Managing Safety in Performance-Based Systems Captain Dan Maurino Flight Safety and Human Factors – ICAO Worldwide Symposium on Performance of the Air Navigation System Montreal 26 – 30 March 2007 1 1 1

Forensic Safety Management Focus on outcomes Unsafe acts at the tip of the arrow Blame & punishment for failure to “perform safely” Address specific safety concern exclusively

The Underlying Paradigm–Rule-based System Deterministic – The world as it should be Aviation system – as pre-specified – is perfect Compliance based Outcome oriented Accident/serious incident investigation

Inefficiency and Perversity The beatings will continue until morale improves 2. Punishment 1. Exhortations to professionalism and discipline 3. Remedial Training 4. Add more procedures & regulations

System Performance “In the Wild” design Baseline performance Operational deployment Operational performance Operational drift

Managing Safety–Navigating the Drift Baseline performance “Practical drift” Operational performance Organization Navigational aids Reactive Proactive Predictive

The Navigational Aids Reactive systems Accident investigation Incident investigation Predictive systems Electronic safety data acquisition systems Direct observation safety data acquisition systems Proactive systems Mandatory reporting systems Confidential reporting systems Voluntary self-reporting systems

Safety Data Systems and Levels of Intervention Safety management levels H i g h M d l e L o w Baseline performance “Practical drift” Operational performance organization Hazards Reactive Predictive Proactive Reactive FDA Direct observation systems ASR Surveys Audits ASR MOR Accident and incident reports Highly efficient Very efficient Efficient Inefficient Desirable management level

Managing Safety: Collapsing the Drift Operational deployment System design Operational drift Operational performance Baseline performance Operational performance Operational deployment System design Baseline performance drift

Emerging Paradigm–Performance-Based System Deterministic – The world as it should be Aviation system – as pre-specified – is perfect Compliance based Outcome oriented Accident/serious incident investigation Ecological – The world as it is Aviation system – as pre-specified – is imperfect Performance based Process oriented Safety data captured from daily, normal operations

Performance-Based Safety: The ABC Senior management’s commitment to the management of safety Initial analysis of system design and risk controls (safety risk management) Continuous safety monitoring and analysis of safety data from normal operations (safety assurance)