Kathy Fox, Board Member System Safety Society – Canada Chapter’s Springtime Symposium June 2010
Impact of Implementation of Safety Management Systems (SMS) on Risk Management and Decision-Making...
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Transcript of Impact of Implementation of Safety Management Systems (SMS) on Risk Management and Decision-Making...
Impact of Implementation of Safety Management Systems (SMS) on Risk Management and Decision-Making
Kathy Fox, Board Member
System Safety Society – Canada Chapter’s Springtime Symposium
June 2010
Outline
• Early thoughts about safety
• TSB Investigation Reports– Lessons to be learned
• Safety Management Systems– What works– What does not work
Early Thoughts on Safety
Follow standard operating procedures
Pay attention to what you’re doing
Don’t make mistakes or break rules
No equipment failure
Things are safe
Safety ≠ Zero Risk
Balancing Competing Priorities
Service Safety
Sidney DekkerUnderstanding Human Error
Human Error
Tools
Tasks
Operating Environment
Why Focus on Management?
1. Management decisions have a wider sphere of influence on operations
2. Management decisions have a longer term effect
3. Managers create the operating environment
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)
Drifting into Failure(aka: Why do “safe systems” fail? )
Image by Worth100
Organizational Drift
• MK Air – Flight duty times
Organizational Drift (cont’d)
Organizational Drift (cont’d)
Source: Dekker (2002: 18, 26)
Safety Management System (SMS)
“A systematic, explicit, and comprehensive process for managing safety risks … it becomes part of that organization’s culture, and [part] of the way people go about their work.”
Reason (2001:28)
Evolution of SMS
Derives from research of:
• High reliability organizations• Strong safety culture• Organizational resilience
Why Change?
• Traditional approach to safety management based on:
• Compliance with regulations• Reactive response following accidents• Philosophy of “blame and re-train”
• This has proven insufficient to reduce accident rate
16
TSB Mandate
To advance transportation safety in the air, marine, rail and pipeline modes of transportation that are under federal jurisdiction by:
• conducting independent investigations• identifying safety deficiencies• making recommendations to address safety deficiencies• reporting publicly on investigations
It is not the function of the TSB to assign fault or determine civil or criminal liability.
TSB Reports
• Observations:
• Employee adaptations• Inadequate risk analysis• Goal conflicts• Failure to heed “weak signals”
Employee Adaptations
• Front line operators create “locally efficient practices”– Why? To get the job done.
• Past successes taken as guarantee of future safety.
Employee Adaptations
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
24
Incident Reporting (cont’d)
Challenges (cont’d):
• 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?
TSB Reports
Observations:
• personnel, workload, supervision
• training, qualifications
• physical or mental fatigue
• ineffective sharing of information
• gaps created by organizational transitions affecting roles, responsibilities, workload and procedures
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 Doesn’t 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
Lessons Learned
• Goal conflicts, local adaptations, and drift occur naturally. SMS can help identify these.
• Organizations can learn from patterns of accident precursors.
Benefits and Pitfalls
• There is no panacea
• But SMS can provide:+ Mindful infrastructure to identify hazards, mitigate risks
+ More reports of “near misses”
+ Help identify safe practices
Conclusion
• Effective SMS depends on “culture” and “process”
• Successful implementation takes unrelenting commitment, time, resources, and perseverance
• There are business benefits and safety benefits
• Ongoing requirement for strong regulatory oversight
Fishing vessel safety
Emergency preparedness on ferries
Passenger trains 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
WATCHLIST
Questions?
References
Slide # 5: Dekker, S. (2006) The Field Guide to Understanding Human Error, Ashgate Publishing Ltd.
Slide # 6: Dekker, S. (2006) The Field Guide to Understanding Human Error, Ashgate Publishing Ltd.
Slide # 8: Dekker, S. (2005) Ten Questions About Human Failure Slide #12: Dekker, S. (2002) The Field Guide to Human Error Investigations.
Ashgate Publishing Ltd.,18, 26 Slide #13: Reason, J. (2001) In Search of Resilience, Flight Safety
Australia, September-October, 25-28 Slide # 15: Dekker, S. (2007) Just Culture, Ashgate Publishing Ltd., p.21 Slide #23: Bosk, C. (2003) Forgive and Remember: Managing Medical
Failure, University of Chicago Press Slide # 24: Dekker, S. & Laursen, T. (2007) From Punitive Action to
Confidential Reporting : Patient Safety and Quality Healthcare September/October 2007