La protección de las fuentes de La protección de las fuentes de información sobre la seguridad información sobre la seguridad

operacional –operacional –La perspectiva técnicaLa perspectiva técnica

Capt. Daniel MaurinoCapt. Daniel MaurinoSeguridad de Vuelo y Factores Humanos – OACISeguridad de Vuelo y Factores Humanos – OACI

Seminario de Seguridad ASPA/OACISeminario de Seguridad ASPA/OACI Cuidad de México, 10 – 11 Abril 2007Cuidad de México, 10 – 11 Abril 2007

Focus on the outcome (s) Focus on the outcome (s) Unsafe acts at the tip of the arrowUnsafe acts at the tip of the arrowBlame & punishment for failure to “perform Blame & punishment for failure to “perform

safely”safely”Address specific safety concern exclusivelyAddress specific safety concern exclusively

Forensic Safety Management Forensic Safety Management

The Underlying Paradigm–Rule-based SystemThe Underlying Paradigm–Rule-based System

Deterministic – The world as itDeterministic – The world as it should be should be Aviation system – as pre-specified – is perfectAviation system – as pre-specified – is perfect Compliance basedCompliance based Outcome orientedOutcome oriented

Accident investigationAccident investigation

Inefficiency and PerversityInefficiency and PerversityThe beatings will continue until morale improvesThe beatings will continue until morale improves

2. Punishment2. Punishment

3.3. RemedialRemedialTrainingTraining

4. Add more procedures & regulations

1. Exhortations to 1. Exhortations to professionalism professionalism and discipline and discipline

Operational performance

Operational performance

OperationalOperationaldeploymentdeployment

System System designdesign

Baseline performanceBaseline performance

Operationaldrift

System Performance “In the Wild”System Performance “In the Wild”

Managing Safety–Navigating the DriftManaging Safety–Navigating the DriftBaseline performanceBaseline performance

“Practicaldrift”

Operational

Operational performance

performance

Organization

Navigational aidsNavigational aids

ReactiveReactive ProactiveProactive PredictivePredictive

The Navigational AidsThe Navigational Aids Reactive systems Reactive systems

Accident investigationAccident investigationIncident investigationIncident investigation

PredictivePredictive systemssystemsElectronic safety data Electronic safety data

acquisition systems acquisition systems Direct observation safety Direct observation safety

data acquisition systems data acquisition systems Proactive systemsProactive systems

Mandatory reporting Mandatory reporting systems systems Confidential reporting Confidential reporting systems systems VoluntaryVoluntary self-reportingself-reporting

systemssystems

Safety Data Systems and Levels of Intervention Safety Data Systems and Levels of Intervention

Baseline performanceBaseline performance

“Practicaldrift”

Operational performance

Operational performance organization

Predictive Proactive Reactive

Highly efficient Very efficient Efficient

Safety management levelsSafety management levels

Reactive

Desirable managementDesirable managementlevel level

Inefficient

ASRASRSurveysSurveysAuditsAudits

ASRASRMORMOR

AccidentAccidentand incidentand incident

reportsreports

HHii gghhMMiiddddllee

LLooww

HazardsHazards

FDAFDADirectDirect

observationobservationsystemssystems

Operational performance

Operational performance

OperationalOperationaldeploymentdeployment

System System designdesign

Baseline performanceBaseline performance

Operationaldrift

Managing Safety: Collapsing the DriftManaging Safety: Collapsing the Drift

OperationalOperationaldeploymentdeployment

System System designdesign

Operational driftOperational performance

Operational performance

Baseline performanceBaseline performance

Emerging Paradigm–Performance-Based SystemEmerging Paradigm–Performance-Based System

Ecological – The world Ecological – The world as it isas it is Aviation system – as pre-specified – Aviation system – as pre-specified – is imperfectis imperfect Performance basedPerformance based Process orientedProcess oriented

Safety data captured from daily, normal operationsSafety data captured from daily, normal operations

Deterministic – The world Deterministic – The world as it should beas it should be Aviation system – as pre-specified – is perfectAviation system – as pre-specified – is perfect Compliance basedCompliance based Outcome orientedOutcome oriented

Accident investigationAccident investigation

Protecting Safety Data – An OdysseyProtecting Safety Data – An OdysseyClearly defined objective Clearly defined objective

Protect Protect sourcessources of safety information of safety informationAt the intersection of safety, law & politicsAt the intersection of safety, law & politics

The solution – Safety and LawThe solution – Safety and LawThe Implementation –The Implementation – Political willPolitical will

An inescapable realityAn inescapable realityNo safety data protection = No SMSNo safety data protection = No SMS

Denial: ritualistic blaming Denial: ritualistic blaming leading to self-delusionleading to self-delusion

Repair: cover-up, cosmetic Repair: cover-up, cosmetic re-writing denying learning re-writing denying learning

Reform: engaging the Reform: engaging the political willpolitical will

Protecting Safety Information – Excuses and FearProtecting Safety Information – Excuses and Fear