From BASI-Indicate to
Safety Systems to Aviation
Safety Regulation in 2010
Dr Graham Edkins
Group General Manager, Personnel
Licensing, Education and Training
April 2006
Where I am coming from…?
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Variety of professional safety roles in Rail and Aviation as regulator,
investigator and safety manager
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Rail
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Rail investigator – Westrail & Victorian Rail Safety Regulator
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Chair, National Rail Safety Regulators Panel (RSRP)
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Chair, Safety Management Systems Expert Panel (SMSEP), Special Commission of
Inquiry into the Waterfall rail accident
•
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Member, SCOT Rail Group Steering Committee on Co-regulation
Aviation
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BASI – Air Safety Investigator, CASA – GGM PLET
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Qantas – Chief Psychologist, Head Human Factors, GM Safety Systems & Education
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Previous President, Australian Aviation Psychology Association (AAvPA)
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Vice Chair, IATA Human Factors Working Group
April 2006
Where I am coming from…?
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Co-author: CASA (1998) Aviation Safety Management: An operators guide.
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Keynote Speaker CASA (2000) Safety Management Systems National
Roadshow
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Chair: Standards Australia: AS5022 Rail Safety Investigations
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Member: Standards Australia: AS4292 Rail Safety Management
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Member: Industry Development Group CASR 119: Safety Management Systems
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ICAM (Incident Causa Analysis Method) Trainer – BHP Billiton
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Master of Psychology (Organisational) – rail human factors
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PhD applied in safety management systems (aviation)
April 2006
Westrail – circa 92-94
Antecedents
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Signals Passed at Danger (SPAD)
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The Reason Model ~ circa 1990
• Developed from Professor James Reason’s work on human
error and “organisational accidents”
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Proactive safety indicators ~ circa 1992
• Tripod Delta for Shell Petroleum
• MESH for British Airways
• PRISM / REVIEW for British Rail
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Focus on proactive identification of General Failure Types (GFTs)
April 2006
Contextual
Conditions
Organisational and System
Factors
People, Task,
Environment
The Reason Model
Human
Involvement
Absent or Failed
Barriers
fe
a
s
“Un ts”
Ac
ACCIDENT
Latent Conditions
Active
Failures
Limited window/s (adapted from
Reason, 1990)
of opportunity
April 2006
General Failure Types
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Hardware
Design
Maintenance Management
Procedures
Error-enforcing Conditions
Housekeeping
Incompatible Goals
Communication
Organisation
Training
Defences
April 2006
Railway Problem Factors (RPF’s)
Organisational Policies
41
21
34
Equipment Design
Housekeeping
Management
50
Staffing
53
Rules/Procedures
28
Working Conditions
55
43
Supervision
126
Staff Attitude
91
92
Maintenance
Operating Env
38
Communication
17
0
20
Training
40
60
80
100
120
140
160
180
April 2006
Implications
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People are very adept at making global estimates of
hazards/risk
Ownership and participation in safety management
drives commitment
Focus on GFT’s avoids focus on individual error and
potential “blaming process”
Complement to “systems” approach to accident
investigation
Management tool - Sets priorities with finite resources
Assumes safety is a management problem
April 2006
Bureau of Air Safety
Investigation (94-97)
Context
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11 June 1993, VH-NDU Monarch Airlines
accident, Young NSW – 7 fatalities
2 October 1994 VH-SVQ – Seaview Air Crash,
en-route Lord Howe Island – 9 fatalities
1995, Staunton Commission Inquiry into
Seaview Air and CAA
1995, Inquiry into safety of General Aviation
sector – Plane Safe
April 2006
Myths
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Safety programs only applicable to high capacity
operators
Costly to implement
Require system safety expertise
Indicate program developed in 1995-1997 and
trialled within Kendell airlines
April 2006
INDICATE assumptions
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People know what the safety hazards are within
their work area – but need to be given
opportunity to report
Fear of blame contributes to reporting reluctance
Feedback consistency affects reporting culture
Defence failures are often revealed too late!
April 2006
Proactive defence evaluation model*
* Edkins, G.D. (1998). The INDICATE safety program; evaluation of a method to
proactively improve airline safety performance. Safety Science, 30: 275-295
April 2006
Six core safety activities
Intervention group Control Group
1.
2.
3.
4.
5.
6.
Appointing an operational safety
manager who is available to staff as a
confidant for safety-related issue
Conducting a series of staff focus
groups to proactively identify company
safety hazards
Establishing a confidential safety
reporting system for staff to report
safety hazards
Conducting monthly safety meetings
with management
Maintaining a safety information
database to record, manage and
evaluate safety recommendations
Ensuring that safety information is
regularly distributed to all staff.
Yes
No
Yes
No
Yes
Yes
Yes
No
Yes
No
Yes
No
April 2006
Proactive identification of safety hazards
5 simple steps:
i. Identify potential airline safety hazards that
may threaten the safety of passengers
ii. Rank the severity of hazards
iii. Identify current defences
iv. Evaluate the effectiveness of each defence
v. Identify additional defences
April 2006
Methodology
April 2006
Airline Safety Culture Index
125
105
85
70
74
Intervention
Control
65
50
59
45
44
41
NOTE: Score between 25-125,
the LOWER the score the
BETTER the result
25
T1
T2
T3
April 2006
Risk Perception - Severity
180
160
140
120
100
80
60
40
20
0
140
139
116
93
90
T1
T2
85
Intervention
Control
T3
April 2006
Risk Perception - Likelihood
180
160
140
120
100
80
60
Intervention
Control
76
66
50
76
40
20
0
39
T1
T2
35
T3
April 2006
Reporting culture – volume of safety
reports submitted
100
90
80
70
60
50
40
30
20
10
0
60
45
49
Intervention
Control
9
T1
T2
April 2006
Qualitative analysis
INTERVENTION
• “ I think the INDICATE program is a
great idea and with its persistence will
force management into improving areas
and procedures that are unsafe. ”
• “ There are countless things that can trip
up an airline in regard to safety. It’s a fine
balance between safety and economics.
Vigilance is the best safety net, therefore
programs like this make me feel that this
is a safe airline. ”
CONTROL
• “ People are reticent to share
experiences and discuss safety
incidents they may have had, as they
feel their positions will be under
threat. ”
• “ There is a general feeling that
management practices are reactive
and not proactive…..”
April 2006
INDICATE - Lessons
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Simple ideas are often effective
Structured framework for communicating safety messages
is crucial
Safety culture has an influence on attitude and behaviour
Continual evaluation of a SMS is crucial – complacency is
easy
Safety systems need to continually evolve – 12 months
later, INDICATE became outdated for Kendell!
April 2006
Qantas – 1997-2003
Case Study
Runway Overrun, Bangkok
September 1999
April 2006
Executive Director, Public
Transport Safety Victoria
(PTSV) 2003-2005
1
2
3
A Case Study of
Systematic Failure
in Rail Safety:
The Waterfall
Accident
April 2006
Human Compensatory Ability: A
case study of a Runaway Train!
April 2006
Implications for Organisations and
Regulators
April 2006
Implications for Organisations (1)
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Do you have Integrated Safety Management Systems –
not stand alone?
Are Risk Management activities system wide and
proactive?
Do you have formal document control processes,
particularly for change management activities?
Does your organisation have expertise and a requisite
understanding of human and organisational factors?
Does your organisation have a program for continued
professional development in safety science?
April 2006
Implications for Organisations (2)
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Is safety culture measured on a periodic basis?
Do your employees really believe that there is a just
approach to incident/accident investigation?
What evidence could you present that indicates your
organisation has a learning culture?
Do you have an integrated safety information
management system that drives strategy?
Do you have a human systems integration program
that incorporates principles of error tolerance?
April 2006
Implications for Regulators (1)
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Is the regulator sufficiently independent and
autonomous from government?
Is there a function for the independent (from
regulator) conduct of safety investigations?
Does the regulator have expertise and an ongoing
professional development program in human and
organisational factors and safety science?
How does the regulator ensure that they don’t lose
touch with current industry practices?
April 2006
Implications for Regulators (2)
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Does the regulator comprehensively assess the
adequacy of safety accreditation/AOC and change
management applications to ensure that they are
rigorous?
Does the regulator require industry operators to collect
causal factors data to an agreed standard so that
emerging safety deficiencies can be identified across
various sectors?
Does the regulator have sufficient resources to enable
compliance and accreditation activities to be effectively
achieved?
April 2006
CASA 2005-
Aviation Safety Responsibilities
DEPARTMENT OF TRANSPORT & REGIONAL SERVICES
International and domestic aviation policy advice
International airline operations regulation
Management of participation in ICAO
Administration of aviation security standards
Publication of air service statistics
AUSTRALIAN TRANSPORT SAFETY BUREAU
Independent investigation of aircraft accidents/incidents
Analysis of safety data
CIVIL AVIATION SAFETY
AUTHORITY (CASA)
AIRSERVICES AUSTRALIA
Air Traffic Control
Standards
Airspace Management
Regulatory Services
Aeronautical Information
Compliance
Airport rescue & fire fighting
services
Safety Promotion
Radio navigation aids
April 2006
April 2006
Surveillance
Old Approach
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Task-focussed
Tended to focus on end-product
of the systems
Identified problems tended to be
fixed by “patches”
Inflexible planning process
Much repetition of tasks
Checklist based
New Approach
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Focuses on
• Organisation’s systems
• Systems used to produce safe
outcomes
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Required fixes based on the
systems needed to produce
consistent results
Surveillance planning is
organisation-based
Planning based on sector and
individual organisation risk
Uses team-based audit
techniques where practical
Recording systems are guidelinebased.
April 2006
History of CASA SMS
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1995 – Introduction of SMS – Dick Wood
1996 – SAPCOM – industry advisory group
1998 – First Guidance booklet (Aviation Safety Management: An
operator’s guide)
1998 – National launch SMS concepts (Reason/Hudson)
2000 – Release of discussion paper on SMS
2001 – National education roadshow “System of safety” – Rob
Lee/Graham Edkins
2002 – NPRM CASR 119, multimedia guidance material
2003-2005 – focus on small to medium size operators
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2006 – safety case (exposition) and integrated SMS
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April 2006
New AOC/CofA
Existing AOC/CofA
CASA Actions
Registration
Notification
Industry Actions
Both
Safety Case (Exposition)
Outline
Consulting &
informing
Safety Duties
•HAZID & safety
assessment
•Design SMS
•Outline control measures
•Demonstrate adequacy
Appeals/Reviews
Amendment/Revision
Co-ordination
Modification
Safety Case Preparation
Development
Submission
Issuing AOC or Cof A
Safety Oversight
Education
Consultation
Adequacy Tests
Review
Liaison
Prepare Conclusion
Periodic Review
Communicate Conclusion
Review
Review after
Accidents / Incidents
Maintenance
April 2006
What might be CASAs focus in 2010?
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One third - Safety Research and Analysis.
Development of Safety regulations which target known safety risks and
supported by credible and appropriate safety analysis. Safety Modelling. A
greater emphasis in providing Industry with the Management and Safety
Systems models which they can criteria reference there own safety
performance against.
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One third - Education and Training.
Supporting CASA Oversight and Compliance staff (and Industry),
with the skills and competencies to build and evaluate
SMS’s.
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One Third - Compliance and safety oversight.
Risk Based Audits. Referencing/Measuring Operators safety profile against
particular models of safety efficiency and effectiveness.
Working with Operators and Case managing continuous improvements.
April 2006
What CASA might look like?
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400-500 staff rather than 700
CASA dominant workforce profile - 30
something, male or female, systems background
Focus on particular pax carrying operators
based on identified risk
General aviation, sports aviation, aerial work –
more self regulating
Main activity – safety education
April 2006
The future of SMS
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SMS will be integrated into all management systems. It
will not be an appendage - it will be an integral part of
normal day to day operations.
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CASA’S focus will be on how well these systems are
designed and how well they are functioning.
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Operators will need to demonstrate continuous
improvement and reapply for AOC/CofA every 3-5 years
(exposition/safety case)
April 2006
April 2006
In case you forgot what I said !
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Regulatory safety requirements are increasing
– Safety case and risk management
– Integrated Safety Management Systems
– Demonstrate continuous improvement
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Unplanned change is your biggest risk
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Taking your people with you, “hearts and minds” , in that
change process is vital (the regulator will look for
assurance this has been done!)
April 2006
Final words
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“Safety is a little
like boarding an
aircraft with no
destination; the
journey never
ends”
Don’t stick your head in the
sand !
April 2006
Questions?
April 2006