Post on 17-Jan-2018
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SMS: Evolving Approaches to Safety Management
Kathy Fox, Board Member Canadian Nuclear Safety Commission Ottawa,
Ontario 25 March 2011 Outline Early thoughts on safety Learning
Lessons
Organizational Drift Employee Adaptations Hazard Identification and
Reporting Safety Management Systems What works What doesnt Why
Early Thoughts on Safety
Dont break rules or make mistakes No equipment failure Pay
attention to what youre doing Follow standard operating procedures
Things are safe Safety Zero Risk But why not? Reasons Model (Swiss
cheese) Sidney Dekker Understanding Human Error
Safety is never the only goal People do their best to reconcile
different goals simultaneously A system isnt automatically safe
Production pressures influence trade-offs ______ Dekker, S. (2006)
The Field Guide to Understanding Human Error, Ashgate Publishing
Ltd. Dekker: Understanding Human Error
Tools Tasks Operating Environment Why Focus on Management?
Management decisions have a wider sphere of influence on operations
Management decisions have a longer term effect Managers create the
operating environment Balancing Competing Priorities
Service Safety Drift Drift is generated by normal processes of
reconciling differential pressures on an organization (efficiency,
capacity utilization, safety) against a background of uncertain
technology and imperfect knowledge. Dekker (2005:43) MK Airlines
(October 2004) Safety Management System (SMS)
SMS integrates safety into all daily activities. It is a
systematic, explicit, and comprehensive process for managing safety
risks it becomes part of that organizations culture, and [part] of
the way people go abouttheir work. Reason (2001:28) Why Change? The
traditional approach to safety management has been based on: Follow
standard operating procedures Compliance with regulations Dont make
mistakes Reactive response following accidents This has proven
insufficient to reduce accident rates Elements of SMS 14 14 Hazard
Identification
Incident Reporting and Analysis Strong Safety Culture 14 14 SMS:
Hazard Identification
The whole point is to find trouble before trouble finds you.
However It is difficult to predict all possible interactions
between seemingly unrelated systems (aka: complex interactions) 1
_________ 1 Perrow, C. (1999) Normal Accidents, Princeton
University Press Requisite Imagination Risk Analysis
Challenges:
Inadequate assessment of risks posed by operational changes(drift
into failure, limited ability to think of ALL possibilities) 1,2
Deviations of procedure reinterpreted as the norm 3 _________ 1
Dekker, S. (2005) Ten Questions About Human Error, Lawrence Erlbaum
Associates 2,3 Vaughan, D. (1996) The Challenger Launch Decision,
University of Chicago Press Employee Adaptations Difficult to
detect from inside an organization as incremental changes always
occur Front-line operators create locally efficient practices Why?
To get the job done. Past successes taken as guarantee of future
safety Fox Harbour Aircraft Attitude at Threshold Goal Conflicts
Weak Signals Incident Reporting Challenges:
Determining which incidents are reportable Analyzing near miss
incidents to seek opportunities to make improvements to system
Shortcomings in companies analysis capabilities given scarce
resources and competing priorities Incident Reporting (contd)
Challenges (contd): Performance based on error trends misleading:
no errors or incidents does not mean no risks Voluntary vs.
mandatory, confidential vs. anonymous Punitive vs. non-punitive
systems Who receives incident reports? 24 SMS: Organizational
Culture
SMS is only as effective as the organizational culture that
enshrines it Work groups create norms, beliefs and procedures
unique to their particular task, thus becoming the work group
culture 1 Undesirable characteristics may develop: lack of
effective communication, over-reliance on past successes, lack of
integrated management across organization 2 _________ 1 Vaughan, D.
(1996) The Challenger Launch Decision, University of Chicago Press
2 Columbia Accident Investigation Report, Vol. 1, August 2003 SMS:
Accountability To criminalize or not: that is the question
According to Dekker Safety suffers when operators punished
Organizations invest in being defensive rather than improving
safety Safety-critical information flow stifled for fear of
reprisals ________ Dekker, S. (2007) Just Culture, Ashgate
Publishing Ltd. Elements of a Just Culture (Dekker, 2007)
Encourages openness, compliance, fostering safer practices,
critical self-evaluation Willingly shares information without fear
of reprisal Seeks out multiple accounts and descriptions of events
Protects safety data from indiscriminate use Protects those who
report their honest errors from blame ___________ Dekker, S. (2007)
Just Culture, Ashgate Publishing Ltd. Elements of a Just Culture
(Dekker, 2007) (cont.)
Distinguishes between technical and normative errors based on
context Strives to avoid letting hindsight bias influence the
determination of culpability, but rather tries to see why peoples
actions made sense to them at the time Recognizes there is no fixed
line between culpable and blameless error ________ Dekker, S.
(2007) Just Culture, Ashgate Publishing Ltd. Implementing SMS: What
Works?
Leadership and commitment from the very top of the organization
Paperwork reduced to manageable levels Sense of ownership by those
actually involved in the implementation process Individual and
company awareness of the importance of managing safety What Doesnt
Work? Too much paperwork Irrelevant procedures
No feeling of involvement Not enough people or time to undertake
the extra work involved Inadequate training and motivation No
perceived benefit compared to the input required Speak to slide
Conclusions Old views of safety are changing
No one can predict the future perfectly Mindful infrastructure
Effective SMS depends on culture and process Accountability is key
No panacea. Time + Resources + Perseverance Ongoing requirement for
strong regulatory help WATCHLIST Fishing vessel safety Emergency
preparedness on ferries
Passengertrains colliding with vehicles Operation of longer,heavier
trains Risk of collisions on runways Controlled flight into terrain
Landing accidents and runway overruns Safety Management Systems
Data recorders Questions? References Slide # 6: Dekker, S. (2006)
The Field Guide to Understanding Human Error, Ashgate Publishing
Ltd. Slide # 10: Dekker, S. (2005) Ten Questions About Human
Failure Slide #12: Reason, J. (2001) In Search of Resilience,
Flight Safety Australia, September-October, 25-28 Slide #15:
Perrow, C. (1999) Normal Accidents. Slide #17: Dekker, S. (2005)
Ten Questions About Human Failure Slide #17: Vaughan, D. (1996) The
Challenger Launch Decision Slide #25: ibid Slide #25: Columbia
Accident Investigation report, Vol. 1, August 2003 Slide #26:
Dekker, S. (2007) Just Culture, Ashgate Publishing, Ltd. Slides
#27, 28: ibid