Gustavo Barba, Deputy President COPAC


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  • Buenos días,
  • Gustavo Barba, Deputy President COPAC

    1. 1. The Evolution from Just to Accountability Culture Safety expectations at the turn of the XXI Century Captain Gustavo J. Barba Román COPAC deputy president ICAO SMS/SSP instructor
    2. 2. Setting the scene <ul><li>“ The increased competition has resulted in continuing downward pressure on revenue yields and consequent business re-organisation”. IATA–Icon , August 2001 </li></ul><ul><li>As forecasted, </li></ul><ul><li>The world must be alert to the threats posed by change, citing the rise of powerful, fast-growing new economies and the fact that many of the former major economies with a long aviation tradition are &quot;struggling&quot;. </li></ul><ul><ul><ul><li>FSF chairman Lynn Brubaker says, March 2011 [EASS Istanbul] </li></ul></ul></ul>
    3. 3. Safety implications <ul><li>Industry Over emphasis on commercial objectives </li></ul><ul><li>Unbalance allocation of resources between production and protection </li></ul><ul><li>Lack of safety performance regulations </li></ul><ul><li>ICAO request SSP for Member States from November 2006 & SMS for A/C operators and AMO from January 2009 </li></ul><ul><li>Regulators dismantled </li></ul><ul><li>Growing and serious shortage of qualified safety oversight staff, liberalization of airlines and competency markets demanded changes in the regulatory schemes . </li></ul><ul><li>Budget pressures are prompting European politicians to target aviation-safety groups: </li></ul><ul><li>&quot;Understaffed regulators are probably going to be even more understaffed ”. Bill Voss, FSF CEO, March 2011 </li></ul><ul><li>“ There simply isn't the same depth of experience or consistent expertise there was years ago”. Mike Ambrose, ERA president, March 2011 </li></ul>
    4. 4. <ul><li>Root cause was a Failure of Management </li></ul><ul><li>Decisions made that increased the risk of the blowout saved time and money without being proved safe </li></ul><ul><li>Financial pressures systematically biased decision making in favor of time- and cost savings </li></ul><ul><li>This disaster likely would not have happened if BP have had committed to safety first </li></ul>Reality check,
    5. 5. A concept of accident causation Activities over which any organization has a reasonable degree of direct control: budget and human resources, business plan, etc. Factors that directly influence the efficiency of people in aviation workplaces : fatigue, training, technical failures , aircraft turnaround times, etc. Actions or inactions by people (pilots, controllers, maintenance engineers, aerodrome staff, etc.) that have an immediate adverse effect . Resources to protect against the risks that organizations involved in production activities generate and must control . Conditions present in the system before the accident, made evident by triggering factors Latent conditions trajectory There is a widespread belief in the aviation industry that the effects of commercial developments can cascade down through organization to affect flight deck operations . This threat is likely to increase as the pace of commercial developments increases . IATA–Icon , August 2001
    6. 6. Evolving System Safety <ul><li>Key Principles </li></ul><ul><li>Shared responsibility for safety </li></ul><ul><li>Regulations do not ensure safety </li></ul><ul><li>Surveillance by the regulator will not identify all safety risks </li></ul><ul><li>Evolving methods for understanding and managing safety risks are necessary </li></ul><ul><li>Public demand for safety improvements </li></ul><ul><li>ICAO Safety Management SARPs </li></ul><ul><li>Three distinct Standards </li></ul><ul><ul><li>State Safety Programme (SSP) </li></ul></ul><ul><ul><ul><ul><li>Acceptable Level of Safety (ALoS) </li></ul></ul></ul></ul><ul><ul><li>Safety Management Systems (SMS) </li></ul></ul><ul><ul><ul><ul><li>Safety performance of the SMS </li></ul></ul></ul></ul><ul><ul><li>Management accountability </li></ul></ul><ul><ul><li>Obligation or willingness to account for one’ s actions </li></ul></ul>
    7. 7. Safety data driven approach <ul><li>States shall require, as part of their SSP, that a [service provider] implement an SMS acceptable to the State that, as minimum: </li></ul><ul><li>Focus on Hazard identification </li></ul><ul><ul><li>Identifies safety hazards </li></ul></ul><ul><ul><li>Ensures the implementation of remedial action necessary to maintain agreed safety performance </li></ul></ul><ul><ul><li>Provides for continuous monitoring and regular assessment of the safety performance </li></ul></ul><ul><ul><li>Aims at a continuous improvement of the overall performance of the safety management system </li></ul></ul>Hazard identification is a wasted effort if restricted to the aftermath of rare occurrences where there is serious injury, or significant damage 1 – 5 Accidents 30 – 100 Serious incidents 100 – 1000 Incidents 1000 – 4000 Latent conditions SMS
    8. 8. Hazard Identification by reporting <ul><li>Why people are reluctant to report? </li></ul><ul><ul><ul><li>Retaliation </li></ul></ul></ul><ul><ul><ul><li>Self-incrimination </li></ul></ul></ul><ul><ul><ul><li>Embarrassment </li></ul></ul></ul><ul><ul><ul><li>Liability </li></ul></ul></ul><ul><li>Just Culture </li></ul><ul><li>Individuals are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training but which result in a reportable event; but </li></ul><ul><li>Where gross negligence, willful violations and destructive acts are not tolerated </li></ul><ul><li>But, Just Culture is not enough: </li></ul><ul><li>Only good will understanding </li></ul><ul><li>No relationship with Judicial Authorities </li></ul><ul><li>No commitment with safety concerns resolutions </li></ul><ul><li>Focus on protecting operational staff from active failures </li></ul><ul><li>No managerial accountabilities by latent conditions </li></ul>
    9. 9. Protection of sources of information <ul><li>Hazard s to sources </li></ul><ul><li>Civil Litigation </li></ul><ul><li>Regulatory sanctions </li></ul><ul><li>Criminal Proceedings </li></ul><ul><li>Company disciplinary actions </li></ul><ul><li>Public disclosure </li></ul><ul><li>Principles of protection </li></ul><ul><li>Information from reporting and recording processes at SMS will not be used as evidence for enforcement action </li></ul><ul><li>Safety information must not be used for purposes other than the purposes for which it was collected (ICAO Assembly Resolution 35/17) </li></ul><ul><ul><li>Legal guidance in ICAO Annex 13, Attachment E </li></ul></ul>
    10. 10. One step beyond by ICAO SARPs <ul><li>Management commitment and responsibility </li></ul><ul><li>Clear statement about provision of the necessary resources for the implementation of the safety policy and ensure the implementation of remedial action necessary to maintain agreed safety performance </li></ul><ul><li>Lines of accountability </li></ul><ul><li>A safety management system shall clearly define lines of safety accountability throughout the operator’s organization, accountability for safety including a direct on the part of senior management. </li></ul>
    11. 11. How to asses the safety accountability ? <ul><li>Duty of Care </li></ul><ul><li>Responsibility or the legal obligation of a person or organization to avoid acts or omissions (which can be reasonably foreseen ) to be likely to cause harm to others </li></ul><ul><li>It is owned by every party of the other contracting parties </li></ul><ul><li>The first element to proceed with an action in negligence </li></ul><ul><li>Test for duty of care </li></ul><ul><li>Some required concurrent conditions: </li></ul><ul><ul><li>The foreseeable harm or injury; </li></ul></ul><ul><ul><li>The possible magnitude of the potential harm or injury; </li></ul></ul><ul><ul><li>The usefulness of the conduct to the defendant; </li></ul></ul><ul><ul><li>The feasibility of alternative conduct; </li></ul></ul><ul><ul><li>The costs and burdens associated with the alternative conduct; </li></ul></ul><ul><ul><li>The relative usefulness of the alternative conduct; and, </li></ul></ul><ul><ul><li>The relative safety of the alternative conduct </li></ul></ul>
    12. 12. <ul><li>Disclosing accidents/incidents predictors: </li></ul><ul><ul><li>N ot only to know: What-Who-When? </li></ul></ul><ul><ul><ul><li>Also is essential: Why & How? </li></ul></ul></ul><ul><li>Safety data is needed for that: </li></ul><ul><ul><ul><li>No protection of sources of information </li></ul></ul></ul><ul><ul><ul><ul><li>= No safety data available </li></ul></ul></ul></ul><ul><li>Managing Accountabilities: </li></ul><ul><ul><ul><li>Are essential to ensure SMS performance in a very complex and competitive industry </li></ul></ul></ul><ul><ul><ul><li>Regulatory accountability shall be addressed by a balanced and sustainable enforcement policy </li></ul></ul></ul><ul><ul><ul><li>Judicial accountability shall operate to encourage compliance with the appropriate regulations and procedures </li></ul></ul></ul><ul><ul><ul><li>Judicial Authorities shall protect operational staff ,that take actions to comply safety regulations , against employer reprisals </li></ul></ul></ul>Cooperation is needed between aviation and judicial authorities for:
    13. 13. A balanced perspective <ul><li>… The pilot-in-command must bear responsibility for the decision to land and take-off in Dryden… However, it is equally clear that the air transportation system failed him by allowing him to be placed in a situation where he did not have all the necessary tools that should have supported him in making the proper decision … [ Honourable Virgil P. Moshansky ] </li></ul>