La protecci

1
La protección de las fuentes de información
sobre la seguridad operacional La perspectiva
técnica

• Capt. Daniel Maurino
• Seguridad de Vuelo y Factores Humanos OACI
• Seminario de Seguridad ASPA/OACI
• Cuidad de México, 10 11 Abril 2007

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Forensic Safety Management

• Focus on the outcome (s)
• Unsafe acts at the tip of the arrow
• Blame punishment for failure to perform
  safely
• Address specific safety concern exclusively

3
The Underlying ParadigmRule-based System

• Deterministic The world as it should be
• Aviation system as pre-specified is perfect
• Compliance based
• Outcome oriented
• Accident investigation

4
Inefficiency and Perversity

• The beatings will continue until morale improves

2. Punishment
3. Remedial Training
1. Exhortations to professionalism and discipline
4. Add more procedures regulations
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System Performance In the Wild
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Managing SafetyNavigating the Drift
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The Navigational Aids

• Reactive systems
• Accident investigation
• Incident investigation

• Predictive systems
• Electronic safety data acquisition systems
• Direct observation safety data acquisition
  systems

• Proactive systems
• Mandatory reporting systems
• Confidential reporting systems
• Voluntary self-reporting systems

8
Safety Data Systems and Levels of Intervention
Safety management levels
Desirable management level
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Managing Safety Collapsing the Drift
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Emerging ParadigmPerformance-Based System

• Deterministic The world as it should be
• Aviation system as pre-specified is perfect
• Compliance based
• Outcome oriented
• Accident investigation

• Ecological The world as it is
• Aviation system as pre-specified is imperfect
• Performance based
• Process oriented
• Safety data captured from daily, normal operations

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Protecting Safety Data An Odyssey

• Clearly defined objective
• Protect sources of safety information
• At the intersection of safety, law politics
• The solution Safety and Law
• The Implementation Political will
• An inescapable reality
• No safety data protection No SMS

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Protecting Safety Information Excuses and Fear

• Denial ritualistic blaming leading to
  self-delusion
• Repair cover-up, cosmetic re-writing denying
  learning
• Reform engaging the political will