Aviation Safety

1

• Aviation Safety
• An ICAO Perspective

Glenn W. Herpst Chief, Flight Operations
Airworthiness Section, Air Navigation Bureau 15
October 2004
2
An Important Question

• What is the objective of contemporary safety
  management in aviation?
• Zero accidents incidents?
• Regulatory compliance?
• Error avoidance?

• Increasing the resistance of
• organizations to the risks inherent to the
  accomplishment of their production goals

3
The Dilemma of Civil Aviation
Bankruptcy
Protection
Comfort zone
Catastrophe
Production
4
Navigating the Safety Space
Increasing vulnerability
Increasing resistance
organization
Target zone
Navigational aids
Reactive outcome measures
Proactive process measures
5
Safety Management

• Traditional Approach
• Focus on proximate cause...(often unsafe acts by
  operator)
• Attach blame for failure to assess risks
• Traditional safety management uncovers

WHAT?
WHEN?
WHO?
Traditional safety management seldom uncovers
WHY?
HOW?
6
Safety Management-Changing Focus
TECHNICAL FACTORS
PRESENT
HUMAN FACTORS
ORGANIZATIONAL FACTORS
1950s
1970s
1990s
7
A Systemic Perspective
A c c i d e n t
Latent conditions trajectory
8
The Strongest Foundations
INCREASED RISK POTENTIAL
Defenses
MANAGEMENT

MAINTENANCE
People
Workplace
OPERATIONS
Organization
9
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

10
Organizational Processes
Safety defences
11
Organizational Processes
Breaches in safety defences harbour latent
conditions

• 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

Safety defences
Latent conditions
12
Organizational Processes
Workplace conditions
- Job stability - Low staff turn-over - Adequate
support equipment, facilities and guidance -
Current qualifications - Proper experience - High
employee morale - Credibility and trust
13
Organizational Processes
Adverse workplace conditions result in active
failures
Workplace conditions

• 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

Active failures
14
Organizational Processes
REINFORCE
ENHANCE
Workplace conditions
Safety defences
AVERT
IDENTIFIFY
Active failures
Latent conditions
PREVENT
15
Waiting for Bad Outcomes

Design manufacture
Management supervision
Training maintenance
Stakeholders

Operational personnel

16
Looking into the System

Design manufacture
Management supervision
Training maintenance
Stakeholders
Operational personnel


17
Safety Management A Vision

• Aviation cannot be entirely specified
• Humans will inevitably make errors
• Basic normative framework
• Implementation of the framework
• Deviation management
• Danger loss of control of the deviation
  management process rather that deviations
  themselves

Dr. Assad Kotaite International Civil Aviation
Day, 7 December 1999