Risks


                                                          Decision Making:                              Modify
                                                        Develop an Action Plan                      System/Process

          System/Process Review
                                                         Validation of Control:
                                                       Results for Further Action


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                                                                              System Safety and Risk Management
                    Documentation
         Module 1   Module 2       Module 3         Module 4       Module 5      Module 6

          Outline   Fundamentals      Definitions       Concepts      Risk Factors   System Safety   Summary




System Safety Process
1 - Identify the task(s)/functions –

2 - Describe the environment –

3 - Identify the hazards –

4 - Evaluate the risk ...



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                                                                                System Safety and Risk Management
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          Outline   Fundamentals      Definitions       Concepts      Risk Factors   System Safety   Summary




System Safety Process
5 - Identify and evaluate mitigating strategies –


6 - Decide on a course of action


7 - Evaluate effectiveness of controls –




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                                                                                System Safety and Risk Management
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        Outline        Fundamentals      Definitions       Concepts      Risk Factors   System Safety   Summary




Risk Perceptions
    “Carelessness and
   overconfidence are more
  dangerous than deliberately
        accepted risk”

                     - Wilbur Wright, 1901


                        Wilbur Wright gliding, 1901
                  Photographs: Library of Congress




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                                                                                   System Safety and Risk Management
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     Outline   Fundamentals      Definitions       Concepts      Risk Factors   System Safety   Summary




Summary




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                                                                           System Safety and Risk Management
System Safety and Risk Management

Module 3
 System and
  Organizational
   Principles




                   Friday, July 22, 2011   Presented by AFS-900
Module 1       Module 2         Module 3      Module 4       Module 5        Module 6

 Outline   System         Attributes   Operator Objectives   Regulator’s Objectives     Summary




   Module 3 Outline
              What is a system?
                    Tasks, functions and environments
              System attributes
              Operator's Objectives
              Regulator’s Objectives
              Summary



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                                                                           System Safety and Risk Management
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         Outline   System      Attributes     Operator Objectives    Regulator’s Objectives     Summary




System and Organizational Principles
“Accidents Are Not Due to Lack of Knowledge, but Failure
to Use the Knowledge We Have.”
                                                              - Trevor Kletz, “What Went Wrong?”


                            July 17, 1996
                            8:31:10 PM
                            TWA Flight 800
                            Boeing 747-131, N93119
                            153rd aircraft built (1971)




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                                                                                   System Safety and Risk Management
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         Outline      System      Attributes   Operator Objectives   Regulator’s Objectives     Summary




What’s a System?
“A system is a composite of people, tools, procedures,
materials, equipment, facilities, and software operating in a
specific environment to perform a specific task or achieve a
specific purpose, support, or mission requirement.”
                   - Roland and Moriarty, System Safety Engineering and Management


Systems
   People Software that act together as a whole
                      ...a set of components

 Tools Equipment            to achieve a common goal
Procedures Facilities
        Materials                                    47
                                                                                   System Safety and Risk Management
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          Outline   System      Attributes   Operator Objectives   Regulator’s Objectives     Summary




Situation - Environment
What Are the Conditions?
   Physical environment
      Facilities

      Airports

      Weather patterns


   Operational environment
      Type of operation

      Type of equipment

      Employee demographics

      Financial factors                                                                                     48
                                                                                 System Safety and Risk Management
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          Outline   System      Attributes   Operator Objectives   Regulator’s Objectives     Summary




Situation - Tasks and Functions
What Is Being Done?
   Tasks - accomplished by humans
      Pilot tasks - Advanced Qualification Program (AQP)

      Maintenance tasks - Work cards


   Functions - organizational structures to accomplish tasks




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                                                                                 System Safety and Risk Management
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        Outline   System      Attributes   Operator Objectives   Regulator’s Objectives     Summary




System Safety Attributes

                                       Responsibility

          Interfaces
                                                                    Authority
                      System Safety
    Process             Attributes
  Measurement
                                                           Procedures

                           Controls                                                                        50
                                                                               System Safety and Risk Management
What is a Process?
A Process is a set of tasks, work-flows and information flows that
produce a desired result.
                                            Source: System Safety Course, FAA Academy




If you can't describe what you are doing as a process, you don't know
what you're doing.

                                                             W. Edward Deming
                                                      US business advisor & author
                                                                    (1900 - 1993)


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                                                    System Safety and Risk Management
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      Outline   System      Attributes   Operator Objectives   Regulator’s Objectives     Summary




System Based Process

                                                Controls




     Inputs                                       Process                                           Outputs




                                                Resources


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                                                                                                                 Responsibility
                    Outline   System      Attributes     Operator Objectives   Regulator’s Objectives     Summary
                                                                                                                                  Authority
                                                                                                               System



Jobs and Tasks
                                                                                                               Safety
                                                                                                              Attributes
                                                                                                                           Procedures




 Responsibility /              Procedures
   Authority



Function

              Job
 Input          Task          Task     Task            Task                Output




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                                                                                             System Safety and Risk Management
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                                                                                                                       Responsibility
                    Outline   System      Attributes     Operator Objectives   Regulator’s Objectives     Summary
                                                                                                          Interfaces
                                                                                                                                        Authority
                                                                                                                    System



Interfaces Between Tasks
                                                                                                                    Safety
                                                                                                                   Attributes
                                                                                                                                Procedures

                                                                                                                   Controls


 Responsibility /              Procedures                         Interfaces        Controls
   Authority



Function

              Job                                                    Job
 Input          Task          Task     Task            Task            Task     Task        Task          Task                          Output




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                                                                                             System Safety and Risk Management
               Module 1              Module 2         Module 3        Module 4       Module 5        Module 6
                                                                                                                             Responsibility
                    Outline     System          Attributes     Operator Objectives   Regulator’s Objectives     Summary
                                                                                                                Interfaces
                                                                                                                                              Authority
                                                                                                                          System



And More Tasks
                                                                                                                          Safety
                                                                                                                         Attributes
                                                                                                                                      Procedures

                                                                                                                         Controls


 Responsibility /                    Procedures                         Interfaces        Controls
   Authority



Function

              Job                                                          Job
 Input          Task            Task        Task             Task            Task     Task        Task          Task                          Output




                        Job
 Input                        Task       Task         Task          Task


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                                       Resources               Process                             System Safety and Risk Management
                                                               Controls
               Module 1              Module 2         Module 3        Module 4       Module 5        Module 6
                                                                                                                             Responsibility
                    Outline     System          Attributes     Operator Objectives   Regulator’s Objectives     Summary
                                                                                                                Interfaces
                                                                                                                                              Authority
                                                                                                                          System



Feedback and Information
                                                                                                                          Safety
                                                                                                           Process       Attributes
                                                                                                         Measurement
                                                                                                                                      Procedures

                                                                                                                         Controls


 Responsibility /                    Procedures                         Interfaces        Controls
   Authority



Function

              Job                                                          Job
 Input          Task            Task        Task             Task            Task     Task        Task          Task

                                                                                                                                              Status


                        Job
                                                                                                              Process
 Input                        Task       Task         Task          Task                                      Measures



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                                       Resources               Process                             System Safety and Risk Management
                                                               Controls
               Module 1              Module 2         Module 3        Module 4       Module 5        Module 6
                                                                                                                             Responsibility
                    Outline     System          Attributes     Operator Objectives   Regulator’s Objectives     Summary
                                                                                                                Interfaces
                                                                                                                                              Authority
                                                                                                                          System



Completed Function
                                                                                                                          Safety
                                                                                                           Process       Attributes
                                                                                                         Measurement
                                                                                                                                      Procedures

                                                                                                                         Controls


 Responsibility /                    Procedures                         Interfaces        Controls
   Authority



Function

              Job                                                          Job
 Input          Task            Task        Task             Task            Task     Task        Task          Task                          Output

                                                                                                                                              Status


                        Job
                                                                                                              Process
 Input                        Task       Task         Task          Task                                      Measures



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                                       Resources               Process                             System Safety and Risk Management
                                                               Controls
         Module 1    Module 2         Module 3      Module 4       Module 5        Module 6

          Outline   System      Attributes   Operator Objectives   Regulator’s Objectives     Summary




Operator’s Objectives
   What regulatory requirements are trying to achieve

   Designing systems that ensure regulatory compliance
    and safety




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                 Outline   System      Attributes        Operator Objectives   Regulator’s Objectives     Summary




Organizational Decision Factors
                                             Delicate
                                               and
    Outcome relatively                           Complex Balance
        uncertain                                                                      Outcome relatively certain
  Measured by absence of                                                               Measured in positive terms
      negative events                                    Resources
                                                    •   Available Money
                                                    •   Equipment
                                                    •   Personnel/Expertise
                                                    •   Available Time


             Safety                                                                                     Production
             Goals                                      Decision Makers                                   Goals



Protection                                               Defensive                                                   Production
                                                          Filters

                                                                                                                                  59
                                                                                             System Safety and Risk Management
         Module 1    Module 2         Module 3      Module 4       Module 5        Module 6

          Outline   System      Attributes   Operator Objectives   Regulator’s Objectives     Summary




Regulator’s Objectives
   Understand what the system is designed to do
   Assure the operator’s are complying with applicable
    regulations
   Assure that operator’s follow it’s approved or accepted
    programs




                                                                                                             60
                                                                                 System Safety and Risk Management
          Module 1    Module 2         Module 3      Module 4       Module 5        Module 6

           Outline   System      Attributes   Operator Objectives   Regulator’s Objectives     Summary




System Safety Philosophy
System safety is:

   Validation of regulatory compliance

   Review and validation of systems and entire programs,
    not portions

   Application safety attributes

   Application of risk management


                                                                                                              61
                                                                                  System Safety and Risk Management
         Module 1    Module 2         Module 3      Module 4       Module 5        Module 6

          Outline   System      Attributes   Operator Objectives   Regulator’s Objectives     Summary




Summary
   Importance of system design

   Delicate balance within an organization

   Understanding the objectives

   The problems are usually related to human error




                                                                                                             62
                                                                                 System Safety and Risk Management
System Safety and Risk Management

Module 4
 Human Factors




                 Friday, July 22, 2011   Presented by AFS-900
Module 1       Module 2   Module 3      Module 4      Module 5        Module 6

 Outline   Human Error    Understand Causes    Assessing Organizational Health   Inspections   Summary




   Module 4 Outline
              Human Performance
              Human Error
              Understand Causes
              Summary




                                                                                                     64
                                                                     System Safety and Risk Management
Human Performance
 Basic  motor reflexes
 Skill-based performance

 Rule-based performance

 Knowledge-based performance




                                                       65
                           System Safety and Risk Management
Human Factors in the Decision Process
   Information processing
   Situation awareness
   Cognitive (Mental) workload
   CRM (Cognitive Resource Management)




                                          System Safety and Risk Management
Situation Awareness
  Situation awareness is the perception of the elements in
  the environment within a volume of time and space, the
  comprehension of their meaning and the projection of
  their status in the near future.
                          -Mica Endsley, 1993




                                                                            67
                                                System Safety and Risk Management
Human Thought Process


                   Mental Model




   Perception   Comprehension          Projection

                                   Source: Dr. Mica Endsley   68
                                  System Safety and Risk Management
Situation Awareness Errors
   Level 1 - Failure to correctly perceive the situation.
   Level 2 - Failure to comprehend the situation.
   Level 3 - Failure to comprehend the situation into the
    future.




                                                                           69
                                               System Safety and Risk Management
Situation Awareness Analysis
   ASRS data.
   169 errors in 113 incidents.
      80.2% Level 1 Errors

      16.9% Level 2 Errors

      2.9% Level 3 Errors




                                                               70
                                   System Safety and Risk Management
Cognitive (Mental) Workload
   Human working memory is limited
   The magic 7 plus or minus 2 (Miller, 1956)
   Fatigue can reduce this
   Interruptions can “bump” material in working memory
   Information needed for a typical instrument approach can
    exceed the capacity available




                                             System Safety and Risk Management
Fatigue and Workload
   Activities late in flight have high workload
   Capacity is diminished by fatigue
   High accident potential (Boeing studies)




                                                   System Safety and Risk Management
         Module 1    Module 2     Module 3      Module 4       Module 5       Module 6

          Outline   Human Error   Understand Causes    Assessing Organizational Health      Inspections   Summary




Human Error
   Most accidents are human related

   Accident Rates                                                                       Human Error
      1977

      1992
                                                           Mechanical/Environmental
                                                                   Factors
   2002 - What can we do?


                                                                                                                73
                                                                             System Safety and Risk Management
Human Error
   Error is ubiquitous - it’s a human thing.
   Most accidents are human related.
   Rules and attention to detail are essential in a systematic
    approach to safety, but...
   Regulations and exhortations often have limited
    effectiveness in error prevention.
   “Be careful” only works so far.




                                                System Safety and Risk Management
Human Error
   Slips/lapses are most often associated with
    psychomotor or automatic skills.
       Skill or “action”-type problems most often responsible
        for frequent, low-severity events.
   Mistakes are often associated with cognitive tasks
    such as decision-making.
       Decision-type problems more often responsible for high-
        severity events (fatal accidents).
   Many inadvertent rule “violations” are really decision
    or knowledge problems.

                                                  System Safety and Risk Management
New Zealand GA Study
   200 GA accidents analyzed
   Decision errors:
      31% of minor/non-injury accidents

      63% of fatal accidents

   Action (skill) errors:
      48% of non-injury accidents

      16% of fatal accidents




                                                                       76
                                           System Safety and Risk Management
Error Mitigation
   Skill-based errors

   Rule-based errors

   Knowledge-based




                                                     77
                         System Safety and Risk Management
         Module 1    Module 2     Module 3      Module 4      Module 5        Module 6

          Outline   Human Error   Understand Causes    Assessing Organizational Health   Inspections   Summary




Understand Causes
   Active Failures

   Latent Failures

   Air Ontario - Dryden
      Pilot Error

      Organizational Failures




                                                                                                             78
                                                                             System Safety and Risk Management
         Module 1    Module 2     Module 3      Module 4      Module 5        Module 6

          Outline   Human Error   Understand Causes    Assessing Organizational Health   Inspections   Summary




Latent Failures
   Operational Personnel

   Diminishing Returns

   Redirect Safety Efforts

   Judging Safety Health




                                                                                                             79
                                                                             System Safety and Risk Management
             Module 1       Module 2      Module 3      Module 4      Module 5        Module 6

              Outline     Human Error     Understand Causes    Assessing Organizational Health   Inspections   Summary




James Reason Model
Organization                 Workplace                People/Team
                                                                                      Controls
 Organizational             Local                       Active
 Factors                    Factors                     Failures
                                                                                                           Outcome
 • Communication            • Physical                  • Performance
 • Management                 Environment               • Errors
   Structure                • Operational                   - Mistakes                                  Accidents
 • Goals                      Environment                   - Slips
 • Policy &                 • Task Design                   - Lapses
   Procedure                                            • Violations

                        Active Error Path


                        Latent Error Path
                        Source: The organizational connections to hurt                                               80
                        bodies and bent metal, by: Dr. James Reason                  System Safety and Risk Management
             Module 1       Module 2      Module 3      Module 4      Module 5        Module 6

              Outline     Human Error     Understand Causes    Assessing Organizational Health   Inspections   Summary




James Reason Model
Organization                 Workplace                People/Team
                                                                                      Controls
 Organizational             Local                       Active
 Factors                    Factors                     Failures
                                                                                                           Outcome
 • Communication            • Physical                  • Performance
 • Management                 Environment               • Errors
   Structure                • Operational                   - Mistakes                                  Accidents
 • Goals                      Environment                   - Slips
 • Policy &                 • Task Design                   - Lapses
   Procedure                                            • Violations

                        Active Error Path


                        Latent Error Path
                        Source: The organizational connections to hurt                                               81
                        bodies and bent metal, by: Dr. James Reason                  System Safety and Risk Management
             Module 1       Module 2      Module 3      Module 4      Module 5        Module 6

              Outline     Human Error     Understand Causes    Assessing Organizational Health   Inspections   Summary




James Reason Model
Organization                 Workplace                People/Team
                                                                                      Controls
 Organizational             Local                       Active
 Factors                    Factors                     Failures
                                                                                                           Outcome
 • Communication            • Physical                  • Performance
 • Management                 Environment               • Errors
   Structure                • Operational                   - Mistakes                                  Accidents
 • Goals                      Environment                   - Slips
 • Policy &                 • Task Design                   - Lapses
   Procedure                                            • Violations

                        Active Error Path


                        Latent Error Path
                        Source: The organizational connections to hurt                                               82
                        bodies and bent metal, by: Dr. James Reason                  System Safety and Risk Management
Individual Differences - Attitudes
   Antiauthority (don’t tell me!).
   Impulsivity (do something quickly!).
   Invulnerability (it won’t happen to me).
   Macho (I can do it).
   Resignation (what’s the use?).




                                                                     83
                                         System Safety and Risk Management
Individual Differences – Personality (“Big 5”)
 Openness   to experience
 Conscientiousness

 Extraversion/Introversion

 Agreeableness

 Neuroticism (emotional stability)




                                                            84
                                System Safety and Risk Management
Group Differences - Culture
 Uncertainty Avoidance
 Masculinity/Femininity

 Individualism/Collectivism

 Power Distance

 Short/Long-Term Orientation




                                                            85
                                System Safety and Risk Management
          Module 1    Module 2     Module 3      Module 4      Module 5        Module 6

           Outline   Human Error   Understand Causes    Assessing Organizational Health   Inspections   Summary




Managing Human Factors
   Safety Culture

   Incident Investigation

   Feedback

   Increase Tolerance

   Limit Error Potential

   Closed Loop

                                                                                                              86
                                                                              System Safety and Risk Management
         Module 1       Module 2     Module 3      Module 4      Module 5        Module 6

             Outline   Human Error   Understand Causes    Assessing Organizational Health   Inspections   Summary




Organizational Response
   Denial

   Repair

   Reform




                                                                                                                87
                                                                                System Safety and Risk Management
         Module 1    Module 2     Module 3      Module 4      Module 5        Module 6

          Outline   Human Error   Understand Causes    Assessing Organizational Health   Inspections   Summary




Addressing Human Factors
   Humans Will Make Mistakes

   Controls
      Increase Tolerance

      Lessen Potential



“Using the checklist is statistically safer than thinking.”
                                                                  - British Airways Check Airman




                                                                                                             88
                                                                             System Safety and Risk Management
         Module 1    Module 2     Module 3      Module 4      Module 5        Module 6

          Outline   Human Error   Understand Causes    Assessing Organizational Health   Inspections   Summary




Summary
   Why Study Human Factors

   Active and Latent Failures

   Errors and Violations

   Controls

   Managing Human Factors



                                                                                                             89
                                                                             System Safety and Risk Management
System Safety and Risk Management

Module 5
 Data and Analysis




                     Friday, July 22, 2011   Presented by AFS-900
Module 1       Module 2     Module 3     Module 4       Module 5      Module 6

 Outline   Decision-Making Hierarchy   Question     Analysis   Data     Contribution of Data   Summary




   Module 5 Outline
              Decision-Making Hierarchy
              Question
              Analysis
              Data
              Contribution of Data to System Safety
              Summary



                                                                                                         91
                                                                      System Safety and Risk Management
      Module 1    Module 2        Module 3     Module 4       Module 5      Module 6

       Outline   Decision-Making Hierarchy   Question     Analysis   Data     Contribution of Data   Summary




Decision-Making Hierarchy

                                        Action
                                      Decision
                                   Knowledge
                                   Information
                                         Data
                                  Observation

                                                                                                               92
                                                                            System Safety and Risk Management
           Module 1    Module 2        Module 3     Module 4       Module 5      Module 6

            Outline   Decision-Making Hierarchy   Question     Analysis   Data    Contribution of Data   Summary




Biases
   Humans tend to use simple “rules of thumb” called
    heuristics.
   These heuristics simplify mental processes but they can
    also lead to over simplification and error. Typical biases
    include:
      Representativeness heuristic

      Salience - most attention-getting rather than most useful

      Availability heuristic - recency

      Confirmation bias - tendency to focus on initial
        hypothesis
      “As if” weighting (all info assumed of same quality)
                                                                               93
      Conservatism                               System Safety and Risk Management
      Module 1    Module 2        Module 3     Module 4       Module 5      Module 6

       Outline   Decision-Making Hierarchy   Question     Analysis   Data     Contribution of Data   Summary




Decision-Making Hierarchy

                                        Action                              Question/Problem
                                      Decision
                                   Knowledge
                                                                                    Analysis
                                   Information
                                         Data
                                                                                                 Data
                                  Observation

                                                                                                               94
                                                                            System Safety and Risk Management
         Module 1    Module 2        Module 3      Module 4       Module 5      Module 6

          Outline   Decision-Making Hierarchy    Question     Analysis   Data     Contribution of Data   Summary




Counteracting Biases
                                            Question
                                                 Clear
Bias can be reduced                             Empirical
through the careful                             Question
    use of data
            Data                                                                 Analysis
            Good                                                                  Appropriate
           Quality                                                                  Data
            Data                                                                   Analysis

                                                                                                                   95
                                                                                System Safety and Risk Management
         Module 1    Module 2        Module 3     Module 4       Module 5      Module 6

          Outline   Decision-Making Hierarchy   Question     Analysis   Data     Contribution of Data   Summary




                                         Question
   Problem Definition - What do we want to know?
      System definition and analysis

      Description of the situation

      Risk or Problem statement

      Operational definitions are important




                                                                                                                  96
                                                                               System Safety and Risk Management
          Module 1    Module 2        Module 3     Module 4       Module 5      Module 6

           Outline   Decision-Making Hierarchy   Question     Analysis   Data     Contribution of Data   Summary




                                          Analysis
   Types of information
       Records
       Inferences
       Judgments
   Important to separate reports (facts) from inferences and
    judgments
   Recording only judgments or conclusions will usually
    decrease data reliability
   Data must fit:
       Analysis needs
       Nature of observation
       Observation situation                                                                                      97
                                                                                System Safety and Risk Management
         Module 1    Module 2        Module 3     Module 4       Module 5      Module 6

          Outline   Decision-Making Hierarchy   Question     Analysis   Data     Contribution of Data   Summary




                                         Analysis
Aggregation
   Cannot create system level analyses by “rolling up”
    unrelated data

   Result will depend more on mix of data than
    performance of any element

   Trends are especially sensitive

   Can’t mix apples and oranges and compare fruit baskets

                                                                                                                  98
                                                                               System Safety and Risk Management
          Module 1    Module 2        Module 3     Module 4       Module 5      Module 6

           Outline   Decision-Making Hierarchy   Question     Analysis   Data     Contribution of Data   Summary




                                          Analysis
Comparisons
   Many comparisons are legitimate:
       Norms / thresholds
       Association with factors
       Comparisons between subgroups (e.g. location, aircraft fleet)
       Trends

   Comparisons should be avoided in uses to
    “rate” offices or people

                                                                                                                   99
                                                                                System Safety and Risk Management
         Module 1    Module 2        Module 3     Module 4       Module 5      Module 6

          Outline   Decision-Making Hierarchy   Question     Analysis   Data     Contribution of Data   Summary




                                         Analysis
Trend Analysis

   A special type of comparison

   Often confused with “generalization”

   Must be based upon a reliable, quantifiable metric
    at progressive time points

   Must have good internal validity

   Must have data available in
    adequate quantity, regular intervals                                                                      100
                                                                               System Safety and Risk Management
          Module 1    Module 2        Module 3       Module 4       Module 5      Module 6

           Outline   Decision-Making Hierarchy    Question      Analysis   Data     Contribution of Data   Summary




                                                 Data
Data Torturing

   Inappropriate use of data
       Inappropriate comparisons to averages, specifications,
        targets and percentages
       Smoothing
       Limited point trends
       Use of raw counts


                                                 Source: Dr. Marcey Abate, Sandia National Labs, 1998

                                                                                                                 101
                                                                                  System Safety and Risk Management
         Module 1    Module 2        Module 3     Module 4       Module 5      Module 6

          Outline   Decision-Making Hierarchy   Question     Analysis   Data     Contribution of Data   Summary




                                                Data
What is data?

   Information organized for analysis or used as a basis for
    decision making

   Factual data is not a record of conclusions, concerns, or
    opinion

   Factual data is a record of facts upon which to base
    conclusions


                                                                                                              102
                                                                               System Safety and Risk Management
          Module 1    Module 2        Module 3     Module 4       Module 5      Module 6

           Outline   Decision-Making Hierarchy   Question     Analysis   Data     Contribution of Data   Summary




                                                 Data
Automation and Data

   Good quality automation is essential to manage the
    workload of providing data, but…

   Neither automation nor analysis can add information
    which is not in the data

    “Computers do not produce new sorts of errors. They merely
    provide new and easier opportunities for making old errors.”

                                                              Source: Trevor Kletz, Wise After the Event

                                                                                                               103
                                                                                System Safety and Risk Management
          Module 1    Module 2        Module 3     Module 4       Module 5      Module 6

           Outline   Decision-Making Hierarchy   Question     Analysis   Data     Contribution of Data   Summary




                                                 Data
Sampling
   Sample data represents a larger group with data from a
    small group
   Distribution of observations is important
   Must identify factors that can effect performance
   Problems can be created in “rollups”
   Normal trends (e.g. season) may be involved
   Statistical confidence is unlikely. Confidence in what?
                                                                                                               104
                                                                                System Safety and Risk Management
          Module 1    Module 2        Module 3     Module 4       Module 5      Module 6

           Outline   Decision-Making Hierarchy   Question     Analysis   Data     Contribution of Data   Summary




                                                 Data
Text and Narratives

   Text is very flexible, however, very unreliable as as a
    data source

   Narratives are valuable adjuncts to explain observations

   Text may be coded into quantitative form using an
    appropriate taxonomy; however, this procedure is very
    time-consuming and adds another source of error

   Anecdotes may not be representative of any larger
    group                                                                                                      105
                                                                                System Safety and Risk Management
          Module 1    Module 2        Module 3     Module 4       Module 5      Module 6

           Outline   Decision-Making Hierarchy   Question     Analysis   Data     Contribution of Data   Summary




                                                 Data
Data Quality Attributes

   Validity

   Reliability

   Sensitivity

   Representativeness



                                                                                                               106
                                                                                System Safety and Risk Management
          Module 1    Module 2        Module 3     Module 4       Module 5      Module 6

           Outline   Decision-Making Hierarchy   Question     Analysis   Data     Contribution of Data   Summary




                                                 Data
Data Validity

   Validity means that the data measure what they are
    intended to measure

   Validity is weakened or reduced by:
       Vague Definitions
       Insufficient Evaluator Training
       Casual Data Collection Methods
       Operator Discretion
                                                      Source: AQP Data Management Guide, 1998

                                                                                                               107
                                                                                System Safety and Risk Management
           Module 1    Module 2        Module 3     Module 4       Module 5        Module 6

            Outline   Decision-Making Hierarchy   Question     Analysis     Data     Contribution of Data   Summary




                                                  Data
Data Reliability

   Consistency between raters

   Consistency among items

   Stability in measurements over time

   Factors effecting data reliability
        Definition of item(s) to be observed
        Standards of evaluation
                                                                          Source: AQP Data Management Guide, 1998
        Training of inspectors
        Type of measurement used                                                                                 108
                                                                                   System Safety and Risk Management
          Module 1    Module 2        Module 3     Module 4       Module 5      Module 6

           Outline   Decision-Making Hierarchy   Question     Analysis   Data     Contribution of Data   Summary




                                                 Data
Data Sensitivity
   Sensitivity means that small gradations or variations in
    the parameter being measured are reflected in some
    variation in the measurement
   Multi-point scales allow more sensitivity than pass/fail
    grading
   Using multiple items to measure individual components
    of performance and then combining them into a
    composite score or index could increase sensitivity
                                                                 Source: AQP Data Management Guide, 1998

                                                                                                               109
                                                                                System Safety and Risk Management
           Module 1    Module 2        Module 3     Module 4       Module 5      Module 6

            Outline   Decision-Making Hierarchy   Question     Analysis   Data     Contribution of Data   Summary




                                                  Data
Data Problems
 Confounding
       Confounding occurs when two different factors can explain the
        same result
       When research is confounded, it is impossible to determine what
        variable is responsible for any obtained difference in performance
       When no confounding is present, a research study is said to have
        internal validity
   Contamination
       Behavior changes as a result of evaluation process
       Observer effects
       Announced inspections
                                                                                                                110
                                                                                 System Safety and Risk Management
         Module 1    Module 2        Module 3     Module 4       Module 5      Module 6

          Outline   Decision-Making Hierarchy   Question     Analysis   Data     Contribution of Data   Summary




                                                Data
Improving Data Collection

   Develop focused factual information requirements

   Document the requirements

   Seek answers that are:
      System configuration information

      System performance information


   Data must be factual and representative

                                                                                                                  111
                                                                               System Safety and Risk Management
         Module 1    Module 2        Module 3     Module 4       Module 5      Module 6

          Outline   Decision-Making Hierarchy   Question     Analysis   Data     Contribution of Data   Summary




Contribution of Data to System Safety
   System Validation

   Hazard Identification

   Risk Analysis/Assessment




                                                                                                              112
                                                                               System Safety and Risk Management
          Module 1    Module 2        Module 3     Module 4       Module 5      Module 6

           Outline   Decision-Making Hierarchy   Question     Analysis   Data     Contribution of Data   Summary




Summary
   Collection of pertinent and quality data, and appropriate
    analysis will enhance current and future programs

   Data-driven surveillance programs will result in
    enhanced System Safety, whereby issues and hazards
    are identified early and addressed adequately




                                                                                                               113
                                                                                System Safety and Risk Management
System Safety and Risk Management

Module 6
 Risk Management




                   Friday, July 22, 2011   Presented by AFS-900
Module 1       Module 2    Module 3       Module 4            Module 5     Module 6

 Outline   System Safety Process      Practical Application         Case Study        Summary




   Module 6 Outline
              System Safety Process

              Practical Application

              Case Study

              Summary



                                                                                                     115
                                                                          System Safety and Risk Management
         Module 1    Module 2       Module 3       Module 4            Module 5     Module 6

          Outline   System Safety Process      Practical Application         Case Study        Summary




What, How, Why
   System Safety’s primary objective

   Consider the entire system

   Understanding the operator’s accident prevention
    program




                                                                                                              117
                                                                                   System Safety and Risk Management
       Module 1    Module 2       Module 3         Module 4           Module 5     Module 6

        Outline   System Safety Process       Practical Application         Case Study        Summary




System Safety Process                                                                     Risk Management

                                                           Hazard Identification:
                                                         Hazard Identification:
     Define Objectives
     Define Objectives
                                                    Identify Hazards Consequences
                                                   Identify Hazards & Consequences



    System Descriptions
    System Descriptions                                      Risk Analysis:
                                                            Risk Analysis:
                                                                    & Identify Risks
                                                    Analyze Hazards & Identify Risks
                                                    Analyze



                                                          Risk Assessment:
                                                          Risk Assessment:
                                                      Consolidate & Prioritize Risks


                                                            Decision Making:
                                                            Decision Making:                                 Modify
                                                                                                            Modify
                                                          Develop an Action Plan                        System/Process
                                                                                                        System/Process

          System/Process Review
         System/Process Review
                                                           Validation Control:
                                                          Validation of Control:
                                             Yes        Results for Further Action               No


                                                                                                                   118
                                                                                  System Safety and Risk Management
                      Documentation
     Module 1     Module 2       Module 3         Module 4       Module 5      Module 6

      Outline     Fundamentals      Definitions       Concepts      Risk Factors   System Safety    Summary




Risk Assessment Matrix
                                                                 SEVERITY

     LIKELIHOOD              Negligible               Marginal               Critical        Catastrophic

     Frequent

     Probable                                                                                      High
     Occasional                                                             Serious
     Remote                                         Medium
     Improbable                  Low



                                                                                                              124
                                                                              System Safety and Risk Management
         Outline   System Safety Process   Practical Application   Case Study   Summary



                    April 28, 1988 Near Maui, Hawaii
                    Flight 243 - Boeing 737-200 (N7371I)




                                                                                                   128
                                                                         System Safety and Risk Management
Puzzle
       Module 1    Module 2       Module 3       Module 4            Module 5     Module 6

        Outline   System Safety Process      Practical Application         Case Study        Summary




System Safety Process                                                                    Risk Management

                                                         Hazard Identification:
     Define Objectives                            Identify Hazards & Consequences



    System Descriptions                                    Risk Analysis:
                                                  Analyze Hazards & Identify Risks


                                                         Risk Assessment:
                                                     Consolidate & Prioritize Risks


                                                           Decision Making:                                Modify
                                                         Develop an Action Plan                        System/Process

          System/Process Review
                                                         Validation of Control:
                                                       Results for Further Action


                                                                                                                  129
                                                                                 System Safety and Risk Management
                      Documentation
          Module 1    Module 2       Module 3       Module 4            Module 5     Module 6

           Outline   System Safety Process      Practical Application         Case Study        Summary




Summary
   Understand...
      the System Safety Process

      how It Will Assist You in Your Job




                                                                                                              130
                                                                                    System Safety and Risk Management
    Additional Sources
   Training Available at FAA Academy in Oklahoma City
        ATOS Overview
         Course Length: 24 hours
         Course Description: This course is designed to familiarize industry
         personnel, international students, and government agencies other than FAA
         with ATOS. It will provide instruction on the ATOS access, ATOS system,
         including the tools, the policy and guidance, that make the ATOS system
         work.

        System Safety
         Course Length: 24 hours
         Course Description: The purpose of this course is to train FAA aviation
         safety inspectors on system safety and risk management processes and the
         importance of both as they relate to systems management. This will be
         accomplished by demonstrating how system safety and risk management
         are used throughout the FAA environment.This course is available to
         industry personnel based on class availability                                  131
                                                               System Safety and Risk Management
    Additional Sources
        System Safety and ATOS Overview
         Course Length: 32 hours
         Course Description: This seminar is designed to provide an introduction to
         system safety and risk management processes as they are used by the FAA
         for air carrier oversight. The seminar also familiarizes industry personnel with
         the FAA's Air Transportation Oversight System (ATOS). The four-day
         seminar is conducted on location by special arrangement with the
         sponsoring organization for up to 50 students.

        Contact: Mr. Joseph Souza 405-954-4321.

   http://www.faa.gov/avr/afs/
   Don Arendt - AFS-900 FSAIC Manager 703-661-0516

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                                                                    System Safety and Risk Management

				
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Description: Safety Data Management Summary document sample