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La proteccin de las fuentes de informacin sobre la seguridad operacional La perspectiva tcnica

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La protecci n de las fuentes de informaci n sobre la seguridad operacional ... Forensic Safety Management. The Underlying Paradigm Rule-based System ... – PowerPoint PPT presentation

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Title: La proteccin de las fuentes de informacin sobre la seguridad operacional La perspectiva tcnica


1
La protección de las fuentes de información
sobre la seguridad operacional La perspectiva
técnica
  • Capt. Daniel Maurino
  • Seguridad de Vuelo y Factores Humanos OACI
  • Seminario de Seguridad ASPA/OACI
  • Cuidad de México, 10 11 Abril 2007

2
Forensic Safety Management
  • Focus on the outcome (s)
  • Unsafe acts at the tip of the arrow
  • Blame punishment for failure to perform
    safely
  • Address specific safety concern exclusively

3
The Underlying ParadigmRule-based System
  • Deterministic The world as it should be
  • Aviation system as pre-specified is perfect
  • Compliance based
  • Outcome oriented
  • Accident investigation

4
Inefficiency and Perversity
  • The beatings will continue until morale improves

2. Punishment
3. Remedial Training
1. Exhortations to professionalism and discipline
4. Add more procedures regulations
5

System Performance In the Wild
6
Managing SafetyNavigating the Drift
7
The Navigational Aids
  • Reactive systems
  • Accident investigation
  • Incident investigation
  • Predictive systems
  • Electronic safety data acquisition systems
  • Direct observation safety data acquisition
    systems
  • Proactive systems
  • Mandatory reporting systems
  • Confidential reporting systems
  • Voluntary self-reporting systems

8
Safety Data Systems and Levels of Intervention
Safety management levels
Desirable management level
9

Managing Safety Collapsing the Drift
10
Emerging ParadigmPerformance-Based System
  • Deterministic The world as it should be
  • Aviation system as pre-specified is perfect
  • Compliance based
  • Outcome oriented
  • Accident investigation
  • Ecological The world as it is
  • Aviation system as pre-specified is imperfect
  • Performance based
  • Process oriented
  • Safety data captured from daily, normal operations

11
(No Transcript)
12
Protecting Safety Data An Odyssey
  • Clearly defined objective
  • Protect sources of safety information
  • At the intersection of safety, law politics
  • The solution Safety and Law
  • The Implementation Political will
  • An inescapable reality
  • No safety data protection No SMS

13
Protecting Safety Information Excuses and Fear
  • Denial ritualistic blaming leading to
    self-delusion
  • Repair cover-up, cosmetic re-writing denying
    learning
  • Reform engaging the political will
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