human factors and safety management: the role of the regulator€¦ · human factors and safety...
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Human Factors andHuman Factors andSafety Management:Safety Management:
The Role of the RegulatorThe Role of the Regulator
Captain Dan Captain Dan MaurinoMaurinoFlight Safety and Human Factors - ICAOFlight Safety and Human Factors - ICAO
14th Annual FAA/CAA/TC Human Factors14th Annual FAA/CAA/TC Human Factorsin Aviation Maintenance Symposiumin Aviation Maintenance Symposium
Vancouver, BCVancouver, BC28-30 March 200028-30 March 2000
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Raising the flight levelRaising the flight level
“To remain successful, we must“To remain successful, we mustchallenge the status quochallenge the status quo, refine existing, refine existingpractices, practices, adopt new best practicesadopt new best practices,,focus on where we want to be in thefocus on where we want to be in thenext five years and next five years and what strategieswhat strategies we weneed to embrace to get there”need to embrace to get there”
Art Art LaFlammeLaFlammeDirector General, Civil Aviation Director General, Civil Aviation Transport CanadaTransport Canada
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Two Fundamental StrategiesTwo Fundamental Strategies
ll Countermeasures to Countermeasures to operationaloperational errors errorsêêhuman error human error does notdoes not cause cause
accidentsaccidents
ll Risk and Risk and deviation deviation managementmanagement
êê“more of the same” will not be“more of the same” will not beenoughenough
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Operational Operational BehavioursBehaviours
safetysafety productionproduction
A balance A balance compromisecompromise
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Training Training BehavioursBehaviours
safetysafety productionproduction
Going “by the book”Going “by the book”
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Errors & Accidents\IncidentsErrors & Accidents\Incidents
CausesCauses and andconsequencesconsequences
have nohave nosymmetry insymmetry in
theirtheirmagnitudemagnitude
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Understanding Operational ErrorsUnderstanding Operational Errors
errorerror
deviationdeviation
amplification of the deviationamplification of the deviation
system degradation/breakdownsystem degradation/breakdown
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Errors Errors as as They They Relate to Relate to SafetySafety
FlapsFlapsomittedomitted
Error Error DeviationDeviation AmplificationAmplification
ChecklistChecklistcompletecomplete
WarningWarning
Normal Normal operationoperation
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Errors Errors as as They They Relate to Relate to SafetySafety
Error Error DeviationDeviation AmplificationAmplification Degradation/Degradation/breakdownbreakdown
Flaps Flaps omittedomitted
ChecklistChecklistomittedomitted
No Nowarningwarning
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The Data on Error We Collect The Data on Error We CollectThe Data on Error We Collect
Design & manufactureDesign & manufacture
Management & supervisionManagement & supervision
Training & maintenanceTraining & maintenance
StakeholdersStakeholders
OperationalOperationalpersonnelpersonnel
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The Data on Error We Must CollectThe Data on Error We Must CollectThe Data on Error We Must Collect
OperationalOperationalpersonnelpersonnel
Design & manufactureDesign & manufacture
Training & maintenanceTraining & maintenance
Stakeholders Stakeholders
Management & supervisionManagement & supervision
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Line Operations Safety Audit (LOSA)Line Operations Safety Audit (LOSA)((500 segments, four large carriers)500 segments, four large carriers)
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SegmentsSegments with 1 errorwith 1 error
Segments with 2 errorsSegments with 2 errors
Segments with 3 errorsSegments with 3 errors
SegmentsSegments with 4 errorswith 4 errors
SegmentsSegments with 5 or more errorswith 5 or more errors
Segments with observed errors -- Segments with observed errors -- 74%74%
24%24%
20%20%
10%10%
8%8%
12%12%
AverageAverage number of errors per flight -- number of errors per flight -- 2.02.0Automation-related errors --Automation-related errors -- 31% 31%
Line Operations Safety Audit (LOSA)Line Operations Safety Audit (LOSA)((500 segments, four large carriers)500 segments, four large carriers)
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Operational Errors and SafetyOperational Errors and Safety
% of all errors% of all errors
Without consequencesWithout consequences 85%85%Undesired stateUndesired state 12%12%
Outcome typeOutcome type
Additional errorAdditional error 3%3%
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Why Monitor Normal OperationsWhy Monitor Normal Operations
ll Operational personnel develop errorOperational personnel develop errormanagement skillsmanagement skills
ll Understand these skills to supportUnderstand these skills to support
êêdesigndesign
êêtrainingtrainingêêproceduresprocedures
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Why Monitor Normal Operations Why Monitor Normal Operations
The “big picture” of operational errorsThe “big picture” of operational errorsis poorly understoodis poorly understood
ll We We don’t needdon’t needêêmore accident/incident reportsmore accident/incident reportsêêmore edicts/motivational postersmore edicts/motivational posters
ll We We needneedêêdata on error(s) within the context ofdata on error(s) within the context of
specific operational environmentsspecific operational environments
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The Problem: Our CultureThe Problem: Our CultureêêConfidentialConfidential reporting systems reporting systemsêêSevere protections to FOQA/QARSevere protections to FOQA/QARêêPresidential protection to ASAPPresidential protection to ASAPêêSuspensions/revocations/sackingSuspensions/revocations/sackingêêRemedial trainingRemedial trainingêêAccident investigationAccident investigationêêMedia (Media (CVR on NBCCVR on NBC))êêCriminal liabilityCriminal liabilityêêICAO Safety Oversight AssessmentICAO Safety Oversight Assessment
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A Safety Culture?A Safety Culture?
What would happen if we removeWhat would happen if we removeregulation?regulation?
êêUtopian idealsUtopian ideals
êêHopes of safe and efficient individualHopes of safe and efficient individualand system behavioursand system behaviours
ååA clear role for the RegulatorA clear role for the Regulator
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More of the Same will not Be Enough M More of the Same will not Be Enoughore of the Same will not Be Enough
improve humanimprove humanperformance?performance?
improve theimprove theprocessesprocessessupporting humansupporting humanperformance?performance?
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ll Aviation cannot be entirely specifiedAviation cannot be entirely specified
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ll Aviation cannot be entirely specifiedAviation cannot be entirely specifiedll Humans will inevitably make errorsHumans will inevitably make errors
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ll Aviation cannot be entirely specifiedAviation cannot be entirely specifiedll Humans will inevitably make errorsHumans will inevitably make errorsll Normative prescription (music score)Normative prescription (music score)
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ll Aviation cannot be entirely specifiedAviation cannot be entirely specifiedll Humans will inevitably make errorsHumans will inevitably make errorsll Normative prescription (music score)Normative prescription (music score)ll Real-time implementation of the scoreReal-time implementation of the score
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ll Aviation cannot be entirely specifiedAviation cannot be entirely specifiedll Humans will inevitably make errorsHumans will inevitably make errorsll Normative prescription (music score)Normative prescription (music score)ll Real-time implementation of the scoreReal-time implementation of the scorell Deviations will take placeDeviations will take place
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ll Aviation cannot be entirely specifiedAviation cannot be entirely specifiedll Humans will inevitably make errorsHumans will inevitably make errorsll Normative prescription (music score)Normative prescription (music score)ll Real-time implementation of the scoreReal-time implementation of the scorell Deviations will take placeDeviations will take placell DangerDanger:: loss of control of deviation loss of control of deviation
management process rather thatmanagement process rather thatdeviations themselvesdeviations themselves
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ll Aviation cannot be entirely specifiedAviation cannot be entirely specifiedll Humans will inevitably make errorsHumans will inevitably make errorsll Normative prescription (music score)Normative prescription (music score)ll Real-time implementation of the scoreReal-time implementation of the scorell Deviations will take placeDeviations will take placell DangerDanger:: loss of control of deviation loss of control of deviation
management process rather thatmanagement process rather thatdeviations themselvesdeviations themselves
Risk & Deviation ManagementRisk & Deviation Management
Aviation cannot be entirely specifiedAviation cannot be entirely specified
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Risk & Risk & Deviation ManagementDeviation Management
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Risk & Risk & Deviation ManagementDeviation Management
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Rigid frameRigid frame
Normative safetyNormative safety
Risk & Risk & Deviation ManagementDeviation Management
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Rigid frameRigid frame
Normative safetyNormative safety
Flexible linksFlexible linkswith damperswith dampers
Generative safetyGenerative safety
Risk & Risk & Deviation ManagementDeviation Management
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Risk & Deviations: Defining the BoxRisk & Deviations: Defining the Box
Operational Operational demanddemand
%%
The “coffinThe “coffincorner”corner”
LowLow NormalNormal HighHigh
Error rateError rate
Recovery rateRecovery rate
MaxMax
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The Regulator’s ContributionThe Regulator’s Contribution
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The Regulator’s ContributionThe Regulator’s Contribution
ll Think about the Think about the spirit spirit rather than therather than theletterletter of the law of the law
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The Regulator’s ContributionThe Regulator’s Contribution
ll Think about the Think about the spirit spirit rather than therather than theletterletter of the law of the law
ll Foster a cultural shiftFoster a cultural shiftêêwhat what dodo people do people do after after they committhey commit
errorserrorsêêwhat what shouldshould they do they do after after they they
commit errorscommit errors
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The Regulator’s ContributionThe Regulator’s Contribution
ll Think about the Think about the spirit spirit rather than therather than theletterletter of the law of the law
ll Foster a cultural shiftFoster a cultural shiftêêwhat what dodo people do people do after after they committhey commit
errorserrorsêêwhat what shouldshould they do they do after after they they
commit errorscommit errorsll Stop the beatings (morale won’tStop the beatings (morale won’t
improve)improve)