Aviation Safety Aviation
Safety
Management
Bruce Byron
Expectations
• ‘‘Safety’ ‐
f ’ The state of being safe; freedom h
fb
f f d
from the occurrence or risk of injury, danger, or loss (Absolute safety) • Absolute safety –
Absolute safety – highly unlikely
highly unlikely
• Practically, ‘Safety’ is defined by outcomes ‐ bad things happening
No transport activity is likely to achieve
• No transport activity is likely to achieve ‘absolute’ safety
The Reality
The Reality
• Try to reduce the likelihood of bad things happening
• Try to reduce the consequences if something does go wrong
• = Risk Management
Risk Management
Risk Management in Aviation
Risk Management in Aviation
• AS/NZS ISO 31000:2009 Risk Management –
Principles & Guidelines
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• International Civil Aviation Organisation (ICAO) Safety Management Manual (SMM)
(ICAO) Safety Management Manual (SMM) • The ‘As Low as Reasonably Practical’ (ALARP) Concept – in effect, a compromise
So in Aviation ‘Safety’
So, in Aviation –
Safety is ‐
is
• The state in which the possibility of harm to persons or of property damage is
to persons or of property damage is reduced to, and maintained at or below, an acceptable level through a continuing bl l l h
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process of hazard identification and safety risk management (ICAO).
• That’s the theory!
Safety Management and Risk
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Maurino amended by Byron 2007
Evolution of Safety Focus in Aviation
Evolution of Safety Focus in Aviation
Understanding Why Things go Wrong
Understanding Why Things go Wrong
• Technical Factors (design, maintenance, q p
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equipment failure, suitability for the job)
• H
Human Factors (relationship of operator to F
( l i hi f
other elements in the system)
• O
Organisational Factors (regulations, rules, i ti
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procedures, training)
Human Factors Errors & Violations
Human Factors ‐
Errors & Violations
• Errors
– Slips & lapses (execution)
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p
(
)
– Mistakes (the plan)
• Strategies for Errors
St t i f E
– Reduction, capturing & tolerance • Violations
– Situational
– Routine & Organisation induced
Understanding HF Relationships
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p
The SHELL Model – Frank Hawkins 1984
Accident Causation
The Swiss Cheese Model James Reason
The Swiss Cheese Model –
James Reason
POSSIBLE FAILURE
POSSIBLE FAILURE
DEFENCES
Accident
The Swiss Cheese Model 2
The Swiss Cheese Model ‐2
Safety Culture
Safety Culture
An over‐used term in aviation
Assumes you have it or not (switch on or off!)
Assumes you have it or not (switch on or off!)
Really boils down to attitudes & behaviours
The attitude of business owners, directors & CEO
• The behaviours of management
• The behaviours of front line people
•
•
•
•
Safety Culture How do you get it?
Safety Culture –
How do you get it?
•
•
•
•
•
•
•
Policy
Training
Open reporting
Communication
Staff engagement & surveys
Staff engagement & surveys
Sharing information
Transparency
Bruce’ss View
Bruce
View
• Very careful consideration must be given to the:
– What
– How, and
How and
– Who
Of managing safety.
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Managing Safety –
g g
y What ?
The Safety Space – James Reason
Managing Safety How?
Managing Safety –
•
•
•
•
•
•
•
Identify Hazards
Assess risks
Assess risks
Make decisions
Training
Outcome based rules ‐ simple
Outcome based rules Implement a safety culture
Information is King
Managing Safety Who ?
Managing Safety –
Who ?
• O
Operators??
• Safety Theorists?
• Compromise
– An eye on the detail
An eye on the detail
– An eye on the big picture
• The Operational Egoist will send you to an inquiry Th O
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l E i t ill
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t
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or court
• The Safety Fanatic and the Technical Enthusiast h S f
i
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h i l
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will both send you broke