Gustavo Barba, Deputy President COPAC

Safety Information: The Cooperation between

Aviation and Judicial Authorities

Madrid, 24 – 25 March 2011Madrid, 24 – 25 March 2011

The Evolution from Just to Accountability Culture

Safety expectations at the turn of the XXI Century

Captain Gustavo J. Barba RománCOPAC deputy president

ICAO SMS/SSP instructor




Setting the scene“The increased competition has resulted in continuing downward pressure on revenue yields and consequent business re-organisation”. IATA–Icon , August 2001

As forecasted,The world must be alert to the threats posed by change, citing the rise of powerful, fast-growing new economies and the fact that many of the former major economies with a long aviation tradition are "struggling".

FSF chairman Lynn Brubaker says, March 2011 [EASS Istanbul]




Safety implicationsIndustry Over emphasis on commercial objectives

Unbalance allocation of resources between production and protection

Lack of safety performance regulations

ICAO request SSP for Member States from November 2006 & SMS for A/C operators and AMO from January 2009

Regulators dismantled

Growing and serious shortage of qualified safety oversight staff, liberalization

of airlines and competency markets demanded changes in the regulatory

schemes . Budget pressures are prompting European politicians to target aviation-safety groups:

"Understaffed regulators are probably going to be even more understaffed”. Bill Voss, FSF

CEO, March 2011

“There simply isn't the same depth of experience or consistent expertise there was years

ago”. Mike Ambrose, ERA president, March 2011




Root cause was a Failure of

Management

Decisions made that increased the risk

of the blowout saved time and money

without being proved safe

Financial pressures systematically

biased decision making in favor of time-

and cost savings

This disaster likely would not have

happened if BP have had committed to

safety first

Reality check,




A concept of accident causation

Activities over which any organization has a reasonable degree of direct control: budget and human resources, business

plan, etc.

Factors that directly influence the efficiency of people in aviation workplaces: fatigue, training, technical failures, aircraft

turnaround times, etc.

Actions or inactions by people (pilots, controllers, maintenance engineers, aerodrome staff, etc.) that have an immediate

adverse effect.

Resources to protect against the risks that organizations involved in production activities generate and must control.

Conditions present in the system before the accident, made evident by triggering factors

Latent conditions trajectory

There is a widespread belief in the aviation industry that the effects of commercial developments can cascade down through organization to affect flight deck operations. This threat is likely to increase as the pace of commercial developments increases. IATA–Icon , August 2001




Evolving System Safety

Key PrinciplesShared responsibility for safety

Regulations do not ensure safety

Surveillance by the regulator will not identify all safety risks

Evolving methods for understanding and managing safety risks are necessary

Public demand for safety improvements

ICAO Safety Management SARPs

Three distinct Standards

State Safety Programme (SSP)

Acceptable Level of Safety (ALoS)

Safety Management Systems (SMS)

Safety performance of the SMS

Management accountability

Obligation or willingness to account for one’ s actions




Safety data driven approachStates shall require, as part of their SSP, that a [service provider] implement an SMS acceptable to the State that, as minimum:

Focus on Hazard identification

a) Identifies safety hazardsb) Ensures the implementation of

remedial action necessary to maintain agreed safety performance

c) Provides for continuous monitoring and regular assessment of the safety performance

d) Aims at a continuous improvement of the overall performance of the safety management system

1 – 51 – 5

AccidentsAccidents

30 – 10030 – 100

Serious incidentsSerious incidents

100 – 1000100 – 1000

IncidentsIncidents

1000 – 40001000 – 4000

Latent conditionsLatent conditions

SMS

Hazard identification is a wasted effort if restricted to the aftermath of rare occurrences where there is serious injury, or significant damage




Hazard Identification by reportingWhy people are

reluctant to report? Retaliation

Self-incrimination

Embarrassment

Liability

Just CultureIndividuals are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training but which result in a reportable event; but

Where gross negligence, willful violations and destructive acts are not tolerated

But, Just Culture is not enough:

Only good will understandingNo relationship with Judicial AuthoritiesNo commitment with safety concerns resolutionsFocus on protecting operational staff from active failuresNo managerial accountabilities by latent conditions




Protection of sources of informationHazards to sourcesCivil Litigation

Regulatory sanctions

Criminal Proceedings

Company disciplinary actions

Public disclosure

Principles of protectionInformation from reporting and recording processes at SMS will not be used as evidence for enforcement action

Safety information must not be used for purposes other than the purposes for which it was collected (ICAO Assembly Resolution 35/17)

Legal guidance in ICAO Annex 13, Attachment E




One step beyond by ICAO SARPs

Management commitment

and responsibility

Clear statement about

provision of the necessary

resources for the

implementation of the safety

policy and ensure the

implementation of remedial

action necessary to

maintain agreed safety

performance

Lines of accountability

A safety management

system shall clearly define lines

of safety accountability

throughout the operator’s

organization, accountability for

safety including a direct on

the part of senior

management.




How to asses the safety accountability ? Duty of Care

Responsibility or the legal obligation of a person or organization to avoid acts or omissions (which can be reasonably foreseen) to be likely to cause harm to others

It is owned by every party of the other contracting parties

The first element to proceed with an action in negligence

Test for duty of careSome required concurrent conditions:

The foreseeable harm or injury; The possible magnitude of the

potential harm or injury; The usefulness of the conduct to the

defendant; The feasibility of alternative conduct; The costs and burdens associated

with the alternative conduct; The relative usefulness of the

alternative conduct; and, The relative safety of the alternative

conduct




Disclosing accidents/incidents predictors: Not only to know: What-Who-When? Also is essential: Why & How?

Safety data is needed for that: No protection of sources of information

= No safety data available

Managing Accountabilities: Are essential to ensure SMS performance in a very complex and

competitive industry Regulatory accountability shall be addressed by a balanced and

sustainable enforcement policy Judicial accountability shall operate to encourage compliance with

the appropriate regulations and procedures Judicial Authorities shall protect operational staff ,that take

actions to comply safety regulations, against employer reprisals

Cooperation is needed between aviation and judicial authorities for:




A balanced perspective

……The pilot-in-command must bear responsibility for The pilot-in-command must bear responsibility for

the decision to land and take-off in Dryden… However, the decision to land and take-off in Dryden… However,

it is equally clear that the it is equally clear that the air transportation system air transportation system

failed himfailed him by allowing him to be placed in a situation by allowing him to be placed in a situation

where he did not have all the necessary tools that where he did not have all the necessary tools that

should have supported him in making the proper should have supported him in making the proper

decision decision … … [Honourable Virgil P. Moshansky ]

Gustavo Barba, Deputy President COPAC

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