Managing Safety in PerformanceBased Systems

1
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

2
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

3
The Underlying ParadigmRule-based System

• Deterministic The world as it should be
• Aviation system as pre-specified is perfect
• Compliance based
• Outcome oriented
• Accident/serious incident investigation

4
Inefficiency and Perversity

• The beatings will continue until morale improves

2. Punishment
3. Remedial Training
1. Exhortations to professionalism and discipline
4. Add more procedures regulations
5

System Performance In the Wild
6
Managing SafetyNavigating the Drift
7
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

8
Safety Data Systems and Levels of Intervention
Safety management levels
Desirable management level
9

Managing Safety Collapsing the Drift
10
Emerging ParadigmPerformance-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

11
Performance-Based Safety The ABC

• Senior managements 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)