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When will airlines start preparing safety cases?

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When will airlines start preparing safety cases?

Old 4th Feb 2011, 21:40
  #61 (permalink)  
 
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I've seen safety cases and can confirn that, in my opinion (given free to all readers), they are the largest waste of money ever given to so-callled safety engineers.

Safety cases are an over-rated system of ever decreasing argument against any action anyone would want to make to improve an operation. The series of nit-picking and smugness from said SE's is astounding and unbelieveable. And their wages are unsustainable considering the profit they rob from the company.

It is the one "standard" that everyone should rightly ignore until it goes away.
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Old 5th Feb 2011, 16:57
  #62 (permalink)  
PBL
 
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Rigga,

you cannot judge the worth of a safety case from an experience of reading only bad ones.

As I have pointed out, the certification documents for all commercial transport aircraft contain one large safety case. The regulations define a risk matrix for single-point failures (although it is not called that; it is called a "relationship between probability and severity of effects" in Table 4-1 of Lloyd and Tye's Systematic Safety, CAA Publications, 1982). There is a systematic hazard analysis of every system on board and it is accompanied by a demonstration that the requirements of the risk matrix are satisfied.

Airworthiness certification is obviously very effective. Commercial air transports are amongst the most trustworthy artefacts subject to dangerous failures which have ever been built.

So much for your contention that safety cases are mostly rubbish.

PBL
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Old 10th Feb 2011, 23:21
  #63 (permalink)  
 
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"Rigga,

you cannot judge the worth of a safety case from an experience of reading only bad ones.

If "Bad" Systems are all that I see I cannot make another judgement against the evidence present - Show me a good one.
As I have pointed out, the certification documents for all commercial transport aircraft contain one large safety case. The regulations define a risk matrix for single-point failures (although it is not called that; it is called a "relationship between probability and severity of effects" in Table 4-1 of Lloyd and Tye's Systematic Safety, CAA Publications, 1982). There is a systematic hazard analysis of every system on board and it is accompanied by a demonstration that the requirements of the risk matrix are satisfied.

Airworthiness certification is obviously very effective. Commercial air transports are amongst the most trustworthy artefacts subject to dangerous failures which have ever been built.

If this is so good then why is there a need to have another level of safety bureaucracy inside the airline itself?
So much for your contention that safety cases are mostly rubbish.

See my earlier answer.

PBL,
I have checked out your website (because I used to live in Avenwedde) and I have downloaded and read your department missives on safety analysis systems - I have even used my interpretation of "Why-Because" in a recent MEDA investigation (and I thought it worked well, too) but a university position and membership of glorious societies does not a perfect solution make!

I believe that the theory of mandating everyone has a set of tools to self-assess for perfection is flawed in its concept.

I believe that theory emulates the ISO9001 theory of perfection, in that it becomes a beast of horror and self-destruction if allowed to consume more and more effort to achieve the "perfect" status.

You find the best ISO9001 company and I'll show you a very large and very expensive QA dept with a low reputation.

By the way - I do like your published theories and tools, especially the Why-Because thing. But I think they may not aptly apply in all the areas you think.

Last edited by Rigga; 10th Feb 2011 at 23:28. Reason: add colour
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Old 11th Feb 2011, 20:42
  #64 (permalink)  
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Originally Posted by Rigga
Show me a good one.
If you now live in Anglia, I recommend you call up my colleagues at Adelard in London. They have devised plenty of very good safety cases. Whether they have one to show you is likely a matter of your justifiably professional interest.

I am rather surprised, since you have to do with safety cases, that you don't appear to know of them. They provide the software with which most of the MoD safety cases are nowadays prepared.

Originally Posted by PBL
Airworthiness certification is obviously very effective.
Originally Posted by Rigga
If this is so good then why is there a need to have another level of safety bureaucracy inside the airline itself?
Because, as you will know, not speaking entirely from within your hat on safety case matters, operational safety is a different matter from fit-for-purpose certification. I wonder why you even asked the question?

To your comment on WBA:
Originally Posted by Rigga
...a university position and membership of glorious societies does not a perfect solution make!
You imagine you can infer someone's capabilities from their day job? Maybe you can. BTW, I am curious to know which societies I belong to you think are "glorious".

The industrial users of WBA are very happy with it. That's good enough for me (and the tech-transfer company's pocketbook).

Originally Posted by Rigga
I believe that theory emulates the ISO9001 theory of perfection, in that it becomes a beast of horror and self-destruction if allowed to consume more and more effort to achieve the "perfect" status.
How insightful! Can we cite you as a reference?

PBL
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Old 12th Feb 2011, 11:26
  #65 (permalink)  
 
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PBL

As you have said:

As I have pointed out, the certification documents for all commercial transport aircraft contain one large safety case.

There is a systematic hazard analysis of every system on board and it is accompanied by a demonstration that the requirements of the risk matrix are satisfied.

Airworthiness certification is obviously very effective.
I'd welcome your views on this where those practices seem to have been less effective: http://www.pprune.org/safety-crm-qa-...dy-safety.html

Plus I really would love to know what Shell Management will do in his Safety Cases in regard to this recommendation:

...prohibit commercial operation of Category A transport helicopters over water when the sea state will not permit safe ditching and successful evacuation.
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Old 12th Feb 2011, 14:31
  #66 (permalink)  
 
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Squib;

Surely Shell management will do what Shell management (and all the other oil companies) do whenever that recommendation is made; They'll ignore it. (Or follow it until it causes production or exploration delays).

There are lies, damn lies and oil company safety cases.

Shell management I do wonder if you realise just how many of us involved in commercial avaition and aviation safety cases think what a total c*** you are. Lets face it all of our ops manuals, AFMs and certification standards are there for safety, not decoration.

Personally I also add the proviso "would I let my family fly with that operation?" Trust me if the operation had any form of Shell input there would be no way.
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Old 12th Feb 2011, 21:01
  #67 (permalink)  
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Squibb,

Neither I nor my colleagues are familiar with oil rig helo operations. I am not familiar with helo certification requirements. If I were/if we were, I would be more than glad to answer your question. But I ain't, so I can't.

PBL
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Old 12th Feb 2011, 23:03
  #68 (permalink)  
 
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PBL,

Please do quote me! - probably my first time in university publications.

...and not all of anglia is run by MOD. Some of us have to work for a living!


I'll carry on with the WB thing - I like it.

Und Tchuess!
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Old 14th Feb 2011, 22:38
  #69 (permalink)  
Spitoon
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I just know I'm going to regret this, but.....
Simple, as I've already discussed the Adverse Weather Policy Shell introduced nearly 20 years ago, which is a risk based approach to controlling the hazard
An Adverse Weather Policy sounds simply like professional common sense. There is no need to wrap it up in some form of mystique and call it safety management.

And, by the way, a policy is not a safety case, nor is it a safety management system. It's a policy. This one, perhaps, crossing the line into an operational procedure. A safety case will present an argument for why the policy will assure an acceptable level of safety and evidence to show that the arguments are valid.

But, hey, what do I know? I don't work for Shell.
 
Old 16th Feb 2011, 07:14
  #70 (permalink)  
Spitoon
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I knew I was going to regret it.

Thanks SM, now I understand that point. I hope I've got enough time on this Earth to understand the whole safety management thing as well as you do.
 
Old 16th Feb 2011, 09:04
  #71 (permalink)  
 
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Hi Shell Management

For what it's worth ....

I work for a relatively small operator in Australia and I can assure you that we are frequently required (by our own internal policies) to develop safety cases for significant changes to our MO, and in nearly all submissions made to our Regulator, a safety case is required. Our compliance and methodology is at least IOSA standard, and our Safety and Quality objectives and requirements are an integral part of all Flight Crew Operating Manuals. Maybe it's not the same in other parts of the world, but we would not contemplate a significant change to our MO without a safety case examination - we would never pass the most fundametal business risk assessment (our own internal policies) without it. Kind Regards
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Old 16th Feb 2011, 09:46
  #72 (permalink)  
 
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Spitoon and Olive, don't fall into Shellies web of professed expertise in safety. He knows zip, narda, nix, zero - well you get the idea. He claims that he invented the Swiss Cheese Model of accident causation and as yet has failed to provide proof to back up his claim. Which is a shame, because all in the professional safety field and aviators believe Professor James Reason was the originator. Shellie might be missing out on a medal.

But, hey, what do I know? I don't work for Shell.
You're vastly over qualified for a role in Shellies organisation, for a start you ain't brain dead.
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Old 17th Feb 2011, 00:41
  #73 (permalink)  
 
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Brian, it pays to read what is written closely
That I did and you said "Shell invented the Swiss Cheese Model". You made no qualification as to
Shell funded Prof Reason's work and allied programmes in the Netherlands that formed the basis of a lot of modern safety theory
You have been asked to provide evidence to support Shells association with Reason and the Swiss Cheese Model but so far have failed to do so.
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Old 17th Feb 2011, 02:19
  #74 (permalink)  
 
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Brian, your trying to be the expert that you aren't. Go have a Fosters and ponder the Felonious DNA that cripples your logic.
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Old 17th Feb 2011, 03:01
  #75 (permalink)  
 
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your trying to be the expert that you aren't
theficklefinger, you're new around here so your ignorance is excused. You will find NO WHERE where I have pretended to be an expert, quite the reverse. For your edification Shellie has a well earned reputation here on PPRuNe for being the self appointed expert. Unfortunately he has always been found wanting by, not only real safety professionals, but the run of the mill aviators like me. That is quite apart from his troll reputation, which has been recognised, and commented on, by the Mods.

Get in out of the cold and revive yourself with a Schnapps before Felonious DNA cripples your logic.
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Old 17th Feb 2011, 08:28
  #76 (permalink)  
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tff,

the person self-identifying as "Shell Management" has, over time produced a number of what Flying Lawyer has termed "extreme views", and also misinformation concerning matters on which he self-presumes to be knowledgable, such as safety and organisational safety.

Brian Abraham is just one of the people who have become publically fed up with SM's facile and misleading interventions. I understand Brian's exasperation very well, and sympathise. I am also grateful that he flags the distortions so that people who don't know that much about safety are not misled.

SM's interventions do have a plus side, however. Occasionally I feel the need to correct a particularly egregious misreprentation, and so I can write a few paragraphs summarising some aspect of the history of safety which I may not have written on before. Then a couple people here might be grateful to read it, and I myself have text I can use again when the need arises.

So here are a few paragraphs on some of Jim Reason's work (which I will be able to use again). I follow these with a couple of comments on SM's misrepresentations.

The so-called "Swiss Cheese Model" is a picture which appears in Reason's book Human Error (Cambridge U.P. 1990) as Figure 7.5. in Chapter 7, "Latent Errors and Human Disasters", in which Reason considers various well-known accidents. The caption is "The various human contributions to the breakdown of complex systems are mapped onto the basic elements of production. It is assumed that the primary systemic origins of latent failures are the fallible decisions taken by top-level plant and corporate managers. These are then transmitted via the intervening elements to the point where system defences may be breached." In order to interpret this diagram, one needs to know what the "basic elements of production" are (they are given in a similarly layered diagram, with feedback loops, in Figure 7.4). One must also buy the assumption of whence the "primary systemic origins of latent failures" derive. Reason was talking specifically about complex human organisations and complex accidents. TNI, Bhopal, Challenger, Chernobly, Herald of Free Enterprise capsize at Zeebrugge, King's Cross station underground fire.

One thing Reason does not explicitly say is that his conceptualisation in Figure 7.5 is based on a barrier-analysis conception of accidents. An aviation accident to which barrier analysis is obviously well applicable is 1988 A320 Habsheim, which involved a lot of failures in the corporate and institutional controls over the pilot's planning and behavior beforehand. An aviation accident to which it is not very well applicable is 1992 Warsaw, which was a combination of what I call a "requirements failure" (namely, the systems worked as designed, but in circumstances in which one would have preferred rather than they had done something else), and physical barrier built at the end of the runway, making the consequences of any overrun very severe.

In the intervening twenty years, most of the context (and content) of Figure 7.5 seems to have disappeared. The picture gets reproduced as the "Swiss Cheese Model" and, for example, pilots all over PPRuNe talk about "the holes in the cheese lining up" without often having the slightest idea of the analysis technique to which they are ultimately referring, or even the labels on the various "slices" of "cheese" whose holes line up.

Reason's model was specifically designed for analyses in which human error and organisational missteps and holes play a large role. I don't believe it is a general model of accident causation and as far as I know Reason has not promoted it as such. But sometimes things take on a life of their own.

The work reported in Chapter 7 of his book, including this diagram, is his own work, which has been informed by projects with many clients. Reason's group at the Uni Manchester worked with the Uni Leiden on Tripod-Delta for Shell Internationale Petroleum Maatschappij (now Shell International Exploration and Production BV). The project started in 1988. The technique was developed in various Shell operating companies in 1989-92, rolled out across Shell in 1993 and generally in 1996. The methods were developed later in REVIEW, for British Rail Research, and MESH, for British Airways Engineering, also at the Uni Manchester. The main programmer of REVIEW and MESH also wrote Tripod-Beta, which is also marketed by a Dutch firm with a similar name.

SM has suggested in previous notes here that, after Piper Alpha, other oil companies followed Shell's "lead" in developing safety cases, and has even suggested that safety cases derive from Shell's work. All of this is just wrong. I have asked him to correct himself (assuming SM is male), but he declines to do so. That may be because he simply doesn't know. He doesn't appear to know, for example, whence safety cases derive. And he doesn't appear to know who the main players in the safety-case development field are.

He seems in his latest note to be suggesting by implication that Reason's main intellectual work was also paid for by Shell. That is not what I understand. I think grants for this work, in so far as additional money was needed, came from the usual sources.

SM also presents himself as someone who knows about safety. But he doesn't know who I am, and replied rather rudely when I suggested that I know quite a lot about it.

So I wouldn't pay a whole lot of attention to what SM says, if I were you, without checking out what he says very carefully. I wish he would stop distorting matters and start producing worthwhile contributions to the ongoing safety discussion. On the other hand, if he did, then I might not have so many notes I can use again....

PBL
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Old 20th Feb 2011, 11:17
  #77 (permalink)  
 
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I have followed this thread with a lot of interest over the last few weeks and would now like to throw my own thoughts into the pot with regard to Shell Managements view below.

Quote:

"The steps are:
  • Top management commitment
  • Prepare a safety case
  • Define accoiuntabilities
  • Implement an SMS
  • Hold people accountable
If you do that the workers will follow the right culture."

No problem with this as a general approach.

My view of SMS is that it is a very simple concept; it is the proactive management of safety. The pillars of a good SMS are already established as concepts, and much is Regulated for; a Flight Data Monitoring Programme, a good open reporting system, a method of risk assessment and analysis off the results, implementation of recommendations out of that programme, an appropriate management system, and an independent quality system to monitor the whole operation.

Let’s look at the steps quoted above in a little more detail. I think Helen49’s remarks have been overlooked during the debate:

Quote:

"Unless there is an intent and culture of safety at the 'top' of the organisation, all the systems, documents, safety cases etc in the world will not help you. If the culture is there, the simplest of documents and systems will go a long way towards enabling a safe operation. Simple!"

The most important element of a good SMS is getting the right culture, on that I hope we can all agree? The problem we now face as an industry is that “top management” now see SMS as another Regulatory hurdle to overcome. Talking in broad terms, very few senior managers appear to understand the importance of the cultural aspects and grasp that they already possess the basic building blocks for an SMS within their organisations. Senior Management perception in my recent experience is that their commitment ends with a signature to a safety policy.

Safety Case: has anyone ever thought to consider that the initial safety case for a start up organisation is the manuals suite which has to be accepted by the Regulator? These manuals have to meet the minimum standards, set and define the scope of approval/areas of operations, along with Accountability, Responsibility and the procedures within an organisation to support those elements. I raise this as a discussion point for debate and learning, because the original question was “when will airlines start producing safety cases”. The answer could be maybe they have produced the vast majority of this work prior to start up?

Implement an SMS: I believe the basic pillars have already been outlined earlier. The implementation is about top management/senior management being seen to say and do the right things, and allowing a just and learning culture through the application of continual improvement techniques and the proactive management of risks. This should be simple and understood by all. The “holding people accountable” element should extend to the top management of an organisation, as actually they are the ones who are accountable. Top management need to understand they can delegate responsibility, not accountability.

Ultimately SMS is all about getting the right culture into an organisation. Don’t let anyone fool you otherwise. How you choose to do this is largely down to you, no one model fits all, it is the ability to take elements from many different ideas, concepts and models and make them work for you that is important. The SMS should ultimately be tailored to the needs and complexity of your organisation and your employees will judge your success through playing their part in the culture. We need to learn from one another, are all in this together, and should respect one another’s opinions. I fear sometimes we are all in extreme danger of losing sight of common sense during the SMS debate.
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Old 20th Feb 2011, 18:49
  #78 (permalink)  
 
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Talking of culture, what should we really make of this story:-
United’s 757 Grounding: What It Really Says About Airline Safety | BNET
A 5 year delay in acting or a sound culture when a problem found?
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Old 21st Feb 2011, 08:14
  #79 (permalink)  
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Originally Posted by sox6
A 5 year delay in acting or a sound culture when a problem found?
Recall we have recently had two US airlines fined by the FAA because they did not keep up with ADs concerning structural problems.

I would say that US airlines have been on notice for some time that some lax safety practices, in particular AD compliance, will no longer be tolerated by the regulators, and the "culture" is adapting to the "new" (actually old, but now more actively enforced) reality.

I do applaud the action by UA to declare and fix. I am told almost all aircraft were back in the air within 24 hours.

PBL
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Old 22nd Feb 2011, 17:04
  #80 (permalink)  
 
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I have to side somewhat with shell management. The united case is shocking for many reason. It isn't just about missing an AD.

I still owe PBL an explanation as to my concerns but safety is talked about and nothing more. A serious approach to operational safety at least is more than lacking. Managers are extracting urine for want of a better word.
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