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information that would contradict it. As the strength of our mental model increases, we are reluctant
to accept facts that do not line up nicely with what we already “know”. Time pressures can lead to
erroneous assumptions that do not accurately reflect the current reality.
e) Group conformity or “group think” bias. A variation on conformity bias is “group think”. Most of
us have a tendency to agree with majority decisions; we yield to group pressures to bring our own
thinking in line with that of the group. We do not want to break the group’s harmony by upsetting the
prevalent mental model. In the interests of expediency, it is a natural pattern to fall into.
f) Overconfidence bias. There is a tendency for people to overestimate their knowledge of the
situation and its outcome. The result is that attention is placed only on information that supports their
choice and contradictory evidence gets ignored.
___________________
1. Adapted from the Human Factors Guidelines for Safety Audits Manual (Doc 9806).
10-1
Chapter 10
SAFETY PERFORMANCE MONITORING
10.1 INTRODUCTION
10.1.1 Safety management requires feedback on safety performance to complete the safety
management cycle. Through feedback, system performance can be evaluated and any necessary changes
effected. In addition, all stakeholders require an indication of the level of safety within an organization for
various reasons, for example:
a) Staff may need confidence in their organization’s ability to provide a safe work environment.
b) Line management requires feedback on safety performance to assist in the allocation of resources
between the often-conflicting goals of production and safety.
c) Passengers are concerned with their own mortality.
d) Senior management seeks to protect the corporate image (and market share).
e) Shareholders wish to protect their investment.
10.1.2 Although the stakeholders in an organization’s safety process want feedback, their individual
perspectives as to “what is safe?” vary considerably. Deciding what reliable indicators exist for acceptable
safety performance depends largely upon how one views “safety”, for example:
a) Senior management may seek the unrealistic goal of “zero accidents”. Unfortunately, as long as
aviation involves risk, there will be accidents, even though the accident rate may be very low.
b) Regulatory requirements normally define minimum “safe” operating parameters, e.g. cloud base and
flight visibility limitations. Operations within these parameters contribute to “safety”; however, they
do not guarantee it.
c) Statistical measures are often used to indicate a level of safety, e.g. the number of accidents per
hundred thousand hours, or fatalities per thousand sectors flown. Such quantitative indicators mean
little by themselves, but they are useful in assessing whether safety is getting better or worse over
time.
10.2 SAFETY HEALTH
10.2.1 Recognizing the complex interactions affecting safety and the difficulty in defining what is safe
and what is not, some safety experts make reference to the “safety health” of an organization. The term
safety health is an indication of an organization’s resistance to unexpected conditions or acts by individuals.
It reflects the systemic measures put in place by the organization to defend against the unknown.
Furthermore, it is an indication of the organization’s ability to adapt to the unknown. In effect, it reflects the
safety culture of the organization.
10-2 Safety Management Manual (SMM)
10.2.2 Although the absence of safety-related events (accidents and incidents) does not necessarily
indicate a “safe” operation, some operations are considered to be “safer” than others. Safety deals with risk
reduction to an acceptable (or at least a tolerable) level. The level of safety in an organization is unlikely to
be static. As an organization adds defences against safety hazards, its safety health may be considered to
be improving. However, various factors (hazards) may compromise that safety health, requiring additional
measures to strengthen the organization’s resistance to misadventure. The concept of the safety health of
an organization varying during its life cycle is depicted in Figure 10-1.
Assessing safety health
10.2.3 In principle, the characteristics and safety performance of the “safest” organizations can be
identified. These characteristics, which reflect industry’s best practices, can serve as benchmarks for
assessing safety performance.
Symptoms of poor safety health
10.2.4 Poor safety health may be indicated by symptoms that put elements of the organization at risk.
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