ICAO addressed the systemic nature of human error and the management of human factors in the 1993 circular Human Factors Digest no 102. The main ideas expressed in the circular concern contemporary approaches to safety management such as Reason's (19903) Accident Causation Model4, Degani and Wiener's "four Ps of flight deck operations" (19911) and broad risk management procedures. Although the publication itself is relatively old, the ideas it describes are generic enough to remain valid today. What follows is a synopsis of the contents of that circular.
15. Contemporary views now embrace a systems' perspective of aviation safety, rather than focusing solely on individual operator performance.
3. Within systems, safety breaches are better understood as processes as opposed to one-off events. As such, multiple interactions, multiple contributors and a relatively long history of minor errors and complacencies are commonly observable in any accident.
4. The origins of the above-mentioned interactions, contributors, minor errors and complacencies span the whole organization and can normally be traced back to a lack of Human Factors considerations during the design and operational stages. Furthermore, aviation is a sociotechnical system (i.e. interactions occur between human and technological components) that is inherently complex and prone to unexpected interactions. All these variables pose unwarranted burdens on operational personnel, limiting, reducing or overcoming their capability to prevent an accident, in their position, as the last element in the causation chain.
5. The purpose of attending to management and organizational aspects of Human Factors is not to ignore the role, if any, that operational personnel may play in an accident. Rather, it is to look for system deficiencies and root causes in the aviation system at large, including the operational personnel as part of the system.
6. This ICAO digest addresses the influence of management factors in aviation safety, assumes that the responsibility for safety in any organization rests with management and advocates a systems' approach to accident prevention.
7. Therefore, this digest is relevant to corporate management, regulatory authorities, manufacturers and professional associations.
Chapter 1. From individuals to organizations
1.3. Aviation organizations have evolved towards complex sociotechnical systems. The interfaces between the people and technology that comprise these systems are highly interactive, interdependent and affected by the same environmental events. Sociotechnical systems also tend to have two common features; high technology and high risk activities. As such; they require less direct operation (as technology replaces the human operator) but more remote supervision (the operator now supervises the technology remotely); are more opaque (it is becoming increasingly difficult to know exactly what the technology is doing); are highly hazardous and thus high-risk; and have greater potential for catastrophic consequences (i.e. accidents).
1.2. Traditionally, operators have been considered as solely responsible for safety (and still now, many managers (and lawyers) want to place sole responsibility for safety on operators). However, operational personnel do not act in isolation but act as part of an organization. Their actions reflect processes, procedures and attitudes (e.g. the safety culture) of other parts of the organization both horizontally (from colleagues and other operational departments) as well as vertically (from managers and designers).
1.4. Managing safety in complex systems like aviation therefore requires a systems' approach. Such a broad approach focuses on the system at large, including not only its structure but also the interactions and interdependencies between elements in that structure. A systems' approach also takes a deeper view, looking for organizational deficiencies and management factors, such as small uncorrected system safety deficiencies, that accumulate over time ("incubation" periods) until a trigger event leads to an accident.
1.9. A systems' approach helps pinpoint those elements in the system that can provide the greatest contribution to safety. Typically, decision-makers such as high-level managers, designers and regulators are in the best position to take remedial action.
1.14. In any case, a systems' approach does not intend to shift responsibility from operational personnel onto management. When operational personnel are in the best position to manage safety then their responsibility is to do so.
Chapter 2. Safe and unsafe organizations
2.2. Basically, there are two types of aviation organizations: those oriented towards production where safety is a supporting goal (e.g. airlines, airports, etc.), and those oriented towards safety as a primary goal (e.g. ICAO, civil aviation administrations, ISASI, etc.).
2.3. Consequently, the safety cultures of organizations differ according to the priority safety gets. Culture, in this sense, could be considered like the "personality" of an organization.
2.5. Culture has been defined as the beliefs and values shared by the members of a group (be this as big as the whole organization, or smaller subgroups within it). As beliefs and values are shared, they shape the perceptions, attitudes and behaviours’ of the members of the group. That is, members tend to perceive, think and act similarly, giving similar importance to things such as values. Typically, however, people tend to follow the norm of "leaders" who, in the case of organizations, tend to be the managers. Thus, if managers do not give real value to safety, it is more than likely the rest of the organization will eventually acquire such a culture.
2.7. Safety culture can therefore be regarded as beliefs, values, attitudes, behaviours’, etc., related to safety and shared by an organization at large (culture) or smaller groups within an organization (subcultures).
2.8. Generally, a safe culture is defined by characteristics such as:
- Strong emphasis on safety by senior managers
- Lack of managers using their influence to force their views or avoid criticism
- Good climate towards reporting safety issues, comments and criticisms
- Good communication of safety issues within the organization and with relevant outside entities
- Realistic and workable rules regarding hazards and safety, supported and endorsed throughout the organization
- Realistic perception of short-term and long-term hazards is held by all personnel
- Personnel well trained, well educated and fully aware of the consequences of unsafe acts
2.12. If culture represents the "personality" of an organization then structure represents the "body" of an organization. The design nature of an organization, i.e. its structure and hierarchy, is to facilitate the interface between its structural components (e.g. departments, sections, etc). Safety should be kept in mind during this design process.
2.14. Several components need to be considered when designing the structure of an organization:
- Complexity (hierarchical levels, departments, geographical dispersion versus centralization, communication mechanisms etc.)
- Degree of standardization (standardized versus specialized)
- Centralization of the decision-making process (low or high centralization)
- Adaptability (flexible or stable) to the environment (which can be uncertain or stable)
2.15. Organizations with unnecessarily complex structures (e.g. too many hierarchical levels or departments) foster dilution of responsibility, lack of accountability and poor interdepartmental communication. This may lead to reduced safety margins and safety breakdowns.
2.20. Within complex sociotechnical systems such as aviation, safety defences are generally strong enough to ward off many safety threats at operational levels (such as equipment failures or personnel errors).
2.21. Failures can be divided into active failures (that have immediate and easily observable consequences) and latent failures (that have no immediate consequences but tend to remain dormant for a long time). Active failures are typically carried out by operational personnel, whereas latent failures are due to decisions or actions typically performed by decision-makers such as managers and system designers. However, more often than not, operational personnel inherit latent failures and with the right conditions (such as active failures, technical problems and adverse conditions) those failures break through the system defences with catastrophic results.
2.22. Thus, most system failures can be traced back to errors and decisions made by decision-makers and system designers as well as by line management.
2.23. Management response to safety information is, thus, an important ethos in safety management. This response may vary from denial to repair actions to reform actions, depending on the organizational culture or a manager's personality.
2.17. Organizations with a rather poor internal responsibility for safety rely on regulations (and thus on regulatory authorities) for their safety management. That is, they tend to comply with safety regulations but rarely go beyond what is stipulated. However, because safety regulations normally represent minimum levels of safety standards, applicable to a broad range of situations, they may not offer enough assurance for the safety risks of a particular organization.
2.27. In general terms, the traits of a safe organization are:
- Considers safety as one of the objectives of the organization and a major contributor to achieving production goals
- Has appropriate risk management structures that reflect an appropriate balance between production and risk management
- Has an effective organizational safety culture
- Relies on internal responsibility to achieve safety objectives
- Responds to both active failures and latent failures when managing safety
- Possesses a suitable structure, giving due consideration to the components described in paragraph 2.14
Chapter 3. Management's contribution to safety
3.5. Safety is not just a moral duty but also has economic benefits for organizations, especially in the long term. Therefore even the heartless manager is better off managing safety than not managing safety.
3.6. Many companies contract insurance to offset the potential financial consequences of accidents. However, there are also many uninsured costs that managers should be aware of when contemplating trade-offs between safety and production.
3.7. Typically, the people who are in the best position to introduce changes to manage risks appropriately are those in management positions. This is a compelling reason for managers to play an active role in safety management.
3.9. Management's most obvious contribution to safety rests on the allocation of resources to safety.
3.10. Another contribution is the implementation of a comprehensive safety programme across different operations (e.g. flight operations, ramp, maintenance, etc.) to be managed by quality control departments (which are relatively independent from, and free from conflicts of interest with production departments). As part of this programme, safety feedback systems are also required for reporting active risks and hazards, auditing the organization to uncover latent failures and dissemination of information throughout the industry.
3.11. A third management contribution to safety is the development of, implementation of, and adherence to, standardized operating procedures (SOPs).
3.16. A fourth management contribution to safety is to set up a feedback and trend monitoring system for the organization. This system should cover not only accidents and incidents but should also be able to capture active failures at operational levels and latent failures at line management levels.
3.17. A fifth management contribution to safety is to implement a risk management process, normally based on the following four steps:
3.18. Step 1: Accurately assess hazards. For example, assess hazards in terms of their probability of occurrence, severity and exposure. Step 2: Assess the risk involved (against the risk the organization is willing to accept). Step 3: Eliminate those hazards that can be eliminated. Step 4: When hazards cannot be eliminated, reduce them (e.g. reduce their probability of occurrence, reduce the severity of their consequences or develop means for safely coping with hazards).
3.19. Risk assessments are a very subjective judgment, made in a social and legal context, and as such are subject to various socio-cultural variables. However, when the risks are unacceptable, canceling operations may be the best option (at least in the short term). In the long term, structural and cultural changes within the organization would be necessary before the operation can resume.
Want to know more?
- ICAO Human Factors Digest No 10
- ICAO - INTERNATIONAL CIVIL AVIATION ORGANIZATION (1993). Human factors digest no 10. Human factors, management and organization. Circular 247-AN/148. ICAO (Montreal, Canada), 1994.
Jose D PEREZGONZALEZ (2009). School of Aviation, Massey University, New Zealand (JDPerezgonzalez).