“Safety, Risk Management, Governance and Accountability”Kathy Fox, Transportation Safety BoardApril 11, 2013Business Aviation Safety SeminarMontreal, QC

• Evolution of accident investigation• Organizational Drift into failure• Evolution of Safety Management Systems (SMS)• Investigating for organizational factors

o Goal conflictso Inadequate risk analysiso Employee adaptationso Weak signals

• The role of governance / regulatory oversight

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Outline

• “What” happened vs. “why” it happened• Evolution of accident investigation:

• aircraft design• cockpit design• physiological factors• psychological influences on decision-making

and risk-taking• performance of the flight crew, not just the pilot

(CRM, TEM)• organizational factors

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Background

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Balancing Competing Priorities

Service Safety

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Limits of Acceptable Performance

Rasmussen, J. (1997). Risk management in a dynamic society: a modelling problem. Safety Science, 27, 183-213

“Drift is generated by normal processes of reconciling differential pressures on an organization

(efficiency, capacity utilization, safety) against a background of uncertain technology and imperfect

knowledge.”

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Organizational Drift

Dekker, S. (2005). Ten Questions About Human Error: A New View of Human Factors and System Safety. Lawrence Erlbaum Associates, Inc.

By their nature, management decisions tend to have a wider sphere of influence on how the organization operates, and a longer-term effect, than the individual actions of operators.

Decision-makers need to develop “mindfulness” to avoid “blind spots.”

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Impact of Management

Weick, K. E. & Sutcliffe, K. M. (2007). Managing the Unexpected: Resilient Performance in an Age of Uncertainty. (2nd ed.) John Wiley & Sons Inc.

• Track small failures• Resist oversimplification• Remain sensitive to operations• Maintain capabilities for resilience• Take advantage of shifting locations of expertise• Listen for, and heed, weak signals

* Weick, Karl E.; Kathleen M. Sutcliffe (2001). Managing the Unexpected - Assuring High Performance in an Age of Complexity. San Francisco, CA, USA: Jossey-Bass. pp. 10–17. ISBN 0-7879-5627-9.

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A “Mindful Infrastructure” Would …

• a strong organizational emphasis on safety;• high collective efficacy (i.e., a high degree of

cooperation and cohesiveness);• congruence between tasks and resources;• a culture encouraging effective and free-flowing

communications;• clear mapping of its safety state;• a learning orientation;• clear lines of authority and accountability.

*Westrum, R. (1999). Organizational Factors in Air Navigation Systems Performance (Review Paper for NAV CANADA.)

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Characteristics* of Effective Safety Management

SMS integrates safety into all daily activities.

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

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Safety Management Systems (SMS)

Reason, J. (2001). In search of resilience. Flight Safety Australia September-October, 25-28.

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SMS Requires the Following:

• Goal conflicts

• Inadequate risk analysis

• Employee adaptations

• Missed “weak signals”

COMPLEX INTERACTION = NO SINGLE FACTORAS SOLE CAUSE

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Investigating for Organizational Factors

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Goal Conflicts

TSB Investigation Report A04H0004

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Inadequate Risk Analysis

TSB Investigation Report A07A0134

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Aircraft Attitude at Threshold

• Faced with time pressures or multiple goals, workers and management may be tempted to create “locally efficient practices.”

• Why? To get the job done!

• Past successes are taken as a guarantee of future safety.

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Employee Adaptations

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Employee Adaptations (cont’d)

Kelowna Flightcraft Boeing 727 at St. John’s International Airport. TSB Investigation Report A11A0035

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Weak Signals

YVR seaplane dock, 16 November 2008 (A08P0353)

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Weak Signals (cont’d)

Collision with terrain: Sandy Bay, SK (A07C0001)

“We didn’t see [these recent accidents]coming, and we should have … the

data were trying to tell us something.”

-William Voss, President andCEO of Flight Safety

Foundation

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Weak Signals (cont’d)

Findings as to Risk (Sunwing A11O0031)•When an operator’s proactive and reactive SMS processes do not trigger a risk assessment, there is an increased risk that hazards will not be mitigated.

•Operators that do not recognize a reportable occurrence may not conduct an investigation or preserve data from the digital flight data recorder.

•If operators do not thoroughly document aircraft malfunctions, there is an increased risk that deficiencies will not be corrected.

•The acceptance by flight crews and companies of known equipment problems could put safety at risk.

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SMS in Air Carrier Operations

• Drift, goal conflicts and adaptations are natural

• No one sets out to have an accident; they just want to get the work done

• The decision to value production over safety is implicit

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Pilot Error or Management Error?

• With each success, people underestimate the amount of risk involved

• If investing in safety improved quarterly returns, the company would do it

• There is a complex relationship between culture and process

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Pilot Error or Management Error? (cont’d)

Q) Who holds decision-makers to account?

A)Board of Directors / ownerShareholders / financial backersCustomersInsurance companiesRegulatorsAll of the above

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The Role of Governance / Oversight

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Governance / Oversight (cont’d)

TSB Investigation Report A10Q0098

“The gap between what is legal and whatis safe already is large, and it will getbigger. … Is this regulatory approachsustainable? Is it fair to airlines that doeverything right? Is it fair to anunknowing public?”

-William Voss, Flight Safety Foundation

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Governance / Oversight (cont’d)

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TSB WatchlistMarine

•Safety management systems•Loss of life on fishing vessels

Air•Collisions with land and water•Landing accidents and runway overruns•Risk of collisions on runways•Safety management systems

Rail•On-board video and voice recorders•Following signal indications•Passenger trains colliding with vehicles

• “Mindful infrastructure”• Effective Safety Management depends on “culture”

and “process”

• Organizational accountability is key

• Effective regulatory oversight is essential

• Success takes commitment, perseverance, and time

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Conclusions

QUESTIONS?

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