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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