Advancing Approaches to Managing Safety and Investigating Accidents

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Advancing Approaches to Managing Safety and Investigating Accidents Kathy Fox, Member Transportation Safety Board of Canada International Women in Aviation Conference Orlando, Florida February 27, 2010

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Presentation Outline Personal encounters Accident causation and anticipation – Concepts Introduction of Safety Management Systems (SMS) Role of the Transportation Safety Board (TSB) Conclusion

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Early Thoughts on Safety Follow standard working methodology + Pay thoughtfulness regarding what you're doing + Don't commit errors or break rules + No hardware disappointment = Things are protected

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Balancing Competing Priorities Safety Service

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Reason's Model

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Sidney Dekker Understanding Human Error Safety is never the main objective People do their best to accommodate distinctive objectives at the same time A framework isn't consequently sheltered Production weights impact exchange offs ______ Dekker, S. (2006) The Field Guide to Understanding Human Error , Ashgate Publishing Ltd.

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Sidney Dekker Understanding Human Error (cont.) ______ Dekker, S. (2006) The Field Guide to Understanding Human Error , Ashgate Publishing Ltd.

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Safety Management Systems (SMS) Integrating security into an association's day by day operations "An efficient, express and far reaching process for overseeing dangers … it turns out to be a piece of that association's way of life, and the way individuals approach their work." - James Reason, 2001

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Safety Management Systems (SMS) 9

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Elements of SMS 10

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SMS: Hazard distinguishing proof Organizations must proactively recognize perils and look for approaches to lessen or kill dangers Challenges : Difficulty in foreseeing every single conceivable connection between apparently irrelevant frameworks – complex communications 1 _________ 1 Perrow, C (1999) Normal Accidents, Princeton University Press

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SMS: Hazard ID (cont'd) Challenges (cont 'd) : Inadequate appraisal of dangers postured by operational changes – float into disappointment, restricted capacity to think about ALL potential outcomes 1,2 Deviations of strategy reinterpreted as the standard 3 _________ 1 Dekker, S (2005) Ten Questions About Human Error , Lawrence Erlbaum Associates 2, 3 Vaughan, D. (1996) The Challenger Launch Decision , University of Chicago Press

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MK Airlines (October 2004)

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Organizational Drift/Employee Adaptations Difficult to recognize from inside an association as incremental changes dependably happen Front line administrators make "locally productive practices" to finish work rapidly and cost-successfully Were dangers satisfactorily evaluated? Past victories taken as assurance of future wellbeing

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Fox Harbor – Touch Down Short of Runway (November 2007)

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SMS: Incident Reporting Challenges : Determining which episodes are reportable Analyzing 'close to miss' occurrences to look for chances to make upgrades to framework Shortcomings in organizations' investigation capacities given rare assets and contending needs

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SMS: Incident Reporting Challenges (cont 'd ) : Performance in light of blunder patterns misdirecting: no mistakes or occurrences does not mean no dangers Voluntary versus required, classified versus mysterious Punitive versus non-reformatory frameworks 1 Who gets occurrence reports _________ 1 Dekker, S. & Laursen, T. (2007) From Punitive Action to Confidential Reporting Patient Safety and Quality Healthcare September/October 2007 17

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SMS: Organizational Culture SMS is just as viable as the hierarchical culture that cherishes it Work bunches make standards, convictions and techniques one of a kind to their specific undertaking, along these lines turning into the work assemble culture 1 Undesirable attributes may create: absence of viable correspondence, over-dependence on past victories, absence of coordinated administration crosswise over association 2 _________ 1 Vaughan, D (1996), The Challenger Launch Decision , University of Chicago Press 2 Columbia Accident Investigation Report, Vol. 1, August 2003

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SMS: Accountability Recent patterns are towards criminalization of human blunder Sidney Dekker, Just Culture Safety endures when administrators rebuffed Organizations put resources into being protective instead of enhancing security Safety-basic data stream smothered for fears of retaliations ________ Dekker, S (2007) Just Culture , Ashgate Publishing Ltd.

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Elements of a "Simply Culture" (Dekker 2007) Encourages openness, consistence, cultivating more secure practices, basic self-assessment Willingly shares data without dread of retaliation Seeks out different records and portrayals of occasions Protects wellbeing information from aimless utilize Protects the individuals who report their genuine mistakes from accuse ___________ Dekker, S (2007) Just Culture , Ashgate Publishing Ltd.

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Elements of a "Simply Culture" (Dekker 2007) (cont.) Distinguishes amongst specialized and regularizing blunders in view of setting Strives to abstain from giving insight into the past a chance to predisposition impact the assurance of culpability, yet rather tries to see why individuals' activities sounded good to them at the time Recognizes there is no altered line amongst at fault and irreproachable mistake ________ Dekker, S (2007) Just Culture , Ashgate Publishing Ltd.

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SMS: Benefits and pitfalls Nothing will dependably ensure that every perilous condition in everyday operations will be found, broke down and followed up on. Be that as it may, SMS is advantage where it's executed. "careful foundation" for peril distinguishing proof and hazard moderation more reports of "close misses" when representatives feel safe about reporting them and when episodes are followed up on. recognizing limits of safe operations and when organizations float from these.

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About the TSB Independent association exploring marine, pipeline, rail and air events Finds out what happened and why Makes proposals to address security insufficiencies Not a controller or a court Does not relegate blame or decide common or criminal risk

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About the TSB (cont.) Reason's Model received in mid 90s Multicausality Human blunder inside more extensive hierarchical setting Integrated Safety Investigation Methodology (ISIM) Determining if full examinations are justified in light of potential to propel wellbeing Use of different human and authoritative variables structures (Westrum, Snook, Vaughan, Dekker)

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Summary Adverse results from complex communications of components hard to anticipate People at all levels in an association make security 'Close to misses' must be seen as "free open doors" for hierarchical learning 1 ________ 1 Dekker, S. & Laursen, T. (2007) From Punitive Action to Confidential Reporting Patient Safety and Quality Healthcare September/October 2007

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Summary Accident specialists must concentrate on what seemed well and good at the time, not be judgmental, keep away from insight into the past predisposition 2 Accountability requires associations and experts to assume full liability to settle issues 3, 4 ________ 2 Dekker, S. (2006) The Field Guide to Understanding Human Error Ashgate Publishing Ltd. 3 Sharpe, V.A. (2004) Accountability Patient Safety and Policy Reform Georgetown University Press 4 Dekker, S. (2007) Just Culture Ashgate Publishing Ltd.

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