AUP Advances - Current Issue

Safety investigations fall under the typical definition of a project since they have definite start and end dates and offer a specific end-product, meaning the safety recommendations which must be considered by the respective stakeholders as a means to improve the safety of daily operations. The scope of this study was to investigate whether safety investigations could benefit from project management. The research consisted of the following steps: (1) a gap analysis between the PMBPOK standard of the Project Management Institute (PMI) and the ICAO/USAF manuals regarding the main activity/knowledge areas and techniques/tools mentioned in these representative investigation standards, (2) based on the findings of the previous step, administration of a questionnaire to examine the degree to which project management areas and activities are present in regional safety investigation standards, and the perception of the participants about their usefulness. The findings suggested that the project management areas and activities are present in regional investigation standards at levels varying from 10% to 97%. Also, risk, quality, communication and stakeholder management are underrepresented in investigation standards. Most of the areas and activities of project management were perceived as very useful by the participants, who expressed some concerns about the danger to increase bureaucracy and complexity of safety investigations. Similar research can be conducted by other industry sectors and regions to detect whether project management principles can be introduced in safety investigations with the aim to increase their effectiveness and performance. Future research can focus on the project management tools and techniques that can be used in safety investigations as well as the examination of the latter through the lenses of agile project management.

This paper introduces the AVAC-SMS maturity metric and its accompanying tool which were developed in the frame of a research project with the aim to suggest new safety metrics, especially for Small-Medium Enterprises (SMEs). The metric is based on the ICAO Safety Management Manual, it was designed by applying the Systems-Theoretic Process Analysis (STPA) technique and it was reviewed by companies, authorities and field experts. It can be used to assess the institutionalisation, capability and effectiveness of an aviation SMS by following a systematic approach that employs the use of information from the safety department, managers and employees of an organisation. The AVAC-SMS maturity metric is uniform for the aviation sector, customisable to the size and complexity of the organisation, and results in numerical scores that can be used to monitor SMS maturity levels over time or perform benchmarking among companies.

Risk management is considered as the core process of an effective safety management system for identifying hazards and assessing risks. However, recent fatal hull loss accidents appear to have resulted from a combination of factors, none of which can alone cause an accident or even a serious incident. Therefore, traditional safety risk assessment processes, risk matrices, hazard logs and conventional risk management methodologies that mainly address individual risks, in some cases remained less effective in preventing major accidents that resulted from cumulative risks. Consequently, air operators have the need not only to proactively identify the ‘initial’ and the ‘residual’ risk of a hazard, but also to recognize the ‘current’ or ‘actual’ risk state of their system and to take the necessary mitigation actions for preventing an accident or a serious incident that may result from a combination of factors. The aim of this paper is to present and explain the concept of Dynamic Risk Management Dashboards (DRMDs), a tool which is a combined, real-time basis, a cross-departmental effort for managing risks resulting from a combination of factors. DRMD could concurrently examine and visualize the actual risk state of an aerodrome, an aircraft, an aircrew or an air traffic route based on a set of pre-defined Risk Acceptance Criteria that have been developed and tailored by each operator. The DRMDs have been implemented and evaluated by the safety department of a large military aviation organization as a proactive safety tool that complements the existing risk management process. Anecdotal results after a six-month trial period showed that DRMD assist decision makers in identifying the cumulative risks of particular missions and effectively in responding to unacceptable risks before authorizing or dispatching a particular flight.

Current practice regarding risk assessment contemplates the severity and likelihood of risks and employs the use of matrices where these factors are classified and cross-referenced to evaluate risk levels. Depending on the adequacy and reliability of data, the likelihood is estimated with quantitative or qualitative methods; severity is estimated according to experience from past events. This standard technique for assessing risks has been negatively criticised regarding validity and reliability due to effects of cognitive biases and a deterministic view of the possible consequences of risks. Even more, because of the lack of standardisation in risk matrices, a benchmarking across systems and organisations is not feasible. Taking into account the limitations mentioned, as well as the fact that the classification of hazards/causal factors, risk event(s) and consequences always depend on the analyst's view, this study proposes the Safety Risk Avoidance Capability (SAREAC) metric for a defined system. This metric focus on the prevention of risk events and combines quantitative and qualitative parameters referred in the literature but not yet exploited. SAREAC consists of two parts: the influence of hazards and the remaining effects of hazards after implementing or designing controls. Each of the SAREAC parts is calculated through specific steps which they result in a normalized score that allows more reliable comparisons amongst systems or over time. Data from a published risk assessment case study were used to demonstrate the use of SAREAC.

The objective of the study described in this paper is to define safety metrics that are based on the utilisation of resources. The background of this research is a specific need of the aviation industry where small and medium-sized enterprises lack large amounts of safety-related data to measure and demonstrate their safety performance proactively. The research department of the Aviation Academy has initiated a 4-year study, which will test the possibility to develop new safety indicators that will be able to represent safety levels proactively without the benefit of large data sets. The research team has reviewed the academic and professional literature about safety performance indicators and has performed surveys into 13 companies in order to explore what, how, and why safety performance indicators are used and whether there is a statistically linear relation between SMS process metrics and safety outcomes. The preliminary results showed that companies do not use data from all SMS processes in the development of safety performance indicators, they do not ground the selection of indicators on specific criteria, they implement SMS process in different ways, but they are eager to use alternative metrics, including ones potentially to be derived on the basis of contemporary safety models and views. As part of the development of alternative safety metrics, safety performance indicators were defined that are based on the difference between required resources and available resources. Resources are people, time, equipment and budget. This work is inspired by the general notion that a large gap between ‘work as imagined’ and ‘work as done’ has a negative influence on the level of safety. Work as imagined in this context is represented by available resources and work as done by required resources. The metrics were defined by a combination of literature research and semi-structured interviews with operational practitioners in the aviation industry. The suitability of the metrics will subsequently be tested in pilot studies within the aviation industry.

In the dilemma of Work-as-Imagined versus Work-as-Done (WAI/WAD), the delicate balance between rules and reality is often explained by stating that in case of an accident, a drift into failure had occurred. Such explanations refer to either individual operator’s or managerial decision making, where a violation of a predefined rational and hence, optimal and efficient decision making had taken place. Such drift is substantiated by normative theories of Reason, Perrow and Turner, each with their underlying assumptions and simplifications. Their notions of human error and failure of foresight are considered to have gained a generic validity over the years. More modern theories on human error and failure of foresight criticise these assumptions from an academic and theoretical perspective. They do however not take into account their normative component. The socio-economical context in which these theories were developed was to legitimize failure: the values and norms of the Anglo-Saxon society in the 1960’s and 1970’s. Such a construct is criticised nowadays within socio-psychological and organisational, even raising doubts whether safety science is a science or not. This contribution elaborates on several options for closing the gap between WAI/WAD in advocating the abolition of several obsolete notions that hamper a better understanding of the dilemma. Such constructs represent a logic of simplifications, assumptions and linearisations based on a combination of Procrustes bed, Laocoon’s fate and Ockham’s Razor respectively. Drift into failure is a mystifying construct, disregarding notions and knowledge about democratic participation, engineering design principles and socio-economical drivers for optimization.

Safety culture has been a topic of discussion in safety literature in the past three decades. Since its first mentioning after the Chernobyl accident much have been written about what fosters a positive safety culture within organizations. The Aviation Academy of the Amsterdam University of Applied Sciences conducted a literature review into safety culture development guidelines and identified a list of 37 prerequisites for safety culture development. Existing safety culture assessment tools target to measure the subjective perceptions of the workforce without examining the parameters affecting safety culture. Thus, they cannot be used to provide the organisations with guidance on the action points for improving their safety culture. To accommodate the need for practical guidance to companies, and as part of four-year research into Aviation Safety Metrics, the Aviation Academy has developed the AVAC-SCP tool, which aims to shed light on the planning and implementation for developing a safety culture. Knowledge experts and companies have reviewed the tool as a means to meet various criteria referred to literature with regards to safety metrics. The tool will enable organisations to derive actionable points from the results. A scoring method is included in the AVAC-SCP in order provide organizations with the ability to monitor their performance over time, compare between departments, and prioritize changes. The concept, academic background, reviews and other characteristics of the AVAC-SCP are discussed.

Since the very early days of aviation, both civil and military, safety is considered of high importance. Flight Operation Safety (FOS) constitutes a core business element of success and brand recognition for Aviation Organizations (AO). The last decades another aspect of safety, that of Occupational Safety and Health (OSH), has been incorporated in the business context, thus in AO’s. Numerous studies demonstrate OSH as a factor related to positive business performance. The objective of this study was to illustrate, in the operational level of an AO, the importance and interrelation of FOS and OSH institutions along with identifying any potential confusion between them. The study was part of a larger OSH research design performed in the specific AO. The study was conducted via a printed questionnaire distributed to all the AO’s respective departments. An open-ended questionnaire comprised of five questions was distributed to all the AO’s population. The returned questionnaires represented the 8% of the AO’s total population. After a non-parametric check, FOS and OSH were found to interrelate with each other significantly. An interesting finding was that half of the knowledge of each context is mutually exclusive from the other. In that regard, OSH related knowledge was related to working experience. The categorisation of reported themes referring to unsafe acts-incidents-accidents amongst FOS and OSH is confusing according to participants. Confusion between FOS and OSH was found statistically independent with working experience, which was an unexpected result. Concluding, safety, was found to be essential for the examined AO, with significantly less knowledge existence about OSH. The resulted confusion between FOS and OSH in the AO highlights an important issue that should be further examined via focused research.

For five decades complex socio-technical systems have been studied in an attempt to understand and prevent the occurrence of accidents. In this paper, the authors define a concept for a System Complexity metric, comprising the total of all direct interactions between the system elements and the tools the controller has to control the system. Subsequently, the human performance of the operator is taken into account to arrive at the Perceived System Complexity. Finally a hypothesis for a relation between the dynamic actually perceived system complexity, and the occurrence of incidents is postulated, which are still to be proven in practice.

The recently introduced Risk SituatiOn Awareness Provision (RiskSOAP) methodology suggested an indicator to measure the distance between the configuration of a real system and its ideal version or between various system versions. It considers the (in)existence or (mal)functioning of system components, processes and connections based on a binary approach. However, in practice safety requirements can be fulfilled to some degree and each system component might have a different impact on system outcomes. This work suggests the Comparing System Configurations (COSYCO) indicator which introduces (1) the use of continuous values for the behaviour of system components, (2) the inclusion of weights according to the hierarchal system level to which each component belongs, and (3) the consideration of the outgoing connections of each component with other system components. Both RiskSOAP and COSYCO are based on the STPA hazard analysis which is a systematic technique used to define the components and the requirements that the system should ideally meet to achieve its objectives. To demonstrate the applicability and sensitivity of COSYCO, we applied it to a published case for small drones. Drones with same overall differences in the satisfaction of requirements concluded to different values when applying COSYCO, indicating the increased sensitivity of the specific indicator when compared to the RiskSOAP. We envisage that the metric proposed in this work is a first practical and realistic approach to the quantification of the distance between the optimal design and current system states as well amongst various systems and their versions over time.

The objective of the study described in this paper is to define safety metrics that are based on the effectiveness of risk controls. Service providers define and implement such risk controls in order to prevent hazards developing into an accident. The background of this research is a specific need of the aviation industry where small and medium-sized enterprises lack large amounts of safety-related data to measure and demonstrate their safety performance proactively. The research department of the Aviation Academy has initiated a 4-year study, which will test the possibility to develop new safety indicators that will be able to represent safety levels proactively without the benefit of large data sets. As part of the development of alternative safety metrics, safety performance indicators were defined that are based on the effectiveness of risk controls. ICAO (2013) defines a risk control as “a defence with specific mitigation actions, preventive controls or recovery measures put in place to prevent the realization of a hazard or its escalation into an undesirable consequence”. Examples of risk controls are procedures, education and training, a piece of equipment etc. It is crucial for service providers to determine whether the introduced risk controls are indeed effective in reducing the targeted risk. ICAO (2013) describes the effectiveness of risk control as "the extent to which the risk control reduces or eliminates the safety risks”, but does not provide guidance on how to measure the effectiveness of risk control. In this study, a generic metrics for the effectiveness of risk controls based on their effectiveness was developed. The definition of the indicators allows, for each risk control, derivation of specific indicators based on the generic metrics. The suitability of the metrics will subsequently be tested in pilot studies within the aviation industry.