Aviation SafetyAviation Safety An ICAO PerspectiveAn ICAO Perspective

Aviation SafetyAviation Safety An ICAO PerspectiveAn ICAO Perspective

Glenn W. HerpstGlenn W. Herpst

Chief, Flight Operations & Chief, Flight Operations & Airworthiness Section, Air Navigation Airworthiness Section, Air Navigation

BureauBureau

15 October 200415 October 2004

2

An Important Question An Important Question What is the objective of contemporary What is the objective of contemporary

safety management in aviation?safety management in aviation? Zero accidents & incidents?Zero accidents & incidents? Regulatory compliance?Regulatory compliance? Error avoidance? Error avoidance?

Increasing the Increasing the resistance resistance of of organizations to the organizations to the risks risks inherent to the inherent to the accomplishment of their accomplishment of their production goalsproduction goals

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The Dilemma of Civil AviationThe Dilemma of Civil Aviation

PProductionroduction

PPro

tecti

oro

tecti

onn

BankruptcyBankruptcy

CatastropheCatastropheComfort z

one

Comfort zone

4

Navigating the Safety SpaceNavigating the Safety Space

Increasing vulnerabilityIncreasing vulnerabilityIncreasing resistanceIncreasing resistance

DriversDrivers

CommitmenCommitmentt

CompetencCompetencee

TargetTarget zonezone

Navigational aidsNavigational aids

ReactiveReactive::outcomeoutcomemeasuremeasuress

Proactive:Proactive:processprocess

measuresmeasures

organizationorganization

5

Safety ManagementSafety Management Traditional ApproachTraditional Approach Focus on proximate cause...(often unsafe Focus on proximate cause...(often unsafe

acts by operator)acts by operator) Attach blame for failure to assess risksAttach blame for failure to assess risks Traditional safety management uncovers:Traditional safety management uncovers:

Traditional safety Traditional safety management seldom management seldom uncovers:uncovers:

WHAT? WHEN? WHO?

WHY? HOW?

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Safety Management-Changing Safety Management-Changing

FocusFocus

1950s1950s 1970s1970s 1990s1990s

PR

ES

EN

TP

RE

SE

NTTECHNICAL FACTORSTECHNICAL FACTORS

HUMAN FACTORSHUMAN FACTORS

ORGANIZATIONALORGANIZATIONAL FACTORSFACTORS

A Systemic PerspectiveA Systemic Perspective

ManagemeManagementnt

DecisionsDecisions

OrganizatioOrganizatio

nalnalProcessesProcesses

OrganizationOrganization Workplace Workplace

WorkingWorkingconditioconditio

nsns

ErrorsErrors &&

ViolationsViolations

PeoplePeople DefensesDefenses Accident

Latent conditions Latent conditions trajectorytrajectory

The Strongest FoundationsThe Strongest Foundations

OrganizationOrganizationWorkplaceWorkplace

PeoplePeople

OPERATIONSOPERATIONS

MAINTENANCEMAINTENANCE

MANAGEMENTMANAGEMENT

INCREASED RISK POTENTIALINCREASED RISK POTENTIAL

DefensesDefenses

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Organizational ProcessesOrganizational Processes

Adequate regulations, procedures and Adequate regulations, procedures and guidance materialguidance materialAn appropriate safety management systemAn appropriate safety management systemEffective and efficient policy-making systemEffective and efficient policy-making systemEffective implementation of SARPsEffective implementation of SARPsAllocation of adequate resourcesAllocation of adequate resourcesAdequate lines of communicationAdequate lines of communicationEffective planning, certification, supervision Effective planning, certification, supervision and control of all aviation activitiesand control of all aviation activitiesAdequate enforcement policyAdequate enforcement policyAdequate internal auditing systemAdequate internal auditing system

SafetySafetydefencesdefences

CriticalCritical SafetySafety

DefencesDefences

PrimaryPrimarylegislation

legislation Operating

Operating

regulationsregulations

Stru

ctur

e/or

gani

zatio

n

Qualified

Technical

PersonnelTechnical guidance

Licensing/

Licensing/

certification

certification

Resolution

of safety

concerns

Cont

inui

ngsu

rvei

llanc

e

Organizational Processes Organizational Processes

SafetySafetydefencesdefences

LatentLatentconditionsconditions

No effective laws, policy, No effective laws, policy, procedures and guidance procedures and guidance

No clearly established safety No clearly established safety requirementesrequirementes

No implementation ofNo implementation of SARPS SARPS No programmes to certify, inspect No programmes to certify, inspect

and surveille the industryand surveille the industry No training policy and programmes No training policy and programmes Mushrooming of self-regulating Mushrooming of self-regulating

organizationsorganizations No identification of safety concernsNo identification of safety concerns No resolution of safety issuesNo resolution of safety issues

Organizational ProcessesOrganizational Processes

Breaches in safety defences harbour latent conditionsBreaches in safety defences harbour latent conditions

WorkplaceWorkplaceconditionsconditions

Organizational Processes Organizational Processes

- - Job stabilityJob stability- Low staff turn-over- Low staff turn-over

- Adequate support equipment,- Adequate support equipment,facilities and guidancefacilities and guidance- Current qualifications- Current qualifications

- Proper experience- Proper experience- High employee morale- High employee morale

- Credibility and trust- Credibility and trust

- - Job stabilityJob stability- Low staff turn-over- Low staff turn-over

- Adequate support equipment,- Adequate support equipment,facilities and guidancefacilities and guidance- Current qualifications- Current qualifications

- Proper experience- Proper experience- High employee morale- High employee morale

- Credibility and trust- Credibility and trust

Improper use of procedures and Improper use of procedures and documentsdocuments

Deviations from procedures and Deviations from procedures and standards standards

Inability to identify safety situations Inability to identify safety situations and take remedial action and take remedial action

Inability to follow guidance Inability to follow guidance materialsmaterials

““Cutting corners”Cutting corners” Errors and violationsErrors and violations

WorkplaceWorkplaceconditionsconditions

ActiveActivefailuresfailures

Adverse workplace conditions result in active failures

Adverse workplace conditions result in active failures

Organizational Processes Organizational Processes

SafetySafetydefencesdefences

WorkplaceWorkplaceconditionsconditions

LatentLatentconditionsconditions

ActiveActivefailuresfailures

Organizational ProcessesOrganizational Processes

REINFORCEREINFORCE ENHANCEENHANCE

IDENTIFIFY

IDENTIFIFY AVERT

AVERT

AUDITAUDIT

Waiting for Bad Outcomes Waiting for Bad Outcomes

Design & manufactureDesign & manufacture

Management & supervisionManagement & supervision

Training & maintenanceTraining & maintenance

OperationalOperationalpersonnelpersonnel

Stakeholders Stakeholders

Looking into the SystemLooking into the System

Design & manufactureDesign & manufacture

Management & supervisionManagement & supervision

Training & maintenanceTraining & maintenance

Stakeholders Stakeholders

OperationalOperationalpersonnelpersonnel

Safety Management: A Vision Safety Management: A Vision

Aviation cannot be entirely specifiedAviation cannot be entirely specified Humans will inevitably make errorsHumans will inevitably make errors Basic normative framework Basic normative framework Implementation of the frameworkImplementation of the framework Deviation managementDeviation management

Danger: loss of control of the Danger: loss of control of the deviation management process deviation management process rather that deviations rather that deviations themselvesthemselves

Dr. Assad KotaiteDr. Assad KotaiteInternational Civil Aviation Day, 7 December 1999International Civil Aviation Day, 7 December 1999