1. 1 Evolving Approaches to Managing Safety and Investigating Accidents Kathy Fox, Member Transportation Safety Board of Canada Canadian Women in Aviation Conference Montreal, QC June 17, 2011

2. 2 Presentation Outline Practicing Safety Accident causation and prevention Safety Management Systems (SMS) Role of the Transportation Safety Board (TSB) Conclusion

3. 3 Early Thoughts on Safety Follow standard operating procedures + Pay attention to what you’re doing + Don’t make mistakes or break rules + No equipment failure = Things are safe

4. Safety ≠ Zero Risk But why not? 4

5. 5 Balancing Competing Priorities Service Safety

6. 6 Reason’s Model

7. 7 Sidney Dekker Understanding Human Error People do their best to reconcile different goals simultaneously. A system isn’t automatically safe. Production pressures influence trade-offs. ______ Dekker, S. (2006) The Field Guide to Understanding Human Error, Ashgate Publishing Ltd.

8. 8 Sidney Dekker Understanding Human Error (cont.) ______ Dekker, S. (2006) The Field Guide to Understanding Human Error, Ashgate Publishing Ltd. Human Error ToolsTasks Operating Environment

9. Why Focus on Management? Management decisions –have a wider sphere of influence on operations –have a longer term effect –create the operating environment 9

10. 10 Safety Management Systems (SMS) Integrating safety into an organization’s daily operations. “A systematic, explicit and comprehensive process for managing safety risks … it becomes part of that organization’s culture, and the way people go about their work.” - James Reason, 2001

11. 11 Safety Management Systems (SMS) (cont’d) SMS requirements - Transport Canada Accountable executive Corporate safety policy and measurable safety goals Identifying hazards and managing risks Ensuring personnel are trained and competent Internal hazard, incident and accident reporting and analysis Documenting SMS Periodic SMS audits

12. 12 Key Elements of SMS Hazard Identification Incident Reporting and Analysis Strong Safety Culture

13. 13 SMS: Hazard identification Organizations must proactively identify hazards and seek ways to reduce or eliminate risks. Challenges: Very difficult to predict all possible interactions between seemingly unrelated systems – complex interactions. 1 _________ 1 Perrow, C (1999) Normal Accidents, Princeton University Press

14. 14 SMS: Hazard identification (cont’d) Challenges (cont’d): Inadequate risk assessment of operational changes – drift into failure, inability to think of ALL possibilities. 1,2 Deviations from procedure become the norm. 3 _________ 1 Dekker, S (2005) Ten Questions About Human Error, Lawrence Erlbaum Associates 2, 3 Vaughan, D. (1996) The Challenger Launch Decision, University of Chicago Press

15. Alaska Airlines Flight 261 Loss of Control and Impact with Pacific Ocean (January 2000) 15 From NTSB report AAR0201

16. 16 MK Airlines Reduced Power on Takeoff and Collision With Terrain Halifax, NS (October 2004)

17. 17 Organizational Drift/ Employee Adaptations Difficult to detect from inside an organization. Front line workers create “locally efficient practices” to get job done. Past successes taken as guarantee of future safety. Were risks properly assessed?

18. 18 Touchdown Short of Runway Fox Harbour, NS (November 2007)

19. 19 Aircraft Attitude at Threshold

20. 20 SMS: Incident Reporting Challenges: Determining which incidents are reportable. Analyzing ‘near miss’ incidents to seek opportunities to make improvements to system. Shortcomings in companies’ analysis capabilities.

21. Weak Signals 21 Transwest Air, Collision with Terrain Sandy Bay, SK (January 2007)

22. 22 SMS: Incident Reporting (cont’d) Challenges (cont’d): Performance based on error trends misleading: no errors or incidents does not mean no risks. Voluntary vs. mandatory, confidential vs. anonymous. Punitive vs. non-punitive systems. 1 Who receives incident reports. _________ 1 Dekker, S. & Laursen, T. (2007) From Punitive Action to Confidential Reporting Patient Safety and Quality Healthcare September/October 2007

23. 23 SMS: Organizational Culture SMS is only as effective as the organizational culture that enshrines it. Work groups create norms, beliefs and procedures unique to their particular task, thus becoming the work group culture. 1 Undesirable characteristics may develop within organization. 2 _________ 1 Vaughan, D (1996), The Challenger Launch Decision, University of Chicago Press 2 Columbia Accident Investigation Report, Vol. 1, August 2003

24. 24 SMS: Accountability Recent trend: criminalizing human error Consequences: -Organizations become defensive. -Safety-critical information not shared for fear of reprisals. As such, safety suffers. ________ Dekker, S (2007) Just Culture, Ashgate Publishing Ltd.

25. 25 Elements of a “Just Culture” (Dekker 2007) Encourages openness, compliance, fostering safer practices, critical self-evaluation. Willingly shares information without fear of reprisal. Protects those who report their honest errors from blame. Avoids hindsight bias. Tries to see why people’s actions made sense to them at the time. Recognizes there is no fixed line between culpable and blameless error. ___________ Dekker, S (2007) Just Culture, Ashgate Publishing Ltd.

26. SMS: Benefits and pitfalls Nothing will always guarantee that all hazards will be found, analyzed and eliminated. However, SMS is a benefit where it’s implemented. 26

27. 27 About the TSB Independent organization investigating marine, pipeline, rail and air occurrences. Finds out what happened and why. Makes recommendations to address safety deficiencies. Does not assign fault or determine civil or criminal liability.

28. 28 About the TSB (cont’d) Reason’s Model adopted in early 90s. –Multi-causality. –Human error within broader organizational context. Integrated Safety Investigation Methodology (ISIM) –Determining if full investigations are warranted based on potential to advance safety. –Use of various human and organizational factors frameworks. (Westrum, Snook, Vaughan, Dekker)

29. 29 Summary Adverse outcomes result from complex interactions of factors difficult to predict. People at all levels in an organization create safety. ‘Near-misses’ must be viewed as “free opportunities” for organizational learning. 1 ________ 1 Dekker, S. & Laursen, T. (2007) From Punitive Action to Confidential Reporting Patient Safety and Quality Healthcare September/October 2007

30. 30 Summary (cont’d) Accident investigators must focus on what made sense at the time, not be judgmental, avoid hindsight bias 2 Accountability requires organizations and professionals to take full responsibility to fix problems 3, 4 ________ 2 Dekker, S. (2006) The Field Guide to Understanding Human Error Ashgate Publishing Ltd. 3 Sharpe, V.A. (2004) Accountability Patient Safety and Policy Reform Georgetown University Press 4 Dekker, S. (2007) Just Culture Ashgate Publishing Ltd.

31. References Slide 7, 8, 30: Dekker, S. (2006) The Field Guide to Understanding Human Error, Ashgate Publishing Ltd. Slide 10: Reason, J. (2001) In Search of Resilience, Flight Safety Australia, September-October, 25-28. Slide 13: Perrow, C (1999) Normal Accidents, Princeton University Press. Slide 14: Dekker, S (2005) Ten Questions About Human Error, Lawrence Erlbaum Associates. Slide 14, 23: Vaughan, D. (1996) The Challenger Launch Decision, University of Chicago Press. Slide 22, 29: Dekker, S. & Laursen, T. (2007) From Punitive Action to Confidential Reporting Patient Safety and Quality Healthcare September/October 2007. Slide 23: Columbia Accident Investigation Report, Vol. 1, August 2003. Slide 24, 25, 30: Dekker, S (2007) Just Culture, Ashgate Publishing Ltd. Slide 30: 3 Sharpe, V.A. (2004) Accountability Patient Safety and Policy Reform Georgetown University Press. 31

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