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June 2007
content
Concept of safety
The evolution of safety thinking
A concept of accident causation – Reason model
The organizational accident
People, context and safety – SHEL(L) model
Errors and violations
Organizational culture
Safety investigation
Questions and answers
Points to remember
A project supported by AIRBUS and the CAAC
A project supported by AIRBUS and the CAAC
June 2007
Concept of safety
What is safety?
Zero accidents or serious incidents (a view widely
held by the travelling public).
Freedom from hazards (i.e. those factors which
cause or are likely to cause harm).
Attitudes towards unsafe acts and conditions by
employees of aviation organizations.
Error avoidance.
Regulatory compliance.
… ?
A project supported by AIRBUS and the CAAC
June 2007
Concept of safety
Consider (the weaknesses in the notion of perfection)
The elimination of accidents (and serious incidents)
is unachievable.
Failures will occur, in spite of the most accomplished
prevention efforts.
No human activity or human-made system can be
guaranteed to be absolutely free from hazard and
operational errors.
Controlled risk and controlled error are acceptable
in an inherently safe system.
A project supported by AIRBUS and the CAAC
A project supported by AIRBUS and the CAAC
June 2007
Concept of safety (Doc 9859)
Safety is the state in which the risk of harm to
persons or property damage is reduced to, and
maintained at or below, an acceptable level through a
continuing process of hazard identification and risk
management.
A project supported by AIRBUS and the CAAC
June 2007
Safety
Traditional approach – Preventing accidents
Focus on outcomes (causes)
Unsafe acts by operational personnel
Attach blame/punish for failures to “perform safely”
Address identified safety concern exclusively
Identifies:
WHAT? WHO? WHEN?
WHY? HOW?
But not always discloses:
A project supported by AIRBUS and the CAAC
A project supported by AIRBUS and the CAAC
June 2007
The evolution of safety thinking
TODAY
1950s 1970s 1990s 2000s
HUMAN FACTORS(INDIVIDAL )
Fuente: James Reason
A project supported by AIRBUS and the CAAC
June 2007
A concept of accident causation
Latent conditions trajectory
Technology
Training
Regulations
Defences
Errors
and
violations
People Accident
Working
conditions
Organization Workplace
Management
decisions and
organizational
processes
Source: James Reason
A project supported by AIRBUS and the CAAC
A project supported by AIRBUS and the CAAC
June 2007
The organizational accident
Organizational processes
Activities over which any organization has a reasonabledegree
of direct control
Policy-making
Planning
Communication
Allocation of resources
Supervision
...
A project supported by AIRBUS and the CAAC
June 2007
The organizational accident
Conditions present in the system before the accident, made evident
by triggering factors.
Inadequate hazard
identification and
risk management
Normalization of
deviance
A project supported by AIRBUS and the CAAC
A project supported by AIRBUS and the CAAC
June 2007
The organizational accident
Resources to protect against the risks that organizations involved
in production activities generate and must control.
Technology
Training
Regulations Defences
Organizational processes
Latent
conditions
A project supported by AIRBUS and the CAAC
June 2007
The organizational accident
Factors that directly influence the efficiency of people in
aviation workplaces.
Workforce stability
Qualifications and
experience
Morale
Credibility
Ergonomics
...
A project supported by AIRBUS and the CAAC
A project supported by AIRBUS and the CAAC
June 2007
The organizational accident
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AIRWORTHINESS AND FLIGHT STANDARDS(6)
