ARCHIVED - Session 4 - Building an Effective Management System - Joseph Hincke, Board Member - Transportation Safety Board of Canada

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Safety Forum - June 5-6, 2013

Joseph Hincke, Board Member
Transportation Safety Board of Canada

How to manage, control and avoid fatigue in operators?

Caveat - I am not a sleep scientist! The first thing that is required is for organizations to recognize and accept that fatigue is a common issue in all realms of activity. Another is to recognize that there are some physiological realities relating to human performance and sleep. For example, the ability to nap may provide some shorter term augmentation to operator attention and cognitive alertness, but naps will not fill the body’s requirement for restorative sleep. Fact 1 -humans need approximately 7-8 hours of sleep in a 24 hr. cycle and if it is not available a sleep debt will accumulate and lead to fatigue and its related cognitive decrements. Fact 2 -certain times (circadian lows) within the 24 hr cycle are more likely to result in declines in performance.

With this information, it is then important to assess the work and the working environment to identify the risks that accompany schedule requirements, work patterns, how and when complex operations are conducted, as examples, and to create mitigation strategies to reduce these risks. Many strategies are employed today but it will be useful for companies to look specifically at their own requirements so that the mitigations are realistic. It may not be able to entirely possible to eliminate fatigue in operators, but processes can be designed to take this into account by adding redundancy or additional oversight, for example.

What are some examples of weak signals that the TSB has seen in incidents or accidents?

The following is an extract from TSB report A11A0035 (full report available from TSB website) which illustrates a set of circumstances in which the respective Safety Management Systems of two organizations missed weak signals that were available.

  • “Safety Management System

    Comprehensive reporting of safety hazards is essential to an effective safety management system (SMS). This would include reporting of non-routine situations that could represent hazards such as local practices or adaptations from documented procedures (e.g. misting of wheels) and occurrences where issues could have been reported through the company’s RMS (e.g. fuse-plug releases) but were not.

    Even though the company’s RMS was in place and training had been provided, some maintenance and flight crew employees were still not clear on their obligations to report issues. KFL has indicated that even if a potential safety concern is noted, such as the crew’s concern about the condition of the tires, unless the concern falls outside published requirements (such as the airplane maintenance manual) or guidance, then the safety concern is not to be reported and addressed through the RMS. The RMS policy and procedure manual did not provide explicit guidance on what may be considered a hazardous situation or condition, nor was any specific training provided. Employees will submit more incident reports if they are trained to recognize specific hazardous situations or conditions and areas they think the SMS should review. If all employees do not fully understand their reporting obligations and have not adopted a safety reporting culture as part of everyday operations, SMS will be less effective in managing risks.

    Although KFL implemented a number of practices/procedures to address the frequent brake heating/fuse-plug release condition, it did not address these issues through the framework provided by its RMS. This resulted in a missed opportunity to identify potential safety risks (loss of directional control, hydroplaning, runway overruns) and take appropriate mitigating actions. Furthermore, the company RMS did not specifically review the earlier occurrences of hydroplaning at St. John’s Airport to identify the underlying factors and take follow-up corrective action.

    The misting on the brakes was introduced at some locations without being reviewed under the company’s RMS as required by its policy and procedure manual. This practice became standard and was considered normal, even though the aircraft manufacturer did not recommend use of water on the brakes except in specific circumstances. This unapproved adaptation and associated risks could have been identified had it been reviewed by the company’s RMS.

    Transport Canada conducted a program validation inspection in June 2011. Transport Canada determined that the company’s risk management process did not consistently and effectively:
    • identify source hazards from reported events; and
    • define and document risk scenarios associated with all hazards before assessing probability & severity of the worst credible outcome(s)
  • When an operator’s SMS is not fully effective, there is an increased risk that hazards will not be identified and mitigated.

    Although there had been a number of runway overruns at St. John’s Airport, the Airport Authority only did an internal, informal risk assessment and concluded there was no need to proceed any further. When organizations do not conduct formal risk assessments in accordance with their SMS, there is a risk that hazards will not be identified and mitigated.”

Can you speak to the inherent risks/strengths relating to prescriptive approach vs. safety management/leadership?

This question is at the center of most current thinking about safety in operations. The most obvious weakness in prescriptive methodologies is that they do not include means to engage in comprehensive processes to examine operations and proactively identify hazards, create effective mitigations to reduce the risks posed by them and then to ensure that this is done on an on-going basis.

Can you speak to company and regulator roles of risk reduction and shifts to inherently safer technology?

Complex question - First thing to remember is that is going to be some level of risk present in any operation. The regulator obviously has a role in seeking to ensure that the level of risk is within an acceptable range and there are a number of analytical tools and criteria used to establish this. Companies will be coming at this issue from a different perspective as they are also balancing risk reduction activities and costs in the face of their requirement to ensure financial viability at the same time as to meet these established parameters. Within this context, the push to safer technologies can be driven by either. The regulator can determine that a technology will provide a greater level of safety and can require its use -based generally on the same kind of baseline risk analysis as well as other factors. Companies could determine that the implementation of newer, safer technologies will decrease their cost or increase their reputational value and thus competitiveness.

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