Your SlideShare is downloading. ×
Gustavo Barba, Deputy President COPAC
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

Gustavo Barba, Deputy President COPAC

713
views

Published on

Published in: Business

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
713
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
52
Comments
0
Likes
0
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide
  • Buenos días,
  • Transcript

    • 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. Setting the scene
      • “ The increased competition has resulted in continuing downward pressure on revenue yields and consequent business re-organisation”. IATA–Icon , August 2001
      • As forecasted,
      • 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 "struggling".
          • FSF chairman Lynn Brubaker says, March 2011 [EASS Istanbul]
    • 3. Safety implications
      • Industry Over emphasis on commercial objectives
      • Unbalance allocation of resources between production and protection
      • Lack of safety performance regulations
      • ICAO request SSP for Member States from November 2006 & SMS for A/C operators and AMO from January 2009
      • Regulators dismantled
      • Growing and serious shortage of qualified safety oversight staff, liberalization of airlines and competency markets demanded changes in the regulatory schemes .
      • Budget pressures are prompting European politicians to target aviation-safety groups:
      • "Understaffed regulators are probably going to be even more understaffed ”. Bill Voss, FSF CEO, March 2011
      • “ There simply isn't the same depth of experience or consistent expertise there was years ago”. Mike Ambrose, ERA president, March 2011
    • 4.
      • Root cause was a Failure of Management
      • Decisions made that increased the risk of the blowout saved time and money without being proved safe
      • Financial pressures systematically biased decision making in favor of time- and cost savings
      • This disaster likely would not have happened if BP have had committed to safety first
      Reality check,
    • 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. Evolving System Safety
      • Key Principles
      • Shared responsibility for safety
      • Regulations do not ensure safety
      • Surveillance by the regulator will not identify all safety risks
      • Evolving methods for understanding and managing safety risks are necessary
      • Public demand for safety improvements
      • ICAO Safety Management SARPs
      • Three distinct Standards
        • State Safety Programme (SSP)
            • Acceptable Level of Safety (ALoS)
        • Safety Management Systems (SMS)
            • Safety performance of the SMS
        • Management accountability
        • Obligation or willingness to account for one’ s actions
    • 7. Safety data driven approach
      • States shall require, as part of their SSP, that a [service provider] implement an SMS acceptable to the State that, as minimum:
      • Focus on Hazard identification
        • Identifies safety hazards
        • Ensures the implementation of remedial action necessary to maintain agreed safety performance
        • Provides for continuous monitoring and regular assessment of the safety performance
        • Aims at a continuous improvement of the overall performance of the safety management system
      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. Hazard Identification by reporting
      • Why people are reluctant to report?
          • Retaliation
          • Self-incrimination
          • Embarrassment
          • Liability
      • Just Culture
      • 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
      • Where gross negligence, willful violations and destructive acts are not tolerated
      • But, Just Culture is not enough:
      • Only good will understanding
      • No relationship with Judicial Authorities
      • No commitment with safety concerns resolutions
      • Focus on protecting operational staff from active failures
      • No managerial accountabilities by latent conditions
    • 9. Protection of sources of information
      • Hazard s to sources
      • Civil Litigation
      • Regulatory sanctions
      • Criminal Proceedings
      • Company disciplinary actions
      • Public disclosure
      • Principles of protection
      • Information from reporting and recording processes at SMS will not be used as evidence for enforcement action
      • Safety information must not be used for purposes other than the purposes for which it was collected (ICAO Assembly Resolution 35/17)
        • Legal guidance in ICAO Annex 13, Attachment E
    • 10. One step beyond by ICAO SARPs
      • Management commitment and responsibility
      • 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
      • Lines of accountability
      • 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.
    • 11. How to asses the safety accountability ?
      • Duty of Care
      • 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
      • It is owned by every party of the other contracting parties
      • The first element to proceed with an action in negligence
      • Test for duty of care
      • Some required concurrent conditions:
        • The foreseeable harm or injury;
        • The possible magnitude of the potential harm or injury;
        • The usefulness of the conduct to the defendant;
        • The feasibility of alternative conduct;
        • The costs and burdens associated with the alternative conduct;
        • The relative usefulness of the alternative conduct; and,
        • The relative safety of the alternative conduct
    • 12.
      • Disclosing accidents/incidents predictors:
        • N ot only to know: What-Who-When?
          • Also is essential: Why & How?
      • Safety data is needed for that:
          • No protection of sources of information
            • = No safety data available
      • Managing Accountabilities:
          • Are essential to ensure SMS performance in a very complex and competitive industry
          • Regulatory accountability shall be addressed by a balanced and sustainable enforcement policy
          • Judicial accountability shall operate to encourage compliance with the appropriate regulations and procedures
          • Judicial Authorities shall protect operational staff ,that take actions to comply safety regulations , against employer reprisals
      Cooperation is needed between aviation and judicial authorities for:
    • 13. A balanced perspective
      • … 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 ]

    ×