Safety – Different Approaches (IFATCA, 2013)
The safety approach of the industrial age until the closing years of the 20th century was founded on the notion that safety is defined by its opposite: by what happens when safety is missing. This means that safety is measured indirectly, not by its presence or as a property in and of itself, but by its absence or as Hollnagel (2012) describes it, the consequence of its absence. This approach is preoccupied and focused with what goes wrong and improved safety performance is achieved by determining the causal factors(s) that led to the event, incidents and accidents, errors, failures and other inadequacies within socio-technical systems and then removing or mitigating these same causal factors. This reduces the socio-technical system behaviour (which is often complex) to one of a simple cause and effect relationship, intrinsically linear.
Historically speaking therefore, accidents and incidents explained by such a simplistic cause and effect relationship – irrespective of the simple or complex nature of the system itself – reduces or decomposes the safety problem space to a vignette and we no longer notice the implicit model behind our thinking.
Three prominent and widely used models of this perspective of safety science are:
- The “Barrier Model” (Heinrich)
- The ‘Iceberg’ Model’ (Heinrich)
- The ‘Swiss Cheese’ model (Reason)
A number of methods have been developed that provide the means to describe and assess systems behaviours to determine hazards e.g., fault tree, bow tie, SAM, Human Reliability Analysis and Tripod, just to mention a few. These have all have been developed on the principal that systems fail because of the combination of multiple small failures which are each individually insufficient to drive a complex system to fail in some way. This analysis then yields to the quantification of risk and assumes mitigations to these risks. Frequently it is observed that such analyses use the human component as the mitigation strategy to manage this identified risk. This approach is often called the linear model.
Over the last two decades the linear model has come under increasing pressure, primarily because it has been unable to account for more and more complex accidents.
To cope with the more complex system behaviours, i.e. accidents and incidents we face, the systemic model has emerged as an alternative. Instead of decomposing system behaviour into events over time, the systemic approach focuses on systems as a whole – holistically. This approach assumes that system properties can only be treated adequately in their entirety, taking into account all facets relating the social to the technical aspects (Ramo and Simon, 1973) and their emergent properties. There is no or little separation of humans, technology, organisations and society.
Systemic models assume that failure and success stem from the same sources and that its component parts can rarely, if at all, describe socio-technical systems. As the often-unchallenged principal that more technology is the key to more production drives the systems we control, environmental and economic efficiency. They become ever more complex and it becomes very difficult to identify linear cause-effect relations. Paths of system behaviours may be invariant to linear interactions or trajectories. This means that it is not possible to observe incidents and accidents in isolation, if we want to improve the systems we try to control. If this assumption is correct it asks for a more holistic view on safety and the systemic approach requires us to understand the system as a whole instead of by its parts.
ICAO Safety Management Panel – Objectives
IFATCA is represented on the ICAO Safety Management Panel (SMP). The objectives of the panel are, inter alia (ICAO, 2020):
- Analyzing the needs of the aviation stakeholders (States and Service Providers) with respect to the collection, analysis, sharing and exchange of safety data and safety information.
- Contributing to the ongoing development of the Safety Management Manual, (SMM) (Doc 9859) which provides guidance on the high level requirements contained in Annex 19 – Safety Management.
- Identifying, developing and validating practical examples and tools in support of the ongoing understanding and use of data and information collection, analysis, sharing and exchange, including examples and tools submitted to ICAO for posting on the Safety Management Implementation website.
- Ensuring proper liaison takes place with other ICAO Expert Groups where there is a need for co-ordination on safety data and information collection, analysis, sharing and exchange related issues.
- Supporting the aviation Industry in practically implementing the Annex 19 SARPs in relation to safety data and information collection, analysis, sharing and exchange, that meets the intent of the language and effectively measures and improves safety performance amongst the aviation industry.
- Ensuring the effective use and implementation of these SARPs will allow for the vision of Safety Management to be realized, with a mature aviation system that can proactively and predictively manage safety risk, leveraging advances in computing technologies and increased data availability.
- Developing proposals for the amendment of Annex 19 and future revisions of the ICAO SMM that improve aviation safety without creating a regulatory burden for Service Providers.
Identifying appropriate material that is consistent with ICAO provisions to support all stakeholders with respect of the collection, analysis, sharing and exchange of safety data and information to support effective Safety Management.
For more information, visit one of the following WIKIFATCA pages:
- A Better Understanding of the Linear versus the Systemic Approach to Safety
- A Just Culture in Safety Reporting
- A Review of the Policy on the ATM Safety Monitoring Tool
- AAS 1.13 DETERMINING OPERATIONS READINESS OF NEW ATM SYSTEMS
- ADME 2.16 USE OF AERODROME CONTROL FREQUENCY FOR COMMUNICATIONS OF VEHICLE DRIVERS
- Aerodrome – Review ICAO Manual on the Prevention of Runway Incursions
- Aerodrome – Review Provisional Policy on Future ATM Concepts for the Provision of Aerodrome Control Service
- Air Safety Reporting Systems
- Air Traffic Control Separation Monitoring Tool (ASMT)
- Airport Infrastructure Development
- Airspace Design and Procedures Controller Involvement
- Ambient Workplace Recording
- ANNEX A – Safety Management Strategy
- ANSP Key Performance Indicators (KPIs)
- ATCO Performance
- ATS 3.12 MIXED MODE OPERATIONS
- ATS 3.14 SYSTEM DEFENCES DURING PLANNED SYSTEM DEGRADATION
- ATS 3.32 RECATEGORIZATION OF AIRCRAFT FOR WAKE TURBULENCE
- ATS 3.39 CRISIS MANAGEMENT
- ATS 3.40 MOVING TO A NEW FACILITY
- Clarification of Sector Manning Principles
- Crisis Management
- Critical Incident Stress Management – Guidance Material
- Determining Operations Readiness of Automated ATM Systems
- Develop Policy on System Defences During Planned System Degradation
- Educational Issues on Distraction (Guidance Material)
- Evaluating Team Resource Management Implementation within ATC and to Define the Practice for IFATCA
- Human Factors in Accident and Incident Investigation
- IFATCA/ Eurocontrol Prosecutor Expert Course
- Incident Reporting Responsibilities throughout the Whole ATM Domain
- Information Overload in ATC
- Investigate Minimum Safe Altitude Warning Systems (MSAW)
- Investigate Runway Incursions
- Investigate the Mechanisms for Dealing with a Critical Incident/Accident
- Investigate the Professional Aspects of the Difference between Intrinsic and Tactical Safety in the Aerodrome Domain
- Investigate the Subject of Computer Virus
- Just Culture
- Just Culture Revisited – Guidance Material for Member Association
- LM 7.2.1 JUST CULTURE, TRUST AND MUTUAL RESPECT
- LM 7.2.2 EXEMPTION FROM DUTY
- LM 7.2.4 PROTECTION OF IDENTITY
- LM 7.2.5 REFERENCE CARD
- LM 7.2.6 USE OF RECORDED DATA
- Management of Mixed Mode Operations
- MED 8.2.3 CRITICAL INCIDENT STRESS MANAGEMENT
- Monitoring Institutional Framework in ATM
- Moving to a New Facility
- Normal Operations Safety Survey – NOSS
- Performance Measurement in ATC
- Performance Targets in Air Traffic Management
- Position Paper on Remotely Operated Towers
- Produce a Definition of Controller Tools
- Protection of Safety Information
- Protection of Safety Information Sources
- Protection of the Identity of ATM Staff Involved in Serious Incidents / Accidents
- Quality Management Systems in ANSPs and the Relation with the SMS
- Radar Recording in ATC Systems – Technical and Professional
- Relief from Operational Position after an Occurrence
- Relief from Operational Position after an Occurrence
- Remote Control Towers
- Report Writing and ANSP Procedures for Serious Incidents or Accidents
- Resilience and a New Safety Approach – Do We Have the Right Model to Learn from Past and Future Events?
- Review Accident and Incident Investigation Policies in view of the “Just Culture” Philosophy
- Review IFATCA Technical and Professional Manual on Technical Policy Statements related to Mixed Mode Operations
- Review of LM (Legal Matters) – Professional Policy of the TPM
- Review of Part IV – Professional Policy of the TPM
- Review of Provisional Policy – ATM Safety Monitoring Tools (ASMT)
- Review of the IFATCA Vision Document
- Review of the Legal Section Relating IFATCA’s Just Culture Policy
- Review of WC (Working Conditions) – Professional Policy of the TPM
- Review on Just Culture and IFATCA’s Technical and Professional Manual Update
- Review Policy on Mixed Mode Operations
- Review the Use of Safety Cases
- Safety Auditing of Air Traffic Services
- Safety Management Policy Work Plan
- Safety Management Systems (SMS)
- Sectorless ATM
- Study Land and Hold Short Operations
- Study Reporting of TCAS RAs
- Study the ICAO Manual on the Prevention of Runway Incursions
- The 2004 Cagliari Accident and the European Court of Human Rights Decision
- The Reality of Just Culture – A Roadmap for the Changing Landscape of Just Culture
- The Use of Aerodrome Control Frequency for Communications of Vehicle Drivers
- The Use of Safety Nets in ATM
- Transgression in Service Providers
- Update of Accident and Incident Investigation Policy
- Use of Area Recordings
- WC 10.1.8 PERFORMANCE INDICATORS
- WC 10.2.10 SHORT TERM CONFLICT ALERT (STCA): HUMAN FACTORS / LEGAL ASPECTS
- WC 10.2.12 ATM SAFETY MONITORING TOOL
- WC 10.2.7 WORKING WITH UNSERVICEABLE OR INADEQUATE EQUIPMENT
- WC 10.7.2 NORMAL OPERATIONS SAFETY SURVEY
- WC 10.7.3 SAFETY MANAGEMENT SYSTEMS
- WC 10.7.4 INTRINSIC AND TACTICAL SAFETY
- WC 10.7.5 RESILIENCE AND LINEAR VS SYSTEMIC APPROACH TO SAFETY
Last Update: September 19, 2020