Systemic safety from design to operations: examples from

aviation

Nick McDonald Centre for Innovative Human Systems

School of Psychology Trinity College Dublin

OUTLINE

• Basic components of a socio-technical system

• What kind of system?

• The ‘real system’

• How do S-T systems work?

• The process of change

• Socio-technical design principles

• The lifecycle from design to operations

• Activity and culture

SYSTEMS – WHAT ARE WE TALKING ABOUT?

• The target operational system under focus

– Including its social and organisational dimensions

• A system for managing that operational system

– E.g. Safety Management System

• A ‘technical system’ for achieving certain functions

– Theory, model, methodologies, data

– Functional task support

– Transformation and flow of data, knowledge

REQUIREMENTS FOR A THEORY OR MODEL

• Relevance – Address core determinants at appropriate level – Support inferences that are verifiable and correct

• Leverage – Generate cogent recommendations – Support intervention design and evaluation

• Systematic comparison across cases – Common set of dimensions for analysis

• Improve level of prediction – Support prospective risk assessment – Future system design

• No assumption that we can explain all the variance – Just do better than now – C. 50% failure of change, new technology implementation

Basic components of a socio-technical system

Functional System

Action/ interaction

Know-how

Culture

Measure performance

Enable & consolidate

culture

Change system Change competence

WHAT KIND OF SYSTEM? • Main sources of uncertainty in an operational or production

system – Demand and availability of resources

• Materials, parts, tools, people • E.g. Base Maintenance

– Task accomplishment • Complex and indeterminate tasks • E.g. Flight operations • Tightly controlled repetitive tasks that require sustained attention • E.g. Assembly

– Co-ordination • Between tasks, between processes • E.g. Aircraft turnaround at airport

– Goals • Design and change processes

THE ‘REAL SYSTEM’

• Informal practice and embedded routines

– WIPIDO – Well Intentioned People in Dysfunctional Organisations

• Inverse of Human Error

• Double standard – real system is partially hidden and deniable

– Cycles of stability

• When things go wrong much organisational effort addresses the problem but ends up reinforcing the status quo

– 3-4 serious incidents before an effective solution is found

– ‘No-blame’ and train

– Tacit, partially shared knowledge and understanding

• Just sufficient to ensure functional co-ordination

• Creates inertia that reinforces stability / stasis

FOLLY: IGNORING FUNDAMENTAL CONSTRAINTS • Uncertainty about resources

– Create a local demonstration of how the system could work perfectly

• Sucks resources from the rest of the system

– Optimal system performance depends on sub-optimised units

• Uncertainty about task performance

– Seek to automate complex indeterminate decisions

• Uncertainty about co-ordination

– Ignore least visible partner

– Least visible may be key to critical path

How do S-T systems work? SCOPE Analysis Framework

LOGICS OF ORGANISATION

Process logic Knowledge logic Social logic

Core concepts Resources, tasks, co-ordination, critical points

Information, knowledge

Relationships between people

Mechanism Transformation of resources to output

Transformation of meaning

Co-ordination of activity

Relationships Sequential Circular - validation Reciprocal

Timeline Real time Relates past, present and future

Slow build up over time

Key functional parameter

Propagation / control of uncertainty

Common understanding of system and values

Team integration and trust

Value delivered Transactional value Possibility of change Enduring relationships sustain value

SCOPE SOFTWARE

CASE STUDIES Diagnosis Prognosis

A/c Maintenance: “This is what we do but I have never seen it written down before”

Project transformation of process enabled by a/c health monitoring technologies

Collaborative process mapping, improvement team, ‘blocker reports’, management improvement process

Successful maintenance change • Profitable • Reduced incidents • Release from frustration

Airport operational performance • Daily journal, anomalies report, Hazard

ID

Improved operational support Better hands-on management SMS development

Airline SMS • Devlpt & integration of SPIs • Common risk concept Mx & FO

SMS implementation phase • Integrated management concept • Link with Lean improvement • Antecedents and consequences

Airport collaborative decision making • Dispatch coordination at milestones • All stakeholders involved • Serious game fosters collaboration

Training and implementation to focus more on collaboration

KNOWLEDGE AND INFORMATION

• Knowledge about how the system works

– Knowledge is partial and not fully shared

– Needs to be worked on to uncover and transform tacit knowledge

• Information about what the system is doing

– System knowledge seeks data & transforms it into information and enriches shared knowledge

– Antecedents and consequences to understand cause and risk

Achieving value Operational &

Management processes

Analysing Models

Evaluation

Managing information

Data Risk & hazard analysis Operational support

Capacity Building Mentoring

Agile training Masters

Serious Gaming Simulation

Support for Knowledge Cycle MASCA project

Information Cycles Proactive Safety Performance for Operations

Plan Brief

Act Decide

Delegate

Check Review

Demand Aggregator

Crew capacity Synthesis

Dependencies per Phase

Alternatives & Risk

Comparator

Assessment

Dependency Analysis Action list …………….. …………….. …………….. …………….. ……………..

Manage the

Operation

Identify Needs &

Goals

Plan & Prepare

Execute Plan

Review

Knowledge & Information

Social Relations

Goals

Operational Process

Management Process

Dependency Analysis Action list …………….. …………….. …………….. …………….. ……………..

Manage Change

The process of change

CONVERGENCE OF DESIGN AND CHANGE

Generic logic of design for operations Operational System Change Logic

Require technologies that increase customer value through improved system performance

Requirement to reduce cost, improve safety, (etc.) drives demand to improve process.

Technology provides new information at operational level. This changes a key dependency that transforms the logic of supply, planning or ops management.

A new IT application is introduced to support a key process task. This improves value created at local level

Increasing integration of the system-wide information architecture (SWIM) raises the possibility of seamless process integration

Data from applications on the SWIM creates opportunity for integrated performance management.

New applications hosted on the SWIM make the processes work in a new way to deliver new value to the customer

New applications hosted on the SWIM provide better services for internal and external stakeholders (operations, planning & supply, quality & safety, customer, national authority)

New knowledge and information from normal operations enables design of smarter technologies adding value for the customer

New knowledge services hosted on SWIM enhance common understanding, trust in system, embedded learning, change management, design for operations.

Design Concept

Future system model

Operational risk assessment Design risk assessment

Knowledge Exchange and Transformation Modeling

Data integration and analysis Agile Learning

Design Evaluation

Implement &

Change

Change Evaluation

Implementation record

Change assessment Operational risk

profile

Lifecycle Cost and Value Assessment

The lifecycle from design to operations

Closing the System Loops

Activity

• More effective support for operational performance

• More comprehensive data from all stages of the operation

• Core shared understanding of the system minimizes distortions of performance management

Culture

• Participate in mapping, understanding process functions

• Contribute know-how to improvement activity

• Receive benefits from improvement

• Support for and renewal of ‘real system’

Activity and culture

Functional System

Action/ interaction

Know-how

Culture

Measure performance

Enable & consolidate

culture

Change system Change competence

Support performance

Design system to foster culture

UNDERLYING METHODOLOGICAL PRINCIPLES

• The organisational system is what needs to be changed to improve the value delivered by the system. This needs to happen at the following levels: – Social and technical

– Operational and management processes

• The system should fully support the actions of people to achieve that value. This involves: – Progressively and decisively eliminate those blockers that inhibit

that performance

• All this needs to be understood in common – Participative understanding by everyone of how the real system

works

– Flow of information about what the system is doing

System Modeling

Analyse System Risk

Design & Change the Operation

Manage the Operation

Low cost

Integrated service

Hyper-

performance: safety &

environment

Real, sustainable, resilient value Distributed authority Accountable self-regulation

Demand Enabling Mechanism Delivered Outcome

THANK YOU

Support of the European Commission Framework Program is acknowledged