Navigating the edge of risk Bob Dodd, The Aloft Group Dr. Linda Bellamy, White Queen

International Air Safety Seminar

Flight Safety Foundation

Miami November 2015

+ Outline

The Edge

BowTie concepts

Pushing the safety boundary

The view from the edge

BowTie navigation

Resilient risk management

Summary and conclusions

The Edge

Resilient behaviour – Organisation and Individuals

Top Event of Bowtie defines the edge

Small number of high level BowTies cover the operational space

BowTie Concepts

Anything that has the potential to cause harm.

It’s part of NORMAL Business

Aircraft approach and landing

Loading of aircraft during turnaround

The point in time when control over the Hazard is lost

A possible cause for the Top Event

Measures taken to prevent or mitigate events

Pushing the Safety Boundary

Rasmussen, J. 1997 Risk management in a dynamic society: a modelling problem

“Under the presence of strong gradients behaviour will very likely migrate toward the boundary of acceptable performance”

“Rather than striving to control behaviour by fighting deviations from a particular pre-planned path, the focus should be on the control of behaviour by making the boundaries explicit and known and by giving opportunities to develop coping skills at boundaries” (Emphasis added)

Rasmussen, J. 1997 Risk management in a dynamic society: a modelling problem

Threat Pressure

Safety Pressure (Barrier and Behaviour)

Making boundaries explicit

What happens in here?

The view from the edge

+ Resilience Case Studies (European SAFERA Project)

Top professionals

Resilience questionnaire

14

4 3 11

www.resiliencesuccessconsortium.com/resources

+ ANTICIPATING

Scenario-thinking

Getting little things right

Switched on/vigilant to what can go wrong (risk aware)

Cognitive bias mitigation (e.g. countering routine, familiarity, what is easily remembered)

15

MONITORING

Switched on/Vigilant/Alert (for signal detection/change)

Stop and think - hold points/cross check/pause at critical steps

Multiple perspectives, cold eyes review

Cognitive bias mitigation

16

+ RESPONDING

Experienced people

Know the safety margins, one’s own limitations

Open up communications.

Bring together people who can help to reduce the uncertainty.

Use of golden rules/principles (“lines in the sand”)

Time and (multiple) options available (redundancy/flexibility)

Cognitive bias mitigation (e.g. summit fever, aura of the expert, knee jerk reactions)

17

+ LEARNING

Self-reflection, willing to learn

Communication/feedback/trust

Support decisions under high time pressure and uncertainty

Analyse, discuss & expand events

Simulation training

Capture & record

Cognitive bias mitigation (learning)

18

“Standard work methods are important for standard work, but when things are happening that are not standard and the organisation is only built around these standard procedures, you will lack people that have the possibility to think thoroughly. “

+ Intervention Quadrant

19

Foreseen

risks

Unforeseen

risks

STANDARD RESILIENT

Standard Risk Management Interventions

Constraint, control

Coping with foreseen risks and avoiding things going wrong (failures)

Standards, rules and procedures

Designed-in risk control measures

Resilience Interventions (close to edge)

Adaptive & involved

Coping with unforeseen risks and recovering from deviations

Uncertainty reducing

Multiple options – redundancy, diversity

Questioning, second options

What kind of interventions?

Bowtie navigation

+ Leveraging Existing Data

Threats Safety Reports Observations Barrier Failures Safety Reports Observations Investigation Findings Audit Findings Technical Data

Top Event Safety Reports Observations Investigation Findings Technical Data

Recovery Failures Safety Reports Observations Investigation Findings Technical Data

Consequences Industry Data

Thre

at

Risk

Contro

l

Undesire

d

Opera

tional

Sta

te

Reco

very

Contro

lC

onse

quence

Thre

at

Thre

at

Risk

Contro

lRisk

Contro

l

Risk

Contro

lRisk

Contro

lRisk

Contro

l

Risk

Contro

lRisk

Contro

lRisk

Contro

l

Reco

very

Contro

l

Reco

very

Contro

l

Reco

very

Contro

l

Reco

very

Contro

l

Reco

very

Contro

l

Reco

very

Contro

l

Reco

very

Contro

l

Conse

quence

Conse

quence

Conse

quence

+ 23

Accid

en

ts

Seriou

s In

cide

nts

Safety Events and Observations Normal

Operations

Reports: - Safety - Quality - Observations - Audits

Most accidents outside

organisation

Resilient Risk Management

+ Changing the focus

Standard Risk Management

Before the fact

Known risks

Normative structured procedural

Organisational

Resilient Risk Management

Live – as it happens

Unknown or unexpected risks

Adaptive and flexible

Individual

Uncertainty

Time

Organisation

Individual Shifting roles in managing risk approaching and crossing the edge.

+ Risk Management – Up to the edge and beyond

27

Strategic •High Level Risk Analysis (Annual) •BowTie Models covering operational phases •Based on global and local experience •Build on shared models (eg CARM)

Tactical •Monthly Analysis •Tracking trends in BowTie Data •Barrier Management •BT based investigation and audit

Operational •Live process •Shared role of organisation and individual •Train and support individuals for resilient behaviour in high uncertainty/time compressed situations

+ Summary

Operating pressures can push organisational and individual behaviour towards the safety boundary.

Resilient organisations must:

Understand and make explicit the boundaries

Learn to operate at the edge

Recognise the limitations of standard risk management closer to the edge

Support, select and train individuals for resilient behaviours at the edge under conditions of uncertainty and time pressures

BowTie risk models can

Map the risk landscape around the edge

Measure performance dynamically using existing data sources