2. Aviation Safety An ICAO Perspective An ICAO Perspective Aviation Safety An ICAO Perspective An ICAO Perspective Glenn W. Herpst Chief, Flight Operations & Airworthiness Section, Air Navigation Bureau 15 October 2004

3. 2 An Important Question An Important Question What is the objective of contemporary safety management in aviation? What is the objective of contemporary safety management in aviation? l Zero accidents & incidents? l Regulatory compliance? l Error avoidance?  Increasing the resistance of organizations to the risks inherent to the accomplishment of their production goals

4. 3 The Dilemma of Civil Aviation The Dilemma of Civil Aviation Production Protection Bankruptcy Catastrophe Comfort zone

5. 4 Navigating the Safety Space Increasing vulnerability Increasing resistance Drivers Commitment Competence Competence Target zone zone Navigational aids Reactive:outcomemeasuresProactive:processmeasures organization

6. 5 Safety Management Safety Management Traditional Approach l Focus on proximate cause...(often unsafe acts by operator) l Attach blame for failure to assess risks l Traditional safety management uncovers: Traditional safety management seldom uncovers: WHAT?WHEN?WHO? WHY?HOW?

7. 6 Safety Management-Changing Focus 1950s1970s1990s PRESENT TECHNICAL FACTORS HUMAN FACTORS ORGANIZATIONAL FACTORS FACTORS

8. A Systemic Perspective ManagementDecisions Organizationa l Organizationa lProcessesOrganization Workplace Workingconditions Errors&ViolationsPeopleDefenses AccidentAccident Latent conditions trajectory

9. The Strongest Foundations The Strongest Foundations Organization Workplace People OPERATIONS MAINTENANCE MAINTENANCE MANAGEMENT INCREASED RISK POTENTIAL Defenses

10. 9 Organizational Processes Organizational Processes  Adequate regulations, procedures and guidance material  An appropriate safety management system  Effective and efficient policy-making system  Effective implementation of SARPs  Allocation of adequate resources  Adequate lines of communication  Effective planning, certification, supervision and control of all aviation activities  Adequate enforcement policy  Adequate internal auditing system

11. Safetydefences Critical Safety SafetyDefences Primarylegislation Operatingregulations Structure/ organization Qualified Technical Personnel Technical guidance Licensing/certification Resolution of safety concerns Continuing surveillance Organizational Processes

12. Safetydefences Latentconditions  No effective laws, policy, procedures and guidance  No clearly established safety requirementes  No implementation of SARPS  No programmes to certify, inspect and surveille the industry  No training policy and programmes  Mushrooming of self-regulating organizations  No identification of safety concerns  No resolution of safety issues Organizational Processes Breaches in safety defences harbour latent conditions

13. Workplaceconditions Organizational Processes Organizational Processes - Job stability - Low staff turn-over - Adequate support equipment, - Adequate support equipment, facilities and guidance - Current qualifications - Proper experience - High employee morale - Credibility and trust - Job stability - Low staff turn-over - Adequate support equipment, - Adequate support equipment, facilities and guidance - Current qualifications - Proper experience - High employee morale - Credibility and trust

14.  Improper use of procedures and documents  Deviations from procedures and standards  Inability to identify safety situations and take remedial action  Inability to follow guidance materials  “Cutting corners”  Errors and violations Workplaceconditions Activefailures Adverse workplace conditions result in active failures Organizational Processes

15. Safetydefences Workplaceconditions Latentconditions Activefailures REINFORCEENHANCE IDENTIFIFY AVERT AUDIT

16. Waiting for Bad Outcomes Waiting for Bad Outcomes Design & manufacture Management & supervision Training & maintenance Operationalpersonnel Stakeholders

17. Looking into the System Looking into the System Design & manufacture Management & supervision Training & maintenance Stakeholders Operationalpersonnel

18. Safety Management: A Vision l Aviation cannot be entirely specified l Humans will inevitably make errors l Basic normative framework l Implementation of the framework l Deviation management ê Danger: loss of control of the deviation management process rather that deviations themselves Dr. Assad Kotaite International Civil Aviation Day, 7 December 1999