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The “Safety Journey”
an air industry perspective
Patrick Murray
Director
Griffith University Aerospace Strategic Study Cen...
Thank You
patrick.murray@griffith.edu.au
Thanks and acknowledgement
to:
•CASA
•Flight Global ACAS
•IATA
•ICAO
•University ...
Air Transport / Rail
 Complex socio – technical systems
 Passenger & freight transport
 Vital part of national infrastr...
Human Beings are involved
at all levels of the system
Scope
Safety in high reliability systems
Risk in airline operations
Airline safety trends
The “safety journey”
New pa...
How do we measure Safety?
 The absence of accidents ?
 The presence of a Safety Management System ?
 Does an increase i...
The Issue
• Accident risk :
» Extremely high consequence
» Extremely low frequency
= Extreme Risk
(but very difficult to m...
No system
beyond this
point
10-2 10-3 10-4 10-5 10-6
Civil Airlines
Nuclear Industry
Railways (First World)
Charter
Flight...
10-2 10-3 10-4 10-5 10-6
The story of the
next accident will
be a repeat of
previous accidents
The story of the next
accid...
 40’s-70’s Reducing pilot workload
 70’s-90’s Improving situational awareness / CRM
 90’s- Promoting organisational saf...
Griffith Aerospace Safety Centre
Aerospace Strategic Study Centre
“Safety Through Education and Research”
Everyone makes e...
The ubiquity of human error...
Griffith Aerospace Safety Centre
Aerospace Strategic Study Centre
“Safety Through Education...
Safety Management
System Data Sources
Normal Operations
Monitoring
Flight Data
Analysis
Voluntary
Reporting
Predictive Proactive Reactive
Highly efficient More efficient Efficient
Safety management potential
Reactive
Inefficient
S...
ACCIDENTS &
INCIDENTS
UNREPORTED
OCCURRENCES
•Loukopoulos/Dismukes, 2002, NASA
Aerospace Strategic Study Centre
“Safety Th...
• LOSA formally endorsed
by ICAO as an industry
best practice for
monitoring normal
operations
• ICAO Doc 9803 (LOSA)
publ...
Flight deck observations by trained and
calibrated observers
• No jeopardy to crew
• All data de-identified & confidential...
Intentional non – compliance
40+ Airlines / 9,000+ flights
Approx 28% of all errors were
associated with
Intentional non -...
Why do violations occur?
 A culture where getting the job done is more
important than safety?
 Unworkable rules and proc...
VIOLATION or “Getting the job done” ?
What is Culture?
“Values and practices that we share with others that help define us
as a group” .......“Who we think we a...
My suggestions about safety would be acted
upon if I expressed them to management.
Safety
Culture
The managers in Flight O...
% Crews with an Undesired State
14%
54%
67%
0
10
20
30
40
50
60
70
80
90
100
Low Safety Culture
Crews
Avg Safety Culture
C...
PATHOLOGICAL
Who cares as long as
we’re not caught
Organisational and
Individual Trust
Organisational
Openness and
Communi...
Safety Culture
• The Columbia Space Shuttle
Accident Investigation Board found
that… NASA’s organisational
culture had as ...
Have you ever wondered
why you pay extra for
Business Class?
Example of reactive safety management
Griffith Aerospace Safety Centre
Aircraft are certified (windshield, engines etc), t...
Proactive Safety – the next generation?
Griffith Aerospace Safety Centre
 If we only look at the future in the light of t...
Improving Safety
• Management and union leadership demonstrate
commitment to safety
• Understanding and applying the „safe...
Thank You
patrick.murray@griffith.edu.au
Thanks and acknowledgement
to:
•CASA
•Flight Global ACAS
•IATA
•ICAO
•University ...
Patrick Murray
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Patrick Murray

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Professor Patrick Murray, Director, Aerospace Strategic Study Centre, Griffith Aviation delivered this presentation at Rail Safety 2012. For more information on the annual conference, please visit www.railsafetyconference.com.au.

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Transcript of "Patrick Murray"

  1. 1. The “Safety Journey” an air industry perspective Patrick Murray Director Griffith University Aerospace Strategic Study Centre Aerospace Strategic Study Centre “Safety Through Education and Research”
  2. 2. Thank You patrick.murray@griffith.edu.au Thanks and acknowledgement to: •CASA •Flight Global ACAS •IATA •ICAO •University of Texas (HFRP) •The LOSA Collaborative Aerospace Strategic Study Centre “Safety Through Education and Research” aviationresearch@griffith.edu.au www.griffith.edu.au/aviation
  3. 3. Air Transport / Rail  Complex socio – technical systems  Passenger & freight transport  Vital part of national infrastructure  Transition from Government – private ownership  High reliability systems  Large investments in Safety  Inherently dynamic (unstable) system Aerospace Strategic Study Centre “Safety Through Education and Research”
  4. 4. Human Beings are involved at all levels of the system
  5. 5. Scope Safety in high reliability systems Risk in airline operations Airline safety trends The “safety journey” New paradigms (or old wine in new bottles)? Aerospace Strategic Study Centre “Safety Through Education and Research”
  6. 6. How do we measure Safety?  The absence of accidents ?  The presence of a Safety Management System ?  Does an increase in reported incidents show: • A decrease in safety? • An improvement in safety (better reporting culture)?  Regulatory compliance = safety?  Can organisations be compared? Aerospace Strategic Study Centre “Safety Through Education and Research”
  7. 7. The Issue • Accident risk : » Extremely high consequence » Extremely low frequency = Extreme Risk (but very difficult to measure and manage) Aerospace Strategic Study Centre “Safety Through Education and Research”
  8. 8. No system beyond this point 10-2 10-3 10-4 10-5 10-6 Civil Airlines Nuclear Industry Railways (First World) Charter Flights Hymalaya mountaineering Road Safety Anesthesiology Blood transfusion Professional Fishing Crop spraying Very unsafe Ultra safe Medical risk average Chemical Industry (total) Helicopters 10-1 Tubes/metros Relative system safety Aerospace Strategic Study Centre “Safety Through Education and Research” Risk of Fatality Surgery Adapted from Rene Almaberti 2006
  9. 9. 10-2 10-3 10-4 10-5 10-6 The story of the next accident will be a repeat of previous accidents The story of the next accident is a combination of parts of previous accidents or incidents, in particular using the same precursors The next accident is an original story and context never seen before together. Decomposition of the story may reveal a series of already seen micro incidents, but for the most part, not previously considered as consequential Aerospace Strategic Study Centre “Safety Through Education and Research”
  10. 10.  40’s-70’s Reducing pilot workload  70’s-90’s Improving situational awareness / CRM  90’s- Promoting organisational safety / QA  Mid 90’s- understanding human error / culture  Next challenge : Improving resilience ?? The Long and Winding Road Aerospace Strategic Study Centre “Safety Through Education and Research”
  11. 11. Griffith Aerospace Safety Centre Aerospace Strategic Study Centre “Safety Through Education and Research” Everyone makes errors
  12. 12. The ubiquity of human error... Griffith Aerospace Safety Centre Aerospace Strategic Study Centre “Safety Through Education and Research” If we really accept that errors will always be a part of the human condition - perhaps even a by - product of that ingenuity and resilience that only human beings exhibit.... ...then it is only by analysis of these errors (ingenuity?) and the surrounding context can we move to the next frontier in safety....
  13. 13. Safety Management System Data Sources Normal Operations Monitoring Flight Data Analysis Voluntary Reporting
  14. 14. Predictive Proactive Reactive Highly efficient More efficient Efficient Safety management potential Reactive Inefficient Surveys Audits Incident Reports Accident reports Normal Operations Normal Operations Monitoring Safety management instruments Aerospace Strategic Study Centre “Safety Through Education and Research”
  15. 15. ACCIDENTS & INCIDENTS UNREPORTED OCCURRENCES •Loukopoulos/Dismukes, 2002, NASA Aerospace Strategic Study Centre “Safety Through Education and Research”
  16. 16. • LOSA formally endorsed by ICAO as an industry best practice for monitoring normal operations • ICAO Doc 9803 (LOSA) published in 2002 Aerospace Strategic Study Centre “Safety Through Education and Research”
  17. 17. Flight deck observations by trained and calibrated observers • No jeopardy to crew • All data de-identified & confidential • Significant data cleaning to remove “noise” • Report on:  Specific threat environment  Nature and prevalence of errors  Threat and error management by crews Methodology Aerospace Strategic Study Centre “Safety Through Education and Research”
  18. 18. Intentional non – compliance 40+ Airlines / 9,000+ flights Approx 28% of all errors were associated with Intentional non - compliance Aerospace Strategic Study Centre “Safety Through Education and Research”
  19. 19. Why do violations occur?  A culture where getting the job done is more important than safety?  Unworkable rules and procedures?  Personnel using „short-cuts‟ and „work-arounds‟ to achieve organisational goals  Are we suppressing human ingenuity? Aerospace Strategic Study Centre “Safety Through Education and Research”
  20. 20. VIOLATION or “Getting the job done” ?
  21. 21. What is Culture? “Values and practices that we share with others that help define us as a group” .......“Who we think we are, what we believe in and what is important to us” (Prof Ashleigh Merritt - 1997) “The way we do things around here” (Anon) “When I hear the word “culture”, I want to reach for my Luger” (Reich Marshal Herman Goering 1936) Aerospace Strategic Study Centre “Safety Through Education and Research” “The way we do things around here - when no-one is watching”!
  22. 22. My suggestions about safety would be acted upon if I expressed them to management. Safety Culture The managers in Flight Operations listen to us and care about our concerns. Management will never compromise safety concerns for profitability •. I am encouraged by to report any unsafe conditions I observe. I know the proper channels to report my safety concerns. I am satisfied with Chief Pilot and Assistant Chief Pilot availability. Safety Culture Survey Questions Aerospace Strategic Study Centre “Safety Through Education and Research”
  23. 23. % Crews with an Undesired State 14% 54% 67% 0 10 20 30 40 50 60 70 80 90 100 Low Safety Culture Crews Avg Safety Culture Crews High Safety Culture Crews Scale0-100 Base Rate Aerospace Strategic Study Centre “Safety Through Education and Research” Safety culture and crew performance
  24. 24. PATHOLOGICAL Who cares as long as we’re not caught Organisational and Individual Trust Organisational Openness and Communication - REACTIVE Safety is important when we have an accident PROACTIVE We fix problems that we find CALCULATIVE We have systems in place to manage hazards GENERATIVE Safety is fully integrated into all operations + - + Adapted from Prof Patrick Hudson Where is your organisation ?
  25. 25. Safety Culture • The Columbia Space Shuttle Accident Investigation Board found that… NASA’s organisational culture had as much to do with the accident as the foam did… Columbia Accident Investigation Board Report August 2003
  26. 26. Have you ever wondered why you pay extra for Business Class?
  27. 27. Example of reactive safety management Griffith Aerospace Safety Centre Aircraft are certified (windshield, engines etc), to continue flying after an impact of any bird below 4 lbs and multiple impacts of smaller birds Resistance assessed by “chicken-guns” But…. Speed at impact too small in certification test 36 species of bird weigh over 4 lbs in North America 30% ingestion of birds weighing over 4 lbs (USA) New regulation coming: >> 8 lbs But geese may weigh over 15 lbs and fly in “squadrons” !! Aerospace Strategic Study Centre “Safety Through Education and Research”
  28. 28. Proactive Safety – the next generation? Griffith Aerospace Safety Centre  If we only look at the future in the light of the past……  ….our understanding of what has happened inevitably colours our anticipation and preparation for what could go wrong and thereby holds back the requisite imagination that is essential for safety  The next generation of safety will be organisations, groups and individuals who are resilient ….  …..recognise, adapt to and absorb variations, changes, disturbances, disruptions, and surprises – especially disruptions that fall outside of the set of disturbances the system is designed to handle Aerospace Strategic Study Centre “Safety Through Education and Research”
  29. 29. Improving Safety • Management and union leadership demonstrate commitment to safety • Understanding and applying the „safety balance‟ of production versus safety • Integrated application of risk management principles – By operators – By regulators • Risk (not compliance) based investigations • Fair and accountable safety processes “A Just Culture” ?
  30. 30. Thank You patrick.murray@griffith.edu.au Thanks and acknowledgement to: •CASA •Flight Global ACAS •IATA •ICAO •University of Texas (HFRP) •The LOSA Collaborative Aerospace Strategic Study Centre “Safety Through Education and Research” aviationresearch@griffith.edu.au www.griffith.edu.au/aviation
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