Professional Documents
Culture Documents
Presented by AFS-900
Amer M. Younossi
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Modules
1 Why Flight Standards Is Implementing
System Safety and Risk Management
2 3 4 5 6
Risk Concepts System and Organizational Principles Human Factors Data and Analysis Risk Management
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System Safety and Risk Management
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System Safety and Risk Management
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90-Day Safety Review White house and congressional mandates to reduce the accident rate by 80% in 10 years
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System Safety and Risk Management
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The task force categorized issues into six general areas: certification policy and process resource targeting to address safety risks newly certificated air carrier operations and growth outsourcing and varied fleet mix inspector and air carrier guidance material inspector resources
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System Safety and Risk Management
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Aggressive attitude with respect to aviation safety Pro-active approach Air carrier to maintain the highest possible degree of safety Achieve this in the most economical and efficient manner to the government and the carrier
Source: FAA Order 1000.1A
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System Safety and Risk Management
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Setting regulations and standards for: air carriers Flight Standards Vision air commerce To be recognized and respected worldwide as the foremost authority on system air agencies safety approaches for regulation and airmen, etc. certification
Accomplishing certification, surveillance, inspection, investigation and enforcement activities Managing the systems for registry of ... aircraft airmen
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System Safety and Risk Management
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Air traffic is increasing Aviation operations are becoming more complex FAA oversight staff and resources are constrained We can no longer afford to function as a direct source of QC Systems approach is proactive Stresses process improvements System safety is good business
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System Safety and Risk Management
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System Safety and Risk Management
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System safety is: Validation of regulatory compliance Review and validation of systems and entire programs, not portions Application of safety attributes Application of risk management
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System Safety and Risk Management
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AFS-900 Objectives
Air carrier certificates are our gold standard to measure how well we are accomplishing our responsibilities.
Dave Gilliom ~ AFS-900
Standardize air carrier certification Standardize systems and targeting risks Centralize information management functions Six Processes are ISO-9000 Certified
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System Safety and Risk Management
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ATOS Model
Policy --------------------------------------------------
Module 2
Certificate Management
Module 3
Surveillance Resource Mgmt
Module 1
System Configuration
Module 4
Surveillance
Module 8
Implementation
Module 5
Reporting
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Analysis
Module 6
Evaluation
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System Safety and Risk Management
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AFS-900 Functions
Certification Surveillance/Evaluation Planning Aircraft conformity team Technical support program Improve the certification and surveillance processes for air carriers Ensure regulatory compliance and incorporate a systems approach Enhance the surveillance process Standardize the surveillance processes
Provide analytical support to Flight Standards Identify industry-wide risk areas Partnership with aviation safety research institutions
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AFS-800 Function
System Safety Approach for General Aviation (SAGA)
Improve the oversight process for general aviation Open communications with air operators. Identify focus areas to target, and provide feedback to operators.
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System Safety and Risk Management
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Business process procedures, guidelines, and automation tools Data quality enhancement and database standardization Risk management/analysis procedures and automation Interconnectivity of agency and industry databases
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System Safety and Risk Management
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System Safety and Risk Management
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USC Title 49
Sec. 44702. Issuance of certificates
... (B) considerations. - When issuing a certificate under this chapter, the administrator shall (1) consider (a) the duty of an air carrier to provide service with the highest possible degree of safety in the public interest. ...
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System Safety and Risk Management
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USC Title 49
Sec. 44701. General requirements
(A) promoting safety. The administrator of the FAA shall promote safe flight of civil aircraft in air commerce by prescribing ... (2) regulations and minimum standards in the interest of safety
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System Safety and Risk Management
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System Safety and Risk Management
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Operators organizational structures Systemic orientation and completeness of regulations Defining and measuring safety FAA and industry cultures Human factors Availability of valid, reliable data that are representative of the system Risk management application
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System Safety and Risk Management
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Summary
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System Safety and Risk Management
Presented by AFS-900
Module 1 Outline
Module 2 Fundamentals
Module 3 Definitions
Module 4 Concepts
Module 5
Risk Factors
Module 2 Outline
Fundamentals of Risk
Definitions of Risk Common Concepts of Risks Risk Factors/Controls System Safety
Summary
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System Safety and Risk Management
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Risk Factors
Risk Management
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System Safety and Risk Management
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Risk Factors
Exposure to hazard...
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System Safety and Risk Management
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Risk Factors
Schools of Thought
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System Safety and Risk Management
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Risk Factors
Definition(s) of Risk
Several definitions exist, based upon the context for which they were developed
More than one are used in AFS programs
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System Safety and Risk Management
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Risk Factors
Common Concepts
What is it that I will run into, hit, trip on, etc.? Hazard, condition, failure, threat Something bad can happen to us Undesired event, mishap, consequence
How likely is it to happen? Likelihood, probability (impact)1 How bad will it hurt if it does? Severity, impact (impact)1
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System Safety and Risk Management
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System Safety and Risk Management
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Risk Factors
Risk Factors
Things about the inherent hazard, system design, or organizational performance that affect risk likelihood or severity.
Task complexity
Environmental factors
Difficult procedures Poor or missing supervisory controls
Poor Communications
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System Safety and Risk Management
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System Safety and Risk Management
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System Safety and Risk Management
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Risk Factors
Operation
Hazard
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System Safety and Risk Management
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Risk Factors
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System Safety and Risk Management
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Risk Factors
System Performance
Conformance/compliance
Effectiveness
Does the system accomplish its intended function (control the risk factors)?
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System Safety and Risk Management
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System Safety and Risk Management
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The FAA will use the System Safety Process Model as a basis.
Model was adapted from Nicholas J. Bahr by AFS-900 and ASY-300 for use by Flight Standards
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System Safety and Risk Management
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Risk Factors
Risk Management
System Descriptions
Modify System/Process
System/Process Review
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Documentation
System Safety and Risk Management
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Risk Factors
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System Safety and Risk Management
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Risk Factors
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System Safety and Risk Management
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Risk Factors
Risk Perceptions
Carelessness and overconfidence are more dangerous than deliberately accepted risk
- Wilbur Wright, 1901
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System Safety and Risk Management
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Summary
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System Safety and Risk Management
Presented by AFS-900
Module 1 Outline
Module 2 System
Module 3 Attributes
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Operator Objectives
Regulators Objectives
Module 3 Outline
What is a system?
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System Safety and Risk Management
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System Safety and Risk Management
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Whats a System?
A system is a composite of people, tools, procedures, materials, equipment, facilities, and software operating in a specific environment to perform a specific task or achieve a specific purpose, support, or mission requirement.
- Roland and Moriarty, System Safety Engineering and Management
Systems
Procedures
...a set of components that act together as a whole to achieve a common goal
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System Safety and Risk Management
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Situation - Environment
What Are the Conditions?
Physical environment Facilities Airports Weather patterns Operational environment Type of operation Type of equipment Employee demographics Financial factors
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Tasks - accomplished by humans Pilot tasks - Advanced Qualification Program (AQP) Maintenance tasks - Work cards Functions - organizational structures to accomplish tasks
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System Safety and Risk Management
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Process Measurement
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System Safety and Risk Management
What is a Process?
A Process is a set of tasks, work-flows and information flows that produce a desired result.
Source: System Safety Course, FAA Academy
If you can't describe what you are doing as a process, you don't know what you're doing.
W. Edward Deming
US business advisor & author (1900 - 1993)
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System Safety and Risk Management
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Inputs
Process
Outputs
Resources
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System Safety and Risk Management
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Responsibility
Operator Objectives
Regulators Objectives
Authority
Output
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System Safety and Risk Management
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Interfaces Authority Responsibility
Operator Objectives
Regulators Objectives
Controls
Job
Task Task Task Task
Output
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System Safety and Risk Management
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Interfaces Authority Responsibility
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Controls
Job
Task Task Task Task
Output
Job Input
Task Task Task Task
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Resources Process Controls System Safety and Risk Management
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Interfaces Authority Responsibility
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Process Measurement
Controls
Job
Task Task Task Task
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Resources Process Controls System Safety and Risk Management
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Interfaces Authority Responsibility
Operator Objectives
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Completed Function
Responsibility / Authority
Procedures Interfaces Controls
Process Measurement
Controls
Job
Task Task Task Task
Output
Status
Job Input
Task Task Task Task
Process Measures
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Resources Process Controls System Safety and Risk Management
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Operator Objectives
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Operators Objectives
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System Safety and Risk Management
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Operator Objectives
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Safety Goals
Decision Makers
Production Goals
Protection
Defensive Filters
Production
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System Safety and Risk Management
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Operator Objectives
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Regulators Objectives
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System Safety and Risk Management
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Validation of regulatory compliance Review and validation of systems and entire programs, not portions Application safety attributes Application of risk management
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System Safety and Risk Management
Module 1 Outline
Module 2 System
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Module 6 Summary
Operator Objectives
Regulators Objectives
Summary
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System Safety and Risk Management
Presented by AFS-900
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Understand Causes
Module 4 Outline
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System Safety and Risk Management
Human Performance
Basic
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System Safety and Risk Management
Information processing Situation awareness Cognitive (Mental) workload CRM (Cognitive Resource Management)
Situation Awareness
Situation awareness is the perception of the elements in the environment within a volume of time and space, the comprehension of their meaning and the projection of their status in the near future.
-Mica Endsley, 1993
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System Safety and Risk Management
Mental Model
Perception
Comprehension
Projection
Source: Dr. Mica Endsley
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Level 1 - Failure to correctly perceive the situation. Level 2 - Failure to comprehend the situation. Level 3 - Failure to comprehend the situation into the future.
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System Safety and Risk Management
ASRS data. 169 errors in 113 incidents. 80.2% Level 1 Errors 16.9% Level 2 Errors 2.9% Level 3 Errors
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System Safety and Risk Management
Human working memory is limited The magic 7 plus or minus 2 (Miller, 1956) Fatigue can reduce this Interruptions can bump material in working memory Information needed for a typical instrument approach can exceed the capacity available
Activities late in flight have high workload Capacity is diminished by fatigue High accident potential (Boeing studies)
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Understand Causes
Human Error
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System Safety and Risk Management
Human Error
Error is ubiquitous - its a human thing. Most accidents are human related. Rules and attention to detail are essential in a systematic approach to safety, but... Regulations and exhortations often have limited effectiveness in error prevention. Be careful only works so far.
Human Error
Skill or action-type problems most often responsible for frequent, low-severity events.
Decision-type problems more often responsible for highseverity events (fatal accidents).
200 GA accidents analyzed Decision errors: 31% of minor/non-injury accidents 63% of fatal accidents Action (skill) errors: 48% of non-injury accidents 16% of fatal accidents
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System Safety and Risk Management
Error Mitigation
Skill-based errors
Rule-based errors Knowledge-based
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System Safety and Risk Management
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Understand Causes
Understand Causes
Active Failures
Latent Failures Air Ontario - Dryden Pilot Error Organizational Failures
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System Safety and Risk Management
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Understand Causes
Latent Failures
Operational Personnel
Diminishing Returns Redirect Safety Efforts Judging Safety Health
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System Safety and Risk Management
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Understand Causes
Workplace
Local Factors
Physical Environment Operational Environment Task Design
People/Team
Active Failures
Performance Errors - Mistakes - Slips - Lapses Violations
Controls Outcome
Accidents
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System Safety and Risk Management
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Understand Causes
Workplace
Local Factors
Physical Environment Operational Environment Task Design
People/Team
Active Failures
Performance Errors - Mistakes - Slips - Lapses Violations
Controls Outcome
Accidents
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System Safety and Risk Management
Module 1 Outline
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Understand Causes
Workplace
Local Factors
Physical Environment Operational Environment Task Design
People/Team
Active Failures
Performance Errors - Mistakes - Slips - Lapses Violations
Controls Outcome
Accidents
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System Safety and Risk Management
Antiauthority (dont tell me!). Impulsivity (do something quickly!). Invulnerability (it wont happen to me). Macho (I can do it). Resignation (whats the use?).
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System Safety and Risk Management
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System Safety and Risk Management
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System Safety and Risk Management
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Understand Causes
Safety Culture
Incident Investigation Feedback Increase Tolerance Limit Error Potential
Closed Loop
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System Safety and Risk Management
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Understand Causes
Organizational Response
Denial
Repair Reform
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System Safety and Risk Management
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Understand Causes
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System Safety and Risk Management
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Understand Causes
Summary
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System Safety and Risk Management
Presented by AFS-900
Module 1 Outline
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Decision-Making Hierarchy
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Decision-Making Hierarchy Question Analysis Data Contribution of Data to System Safety Summary
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System Safety and Risk Management
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Decision-Making Hierarchy
Decision-Making Hierarchy
Action
Decision
Knowledge
Information Data Observation
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System Safety and Risk Management
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Decision-Making Hierarchy
Biases
Humans tend to use simple rules of thumb called heuristics. These heuristics simplify mental processes but they can also lead to over simplification and error. Typical biases include: Representativeness heuristic Salience - most attention-getting rather than most useful Availability heuristic - recency Confirmation bias - tendency to focus on initial hypothesis As if weighting (all info assumed of same quality) 93 Conservatism System Safety and Risk Management
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Decision-Making Hierarchy
Decision-Making Hierarchy
Action
Decision
Question/Problem
Knowledge
Information Data Observation
Analysis
Data
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System Safety and Risk Management
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Decision-Making Hierarchy
Counteracting Biases
Question
Bias can be reduced through the careful use of data Clear Empirical Question
Data
Good Quality Data
Analysis
Appropriate Data Analysis
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System Safety and Risk Management
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Decision-Making Hierarchy
Question
Problem Definition - What do we want to know? System definition and analysis Description of the situation Risk or Problem statement Operational definitions are important
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System Safety and Risk Management
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Decision-Making Hierarchy
Analysis
Types of information
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System Safety and Risk Management
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Decision-Making Hierarchy
Analysis
Aggregation
Result will depend more on mix of data than performance of any element
Trends are especially sensitive
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System Safety and Risk Management
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Decision-Making Hierarchy
Analysis
Comparisons
Norms / thresholds Association with factors Comparisons between subgroups (e.g. location, aircraft fleet) Trends
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System Safety and Risk Management
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Decision-Making Hierarchy
Analysis
Trend Analysis
A special type of comparison Often confused with generalization Must be based upon a reliable, quantifiable metric at progressive time points Must have good internal validity Must have data available in adequate quantity, regular intervals
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System Safety and Risk Management
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Decision-Making Hierarchy
Data
Data Torturing
Inappropriate comparisons to averages, specifications, targets and percentages Smoothing Limited point trends Use of raw counts
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System Safety and Risk Management
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Decision-Making Hierarchy
Data
What is data?
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System Safety and Risk Management
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Decision-Making Hierarchy
Data
Automation and Data
Good quality automation is essential to manage the workload of providing data, but
Neither automation nor analysis can add information which is not in the data
Computers do not produce new sorts of errors. They merely provide new and easier opportunities for making old errors.
Source: Trevor Kletz, Wise After the Event
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System Safety and Risk Management
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Decision-Making Hierarchy
Data
Sampling
Sample data represents a larger group with data from a small group Distribution of observations is important Must identify factors that can effect performance Problems can be created in rollups
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System Safety and Risk Management
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Decision-Making Hierarchy
Data
Text and Narratives
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Decision-Making Hierarchy
Data
Data Quality Attributes
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System Safety and Risk Management
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Decision-Making Hierarchy
Data
Data Validity
Validity means that the data measure what they are intended to measure
Vague Definitions Insufficient Evaluator Training Casual Data Collection Methods Operator Discretion
Source: AQP Data Management Guide, 1998
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System Safety and Risk Management
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Decision-Making Hierarchy
Data
Data Reliability
Consistency between raters Consistency among items Stability in measurements over time Factors effecting data reliability
Definition of item(s) to be observed Standards of evaluation Training of inspectors Type of measurement used
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System Safety and Risk Management
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Decision-Making Hierarchy
Data
Data Sensitivity
Sensitivity means that small gradations or variations in the parameter being measured are reflected in some variation in the measurement
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System Safety and Risk Management
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Decision-Making Hierarchy
Data
Data Problems Confounding
Confounding occurs when two different factors can explain the same result When research is confounded, it is impossible to determine what variable is responsible for any obtained difference in performance When no confounding is present, a research study is said to have internal validity
Contamination
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Decision-Making Hierarchy
Data
Improving Data Collection
Develop focused factual information requirements Document the requirements Seek answers that are: System configuration information System performance information
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System Safety and Risk Management
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Decision-Making Hierarchy
System Validation
Hazard Identification Risk Analysis/Assessment
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System Safety and Risk Management
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Decision-Making Hierarchy
Summary
Collection of pertinent and quality data, and appropriate analysis will enhance current and future programs Data-driven surveillance programs will result in enhanced System Safety, whereby issues and hazards are identified early and addressed adequately
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System Safety and Risk Management
Presented by AFS-900
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Case Study
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System Safety and Risk Management
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Case Study
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System Safety and Risk Management
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Case Study
Risk Management
HazardIdentification: Identification: Hazard Identify Hazards Hazards & Consequences Identify Consequences
No
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Documentation
System Safety and Risk Management
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Risk Factors
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System Safety and Risk Management
Outline
Practical Application
Case Study
Summary
April 28, 1988 Near Maui, Hawaii Flight 243 - Boeing 737-200 (N7371I)
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Puzzle
System Safety and Risk Management
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Case Study
Risk Management
System Descriptions
Modify System/Process
System/Process Review
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Documentation
System Safety and Risk Management
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Case Study
Summary
Understand... the System Safety Process how It Will Assist You in Your Job
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System Safety and Risk Management
Additional Sources
ATOS Overview Course Length: 24 hours Course Description: This course is designed to familiarize industry personnel, international students, and government agencies other than FAA with ATOS. It will provide instruction on the ATOS access, ATOS system, including the tools, the policy and guidance, that make the ATOS system work.
System Safety Course Length: 24 hours Course Description: The purpose of this course is to train FAA aviation safety inspectors on system safety and risk management processes and the importance of both as they relate to systems management. This will be accomplished by demonstrating how system safety and risk management are used throughout the FAA environment.This course is available to industry personnel based on class availability
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Additional Sources
System Safety and ATOS Overview Course Length: 32 hours Course Description: This seminar is designed to provide an introduction to system safety and risk management processes as they are used by the FAA for air carrier oversight. The seminar also familiarizes industry personnel with the FAA's Air Transportation Oversight System (ATOS). The four-day seminar is conducted on location by special arrangement with the sponsoring organization for up to 50 students.
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System Safety and Risk Management