integrating human factors into a safety management … the interface between people and the...
TRANSCRIPT
1
Remi JolyOffice of Safety
and QualityCASS 2006
Integrating Human Factors into a Safety Management System
Overview
• Elements of NAV CANADA’s Safety Management System
• Using the four P’s• Thoughts on Approach• Conclusion
Elements of the SMS
Safety Planning
Operational Risk
Management
Exchange of Safety
Information
Safety Performance Measurement
Safety Management Assurance
Safety Management System
Human Factors Framework
Strong Safety Culture
Definition of Human Factors
NAV CANADA’s Definition:
Human Factors is the discipline which seeks to optimize the interface between people and the equipment they use, the tasks they perform and the physical and organizational environment in which they work.
The Four P’s
• Philosophy• Policy• Procedures• Processes
The Four P’s: Philosophy
– Human Factors Framework• Socio-technical system• Models
– Reason’s Accident Causation model– PETE model– Generic Error Modeling System (GEMS)
• Common understanding throughout the Company
Reason’s Accident Causation Model
HAZARDsRISKs
IncidentorAccident
Localworkplace Errors
Organization
System Safety
Deficiencies
PETE PETE GEMS
Weak or MissingDefences
The PETE Model
P: PersonE: EquipmentT: TaskE: Environment
P
E
T
EP
The PETE Model
The Four P’s: Policy
– HF is part of our SMS policies– Clearly defined objective– Clearly defined responsibilities
Human Factors Policy:An example
The Vice President, Safety & Quality is responsible for:
(a) reviewing and assessing the effectiveness of safety-related policies and procedures in taking account of the role of human and organizational factors;
(b) providing or facilitating the provision of Human Factors training as it relates to corporate safety management;
(c) evaluating the application of Human Factors in hazard analyses and occurrence investigations; and
The Four P’s: Procedures
– Hazard Analysis Procedure
Hazard Analysis Procedure
- Use the PETE model to describe the system- Task
- Sequence aircraft for landing
- Person – ATC- Qualified and checked-out- Experience and qualifications
- Equipment- Radio- Radar Display
Hazard Analysis Procedure
- Introduce change (new sequencing tool) and identify potential impact on operator performance- Task
- Sequence aircraft for landing (?)
- Person – ATC- Qualified and checked-out- Experience and qualifications (?)
- Equipment- Radio- Radar Display (?)
The Four P’s: Processes
– Operations Safety Investigation (OSI)– NAV CANADA Aviation Safety Tracking
System (NCASTS)– Safety Culture Assessment Tool– Corporate Safety Planning
Operations Safety Investigation
Human performance (GEMS)
Context (PETE Model)
Defenses & associated deficiencies(Reason’s Model)
NCASTS
Person - Equipment
0
40
80
120
160
200
Hardware Software Tools
87
26
189Number of Issues
Hardware 87Software 26Tools 189Total 302
NCASTS
0
2040
60
80
100
120
140
Checklists Procedures Written Material Required for Operational Controls
1
129
59
Number ofIssues
Person –Equipment – Tools
Checklists 1Procedures 129Written Material Required for Operational Controls 59 Total 189
NCASTS
0
20
40
60
80
100
Adequacy Availability Usage
92
18 19
Number of Issues Person - Equipment – Tools - Procedures
Adequacy 92Availability 18Usage 19Total 129
Safety Culture Assessment Tool
– Emphasis and importance given to Safety– Degree of cooperation and cohesiveness– Match between task and resources – Effective and free flowing communications – Clear mapping of the safety state – Strong learning orientation – Clear lines of authority and accountability
The Four P’s: Processes
– Operations Safety Investigation (OSI)– NAV CANADA Aviation Safety Tracking
System (NCASTS)– Safety Culture Assessment Tool– Corporate Safety Planning
Thoughts on Approach
• Start with focused activity• Take small steps • No one element should be thought of as the
panacea to improving safety• Still need to cover the basics• It’s integrated – it’s the way we do business • Not a huge dedicated resource requirement
Last Thought
Human and Organizational Factors have to be quantified in safety risk management terms.