My name is Daniel Maurino, and I am what in English is called a ‘safety practitioner’.
I have dedicated most of my professional life to work on issues related with the safety management systems in aviation. The topic of this presentation is the ‘reporting system’, why they are so much needed and how they should work in order to be effective and efficient.
It is interesting to consider that no manmade system is perfect. No production system, irrespectively conceived to produce commodities or services, is faultless or free from deficiencies; neither fully protected from enabling human errors.
Let see how it works. On one side there is the ‘theoretical design’ of a system, its theoretical conception and on the flip side there its operational use.
At project stage, designers maximise the use of technological resources to achieve the production objectives of the system. In this phase, it is defined the personnel competence required to operate such the system as well as the SOPs and staff behaviour requirements. Once those parameters are defined, the designers ‘run’ the system.
Most of the time, the system works as per the conceived parameters. However, as time pass, an operational drift from the initial parameters starts to create within the operational use of the system.
This defines two things: the theoretical conception of the system and the ‘operational drift’. The operational drift is generated as a ‘consequence’ of the system daily use. It is also known in SMS as the ‘practical drift‘ of the system.
The consequence is a symptom of technology that does not work as it was conceived during the design phase or SOPs that work very well at the drawing office, but which might be inadequate or hard to comply with, in reality.
Another symptom of operational drift can also be the lack of staff competence that the system requires to achieve the desired output or production objectives.
Even though all the above set of deficiencies, the sharp-end staff and operators try to adapt to keep-on achieving the production objectives. This creates a generation of a corporative knowledge and a new set of skills, even when the company should have stopped the production factors due all latent failures rising rapidly.
Here is where a ‘healthy reporting system’ plays a fundamental role in catching the collective knowledge within the organization operating such system.
A corporate knowledge usually is shared in an informal or verbal way, from experts to juniors workers, on how to arrange themselves or find in an informal way, how to overcome systemic deficiencies while striving to maintain production levels high.
If I would really like to know how the system works, I would not read the operating instructions and directly go to sharp-end staff and operators of the system, just to ask them how the system works.
In my area of expertise, aviation, the practical drift is well know when, as soon as one finished the formal training and go to line training (his/her working place), the senior staff might say: just forget what you have learnt at the school, I will show you how the system works. And this is the ‘practical drift’.
The practical drift is not bad, unless is properly tracked and effectively controlled by the organization. The reason is that those local practical drift events could create an undesired unbalance within the system which could led the system to collapse.
However, if the ‘operational drift capture’ is performed in an indoctrinated and programed way (i.e.: a safety reporting system), this would allow the organization to get an enormous amount of useful information that the organization may collect to provide feedback and an effective continuous improvement.
Once again, the great opportunity that any SMS has is to capture useful information directly from sharp-end staff or operators. Safety reporting is a tool that was never used to the full to its potential value.
Traditionally, the dilemma that any organization phases, is to work safely in the context of production, achieving both objectives in a balanced way. The practical drift may be described as the conflict between production and protection.
Today, there are several tools to capture the operational drift. Some are electronic such as DFDRs or audits or inspections, just to name few.
However, once again, if we consider that no system is perfect. And that the operational drift is a natural deviation that inevitably will nest in any operational system as well as its relationship with those that work on the system, the reporting systems acquire a crucial value to control the operational drift.
There is a common error in believing that individuals are ‘natural reporters’, which is not true at all. Individuals do not necessarily know what to report or what the organization is looking forward to get from reporters. So, to convert an effective reporting system as part of the SMS, it is crucial to train the messengers. The training will focus on what kind of information the organization is looking for in order to control the operational drift.
Another key aspect of this issue is the answer that the reporter receives. If the messenger reports one, two, three times and there is no an evident change in his/her working environment, the perception of the reporter is that his/her reports are useless, and that he/she may opt not to report anymore.
This is to say that it is not only crucial to train the messenger, even more the messenger has to receive a positive feedback. It should be bear in mind that the messenger needs energy and willingness to report.
Another aspect is ‘the line’ that may be ‘draw on the sand’ but has to exits, to divide the system limit regarding protection and accountability/liability. The line defines the limit where the messenger is protected and beyond that line the messenger is liable of his/her actions or inactions.
The line is draw on the sand because depends on several factors such as the prevailing legal system or for the local practices and other relevant factors which may be different in different contexts.
Nevertheless, that line has to be defined by the organization making clear what is acceptable and what is not.
The last point is the use or mismanagement of the information collected by the reporting system. The messenger observes deficiencies in the system. The reporting will mainly report that and the traditional organizational behaviour is denial of such deficiencies and rather apportion of blame.
A reporting system will remain healthy as far as the information will be only used to track and control the practical drift. Should the information be used in other context, perceived or use for apportion of blame, the reporting system will immediately die.
A SMS and its reporting system is like a baby, quite fragile and that requires an enormous amount of time and effort to feed it and to make it grow healthy.
Finally, we are living now in a fundamental change, not only in aviation, where pass success does not guarantee future success. Is not correct to keep on trying old strategies, adapted to match today’s system demand. It is a time where we should review current strategies and allow us to make more use of lateral thinking. I am convinced that reporting systems implemented with a contemporary prospective are essential useful tools to guarantee safe operations.
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