Practical Application of Safety-II in a Large Commercial Airline Adam Johns WHO ARE CATHAY PACIFIC?
Practical Application of Safety-II in a Large Commercial Airline Adam Johns WHO ARE CATHAY PACIFIC?
Two airlines: Cathay Pacific & Cathay Dragon
Based in Hong Kong, formed in 1946
Approx. 200 aircraft (A350, B777, B747…)
Over 25,000 employees worldwide
Approx. 40 million passengers per year (2018)
Approx. 180,000 flights per year (2018)
Over 100 worldwide destinations
14 billion USD turnover (2018)
Founder member of oneworld
Group also includes HK Express & Air Hong Kong THE CATHAY ORGANISATION (Ops only)
Executive Leadership
Operations Leadership
Flight Cabin Ramp Cargo Corporate Engineering Operations Operations Operations Operations Safety THREE THEMES
1. Changing language to change thinking
2. Getting the word out
3. Developing the Operational Learning Review SOCIALISING NEW IDEAS
Safety-II introduction Chronic unease Efficiency-thoroughness trade-off Local rationality Varieties of human work (WAI-WAD) Complicated & complex systems Equivalence Resilience
PILOT PERFORMANCE OBSERVATION
Why did it make sense to them?
OBSERVE RECORD CLARIFY CLASSIFY EVALUATE PILOT TRAINING ASSESSMENT
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4
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Source: Erik Hollnagel SYSTEMS THINKING IN SAFETY
Source: EUROCONTROL RECURRENT TRAINING – 3 SAFETY TRUTHS
1 You can’t fix pilot error, but you can be incident free
2 Pilots don’t come to work to do a bad job
3 You can’t fix safety by focusing on safety OPERATIONAL LEARNING REVIEW (OLR)
WHAT IS AN OPERATIONAL LEARNING REVIEW?
• Ensures learning and improvement are the core goals of safety management
• Designed to help understand why it made sense for people to do what they did
• Use in context of operational safety events, but also in situations where no safety event occurred OLR OBJECTIVE
Facilitate organisational learning, whilst fulfilling all Company and regulatory requirements. KEY PRINCIPLES AND PROTOCOLS
• System learning before individual learning
• Individual asked what they need to learn first
• Interventions focused on individuals shall not be punitive (no “intent to punish”) • Interventions are to protect system integrity and avoid risk, but not miss out on system learning CAPTURING THE OLR
Context System disturbances Sensemaking Resilience (A/M/R/L) Controls Learning 1. System 2. Individual Recommendations A LANGUAGE FOR RESILIENT PERFORMANCE CAPTURING RESILIENT PERFORMANCE
• Robust task management skills • Spare capacity to problem solve • Safe and expeditious operation • Effective prioritising • Use of resources to reduce workload • Complete tasks without succumbing to distractions • Understanding of procedures • Delegation • Clear division of tasks • Use an effective problem solving model • Strong communication skills • Effective monitoring through acknowledgement and confirmation • Clear briefing • Anticipate future considerations • Persistence BENEFITS OF THE OLR
• Chief Pilots more informed about work-as-done
• Starting to see positive change in safety climate from OLR experiences
• Pilots see that someone is actually listening to them – opportunity to tell story and improve the system
• Better safety improvements identified (system and individual) CATHAY PEOPLE YOU CAN CONTACT
Pete McCarthy – Head of Group Human Factors [email protected]
Captain Peter Hudson – Flight Operations Risk Manager [email protected]
First Officer Valerie Stait – Deputy Flight Operations Risk Manager (Boeing) [email protected]
First Officer Lok Lee – Deputy Flight Operations Risk Manager (Airbus) [email protected] Thank you for listening