JAL Group`s Approach to Safety (PDF:1860KB)

Transcription

Provisional Translation
Document 4, The 4th Meeting,
Working Group on Voluntary Efforts and Continuous
Improvement of Nuclear Safety,
Advisory Committee for Natural Resources and Energy
JAL Group’s Approach to
Safety
- Fostering a Safety Culture October 7, 2013
Nobuyoshi Gondo
Corporate Safety & Security Division, Japan Airlines
Copyright © 2013 JAPAN AIRLINES. All rights reserved.
1
Safety Management in the Aviation Industry
Safety Management Structure of the JAL
Group
Safety Management System
Fostering a Safety Culture
2
Safety Management in
the Aviation Industry
3
World Aviation Accident Rate
Worldwide Commercial Jet Fleet - 1959 Through 2012
総事故率 All accident rate
全損事故率 Hull loss accident rate
死亡事故率 Fatal accident rate
年間事故率
100万出発回
あたりの
事故件数
搭乗者死者数
Onboard fatalities
Hull loss
accidents rate
in the world is
below 1 out of
1 million flights
年間
搭乗者
死者数
There is no absolute safety as long
as aircraft is operated
暦年 Year
Source:
4
Measures to Reduce the Accident Rate
Technological
advance
Accident rate
Skill improvement
through training
Human factor study
・Safety management
・Establishment of a
safety culture
Times
5
ICAO’s International Standards
ICAO
International Civil Aviation Organization
国際民間航空機関
 Its member countries shall establish domestic standards in line with
regulations, standards, etc. stipulated by ICAO in principle. The Annex
to the Chicago Convention (Convention on International Civil Aviation)
(ICAO ANNEX) requires individual airlines, control organizations, and
airport administrators to implement safety management measures
approved by their national governments.
SMS(Safety Management System)
 Safety means a state in which the risk of harm to people or damage
to properties is reduced to the acceptable level and maintained
below the acceptance level through identification of the risk factors
and continuous risk management.
6
Safety Management in Japan
Trends in Japan
In June 2005, a “Committee for Study of Measures to
Prevent Public Transport Accidents Caused by Human
Errors,” consisting of the vice minister, concerned bureau
chiefs, academic experts, etc., was inaugurated.
As a result of studies at the committee, a “Law for Revising
Part of the Railway Business Act, etc. in Order to Improve
Transport Safety (Comprehensive Law for Transport
Safety),” which mandates formulation/notification of a
safety management rule, appointment/notification of a
safety supervisor, disclosure of information on transport
safety, etc., was established, and enforced in October 2006.
JAL Group’s Safety Management
7
Safety Management System Framework
Safety policy and objectives
・It starts with defining rules
① business promises and duties
・Risk management alone is not enough
② Safety responsibility
③ Safety supervisor’s nomination
④ Adjustment of the emergency plan
⑤ Documentation of the safety management system
Management of the safety risk
⑥ Identification of the hazards
⑦ Risk evaluation and reduction
Safety assurance
⑧ Monitoring and measurement of safety performance
⑨ Management of modifications
⑩ Continuous improvement of the safety management
system
Promotion of safety
⑪ Training and education
⑫ Communication on safety
8
Safety Supervisor
(General guidelines for establishment of a safety management structure, a circular notice by the
Director-General, Civil Aviation Bureau)
 A safety supervisor is a person who holds an
administrative position participating in important
decision making on business operation, or in other
words, holds an administrative position allowed to
become directly involved in important business
judgment related to safety such decisions on safety
measures and safety investments, and is allowed to
directly express his/her opinions at the highest
management decision-making bodies such as a the
board of directors.
Managements must properly perceive safety risk
9
Safety Management
Structure of the JAL Group10
Problems resulting from human errors occurred in succession.
Dec. 2004
Erroneous use of a main landing gear part of a
freighter
Jan. 2005
Violation of a control instruction at the Chitose Airport
Mar. 2005
Misunderstanding of a control instruction at the
Incheon International Airport
Mar. 2005
Failure to change the door mode of emergency escape
doors
11
An Order to Improve Operations
On Mach 17, 2005, we received the following from the
Minister of Land, Infrastructure and Transportation:
 an “order to improve operations” and a warning letter
A very serious situation
for a company
Article 112 of the Civil Aeronautics
Act
The Minister of Land, Infrastructure, Transport
and Tourism may, when he/she finds that the
business of any domestic air carrier adversely
affects transportation safety, convenience to
users, and other public interests, …
Seriousness with only two
precedents
12
Self-analysis of JAL
 Efforts of the management were insufficient to emphasize and
spread the fact that top priority should be given to safety under
any environment to the whole Group.
 Through our work on the improvement of punctuality,
recognition when improving punctuality that safety should be the
by far the main focus tended to lessen, creating an atmosphere
favorable to the coexistence of safety and punctuality.
 In the framework consisting of a holding company and two
business companies, created in the process of business
integration, the management and field workers were not working
in close enough contact, and communication among divisions
was lacking.
 Bidirectional communication from top management to field
workers, who directly support safety, was inadequate.
13
Content of Our Response
Improvement measures in response to the
order to improve operations
1. Strengthening of the safety management
structure
2. Company-wide efforts to improve safety
consciousness
3. Review of the procedures and manuals for
preventing human errors and thorough
implementation of compliance
4. Other
14
Establishment of a Safety Advisory Group
August 2005
A “Safety Advisory Group” was established
Mr. Kunio Yanagida (Chair)
Mr. Yotaro Hatamua
Mr. Shinichi Kamata
Writer, critic
Professor, Kogakuin University
Professor Emeritus, University of
Tokyo
(specializes in “creative
engineering” and “learning from
failure”)
Professor, National Defense
Academy
(specializes in “organizational
theory” and “business
administration”)
Mr. Shigeru Haga
Mr. Akinori Komatsubara
Professor, College of
Contemporary Psychology,
Rikkyo University
(specializes in “traffic
psychology” and “industrial
psychology”)
Professor, Faculty of Science
and Engineering, Waseda
University
(specializes in “human life
engineering”)
Problems of an organization are
difficult to find from inside the
organization, or difficult to point
out even if they are found.
15
Recommendations from the Safety Advisory Group
December 2005
We received a “Recommendation for Revival as
a Company with a High Safety Standard.”
December 2009
We received a new recommendation entitled
“Guard the Stronghold of Safety.”
Proposal of a concrete undertaking
aimed at a specific corporate
culture, at creating a specific
working atmosphere
16
Outline of the recommendation
Organizational reform: establishment of a
central body responsible for safety
Reform in the way of thinking: having the
viewpoint of families or passengers
Lessons learned from accidents: establishment
of a Safety Promotion Center
Communication: look for breakthrough words
and so on
17
Outline of the new recommendation
Concept of “safety layer”
4 pillars of “safety culture”
Culture of decision-making by yourself and
taking on challenges
Culture of maintaining communication
Culture of refining the manuals
Culture of having the “viewpoint of the 2.5th
person”
and so on
18
Strengthening the Safety
Organization Structure
19
Establishment of a Central Safety Organization
(Corporate Safety & Security Division)
Recommendation
 The division responsible for safety and the
corporate planning division are the engines on
the wings that drive the company
 Establish a central organization responsible for
safety as a powerful “general staff office” for the
top management
In April 2006, a “Corporate Safety & Security Division,”
consisting of professional staff members knowledgeable
of field works of operation, maintenance, cabins, airports
and cargos, was established.
Using this organization as a source of power, drive a
safety management structure across the whole group.
20
Corporate Safety & Security Division
Corporate Safety & Security Division
Operation Group
14 members
Performs the division’s operations in
general, operation of the Safety
Promotion Center, operation of safety
promotion/education, etc.
One Director,
6 Dept. Managers
Casualty Care Office
4 members
A contact service for bereaved families
and casualties
Safety Planning Group
16 members
Performs planning, safety audit, etc.
related to aviation safety and
aviation security
41 members in total
(as of October 1, 2013)
21
Establishment of a Central Safety Organization
(Corporate Safety & Security Division)
 Safety Management Structure of the JAL Group
Safety promotion at
the head office level
President
President
Safety
SafetyMeasure
MeasureCouncil
Council
Aviation
AviationSafety
SafetyPromotion
PromotionCommittee
Committee
Corporate
CorporateSafety
Safety&&Security
SecurityDivision
Division
Safety promotion at levels
of field works/companies
Operation
Operation
Division
Division
Group airlines
Cabin Division
Cabin Division
Maintenance
Maintenance
Division
Division
Airport Division
Airport Division
Cargo & Mail
Cargo & Mail
Division
Division
Operation Safety
Operation Safety
Promotion Dept.
Promotion Dept.
Cabin Safety
Cabin Safety
Promotion Dept.
Promotion Dept.
Maintenance Control
Maintenance Control
Dept.
Dept.
Airport Planning
Airport Planning
Dept.
Dept.
Operations Dept.
Operations Dept.
Operation Safety
Operation Safety
Committee
Committee
Cabin Safety
Cabin Safety
Committee
Committee
Maintenance Safety
Maintenance Safety
Committee
Committee
Airport Safety
Airport Safety
Committee
Committee
Cargo Safety
Cargo Safety
Committee
Committee
Operation
Operationcrew,
crew,cabin
cabincrew,
crew,mechanics,
mechanics,ground
groundoperation
operationstaff,
staff,airport
airportstaff
staff
JTA
JTA
JEX
JEX
JAC
JAC
JAIR
JAIR
RAC
RAC
Company-wide safety promotion
22
Establishment of a Council Structure
Creation of a Safety Measure Council
President
In March 2005, the council was
established with as its members:
the President, vice-presidents, the
Safety Measure (Board of
Directors)
safety supervisor, directors
Council
responsible for safety, and directors
responsible for operations,
Aviation Safety
maintenance, cabins, airports and
cargos.
Promotion Committee
Undertakings (meetings 1~2 times a month): policy
decisions and quarterly review of important aspects
of safety (course of action, safety objectives, safety
policy) among others, sharing of safety data,
verification of unsafe event handling, etc.
23
Safety Management System
24
Method for Safety Management
– Excerpt from the Safety Management Rule –
Conduct continuous review of the Safety
Management System, and pursue
maintenance/improvement of safety of air
transport, by implementing efforts for a
safety management cycle.
25
Safety Management Cycle
(PDCA cycle)
Safety policy
Evaluation and
Collection of
improvement
information
of measures
Spiral Up
[PDCA cycle]
Implementation
of measures
•
•
Grasping/analysis
of problems
Study of measures
Review and continuous improvement
Successful undertakings outside the company are vigorously documented upon
and used as reference material.
26
Safety promotion at
the head office level
President
President
Safety promotion at levels
of field works/companies
Safety
SafetyMeasure
MeasureCouncil
Council
Aviation
AviationSafety
SafetyPromotion
PromotionCommittee
Committee
Corporate Safety &
Security Division
Group airlines
Cargo & Mail
Cargo & Mail
Division
Division
Operation Division
Operation Division
Cabin Division
Cabin Division
Maintenance
Maintenance
Division
Division
Operation Safety
Operation Safety
Committee
Committee
Cabin Safety
Cabin Safety
Committee
Committee
Maintenance Safety
Maintenance Safety
Committee
Committee
Airport Safety
Airport Safety
Committee
Committee
Cargo Safety
Cargo Safety
Committee
Committee
PD
AC
PD
AC
PD
AC
PD
AC
PD
AC
Operation Safety
Operation Safety
Promotion Dept.
Promotion Dept.
Cabin Safety
Cabin Safety
Promotion Dept.
Promotion Dept.
Maintenance
Maintenance
Control Dept.
Control Dept.
Airport Planning
Airport Planning
Dept.
Dept.
Airport Division
Airport Division
Operations Dept.
Operations Dept.
PD
AC
JEX
JEX PD
AC
JAC
JAC PD
AC
JAIR
D
JAIR P
AC
RAC
D
RAC P
AC
JTA
JTA
27
Management of Safety Risks
 Information collection
 Hazard identification and
management
Reactive
•Accident/serious incident
investigation
•Mandatory reporting system
•Interview program, etc.
Safety information database
Ope
-ration
Proactive
•Voluntary reporting system
•Safe roving
•Machinery/material quality
monitoring, etc.
Predictive
•Operation monitoring (Flight
Data Monitoring, LOSA,
Maintenance Operation
Monitor, etc.)
Cabin
Safety
promotion
Airport
•
•
Mainte
-nance
Cargo
+
Group airlines
Risk management is affected by the quality, the
quantity and the speed of the information
Data must be gathered, shared and put to use
28
Evaluation of Safety Risks
Risk = Severity × Probability
* Severity
[Index (examples)] Impact on flights, impact on customers,
impact on the environment, degree of
casualties, degree of reputation/media
coverage
* Probability
[Index (examples)] Occurring 2 to 3 times a week, occurring 2
to 3 times a year, occurring 2 to 3 times a
decade
Severity
Probability
29
Safety Risk Matrix (Example)
Severity
5
4
3
2
1
5
A
A
B
B
C
4
A
B
B
C
C
3
B
B
C
C
D
2
B
C
C
D
D
1
C
C
D
D
D
Probability
Risk level
Description
Action
A
Extreme Risk
(Unacceptable)
Immediately interrupt the respective operation/project (or after taking an
emergency action), take a measure to reduce the risk to an acceptable level.
B
High Risk
(Unacceptable)
Formulate a measure to control the risk to an acceptable level as soon as
possible, and implement the measure.
C
Medium Risk
(Tolerable)
Implement a measure to control the risk to an acceptable level in a planned
manner (specify the plan).
D
Low Risk
(Acceptable)
Unnecessary to take any particular action.
・Set a matrix for each areas
・Also evaluate possible worst cases
30
Reduction of Safety Risks
 Risk reduction
Formulation/implementation of risk reduction
measures according to risk levels
Recurrence prevention PDCA
checklist
•Validation of the reduction
measures
•Lateral spread among the
Group
(draw a lesson from the
information)
•Reviewing the effect after
implementation
31
Safety Indexes and Safety Goals of the JAL Group
 JAL Group safety indexes
 Number of aviation
accidents
 Number of serious
incidents
 Number of irregular flights
 Number of injuries to
customers
 Number of defects due to
human errors
 Management of other indexes
・Visualization of safety level
・Index showing employee efforts
・Undertakings to thicken safety layers
32
Continuous Improvement of the Safety
Management System
Safety audit (internal audit)
Comprehensive information
collection
Defect events
Safety indexes
Safety promotion council
structures
Field investigation (safe roving,
operation investigation)
Business plan (change in the
business environment)
Recommendations from the
Safety Advisory Group
Transport safety management
evaluation
Audit by the Civil Aviation
Bureau, IOSA, and code-sharing
partners
Other
Audit summary
Analysis
Evaluation
・Extraction of
problems
・Checking the
improvement
measure
(direction)
Safety
measure
Implementatio
n of
improvement
action
・Extract essential problems such as those with organizations and safety culture
・From compliance to performance basis
33
34
A safety culture is a “habit of mind”
A safety culture is created from the viewpoint
of passengers
Excerpt from the recommendation by the Safety Advisory Group
35
Top management’s
commitment
Culture where
necessary information
reaches all parts of
the organization
Culture of repotting
Example: voluntary reporting system
Example: lateral spread and sharing
of safety information
Safety
Management
Cycle
Culture of learning
Fair culture
Non-disciplinary
policy
Example: Safety Promotion Center
Facilitator education
Viewpoint of the 2.5th
person
Maintain the memories
of accidents
36
Top management’s
commitment
Culture where
the organization
Example: voluntary reporting
system
Safety
Management
Cycle
Culture of learning
Fair culture
Non-disciplinary
policy
person
of accidents
37
Top Management’ Commitment
 JAL Group Safety Charter
Safety Charter
Safety in flight operations is the very foundation and
social responsibility of the JAL Group.
To carry out our mission of assuring safety, the
management will exert its strong resolve and the
employees will bear an awareness of their individual
roles and responsibilities, and together we will combine
our utmost knowledge and capabilities to ensure the
safety and reliable operation of each and every flight.
In order to carry out our mission, we will conduct;
Perform our duties in compliance with regulations,
faithfully following the basics.
Be sure to make checks, without relying on
assumptions.
Relay information thoroughly, promptly and accurately,
and ensure transparency.
Respond to problems and issues quickly and precisely.
Maintain a constant awareness of issues, and make
necessary reforms without hesitation.
Management’s commitment and strong resolve
38
Top management’s
commitment
Culture where
the organization
Safety
Management
Cycle
Culture of learning
Fair culture
Non-disciplinary
policy
person
of accidents
39
Voluntary Reporting System
Minor human errors with which safety problems have not surfaced
(that have not resulted in major problems) will be buried without
being reported. However, even such minor errors may develop into
major problems if they occurred in different circumstances.
Therefore, it is important to analyze even minor human errors and
utilize them for preventive measures in order to prevent major
problems from occurring. A system for collecting such minor
human errors is the voluntary reporting system (*).
(*) Introduce the system to operations involving operation crew,
cabin crew, mechanics, airport staff and cargo services
Gather even limited data
40
Non-disciplinary Policy
Introduced to the JAL Group in February 2007
 If the person making such an error is punished, the
workplace will stagnate and the lesson learned will
not easily be shared. Excerpt from the recommendation by the Safety Advisory Group
 To ensure that the interview program and the
voluntary reporting system will effectively work, it is
necessary to establish a rule under which reporters
shall not be internally disciplined.
Gather accurate data
41
Top management’s
commitment
Culture where
the organization
Safety
Management
Cycle
Culture of learning
Fair culture
Non-disciplinary
policy
person
of accidents
42
Communication on Safety





Corporate Safety (e.g., business message, state of safety goal achievement)
[transmitted 20 times]
Corporate Safety Information (lateral spread of safety information among
companies/divisions) [transmitted 15 times]
Full-time disclosure of safety information via the intranet (e.g., state of safety
goal achievement)
Workplace rounds by executives [180 times]
 Summer safety campaign
 Thorough safety examination of year-end/
Figures in [ ] are
FY 2012 results
new-year transport
Face-to-face dialog by the Safety Advisory
Group
 Face-to-face dialog with employees
[20 times]
 Feedback to the management [twice]
 Communication leader meeting [11 times]
・Share the acquired information, and draw a
lesson from it.
・Vocal communication is the basics.
43
Top management’s
commitment
Culture where
the organization
Safety
Management
Cycle
Culture of learning
Fair culture
Non-disciplinary
policy
person
of accidents
44
“Viewpoint of the 2.5th Person”
Viewpoint of 1st
person
Viewpoint of the 2nd
person
If you were a customer
If your family were a customer
Make judgment while attaching importance to affection and
consideration.
Act in tune with each individual without sticking to conventional rules.
Respond according to individual requests/circumstances of
customers.
45
Viewpoint of the 3rd person
Calm and dry viewpoint
Make expert judgment as a professional in a calm manner.
Perform your work while faithfully observing what are written in the
rule.
Respond without being influenced by various requests/circumstances
of customers.
46
Viewpoint of the 2.5th person
Calmly perform your duties from the “viewpoint of the
3rd person” as a professional while at the same time
having the “viewpoints of the 1st and 2nd person”
It is important to always act from the other person’s viewpoint
Instead of thinking that you “should only do what are written in the rule”
and automatically responding, always act from a different viewpoint by
staying a while to think if “there is anything else I can do” and if “it is
necessary to check again.”
To be able to act spontaneously, acquire the “habit of mind” by
having the way of thinking from the “viewpoint of the 2.5th person”
on a regular basis.
The motivation to improve safety
47
Top management’s
commitment
Culture where
the organization
Safety
Management
Cycle
Culture of learning
Fair culture
Non-disciplinary
policy
person
of accidents
48
Accidents of the JAL Group
Date
Flight name, model
Place
Outline of the accident
Number of casualties
April 9, 1952
JAL301, Martin 202
Mokusei-go
Izu Oshima
Island
Collided to Mt. Mihara of the Izu
Oshima Island on the projected
course
37 passengers and crew
members were all killed
July 3, 1971
TDA63, YS-11A
Bandai-go
Hakodate
Crashed into the south slope of Mt.
Yokotsudake while approaching to
the Hakodate Airport
June 14, 1972
JAL471, DC-8-53
New Delhi
Slammed to the bank of the
Yamuna River before the Palam
Airport
members were killed
and 3 seriously injured
November 28,
1972
JAL446, DC-8-62
Moscow
Crashed immediately after taking
off from the runway of the
Sheremetyevo Airport
members were killed
JAL1045, DC-8-62F
Anchorage
Crashed immediately after taking
off from the Anchorage Airport
September 27,
1977
JAL715, DC-8-62
Kuala Lumpur
Collided to a hill before the Kuala
Lumpur airport while descending
to approach the airport
members were killed
February 9,
1982
JAL350, DC-8-61
Haneda
Crashed into a shallow water of
the Tokyo Bay off the runway C
while landing
44 passengers were killed
August 12,
1985
JAL123, 747
Gunma
Prefecture
Crashed into the ridge of Mt.
Osutaka in Gunma Prefecture
members were killed
January 13,
1977
49
Starting Point of Our Approach to Safety
JL123 (JA8119) crash accident
 Around 18:56 on Aug. 12, 1985, the airplane crashed into a
mountain (Mt. Osutaka) in Gunma Prefecture.
 The airplane got out of control because all hydraulic systems
became inoperable due to partial loss of the vertical tail and the
rear fuselage as a result of breakage of the rear bulkhead.
 The cause was a defective work performed by Boeing during a
repair after accidental contact of the tailpiece at the Itami
Airport in 1978 (summary of the Transport
Ministry's Aircraft Accident Investigation report )
 Of the 524 people on board,
520 (505 passengers and 15 crew
members)
were killed, and 4 survived
50
Maintaining the Memories of Accidents
Creating a corporate climate of securing safety with the Mt. Osutaka
accident as the starting point
Education on “gen-chi (site),” gen-butsu (real thing) and
gen-jin (living people)”
“Gen-chi (site)”: Mt. Osutaka
ridge climbing
“Gen-butsu (real thing)”: Safety Management
Center tour
“Gen-jin (living people)”: Messages from
bereaved families and
from employees who
engaged in the
accident at that time
(watching educational material consisting of video images of
interviews with bereaved families and employees)
The idea is that you can understand the true nature of things only by actually
visiting the site (gen-chi), seeing the real things (gen-butsu) and listening to those
who experienced the accident (gen-jin) (*).
* Source: Safety Advisory Group’s recommendation – Annex by member Yotaro Hatamura
51
Safety Promotion Center
On April 24, 2006, a “Safety Promotion Center”
Closed for relocation and construction f
was opened.
or 3 months since October 1, 20130
Number of visitors
(as of end of August 2013)
Total: 129,766 people
(employees account for 50%)
Keep the lessons learned from this accident in our minds , and hand
them down to the next generation
Promote safety consciousness among JAL Group employees
The shape of safety cannot be displayed. Results of being unsafe
will be visualized.
52
JAL Group’s Safety Education
Outline of the education
Learn lessons from past accidents
“Learn about, be conscious of and
think about” the Mt. Osutaka accident
Think about the connection between
your duties and safety.
Set your own “my safety declaration” before returning to your
workplace.
This education has been conducted for all the 36,000
employees of the JAL Group for approximately two
years.
“Make the safety layer thicker” by accumulating
awareness and actions through the safety declaration.
53
Thank you very much for your attention.
54

JAL Group`s Approach to Safety (PDF:1860KB)

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