Page 8 - Index

ISASI 2021 Keynote Speech:

Navigating the Safety

Investigation Hurricane

By Kathy Fox, Chair, Transportation Safety Board of Canada

(Adapted with permission from the author’s keynote address presented on Aug. 31, 2021 during ISASI
2021, a virtual meeting hosted from Vancouver, B.C., Canada, due to COVID-19 restrictions.—Editor) Kathy Fox

’d like to thank ISASI for the opportu- families, friends, lawyers—not to mention accident can be caused by many factors—
nity to speak today. As you know, this politicians, reporters, bystanders, and Reason’s model isn’t the only one out
event was originally to be held a year members of the general public—may all there.
Iago, and in person in beautiful Mon- be looking over your shoulder, shout- Another model, formulated by Jens
tréal. But then the world changed, and we ing about what they think the outcome Rasmussen, is known as the “safe operat-
had to change along with it. Fortunately, should be? ing envelope,” and it shows how opera-
change is nothing new to this audience. That’s a tough question, and before I tors, like any business, face competing
The way we work is always evolving, as can give you my opinion, I need to back pressures—pressures that they have to
it should. But the speed and scope of the up a bit—over 30 years, actually. manage in order to deliver a service, to
transformation over the past 18 months One of the most famous models of stay safe, and also to stay economically
has been extraordinary. Almost overnight, accident causation is the so-called “Swiss viable (see Figure 1).
the Transportation Safety Board (TSB) of cheese” model, which was conceptual- And, for the record, these pressures ap-
Canada was doing everything remotely— ized in the 1980s and 1990s and given ply to all operators, including those with
even some deployments. its famous moniker by James Reason in a healthy safety culture, who are actively
And anyone who has worked on 2000. The model shows multiple layers of striving to create safety in their day-to-
a high-profile safety investigation in defenses in the system, each represented day operations. This model is particularly
the past few years has likely seen oth- by a slice of cheese. Yes, any given layer relevant as the aviation industry regains
er changes, too, fueled in part by the may have a weakness, or flaw—represent- momentum and opens up despite the
increasing use of social media and the ed by the hole in that slice of cheese—but pandemic.
growing demand for instantaneous if you have enough different layers, any Now, as long as those competing pres-
information. In particular, investigations weakness in one layer is likely mitigated sures stay in relative balance—in other
are sometimes conducted against the elsewhere, thus preventing a single point words, as long as the aircraft onscreen
backdrop of a highly charged atmosphere, of failure. stays somewhere within those three
filled with constant demands for under- What this demonstrates is that acci- boundaries—operations should carry on
standing what or who is to blame, justice, dents are typically a complex interaction safely.
and accountability. I call it “working of latent unsafe conditions, acts, omis- But here’s the thing: those pressures are
during a hurricane.” And yet we as safety sions, or adverse events. In other words, seldom in balance. In fact, they’re always
investigators must try to stay impartial all the holes must line up at the same shifting, always pushing an operation
and objective and do our job: conducting time to create a “window of opportuni- toward those boundaries. And when
a safety-focused investigation in which ty”—which hopefully doesn’t happen very you cross any of them, there are…conse-
blame isn’t our focus. often. quences.
So how does one navigate that space? It’s a very linear concept though, and That’s where the problem lies—when
How do you as safety investigators do while it may be useful to some extent— the various pressures force an operator or
your job and stay neutral when victims’ certainly to explain to people how an crew to approach those boundaries. And
8 • October-December 2021 ISASI Forum