hazard identification session 4. hazard identification hazard identification starts from two basic...

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

IATA Training & Development Institute 2

Here is what it looks like graphically


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


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)


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


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

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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


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


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


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”



Anatomy of an AccidentThree necessary components to any accident


Defenses

Unsafe Acts

Preconditions

Line Management

Decision Makers

AccidentAccident


2-Unsafe Acts


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This is what most accidents are

Here is how it all fits together


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


Safety Management System


Procedures

People

FacilitiesSoftware

Tools

Materials

Equipment

There may be “latent” unsafe conditions in all of these components


Detection of Latent Unsafe Conditions

THERE ARE MANY SYSTEMS

(none of which are unsafe when

isolated)


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


Paradigm Shift in Safety Management


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


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



Let us be clear on what we are trying to do: We are attacking the first link in the causal chain of an accident


Defenses

Unsafe Acts

Preconditions

Line Management

Decision Makers

AccidentAccident


2-Unsafe Acts


Detect and Correct

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We are here

PREVENTION =INTERRUPT THE CYCLE AT THE FIRST LINK IN THE CAUSAL CHAIN OF EVENTS


Elimination of Unsafe Acts: We are attacking the second link in the causal chain of an accident


Defenses

Unsafe Acts

Preconditions

Line Management

Decision Makers

AccidentAccident



1-Latent Unsafe Condition(s)+

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We are here

PREVENTION =INTERRUPT THE CYCLE AT THE SECOND LINK IN THE CAUSAL CHAIN OF EVENTS


Big difference between first and second


Defenses

Unsafe Acts

Preconditions

Line Management

Decision Makers

AccidentAccident


2-Unsafe Acts


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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


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

IATA Training & Development Institute 26©Aurion®2008

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


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



Elimination of Unsafe Acts: We are attacking the second link in the causal chain of an accident


Defenses

Unsafe Acts

Preconditions

Line Management

Decision Makers

AccidentAccident




+

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


THE ELEMENTS CHAIN – Here are the essentialsLATENTUNSAFE CONDITIONS

UNSAFEACTION

WINDOWOfOPPORTUNITY

Safety = Disrupt Causal Chain

Any questions?


Workshop – 2Identify and List All Hazards Related to

being in the Class Room

hazard identification session 4. hazard identification hazard identification starts from two basic...

Documents

hazard identificationsession

core competencies important

probability of accidents

loss of life

organizational systems

true naturea runway

backgroundnot visible

organizations smseverything