1. 1 Evolving Approaches to Managing Safety and Investigating Accidents Kathy Fox, Member Transportation Safety Board of Canada International Women in Aviation Conference Orlando, Florida February 27, 2010

2. 2 Presentation Outline Personal experiences Accident causation and prevention – Concepts Introduction of 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. 4 Balancing Competing Priorities Service Safety

5. 5 Reason’s Model

6. 6 Sidney Dekker Understanding Human Error Safety is never the only goal 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.

7. 7 Sidney Dekker Understanding Human Error (cont.) ______ Dekker, S. (2006) The Field Guide to Understanding Human Error, Ashgate Publishing Ltd. Human Error ToolsTasks Operating Environment

8. 8 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

9. 9 Safety Management Systems (SMS) SMS requirements - Transport Canada Accountable executive Corporate safety policy and measurable safety goals Identification of hazards and managing risks Ensuring personnel are trained and competent Internal reporting and analyzing of hazards, incidents and accidents Documenting SMS Conducting periodic audits of SMS

10. 10 Elements of SMS Hazard Identification Incident Reporting and Analysis Strong Safety Culture

11. 11 SMS: Hazard identification Organizations must proactively identify hazards and seek ways to reduce or eliminate risks Challenges: Difficulty in predicting all possible interactions between seemingly unrelated systems – complex interactions 1 _________ 1 Perrow, C (1999) Normal Accidents, Princeton University Press

12. 12 SMS: Hazard identification (cont’d) Challenges (cont’d): Inadequate assessment of risks posed by operational changes – drift into failure, limited ability to think of ALL possibilities 1,2 Deviations of procedure reinterpreted as 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

13. 13 MK Airlines (October 2004)

14. 14 Organizational Drift/ Employee Adaptations Difficult to detect from inside an organization as incremental changes always occur Front line operators create “locally efficient practices” to complete work quickly and cost- effectively –Were safety risks adequately assessed? Past successes taken as guarantee of future safety

15. 15 Fox Harbour – Touch Down Short of Runway (November 2007)

16. 16 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 given scarce resources and competing priorities

17. 17 SMS: Incident Reporting 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

18. 18 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: lack of effective communication, over-reliance on past successes, lack of integrated management across organization 2 _________ 1 Vaughan, D (1996), The Challenger Launch Decision, University of Chicago Press 2 Columbia Accident Investigation Report, Vol. 1, August 2003

19. 19 SMS: Accountability Recent trends are towards criminalization of human error Sidney Dekker, Just Culture –Safety suffers when operators punished –Organizations invest in being defensive rather than improving safety –Safety-critical information flow stifled for fears of reprisals ________ Dekker, S (2007) Just Culture, Ashgate Publishing Ltd.

20. 20 Elements of a “Just Culture” (Dekker 2007) Encourages openness, compliance, fostering safer practices, critical self-evaluation Willingly shares information without fear of reprisal Seeks out multiple accounts and descriptions of events Protects safety data from indiscriminate use Protects those who report their honest errors from blame ___________ Dekker, S (2007) Just Culture, Ashgate Publishing Ltd.

21. 21 Elements of a “Just Culture” (Dekker 2007) (cont.) Distinguishes between technical and normative errors based on context Strives to avoid letting hindsight bias influence the determination of culpability, but rather 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.

22. SMS: Benefits and pitfalls Nothing will always guarantee that all hazardous conditions in day-to-day operations will be found, analyzed and acted upon. However, SMS is benefit where it’s implemented. –“mindful infrastructure” for hazard identification and risk mitigation –more reports of “near-misses” when employees feel safe about reporting them and when incidents are acted upon. –identifying boundaries of safe operations and when companies drift from these.

23. 23 About the TSB Independent organization investigating marine, pipeline, rail and air occurrences Finds out what happened and why Makes recommendations to address safety deficiencies Not a regulator or a court Does not assign fault or determine civil or criminal liability

24. 24 About the TSB (cont.) Reason’s Model adopted in early 90s –Multicausality –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)

25. 25 Summary Adverse outcomes 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

26. 26 Summary 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.

27. 27