Segurança Operacional: Teoria e Prática (Webinário ANAC Safety - 1ª edição)

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[Music]
and hello
good morning everyone I'm wagner
moraes na operational safety advisory
and it's a pleasure  have you
here with us today for the first
webinar about the anaxi brand we
have several initiatives about
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for this first live from a max we
will have a strong team here, each one
is certainly a reference and towel from the
heart I thank you
with the participation of éder donating evani
do humberto for accepting the invitation
to participate in this discussion but
certainly the discussion will be very
sexist but your participation is
in order and for that there must be one that cold there
on the screen there must also be a link in the
video description and you can
forward your question and we will era
to offer this question to one of the
speakers here, we will have
theory and practice as a central operational theme,
so we have a group here
and it will be more academic and
regulatory, but we also have
colleagues who will talk about the application
of these concepts and how  this is
developed in practice for us to
start the discussion I go
to each of you in the following sequence
that I weather joão in the sequence
ivan and humberto give a small
introduction of the theme from his perspective
that is weather talking about how it was  the
evolution of the topic of operational safety
within the academic world of concepts
and theory that has been evolving
over time joão regarding the
evolution of sleep regulations than
came from cal and following ivan how
this was perceived in practical application
at  in the certified operators and in the
same way humberto how this was
perceived and applied by the operators is
private guys again thank you very much
for participating and she is at ease
for yours
good thank you good morning everyone
initially went to thank anax for the invitation
i thank you for your  person wagner the
mass extensive this obviously the
institution anac the colleagues who helped
organize this event gerson costa
walber own luciana who is giving
support today and at the same time greeting
colleagues from and binary commander ivan
oak known jade for some time the
person i have  the person I
have extreme admiration for the
professional work done by the
site management and quality of azul joão
garcia humberto nice to meet
you here already knew him by name had not
yet had this
opportunity to rent with you good from the point
of view  In view of
the theory, at least in the academy, as
these concepts are not evolving, right?

of
safety management practice of
accident prevention of course for many years there
before the pre-industrial era so to
speak accidents were explained as an
act of the gods it is not a misfortune that
happened by the will of the gods mass so to
speak pre-industrial revolution
industrial revolution to date and the whole
movement of modernity in which
science takes accidents with objects
everything comes to treat the accident as an
unexpected event and with undesired consequences

it's something unexpected and unwanted,
right, but not, so to speak, it doesn't mean
that we just cross our arms and
do nothing. It's also important.

it was composed of many
types of organizations within it
we have organizations that operate because
we can call it the pre-
Taylorist phase, that means organizations
that operate without established routines in
management and control processes of their
activities and so on then  it's
almost an extreme would be risking
saying that it's a trial and error no I
say that everything is if it works in this store
but we do have
civil aviation activities that also do the black
illustrates we have in civil aviation
today in brazil also activities  which are
carried out obviously following the
principles of scientific administration and
modern management principles, but within
that we also find different
levels of maturity, right?

some organizations
with fundamentally mature safety management systems, you know,
I
really like studying accidents because
accidents are showing us less they
make us understand the limits and our
capabilities and control our risks
the risks of the activities in the industrial
in the operative which we operate  people
drive, right, also manage accidents
is what we know what
we know how to do with our
technologies the limits of this show us
the limits of the predictability of
events, in fact, accidents were
predictable for us and maybe we could
reach zero accidents, right?  and accidents in
a certain way also contribute to validate
or invalidate our
design hypotheses of the systems that we design
and the way we generate systems
in the contemporary science of
accident prevention, so to speak, we
consider that these are the accidents then
unexpected events with
unintended consequences but they never
result from isolated causes or
static factors that can be
identified in the field they emerge from
complex interactions which are not
fully knowable measurable and
controllable there are decades of
research that show this show that
accidents are like that  that a
book now from
the academy there is a book published in
2007 but if it has been much discussed
now in the time of the pandemic it is the book
nassim taleb called black swan
accident in a way they are swan
rules of what are black swan are
rare events  of high impact and with
predictability only retrospectively, I
mean looking at an
accident in hindsight, we can understand how
it was predicted that it could happen,
but in practice, looking
prospectively, it is difficult for us to
define precisely the predictability
of the accident, he still warns  for
absence or nassim taleb na he still
warns of the general lack of
awareness in this situation there and worse
we spend time involved in
minutiae often filling out
spreadsheets collecting data rendering
accounts about what is known
about what is repeated as if that
good today will be  guaranteeing the safety
of what we are going to do tomorrow,
we suffer, therefore, in this sense, from the
illusion of understanding, and from the
retrospective distortion and from this
factual overvaluation, so to speak, the systems
that have evolved in terms of
safety performance are those that improve
generally the best  manage to engender
this relationship between regulation, operation and
service provision, right, structuring the
management system wisely for
risk control and also to define
maximum systems performance containers
insofar as we operate
in a competitive environment, all of our
road practically the  perry in a
competitive environment in a
competitive environment we always deal with the
problem of scarcity we have to
somehow face scarcity sometimes the
scarcity of resources for you to
manage a security sometimes the
scarcity is d
is for profit  results they the shortage
is of equipment sometimes the shortage is of
personnel to supervise the
activities sometimes even in the
regulation to be able to have an arm to
cover everything that needs to be regulated and
control everything that needs to be
controlled so a competitive environment
the present scarcity  in a book and I'm going to
finish passing on the word to colleagues so that
we can follow this conversation
is the same as I really like being a
book written by commander carlos
germano i'm bad arrived karev you should
meet carlos germano was
flight safety manager at  rio sul is for many
years and he wrote there in 2002/2003 he
doesn't remember precisely the year I
wrote a book that won the
jabuti prize including called the witch's trail
he basically writes a report each
chapter of the book is a report of the
accident accidents  of
Brazilian commercial aviation
for almost a hundred years of reports of accidents in
Brazilian commercial aviation and it is
very interesting in the narrative of the book that
we start to notice the
explanations that are given with the
accidents so the first accidents
until the 60's are basically the
reliability and
technology problems, so it's a valve that failed, a
propeller that suffered structural collapse in
flight or structural words of the
fuselage itself or the wings of the aircraft, in short,
a lot of problems related to
mechanical failures, right, which in a way
was corrected over time
with an increasingly effective engineering process
with increasingly
better materials and so on, not that
we don't have problems with
technological reliability, the 737 max
there, that's right, it's an example, but it has been
reduced a lot to a long time
for decades  then the number of accidents
attributed to the technological factor not to
mention the material factor in compensation in the
second part of the book begins to appear
what begins to appear the problem of
human error does not mean planes that
are in perfect operation so to
speak but that of  somehow
disastrously they are forced to
collide with the terrain to collide with an
obstacle to run out of fuel and of course
that there you know was the motto for
the entrance right for crossing there a
gap in the discipline the human factors
and ergonomics in aviation and so to speak it gave
it  strength to the appearance there of
the crm as for example one of the practices
there that we have of training today
widely used for the
development of thousands the technique
right and of course reaching the third part of the
book the accidents begin to be
explained as a problem of
organizational management is the  people notice exactly
this movement of theories, right the theories
of technological accounting that the
theories of human accounting and the
theories of organizational accounting
the theory of organizational accounting
developed in the 80s it
presupposes that there are certain
characteristics that a
high reliability organization has and we could
could be transferable to other
organizations also generating high
reliability in oil by the

oi organizations and we know that these theories have
some limitations but so to speak
we could say that the state of the art
today at least from the theoretical point of view
on aviation accidents  it is
closely related to the logic that the
accident is organizational na it
cannot be treated as an event it
is generated by an individual or by some
individuals it is an
organizational event because it is up to the organization
selected in the people to define which
equipment will be used define  only
what circumstances will the operation be
carried out which risks will be acceptable
and which risks will not be acceptable
so in that sense the organization ends up
creating a context in which
all the operational activity takes place and of course this
is not the isolated number because this
exists in the  the other layer, let's say a
large socio-technical system that approves

the regulation and the market for the layer is today we
could say that the accident
air accidents today they are treated
a lot like organizational accidents and

total systems industry accidents so to speak and the  What is known is
that even though the aviation organization
has very good levels, aviation,
especially regular air transport,
has very good levels of safety.

a
residual of uncertainty and risk always ok
I saw one leaving the factory already has a
residual and the feline design, right, it already leaves
with the residual of uncertainties and risk and
risks in the present and to
face these residuals of
uncertainty at risk we  obviously needs

certain capacities in organizations and
these capacities there the theories today
more and more explore the development of
these capacities are the theories of the
so-called engineering of residences right
or also with some names are
appearing there right this thought this
thought is also appearing with
some  notions of 102 and the
danish professor eric ronaldo has been
promoting there are around, right the professor
decides on the idea he has been talking about
know the business in australia has
very influential work he has also been
talking about different embellishments anyway what
these notions they bring again
they  bring the importance of creating
mechanisms to study and research
mechanisms that develop the capacity
of these organizations to
face these residuals of
uncertainty and risk and learn while they
do it so fundamentally today
the panorama at least from the point of view
of research on the subject it counts  for
these directions
and edson the people here are asking
you to repeat the book reference before
passing it on to joão if you can
repeat the level reference for the
people it's me the book i commented on
there, right it was the book i like  this one from the
jabuti award is called the witch's trail, right,
commander carlos germano a
o ok thank you joão if you can
participate explaining how the
topic of operational safety has evolved
natal and I don't know
and thanks wagner and for me how to
trigger the comment is  it's a pleasure to be
here discussing this subject,
we can always stay here for many hours
talking for sure there will be a subject for a
long time but the idea a little today the
request of the only one that was we focus
more on how this history has been the
implementation  of these concepts in the
regulatory structure, right, I'm going to
talk a little about how we
are implementing this here in Brazil,
plus a greater focus on the evolution of this
in the structure there of the voice and just taking advantage of
the word, congratulations to
you there wagner  lucky team for the
promotion initiatives, I think they are
very important even if we
manage to bring quality information,
right, some things that we already
enter in the mind of the agency or
quality material that we receive from the
partners, then the clothes will be that  I'm telling you about
one of the sources of coded information
that we have for general aviation,
for operational safety as a whole, I
think these initiatives will help
a lot to make this information
reach those who really need
more operational personnel, so congratulations
again to the  initiative is I think you
just as a general introduction, I think
the professor's presentation is very relevant
because it gave the context of
how the concepts
evolved, what we expect
from this implementation and everything  well
there are things that are positive but I
need to think about how to incorporate it and this
in terms of regulation is not always a
good idea when it becomes
mandatory it gets better, so
what is the logic how do we
incorporate the concepts into the rule  here
historically what we always did
was existed right then we commented there
at the beginning of
and the improvement of operational safety
we went there they identified problems there
more at the beginning normally in relation to the
project after the issue of the
contribution of individuals in this
system afterwards  more organizational part
but normally the answer was like this they went
there they identified danger they welded if the
problem identified the possibility
of dealing with that
specific problem or specific actions to
mitigate that problem and
normally incorporated if that in the
regulatory framework requirements were created for
those those defenses  that were
developed were implemented
throughout the system and I knew we
got a quick return and
incorporation of these learnings from these
accidents in the regulatory structure and
implementation of the industry as a
whole
is but normally this can also cause
some difficulties, right if
we only  think about this regulatory solution
I want to create items try to be
exhaustive in considering all the
possible problems and put items in the
rule specific medications for these
various problems this can generate some
ineffectiveness I will put a
presentation here that I prepared just
to help with the description of these
contexts  in these councils and if you
can just indicate there when I see it

we are seeing john thanks
it's good we have this history
then I have a series of things that
are established in the regulations and
are important to be addressed by
any operator but  for these the action
of any company is to try to ensure
compliance I need to work
to ensure that my company complies
with all these items to avoid and in the
case of a possible violation not all
regulations are associated with a
safety issue in my operation
I  I will be exposed to different hazards
and I will not always have all these
hazards covered by a regulation item

and we hope that this intersection
is as large as possible so I
hope that common causes of accidents are
treated then causes of accidents
that  are exposing a
significant number of operators they are
covered by regulation item so I
will have that they are part of the rule and
have dangers inscription but if I have
causes that are specific to a
certain operator for example if I
have a very particular context of
a  a certain operation may
not be desirable or efficient when
including it within the
regulatory structure and despite that it is important
for this managerial operator to follow it
may be that
regulatory action is not necessary a specific item
of regulation that we always try to
reserve for the imposition of  rules for
these items that are more transversal than
the industry and how do we do
so that
these specific risks are
addressed in a less
prescriptive way, we will see less delimited
in the a priori rule and leaves a little
more flexibility  for the operators
to try to identify the specific causes
that their operations are exposed to, the
idea then was the implementation of

operational safety management systems and it has this focus of
being a regulation item at the same time, it
requires a change of thinking from  that
not only complied with the regulation is
enough I also need to address
those dangers here my operation
will be exposed and I need to do
this in a structured way and therefore
the incorporation of the concepts and
structure of the sgso in the insurance and so on
other authorities and  anac
developed over that time
and how this concept was then
incorporated there by accinelli
initially it did not exist this
idea within the regulatory framework of
civil aviation of the sms of the
operational safety management system
but people have already started to think  on
how to incorporate these these ideas of
management systems into
disney management and with that back in 2001 al assi
created its first annex charged
air traffic service providers and
certified aerodrome operators
to implement a
safety management program  operational,
this evolves quickly, right, even with
information that came from other
industries there and then in 2006, oaci
reviewed these annexes and went on to
demand the implementation of sms, which is what
we know today the
operational security system and  then what is the name
of the time understanding these
benefits that I mentioned we would have
to balance more or less
prescriptive requirements with effectiveness the same as the
treatment of hazards here a
private operator ok husband this was being
implemented within the various annexes
so the ones themselves  operators there from to
this aerodromes air and
maintenance operators international general aviation
received requirements from this
also instruction these over time
evolved to cover all the
annexes from the ua requiring the
implementation of sms until it
even reached us in the
project organizations  and aircraft manufacturing in
2013
oh but that's ok the logic is positive it
works for the operators they can
understand their children but if this
logic works for the operators who have
specific risks to see if it
also works for the states the states
are also responsible  for implementing
risk management measures to monitor the
system and try to improve the effectiveness of
its regulatory action to
cover these more systems that I
mentioned and from this also came the idea of
implementing an analogue to an SMS for
the states which was called the  side
I liked free program west sp
and what is the excess what is it
ssp is a management system focused on
improving the regulatory and
administrative capacity on the
operational safety of civil aviation mine I
commented on the components right the logic of the
system is very  similar despite the fact that the
state does not operate directly it is not good
to have more direct actions to mitigate
a risk of operations this for the
operators the service providers there
as I mentioned is the system that should
run in the state is very similar to the one
that runs  not service provider
there we have the four
components of the ssp which are objectives
resources and policy objectives and in the case
of the state resources
risk management ensuring safety and promotion
in the same way that one these components
are present there for the  service providers

to go to the states so steel
was also incorporating these concepts in its
regulatory framework there in the different
annexes the first requirements for the
implementation of sp were incorporated
there in annexes 6 11 and 14 of
aerodrome operators and the
o and air traffic service provider
in 2006 and it evolved into other attachments
but there came a time when the
distribution of items on the same
subject both sgs and ssp in various
attachments began to cause some confusion
there were points of conflict, right,
harmonization between these various despite
all  they were putting requirements
for the implementation of the sms sgso
some requirements for specific areas
were changing the general concept a little
and the idea is that the sgto should be
general even implementable by any
civil aviation service provider in the
same way that you have quality management
it can be implemented by
organizations of very
different complexity than the sgso idea that it was and
also a single system implemented by
several civil aviation organizations and to
try
to see a little of these conflicts and this
need for harmonization there were two
important events at the nightclub there in 2006
in  2010 if I'm not mistaken wagner even
participated in this raila you may
need it 2010 is necessity and that was
where this guideline for the creation of a
new annex dedicated to the management of
operational safety came out the idea then was to
consolidate this information that was
scattered in the various annexes to  a
single annex that became annex 19
that I think
many of you who are watching are aware of and and
for that purpose a panel was created to
work on the
development of new rules through
expert panels love
specialists from several countries to
help them contribute to the creation of
this new annex that comes to the cell phone on
Thursday 19 a photo from the last meeting
of the father
this is brazil is very active on this
on this panel since its creation it has
taken input from  very
significant there for discussions and
all the organizations in all the
Brazilian authorities
actively participate in the panel involved with
concepts how this
work was done, right, it was done basically in
two phases a first phase the focus was
mainly on the consolidation and of these
different of these different  standards for
the different annexes as I mentioned,
trying to unify it all in one
place just to guarantee consistency,
and this first phase then became
applicable in 2013 and will
start a work of reviewing
these annexes and incorporating new
ideas  and new lessons learned from the
implementation of
the edition in a new revision that came out there
and became applicable in 2019 I think it is
not appropriate here to go into the details
of the tv in this new revision
the most recent one, what do we have in terms
of evolution also as a result of the
panel fourth edition of doc 9859 that
the basis there of the concepts for
implementing this concept of being
yourself and something positive also there has
always been a discussion that we
have is like the focus of this document
should be more practical or more
conceptual recently so  the decision
was that it should be both
the document itself or a
more conceptual focus was maintained but a document was created
an internet site for
sharing experiences and
tools between operators and
different states and more recently
also what  we have on the horizon
there the revision of for the extension of the
applicability of the sms of the
sms requirements for, for example,
certified operators of the aircraft
remotely by
andthere
and in brazil how do we
implement this, trying to pass here
a little more rare  we commented it says
concept right the state need to implement

operational safety management concepts but in brazil we have
several authorities we didn't want
this brazilian system to be the
sum of several independent systems
because we know that we have
risks  and problems that can be
transversal and that have to be
addressed jointly by the
various authorities, so recently
an operational safety committee was created,
which is made up of those
responsible there anac and down to the
regulation of the sector are guided by a
high-level document that  it is the ps obr
which serves as a reference document
for the implementation of the ssp in brazil
evidently receives inputs and support from the n
to calm down the discussions
that take place in this committee it establishes the
national plan
is for operational safety and brings plans
of actions and  specific objectives for
in safe indicators and of course yours
to monitor this and feed the
committee's actions to advance in this
management from the point of view of the
state
and that was not it I think I spent
a little time there but I wanted to give this
overview  From this evolution of
what we've been doing
from the point of view of the Brazilian state
moving forward in this implementation I'm going
to share it here thanks thanks

sorry if I'm a little late
thank you joão guys you can be
thinking but yeah  very conceptual
very theoretical real life is something else
right so ivan you have this
responsibility now for how news
that ederson luciano academic theoretical point of view
joão on the evolution
of the regulation and structuring of
herbs how the operators perceived
this when  over time and if you
can, you have developed the practical aspect of
all this that we are discussing here
and thanks wagner telas thank you also for the
initiative is on the accident coast to do
this is an open debate at the moment
that we have these tools you can
use some  people it is practical and
specific topics and it was very good for me to see
éder or I am the theoretical part
academic part and joão also pleasure the
regulator's view of how this was
structured and the image of how we
translate all this location first
challenge when  we talk about an
organization is organization and
the question we have to do is the
following reflection wagner just a
requirement or do we recognize that this
national security system can be
translated into a management tool
we make several entities and
organizations feel  not only today but
they are always looking at what the
safe app can be but one always has the
systemic view that what you
identify with the period analyzes the
potential risk and barriers
these barriers are not always effective we
cannot trust it  only in the construction of the parents
and
and then you answer me we make an
organization perception we say
something called culture the second
watch we use the universal value
must be reflected in the avenue united nations
to the behavior of the organization
even if it is not  from the point of view of the
autonomy of the last update
we understand the behavior of the
organization safety operation this
translates into the culture of safety and that
which studies prisoner men and lamps bring
a social thing
the ointment that possessions how many question
companies course I tell me until  the moment
today was to identify and
inform essential to avoid, right so do you think
that for you to translate this side is the
game itself is whose own lace is
we need to work a lot part of
culture and culture is there in compromised the
child values and priorities everything  this
together
ah ok good luck if you are going to be this one
is stuck with the pillars her where you on
the other hand are skills and this
set of skills they will give
as a result we call the door the
eyes and this translates into behaviors
so stomach what  I can tell
you that this set of things has
to be worked on in a global way
by the company, it only happens
when you manage to create a culture
and where safety management really is
something that is lip service and not a clear thing
so you can do this it's very
tempting it's necessary to
organize everyone's wedding wedding because I
mentioned it before main information
any security department of the
company and alone it's normal it doesn't solve
anything basic input that we are security
is one of the most parts that we
know  what we don't know
and look at saldanha managed to
make measurements hold because it is and you
have a totally safe environment maybe
you didn't have a lot of
art information but when we talk about a
more complex system the
information it was the main foundation of the
project  being able to make security
really a tool so the
security capacity the example and then
I do another one on the street inside the seam
he needs pastors of the leadership
the and the tools that you
make available is normal because this
information of yours licks and it flows it
has a miracle  they are very cool
what is the fair cure
well then they make an analogy me anderson
said how did you say people put all
this together to bring it into a

popular air operator organization it is very important for the
safety culture to be the great foundation
and it is without that  you're only going to have a few
catchphrases a wall here is not the
gift that we want the culture
it's dynamic based on information
supported by a culture it's the form of
your collaborator of that food at the
end that he can raise his hand to say
that look  I made a mistake this will not be used
to polish so this is very important
in the dynamics of this one at this moment much
more because of nostalgia and
theirs the braids and getting married is what
éder said resilience than
its physical structure as an
organization and  When we talk in this
passage, it's not residence, it's a
key word, it's all the
personal points, results from the time of the
operation or
I'm going to good origin, so all
the stakeholders, they're suffering
the same way and it's very important
that you have excellence.  a culture
where security is ready to arrive in
a usual way the organization one
mainly the information and and more
pure and
hi nowadays just to finish we
know how much mainly the prey
they remove mud today we have and
so many years alternated from  from
scratch and where it is said that
security data management is manchester
I agree it is an anastácio he is part of
that information cycle is but he
is not only he is necessary he is necessary among
i the management of security through
very protocol  going in the closet x belongs
to managerial validation here you can
transport
the old men can have better
personal training because this
information will also serve as feedback
in the account what we will learn for
sure we will learn or
any acts that happened so it is
important  that there is yours this
way mine so I wanted to show that
éder spoke joão spoke I believe and this
is an operating system and as
a management tool
and thank you sister and humberto in the same
line, right your day-to-day point of view
from operations how does this thought
of operational safety end up being
perceived and incorporated within the
environment that we have, which is more
diffuse than that of private operators
thanks for the participation humberto good thanks
wagner thanks to all the
colleagues who are participating there is a  It's an
honor for us to say oops to be able to
invest this time to deal with
such an important subject. I consider it
undoubtedly the most
important of all when the subject is
aviation.

this provocation made
by wagner is bringing a
step back and seeking to contextualize it
is the participants all grandson in the
people who are accompanying us is
exactly in line with what commander
ivan brought there from operational security
as part of a system in not only
as part of a minor procedure,
but the relevance of safety is
playing a systemic role in the environment, right?
It's Brazilian aviation. Talking about
operational safety in
Brazilian aviation necessarily implies
balancing a complete
complex.

right so when we take
today it is roughly speaking the
Brazilian fleet of aircraft flying in brazil
we have
something like 12 13 14 thousand aircraft in
operation in the this puts us in a position
of the main ones puts us among the
main fleets  operations in the
world certainly the second most
important in America, right, and then when
we look at this whole system, right,
14 and 15 thousand aircraft, we will
realize that here something like
600, 700 aircraft
and it's kicking high over 1000 aircraft
of this  universe everything is are
somehow aggregated to operations that
have their own systems, whether they are
created by the very cultural nature
of the organization or stimulated by the
regulatory processes that make
these thousand ships or lose, let's say,
within an environment of relative
control and security  now we have
another 12,000 aircraft outside the
systems but let's say more
doctors are precisely the
general aviation aircraft so to a
point that I think it is fundamental for
us to think
and that's how we manage
establish processes and policies and
promote the safety of
Brazilian aviation, including this
gigantic portion of aeronautical operations
carried out by a large part of the
aircraft that make up the Brazilian fleet and
which are outside systems, it takes
more genetic control and greater
reliability from the point of view
managerial view what are these aircraft
aircraft operated there in the most varied
aviation activities in activities
these are absolutely essential to
connect a country the size of brazil
we think in practical terms there pre-
pandemics the set of aircraft is
and is of the regular airlines
serves  there, roughly speaking, the universe 150
140 cities 140 destinations in
Brazil connected 150 pairs 150 destinations
in the country is the other 12,000
general aviation aircraft connecting 3,500 destinations and
operating in an absolutely
centralized way is where the
responsibility for the operation of  of the flight
it falls almost exclusively on the
operator and the pilot right and that is in their
operational nature is they are alone
roughly speaking
who are they the aircraft and nature and
god right because there is no system
outside of that this alteration is guaranteed
is by definition none no
support from the point of view of
decision-making no support from the point of view
of control of operational limits is and
not even any aspect ad fidebeque is
considering the prevention of occurrence
of events is unsafe na 12 thousand were
ships operate a a  based on a logic it is
individual i would say practically
individual the the
good is so what is this what what
system produces this system it
produces an aviation environment is as i
said at the beginning quite heterogeneous is
that it needs to operate insecurity because
because society  it does not tolerate aviation and it has been
safe for a long time so
commercial aviation, for example, it has not achieved
very high levels of safety
only because it is a gesture of
goodwill because it thought this was
important it will do it basically because
let's see with two great incentives
for that  if the first
incentive occurs it is a natural incentive for
any company economic incentive the
accident or incident is very expensive
so it has become very important to
take care that accidents do not happen
it is for the simple reason and for the
simple necessity
ah and not to cause damage to the
organization company  airline and the same
thing, in a certain way, applies to air taxis

and the second fundamental incentive is what
made commercial aviation
so safe was
society's own intolerance regarding
the occurrence of the accident I don't know 40 50
60 years ago  society treated it in a
different way, along the lines of what the
professor put it at the beginning,
almost as if an accident were part of the
fact that aircraft are flying around from time to time,
it is an act
almost of the nature of the
air-naval operation in  As this has
evolved technology has evolved
aviation has become a part of people's lives
all over the world the way it has
become is society has become
intolerant of the idea of aircraft
crashing in a way that is either
motivated by public opinion or
motivated by
regulation bars cost
airlines or regular or
air taxi operations forced to disseminate to
deploy as as ivan put it it's
more or less developed systems
more or less it's it's we're going to be like that
culturally more or less robust of
operational safety now
general aviation it  it's in it's in it's in it's in it's in the
metaphor before all this it's at
a stage where it's the dissemination of the
philosophy of culture it's for security
it needs to happen in a way it's
extremely effective
because some countries in the world have already
managed to do it  But here in Brazil,
in my opinion, people still haven't had
enough space to put this
discussion where it should
be and why is the price like that
because look at the whole
transport system it has the most robust operations at the top of it
and
commercial aviation regulars of the 135 of the 121 anyway
then there at the top of this food chain
let's put it like this but it's the top of the
pyramid that little part at the top
is the base of this whole system is this
segment of the code's transport you're
talking about here what is it  it's what
even feeds this whole this this process
all of us here who fly come out of
general aviation, right there at aeroclubs at
flight schools in private operations
so that some of these
people go to the environments we'll
see more controlled by the
big airlines  air taxis and
carry out their operations in these
environments but a lot of operations still
take place will continue to take place in this
general aviation segment how do
we permeate a culture of
safety in a heterogeneous and
diffuse environment like this is a huge challenge without a
doubt  it's a challenge the size of
general aviation there the size of brazil
and in my opinion it's this challenge it's
only
achieved when in fact it's the issue of
general aviation becoming a
strategic choice for aviation as a whole
in practice what i  What I mean
by this is that this will only
become a reality when the
Brazilian state when the Brazilian government
waves Brazilian institutions ANAC
Civil Aviation Secretariat really
make the decision to place this entire
heterogeneous universe of general aviation
as a top priority
and it is like a priority of the utmost
importance, based on the assumption
that this base has 12 thousand aircraft, it
feeds the entire Brazilian aviation system,
so while this is still
treated in a secondary way, it
seems to me that we will
still remain in the field  very cool between
discourse and practice and there is nothing worse
for a safety culture than
saying one thing sending a message
to your interlocutor and practicing something
completely different it is necessary to break
any logic of trust that is the
necessary basis for a
healthy culture  of safety if it spreads,
so I think it's one of the
main message I would like to
give you and and put up for discussion here of the
rules and the participants the following
how does the agent do so that the
general aviation operator is if
raise awareness and feel engaged as an integral part
of a security system
when it is carrying out its operation
there in the interior of Mato Grosso when, for
example, operating agricultural aviation that
we will get there in agricultural aviation
the level of security that we want to
see reflected  the road system as
a whole how do we get to
flight schools throughout brazil
a healthy culture of
operational safety how do we permeate
private operations with a mentality
that operating safely is much
better than  that operating safely is
making
an operation much more efficient,
both from the point of view of coco
and to permeate this safety culture
in the road as a whole, we
need to make it really is
nakita is the national agency  of
civil aviation is that the ones here should be the
civil aviation secretariat and not to the
detriment of commercial aviation, but that they
are not just thinking about what you
had to do, see, I'm not
criticizing here, I understand that the priority
if this priority these choices you made
will need to be  done but I
think that now more than ever the
systemic thinking about civil aviation
the whole world needs to prevail and we
will not have a safe Brazilian aviation
while general aviation
if they have this in the safety culture environment
I think this is the great
challenge I think we have to
finalize extraordinary examples of
success in the path that was taken
in this sense, when we take the
example of australia we have
sensational cases we have the case in
canada we have cases in the united states
anyway there is a lot a lot  in many cases
many successful experiences in
disseminating this
safety mentality is making the system
as a whole become impermeable to this
philosophy and by making this
safety philosophy permeable you tell
Minnie positively about the whole process
so that when the commander
the new classes of
aviators in the blue are welcome, for example, they
're good, a mass of people, right because deep
down, culture is, as Ivan said, it's
produced in people's behavior and
practices, these people will
reach any point in the system  of
aviation with the mentality with the doctrine
of operational safety and that
will happen when we manage to
do what it becomes is permeable
general aviation is a huge challenge there is a
challenge there in terms of logistics without a doubt
it is a challenge  of language I
think that the language is ours needs
to be extremely adapted so that it
can reach this whole heterogeneous age
of the road there is a huge challenge
which is the regulatory challenge in how the
agent adapts regulations to
the completely different operational realities
in the  there is, above all, to
complete the challenge of trust, right, it is the
general aviation operator, he has to
concretely feel safe and
confident to interact with the
air traffic control agency for the benefit
of his own safety and the safety
of the others who are operating  in the same
place is the operator needs to feel
safe
and confident to interact with anax and
believe that she has an
ally in making his operation of the
system safer and with that making
the whole system proliferate
positively with the
more solid and widespread spirit of safety I
think this is the message I would like
to put there so we can
discuss sharing thanks edson thanks
humberto thanks to the four of you, right
I thought let's go were
very enriching considerations that were
posted right and the reflection of that  it's just that we
have a lot of questions here I'm going to
start asking them isn't it we still have
a 20 minutes there and from within the conversation
so of course without losing the city of
answering the question I ask
you to be
more assertive  as possible in the
explanation so that we can
cover as many
questions as possible, right the most outline that
appeared here was in relation to the fourth
publication of doc 9859 that address a
more systemic view and not just an
organizational one like the one that has been
implemented  these changes I understand
that this one goes out to you john if you
managed to understand the question here I will
repeat it regarding the fourth publication
of doc 9859 of addressing a more
systemic and not just organizational vision
as an anarchist implemented these
changes
and I think it is one of the tales  of the
concepts that are proposed are an
evolution in the transversal risks
integrated risk management system that
brought concepts that were not so
clear before in the structure of doc 9859
third edition and we are being
incorporated now sometimes we may
have risks to follow if  for example,
when mitigating the risk of following, if we
wanted a service risk and this is one
of the concepts that are being evaluated,
yes, and look at how he commented there,
I don't know if it has the name of salomão
salomão commented there is one sometimes
When we have our
Brazilian system here, we have
different authority, different areas,
institutions that deal with
specific issues, but there are also several
problems that are transversal problems

and this idea of not only evaluating problems
in individual cases and this
has been brought up a little  in these evolutions
in the 9,985 9 now presented the
agency as i mentioned it has been taking
several measures in this sense the very
role of the own within the agency
brought a new attribution of supporting the
areas that normally deal with
private matters with operations with
navigability with airports is  a gives
this more systemic view of problems
that the system may have and how we
can work within the agency to
tackle these problems more
effectively and in parallel we have these
actions of the operational safety committee
and it is presided over by the two  authorities
by the director of iceia and by the
director-president of anac where
we sit down and periodically discuss
integrated actions to understand to
understand to anticipate problems to
identify problems and eventually
work together to
address them so following this line is
a series of measures being  sockets and
some more low-level let's say
identifying
specific cross-cutting problems like those
I mentioned below now we have
a big difficulty there the
big challenge that the issue of cyber security
at isc sportster in aviation as a whole
so let's go  having to create ways of
acting to better understand these
problems and anticipate to avoid
those suggest bigger problems to
see but in general without much
reduction is an overview of how the
agency has been structured and the
Brazilian civil aviation system the
authorities have been  structured to
address some of these points
is to force the bread and I forgot to comment on
the colleagues but it is a chat so if
anyone wants to make any consideration
feel free, of course
some questions are directed
to a specific participant but if
anyone wants to  make some consideration feel
free to just analyze
one more question that was highly
scored here then I'll read it the way it
was done so as not to try to
distort the understanding of the question to
master éder in general terms what is the
best way to  As a
safety manager of an air service provider I
could change the
company's safety culture
football thanks thanks for messi
dei apple the almost million
dollar question I think I really liked the
approach that captain grandma brought up I
wrote it down here  some things, I think
fundamentally, even from the
perspective of this document of this fourth
edition, what I perceive more
strongly in this fourth edition of the
sms manual document itself, hence such is a
stronger logic of evidence-based management
with a focus on performance  na and then of
course this implies I wouldn't have time here
to develop this but it implies the
choice of some safety management strategies
that is to say not not taking the
prescription of the manual itself for
structuring a safety management system
as the purpose as the
purpose  The essence of the thing
is based on it to create some
strategies or some
security management strategies if
fundamentally this is a
matter of data intelligence that
Commander Ivo Carvalho there raised, right,
but I think we need to build
in these spaces too the  based on this
evidence-based and performance-oriented management,
we need to
build a culture of
learning environments, it's more than
continuous improvement, because continuous improvement
predisposes us to do better than I already do,
learn, develop, innovate,
based on the evidence that  I have
a culture of safety in my environment, you know,
I also really liked that the
commander leaked the term habit because
there is a sociologist called Pierre Bordieu,
some of you might know a
famous French sociologist and he uses this
notion of habitus a lot.
effect is what he
also calls incorporated cultural capital
the effect of how
individuals perceive and act on the world is
what makes us feel the thinking and acting
within organizations and then organize
an environment with a given culture through which it
strongly opposes what the  humberto said
working with two dimensions for me
who is coherence and consistency is
not supported by a safety management system
within an organization
or within a broader system
total system in which there is no coherence
between what is said and what  if you do if the
second is consistency it means
persistently seeking a certain habit
the promotion of a certain habit within the
organization
and thank you éder here ivan has
rodrigo edson da reflex he
identified himself here wish you a good day and
asks the following question  right, due to the
pandemic, many actions became
remote, such as inspections, what's your opinion
on this?
rodrigo pegada is really a challenge for
all of us.

that he is the only one who
is here in our mind there in the operation
he can bring us information
we create that we try to call
safety right now we are the
mechanics for the knowledge about, for
example, infrastructure he can make
a checklist for us  go
I can bring important information
from the infrastructure area even if I
'm not a specialist but the pandemic brought it
is really we are inventing
despite the crisis opportunities arise
and this is the point that was a pioneer in
doing we are also going more or
less parallel some  uncle éder said
that joão talked about the last time that
really where we can be
asked is just be very careful in
data analysis or because when
he arranges the time situation you
have one
in your critical analysis of such an example
we bring here it was us in all
eras monitor their ter forms but we
would like to see us hours and the
person behind that one
as big as he is in
relation to the ancients so we start
the crusade or the  ranger we had there in the
wealth of details including making
us take certain actions
such as the most critical airports being
operated in the last key of a
certain one there in the
good so this is very important and
watching me the data sometimes only brings us
lightly combined you are  the wealth of
details and the coverage said I think it's
essential that it touches people I don't know I
think it can be very important to be able to
give us one to increase
security that's it I think the big thing
stolen and it's the schools is
basic training and it  it feeds not only the
huge arms roberto spoke and relations
food also the
regular aviation system itself so important only that
we can resume the state is the
head to do someone and especially
today we can really invest
to be able to be sure
and thanks evan a vou  pass the last
question just to keep the pattern here
of the most populated ones I will put it
unfortunately we will not be able to
put all of them for the answer but joão
here joaquim do rei he asks the
following in relation to the sms the
check the box culture is observed  the
requirements but not necessarily
promoting safety like anac see this
phenomenon
and thank you joaquim wagner for the question
i think it is very continent and has a lot to
do with what we talked a lot here
ivan already knew i think the
implementation of sgso there brought a
possibility  for us to do something new right
there within the conversations that an
authority ends up taking a step back and
failing to prescribe in detail what
an institution needs to implement
and starts to rely a little more on the
possibility of innovative solutions
to mitigate a specific risk
then  the idea is very positive, I understand
that it has the potential to be much more
effective than what we have already done.

great for the
system as a whole on the one hand
and it brings a difficulty that before
I had a simpler job of
monitoring exactly what I think I
should and evaluating it is simpler is to say
whether you complied or not
and I pass it on  that having the ability to
monitor evaluate effectiveness evaluate
performance as we said this is a
challenge for the agency, we have
evolved in this sense of restructuring
our regulations to leave a
little more based on performance an
example there, right, we are always a
discussion  very old in brazil is what
is the minimum hours for instructor and there
are people who said that it has to be a thousand
hours we have to be without because
otherwise we will have instruction the fact is
like that what is important is
important  the quality of the instruction
so if I have a
quality instruction builder of 300 400 500
this is important here I'll evaluate if
the final product is coming out positive but of
course it's much easier for me to go there and
buy an hourly counter and say that  it has
to leave there is 150 there is eh so it poses a
challenge for us but it also poses a
challenge for the policyholders he has to
leave that position that before
like this does not buy everything that the authority
signed up for so now I am safe
and it needs to pass until it is  move in the
sense of understanding the context analyzing
the information is available for
them to identify new ways of
addressing a risk for that
husband and I think that this effect that
joaquim commented on is the effect of this
maturation process even though we
implemented a system  the system allows for
an evolution a very large potential for the evolution of
effectiveness and for the treatment of
safety but it takes
time to be incorporated to be
introduced little by little both the agency
and the operators are structuring
and seeking to achieve this effectiveness in the beginning
the focus is more  prescriptive so ok
your implemented the system the way it's
specified it has the four
components ok some time we'll
start to get into it but the details and
evaluate effectiveness here you are
monitoring your children show me
what the last discs were what
is identified  and treated evaluated the
consequences of this medication to see
if there are new problems do not appear the
system as a whole is maturing and
management systems the impression like that, right,
they have the potential to mature and the
idea is that everyone reaches it even if not
all are at that moment  more mature
the tendency that all mature people
we have to do this not
follow-ups initially we go
through this in the larger companies in the 121 with
the implementation of we have viciasse
maturation for the smaller companies
135 they come out in several cases that need to
implement the sujes ior and I think that  that's
what roberto said so the focus now
we know how to take these concepts
is not so direct applied to general aviation
but how can we take
at least the board the culture of
operational maturity to
general aviation tumblr
and thank you joão guys going  for the
end of our our webinar is I will
ask each of you to make your
final consideration again is to try to
be very succinct but ah I think it
would also be interesting for you to speak
as each of you that is to say you
presenting a segment  what is the
contribution that this segment
can make to
operational safety for example éder discussing
how the academic world or even
students who are preparing to
enter the job market and can
take some action that contributes to
safety joão speaking  your point of
view of the authorities ivan
representing the
certified operators and humberto the
private operators and the word would be getting out of and

you too so in this sequence is to
see if you can start
it's good you know here i'm the
representative of the universities right
So to speak, of course I'm a professor at the puc
in rio grande do sul but in a way here
I think I'm a university student
here at record, so I think there are
two fundamental points, the
first of which is that, of course, the
university is always a space
like  aviation schools are spaces
for training in so I think that we who
have a formative role, I'm not
just saying universities but
aviation schools too, right, we have a
tremendous responsibility, right in the sense
of contributing to the system, my
role as a teacher is  I think that
my mission is noble is to help the
Brazilian civil aviation system to
develop by training people who
obviously get tattoos or fly
aircraft or even work in other
areas of management and organization of this
great system
and this is one of the fronts of our
contribution to  another front of our
contribution universities are
also spaces for research and production
of knowledge and in this sense we
also have a responsibility that the
responsibility of helping companies,
regulators, operators to leverage
their potentials, right from
the point of view of  with a view to achieving
even better safety performance, whether it is
also in relation to improving the
competitiveness of these organizations
worldwide, where the
most competitive innovation systems advance are those in
which there is a close relationship between the
government or regulators, or for
municipalities, or companies, and  Universities, I
mean the best
innovation systems in the world, will not always
find this sink working
very well
and then I need airlines to
be able to train my students well to
develop research
airlines need well-trained people
obviously and also  they can benefit
from knowledge and from models with
techniques that can be scaled and
adjusted so that they can
obviously leverage their business, right, and in the
same way with the regulatory authorities,
so I see there is a point here we in
Brazil that we have in terms of the system
of  Brazilian civil aviation I'm not
saying this, I'm not putting the
responsibility on any of the parties,
the triple responsibility, and we
need to at some point build
this relationship better, university,
government, or regulatory authority,
companies, because that's the way that's
working in the main  places in the
world a wreckage of innovation
competitiveness and
knowledge works challenge
to find a place where it's not like this even
in china right so then that would be my
final message and thank you very much to all
colleagues there for the opportunity to listen
to us 20 participate thank you leader  joão in the
same way about the point of view of
authority and how much is the word tyrant there
is a support group advising me
here there I received an ear pull
here that there were two questions on
the same subject so in the ranking
of her questions it ended up no no  being
he level but in fact it got more
votes if you join the two questions on the
same topic so if you can in your
answer also say if anac has any
plans to implement something along the
lines of the win do bye program
and thanks wagner I think this is it  A
pertinent question, I think I
say another question also
related to the implementation of margin systems.

system with the implementation
of the system and when the system is mature
[Applause] it
is absurd, it brings several
elements that are those that we
eventually want is all that we
understand that there is a problem when we
create a rule in the specific requirements
and such  we manage to solve
simple knots less intrusive in a better way
through the implementation of the sgq and then the
implementation of the sgso by the certified operators

and the dissemination of the culture and on that
side of the promotion by the
general aviation operators so I think the
actions I commented  at the beginning, right, the actions
that you have been doing at sop to create this
structure, this promotion movement is
extremely positive and on our part
here, you can count on us to build
a program in this line of windows
because I think it is also in line
with  that humberto talked about creating
non-regulatory incentives to
improve the quality of the perception and the
system's perception of who
our models are, right?

today we already
see this movement changing and even
posts on social networks you people we
see people post something
weird there it usually comes already
and it's not just absurd it doesn't disturb the
image of the sector you break
society's perception in relation to  dom aviation I
'm very optimistic about these
partnerships and the promotion actions and
again at anac we can't do anything
alone we've been partnering
with you and the upa people to
disseminate this I think we
have potential  to leverage this
a lot through programs like this
qfa has, right, which encourages bringing
people who maybe weren't
interested at the time ah, it's exposed to these
discussions that we have a
promotion environment for this environment and always
planted a little seed there that  when
it's time to decide if it's
going to take off you're not going to take off he's going to
have one even if his culture or
his training had been deficient
in these aspects this could contribute
to him at least thinking twice
about taking
one of these  for eventually exposing the
family itself, these so I think
we have a lot of potential to follow
this path.

the authority and general aviation
for us to build these paths with many hands
I'm sure we
'll be able to make a real leap in
quality in that sense I don't know
if I answered all the points I met
I didn't answer he sure I remembered
but let's thank you  everyone there is a
huge satisfaction for me to be at a table
with such illustrious people here who
know the subject thank you joão
ivan if you can make your
final remarks there are people ah i
think i see it
and i leave it for it's
always that i think 90 i'm very
from this link or academic area of gonçalo
i think we research that there the
ice cream fruit we are in today
how many sessions there the cells a room
between wills the real environment bring
this brings benefits for the company for the
school with modern themes and i believe
that we can use this example
within the aviation schools I think
that an example and regular regular can
bring or a rib a little stronger
participation I see that they are
the são bento academy renault bring
so many people to be able to stick alive and
maybe  we were in environments
and it may not have to happen
sometimes so it is an opportunity to
extend Brazil has an aerial vocation
the bills and we have the sound of the waves in
Santos football is a country that depends
fundamentally on the so I see that  you
have to put your arms around and build and
we really have to thank
the big one the rule is attention my name
has no weight here you
stop thank you
and thank you ivan humberto please your
final considerations good is not to be
redundant i will not  to say nothing more
than what all our colleagues have already
said here I think I'll just add
something like that I I I
strongly believe it's not us at upa we believe
strongly it's in practical terms we
work a lot in the united states with
this whole process of  qualification of
general aviation for operational safety
and it has been four four five years now good
first that in the united states there are
solid statistics to understand the
problem of operational safety
general aviation for 29 years and in the last 45
years they have managed to increase us pozzano
levels of  safety in a
very solid way
this is a body praying concepts that until
a few years were restricted to
commercial aviation and those that have already spread and
are available not for anyone
but in the road so I think there is
no shortage of experience tools for us to be
able to make the system

I think the
coolest spirit of travel is
camaraderie, right?  I think

our challenge is to make
Brazilian aviation safer as a
whole, this will happen through the spirit of
camaraderie.

that it is a dream I
think it is perfectly possible we have
several communities in which we add
aviators with the most
varied levels of experience and
we will only be able to say that
Brazilian aviation is safe when everyone is
followed when everyone is  had the
same mentality different degrees in there
obviously each one adapted to their
own
requirement levels so that's my
final message I thank the
organizers I thought it was an excellent initiative
the more we can we're all
together in this spirit that's  promoting
aviation we are helping brazil to
the transport the country deserves that's what it's for
everyone here for you
theactor
hello everyone thanks for participating it's
from joam evan humberto but mainly
thanks to you who followed this webnar
thanks for forwarding  of the
questions were really
enriching and this initiative anac
saft it is not an initiative of na tela it is
our initiative it is an environment
so that we can build together
an adequate operational culture so
participating yes the participants sign up
send your suggestion through the
send your
objective criticism to our lucky email anac.gov.br to make these
initiatives increasingly
robust and more suited to the
needs of our
aviation community thanks for participating and
see you next time on the next sneeze good
morning everyone
when buying an airline ticket,
checking in, taking off and landing on
time and safely, this is what the
passenger expects and this is what the
national civil aviation agency
works for
and today there are almost 1,600 employees
committed to ensuring the safety and
excellence of civil aviation  fulfilling the
role of regulating and supervising
brazilian air transport the agency's focus
is on procedures that
ensure that everyone uses it without
insecurity anac is also dedicated to making
the brazilian market
competitive by offering flights to more
destinations and better services to
passengers to be  so safe
Brazilian aviation comply with requirements followed
by most countries in the world and it is
anax that represents brazil in the
main international forums where
rules are created imagine practice do you
know how anac's work is done
runways and airport terminals are
regularly inspected so that
pilots,
flight attendants and mechanics must always
be in good condition for ANAC to
issue their licenses and qualifications
and maintenance of planes and
helicopters must be carried out by companies
certified by the agency and ANAC is always
up to date.  test and certify
new airports new aircraft and the
products used in their construction
to airlines must prove their
technical and operational capacity to
provide a safe service to
passengers
the agency is also responsible for
granting airports to the
private sector and managing contracts regulate
transport  air is a complex mission that
requires great responsibility, so
anac is proud of what I do
to guarantee the safety and excellence of
civil aviation
[Music]
and then
gabrielmacedoanac / sub

Segurança Operacional: Teoria e Prática (Webinário ANAC Safety - 1ª edição) #16

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