AVIATION SAFETY Almaty, 5 to 9 September 2005

A new safety policy Partnership Increased performance Reduced costs Improved safety A New Safety Policy Civil Aviation has embarked on a journey where regulators and industry partners, will implement this new approach as a way to reduce an already low accident rate in order to compensate for expected industry growth. Furthermore, this policy should address some of the demographic problems all regulators are facing by increasing safety performance while at the same time reducing operating costs. It is believed that the new policy will reduce the loss of life and property, increase public confidence in the safety of air travel, reduce government safety oversight costs, and improve industry profitability. It’s a natural evolution for civil aviation, but revolutionary in its approach. Almaty, 5 – 9 September 2005

Accountability Regulator’s intervention Certificate holders Reduced different Certificate holders Assume responsibilities New approach Performance linked Safety economic Accountability The first thing to change will be the accountability framework. Today regulators are expected to intervene at the operational level with audits and inspections of actual activities. Tomorrow, the first level of intervention will be at the systems level. Industry, and this means all certificate holders, airports, air operators, AMO Service providers, etc, will be accountable for day-to-day operations and will have the freedom to use the most cost-effective method of improving safety performance. In short, what is being changed with the new approach is the accountability framework for managing risk. Changing the accountability framework is more about integrating the processes that already exist in most aviation organizations and less about creating new ones. For the first time, a clear link between safety performance and economic performance can be made under this approach. The old adage that “safety is good business” now has some clarity to it. Where such an approach has already been taken, safety and economic performance have dramatically improved. While the basic principles seem simple enough, implementing them in the face of general opposition to change, scepticism and misunderstanding of the concepts is challenging. The primary reason for these difficulties is that the new safety management approach demands cultural changes. The nature of these cultural changes and the objectives of these changes must be clearly understood if the new approach is to be successful. Almaty, 5 – 9 September 2005

The accountable executive Cultural changes Starts at the top Chief executive Person with power Impose policy Lead implementation Fund it Accountable Operational performance Safety performance The Accountable Executive Cultural change must begin at the top of an organization - at the level of power, leadership and ultimate accountability. The new safety management approach makes the person who has the power to impose a new policy, lead its implementation, fund it and sustain it, accountable for the safety performance of the civil aviation organization. The accountable executive is likely the owner or the Chief Executive Officer of the enterprise. For all intents and purposes, it is the person ultimately responsible for the profitability of the enterprise - from a regulator’s perspective, it puts a name and a face on the certificate holder Almaty, 5 – 9 September 2005

A safety culture Is safety New approach Safety becomes Everyone’s business? Limited to one section? New approach Responsibilities on operating units Responsible Accountable Support services may be used Support operating divisions Safety becomes Everyone’s business Safety Culture Today, it has become almost a cliché to assert that safety is everyone’s business in a civil aviation enterprise. Where safety programs exist, they are under a safety organization to which everyone looks to, to ensure safe operations. Under the new approach, not only will the requirement for a Flight Safety Officer or Safety Program Manager be removed, the whole concept of being able to point to a person who is not involved in the operation as being responsible for safety performance will no longer exist. It can go so far as to say that there should not be a department with the word “safety” in its title within a certificate holder’s organization to drive the point home that cultural change is necessary if safety truly is to be the first priority for everyone. There could be an organization to provide support services to the operational divisions. These support service would be things like risk and data analysis, internal audit, and report management and these support services would be provided at the request of the operating division. It’s those operational divisions that are rightly charged with the responsibility for safety performance. By clearly placing responsibility for safety performance in the hands of all of the operating divisions, safety does become everyone’s business. Only then is it possible to create a true safety culture in an organization. Almaty, 5 – 9 September 2005

A reporting culture Management Building the culture Quality information Free flowing information Proactive reactive Building the culture Enforcement policy Operator Authority immunity Feedback Reporting Culture It should go without saying that a safety culture exhibits a reporting culture. And we all know that quality risk management is based on quality information. Information must be free flowing within an enterprise and between the enterprise and its safety partners for this new policy to work. The reporting system must encourage and accommodate both the proactive reporting of hazards and the reactive reporting of incidents and accidents. Every report must be treated systematically and transparently, and not generate disciplinary action or any other form of retribution against the reporter where no wilful malfeasance or negligence was involved. The normal starting point to building this reporting culture is the creation of an internal disciplinary policy, which clearly delineates where immunity begins and ends. Within an aviation enterprise, this is simpler than one might assume. Immunity from enforcement by the regulator should depend on how the regulator learns of the event reported, on the aviation organization’s reaction to the report and on the recorded information on how it has been dealt and the seriousness of the event reported. Everything possible should be done to maintain the integrity of the disciplinary policy, keeping in mind that once an event impacts other jurisdictions, the regulator’s approach must not conflict with other legislative requirements. Serious incidents and accidents often involve entities like the police or other investigative body whose reports and actions arising from those reports are beyond the control of the organization or the civil aviation regulator. These are clearly outside the organization’s or the civil aviation regulator’s ability to provide immunity. Thankfully, these serious occurrences are rare and should have little impact on creating a good reporting culture. Once members of a civil aviation organization feel free to report hazards, incidents and accidents, they will continue do so if they see results from their reports. This means that they must receive feedback on what is being done about the issues raised in the report Almaty, 5 – 9 September 2005

A risk management culture Reports Risk analysis Mitigation strategy Reduce risk Eliminate risk Root causes Identification Corrective actions All decisions All divisions A Risk Management Culture For the new approach to work, every report must be subjected to a formal, documented risk analysis, which can have only two outcomes: (1) acceptance of the risk with or without mitigation strategies or (2) reduction or elimination of the risk. In the first instance, acceptance is documented and filed. In the second, a root cause analysis is required and a corrective action plan is developed to address the root cause or causes of the problem thereby reducing the risk to an acceptable level or eliminating it. Under the new approach, the integration of formal risk management into an organization must go beyond the analysis of hazard, incident and accident reports. Making safety performance everyone’s responsibility represents a major cultural shift in most organizations. All decisions will be subject to a risk analysis. Operational divisions, including marketing, customer service and finance, which historically took decisions without consideration of the impact on safety performance, should no longer be able to do so. Almaty, 5 – 9 September 2005

A quality assurance culture Reporting Encouraged Risk assessment Integrated in decision making Human factors Verify if solution works Operational level considerations System level considerations Quality assurance Almaty, 5 – 9 September 2005

The changing role of the inspector More important role Intervenes at system level System failures More critical Operational level Interventions still possible When warranted Change in the accountability level Almaty, 5 – 9 September 2005

Civil aviation regulators Management Performance based Risk management Risk analysis Action taken Safety framework Legislation Procedures practices Cost/benefit analysis Almaty, 5 – 9 September 2005

Conclusion Safety management Implementation challenges Different meaning for different people Changing risk management framework Implementation challenges Good safety records Growing industry Current safety framework Unsustainable Together, we build the future! Almaty, 5 – 9 September 2005

AVIATION SAFETY Almaty, 5 to 9 September 2005 - END -