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Evolving Approaches to Managing Safety and Investigating Accidents. Kathy Fox, Member Transportation Safety Board of Canada International Women in Aviation Conference Orlando, Florida February 27, 2010. Presentation Outline. Personal experiences Accident causation and prevention – Concepts

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evolving approaches to managing safety and investigating accidents

Evolving Approaches to Managing Safety and Investigating Accidents

Kathy Fox, Member

Transportation Safety Board of Canada

International Women in Aviation Conference

Orlando, Florida

February 27, 2010

presentation outline
Presentation Outline
  • Personal experiences
  • Accident causation and prevention – Concepts
  • Introduction of Safety Management Systems (SMS)
  • Role of the Transportation Safety Board (TSB)
  • Conclusion
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

sidney dekker understanding human error
Sidney DekkerUnderstanding Human Error
  • Safety is never the only goal
  • People do their best to reconcile different goals simultaneously
  • A system isn’t automatically safe
  • Production pressures influence trade-offs

______

Dekker, S. (2006) The Field Guide to Understanding Human Error,

Ashgate Publishing Ltd.

sidney dekker understanding human error cont
Sidney DekkerUnderstanding Human Error (cont.)

______

Dekker, S. (2006) The Field Guide to Understanding Human Error,

Ashgate Publishing Ltd.

safety management systems sms
Safety Management Systems (SMS)

Integrating safety into an organization’s daily operations

“A systematic, explicit and comprehensive process for managing safety risks … it becomes part of that organization’s culture, and the way people go about their work.”

- James Reason, 2001

sms hazard identification
SMS: Hazard identification

Organizations must proactively identify hazards and seek ways to reduce or eliminate risks

Challenges:

  • Difficulty in predicting all possible interactions between seemingly unrelated systems – complex interactions1

_________

1 Perrow, C (1999) Normal Accidents, Princeton University Press

sms hazard identification cont d
SMS: Hazard identification (cont’d)

Challenges (cont’d):

  • Inadequate assessment of risks posed by operational changes – drift into failure, limited ability to think of ALL possibilities1,2
  • 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

organizational drift employee adaptations
Organizational Drift/ Employee Adaptations
  • Difficult to detect from inside an organization as incremental changes always occur
  • Front line operators create “locally efficient practices” to complete work quickly and cost-effectively
    • Were safety risks adequately assessed?
  • Past successes taken as guarantee of future safety
sms incident reporting
SMS: 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
sms incident reporting17
SMS: Incident Reporting

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 systems1

Who receives incident reports

_________

1 Dekker, S. & Laursen, T. (2007) From Punitive Action to Confidential Reporting Patient Safety and Quality Healthcare September/October 2007

17

sms organizational culture
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
SMS: Accountability
  • Recent trends are towards criminalization of human error

Sidney Dekker, Just Culture

    • Safety suffers when operators punished
    • Organizations invest in being defensive rather than improving safety
    • Safety-critical information flow stifled for fears of reprisals

________

Dekker, S (2007) Just Culture, Ashgate Publishing Ltd.

elements of a just culture dekker 2007
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
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 people’s 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.

sms benefits and pitfalls
SMS: Benefits and pitfalls
  • Nothing will always guarantee that all hazardous conditions in day-to-day operations will be found, analyzed and acted upon.
  • However, SMS is benefit where it’s implemented.
    • “mindful infrastructure” for hazard identification and risk mitigation
    • more reports of “near-misses” when employees feel safe about reporting them and when incidents are acted upon.
    • identifying boundaries of safe operations and when companies drift from these.
about the tsb
About the TSB
  • Independent organization investigating marine, pipeline, rail and air occurrences
  • Finds out what happened and why
  • Makes recommendations to address safety deficiencies
  • Not a regulator or a court
  • Does not assign fault or determine civil or criminal liability
about the tsb cont
About the TSB (cont.)
  • Reason’s Model adopted in early 90s
    • Multicausality
    • Human error within broader organizational context
  • Integrated Safety Investigation Methodology (ISIM)
    • Determining if full investigations are warranted based on potential to advance safety
    • Use of various human and organizational factors frameworks (Westrum, Snook, Vaughan, Dekker)
slide25

Summary

  • Adverse outcomes from complex interactions of factors difficult to predict
  • People at all levels in an organization create safety
  • ‘Near-misses’ must be viewed as “free opportunities” for organizational learning1

________

1 Dekker, S. & Laursen, T. (2007) From Punitive Action to Confidential Reporting Patient Safety and Quality Healthcare September/October 2007

slide26

Summary

  • Accident investigators must focus on what made sense at the time, not be judgmental, avoid hindsight bias2
  • Accountability requires organizations and professionals to take full responsibility to fix problems3, 4

________

2 Dekker, S. (2006) The Field Guide to Understanding Human

Error Ashgate Publishing Ltd.

3 Sharpe, V.A. (2004) Accountability Patient Safety and Policy Reform Georgetown University Press

4 Dekker, S. (2007) Just Culture Ashgate Publishing Ltd.