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Safety management systemsIndustrial Railway Safety ConferenceFaye AckermansMember, Transportation Safety Board of CanadaFort Saskatchewan, Alberta 29 April 2015
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• A history of Safety Management Systems (SMS)
• Three approaches to safety management• SMS requirements for Canadian railways • How it applies to you?• Where does safety culture fit?
Outline
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• 1974 Flixborough, Explosion at petrochemical facilityU.K. First
requirement for a “Safety Case”
• 1976 Seveso, Release of 6 tons of chemicalsItaly European safety
regulations
• 1988 Piper Alpha, Explosion and fire aboard oil and gas rigNorth Sea, U.K. Cullen Enquiry
recommends “formalassessments of
major hazards to beidentified and
mitigated” (i.e., a “safety case”)
A history of SMS
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Fatality
Major Injury
Minor Injury
Medical
Close Call
Three approaches to safety management
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Process safetyReliability engineeringErgonomic and cognitive engineeringAssessing and managing riskHuman reliability
Hazard analysisRisk assessmentsTechnical safety auditsHuman reliability assessmentsCognitive task analysis
Ergonomic guidelines
What it is
Outcomes
Three approaches to safety management (cont’d)The Technical/Engineering Model
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What it is
Success defined by
Three approaches to safety management (cont’d)The Organization Model
• Having pro-active (or leading) indicators of the health of the system
• Safety decision-making embedded throughout the organization
• Organization performance - find opportunity for actions to prevent accidents (“find trouble before trouble finds you”)
• Human error viewed as consequence not cause
• Errors are symptoms of latent conditions in the system
• Latent conditions the result of:o Management
decisionso Designo Changes
introduced after earlier accidents
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HumanUnsafe Acts
Mistakes
Human Performance
Error Management
Technical/Engineering
MechanicalTechnicalDesign
Man-MachineInterface
Organizational
SMSOrganization
alCulture
Summary: Three approaches to safety management
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Safety, leadership, and culture
Source: Leading with Safety. Tom Krause, Behavioral Sciences Technologies
Leadership
Organizational Culture
Safety Enabling Systems
Hazard Recognitionand Mitigation
Skills. Knowledge and Training
Policies and StandardsExposure reduction
Organizational Sustaining Systems
Selection and Development
StructurePerformance Management
Rewards and Recognition
ProcessWorker
Facilities & Equipment
Working Interface
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Simple definition
:
The way we do things around here
Culture change
Takes Time
Can be difficult to measure
Key notions:
Behavioural
statement
Leaders must find ways to change
behaviours
Behaviour changes lead to
changes in beliefs which changes the
culture
What is culture?
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• Manage occurrences• Report contraventions and hazards• Manage knowledge• Scientifically based schedules for
operating employees
Majors
• Accountability• Establish targets and develop
initiatives• Continuous improvement
Majors andLocal Class I
• Safety policy• Compliance with regulations• Identify safety concerns• Implement / evaluate remedial action• Risk assessments
All railroads(Majors, Local Class I
and II)
SMS requirements for Canadian railways
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SMS elements of regulations are all “enabling”
Therefore, they are essential but not sufficient
Paradox: Perception of an overly bureaucratic process versus the
need to make these “living” documents
Risk: A system on paper that does not exist on the shop floor
SMS requirements for Canadian railways – conclusions
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• Safety policy• Compliance with regulations• Identify safety concerns• Implement / evaluate remedial
action• Risk assessments
All railroad
s(Majors,
Local Class I and II)
SMS requirements for Canadian railways
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• A leadership statement provides an overarching VISION to all employees
• What should it look like?• Use behavioural terms• Keep it short
• What should you do with it?• Communicate, communicate, communicate• “Live” it
• When should you change it?• Not often, but not never
Safety policy
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Having a statement and communicating it are not enough:• You must believe in it;• Your actions must match your words;• Your decisions must be consistent with your
statement; and• You must be seen to be credible.
But you must also be aware that …
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• Do you have a process for reporting what happened?
• What about a process for reporting what almost happened?
• How do you tap into the knowledge of the “guy” with the boots on the ground?
• How often do you “walk about”?• When you do, are you looking for conditions or
behaviours?• How do you correct the behaviours you see?
Identifying safety concerns
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• Do you know how to assess risk?• What triggers a risk assessment?• What should trigger it?• What tools do you use?• Do you document the assessments?• Who do you get involved in the risk assessments?• How do you judge the quality of your process?
o The quality of the product?
Risk assessments
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Implementation• How do you decide what the possible actions
are?• How do you decide which actions to take?• What can you do short term?• What needs to be done long term and what
barriers need to be overcome?• Do you have physical defences? Administrative
defences?Evaluation• How do you know if your actions are working?
Implementing and evaluating remedial actions
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• Is what I say consistent with what I do?• How quickly do I react to concerns raised?• Has something changed today compared to
yesterday?• What can I do to reduce risk in my operation?• By making a change here, have I created more
risk somewhere else?• How do I know the changes have been truly
implemented?
Ask these questions:
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“[An SMS] is a formal framework that helps railway
companies integrate safety into their day-to-day operations.
It encourages the development of a safety culture
throughout all levels of an organization and ensures that
safety is considered a factor in all decision-making.”
Louis Lévesque, Deputy Minister of Transport24 November 2014: Report of the Standing Committee on Public Accounts
SMS: Transport Canada’s vision
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• Comply with existing regulations• Examine:
• Operations• Decisions around those operations
• Continuous improvement• Predict hazards using data collection and employee reports• Analyze, assess, control risk
• Monitor controls• Monitor system itself for effectiveness
• Move from reactive to predictive thinking• Change safety culture of leadership, management, and
employees
Wrap-up: SMS for any organization
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Reactive
• Respond to accidents
• Write another procedure
Proactive
• Seek hazardous conditions
• Change something to mitigate the risk
Predictive
• Analyze processes to identify potential problems
• Change process and monitor effect of changes
From past to present to future
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• Possession of an SMS is NECESSARY but NOT SUFFICIENT ON ITS OWN to ensure sustained safety improvement.
• You still need an organizational culture that supports the system.
• Culture change is led from the top. • Every level of organization must promote and
practice risk reduction.
Reminder: Going beyond regulations
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“No amount of regulations for safety management can make up for deficiencies in the way in which safety is actually managed. The quality of safety management … depends critically, in my view, on effective safety leadership at all levels and the commitment of the
whole work place to give priority to safety.”
Lord Cullen
2013 Conference 25th Anniversary Piper Alpha
Notable Quotes – 1
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“While the precise circumstances and context of major incidents differ in some respects, at heart I am left with the feeling that there are no new accidents. Rather, there are old accidents repeated by new people.”
Judith Hackitt CBE, Chair of UK HSE
2013 Conference 25th Anniversary Piper Alpha
Notable Quotes – 2
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Questions?
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