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Evolving Approaches to Managing Safety and Investigating Accidents

Kathy Fox, Member

Transportation Safety Board of Canada

Canadian Women in Aviation ConferenceMontreal, QCJune 17, 2011

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Presentation Outline

• Practicing Safety

• Accident causation and prevention

• Safety Management Systems (SMS)

• Role of the Transportation Safety Board (TSB)

• Conclusion

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Early Thoughts on Safety

Follow standard operating procedures +

Pay attention to what you’re doing +

Don’t make mistakes or break rules +

No equipment failure =

Things are safe

Safety ≠ Zero Risk

But why not?

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Balancing Competing Priorities

ServiceSafety

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Reason’s Model

D e f en c e s

A c tiv it ie sP r o du c t iv e

U n s a fe A c t s

O c c u rr e n c e

O c c ur re n c e O p po r tu n it y

L ine M a na g e m e ntD e fi c ie n c i e s

L a te n t U ns a fe C o n d it io n s

P r e co n d it io n s

A c tiv e F ai lu r e s &

A c tiv e F ai lu r e s

L im it ed W in d o w o f

P r e c u r s o r s o f U n s a feA c t s

P s y c h o l o g ic a l

In ad eq u ate

L a te n t U ns a fe C o n d it io n s

L a te n t U ns a fe C o n d it io n s

L a te n t U ns a fe C o n d it io n s

M ak e rsD e c is io n -

F a l l ib l e D e c is i o n s

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Sidney DekkerUnderstanding Human Error

• People do their best to reconcile different goals simultaneously.

• A system isn’t automatically safe.

• Production pressures influence trade-offs.

______Dekker, S. (2006) The Field Guide to Understanding Human Error, Ashgate Publishing Ltd.

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Sidney DekkerUnderstanding Human Error (cont.)

______Dekker, S. (2006) The Field Guide to Understanding Human Error, Ashgate Publishing Ltd.

Why Focus on Management?

Management decisions

– have a wider sphere of influence on operations

– have a longer term effect

– create the operating environment

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Safety Management Systems (SMS)

Integrating safety into an organization’s daily operations.

“A systematic, explicit and comprehensive process for managing safety risks … it becomes part of that organization’s culture, and the way people go about their work.”

- James Reason, 2001

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Safety Management Systems (SMS) (cont’d)

SMS requirements - Transport Canada

Accountable executive

Corporate safety policy and measurable safety goals

Identifying hazards and managing risks

Ensuring personnel are trained and competent

Internal hazard, incident and accident reporting and analysis

Documenting SMS

Periodic SMS audits

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Key Elements of SMS

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SMS: Hazard identification

Organizations must proactively identify hazards and seek ways to reduce or eliminate risks.

Challenges:

• Very difficult to predict all possible interactions between seemingly unrelated systems – complex interactions. 1

_________

1 Perrow, C (1999) Normal Accidents, Princeton University Press

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SMS: Hazard identification (cont’d)

Challenges (cont’d):

• Inadequate risk assessment of operational changes – drift into failure, inability to think of ALL possibilities. 1,2

• Deviations from procedure become the norm. 3

_________

1 Dekker, S (2005) Ten Questions About Human Error, Lawrence Erlbaum Associates2, 3 Vaughan, D. (1996) The Challenger Launch Decision, University of Chicago Press

Alaska Airlines Flight 261Loss of Control and Impact with Pacific Ocean

(January 2000)

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From NTSB report AAR0201

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MK AirlinesReduced Power on Takeoff and Collision With Terrain

Halifax, NS (October 2004)

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Organizational Drift/ Employee Adaptations

• Difficult to detect from inside an organization.

• Front line workers create “locally efficient practices” to get job done.

• Past successes taken as guarantee of future safety.

• Were risks properly assessed?

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Touchdown Short of RunwayFox Harbour, NS (November 2007)

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Aircraft Attitude at Threshold

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SMS: Incident Reporting

Challenges:

• Determining which incidents are reportable.

• Analyzing ‘near miss’ incidents to seek opportunities to make improvements to system.

• Shortcomings in companies’ analysis capabilities.

Weak Signals

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Transwest Air, Collision with TerrainSandy Bay, SK (January 2007)

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SMS: Incident Reporting (cont’d)

Challenges (cont’d):

• Performance based on error trends misleading: no errors or incidents does not mean no risks.

• Voluntary vs. mandatory, confidential vs. anonymous.

• Punitive vs. non-punitive systems.1

• Who receives incident reports.

_________

1 Dekker, S. & Laursen, T. (2007) From Punitive Action to Confidential Reporting Patient Safety and Quality Healthcare September/October 2007

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SMS: Organizational Culture

• SMS is only as effective as the organizational culture that enshrines it.

• Work groups create norms, beliefs and procedures unique to their particular task, thus becoming the work group culture. 1

• Undesirable characteristics may develop within organization. 2

_________1 Vaughan, D (1996), The Challenger Launch Decision, University of Chicago Press2 Columbia Accident Investigation Report, Vol. 1, August 2003

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SMS: AccountabilityRecent trend: criminalizing human error

Consequences:

- Organizations become defensive.- Safety-critical information not shared for fear of

reprisals.

As such, safety suffers.

________Dekker, S (2007) Just Culture, Ashgate Publishing Ltd.

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Elements of a “Just Culture”(Dekker 2007)

• Encourages openness, compliance, fostering safer practices, critical self-evaluation.

• Willingly shares information without fear of reprisal.

• Protects those who report their honest errors from blame.

• Avoids hindsight bias. Tries to see why people’s actions made sense to them at the time.

• Recognizes there is no fixed line between culpable and blameless error.___________Dekker, S (2007) Just Culture, Ashgate Publishing Ltd.

SMS: Benefits and pitfalls

• Nothing will always guarantee that all hazards will be found, analyzed and eliminated.

• However, SMS is a benefit where it’s implemented.

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About the TSB

• Independent organization investigating marine, pipeline, rail and air occurrences.

• Finds out what happened and why.

• Makes recommendations to address safety deficiencies.

• Does not assign fault or determine civil or criminal liability.

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About the TSB (cont’d)

• Reason’s Model adopted in early 90s.– Multi-causality.– Human error within broader organizational context.

• Integrated Safety Investigation Methodology (ISIM)

– Determining if full investigations are warranted based on potential to advance safety.

– Use of various human and organizational factors frameworks. (Westrum, Snook, Vaughan, Dekker)

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Summary

• Adverse outcomes result from complex interactions of factors difficult to predict.

• People at all levels in an organization create safety.

• ‘Near-misses’ must be viewed as “free opportunities” for organizational learning.1

________1 Dekker, S. & Laursen, T. (2007) From Punitive Action to

Confidential Reporting Patient Safety and Quality Healthcare September/October 2007

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Summary (cont’d)

• Accident investigators must focus on what made sense at the time, not be judgmental, avoid hindsight bias2

• Accountability requires organizations and professionals to take full responsibility to fix problems3, 4

________2 Dekker, S. (2006) The Field Guide to Understanding Human

Error Ashgate Publishing Ltd.3 Sharpe, V.A. (2004) Accountability Patient Safety and Policy

Reform Georgetown University Press4 Dekker, S. (2007) Just Culture Ashgate Publishing Ltd.

References• Slide 7, 8, 30: Dekker, S. (2006) The Field Guide to Understanding Human

Error, Ashgate Publishing Ltd.• Slide 10: Reason, J. (2001) In Search of Resilience, Flight Safety Australia,

September-October, 25-28.

• Slide 13: Perrow, C (1999) Normal Accidents, Princeton University Press.

• Slide 14: Dekker, S (2005) Ten Questions About Human Error, Lawrence Erlbaum Associates.

• Slide 14, 23: Vaughan, D. (1996) The Challenger Launch Decision, University of Chicago Press.

• Slide 22, 29: Dekker, S. & Laursen, T. (2007) From Punitive Action to Confidential Reporting Patient Safety and Quality Healthcare September/October 2007.

• Slide 23: Columbia Accident Investigation Report, Vol. 1, August 2003.

• Slide 24, 25, 30: Dekker, S (2007) Just Culture, Ashgate Publishing Ltd.

• Slide 30: 3 Sharpe, V.A. (2004) Accountability Patient Safety and Policy Reform Georgetown University Press.

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