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Hazard IdentificationSession 4
Hazard Identification
Hazard Identification starts from two basic fundamental ideas:
Something causes accidents Identify the hazard, latent or otherwise, and you go a long way in
preventing the accident from occurring
Accidents are organizational in nature It is the complexity of many organizational systems which give rise
to failure. Usually it is difficult to pinpoint just one internal system and just one failure
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Here is what it looks like graphically
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Here is how it all fits together
SAFETY BY DEFINITION
A Continual Process of Hazard Identification & Risk Management(As Core Competencies)
Let us look at this more closely
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These are the two core competencies that each organization must master
Here is how it all fits togetherSAFETY BY DEFINITION
A Continual Process of Hazard Identification & Risk Management(As Core Competencies)
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Anatomy of An Accident – What Causes Accidents?Any Accident has all three
REASON’S MODEL OF ANACCIDENT
Defenses
Unsafe Acts
Preconditions
Line Management
Decision Makers
AccidentAccident
3-Windowof OpportunityFavorable conditions or
sequence of events compounded by 1. and 2.
2-Unsafe ActsActive failures
(errors or violations by the system’s operator)
1-Latent Unsafe Condition(s)i.e Gaps in supervision,
undetected defects, failures of maintenance
+
+
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The Anatomy gives rise to the PreventionPrevention = Interrupt the cycle at any point
REASON’S MODEL OF ANACCIDENT
Defenses
Unsafe Acts
Preconditions
Line Management
Decision Makers
AccidentAccident
3-Windowof Opportunity
Identify and Avoid
2-Unsafe ActsTrain & Prevent
1-Latent Unsafe Condition(s)
Detect and Correct
+
+
Take away any one of the three and the probability of accidents goes away
Why are these core competencies important?
These two core competencies are the very heart of any organizations SMS
Everything else flows from this
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HAZARD IDENTIFICATION
+RISK
MANAGEMENT
Hazard Identification
What is a Hazard?
The condition or circumstance that can lead to a loss of life or an aircraft
First core competency
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Hazard DefinitionICAO Definition states that
Hazard is a condition, object or activity with the potential of causing injuries to personnel, damage to equipment or structures, loss of or reduction of, ability to perform a prescribed function
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Source ICAO
Lions in Africa
Understanding Hazards Hazards are easy to define Hard to identify Harder to understand Natural tendency is to describe a hazard as an outcome
Describing a hazard by its outcome disguises its true nature A “runway incursion” or “unclear airport signage”
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Anatomy of an AccidentThree necessary components to any accident
REASON’S MODEL OF ANACCIDENT
Defenses
Unsafe Acts
Preconditions
Line Management
Decision Makers
AccidentAccident
3-Windowof Opportunity
2-Unsafe Acts
1-Latent Unsafe Condition(s)
+
+
This is what most accidents are
Here is how it all fits together
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SAFETY BY DEFINITION
A Continual Process of Hazard Identification & Risk Management(Our Two Core Competencies)
Latent Unsafe Conditions(as one of the three elements of an accident)
Definition of Latent
“Latent” means Resting into the background Not visible or apparent Accessible but undetected
Now apply all these meanings to
“Latent” Unsafe Conditions
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Safety Management System
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Procedures
People
FacilitiesSoftware
Tools
Materials
Equipment
There may be “latent” unsafe conditions in all of these components
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Detection of Latent Unsafe Conditions
THERE ARE MANY SYSTEMS
(none of which are unsafe when
isolated)
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AccidentAccident
Accident Causes are Non-Linear
(so are the latent unsafe conditions)
Latent Unsafe Conditions
How do we identify them?
We start with the paradigm shift in Safety Management
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Paradigm Shift in Safety Management
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Reactive method(Historical Analysis)
The reactive method responds to the
events that have already
happened, such as incidents and
accidents
Look for trends&
repetitive events
Proactive method(Current Analysis)
The proactive method looks actively for the
identification ofsafety risks
through the analysis of current activities
Look for repetitive events&
non-linear associations
Predictive method(Real Time Analysis)
The predictivemethod captures
systemperformance as
it happens in real-time &
normal operations
Look for deviationsfrom system boundaries
Clear shift towards the Predictive Method – this is the key
Latent Unsafe Conditions Have a degree of predictabililty Predictive (Real time analysis) depends on (i) technology and
(ii) a responsive feedback system
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Predictive method
(Real Time Analysis)
Look for deviations
from
system boundaries
Predictive Analysis
Captures system
performance in
real-time
as it happens
ANY DEVIATIONFROM THE SYSTEM BOUNDARYIS A LATENT UNSAFECONDITION
Detecting “Latent” Unsafe Conditions using known concepts
Use the same Three Concepts (Tools) previously used to determine an “acceptable level of safety” 80-20 Rule Power Curves Double Feedback Loops
All these are good indicators of “Latent” Unsafe Conditions
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Let us be clear on what we are trying to do: We are attacking the first link in the causal chain of an accident
REASON’S MODEL OF ANACCIDENT
Defenses
Unsafe Acts
Preconditions
Line Management
Decision Makers
AccidentAccident
3-Windowof Opportunity
2-Unsafe Acts
1-Latent Unsafe Condition(s)
Detect and Correct
+
+
We are here
PREVENTION =INTERRUPT THE CYCLE AT THE FIRST LINK IN THE CAUSAL CHAIN OF EVENTS
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Elimination of Unsafe Acts: We are attacking the second link in the causal chain of an accident
REASON’S MODEL OF ANACCIDENT
Defenses
Unsafe Acts
Preconditions
Line Management
Decision Makers
AccidentAccident
3-Windowof Opportunity
2-Unsafe ActsTrain & Prevent
1-Latent Unsafe Condition(s)+
+
We are here
PREVENTION =INTERRUPT THE CYCLE AT THE SECOND LINK IN THE CAUSAL CHAIN OF EVENTS
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Big difference between first and second
REASON’S MODEL OF ANACCIDENT
Defenses
Unsafe Acts
Preconditions
Line Management
Decision Makers
AccidentAccident
3-Windowof Opportunity
2-Unsafe Acts
1-Latent Unsafe Condition(s)+
+
1 = Latent, passive, not easily observedvs2 = Active (it must happen) and is easily observable
Eliminating Unsafe ActsCorrective action and elimination is always post occurrence
(after the act)
This means the unsafe act must: Occur Be recognized and noted as unsafe Be recorded and described Be subject to analysis Be subject to enhanced oversight
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Enhanced OversightEnhanced Oversight is a condition of focused and directed
attention and observation Identify further unsafe acts of a similar kind Identify system weakness which permitted the unsafe
act to occur Shape or negotiate a “beta” fix for the weakness Observe and document the effectiveness of the “fix” Analyze and oversight to see if the fix is effective Fully document actions taken & exact nature of the fix
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No copy permitted
INTEGRATE FIX INTO SMS
Unsafe acts can be easily observed in some instances Predictive (Real time analysis) depends on (i) technology
and (ii) a responsive feedback system
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Predictive method
(Real Time Analysis)
Look for deviations
from
system boundaries
Predictive Analysis
Captures system
performance in
real-time
as it happens
ANY ACT WHICH IS A DEVIATION FROM THE SYSTEM BOUNDARYIS AN UNSAFE ACT
Unsafe Act Reporting The majority of unsafe acts are reported The key element in the SMS Voluntary incentives to report unsafe acts Immunity from consequences if reported and detailed as
to unsafe acts or possible unsafe acts
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Elimination of Unsafe Acts: We are attacking the second link in the causal chain of an accident
REASON’S MODEL OF ANACCIDENT
Defenses
Unsafe Acts
Preconditions
Line Management
Decision Makers
AccidentAccident
3-Windowof Opportunity
2-Unsafe ActsTrain & Prevent
1-Latent Unsafe Condition(s)+
+
We are here
PREVENTION =INTERRUPT THE CYCLE AT THE SECOND LINK IN THE CAUSAL CHAIN OF EVENTS
Safety from a New Perspective
Disrupt the Element Chain – take away any single element Remove latent unsafe conditions – examine all possibilities Avoid unsafe actions – examine all procedures Window of Opportunity – identify potential scenarios
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THE ELEMENTS CHAIN – Here are the essentialsLATENTUNSAFE CONDITIONS
UNSAFEACTION
WINDOWOfOPPORTUNITY
Safety = Disrupt Causal Chain
NAPO
Any questions?
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Workshop – 2Identify and List All Hazards Related to
being in the Class Room