Impact of implementation of safety management systems sms on risk management and decision making
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Kathy Fox, Board Member System Safety Society – Canada Chapter’s Springtime Symposium June 2010 PowerPoint PPT Presentation


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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

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Kathy Fox, Board Member System Safety Society – Canada Chapter’s Springtime Symposium June 2010

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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 SymposiumJune 2010


Outline

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

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


Kathy fox board member system safety society canada chapter s springtime symposium june 2010

Safety ≠Zero Risk


Kathy fox board member system safety society canada chapter s springtime symposium june 2010

Balancing Competing Priorities

Service

Safety


Sidney dekker understanding human error

Sidney DekkerUnderstanding Human Error


Why focus on management

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


Drift

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

Drifting into Failure(aka: Why do “safe systems” fail? )

Image by Worth100


Organizational drift

Organizational Drift

  • MK Air – Flight duty times


Kathy fox board member system safety society canada chapter s springtime symposium june 2010

Organizational Drift (cont’d)


Organizational drift cont d

Organizational Drift (cont’d)

  • Source: Dekker (2002: 18, 26)


Safety management system sms

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

Evolution of SMS

Derives from research of:

  • High reliability organizations

  • Strong safety culture

  • Organizational resilience


Why change

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


  • Tsb mandate

    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.

    16


    Tsb reports

    TSB Reports

    • Observations:

      • Employee adaptations

      • Inadequate risk analysis

      • Goal conflicts

      • Failure to heed “weak signals”


    Employee adaptations

    Employee Adaptations

    • Front line operators create “locally efficient practices”

      • Why? To get the job done.

    • Past successes taken as guarantee of future safety.


    Employee adaptations1

    Employee Adaptations


    Kathy fox board member system safety society canada chapter s springtime symposium june 2010

    Aircraft Attitude at Threshold


    Goal conflicts

    Goal Conflicts


    Weak signals

    Weak Signals


    Incident reporting

    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 cont d

    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?

    24


    Tsb reports1

    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

    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

    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

    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

    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

    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


    Kathy fox board member system safety society canada chapter s springtime symposium june 2010

    WATCHLIST

    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


    Questions

    Questions?


    References

    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


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